员工胜任能力分析指南

Implementation of procedures, whether new or revised, requires

planning and organization. Determining the plan of action requires

needs assessment and prioritization of resources.

2.0 Scope and Related Policies

2.1. Personnel shall receive initial and continued training appropriate

to their duties. Training programs shall be available for this

purpose.9.3 (A3.2.1), 9.2 (4.3.2.1; 4.3.2.2)

The effectiveness of the programs shall be assessed at least

annually by regular competency evaluation, and assessment of

program elements by methods such as interviews with participants,

review of test results or monitoring of changes in error rates. 9.1

(A3.2.1; A3.2.3), 9.2 (4.3.2.3; 4.3.3.1)

2.2. The blood bank or transfusion service shall have a process to

ensure the employment of adequate numbers of qualified (by

education and experience) individuals, the provision of initial and

ongoing training, and competency assessments of these individuals

at specified intervals. 9.1 (A3.1.1; A3.2.1; A3.2.3), 9.2 (4.3.1.1; 4.3.2.1; 4.3.3.1)

2.2.1. Records of the qualifications, training, and continuing

competence of individuals shall be maintained. 9.1(A3.1.3;

A3.2.1; A3.2.3), 9.2 (4.3.1.2; 4.3.3.1; 4.3.4)

3.0 Specimens

N/A

4.0 Materials

Competency assessment checklists

Written assessment material5.0 Quality Control

5.1. The recommended frequency of assessment is upon completion of

orientation, annually and as required for performance

management of technologists who rotate through or work in the

transfusion medicine area of the laboratory.

5.2. Ideally, the trainer should be a transfusion service technologist

with significant experience and good communication and feedback

skills. The employer should support and provide continuing

education in instructional skills and communications.

5.3. Written assessment material, including the answers, should be

available for all personnel to review as required, either individually

or with a trainer.

6.0 Procedure

6.1. Identify training needs. See the Guide for Use of the Technical

Resource Manual or, alternately, identify areas by evaluating

existing documentation. This may include the following.

6.1.1. Initial training and orientation

6.1.2. New or revised procedures

6.1.3. Error or incident reports involving test results or blood

products.

6.1.4. Exception reports or quality control documentation

indicating a trend or showing that a process or a test is

falling out of control.

6.1.5. Documentation of specific performance-related issues.

6.2. Select the guideline(s) that relate to the training need. Select

procedures performed by all technologists and any specific

training areas. See procedural notes 8.1 and 8.2.6.3. Obtain the competency assessment checklist for the guideline(s).

Additional facility-specific key job areas or assessment criteria

related to the guideline may be written onto the checklist. If this

is done, every trainee should be assessed with the same

additional criteria.

6.4. From the checklist, determine the prerequisite activities (if any)

required to fulfil the competency.

6.5. Determine the time required for each staff member to

demonstrate the prerequisite activities (if applicable) and

required competencies to the trainer. If assessment of many

guidelines is required, break the task down into smaller

“projects” that involve up to a maximum of 5-6 guidelines.

6.6. Communicate the plan to staff. Disseminate all materials for

review and comment. Allow all staff time to absorb the

information and to begin the task (see Trainee Information). Try

to allow enough time to prepare, but set timelines for completion.

6.7. Post timelines for staff. Ask staff to notify the trainer when they

are ready to proceed.

6.7.1. Allow time for staff to self-assess using the checklist(s).

6.7.2. Allow staff access to the written evaluation answers, to

encourage self-assessment and learning opportunity.

6.8. Schedule time for the trainer and trainee to complete the direct

observation. The written assessment may be reviewed before or

after the direct observation of the guideline.

6.9. Record direct observation results on the checklist. If the trainee

does not perform one of the steps or if the trainer answers “no” to

one of the questions in the “Key Job Areas / Assessment Criteria”

section, proceed to step 6.11.1.

6.10. If all rows on the checklist are answered “Yes”, place a checkmark

in the “Yes” box beside the “Is trainee competent to perform

procedure” question.6.11. If any assessment questions on the checklist are answered “No”,

place a checkmark in the “No” box beside the “Is trainee

competent to perform procedure” question.

6.11.1. Details of the actions the trainee performed in the

deficient key job area should be recorded in the

comments area at the end of the checklist.

6.11.2. A plan for remedial and corrective action should be

written on the checklist. This should include steps that

the trainee must complete before reassessment will be

done. See procedural note 8.3.

6.11.3. The trainee should not perform the test or procedure

that was under assessment unsupervised until

competency assessment is successful.

6.12. Both the trainer and the trainee should acknowledge that the

information on the checklist is correct by signing the

acknowledgement area.

7.0 Reporting

7.1 Records of competency assessment should be summarized on

form TG.001F1. The original checklist should be retained in the

trainee file.

