Anti-HIV quality assurance programs in Australia and the southeast Asian and Western Pacific regions

Anti-HIV testing is the most regulated area of laboratory medicine in Australia. These regulations have placed the National Sero-logy Reference Laboratory, Australia (NRL) in a unique position to implement a comprehensive quality assurance (QA) program for HIV testing. The elements of our QA program include pre-market evaluation of assays, external quality assessment schemes (EQAS), quality control, specificity monitoring, consultations, and training workshops. The results of the NRL EQAS for Australian laboratories were compared with those of a program developed by the NRL for reference laboratories in the Southeast Asian and Western Pacific (SEAWP) regions. For laboratories authorized to use tests for HIV in Australia, participation in the entire QA program is mandatory, whereas the SEAWP EQAS program is voluntary. While the overall percentage of discrepant results for these programs are similar, the percentage of false negatives, variation in laboratory results, and choice of assay differ. These differences have decreased with time with improvements in assays and laboratory testing practices. The educational component of both EQAS, which comprises workshops, laboratory questionnaires, consultancies, and newsletters, has had a critical impact on the testing practices of laboratories. Received: 30 October 2000 Accepted: 9 December 2000     

Experience with in-house PT-schemes in the chemical industry

There are many different means of demonstrating the quality of performance of an analytical laboratory. Proficiency testing (PT) is just one! As in other analytical fields, interlaboratory comparisons play an important role in the chemical industry. Collaborative trials or method performance studies do have a long tradition in this field. Sometimes they were designed as laboratory performance studies with the clear aim of making analytical results comparable, e.g. petrol, coal, gas, noble metals analyses – not to mention the biggest PT scheme run on a daily world-wide basis – trade itself. All this is an ongoing process, which started long before the idea of assessing and accrediting the performance of analytical laboratories was born. However, when striving for accreditation in 1996, the analytical production laboratories of the Chemicals Business Unit of the Bayer AG in Germany implemented another facet of PT schemes. In-house-PT schemes are performed regularly and turned out to be useful in evaluating, monitoring, and thus improving, the quality of routine analytical work. Received: 5 December 2000 Accepted: 15 January 2001     

An inter-laboratory comparison study for the determination of copper and lead from the wastewater of printed circuit board manufacturing industry in Pakistan

This inter-laboratory comparison study was arranged for 28 laboratories from different public and private sector organizations in Pakistan having wastewater testing capabilities aimed at improving the quality and comparability of test results. This national inter-laboratory study was started in December 2003 and completed in July 2004. Laboratories were invited to analyze the wastewater collected from printed circuit board (PCB) industry for lead and copper contamination. The samples fulfill the criteria for homogeneity and stability as done by the reference laboratory. The results obtained from participating laboratories were analyzed in terms of Hampel Test for outliers, while the performance evaluation of the participating laboratories was done on the basis of Z-score. An assigned value derived from the participant's results was compared with a reference value provided by a reference laboratory. Overall >50% of the participating laboratories have shown good performance in this PT-program     

Quality issues in proficiency testing

 Proficiency testing is a means of assessing the ability of laboratories to competently perform specific tests and/or measurements. It supplements a laboratory's own internal quality control procedure by providing an additional external audit of their testing capability and provides laboratories with a sound basis for continuous improvement. It is also a means towards achieving comparability of measurement between laboratories. Participation is one of the few ways in which a laboratory can compare its performance with that of other laboratories. Good performance in proficiency testing schemes provides independent evidence and hence reassurance to the laboratory and its clients that its procedures, test methods and other laboratory operations are under control. For test results to have any credibility, they must be traceable to a standard of measurement, preferably in terms of SI units, and must be accompanied by a statement of uncertainty. Analytical chemists are coming to realise that this is just as true in their field as it is for physical measurements, and applies equally to proficiency testing results and laboratory test reports. Recent approaches toward ensuring the quality and comparability of proficiency testing schemes and the means of evaluating proficiency test results are described. These have led to the drafting of guidelines and subsequently to the development of international requirements for the competence of scheme providers. Received: 2 January 1999 · Accepted: 7 April 1999     

Proficiency evaluation as a traceability link in chemical metrology

Traceability implies comparison of the results of measurements, or comparison to national or international measurement standards. One of several approaches that have been used in chemistry to provide for such comparisons is distribution of proficiency evaluation materials which have been measured by a reference laboratory. A newer approach is based on receipt and measurement at a reference laboratory of materials that have been produced and analyzed by other laboratories. Traceability concepts and approaches to realization will be described together with discussion of the relative merits of various approaches. Extension into metrological fields other than chemistry will also be explored. Received: 14 November 2000 Accepted: 11 December 2000     

