Defining a roadmap for harmonizing quality indicators in Laboratory Medicine: a consensus statement on behalf of the IFCC Working Group "Laboratory Error and Patient Safety" and EFLM Task and Finish Group "Performance specifications for the extra-analytical phases"

Comprehensive assessment of medical laboratory performance: a 4D model of quality, economics, velocity, and productivity indicators

Laboratory diagnostics play a crucial role in modern medicine and healthcare economics. The effective management of a medical laboratory is based on reliable assessment of indicators characterizing quality of testing, productivity, velocity (speed) and cost-effectiveness. The usual concepts of laboratory management focus on one or two groups of these indicators and exclude a comprehensive assessment of the effectiveness of a medical laboratory. Various guidelines and concepts (ISO, Lean, Six Sigma, etc.) often provide similar approaches but use different terms. This review discusses common options for performance indicators in medical laboratories, as well as practical experience in using these indicators to assess the overall effectiveness of the laboratory and improve medical care for patients. All indicators were divided into four broad groups: quality, economy, velocity, and productivity. Based on these four groups, we describe the new" four-dimensional model" for assessment of medical laboratory performance based on different combinations of indicator groups for different types of laboratories.

Establishing, evaluating and monitoring analytical quality in the traceability era

Poor analytical quality may be the bane of medical use of laboratory tests, and the fight against excessive analytical variability presents a daily struggle. Laboratories should prioritize the perspectives and needs of their customers (the patients and healthcare personnel). Among them, comparability of results from the same patient sample when measured by different laboratories using different in vitro diagnostic (IVD) medical devices is a logical priority to avoid result misinterpretation and potential patient harm. Harmonization (standardization) of laboratory measurements can be achieved by establishing metrological traceability of the results on clinical samples to stated higher-order references and providing an estimate of the uncertainty of measurement (MU). This estimate should be based on an MU budget including all known MU contributions generated by the employed calibration hierarchy, which in turn should be validated against fit-for-purpose maximum allowable MU derived according to internationally recommended models. In this report, we review the available strategies for establishing, evaluating, and monitoring analytical quality, drawing on three decades experience in the field. We discuss the most important aspects that may influence obtaining and maintaining analytical standardization in laboratory medicine, and offer practical solutions aimed at educating all stakeholders for the achievement of harmonized laboratory results. To fully implement the recommended approaches, all involved parties-i.e. reference providers, IVD manufacturers, medical laboratories, and External Quality Assessment organizers-must agree on their importance and enhance their specific knowledge.

Quality indicators for urine sample contamination: can squamous epithelial cells and bacteria count be used to identify properly collected samples?

OBJECTIVES

To evaluate urinalysis parameters useful for identifying mixed cultures in urine culture using an automated urinary particle analyzer to assess quality indicators (QIs) for urine sample contamination.

METHODS

A retrospective observational cross-sectional study was conducted with 2,527 urine samples from patients of a quaternary hospital in Brazil. Urine samples were processed simultaneously in Sysmex UF-5000 flow cytometry analyzer (urinalysis) and MALDI-TOF (culture).

RESULTS

For all samples, a cutoff of 123.8 bacteria/µL was established to discriminate culture-negative specimens. ROC curve indicated the following cutoffs for females and males, respectively: 193.65 and 23.55 bacteria/µL, and 21.35 and 5.05 squamous epithelial cells (SEC)/µL, with the latter two related to scenarios of sample contamination/colonization through mixed cultures. Performing univariate logistic regression, we found a 2.78 (CI95 %: 2.12-3.65) times higher chance of probable mixed culture when SEC values were above the cutoffs for each sex, and 6.91(CI95 %: 4.56-10.47) times for bacteria. For multivariate logistic regression, the OR values were 1.62 (CI95 %: 1.21-2.15) and 5.82 (CI95 %: 3.77-8.98), respectively.

CONCLUSIONS

The fluorescent flow cytometry analyzers could efficiently identify urinary bacteria counts associated with contamination/colonization scenarios using the cutoffs of 21.35 SEC/µL for women and 5.05 SEC/µL for men. The cutoffs for bacteria/µL (193.65 for females and 23.55 for males) indicated that the presence of bacteria in male samples may be more associated with urinary tract infections (UTIs), while in female samples, it may be associated with either UTIs or contamination/colonization scenarios. This makes the analyzer a helpful tool as QI of sample contamination in urine cultures.

Exploring the extent of post-analytical errors, with a focus on transcription errors - an intervention within the VIPVIZA study

OBJECTIVES

We examined the magnitude of transcription errors in lipid variables in the VIPVIZA study and assessed whether education among the research personnel reduced the error frequency at follow-up. We also examined how the errors affected the SCORE2 risk prediction algorithm for cardiovascular disease, which includes lipid parameters, as this could lead to an incorrect treatment decision.

