The Competency Time Bomb in Point-of-Care Testing

Walk onto any large acute hospital site and ask a simple question: right now, this minute, exactly who is authorised and currently competent to run a blood gas on that analyser in the emergency department? Not who was trained at some point. Not who attended the roadshow last spring. Who, today, has a valid, in-date competency for that specific device.

In most trusts, nobody can answer that quickly, and a surprising number cannot answer it at all. The information is scattered across a shared spreadsheet, a filing cabinet, a departmental inbox, and the memory of one or two people who happen to be on annual leave. Meanwhile the analyser keeps producing results, and clinicians keep acting on them, because the machine has no idea who is standing in front of it.

This is the quiet blind spot at the heart of point-of-care testing. We have poured effort into device connectivity, quality control rules and result thresholds, and we have left one of its most consequential failure modes almost entirely to goodwill. My argument is blunt. POCT competency is a systems problem, not a training-day problem, and if you cannot show me today, on demand, exactly who is competent to test on each device, you do not have a competency system. You have a filing cabinet.

The arithmetic nobody wants to do

Start with the numbers, because the numbers are where the comfortable assumptions fall apart. POCT looks small when you picture it: a handful of dedicated operators, a friendly coordinator, a couple of devices. That picture was accurate twenty years ago. It is a fantasy now.

Take a real example rather than a made-up one. At the Norfolk and Norwich University Hospitals NHS Foundation Trust, the point-of-care team records over 6,500 registered POCT operators across its device fleet, and that same trust runs in excess of 1,000 POCT glucose tests every single day. That is one trust. The Royal College of Pathologists puts the general case plainly: POCT services routinely train and monitor several thousand users of every grade, from healthcare support workers to consultant clinicians, and at one regional pathology service the fleet alone already exceeds a thousand analysers of twenty-seven different types. Glucose meters live on every ward. Blood gas analysers sit in emergency, theatres, critical care and maternity. Urinalysis, coagulation, HbA1c, infectious disease and pregnancy testing spread the operator base wider still. Every one of those people is an operator who must be trained, assessed and periodically reassessed, and that is what structured POCT training actually has to cover.

Now do the multiplication. Take the 6,500 operators at that one trust. Say each needs reassessment once a year to stay current. Say a proper reassessment, done well, takes forty minutes of a coordinator's time once you include the observation, the record, the follow-up and the inevitable chasing. Forty minutes is my own working figure, so treat it as illustrative, but it is not a generous one. Six and a half thousand operators times forty minutes is more than four thousand hours of coordinator time, every year, on reassessment alone, before you have trained a single new starter.

Four thousand hours is well over two full-time staff doing nothing but reassessment, all year round. Most POCT services do not have two full-time staff spare. They run on one or two coordinators who are also managing connectivity, quality control, audits, procurement, incident investigation and the standing tide of email. The demand does not fit the capacity. It never fitted. We just did not measure it.

And that is the static picture. It ignores the thing that makes POCT competency genuinely unmanageable by hand: churn.

Churn is the real enemy

A hospital is not a stable population of operators. It is a river. Bank staff appear for a single shift. Agency nurses cover a gap and are gone by Friday. And the largest movements of all are scheduled and national: junior doctors rotate on a timetable that empties and refills whole departments at a stroke. In most of the UK those changeovers land on the first Wednesday of August, then again in December and April. The August one is big enough to have earned its own grim nickname on the wards. Return-to-practice nurses, international recruits, students on placement, staff redeployed during a winter surge: every one of them may need to run a test, and almost none of them arrive on your tidy annual anniversary.

The spreadsheet model assumes a world where everyone is assessed on a neat anniversary. Reality is a firehose of arrivals and departures that never pauses. By the time you have updated the sheet for this week's starters, next week's cohort has already tested on devices they were never formally signed off to use, because the ward was busy and the machine let them.

The machine has no idea who is standing in front of it, and in most trusts neither does the record.

This is why "we did a training day" is one of the most dangerous phrases in the whole field. A training day is an event. Competency is a state. Confusing the two is like confusing a wedding with a marriage. The roadshow was well attended, the sign-in sheet is full, and six weeks later half the attendees have moved wards, a third have never touched the device since, and the register proves attendance, not ability. A signature on a sheet is not a demonstration of skill.

Why competency decays, and why nobody notices

Competency is not a permanent acquisition. It decays, and we can now put numbers on how fast. A systematic review of procedural-skill retention after training found that performance declined significantly within three to six months, with falls of up to around fifty per cent by the six-month mark in some groups, and that most of the studies reviewed showed decline over time. The people running your devices sit on that same kind of curve. An operator who was genuinely excellent in March, assessed properly and performing well, will have drifted by the autumn if they use the device rarely, if the workflow changed, if a new lot of strips behaves differently, or if they simply forgot the step that matters. As one POCT specialist put it, competency is gained through task frequency and diminishes over time without it. This is not a moral failing. It is how human skill works.

