The current status and future of medical laboratory quality regulation and accreditation in Ghana

High-quality and reliable laboratory services are important components of effective and well-functioning health systems. Accurate, reliable and timely medical laboratory testing is crucial to patient care and disease surveillance. Unfortunately, in many sub-Saharan African countries, medical laboratory systems are adversely affected by the unavailability of medical laboratories, poor laboratory infrastructure and lack of well-trained personnel [1]. Quality in the laboratory is only achieved in a systematic way through the implementation of a quality management system. The results of the study showed that approximately 60?% of the 78 respondents were unaware of the requirements of ISO 15189:2007. A trial of proficiency testing, termed ??blind proficiency testing??, was carried out in which 19 laboratories determined the concentrations of urea and cholesterol in a proficiency testing material. Of the 19 laboratories that determined the concentration of urea, 63?% produced satisfactory results with scores between ?2 and +2. Similarly, 63?% of the participating laboratories obtained satisfactory z scores for cholesterol determination. Some of the laboratories that obtained satisfactory scores for urea determination had unsatisfactory scores for cholesterol determination and vice versa. It is recommended that the Ghanaian government pass a law and establish a standard to regulate medical laboratories in Ghana in order to improve quality in a significant way.     

Proficiency testing in the light of a new rationale in metrology

The novel proposed definition of measurement result in the international metrology vocabulary requires a revision of standards and guidelines for proficiency testing (PT), and a new approach to processing proficiency data is needed to test the ability of laboratories to present not only unbiased quantity values, but reliable estimates of their uncertainty. Hence, an accepted reference value with the smallest possible uncertainty is needed to ascertain the proficiency of laboratories reporting results with lower than average uncertainty. A strategy based on the T-statistic is proposed leading to an accepted reference value that fully reflects the uncertainties reported by participants in a PT scheme and permits calculation of E _n numbers to distinguish whether or not measurement results are consistent with the accepted definition of the measurand. The strategy is applied to PT data from a recent international laboratory intercomparison of uranium isotopic ratios.     

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     

Lessons from the first international proficiency test for the detection of spores from the honey bee pathogen Paenibacillus larvae

We report on the first proficiency test in the context of honey bee disease testing on a broad international scale. Honey samples were distributed to 12 participating laboratories for isolation and identification of spores of the etiological agent of American foulbrood, Paenibacillus larvae. Of the 11 laboratories responding to this proficiency testing event, only 6 (54%) provided data that were in full agreement with the previously determined status of the honey samples; eight (72%) laboratories fell within the threshold for qualification as defined a priori in this proficiency test (=level of agreement of at least 90%). Some lessons can now be drawn from the organizational point of view and will certainly improve new initiatives to be taken.     

Laboratory assessment by combined z score values in proficiency tests: experience gained through the European Union proficiency tests for pesticide residues in fruits and vegetables

The obligation for accredited laboratories to participate in proficiency tests under ISO 17025, performing multiresidue methods (MRMs) for pesticide residues, involves the reporting of a large number of individual z scores making the evaluation of the overall performance of the laboratories difficult. It entails, time and again, the need for ways to summarise the laboratory’s overall assessment into a unique combined index. In addition, the need for ways to continually evaluate the performance of the laboratory over the years is equally acknowledged. For these reasons, following 14 years of the European Union Reference Laboratory for Pesticide Residues in Fruits and Vegetables (EUPT-FV), useful formulas have been designed to globally evaluate the assessment of the participating laboratories. The aim is to achieve a formula which is easy to understand, which can be applied and which fits the purposes of long-term evaluation detecting positive and negative trends. Moreover, consideration is needed for a fair compensation of bad results in MRM, taking into account the large number of compounds that are covered. It is therefore important to be aware of the difficulties in getting satisfactory values from a wide range of compounds. This work presents an evaluation of the main well-established combined z score formulas together with those new ones developed here which have been applied to the European proficiency test results (EUPTs) over the years. Previous formulas such as the rescaled sum of z score (RSZ), the sum squared of z score (SSZ) and the relative laboratory performance (RLP) are compared with the newer ones: the sum of weighted z scores (SWZ) and the sum of squared z scores (SZ2). By means of formula comparisons, conclusions on the advantages, drawbacks and the most fit-for-purpose approach are achieved.     

