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AFP Office LaboratoryOur first year residents are scheduled for twelve hours in the first year in our office laboratory with our medical technologist where they review test procedures appropriate for office lab testing. Second and third year residents lab schedules include four hours each year consisting of reviewing proficiency testing, instrument maintenance, writing procedures, OSHA/safety, CLIA personnel requirements, laboratory regulations, laboratory inspection, quality control, quality assurance, test validation and physical design of a laboratory. When finished, the resident will have the 20 hours of training required by CLIA to manage a physician office laboratory.
Dottie teaching
Laboratory Curriculum The Family Physician is often the first link in the diagnosis of everything from common, routine illnesses to complex, serious illnesses. Laboratory testing in the physician’s office improves efficiency and quality of patient care because test results can be available at the time the patient is seen. Altoona Family Physicians Laboratory Rotation Description: The Laboratory rotation is a minimum of a 20 hour curriculum covered during first, second and third year. First year residents receive at least 12 hours of didactic laboratory training and laboratory testing skills during the COFME 1 rotation. A minimum of 4 hours is scheduled during each of the resident’s second and third years during scheduled office hours. Per CLIA certification requirements, the time allocated to didactic training is divided as follows: Regulations: 1hour, Physical Plant: 1 hour, Testing Systems and Equipment: 3 hours, Quality Assurance: 3 hours, Quality Control: 3 hours, Laboratory Personnel: 2 hours, and written policies, procedures and individual performance responsibilities: 2 hours. At the completion of the laboratory rotation, the resident will have the attitudes, knowledge and skills that are critical to family medicine as well as be qualified to direct a physician office laboratory in compliance with federal and state regulations. Each resident will be responsible for successfully demonstrating all required objectives through verbal, written and practical examinations. Objectives will be considered met with verbal and written exam scores of 80% or better and a practical exam score of 100%. Competency Based Rotations Goals and Objectives Patient Care Goal Laboratory testing can play a large role in the medical care of a patient. Family Physicians must be able to utilize laboratory testing in the pre-analytical, analytical and post-analytical stages to appropriately, effectively and compassionately assess and treat the family practice patient Objective 1: The resident will demonstrate that they are capable of compassionately listening to the patient and properly assessing the patient’s symptoms. The resident will also demonstrate proper knowledge, choice and technique in the collection of a variety of laboratory specimens to ensure that appropriate and valid results are obtained and that there is no contamination. The resident will further demonstrate the ability to order ongoing appropriate laboratory studies/testing to ensure proper diagnoses. Objective 2: Laboratory results are sensitive in nature. The resident will demonstrate the ability to use appropriate discretion and compassion in the delivery of these results to the patient.
Medical Knowledge Goal
Residents will learn and demonstrate Laboratory skills and practices that are required to maintain a high-quality laboratory and that are pertinent to becoming a competent Medical Laboratory Director. They will be able to apply these skills and practices to the care of the family practice patient.
Objective 1: The residents will be able to skillfully perform selected laboratory tests, as well as understand each test’s underlying principles and meaning. Objective 2: Procedures, policies and regulations govern the operation of a clinical laboratory. The residents will be able to understand the extent of each of these as well as the necessity of each. Objective 3: The resident will acquire and demonstrate the following knowledge and skills as they relate to laboratory medicine in the family practice setting. These will be assessed and measured through a series of tested competencies defined for each area of laboratory training. Each resident is responsible for successfully demonstrating all required competencies through verbal, written and practical examinations. Knowledge I. CLIA-88 1. Categories of testing complexity 2. Certification requirements and application process a. Types of certification b. Application Process c. Application and inspection fees d. Requested information i. Name of tests ii. Methodology iii. Volume of tests iv. Qualification of personnel 3. Laboratory agreements a. Inspection b. Record availability c. Proficiency testing requirement d. Notification of changes 4. Federal and state inspections a. Fees b. Entrance interview c. Assessment of facilities d. Selection of representative samples i. Criteria used ii. An expanded sample e. Legal implications for noncompliance with CLIA standards 5. Accreditation options a. COLA b. JCAHO c. CAP II. Testing systems and equipment 1. Selecting a reference laboratory: service, quality, price 2. Instrument maintenance/function: calibration a. Instrument documentation b. Log of equipment c. Instrument troubleshooting d. CLIA requirements for maintenance performance 3. Selecting qualitative test kits a. Factors to consider in test-kit instrument selection i. Ease of performance/CLIA test complexity ii. Cost per billable test iii. Space for testing and storage iv. Accuracy, sensitivity and specificity b. CLIA requirements for initiating a new test c. Precaution before using test kits
Skills
I. Use and care of the microscope II. Urinalysis 1. Chemical reaction 2. Microscope a. Crystals b. Red blood cells c. White blood cells d. Casts 3. Quality control 4. Specific gravity, pH III. Complete blood count 1. Manual white blood cell count/red blood cell count 2. Hemoglobin 3. Peripheral smear a. Manual differential b. Morphology c. Platelet estimate 4. Automated procedures not requiring operator interaction 5. Spun micro-hematocrit IV. Chlamydia testing V. Gram stain test 1. Staining procedure 2. Gram-negative 3. Gram-positive 4. Morphology a. Cocci vs. rods vs coccobacilli b. Diplococci, tetrads, etc. VI. Vaginal smears 1. Potassium hydroxide and wet mount 2. Clue cells 3. Yeast 4. Trichomonas vaginalis 5. White blood cells and bacteria VII. Pinworm preparation VIII. Skin Scrapings 1. Yeast 2. Fungal Elements 3. Mites IX. Immunochemical assays 1. Rapid streptococcus test a. Methodology b. Procedure c. Quality Control
Practice Based Learning and Improvement Goal
Residents will demonstrate their ability to investigate and evaluate their patient care practices, appraise and assimilate laboratory testing evidence, and improve their patient care through laboratory testing. They will demonstrate a commitment to lifelong learning of available office-based diagnostic tests and their appropriate use in patient care.