METHODS

The VIPVIZA study includes assessment of lipid parameters, where results for total cholesterol, triglycerides, HDL cholesterol, and calculated LDL cholesterol are transcribed into the research database by research nurses. Transcription errors were identified by recalculating LDL cholesterol, and a difference>0.15 indicated a transcription error in any of the four lipid parameters. To assess the presence of risk category misclassification, we compared the individual's SCORE2 risk category based on incorrect lipid levels to the SCORE2 categories based on the correct lipid levels.

RESULTS

The transcription error frequency was 0.55 % in the 2019 VIPVIZA research database and halved after the educational intervention to 0.25 % in 2023. Of the 39 individuals who had a transcription error in total or HDL cholesterol (with the possibility of affecting the SCORE2 risk category based on non-HDL cholesterol), six individuals (15 %) received an incorrect risk category due to the error.

CONCLUSIONS

Transcription errors persist despite digitalisation improvements. It is essential to minimise transcriptions in fields outside the laboratory environment, as we observed that critical decisions also rely on accurate information such as the SCORE2-risk algorithm, which is dependent on lab results but not necessarily reported by the laboratory.

The surveys on quality indicators for the total testing process in clinical laboratories of Fujian Province in China from 2018 to 2023

OBJECTIVES

This study investigates the application of 15 Quality Indicators (QIs) in clinical laboratories in Fujian Province, China, from 2018 to 2023. It identifies the main causes of laboratory errors and explores issues in the application of QIs, providing a reference for establishing provincial state-of-the-art and operational quality specifications (QSs).

METHODS

All clinical laboratories in Fujian Province were organized to submit general information and original QIs data through the online External Quality Assessment (EQA) system of the National Clinical Laboratory Center (NCCL) for a survey of 15 QIs. Data from 2018 to 2023 were downloaded for statistical analysis, and the current QSs for the 15 QIs in Fujian Province were compared and analyzed with those published by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Working Group on Laboratory Errors and Patient Safety (WG-LEPS).

RESULTS

QIs data from 542 clinical laboratories were collected. The survey on data sources showed that the number of laboratories recording QIs data using Laboratory Information Systems (LIS) increased annually, but the growth was modest and the proportion was less than 50 %. Among the laboratories using LIS to record QIs data, 133 continuously participated in this survey for six years, reporting different QIs. Over the six years, all reported QIs showed significant improvement or at least remained stable. The best median Sigma (σ) metrics were for the percentage of critical values notification and timely critical values notification, reaching 6σ, followed by the percentage of incorrect laboratory reports, with σ metrics ranging from 4.9σ to 5.1σ. In contrast, the percentage of tests covered by internal quality control (IQC) (1.5σ-1.7σ) and inter-laboratory comparison (0.1σ) remained consistently low. Compared to the QSs published by IFCC WG-LEPS, the QSs for the 15 QIs in Fujian Province in 2023 were stricter or roughly equivalent, except for the percentage of incorrect laboratory reports (Fujian Province: 0-0.221, IFCC WG-LEPS: 0-0.03).

CONCLUSIONS

1. The application of QIs has significantly improved the quality of testing in clinical laboratories in Fujian Province, but the percentage of tests covered by IQC and inter-laboratory comparison remain low; 2. Effective application of QIs requires the establishment of comprehensive LIS, unified calculation standards, and other supporting measures.

Improving regional medical laboratory center report quality through a report recall management system

OBJECTIVES

Currently, most medical laboratories do not have a dedicated software for managing report recalls, and relying on traditional manual methods or laboratory information system (LIS) to record recall data is no longer sufficient to meet the quality management requirements in the large regional laboratory center. The purpose of this article was to describe the research process and preliminary evaluation results of integrating the Medical Laboratory Electronic Record System (electronic record system) laboratory report recall function into the iLab intelligent management system for quality indicators (iLab system), and to introduce the workflow and methods of laboratory report recall management in our laboratory.

METHODS

This study employed cluster analysis to extract commonly used recall reasons from laboratory report recall records in the electronic record system. The identified recall reasons were validated for their applicability through a survey questionnaire and then incorporated into the LIS for selecting recall reasons during report recall. The statistical functionality of the iLab system was utilized to investigate the proportion of reports using the selected recall reasons among the total number of reports, and to perform visual analysis of the recall data. Additionally, we employed P-Chart to establish quality targets and developed a "continuous improvement process" electronic flow form.

RESULTS

The reasons for the recall of laboratory reports recorded in the electronic recording system were analyzed. After considering the opinions of medical laboratory personnel, a total of 12 recall reasons were identified, covering 73.05 % (1854/2538) of the recalled laboratory reports. After removing data of mass spectra lab with significant anomalies, the coverage rate increased to 82.66 % (1849/2237). The iLab system can generate six types of statistical graphs based on user needs, including statistical time, specialty labs (or divisions), test items, reviewers, reasons for report recalls, and distribution of the recall frequency of 0-24 h reports. The control upper limit of the recall rate of P-Chart based on laboratory reports can provide quality targets suitable for each professional group at the current stage. Setting the five stages of continuous process improvement reasonably and rigorously can effectively achieve the goal of quality enhancement.