水中易释放氰化物能力验证样品的研制及应用

根据国家地表水环境质量监测网监测任务要求和环境监测的实际需要,制备了水中易释放氰化物能力验证样品。通过均匀性、稳定性检验以及量值一致性评价,研制的样品均匀性良好,在3℃~6℃冷藏避光保存条件下1年内稳定,样品配制值与多家实验室协作测定结果一致。探讨了样品在能力验证活动中的应用,共有来自全国11个省的32家实验室参加了水中易释放氰化物的能力验证计划,实验室满意率在80%以上,实验室结果出现有问题或不满意主要是由于样品前处理以及检测过程质量控制不当导致的。经检测及实验室反馈的数据验证,该能力验证样品能够应用于能力验证活动。     

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.     

Reliability of food measurements: the application of proficiency testing to GMO analysis

This paper reviews the experience of the Food Analysis Performance Assessment Scheme (FAPAS^®) in operating a proficiency testing scheme for the analysis of genetically modified (GM) food. Initial rounds of proficiency testing have shown a tendency for laboratories to over-estimate GM levels, results obtained by polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) detection methods to be significantly different and that data are skewed and not normally distributed until log-transformed. During the initial rounds, it was found that for analysis and quantification of GM material, it was not possible to assign a target value for standard deviation external to the round data, from which performance could be assessed. However, when working in a log scale, the internally derived, robust standard deviation (^σ) was found to be constant and could be used directly to predict a target value (σ) for performance assessment. Results from the first four rounds have provided valuable information and a general overview of laboratory ability. Choosing a target value for standard deviation which reflects current best practice has enabled laboratory performance to be assessed. Issues surrounding the assessment of performance are discussed which highlight some of the implications raised as a result of this initial assessment, regarding the enforcement of European labelling legislation.     

Proficiency tests to evaluate commercially available IVD kits for glucose and cholesterol measurements

The first proficiency testing round 630-IL-1002, was carried out with a Reference Material DMR-180a with reference values obtained by using gas chromatography isotope dilution mass spectrometry methods, in which glucose, cholesterol and creatinine were measured. The serum pool was obtained from blood donors and all the analytes were at the normal concentration in Mexican population. The laboratories participants used different field methods to measure the analytes. The Mexican compulsory standard NOM-064-SSA1-1993 “specifications for equipments in vitro diagnostic (IVD)” requests 5% precision and 5% maximum bias of the IVD equipments in the measurements of analytes like glucose and cholesterol. The results obtained by field laboratories in the proficiency testing round are compared to the reference value and uncertainty provided by the National Metrology Institute (CENAM). The quality of measurements is dependent not only on the laboratory competence but also on the methods used by those commercially available IVD kits. It is concluded that quality assessment of measurements in clinical laboratories should be critically evaluated by using stable and certified reference materials. Presented at MEFNM 2008, September 2008, Budapest, Hungary.     

Evaluation of the use of consensus values in proficiency testing programmes

Proficiency testing (PT) is an essential tool used by laboratory accreditation bodies to assess the competency of laboratories. Because of limited resources of PT providers or for other reasons, the assigned reference value used in the calculation of z-score values has usually been derived from some sort of consensus value obtained by central tendency estimators such as the arithmetic mean or robust mean. However, if the assigned reference value deviates significantly from the ‘true value’ of the analyte in the test material, laboratories’ performance will be evaluated incorrectly. This paper evaluates the use of consensus values in proficiency testing programmes using the Monte Carlo simulation technique. The results indicated that the deviation of the assigned value from the true value could be as large as 40%, depending on the parameters of the proficiency testing programmes under investigation such as sample homogeneity, number of participant laboratories, concentration level, method precision and laboratory bias. To study how these parameters affect the degree of discrepancy between the consensus value and the true value, a fractional factorial design was also applied. The findings indicate that the number of participating laboratories and the distribution of laboratory bias were the prime two factors affecting the deviation of the consensus value from the true value.     

