External quality assurance programmes in medical laboratories

 Medical laboratories have a long tradition of external quality assessment. Starting from pure quality control of laboratory performances, most schemes have evolved to a powerful tool for improving quality of clinical outcome of results. External quality assurance in medical laboratories not only includes laboratory performance evaluation, but also evaluation of method performance, post-marked vigilance, training and help. In the future, the quality of programmes must further be improved by accreditation of schemes and by using electronic data interchange. Received: 9 December 2000 Accepted: 14 December 2000     

The establishment of quality systems in veterinary diagnostic testing laboratories in developing countries: experiences with the FAO/IAEA External Quality Assurance Programme

Quality systems, established to internationally accepted standards, are one mechanism that can assist in evaluations of the sustainability of technology transfer, the proficiency of the user, and the reliability and comparability of data generated, resulting in potential enhancement of laboratory credibility. The means of interpreting existing standards and implementing quality systems in developing country veterinary diagnostic laboratories has become a significant adjunct to the technology transfer element within the Food and Agriculture/ International Atomic Energy Agency, FAO/IAEA programme. The FAO/IAEA External Quality Assurance Programme (EQAP) is given as an example for an initial step towards enhancing the “quality” culture in developing country veterinary laboratories. In 1995 the EQAP began as an effort to assure that test results emanating from laboratories using FAO/IAEA ELISA kits for animal disease diagnosis are valid. For this purpose 15 international external quality-assurance rounds have been performed to date for a variety of animal diseases e.g. Rinderpest, brucellosis, trypanosomosis, and foot-and-mouth disease (FMD). Results indicate that the EQAP is a valuable tool in the assessment of both the results provided by, and use of the ELISA kits provided through, the joint FAO/IAEA programme. Furthermore EQAP can assist laboratory diagnosticians to enhance quality control/quality assurance (QC/QA) procedures for conducting FAO/IAEA ELISAs and to advise on the implementation of similar QC/QA procedures in other laboratory activities. Based on the experiences made during the implementation of the EQAP a proposal for establishing a quality system standard was ratified through the World Organization for Animal Health (OIE) general conference in May 2000. The OIE Standard On Management And Technical Requirements For Laboratories Conducting Tests For Infectious Animal Diseases is based on ISO 17025 and provides a clear formula for establishing quality systems in veterinary diagnostic laboratories world-wide.     

Review of European Union requirements: quality standards for food analysis laboratories

 The European Union has prescribed strict quality standards for official food laboratories and the methods of analysis to be used in laboratories when carrying out official food control work. These requirements, which are based on accreditation, participation in proficiency testing schemes and using validated methods of analysis, are described in detail. The similar approach being taken within the Codex Alimentarius Commission is also outlined. The procedures prescribed will ensure that official food control laboratories have in place the measures to ensure that consistently reliable data can be produced. Received: 29 November 1995 Accepted: 8 January 1996     

Detection of genetically modified organisms in food: critical points for quality assurance

 The detection of genetically modified organisms (GMOs) by the polymerase chain reaction (PCR) is a complex multiparameter problem. Therefore, a number of critical issues in respect to quality control need to be considered. For practical purposes, the PCR process itself can be divided into three subprocesses: template isolation and reaction setup (pre-PCR), PCR reaction and detection of amplification products, and data evaluation (post-PCR). Crucial factors for the pre-PCR process are the following: homogeneity of the sample to be analysed, performance of template isolation and purification in terms of yield and purity, standardized process for the estimation of concentrations of genomic DNA and all reagents used in the reaction. For the PCR itself, crucial factors to be controlled are: setup of reactions, batch to batch variations of reagents, temperature-time programs used for the PCR amplification, and the performance of different types of hardware (e.g. different brands of thermocyclers). The crucial factor for the post-PCR process is the detection of the amplification products of the PCR. The tremendous sensitivity of PCR methods requires a careful and consequent separation of the three processes in terms of hardware, laboratory space and sample handling. The avoidance of contamination is one of the most critical factors. The goal of quality assurance measures must be to ensure appropriate results at maximum sensitivity. The complexity of any PCR system used for the detection of GMOs leads to the requirement of a careful validation process for any laboratory using such methods. For qualitative analyses crucial validation parameters are: specificity, selectivity, repeatability, intermediate precision, reproducibility, limit of detection and robustness. Received: 5 October 1998 / Accepted: 22 February 1999     