Objective 1: Quality control is a tool to detect problems that could affect or invalidate patient results. Every laboratory, under CLIA requirements, must establish and follow written quality control procedures. The resident will demonstrate their knowledge of quality control and the documentation of quality control. They will learn how daily quality control is essential in performing and resulting high quality, reliable laboratory tests.
Objective 2: The residents will be able to evaluate the feasibility of performing tests in a physician office laboratory. The resident will learn what considerations must be made when adding or changing laboratory tests. This will encompass considerations of complexity, specificity, sensitivity and precision of the test, financial considerations, including coding, billing, insurance reimbursement and technician time as well as laboratory space and testing liability.
Objective 3: The residents will demonstrate knowledge of CLIA-88 regulations as well as other national and state regulations which factor into the continual operation and running of a high quality laboratory. The resident will also demonstrate knowledge of proficiency testing and inspection material and information offered by regulatory agencies. The resident will be taught to keep abreast of all new information or regulations pertaining to the above.
System Based Practice Goal
Residents will demonstrate an awareness and responsiveness to the availability of the larger system and context of laboratory testing, as well as the ability to effectively call on the resources available in order to provide optimal healthcare to the entire patient.
Objective 1: The resident will be able to effectively coordinate laboratory testing with patient complaints and symptoms. This will require the knowledge of the availability of laboratory testing not only by the physician office laboratory and regional hospital laboratory, but also by reference laboratories.
Objective 2: Laboratory results that are unexpected or prognosticate poor outcome may lead to further laboratory testing or they may lead to referral of care for other consultative or diagnostic workup. When this occurs, the resident will be able to coordinate with other healthcare professionals to ensure the well being of the entire patient, whether it be medical, physical, surgical or emotional care.
Professionalism Goal
Residents will demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to their patients regarding laboratory tests and results.
Objective 1: Residents will present with professional attire and demeanor at all times. The residents will demonstrate a respect for patient privacy and autonomy regarding laboratory specimen collection, results, further testing and treatment. Many laboratory specimens and results are very sensitive in nature, requiring respect, discretion and privacy. They will treat patients, in the office or hospital setting, with respect, compassion and integrity prior to, during and after laboratory specimen collection and testing. They will demonstrate a responsiveness to the needs of their patients regarding laboratory results, especially untoward or unexpected results, and will recognize and be sensitive to the difficulty or complexity of further testing or treatment. This will be assessed by direct observation and feedback by the precepting physician.
Objective 2: Residents will develop and present a professional attitude required to accept the responsibilities of a physician office laboratory director. The director has the responsibility for the overall administration and operation of the laboratory as well as assuring compliance with regulations. The laboratory director must be accessible to laboratory personnel for consultation as needed.
Interpersonal and Communication Skills Goal
Residents will demonstrate interpersonal and communication skill that result in the effective exchange of information with patients, patients families and professional associates regarding laboratory tests and results
Objective 1: The residents will develop attitudes and skills to discuss unexpected or positive test results with compassion. They will also learn and apply discretion when discussing such test results in the presence of patient family or friends. This will be measured by direct observation and formative feedback.
Objective 2: The resident will demonstrate their ability to exchange information with their precepting physicians as well as with office staff, other physicians and specialists to ensure adequate information is received and complete testing is ordered or performed. Observation and formative feedback will help to measure this objective.
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