Performance evaluation for proficiency testing with a limited number of participants

Proficiency testing (PT) is an essential tool for laboratories to assess their competency. Also, participation in PT has become one of the mandatory requirements for laboratory to seek accreditation according to ISO/IEC 17025. For this reason, the effectiveness of performance evaluation by PT scheme is of great concern for the participants and for accreditation bodies as well. In practice, owing to unavailability of other appropriate alternatives, PT scheme providers may have to choose using consensus values to evaluate the performance of participants. However, such consensus values approach was not recommended by relevant international guidelines for PT schemes with limited number of participants. With the use of Monte Carlo simulation technique, this study attempted to investigate the effectiveness of using consensus values for performance evaluation in PT schemes with limited number of participants. The simulation process was schemed according to the statistical model provided by ISO 5725-1 for laboratory measurement results, which covered components like method bias, laboratory bias, and measurement precision. The effectiveness of the consensus value approach was expressed as the percentage of participants in a simulation run could get the same evaluation result, either satisfactory or unsatisfactory, against the “true value.” The findings indicated that the number of participants, choice of consensus values, mass fraction of analyte, method bias, laboratory bias, and measurement repeatability of participating laboratories would all affect the effectiveness of the consensus value approach but at different extent. However, under certain circumstances, use of consensus value could still be considered as an acceptable approach for performance evaluation even the number of participants was limited. Some of the findings were further verified using real data from PT schemes where appropriate certified reference materials or reliable reference values were available.     

Basic steps towards a self-sustainable quality system and laboratory accreditation

 Laboratory managers are facing the task of altering the attitudes of themselves and their employees in order to implement a quality lifestyle, which is the prerequisite for successful implementation of a quality system complying with appropriate international standards. The alterations require a painstaking and constructive approach. Not all laboratories have the resources to secure the assistance of quality consultants. For those laboratory managers who have to find their way towards quality management on their own, some recommendations are given for a path towards a self-sustaining quality system. Several practical aspects of the basic steps in this path, which starts with assessing the current status of the laboratory and is followed by awareness building, are discussed. The recommendations are derived from the experience of the authors in their own laboratories. Received: 5 June 1997 · Accepted: 7 December 1997     

Twenty years of the Me.Tos. Project: an Italian national external quality assessment scheme for trace elements in biological fluids

The Me.Tos. Project, started in 1983 and still running, is an external quality assessment (EQA) scheme for laboratories performing specialized analyses in occupational and environmental laboratory medicine. Besides the organization of EQA exercises, initiatives for further education of the participants and the harmonization of EQA procedures at a European level are carried out. Participation in EQA schemes allows laboratories to comply with the international standards for the quality and competence of testing and clinical laboratories. The organization of the scheme includes the preparation of control materials, their distribution to the participants, according to strategies aimed to avoid identification of the samples, the statistical analysis of the results and the evaluation of laboratories' performance according to international guidelines and criteria set by the organizers. An overview of the scheme operation and the current performances of participants will be given.     

Metrology in laboratory medicine – Reference measurement systems

 The medical laboratory must provide results of measurements that are comparable over space and time in order to aid medical diagnosis and therapy. Thus, metrological traceability, preferably to the SI, is necessary. The task is formidable due to the many disciplines involved, the high production rate, short request-to-report time, small sample volumes, microheterogeneity of many analytes, and complex matrices. The prerequisite reference measurement systems include definition of measurand, unit of measurement (when applicable), consecutive levels of measurement procedures and calibrators in a calibration hierarchy, international organizations, reference measurement laboratories, dedicated manufacturers, written standards and guides for the medical laboratory, production of reference materials, internal and external quality control schemes, and increasingly accreditation. The present availability of reference measurement procedures and primary calibrators is shown to be insufficient to obtain international comparability of all types of quantity in laboratory medicine. Received: 19 April 2000 / Accepted: 3 July 2000     

Requirements vs acceptability in proficiency testing schemes and other interlaboratory comparisons

Many laboratories take part in proficiency testing schemes, external quality assessment programmes and other interlaboratory comparisons. These have many similarities but also important differences in their modus operandi and evaluation of performance of participating laboratories. This paper attempts to highlight both the similarities and differences. It also puts particular emphasis on requirements called ”target values for uncertainty” and their meaning. Received: 24 January 2001 Accepted: 25 January 2001     

