Health Care Department Operations Manual

Chapter 1 – Health Care Governance and Administration

Article 4.4 – Professional Workforce: Allied Health Services

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1.4.4.2 Laboratory Services Staff Onboarding and Competency Assessment

Policy
- California Correctional Health Care Services (CCHCS) shall provide all newly appointed civil service laboratory services staff, including, but not limited to Laboratory Assistants, Senior Laboratory Assistants, Clinical Laboratory Technologists (CLT), Senior Clinical Laboratory Technologists, and Supervising Clinical Laboratory Technologists who provide clinical and/or support services in California Department of Corrections and Rehabilitation (CDCR) institutions with relevant and job-specific orientation and training (Laboratory Services Staff Onboarding) during the probationary period. This policy shall not be construed as altering existing laws and regulations governing civil service probationary periods or the provisions of any applicable bargaining unit contract.
The CCHCS Laboratory Services shall maintain a Laboratory Services staff competency program to ensure:
- Standard laboratory practice is consistent with the laboratory process and practice established by the Clinical Laboratory Improvement Amendment, California Department of Health, Clinical Laboratory Standards Institute (CLSI), and certification agencies.
- Department Laboratory Services staff demonstrate the knowledge, skills, and abilities required to achieve an appropriate level of competency and perform within their scope of practice.
- Laboratory Services staff complies with CCHCS and CDCR policies and procedures, federal and state laws and regulations, and nationally accepted laboratory standards.
- The competency program includes:
  - Educational programs;
  - Competency validation; and
  - Documentation and tracking of the validation results.
- Competency validation is the evaluation of staff competencies by a subject matter expert (SME) and occurs on a continuum. This continuum shall include assessment of competencies during the hiring process, during the orientation period, annually, and throughout employment as the requirements of the job and needs of the organization change.
Purpose
- To establish a comprehensive and standardized onboarding process for new civil service Laboratory Services staff that:
  - Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new laboratory services staff.
  - Supports newly appointed Laboratory Services staff with relevant orientation and training by experienced SMEs during the probationary period.
  - Facilities adherence to applicable scopes of practice, standards of practice, applicable clinical guidelines, and CCHCS/CDCR standards.
  - Promotes job satisfaction while enhancing Laboratory Services staff effectiveness, efficiency, and knowledge.
- To provide guidelines for the competency and ongoing assessment of Laboratory Services staff.
Responsibility
- Statewide
  - The Statewide Chief of Laboratory Services is responsible for implementation, evaluation, and planning related to this policy and procedure.
- Regional
  - The Regional Health Care Executives are responsible for the application of this policy at the subset of institutions within their assigned region.
  - The Senior CLT with regional responsibilities are responsible for:
    - Coordination with regional and local administration for the local application of this policy and procedure.
    - Application of this policy and procedure at the subset of institutions within their assigned region.
    - Validation and subject matter expertise of the clinical components related to this policy’s onboarding requirements, competency requirements, and ongoing education for all Laboratory Services staff.
    - Maintenance of a competency & education tracking system.
- Institution
  - The Chief Support Executive and/or Correctional Health Care Services Administrator I/II are responsible for the local application of this policy and procedure, and the supervision of onboarding, training, and competency requirements for all Laboratory Services staff.
    - The Chief Support Executive and/or Correctional Health Care Services Administrator I/II shall coordinate with the Senior CLT with regional responsibilities on these tasks.
    - The Chief Support Executive and/or Correctional Health Care Services Administrator I/II shall defer to the Senior CLT with regional responsibilities for the validation component and subject matter expertise of these tasks if they do not have the required clinical expertise and experience to perform them.
  - Laboratory Services staff are responsible for completing all standardized onboarding requirements if they are new to civil service, and all assigned training and competency within the required competency testing frequency.
Procedure
- Orientation and On-the-Job Support During the Probationary Period
  - The direct supervisor and applicable SMEs shall use the New Employee Orientation Checklist and the appropriate Competency checklist to ensure each newly hired staff completes the applicable checklists and orientations during the first 90 calendar days of hire. (The checklist can be found under the Laboratory Services Resources Lifeline page under the “Other” tab.)
    - During the staff’s first two weeks of hire, the staff’s supervisor or SME shall complete items under the “New Employee Orientation Checklist” and complement with the following:
      - Facility tour and introduction to executive staff;
      - Completion of Human Resources and Information Technology departments mandated forms;
      - Overview of the institution’s or work location’s missions and physical layout;
      - Overview of the new staff’s workspace; and
      - Issuance of the new staff’s identification card and other essential work items.
    - Institution or work location-based onboarding shall address the designated topics specified in the Laboratory Services New Employee Orientation Checklist.
    - CDCR Non-Custody New Employee Orientation, as applicable to the staff’s assigned work location, is to be completed by all staff within the six-month or twelve-month probationary period. This training is composed of classroom and computer-based modules. The classroom portion is provided by the institution’s In-Service Training Office.
