Provider Performed Microscopy
When you need a result then and there

General Information

Provider Performed Microscopy (PPM) includes the following five tests at UCSF:

  1. Urine Sediment
  2. Saline Wet Mount
  3. 10% KOH Preparation
  4. Fern Test
  5. PinWorm Microscopy

Federal CLIA ‘88 regulations classify all PPM as ‘moderately complex’ testing and therefore require that all individuals performing PPM, or overseeing PPM performed by trainees, successfully complete an annual (semiannual in the first year) competency assessment and be credentialed and privileged for PPM by the UCSF Credentialling Committee/Medical Staff Office.

Competency Assessment

There are two required components to PPM competency assessment:

  1. Online examination(s)
  2. Direct evaluation by a colleague

Both components must be successfully completed annually (semiannually in the first year) in order to be eligible for Medical Staff privileges to perform PPM.

Online Examination

The UCSF Clinical Laboratories utilizes an on-line PPM competency challenge program hosted by the University of Washington. A link to this program along with additional instructions on how to log into the program will be sent via email by the UCSF Medical Staff Office once privileges are requested. Online competency testing in all five areas is available and can be administered independently of each other. Each subject has approximately five (5) questions and you must answer 80% of the questions correctly to pass.

Direct Evaluation

CLIA regulations require that all six phases of competency assessment be completed:

  1. Direct observations of routine patient test performance, including patient preparation, if applicable, specimen handling, processing and testing
  2. Monitoring the recording and reporting of test results
  3. Review of intermediate test results or worksheets, QC records, PT results, and preventive maintenance records
  4. Direct observations of performance of instrument maintenance and function checks
  5. Assessment of test performance through testing previously analyzed specimens, internal blind testing samples or external PT samples
  6. Assessment of problem solving skills

A competency assessment form (link requires active VPN and compatible browser) will be mailed to each provider. Completion of this form will require involvement by a provider fully credentialed and current on PPM competency assessment at UCSF. If assistance is need to identify a credentialed provider to assist with this task, please contact the UCSF Medical Staff Office at (415) 885.7268 for assistance.

For practitioners who practice at both UCSF and Zuckerberg San Francisco General Hospital (ZSFG), note that the PPM Online competency test requirement satisfies both UCSF and ZSFG. The PPM Direct Observation Evaluation, however, is unique between UCSF and ZSFG and, therefore, will need to be performed independently at each site.

Competency Failure

In the event a practitioner fails the competency assessment the following procedure will be followed:

  1. Failure of one or more on-line competency assessment modules: Practitioner is allowed to retake after one failure (notification will be sent via email after the first failure allowing the practitioner to retake the exam). On repeat failure, the practitioner must be mentored prior to being allowed to retake the examination a second time:
  • Medical Staff Office will assist to identify a mentor who has passed the competency assessment and has current privileges in the area(s) of PPM for which the practitioner failed competency.
  • Practitioner must correctly interpret twelve (12) patient samples with the mentor in each of the examination types that the practitioner failed.
  • The mentor will complete an attestation that the practitioner has successfully completed the (12) sample review and forward to the Medical Staff Office.
  • Upon acceptance of the mentor's attestation the UCSF Medical Staff Office will reset the online competency examination website and the practitioner will be notified that he/she is allowed to re-take the online competency examination(s).
  1. Repeat failure after mentoring: Practitioner must repeat mentoring as above before being allowed to retake the examination.

Repeat failure on an exam or failure to take an exam by the notified date will result in an administrative suspension of privileges for the exam(s) in question.

Please contact the Point of Care Committee Chair, Dr. Anne Deucher ([email protected]) or POCT Senior Supervisor, Wilford Vince Cruz ( [email protected]) if you have any questions regarding Provider Performed Microscopy and/or if you have concerns regarding the on-line competency program.