Proficiency testing schemes for therapeutics and toxicology

 This report addresses the proposition: current proficiency testing (PT) schemes for therapeutics and toxicology can easily engender complacency. The proposition was based on the premise that there are substantial between-laboratory differences and objectives in the supply of services for the measurement of drugs, as a result of which it is difficult to design PT schemes which adequately cover the requirements of all laboratories. Thus, acceptable performance in a PT scheme may lead participants to consider that they have tested their procedures more rigorously than is the case. Four areas, validity of the PT scheme, PT material, frequency of testing and acceptance criteria are examined. Received: 15 April 2000 · Accepted: 15 April 2000     

Quality specifications for evaluation and comparison of performance among external quality assessment schemes in occupational and environmental laboratory medicine

Quality specifications (QS) are proposed for lead in blood and for aluminium, copper, selenium and zinc in serum as part of the aim to set standards of performance for laboratories so that results can be demonstrated to be fit for the purpose to which they are applied. The QS were established taking account of the analytical state-of-the-art, physiological variations in the concentrations of the analyte and the clinical purpose for which the assay is to be used. A procedure was devised that uses these QS to give equivalence of assessment among external quality assessment schemes (EQAS), thus avoiding conflicting information which has been demonstrated in the past. Advantages of this procedure are: to provide direct comparison of performance of laboratories taking part in different schemes, to provide equivalence of assessment of laboratory performance necessary to establish mutual recognition agreements, and to demonstrate the fitness for purpose of results from participants.Presented at the Eurachem PT Workshop September 2005, Portorož, Slovenia     

External quality assessment schemes for clinical analysis in Russia

 The history and the present condition of external quality assessment (EQA) schemes for clinical laboratories in Russia are described briefly. The creation of EQA programmes started in Russia in the 1980s. Now almost 20 years later these schemes have been transformed. The National External Quality Assessment Scheme ensures quality control in the clinical chemistry sector (more than 2000 laboratories) and is the most powerful scheme in Russia. The (Sistema Vneshnego Kontrola Katchestva, *) (BKK) system, covering about 120 Russian laboratories, and a lot of local regional programmes (mainly in Siberia), is also very active. The purposes and design of the operating programs, reference materials used, algorithms of estimation, modes of result representation and development prospects are considered. The basic obstacle to the development of EQA schemes in Russia is financial restriction.     

The correlation of laboratory performance in proficiency testing with other QA characteristics

Although it seems self-evident that proficiency testing (PT) and accreditation can be expected to improve quality, their relative benefits remain uncertain as does their efficacy. The study reported here examines the following issues: (a) Why do laboratories take part in PT schemes? (b) How does participation in PT fit in with a laboratory's overall quality assurance (QA) system? (c) Is there a link between a laboratory's performance in specific PT and it's QA system? (d) How does PT performance change with time and how do laboratories respond to poor performance? The overall conclusion is that there is no evidence from the present study that laboratories with third-party assessment (accreditation and certification) perform any better in PT than laboratories without. The validity of this conclusion and its significance for the future design and operation of such schemes requires further investigation. In particular, study is required of the degree to which good performance in open PT correlates with blind PT performance, where laboratories are not aware that the samples being analysed are part of a quality assessment exercise.     

The Swiss External Quality Assessment Scheme in Bacteriology and Mycology 1992–1996

 The Swiss External Quality Assessment Scheme in Bacteriology and Mycology was created in 1980 and has been organised since 1983 by the Department of Medical Microbiology in Zurich. The number of Swiss participants has steadily risen from 66 in 1989 to 92 in 1996. Twelve bacterial and fungal strains are sent to the participants in four despatches, each containing three specimens, per year. Scores are allocated per specimen and range between 0 and 1. Participants with mean scores of ≤0.75 are considered poor performers. The mean scores increased from 0.85 in 1992 to 0.91 in 1996. This improvement can be attributed to the educational effect of the external quality control scheme, since all participants receive a detailed discussion for each specimen together with their individual results. On average, both large University and Cantonal (state) laboratories as well as private laboratories show satisfactory performance. In particular, laboratories officially recognised by the Swiss Federal Office of Public Health (SFOPH) rate better than non-recognised participants. Many small regional hospital laboratories, most of them not SFOPH-recognised, are often among the poor performers. They are often managed by technical staff and lack a trained microbiologist. The recently introduced legislation in Switzerland renders participation in external quality assessment schemes compulsory, and all clinical microbiology laboratories are required to employ qualified microbiologists. This will certainly help to improve the quality standards of all laboratories performing microbiological tests. Received: 13 November 1997 · Accepted: 28 December 1997     