    - Laboratory Services staff shall complete Electronic Health Record System (EHRS) training and competency validation including completion of CCHCS Learning Management System EHRS Modules consistent with the staff’s duty statement.
    - Laboratory Services staff shall complete orientation and mentoring of specific tasks identified in the appropriate Laboratory Services Onboarding and Competency Assessment Checklist based on job title, and the Urine Drug Screening (UDS) specimen collection process utilizing the UDS Onboarding and Competency Assessment Checklist.
  - Staff beginning independent work shall have access to the Laboratory Services staff with similar job duties for questions and assistance.
  - Within 90 calendar days after the new staff hire date, the direct supervisor shall ensure completion of the Laboratory Services New Employee Orientation Checklist and Competency Assessment Checklists and shall review, sign, and maintain the completed forms in the staff’s supervisory file. If the new Laboratory Services staff member is delayed in completing the Laboratory Services New Employee Orientation Checklist and Competency Assessment Checklist, the direct supervisor may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 90 calendar days.
- Probationary and Professional Performance Evaluations
  - For staff who have a one-year probationary period:
    - In accordance with civil service laws and regulations, the direct supervisor shall complete, at minimum, an STD 636, Report of Performance for Probationary Employee at four months, eight months, and 12 months after hire to assess professional performance and clinical competency.
    - The 12-month STD 636 may be completed as soon as 11 months but no later than 12 months after the hire date.
    - Interim STD 636s may be completed as needed to assess professional performance and clinical competency.
  - For staff who have a six-month probationary period:
    - In accordance with civil service laws and regulations, the direct supervisor shall complete, at minimum, an STD 636 at two months, four months, and six months after hire to assess professional performance and clinical competency.
    - The six-month STD 636 may be completed as soon as five months but no later than six months after the hire date.
    - Interim STD 636s may be completed as needed to assess professional performance and clinical competency.
  - Two to four weeks before the end of the probationary period, the direct supervisor shall review the probationary evaluations and other clinical and performance observations to make a recommendation regarding permanent civil service employment.
  - After the probationary period ends, the direct supervisor shall complete, at minimum, an annual evaluation of the staff’s professional performance and clinical competency. In addition, on an annual basis, the direct supervisor shall review the Laboratory Services staff member’s duty statement with the staff. This shall be acknowledged by the signature of the staff on the duty statement which shall be retained in the staff’s supervisory file.
- Determination of Permanent Civil Service Status
  - After completion of the second STD 636, but no later than one month before the end of the probation, the direct supervisor shall review the findings and recommendations contained in the probationary evaluations and other documented professional observations to make a recommendation about whether to grant permanent civil service status.
  - If there are concerns regarding the performance of the probationary staff, the direct supervisor shall immediately notify their supervisor and the Health Care Employee Relations Officer as soon as issues are identified.
  - A recommendation to reject the staff during the probationary period may occur any time during the probationary period if the previous STD 636s, professional practice evaluations, competency validations, or other documented performance observations show significant concerns regarding the staff’s performance or conduct.
- Re-orientation of Laboratory Services staff (Re-entry Training)
  - For Laboratory Services staff who are out of work but did not separate from service with CDCR (e.g., long-term sick):
    - If staff have been out for six months or less, the following is required:
      - There must be documentation of the previous completion of the Laboratory Services Staff New Employee Orientation Checklist and Competency Assessment Checklists.
      - Staff must review all classes, updates, and mandatory training missed.
      - Validation of competencies shall be completed for the tasks in which staff will be completing.
    - If staff have been out for six months to 12 months, the following is required:
      - There must be documentation of the previous completion of the Laboratory Services New Employee Orientation Checklist and Competency Assessment Checklists.
      - Staff must review all classes, updates, and mandatory trainings missed, including CDCR Non-Custody Annual Block Training and In-Service Training.
      - Validation of competencies shall be completed for the areas in which staff will be working.
    - Staff who are out more than one year shall complete the onboarding process in its entirety upon return.
  - Staff who separate from the Department and then return to state service, regardless of the length of time, shall be required to complete the onboarding process in its entirety.
- Transferring Between Institutions without a Break in Service or Performing Duties at More Than One Institution
  - The direct supervisor is responsible to ensure that all Laboratory Services staff working at that institution are competent to perform all the duties of the position for which the Laboratory Services staff has been hired.
  - The direct supervisor may develop an abbreviated Laboratory Services Staff Onboarding and Competency Assessment Checklist for Laboratory Services staff sharing assignments between multiple institutions.
  - Proof of completion of the onboarding process, clinical competencies, and professional performance shall be maintained at each CDCR location. This does not absolve the direct supervisor at each CDCR location from ensuring that annual performance evaluations are conducted, or Laboratory Services staff are competent to perform the duties required in their position.
- Ongoing Education and Competency
  - Program Development
    - Educational trainings and competencies shall be developed by CCHCS headquarters (HQ) Laboratory Services based upon internal and/or external requirements. Laboratory Services leadership shall review and update all laboratory educational training and competencies developed by Laboratory Services, as needed.