Harmonization and transferability of performance assessment: experience from four serum aluminum proficiency testing schemes

Proficiency testing schemes monitor laboratory performance and provide a stimulus for improvement in accuracy. Where several schemes operate in the same analytical sector, there are risks that assessments of performance may be in conflict. Performance assessment for the determination of trace elements such as aluminum in serum is particularly important due to the high risk of contamination and therefore erroneous results. The objectives of this work were (1) to compare several mathematical models to establish a predefined standard deviation for proficiency assessment and (2) to evaluate the influence of instrumental methods and proficiency testing scheme on the assessment of performance for serum aluminum measurements. For this purpose, three samples were sent to the participants of four proficiency testing schemes. Assigned values were calculated according to algorithm A according to ISO 13528 and standard deviation for proficiency assessment according to three methods based on individual variability, state of the art or previous proficiency testing results. The method based on individual variability produced a more stringent standard deviation compared to analytical imprecision based on the state of the art. The instrumental methods gave similar results, whereas significant differences were observed between the four proficiency testing schemes indicating that harmonization of the standard deviation for proficiency assessment fails to allow transferability from one proficiency testing scheme to another and that additional factor(s) contribute to variability in performance assessment.     

Performance indication improvement for a proficiency testing

The paper discusses peculiarities of Z scores and E _n numbers, which are most often used for the treatment of proficiency test data. The important conditions of proper usage of these performance indicators and their improvement are suggested on the basis of systematic approach, on the idea of accuracy classification, and on some principles of optimality borrowed from information theory. The author believes that this paper may be of interest and practical value for all those engaged in applied metrology, specifically in the field of developing of and participating in proficiency testing programs, and in the activity connected with accrediting testing and calibration laboratories.Presented at 15th International Conference on Quality in Israel, November 2004     

Integration of metrological principles and performance evaluation in a proficiency testing scheme in support of the Council Directive 98/83/EC

Proficiency testing as a means of external quality assessment plays the role of independent evidence of laboratories’ performance. To enable laboratories to fulfil the requirements stated in legislation, methodology for evaluation of laboratories’ performance in proficiency testing schemes should incorporate principles of measurement results which are fit for intended use and incorporate evaluation of laboratories’ performances based on independent reference value. A proficiency testing scheme was designed to support Drinking Water Directive (98/83/EC) specifically. The methodology for performance evaluation, which takes into account a “fitness for purpose”-based standard deviation for proficiency assessment, is proposed and discussed in terms of requirements of the Drinking Water Directive. A ζ′-score, modified by application of target uncertainty was developed in a way that fulfils requirements defined in the legislation. As an illustration, results are reported for nitrate concentration in water. The approach presented can also be applied to other fields of measurements.     

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     

Assessment of performance of laboratories in determining acrylamide in crispbread

A proficiency testing round was undertaken to assess the performance of laboratories to measure acrylamide in a sample of crispbread. Retail samples of crispbread were ground to a fine powder and after thorough mixing were packed in 40 g units for distribution. Ten samples were selected at random and analyzed in duplicate for acrylamide by liquid chromatography/mass spectrometry (LC/MS). Standard statistical tests showed that the material was homogeneous for the purposes of proficiency testing. Test samples were distributed to 55 laboratories in 16 countries in Europe, North America, Australia, and the Middle East. The results were analyzed by standard proficiency testing statistical procedures, and laboratories were awarded z-scores on the basis of their reported results. Based on a target standard deviation (sigmap value) taken from the Horwitz equation, for a robust mean value of 1.2 mg/kg acrylamide, satisfactory results (z-score within +/- 2 for those between 0.8 and 1.6 mg/kg) were obtained by 86% of the 37 laboratories that returned results. Only 1 laboratory was unsatisfactory and 4 had questionable results. About equal numbers of laboratories used gas chromatography (GC)/MS and LC/MS procedures with about 25% using MS/MS and one using GC with electron capture detection. There was no evident trend in performance or bias in results. GC/MS and LC/MS data were evenly distributed across the population of laboratories reporting results.     