CONCLUSIONS

The enhanced iLab system enhances the intelligence and sustainable improvement capability of the recall management of laboratory reports, thus improving the efficiency of the recall management process and reducing the workload of laboratory personnel.

Sigma metric analysis of quality indicators across the testing process as an effective tool for the evaluation of laboratory performance

Background

Laboratories across the world are successfully using quality indicators (QIs) to monitor their performance. We aimed to analyze the effectiveness of using the peer group comparison and statistical tools such as sigma metrics for periodic evaluation of QIs and identify potential errors in the preanalytical, analytical, and postanalytical phases.

Methods

We evaluated the monthly QIs for 1 year. A total of 11 QIs were evaluated across the three phases of the total testing process, using percentage variance, and sigma metric analysis.

Results

Our study observed that based on sigma metric analysis, the performance was good for all the QIs except for the number of samples with the inappropriate specimen hemolyzed samples, clotted samples, and turnaround time (Sigma value < 3). The percentage variance of QIs in all the phases was plotted in a Pareto chart, which helped us in identifying turnaround time and internal quality control performance are the key areas that contribute to almost 80% of the errors among all the QIs.

Conclusion

Laboratory performance evaluation using QIs and sigma metric analysis helped us in identifying and prioritizing the corrective actions in the key areas of the total testing process.

Characterization of add-on testing before and after automation at a core laboratory

Objectives

Add-on testing refers to the process that occurs in clinical laboratories when clinicians request that additional tests be performed on a previously analysed specimen. This is a common but inefficient procedure, highly time-consuming, especially at core laboratories and could be optimised by automating these procedures. The aims of this study are: 1) To describe patterns of add-on testing at a core laboratory at a tertiary hospital, 2) To evaluate turnaround time (TAT) before and after automation of the pre-, post- and analytical phases.

Methods

Retrospective, observational study conducted at the biochemistry area of a core laboratory of all add-on orders received in two different months (pre-automation and post-automation).

Results

A total of 2464 add-on orders were analysed, representing around 5 % of total requests. Most orders were for either one (>50 %) or two (≈20 %) tests. Most orders were received during the week (from Monday to Friday), particularly during the morning shift (>50 %). More than 50 % of requests were made by the Emergency Department. The two most common add-on parameters were C-reactive protein and N-terminal pro-brain natriuretic peptide. After automation, the median TAT decreased by 42.3 % (from 52 to 22 min). The largest decreases in TAT were observed for routine samples (58.89 %) and fully automated analyses (56.86 %).

Conclusions

Automation of our core laboratory substantially reduced turnaround time for add-on testing, indicating an increase in efficiency. Automation eliminated several manual steps in the process, leading to a mean reduction of 15 work hours per day (more than 2 full-time equivalents).

The harmonization issue in laboratory medicine: the commitment of CCLM

The analytical quality of the clinical laboratory results has shown a significant improvement over the past decades, thanks to the joint efforts of different stakeholders, while the comparability among the results produced by different laboratories and methods still presents some critical issues. During these years, Clinical Chemistry and Laboratory Medicine (CCLM) published several papers on the harmonization issue over all steps in the Total Testing Process, training an important number of laboratory professionals in evaluating and monitoring all the criticisms inherent to the pre-analytical, as well as analytical and post analytical phases: from the consensus statement on the most informative testing in emergency setting, to the prevention and detection of hemolysis or to patients identification and tube labeling procedures, as far as to different approaches to harmonize hormones measurements or to describe new reference methods or to harmonize the laboratory report. During these years the commitment of the journal, devoted to the harmonization processes has allowed to improve the awareness on the topic and to provide specific instruments to monitor the rate of errors and to improve patients safety.

The preanalytical phase – from an instrument-centred to a patient-centred laboratory medicine

In order to guarantee patient safety, medical laboratories around the world strive to provide highest quality in the shortest amount of time. A major leap in quality improvement was achieved by aiming to avoid preanalytical errors within the total testing process. Although these errors were first described in the 1970s, it took additional years/decades for large-scale efforts, aiming to improve preanalytical quality by standardisation and/or harmonisation. Initially these initiatives were mostly on the local or national level. Aiming to fill this void, in 2011 the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) working group “Preanalytical Phase” (WG-PRE) was founded. In the 11 years of its existence this group was able to provide several recommendations on various preanalytical topics. One major achievement of the WG-PRE was the development of an European consensus guideline on venous blood collection. In recent years the definition of the preanalytical phase has been extended, including laboratory test selection, thereby opening a huge field for improvement, by implementing strategies to overcome misuse of laboratory testing, ideally with the support of artificial intelligence models. In this narrative review, we discuss important aspects and milestones in the endeavour of preanalytical process improvement, which would not have been possible without the support of the Clinical Chemistry and Laboratory Medicine (CCLM) journal, which was one of the first scientific journals recognising the importance of the preanalytical phase and its impact on laboratory testing quality and ultimately patient safety.