  - Competency Components
    - Laboratory Assistants (LA)
      - The California Public Health Department, Laboratory Field Services Division, sets forth the duties that all laboratory personnel, regardless of role, population, or specialty, are expected to perform competently. The components of competency include, but are not limited to:
      - Venipuncture Specimen Collection: The LA performs venipuncture consistently following CLSI standards for specimen collection through venipuncture.
      - UDS Specimen Collection: The LA follows the special handling collection requirements for UDS as contained in policy.
      - Specimen Collection for “Miscellaneous” Specimens: The LA follows the CLSI and reference laboratory collection standards for “miscellaneous” specimens.
      - Infection Control: The LA follows all Department infection control policies and uses correct personal protective equipment while performing all duties.
      - Specimen processing for blood samples: The LA understands and follows all recommended sample processing requirements listed for every laboratory test collected.
      - UDS Specimen Processing: The LA follows the CCHCS UDS special handling collection and processing requirements in policy.
      - Specimen Processing for “Miscellaneous” Specimens: The LA understands and follows all recommended sample processing for “miscellaneous” specimens.
      - EHRS Documentation: The LA completes all EHRS documentation correctly and thoroughly.
      - Adverse Outcomes/Patient Safety during Collection Procedures: The LA understands the potential for adverse outcomes when performing a venipuncture and knows how to instruct the patient on post-venipuncture care.
    - Clinical Laboratory Technologists (CLT)
      - Education and training shall be provided within the CLT scope of practice and shall be expected to perform competently. The components of competency include, but are not limited to:
      - Venipuncture Specimen Collection: The CLT understands the correct procedure for venipuncture stated in the CLSI standards for venipuncture specimen collection.
      - UDS Specimen Collection: The CLT understands the policy and procedure for UDS collections.
      - Specimen Collection for “Miscellaneous” Specimen: The CLT understands the CLSI and reference laboratory collection standards for “miscellaneous” specimens.
      - Infection Control: The CLT follows all Department infection control policies and uses correct personal protective equipment while performing all duties.
      - Specimen Processing for Blood Samples: The CLT understands all recommended sample processing requirements listed for every laboratory test collected.
      - UDS Specimen Processing: The CLT follows and understands the CCHCS special handling processing requirements for UDS specimens.
      - Specimen Processing for “Miscellaneous” Specimens: The CLT understands all recommended sample processing for “miscellaneous” specimens.
      - EHRS Documentation: The CLT completes all electronic health record documentation correctly and thoroughly. The CLT demonstrates the ability to perform health records audits for policy compliance. The CLT demonstrates the ability to troubleshoot interface errors by applying critical thinking and problem-solving.
      - Adverse Outcomes/Patient Safety during Collection Procedures: The CLT understands the potential for adverse outcomes when performing a venipuncture and knows how to instruct the patient on post-venipuncture care.
      - Teaching and Competency Assessment: The CLT utilizes the best practice tools for teaching and providing instruction to other Laboratory Services staff.
      - Quality Control Practices: The CLT understands quality control practices and can apply continuous quality improvement measures.
  - Validation Frequency
    - Education and competency validation is conducted every six months within the first year of hire; after the first year, validation may occur annually or as needed based upon:
      - Quality improvement;
      - Performance evaluation;
      - Performance Improvement Plan; or
      - New policies and procedures
    - Competency validation results shall be part of a staff’s performance appraisals.
  - Validator Competency
    - Laboratory Services staff must demonstrate competency before teaching educational trainings and validating the competency of other Laboratory Services staff. Methods to acquire knowledge and/or skills include, but are not limited to:
    - Continuing education programs
    - Review of policies and procedures
    - In-service education
    - Training-for-trainers
    - Simulation exercises
    - Observation/demonstration
  - Competency Validation Methods
    - Competency validation methods used to measure the abilities of an individual for a specific competency standard include, but are not limited to:
      - Tests
      - Observation
      - Case studies
      - Mock events
      - Quality improvement monitors
    - Some competencies may require a combination of validation methods. The Laboratory Services leadership shall determine the validation methods for each competency developed by HQ Laboratory Services.
    - Competency Assessment forms can be found on Lifeline Laboratory Services Resources.
  - Documentation and Tracking
    - A record of Laboratory Services staff member’s competency assessments shall be maintained in their supervisory file, as well as in the competency & education tracking system maintained by the Regional Senior CLT.
References
- California Code of Regulations, Title 15, Division 3, Chapter 1, Subchapter 5, Article 4, Section 3435, In-Service Training
- California Code of Regulations, Title 17, Division 1, Chapter 2, Subchapter 1, Group 2, Article 1.5, Section 1034, Certification of Phlebotomy Technicians
- California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 3, Article 18, General Training
- Clinical Laboratory Improvement Amendments (CLIA)
- CLSI Document: GP4 Ed 7: Collecting Diagnostic Venous Specimens
Revision History
Effective: 05/04/2022
Reviewed: 01/05/2026