An error model for evaluation and interpretation of proficiency testing

Data from proficiency testing can be used to increase our knowledge of the performance of populations of laboratories, individual laboratories and different measurement methods. To support the evaluation and interpretation of results from proficiency testing an error model containing different random and systematic components is presented. From a single round of a proficiency testing scheme the total variation in a population of laboratories can be estimated. With results from several rounds the random variation can be separated into a laboratory and time component and for individual laboratories it is then also possible to evaluate stability and bias in relation to the population mean. By comparing results from laboratories using different methods systematic differences between methods may be indicated. By using results from several rounds a systematic difference can be partitioned into two components: a common systematic difference, possibly depending on the level, and a sample-specific component. It is essential to distinguish between these two components as the former may be eliminated by a correction while the latter must be treated as a random component in the evaluation of uncertainty. Received: 20 November 2000 Accepted: 3 January 2001     

Quality management, certification and accreditation in medical laboratories – the view of ECLM

 Increasing demands from health care planners and industrialists conducting clinical trials, as well as general competition, are forcing medical laboratories to seek third-party recognition of their quality management systems. There is a tendency to move from certification of a laboratory director, via certification of the laboratory quality system (ISO 9000 family), to accreditation needing proof of professional and technical competence in laboratory tasks. The requirements of accreditation are presented in several national schemes and in the European Standards series (EN 45 000) and the International Organization for Standardization's guide, ISO/IEC 25, to be amalgamated soon. The latter system provides transnational recognition through participation of the accrediting bodies in the European co-operation for Accreditation. Necessary supplementary guidelines exist for chemical laboratories (Eurachem) and medical laboratories CEAC/ECLM). Traceability and reliability of results are obtained by utilizing a global reference examination system and by participating in transdisciplinary work. The costs of achieving accreditation are considerable and mainly involve the production of quality handbooks and written work procedures by personnel. The rewards are an open system, smoother work, emphasis on prevention of mistakes, and satisfied stakeholders. Received: 5 October 1998 · Accepted: 20 October 1998     

Accreditation of proficiency-testing schemes in The Netherlands

Proficiency testing by laboratories, national accreditation bodies, and other third parties is becoming more and more considered as a standard and integral part of the quality control system. Therefore, it is of utmost importance that the quality of the provided proficiency-testing (PT) service is outstanding. If PT-schemes are set up in order to help laboratories monitor and improve their quality, PT-schemes need not only be of high quality themselves, but the organizer also needs to be able to demonstrate this. In The Netherlands formal accreditation of the organization of proficiency testing schemes is used as a tool to guarantee high quality schemes and also to enable organizers to demonstrate their competence. Since 1996, the Dutch Council for Accreditation (RvA) has used the ISO-Guide 43–1 to assess PT-organizers in The Netherlands. From January 2000, the ISO-guide 43–1 was replaced by the ILAC G13 document for assessing organizers. Up till now, four institutes have been accredited by the RvA for the organization of PT-schemes.     

The Italian way: Accreditation and continuous quality improvement in clinical laboratories

 The transition from quality assurance of the analytical phase to the quality management of total testing in clinical laboratories is still at an early stage. But it has begun. Accreditation through voluntary, educational and professional schemes, like the Clinical Pathology Accreditation scheme, is a useful tool for following defined standards of practice and having these independently confirmed on the basis of a peer review. Approved clinical laboratories can obtain a hallmark of performance and offer reassurance to users of their services. However, accreditation does not guarantee an error-free service; it is not the final step, but an important stage in the improvement process. Quality is a journey and continuous quality improvement is the paradigm for better addressing our efforts to satisfy customers' expectations for the desired health outcomes related to a high-quality laboratory service.     

Regular participation in proficiency testing provides long term improvements in laboratory performance: an assessment of data over time

Data from various proficiency testing schemes, operated by LGC Standards, was collated and reviewed to determine whether regular involvement within third party, proficiency testing, either over a prolonged period of time or via multiple participation, had improved the performance of those laboratories taking part. Three statistical evaluations were applied to historical PT results, a review of improvements over time, demonstrated by the evaluation of satisfactory performance scores achieved, a review of the relative robust standard deviations obtained from multiple methods and a focused review of one analyst participating in proficiency testing over a prolonged period of time. In each case the data indicated that long term participation and evaluation via proficiency testing had resulted in consistent and sustained improvements in laboratory performance.