The next wave of innovation in laboratory automation: systems for auto-verification, quality control and specimen quality assurance

Laboratory automation in clinical laboratories has made enormous differences in patient outcomes, with a wide range of tests now available that are accurate and have a rapid turnaround. Total laboratory automation (TLA) has mechanised tube handling, sample preparation and storage in general chemistry, immunoassay, haematology, and microbiology and removed most of the tedious tasks involved in those processes. However, there are still many tasks that must be performed by humans who monitor the automation lines. We are seeing an increase in the complexity of the automated laboratory through further platform consolidation and expansion of the reach of molecular genetics into the core laboratory space. This will likely require rapid implementation of enhanced real time quality control measures and these solutions will generate a significantly greater number of failure flags. To capitalise on the benefits that an improved quality control process can deliver, it will be important to ensure that an automation process is implemented simultaneously with enhanced, real time quality control measures and auto-verification of patient samples in middleware. Therefore, it appears that the best solution may be to automate those critical decisions that still require human intervention and therefore include quality control as an integral part of total laboratory automation.

Evaluation of a Newly Implemented Critical Thromboelastography (TEG) Value Callback System

OBJECTIVES

Thromboelastography (TEG) measures whole blood coagulation kinetics in real time and is useful in guiding blood product transfusion. At our institution, providers have immediate remote access to TEG results. However, some critical values are occasionally missed. Our patient blood management program implemented a critical TEG value callback system to improve patient management and blood product utilization.

METHODS

This retrospective, observational study assessed the data of trauma and critical care patients preimplementation (n = 20) and postimplementation (n = 100) of the callback system. Provider responses to callbacks and changes in TEG parameters after subsequent testing were compared between the two groups.

RESULTS

In response to callbacks, 42% provided appropriate management and 42% ordered a repeat TEG vs 28% and 33% in the historical group (P < .0001 and P = .0002, respectively). Following callback, 90% of the TEG parameters in the study group showed an improvement vs 57% in the control group (P = .011).

CONCLUSIONS

The increase in appropriate management and the improvement in TEG parameters upon repeat testing in the study group compared to the control group demonstrate the efficacy of the TEG callback system. Further studies are needed to evaluate the callback system effect on patient outcome.

Quality in laboratory medicine and the Journal: walking together

Quality in laboratory medicine is defined as "an unfinished journey", as the more essential the laboratory information provided, the more assured its quality should be. In the past decades, the Journal Clinical Chemistry and Laboratory Medicine has provided a valuable forum for garnering new insights into the analytical and extra-analytical phases of the testing cycle, and for debating crucial aspects of quality in clinical laboratories. The impressive number of papers published in the Journal is testimony to the efforts made by laboratory professionals, national and international scientific societies and federations in the quest to continuously improve upon the pre-, intra- and post-analytical steps of the testing cycle, thus enhancing the quality of laboratory information. The paper appearing in this special issue summarizes the most important and interesting contributions published in the Journal, thus updating our knowledge on quality in laboratory medicine and offering further stimuli to identify the most valuable measures of quality in clinical laboratories.

Quality and performance indicators in Portuguese anatomical pathology laboratories: a panel validation by qualitative Delphi technique

Background

In laboratory medicine, quality and performance indicators (QPIs) are essential tools to ensure the quality of healthcare services and patient safety. QPIs allow comparison of outcomes, favouring accountability and transparency. Internationally, there are some QPI evaluation models, but the fact that they are paid limits their dissemination in smaller/poorer laboratories. In Portugal, each laboratory defines its own QPIs, with no uniformity between institutions. The development of a free QPI panel suitable for anatomical pathology laboratories (APLs) would allow for quality assessment and improvement.

Objective

To develop a consensual and validated QPI panel suitable for Portuguese APLs.

Methods

The study was developed in two stages. First, a bibliographic review was carried out, selecting the adequate QPIs. Afterwards, these QPIs were evaluated by experts through the Delphi method, where they could also suggest other pertinent QPIs.

Results

By the end of the Delphi method, there was a consensus on 64 QPIs (31 for ‘structure’, 30 for ‘process’ and 3 for ‘result’). The consensual QPIs covered all phases of the total test cycle. The lack of specific anatomical pathology QPIs in the bibliography was noticeable. There was greater consensus on ‘process’ and ‘result’ QPIs than on ‘structure’. This was supported by the bibliography, where the first ones were more valued. Nevertheless, it is important to monitor all the main laboratory processes, prioritising the evaluation of QPIs with greater impact on healthcare quality and patient safety. These results should allow APLs to identify the causes behind poor performance and improve their services.