8.0 Procedural Notes

8.1 A general guide to the sequence for training/assessing

competency is given below. This may be changed or rearranged

depending on the size and scope of the transfusion service. Review the Glossary of Terms A.001 Standardized Nomenclature for Blood, Blood Components and

Fractionated Blood Products IM.001 Patient Identification and Specimen Labelling (may not be

applicable to facilities that have a phlebotomy team) PA.001 Pathologist Consultation Protocol QCAI.013 Determining Specimen Suitability PA.002 Reading and Recording Hemagglutination Reactions PA.006 Labelling of Test Tubes and Block Set Up for Compatibility Testing PA.004 Cell Washing Automated and Manual PA.005Quality Control of Reagent Red Cells and Antisera QCAI.001 Patient History Check PA.003 Temperature Calibration of Waterbaths and Heating Blocks QCAI.006 Group and Screen RT.006 Prewarm Technique CT.001 Saline Replacement CT.002 ABO Group Problem Solving CT.003 Weak D Typing RT.003 Rh Typing Problem Solving CT.004 Direct Antiglobulin Test RT.004 Hemagglutination Reading Skills Proficiency Testing QCAI.011 Investigation of a Positive Direct Antiglobulin Test CT.005 Investigation of Transfusion Complications RT.010 Selection of Blood Components for Transfusion CSP.001 Visual Inspection of Blood, Blood Components and Other Related

Blood Products IM.003 Using the Issue/Transfusion Record

Immediate Spin Crossmatch RT.007 Antiglobulin Crossmatch RT.008 Rosette Test RT.009 Temperature Check of Blood and Blood Components QCAI.010 Products IM.002 Final Disposition of Blood, Blood Components and Other Related

Products Not Suitable for Transfusion IM.005 for Shipment.

Shipment of Blood Products Accompanying a Patient IM.007 Exclusion and Confirmation of Antibodies CT.008 Antibody Identification of Cold Reactive Antibodies CT.006 Antibody Identification of Warm Reactive Antibodies CT.007 Antigen Typing - Direct and Indirect Agglutination CT.009 Temperature Documentation of Blood Product Storage Equipment QCAI.002 Maintenance of Blood Product Storage Refrigerators QCAI.003 Maintenance of Blood Product Storage Freezers QCAI.004 Maintenance of Platelet Incubators QCAI.005 Thawing Plasma CSP.002 Thawing and Pooling Cryoprecipitate CSP.003 Pooling Platelets CSP.004 Dividing Red Blood Cells (RBC) CSP.0058.2 Selected Quality Control may be done by designated personnel

(i.e., only one or two technologists may be trained to perform and

have competency assessment for the following guidelines). Functional Calibration of Thermometers QCAI.008 Washers and Serological Centrifuges

Temperature and Alarm Check of Blood Warmers and Rapid

Infusion Devices QCAI.009

8.3 Additional training may include, but is not limited to:

• demonstration by the trainer

• more practice with self-assessment

• review of didactic material.

9.0 References

9.1 Canadian Society for Transfusion Medicine. Standards for

hospital transfusion services, version 1. Ottawa: Canadian Society

for Transfusion Medicine, 2004: A3.1.1, A3.1.3, A3.2.1, A3.2.3.

9.2 Canadian Standards Association. Blood and blood components

(Z902-04). Mississauga, Ontario: Canadian Standards

Association, 2004: 4.3.1.1, 4.3.1.2, 4.3.2.1, 4.3.2.2, 4.3.2.3, 4.3.3.1,

4.3.4.

Facility endorsement if guideline is used as a Standard Operating Procedure (SOP)

Authorized signature(s): __________________________

__________________________ Facility effective date: __________________________

Change Log

Competency Assessment/Training Needs Assessment

and Implementation Guide

Guideline: TG.001 Effective Date: 01 June 2000

Competency Companion to the Technical Resource Manual for Hospital Transfusion Services Page 7 of 6 Change Description Effective Date

Revision 1

2.1: Changed “The effectiveness of the programs shall be

assessed by regular competency evaluation” to “The

effectiveness of the programs shall be assessed at least annually

by regular competency evaluation, and assessment of program

elements by methods such as interviews with participants,

review of test results or monitoring of changes in error rates.”

6.1: Changed “specific areas that require improvement” to “training needs”

6.1.1: Added “Initial training and orientation” 6.1.2: Added “New or revised procedures”. Changed “If no

problem areas are identified, select procedures performed by all technologists and any specific training areas.” to “Select

procedures performed by all technologists and any specific

training areas.”

6.2: Changed “problem area” to “training need”

8.1: Updated names of guidelines

9.0: Deleted references 9.1, 9.2; added new references 9.1, 9.2

July 2003