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Lab Manual for Moffitt-Long and Mount Zion

Lab Manual for SFGH

Internal Resources

Provider Performed Microscopy (PPM) Program

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

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

Federal CLIA '88 regulations classify all PPM as 'moderately complex' testing and therefore requires that all individuals performing PPM pass an annual Competency assessment. At UCSF this is accomplished by use of an on-line Competency evaluation that each provider must take and pass in order to be eligible for medical center privileges to perform PPM in the context of patient care. For new practitioners wishing to perform PPM, successful initial competency testing must be repeated within six (6) months. Therefore new practitioners who pass their initial competency will be asked to retake the competency assessment after six months. Thereafter competency assessment notices will be sent out annually on the anniversary of your first successful competency assessment. Your anniversary month will remain the same even if additional competencies are requested/completed at another time.

The UCSF Clinical Laboratories utilizes on-line PPM competency challenge program hosted by the University of Washington to fulfill the annual competency requirement. The Clinical Labs is given a list of providers by the Medical Staff Office. The Clinical Labs then sends out an email notice to the providers informing them of the testing requirement, providing the URL for the testing site, and providing a user name and a password for the testing site. Testing in all five areas is available and the tests can be taken independently of each other. There is no opportunity to review your answers at the end, so make sure that you are confident of the answer before moving on to the next question. Each subject has approximately 5 questions. You must answer 80% of the questions correctly to pass. The online results are reviewed periodically by the Clinical Laboratories and the results forwarded to the Medical Staff Office.

Note that performing any of these examinations at UCSF requires Medical Staff privileging. UCSF and SFGH PPM competencies are reciprocal, a practitioner who has successfully completed their competency assessment and been granted privileges at one site must only provide proof of this to request privileges at the other campus.

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:

    1. 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.

    2. Practitioner must correctly interpret 12 patient samples with the mentor in each of the examination types that the practitioner failed.

    3. The mentor will complete an attestation that the practitioner has successfully completed the 12 sample review and forward to the Medical Staff Office.

    4. Upon acceptance of the mentor's attestation the laboratory will be notified to reset the competency examination and the practitioner will be notified that he/she is allowed to re-take the on-line competency assessment

  2. Repeat failure after mentoring: Practitioner must repeat mentoring as above before being allowed to retake the examination.

Impact on PPM privileges:

Repeat failure on an exam for failure to take any exam by the notified date will result in suspension of privileges for the exam(s) in question. In addition, he or she must be mentored on PPM examinations in the area(s) where competency was failed until retaking and passing the examination.

Please contact Enrique Terrazas, MD (voice 514-8931 or email Enrique.Terrazas@ucsf.edu) or Cynthia Ishizaki (voice 353-1976 or email Cynthia.Ishizaki@ucsfmedctr.org) if you have any questions regarding Provider Performed Microscopy and/or if you have concerns regarding the on-line competency program.

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