It is also why the standards insist on reassessment rather than one-off certification. ISO 22870, the old standalone point-of-care standard, has been withdrawn, and point-of-care testing now sits inside the main medical-laboratory standard, ISO 15189:2022. Under it, operators, including non-laboratory staff, must be trained, have their competence assessed, and be reassessed at planned intervals, with lower-volume or less frequent testing generally calling for more frequent reassessment, not less. UK regulators say the same thing in plainer words: the MHRA's guidance is that only staff whose training and competence has been established and recorded should carry out POCT, with continued support and regular updates. None of that is a bureaucratic nicety. It exists because the evidence of decades is that skill fades and error creeps back in, and one of the surest defences, alongside supervision, QC and EQA, is to check again.

Picture competency over time as a sawtooth. Each reassessment resets an operator back up toward full currency, and then it declines until the next check. Managed well, the troughs never fall into dangerous territory. But when a reassessment slips, because the coordinator is stretched, because the operator was on leave, because nobody flagged it, the line keeps falling and crosses into a zone where the person is lapsed but still testing. And here is the point that should keep quality managers awake: nothing stops them.

The device does not lock. The result does not carry a warning. The clinician downstream sees a number, not a competency status. A lapsed operator produces results that look identical to a current operator's, which is exactly why competency lapse is the most quietly dangerous POCT failure there is. It does not announce itself with an alarm. It surfaces, if it surfaces at all, as a subtle drift in quality, a cluster of odd results, an incident review months later that traces back to a hands-on step done wrong by someone whose sign-off expired last spring. And when point-of-care testing does go wrong, the analyser is often not the culprit: an audit of well over a hundred thousand point-of-care tests on three venous-testing platforms found that the great majority of recorded errors traced to the operator and the sample, not the box, and while that is one setting rather than the whole field, it points where the risk tends to sit. Competency is the lever precisely because the human hands are where the risk lives.

The spreadsheet was never going to hold

None of this is a criticism of the people running POCT services. They are, in my experience, some of the most conscientious professionals in the health service, holding a vast operator base together with spreadsheets, reminders and sheer determination. The criticism is of the method. A manual, document-based model cannot scale to several thousand operators churning constantly, and pretending otherwise is how organisations end up exposed.

Consider what the spreadsheet cannot do. It cannot stop a lapsed operator from testing, because it is a passive record, not an active control. It cannot tell you your live compliance position without someone manually counting rows. It cannot distinguish the operator who runs forty tests a day from the one who ran a single test last year, so it treats both as needing the same reassessment on the same schedule, which is simultaneously wasteful and unsafe. It cannot survive the coordinator being off sick, because the knowledge lives partly in their head. And it cannot give you, at an audit or a CQC inspection or an incident review, the one thing that matters: proof, on the day, of exactly who was competent to do what.

A filing cabinet answers the question "can we find a record of training if we look". A competency system answers the question "who is competent, right now, to test on this device". Those are different questions, and only the second one keeps patients safe.

What a real competency system looks like

If the manual model is broken, what replaces it? Not another spreadsheet with more columns. A systems approach, where competency is designed into the way testing happens rather than bolted on afterward. Here is what that means in practice, and what I would push any POCT service to build toward.

• Role-based access and device lockout. The single highest-value change, and the one the standards and the connectivity vendors both point to. If an operator is not current for a specific device, the device should decline to accept them, or the result should be flagged and quarantined. POCT middleware already does exactly this: it holds each operator's training, competency and recertification dates and uses lockout to enforce them. The control has to live at the point of testing, not in a report read weeks later. When lockout is real, lapse stops being a silent risk and becomes an immediate, visible prompt to reassess.
• Competency built into the workflow. Reassessment should be a small, frequent, low-friction event woven into normal work, not an annual ordeal that everyone dreads and defers. Short observed checks, quick knowledge confirmations at the device, and evidence captured as testing happens will always beat a once-a-year marathon that half the workforce misses.
• Train-the-trainer cascades. One or two coordinators cannot personally assess several thousand people. They should not try. Build a network of ward-based or department-based assessors, trained and quality-assured by the POCT team, so competency propagates through the organisation instead of bottlenecking on two individuals. This is the only way the arithmetic ever balances. Our consultancy work almost always starts here, because it is the change that unlocks all the others.
• Risk-based reassessment depth. Not every operator and not every device carries the same risk, and ISO 15189 explicitly expects the frequency of reassessment to follow risk and usage. A high-throughput blood gas in critical care is not a monthly pregnancy test on a quiet ward. Match the depth and frequency of reassessment to the clinical risk and the operator's actual usage, so effort goes where harm is most likely rather than being spread thinly and uselessly across everything.
• Live visibility of current competency. Leadership, quality managers and coordinators should see, at a glance, the real-time compliance position: who is current, who is lapsing this month, which devices have coverage gaps, which wards are drifting. Not a report you commission and wait a fortnight for. A dashboard that is true when you look at it.