Key requirements for introducing quality assurance in measurement laboratories

 The implementation of a quality assurance system is fraught with difficulties. However, these difficulties may be overcome if the laboratory uses suitable means to facilitate the process. It is necessary to mobilise the intelligence and energy of all members of the laboratory. In order to command adherence, the project must be shared, and this necessitates a major effort by all concerned. Communication is a major factor in obtaining the support of all parties. Six important steps must be distinguished: – Defining quality policy – Creating awareness, information, training – Creating a quality structure – Establishing a deadline for obtaining accreditation – Progressive implementation – Experimentation and validation. Even if the task of obtaining and maintaining accreditation remains difficult, it clearly promotes a minimum level of organisation and stepwise progress in quality assurance. The laboratory must keep improving its quality system, using European Standard EN 45001 as an effective management model. Received: 9 April 1997 · Accepted: 11 September 1997     

A quality systems approach for identifying and controlling sources of error with point of care testing devices

Historically, due to the size and nature of the instrumentation, highly skilled laboratory professionals performed clinical testing in centralized laboratories. Today’s clinicians demand realtime test data at the point of care. This has led to a new generation of compact, portable instruments permitting ”laboratory” testing to be performed at or near the patient’s bedside by nonlaboratory workers who are unfamiliar with testing practices. Poorly controlled testing processes leading to poor quality test results are an insidious problem facing point of care testing today. Manufacturers are addressing this issue through instrument design. Providers of clinical test results, regardless of location, working with manufacturers and regulators must create and manage complete test systems that eliminate or minimize sources of error. The National Committee for Clinical Laboratory Standards (NCCLS) in its EP18 guideline, ”Quality management for unit-use testing,” has developed a quality management system approach specifically for test devices used for point of care testing (POCT). Simply stated, EP18 utilizes a ”sources of error” matrix to identify and address potential errors that can impact the test result. The key is the quality systems approach where all stakeholders – professionals, manufacturers and regulators – collaboratively seek ways to manage errors and ensure quality. We illustrate the use of one quality systems approach, EP18, as a means to advance the quality of test results at point of care. Received: 26 June, 2002 Accepted: 17 July 2002 Presented at the European Conference on Quality in the Spotlight in Medical Laboratories, 7–9 October 2001, Antwerp, Belgium Abbreviations NCCLS National Committee for Clinical Laboratory Standards (formerly) · POCT point of care testing · QC quality control · HACCP hazard analysis critical control points · CLIA clinical laboratory improvement amendments (of 1988) Correspondence to S. S. Ehrmeyer     

Setting a precedent in international accreditation

 The accreditation procedure that the Department of Laboratory Sciences, CHPPM-Europe underwent is described. The laboratory obtained ISO/IEC 25 accreditation through the American Association for Laboratory Accreditation (A2LA) and the Deutsches Akkreditierungssystem Prüfwesen (DAP) as well as EN 45001 from DAP following the A2LA and DAP joint inspection. The accreditation process and the importance of obtaining national and international accreditation are discussed. Received: 30 May 1997 · Accepted: 16 June 1997     

Is accreditation useful for quality improvement?

 The Laboratory of the Government Chemist (UK) and the Institute for Reference Measurements and Materials (Belgium) evaluated the correlation between accreditation and performance in proficiency tests. It was concluded that accreditation does not have the expected positive effect on the quality of laboratory results. In this journal discussions conducted on this subject during the CITAC workshop at Pittcon in 1998, were published. No satisfactory explanation for this phenomenon was put forward. In this article, it is proposed that the main effect of accreditation is a decrease of intralaboratory spread. The effect on the trueness of laboratory results is not significant due to the lack of certified reference materials and the low frequency of participation in proficiency tests. Proficiency tests cannot be used to find a correlation between accreditation status and quality without changing the set-up of the proficiency test.     

The role of Nordtest in testing and quality assurance

 This article describes on the idea behind Nordtest, the results of its activities and how Nordtest has influenced testing and quality assurance. By financing projects in the field of technical testing Nordtest has been able to utilise the best available Nordic knowledge and resources to respond to Nordic needs and has gained acceptance in all Nordic countries. During Nordtest's 25 years of operation its projects have resulted in over 500 test methods and over 350 technical reports that are widely used both within and outside the Nordic countries. Examples of some project results are given. Important issues in testing and quality assurance are expressed in Nordtest position papers. Nordtest's active participation in the European and global co-operation in testing and quality assurance is also described.     