Conclusions

This panel is a valuable tool for APLs, contributing to quality awareness. It can be the first step towards the development of a free benchmarking quality programme in Portugal, encouraging competitiveness and cost-efficiency.

Evaluation of 18 quality indicators from the external quality assurance preanalytical programme of the Spanish Society of Laboratory Medicine (SEQCML)

Objectives

Most errors in laboratory medicine occur in the pre- and post-analytical phases of the total testing process (TTP). In 2014, the Spanish Society of Laboratory Medicine (SEQC^ML) started the current Preanalytical Phase EQA Programme, with the objective of providing a tool for the improvement of the preanalytical phase. The aim of this study was to review the evolution of quality indicators (QI) and the comparability of established performance specifications (PS) with other EQA programmes.

Methods

In the SEQC^ML programme, participants were asked to register rejections of the main specimens and the causes for rejections. Data collected from 2014 to 2017, and then reviewed biennially (2018-2019), was used to calculate the percentiles; p25, p50, p75, and p90 for every round, and their means were set as PS. These PS were compared with the results of other programmes.

Results

The evolution of QI results for 2018-2019 period showed general maintenance or improvement, e.g., a significant decrease in the number of serum samples with a haemolytic index ≥0.5 g/L, except for EDTA and citrate samples handle, maybe for an improvement in detection. The comparison with PS for the QI of the IFCC Working Group "Laboratory Errors and Patient Safety" and the Key Incident Management and Monitoring System (KIMMS) programme of the RCPA showed comparable results, supporting the validity of the established specifications.

Conclusions

The PS obtained are a helpful tool for benchmarking and to identify processes of the preanalytical phase whose improvement should be set as a priority.

A Potassium-Based Quality-of-Service Metric Reduces Phlebotomy Errors, Resulting in Improved Patient Safety and Decreased Cost

OBJECTIVES

Poor phlebotomy technique can introduce pseudohyperkalemia without hemolysis, requiring additional workup and placing a significant burden on patients, clinical teams, and laboratories. Such preanalytical biases can be detected through systematic evaluation of potassium concentrations on a per-phlebotomist basis. We report our long-term experience with a potassium-based quality-of-service phlebotomy metric and its effects on resource utilization.

METHODS

Potassium monitoring and retraining of 26 full-time phlebotomists were piloted as a quality-of-service intervention. Changes in potassium concentrations and impact on resource utilization were assessed. An algorithm for data monitoring and phlebotomist feedback was developed, followed by institution-wide implementation.

RESULTS

Systematic intervention and retraining normalized K+ concentrations and lowered the percentage of venipunctures with K+ above 5.2 mmol/L, leading to a marked increase in phlebotomist compliance. This change resulted in resources savings of 13% to 100% for individual phlebotomists, reducing the total extra laboratory time required for repeat phlebotomies to determine hyperkalemia, mostly in the high-volume phlebotomist group.

CONCLUSIONS

A quality-of-service algorithm that involved monitoring potassium concentrations on a per-phlebotomist basis with feedback and retraining contributed to a concrete, data-based quality improvement plan. The institution-wide implementation of this metric allowed for significant cost savings and a reduction in critical value alerts, directly affecting the quality of patient care.

Transport stability profiling - a proposed generic protocol

OBJECTIVES

Diagnostic samples are exposed to a spectrum of variables during transport to laboratories; therefore, the evaluation of a rather comprehensive stability profile of measurands is warranted. While appropriate testing standards have been established for pharmaceuticals and reagents, this is not the case for diagnostic samples. The aim of our work was to develop and evaluate a protocol applicable to diagnostic samples.

METHODS

An isochronous approach with representation of temperature and exposure duration in a two-dimensional matrix was established. The deviations of the measurement results from the baseline associated with the exposure are evaluated with respect to the measurement uncertainty of the analytical measurement procedure applied. Variables of the experiment are documented in a standardized matrix. As a proof-of-concept, we profiled the stability patterns of a number of measurands at four temperature levels over up to 72 h in primary serum sample tubes.

RESULTS

The protocol proved to be workable and allowed the description of a comprehensive stability profile of a considerable number of compounds based on 21 small-volume primary samples collected from each volunteer and exposed according to this protocol.

CONCLUSIONS

A straightforward and feasible isochronous protocol can be used to investigate in detail the effects of different pre-processing conditions on the stability of measurands in primary samples during transport to diagnostic laboratories. This is of significance as pre-analytical logistics become increasingly important with the centralization of analytical services.

