Ensuring Personnel Competency at All Levels

By: Chris Wetzel, MLS (ASCP)

Laboratory Specialist

Posted: May 22, 2025

Evaluation of competency is expected for all laboratory testing personnel. This occurs at least twice in the first year that the individual is testing patient specimens and at least annually thereafter. The evaluation must include six specific elements:

1. Direct observation of test performance.
2. Monitoring how test results are recorded and reported.
3. Review of intermediate test results or worksheets, quality control records, PT results, and preventive maintenance records.
4. Direct observation of instrument maintenance and functions checks.
5. Assessment of testing performance using known samples.
6. Assessment of problem solving skills.

The technical supervisor or technical consultant tasked with conducting these evaluations—along with the Clinical Consultant and General Supervisor—is also subject to competency assessment. For those performing patient testing, the elements above apply. If these positions are filled with non-testing personnel, then the standard six elements are not required but, in either case, competencies based on the responsibilities of the position as defined by CLIA must be assessed.

The laboratory director may act in these roles, or they may be delegated to qualified individuals. Written policies and procedures guide competency assessment, including any delegated responsibilities. The laboratory director holds responsibility for defining the frequency of these evaluations (typically on an annual basis).

To assist labs in complying with role-based competency requirements, ACHC offers two checklists that you can download by clicking below.

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Read more articles about Clinical Laboratory Accreditation here.