Notice what these have in common. Every one of them moves competency from a passive record toward an active control, and from a coordinator's private burden toward an organisational system. That is the whole shift. You can support it with good foundational training and sensible documentation, but the templates and courses are the raw materials, not the machine. The machine is the system that makes competency visible, enforceable and shared.

What to do on Monday

You do not have to fix everything at once. You have to change the questions your service can answer. Here is where I would start.

1. Count your true operator base. Not the ones on the training list. Every person who could physically run a test on a live device this month. The gap between that number and your reassessment capacity is the size of your problem, and you cannot fix a problem you have not measured.
2. Find your lapsed-but-testing population. Cross-reference who is out of date against who has actually run tests recently. If you cannot do this in an afternoon, that itself is the finding, and it tells you your record is a filing cabinet, not a system.
3. Pick one high-risk device and make lockout real on it. Prove the principle somewhere it matters most, then spread it. A single blood gas analyser that refuses lapsed operators teaches the whole organisation what a control feels like.
4. Stand up a train-the-trainer network. Identify credible assessors in each area, train and quality-assure them, and stop trying to do everything centrally. This is the change that makes the arithmetic survivable.
5. Build one honest dashboard. Even a simple, live view of who is current by device and ward changes the conversation with your board from anecdote to evidence, and it turns competency from something you assume into something you can show.

If you want a structured way through this, our consultancy and training programmes are built around exactly this shift, and the resources library has starting points you can use today.

The test that matters

Come back to the question I opened with. Right now, this minute, who is competent to test on that device? A mature POCT service answers instantly, with evidence, because competency is a live, enforced state and not a stack of paper. An exposed service goes quiet, opens a spreadsheet, and starts counting.

The time bomb is not that operators lapse. Operators will always lapse, because skill decays and people move on, and no amount of enthusiasm changes that. The bomb is that most services cannot see the lapse until it has already produced a result someone acted on. Make competency visible and enforceable, and you defuse it. Leave it in the filing cabinet, and you are simply waiting to find out, the hard way, who was never really competent at all.

Sources and notes

The operator numbers here come from a large NHS trust's own published figures. The count of over 6,500 POCT operators is drawn from a Norfolk and Norwich University Hospitals recruitment listing and is corroborated by the Royal College of Pathologists' description of services routinely monitoring several thousand users; the trust's figure of more than 1,000 daily glucose tests is from its own laboratory sciences page. The forty-minute reassessment time in Figure 1 and the steady staff inflow in Figure 2 are my own illustrative working assumptions, labelled as such on the charts; the 6,500 operator count and the August, December and April rotation dates are real. The skill-decay percentages are from a systematic review of procedural-skill retention after simulation training, the best published proxy for how fast hands-on competence fades, and Figure 3's curve shape is illustrative of the mechanism rather than a measured dataset.

1. Norfolk and Norwich University Hospitals NHS Foundation Trust. Point of Care Testing role listing, stating over 6,500 POCT device operators within the trust (recruitment data, 2024).
2. Norfolk and Norwich University Hospitals NHS Foundation Trust. Laboratory sciences and point of care testing, noting more than 1,000 POCT glucose tests run daily.
3. Royal College of Pathologists. Quality assurance principles in point-of-care testing, a pragmatic perspective.
4. Radiometer, Acute Care Testing. Keeping a tight lid on operator and competency management in POC testing, including the fleet scale at Surrey Pathology Services and operator lockout.
5. Legoux and colleagues. Retention of critical procedural skills after simulation training, a systematic review. AEM Education and Training, 2020 (10 studies, 317 participants).
6. International Organization for Standardization. ISO 15189:2022, Medical laboratories, requirements for quality and competence, which now brings point-of-care testing inside the laboratory quality standard.
7. UKAS. Point of care testing accreditation, on the withdrawal of ISO 22870 and transition to ISO 15189:2022.
8. Medicines and Healthcare products Regulatory Agency. Management and use of IVD point of care test devices.
9. Fanshawe and colleagues. Pre-analytical error for three point-of-care venous blood testing platforms in acute ambulatory settings. PLOS One, 2020.