Benchmarking medical laboratory performance: survey validation and results for Europe, Middle East, and Africa

OBJECTIVES

Medical laboratory performance is a relative concept, as are quality and safety in medicine. Therefore, repetitive benchmarking appears to be essential for sustainable improvement in health care. The general idea in this approach is to establish a reference level, upon which improvement may be strived for and quantified. While the laboratory community traditionally is highly aware of the need for laboratory performance and public scrutiny is more intense than ever due to the SARS-CoV-2 pandemic, few initiatives span the globe. The aim of this study was to establish a good practice approach towards benchmarking on a high abstraction level for three key dimensions of medical laboratory performance, generate a tentative snapshot of the current state of the art in the region of Europe, Middle East, and Africa (EMEA), and thus set the stage for global follow-up studies.

METHODS

The questionnaire used and previously published in this initiative consisted of 50 items, roughly half relating to laboratory operations in general with the other half addressing more specific topics. An international sample of laboratories from EMEA was approached to elicit high fidelity responses with the help of trained professionals. Individual item results were analyzed using standard descriptive statistics. Dimensional reduction of specific items was performed using exploratory factor analysis and assessed with confirmatory factor analysis, resulting in individual laboratory scores for the three subscales of "Operational performance", "Integrated clinical care performance", and "Financial sustainability".

RESULTS

Altogether, 773 laboratories participated in the survey, of which 484 were government hospital laboratories, 129 private hospital laboratories, 146 commercial laboratories, and 14 were other types of laboratories (e.g. research laboratories). Respondents indicated the need for digitalization (e.g. use of IT for order management, auto-validation), automation (e.g. pre-analytics, automated sample transportation), and establishment of formal quality management systems (e.g. ISO 15189, ISO 9001) as well as sustainably embedding them in the fabric of laboratory operations. Considerable room for growth also exists for services provided to physicians, such as "Diagnostic pathways guidance", "Proactive consultation on complex cases", and "Real time decision support" which were provided by less than two thirds of laboratories. Concordantly, the most important kind of turn-around time (TAT) for clinicians, sample-to-result TAT, was monitored by only 40% of respondents.

CONCLUSIONS

Altogether, the need for stronger integration of laboratories into the clinical care process became apparent and should be a main trajectory of future laboratory management. Factor analysis confirmed the theoretical constructs of the questionnaire design phase, resulting in a reasonably valid tool for further benchmarking activities on the three aimed-for key dimensions.

Analyte stability in whole blood using experimental and datamining approaches

The analytical stability of laboratory tests relies mostly on internal and external quality control procedures. Summarized patient data has in several studies been shown to be a good supplement for monitoring analytical stability. In our present investigation, we evaluate a datamining method for retrospective evaluation and assessment of analyte stability in whole blood. Results from the laboratory information system were used as the basis for the datamining approach. Blood tests were requested by the general practitioners and drawing of the blood sample was either at the general practitioner's or at the hospital outpatient clinics. We were able to split data into groups based on sample collection place and time to analysis. The datamining approach was compared to experiments where samples were incubated at a single temperature as well as an experiment where the temperatures were changed during incubation. To demonstrate the method, we selected three laboratory tests considered representative: potassium, phosphate, and lactate dehydrogenase. The datamining approach showed results similar to the reference experiment. Furthermore, our results show that the analytes phosphate and potassium were not stable after short storage at a lower temperature.

A step towards optimal efficiency of HbA1c measurement as a first-line laboratory test: the TOP-HOLE (Towards OPtimal glycoHemOgLobin tEsting) project

OBJECTIVES

The TOP-HOLE (Towards OPtimal glycoHemOgLobin tEsting) project aimed to validate the HbA_1c enzymatic method on the Abbott Alinity c platform and to implement the HbA_1c testing process on the total laboratory automation (TLA) system of our institution.

METHODS

Three different measuring systems were employed: Architect c4000 stand-alone (s-a), Alinity c s-a, and Alinity c TLA. Eight frozen whole blood samples, IFCC value-assigned, were used for checking trueness. A comparison study testing transferability of HbA_1c results from Architect to Alinity was also performed. The alignment of Alinity TLA vs. s-a was verified and the measurement uncertainty (MU) estimated according to ISO 20914:2019. Turnaround time (TAT) and full time equivalent (FTE) were used as efficiency indicators.

RESULTS

For HbA_1c concentrations covering cut-offs adopted in clinical setting, the bias for both Architect and Alinity s-a was negligible. When compared with Architect, Alinity showed a mean positive bias of 0.54 mmol/mol, corresponding to a mean difference of 0.87%. A perfect alignment of Alinity TLA to the Alinity s-a was shown, and a MU of 1.58% was obtained, widely fulfilling the desirable 3.0% goal. After the full automation of HbA_1c testing, 90% of results were released with a maximum TAT of 1 h, 0.30 FTE resource was also saved.

