A-219 A method for competence evaluation using a cause-and-effect diagram for quality assurance in clinical test: joint operation at multiple facilities

Abstract Background Competence management is important in quality management of clinical laboratories. Shimono et al. (2016, EOQ) proposed and demonstrated a competence assessment method using cause-and-effect diagrams common to specimen testing and physiological function testing in clinical test work. However, its usefulness has been verified only in one institution. Therefore, in this study, we apply the competence evaluation method using the characteristic factor chart in three facilities and clarify its validity. Methods .Selection of applicable facilities: We selected three participating facilities of the QMS-H (Quality Centered Management System for Healthcare) study group: Iizuka Hospital, Kawaguchi City Medical Center, and Koga General Hospital. 2-3 items were selected at each facility.Application of Methodology: Under lecture viewing and instruction, the staff members proceeded to create a characteristic factor chart and a competence evaluation chart. Online reviews were conducted from other facilities on the drafts prepared by the person in charge.Analysis of application results: Application results were analyzed from three perspectives for each facility and item. Results Three perspectives were used to tabulate the data for each facility and item to which it applies. The perspectives and the purpose of the analysis are as followsAverage of achievement level: What is the competence level of the person being evaluated?Difference between the highest and average set levels: Are we presenting more competencies for advanced trainees to aspire to?Difference between the highest and lowest attainment levels: Are we detecting differences in competence among subjects? The aggregate results showed that a) had a distribution of 2.4-3.6, around Level 3, which can be performed by one person; b) had a distribution of 0.4-1.4, which is less than 1 for some items; c) had a distribution of 0.4-2.2, which is less than 1 for some items. C) was 0.4-2.2, showing a large variation among the items. We were able to confirm that there was more variation in potency in the specimen tests than in the physiological function tests. Conclusion The three facilities were able to proceed with the creation of characteristic factor charts and competence evaluation tables. The exchange of opinions and guidance using the reviews among the facilities was particularly important. In addition, analysis of the results of the application from three perspectives suggested that a) it is necessary to examine educational programs to improve competence, since differences were found among the facilities, b) it is necessary to take measures to further improve competence, which means that senior staff have already reached the highest level, and c) the degree of standardization of the work. The results of the study suggest that the standardization of work needs to be considered. The application of the method to eight items at three facilities enabled us to discuss not only the effectiveness of the competency evaluation method, but also its relationship to standardization and educational programs.