Perform staff competency assessments


Accreditation is a proof of competence. Hence an accredited laboratory must have competent staff that can perform all the tasks and responsibilities assigned to them. The competency of the staff must be demonstrated and documented.


Competency can be measured and documented by doing competency assessments. In this process the Laboratory Manager investigates if each staff member is able to correctly and competently perform the tasks and responsibilities assigned to him/her. Several techniques are available for doing competency assessments:

  • Direct observation of the staff member's work
  • Review of worksheets made by the staff member and the laboratory journal of the staff member
  • Assessment of competency in analyzing EQA panels
  • Assessment of skills
  • Assessment of knowledge through examination and asking questions about fictive cases

Another important goal of performing competency assessments is to identify educational needs. The educational background of the staff member must be compared with the tasks he/she must perform. If gaps in the education profile of the staff member are detected, he/she should be sent to the appropriate training (see the activity on assessment of training needs completed in phase 1).

The competency of each staff member must be assessed annually or when a staff member starts performing a new technique: as soon as the formal induction and training period is over (i.e. when the staff member starts performing the test without detailed supervision). Note that the competency of the Laboratory Manager him/herself must be assessed as well. This should be done, if possible, by somebody higher in the hierarchy. In a hospital laboratory the hospital management or an external laboratory expert must perform this assessment.

In the WHO Laboratory Quality Management Systems (LQMS) handbook more detailed information is provided on the procedure of conducting competency assessments.

How & who

Laboratory Manager:

  1. Write an SOP on performing competency assessment following the protocol on writing a Procedure SOP in the Master SOP and use the template for a Procedure SOP attached to the Master SOP. Use the background information provided in the right-hand column for writing the SOP. Also develop a standardized form for recording the findings of the competency assessment. This ensures that nothing is forgotten during the assessments. Add this form as appendix to the SOP.
  2. Perform competency assessments for all the staff members according to the procedures described in the SOP. Compare the tasks and responsibilities described in the job description of each staff member with the educational background of the staff member.
  3. Make reports of the findings of the assessments. Describe the positive findings and the points for improvement. Include a description of the strategy to follow to solve the points for improvement.
  4. Discuss the findings with each staff member. Discuss the points for improvement and how the staff member must work on these.
  5. If the staff member lacks certain competencies, develop a strategy for improvement in discussion with the staff member being assessed.
  6. If training needs were identified: find an appropriate training and search for funds to send this staff member to the desired training.
  7. Store the report of competency assessment in the Personnel File of the staff member (also developed in phase 2).
  8. The competency of the laboratory manager must be assessed as well. See if this is possible in your organization. E.g. when your laboratory is part of a hospital, see if it is possible to be assessed by somebody from the hospital management.

After one year:

  1. Perform the competency assessment again according to the SOP. Before doing this, read the report of the last competency assessment to be able to focus also on the points for improvement found during the previous competency assessment to see if these have improved.

Back to Roadmap Activity Overview
This activity belongs to the QSE Personnel
ISO15189:2007: 4.1.5 4.12.5 5.1.2 5.1.4 5.1.11 5.1.12
ISO15189:2012: 5.1.6