CONCLUSIONS

The traceability of Alinity HbA_1c enzymatic assay to the IFCC reference system was correctly implemented. We successfully completed the integration of the HbA_1c testing on our TLA system, without worsening the optimal analytical performance. The shift of HbA_1c testing from s-a mode to TLA significantly decreased TAT.

Preanalytical errors in a satellite stat laboratory: A Six Sigma analysis of seven years' data

BACKGROUND

There have been few reports regarding the frequency and types of preanalytical errors in stat laboratories, in particular those occurring in the satellite laboratory setting. The impact of this error type on laboratory performance in this environment is largely unknown. We assessed the performance of a stat laboratory serving a population of predominantly elderly patients with suspected or established diagnoses of cancer using Six Sigma methodology and compared the results to previous work on this subject.

METHODS

We performed an observational retrospective study using data from the period 2013-2020. The clinical setting was a satellite laboratory supporting an outpatient medical clinic. The type and frequency of each type of preanalytical error were compiled and were used to derive the quarterly error rate. Overall and quarterly performance were calculated using Six Sigma methodology.

RESULTS

During the study period 1314 preanalytical errors were identified from 247,271 laboratory tests (0.5% of total test volume). There was a steady decrease in the error rate over the course of the study period, ranging from 1.4% in 2013 to 0.14% in 2020, despite a 290% increase in quarterly test volume during this period. The most common error types encountered were order error, hemolysis, collection error, and lab accident.

CONCLUSION

1) The overall performance of a satellite laboratory with a stat testing menu is comparable to hospital-based laboratory stat testing. 2) The most frequent error types encountered in satellite laboratory stat testing differ from those found in hospital-based laboratories. 3) There was an overall improvement in laboratory performance based on Six Sigma methodology.

Benchmarking diagnostic laboratory performance: Survey results for Germany, Austria, and Switzerland

BACKGROUND AND AIMS

The need for patient safety through consistent diagnostic performance has increasingly been brought into focus during the last two decades. Around the globe operational efficiency of diagnostic laboratories plays a key role in satisfying this need, which has impressively been shown during the recent months of the SARS-CoV‑2 pandemic. On a global level, however, there has been a lack to collate and benchmark data for diagnostic laboratories. The goals of this study were to design and pilot a questionnaire addressing key aspects of diagnostic laboratory management.

METHODS

The questionnaire was designed using an iterative process and taking into consideration information that could be extracted from the literature, author experience and feedback from informal focus groups of laboratory professionals. The resulting tool consisted of 50 items, either relating to general information or more specifically addressing the topics of "operational performance", "integrated clinical care performance", and "financial sustainability". A limited number of laboratories were surveyed to be able to further improve the newly developed tool and motivate the global laboratory community to participate in further benchmarking activity.

RESULTS AND CONCLUSION

Altogether, 65 laboratories participated in the survey, 42 were hospital laboratories and 23 were commercial laboratories. Potential for further improvement and standardization became apparent across the board, e.g. use of IT for order management, auto-validation, or turn-around time (TAT) monitoring. Notably, a gap was identified regarding services provided to physicians, in particular "reflexive test suggestions", "proactive consultation on complex cases", and "diagnostic pathways guidance", which were only provided by about two thirds of laboratories. Concordantly, within-laboratory TAT (Lab TAT) was monitored by about 80% of respondents, while sample-to-result TAT, which is arguably the TAT most relevant to clinicians, was only monitored by 32% of respondents. Altogether, the need for stronger integration of the laboratory into the clinical care process became apparent and should be a main trajectory of future laboratory management.

What factors are associated with improvements in productivity in clinical laboratories in the Asia Pacific Region?

INTRODUCTION

Clinical laboratories usually have a quality management system such as ISO 15189, which provides a framework for quality and competence to perform medical testing and internal systems such as audit and nonconformance to ensure consistent processes. However, organizations need to have access to internal procedures and external competitors' performance to improve their operations. These are often seen as commercial or areas where it is difficult to agree on an acceptable goal.

METHOD

In 2019, 1158 laboratories from 17 countries/regions in the Asia Pacific Region answered the survey, including 399 Chinese sites. The survey collected information on quality, turnaround time and productivity.

RESULTS

Median productivity for laboratories in the Asia Pacific Region not including Chinese sites was 25 samples/FTE/day for small laboratories (workload: <250 samples/day), 100 for medium-sized laboratories (workload: 251-1000 samples/day) and 220 for large laboratories (workload: >1001 samples/day). The parameters associated with increased productivity in some laboratories were automation, middleware, Lean Six Sigma quality improvement activities and International Accreditation.

CONCLUSION

This survey provides evidence of an association of quality improvement activities on laboratory productivity. There are differences in the effect of these activities in Chinese and non-Chinese laboratories in the Asia Pacific Region. The survey confirmed that the implementation of automation is associated with increased median productivity in all sites. Implementation of Lean Six Sigma and International Accreditation is associated with increased productivity in large laboratories.