Total quality management in hematology

 Healthcare is changing and clinical laboratory testing must change with it. In no discipline is this change more profound than in hematology. The principles of total quality management (TQM) including continuous quality improvement, reengineering and strategic planning can facilitate these changes. In the past, hematology has often been exlcuded from these processes due to its many manual procedures and the degree of expertise and skill needed to perform the testing. As automated technology continues to evolve, hematology testing, like other testing, will become integrated into the core, clinical laboratory. We suggest TQM can, and should, guide the way. Received: 15 April 2000 · Accepted: 19 April 2000     

A specific standard for quality in fundamental research

 The specific standard described here constitutes the heart of the quality system set up by the Commissariat à l'Energie Atomique – French Atomic Energy Commission – for its main "Fundamental Research" entity, the Directorate for the Sciences of Matter. It is a coherent standard (set of shared rules and provisions laid out in a clear fashion) designed, in the first instance, to provide those taking part in research, including the hierarchy, with the means to satisfy their requirements in the field of quality. And, secondly, to create the conditions for recognition of this action by third parties, which all research entities must nowadays convince of their trustworthiness (supervisory ministries, research partners, industrial companies, etc.). This standard places particular emphasis on the preponderant roles of initiative and freedom in fundamental research, which are a prerequisite for creativity, innovation and, last but not least, the motivation of personnel.     

The quest for comparability: Calibration 2000

 Most efforts in quality control have been focussed on the reduction of intralaboratory variation and the assessment of interlaboratory variation. Over the last few years, the importance of bias in interlaboratory variation and intralaboratory shifts has become clear. Small shifts can sometimes have a large impact on the number of treated patients, particularly in assays where cut off values are used. For example in cholesterol, HDL-cholesterol, HbA1c and TSH assays. There is an obvious need for adequate calibration material. However, the process of development of international primary reference materials and reference methods takes time, and even if reference materials exist and are used by in vitro diagnostics manufacturers, there still remains significant and clinically relevant interlaboratory variance and intralaboratory shifts, as is seen, e.g. in protein chemistry. The harmonization of inter laboratory and intralaboratory results needs an impulse from professional organizations to convince individual laboratories of the importance and significance of bias. This applies to all subdisciplines of laboratory medicine. On the occasion of the 25th anniversary of the Foundation for External Quality Assessment (SKZL), a large interdisciplinary harmonization project called Calibration 2000 was launched in The Netherlands The strategy and first results are reported in this paper. The project aims at harmonization of laboratory data of several disciplines, using secondary calibration materials, leading to common reference ranges throughout The Netherlands. Received: 15 April 2000 · Accepted: 15 April 2000     

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     

Sense and nonsense of quality assurance in an R&D environment

Quality has always been one of the key issues in laboratories in general and formal quality assurance (QA) in testing laboratories has gained popularity over the last decade. However, the implementation QA in research and development (R&;D) laboratories is still the domain of a few pioneers. We can even ask whether a QA system in research makes sense at all and if such a system really provides any added value? Difficulties with respect to the implementation of such a system are mainly associated with the nature of the research process itself. However, it is obvious that QA offers clear advantages in R&;D, if some critical success factors have been taken into account. An important issue is the selection of a good QA standard for R&;D. This is certainly not an easy task, since there are no specific standards. Fortunately, some useful international guides have been published recently.     

Quality assurance programs for countries in need: a global view from the College of American Pathologists

Providing laboratory external quality assessment (EQA) programs for countries in need requires special considerations not ordinarily part of EQA for laboratories in industrialized countries. Cultural, professional, service and economic factors must be understood and accommodated in order to carry out successful programs. Coordination of worldwide efforts for countries in need requires more resources and planning than have thus far been devoted to the enterprise.     

Need for quality management in research and development

 There is growing interest in setting up a general concept for quality management and quality control in research and development, which in this case means, for example, research in the fields of medicine and social sciences. This article is a strong plea for a quality management system in all fields of research and development and will probably initiate broad discussion on this delicate topic. Received: 28 June 1998 · Accepted: 13 July 1998     

Quality assurance for the analytical data of micro elements in food

The micro element content of food is an important quality index due to the action of these elements on human health. In this article, we discuss how to ensure the reliability of analytical data on micro elements in order to truly represent the condition of food. Sampling, treatment of the analytical sample, selection of the analytical method, standard solution, and certified reference material, blank test, calibration of the instrument and equipment, application of the quality control chart, assessment of the final analytical result, and quality assurance system are briefly described. Received: 5 July 2001 Accepted: 19 November 2001     

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.