Advances for proficiency testing for genetic laboratory science

Nucleic acid based clinical genetic testing has undergone explosive growth in recent years due in large part to the human genome project. Characterization of the human genome has led to a molecular understanding of the pathogenesis of many human diseases, and ultimately to clinical molecular tests becoming routinely used to diagnose a wide diversity of diseases. This rapid growth in clinical molecular genetic testing coupled with the complexity of the analytical procedures underscores the necessity for proficiency testing (i.e. external quality assessment) to allow laboratories offering such services the ability to evaluate their analytical procedures via inter-laboratory comparisons. The American College of Medical Genetics (ACMG) in partnership with the College of American Pathologists (CAP) have been offering proficiency testing for clinical molecular genetics laboratories since 1995, and presently have more than 230 laboratories from 11 countries enrolled in this program. This paper describes the evolution of this program and several challenges encountered in the delivery of a proficiency testing program for laboratories offering clinical molecular genetic services. Received: 13 April 2002 Accepted: 18 July 2002     

The application of data from proficiency testing to laboratory accreditation according to ISO 17025

Current methods of testing laboratories for their proficiency in reporting correct measurement results are liable to substantial errors of the second kind. This means that laboratories with deflated uncertainties are accepted as proficient, even though their reported measurement results pave the way for erroneous conclusions. Only by using E _n numbers based on an accepted reference value with the lowest possible uncertainty can the risk of recognising incorrect measurement results be kept at an acceptable level. Based on an actual set of proficiency test (PT)-data for the concentration of Pb in water, this paper compares PT results obtained by methods using E _n numbers with methods based on z-scores. Kaj Heydorn is a technical assessor at The Danish Accreditation and Metrology Fund (DANAK).     

Achieving traceability in chemical measurement—a metrological approach to proficiency testing

ISO/IEC 17025 requires that testing laboratories establish the traceability of their measurements, preferably to the SI units of measurement. The responsibility for establishing traceability lies with each individual laboratory and must be achieved by following a metrological approach.The results of measurements made in such a way are traceable to the standards used in method validation and to the calibration standards used during the measurement process. If these standards are traceable to SI then the measurements will also be traceable to SI.Participation in appropriate proficiency studies (an ISO/IEC 17025 requirement) enables laboratories to demonstrate the comparability of their measurements. If the materials used for the studies have traceable assigned values, then proficiency testing also provides information about measurement accuracy and confirms, or otherwise, that appropriate traceability has been established. This paper will report on a new approach for the establishment of traceable assigned values for chemical testing proficiency studies. The work is conducted at a "fit for purpose" level of measurement uncertainty, with costs contained at a level similar to previous "consensus" based proficiency studies. By establishing traceable assigned values in a cost effective way, NARL aims to demonstrate the added value of the metrological approach to participant laboratories.     

The challenges and benefits of implementing the requirements of ISO/IEC 17043 by PT/EQA providers

ISO/IEC 17043 Conformity assessment??general requirements for proficiency testing is intended to replace previous international guides used to assess the competence of proficiency testing (PT) providers. It expands on the requirements of previous guides and is intended to accommodate PT providers of calibration laboratories and testing laboratories handling both qualitative and quantitative data. QMP-LS is an office-based external quality assessment provider for medical laboratories in Ontario, Canada and operates 46 different PT schemes for approximately 250 diagnostic tests. In 2010, these schemes were accredited to ISO/IEC 17043. Schemes included tests from the following disciplines: chemistry, hematology, microbiology, transfusion medicine, cytology, histology and genetics. Thirty of the schemes were qualitative. The challenges and benefits of implementing ISO/IEC 17043 are discussed, with particular emphasis on clauses addressing the following requirements: statistical design, determination of assigned value, homogeneity and stability testing, packaging, labeling and distribution, performance evaluation and subcontracting services.