Risk assessment of the total testing process based on quality indicators with the Sigma metrics

Background Evidence-based evaluation of laboratory performances including pre-analytical, analytical and post-analytical stages of the total testing process (TTP) is crucial to ensure patients receiving safe, efficient and effective care. To conduct risk assessment, quality management tools such as Failure Mode and Effect Analysis (FMEA) and the Failure Reporting and Corrective Action System (FRACAS) were constantly used for proactive or reactive analysis, respectively. However, FMEA and FRACAS faced big challenges in determining the scoring scales and failure prioritization in the assessment of real-world cases. Here, we developed a novel strategy, by incorporating Sigma metrics into risk assessment based on quality indicators (QIs) data, to provide a more objective assessment of risks in TTP. Methods QI data was collected for 1 year and FRACAS was applied to produce the risk rating based on three variables: (1) Sigma metrics for the frequency of defects; (2) possible consequence; (3) detection method. The risk priority number (RPN) of each QI was calculated by a 5-point scale score, where a value of RPN > 50 was rated as high-risk. Results The RPNs of two QIs in post-analytical phase (TAT of Stat biochemistry analyte and Timely critical values notification) were above 50 which required rigorous monitoring and corrective actions to eliminate the high risks. Nine QIs (RPNs between 25 and 50) required further investigation and monitoring. After 3 months of corrective action the two identified high-risk processes were successfully reduced. Conclusions The strategy can be implemented to reduce identified risk and assuring patient safety.

The response of total testing process in clinical laboratory medicine to COVID-19 pandemic

Introduction

Following a pandemic, laboratory medicine is vulnerable to laboratory errors due to the stressful and high workloads. We aimed to examine how laboratory errors may arise from factors, e.g., flexible working order, staff displacement, changes in the number of tests, and samples will reflect on the total test process (TTP) during the pandemic period.

Materials and methods

In 12 months, 6 months before and during the pandemic, laboratory errors were assessed via quality indicators (QIs) related to TTP phases. QIs were grouped as pre-, intra- and postanalytical. The results of QIs were expressed in defect percentages and sigma, evaluated with 3 levels of performance quality: 25^th, 50^th and 75^th percentile values.

Results

When the pre- and during pandemic periods were compared, the sigma value of the samples not received was significantly lower in pre-pandemic group than during pandemic group (4.7σ vs. 5.4σ, P = 0.003). The sigma values of samples transported inappropriately and haemolysed samples were significantly higher in pre-pandemic period than during pandemic (5.0σ vs. 4.9σ, 4.3σ vs. 4.1σ; P = 0.046 and P = 0.044, respectively). Sigma value of tests with inappropriate IQC performances was lower during pandemic compared to the pre-pandemic period (3.3σ vs. 3.2σ, P = 0.081). Sigma value of the reports delivered outside the specified time was higher during pandemic than pre-pandemic period (3.0σ vs. 3.1σ, P = 0.030).

Conclusion

In all TTP phases, some quality indicators improved while others regressed during the pandemic period. It was observed that preanalytical phase was affected more by the pandemic.

Brazilian laboratory indicators benchmarking program: three-year experience on pre-analytical quality indicators

OBJECTIVES

In the laboratory medicine segment, benchmarking is the process in which institutions seek to compare with the macro environment (performance comparison and best practices with different laboratories) and improve their results based on quality indicators. The literature has highlighted the vulnerability of the pre-analytical phase in terms of risks and failures and the use of interlaboratory comparison as an opportunity to define a strategic performance benchmark aligned with the laboratory medicine sector, which has been a promising strategy to ensure continuous improvement, identifying within the pre-analytical process the critical activities to guarantee patient safety. In this context, this paper aims to present the three-year experience (2016-2018) of the Benchmarking Program and Laboratory Indicators - in Portuguese, Programa de Benchmarking e Indicadores Laboratoriais (PBIL) - with emphasis on pre-analytical indicators and their comparison against literature references and other programs of benchmarking in the area of laboratory medicine. PBIL is organized by the Brazilian Society of Clinical Pathology/Laboratory Medicine (SBPC/ML) in conjunction with Controllab and coordinated by a Brazilian group with representatives from different countries.

METHODS

The data presented in this paper involving the performance results of 180 laboratories with active participation. Results are presented in percentage (%, boxplot graphical in quartiles) and Sigma metric, recognized as the metric that best indicates the magnitude of failures in a process. The Pareto Chart was used to facilitate ordering and to identify the main errors in the pre-analytical phase. The Radar Chart was made available in this work for the purpose of comparing the results obtained in Sigma by the PBIL and IFCC Working Group Laboratory Errors and Patient Safety (WG LEPS).

RESULTS

In the study period, just over 80% of the pre-analytical failures are related to Blood culture contamination (hospital-based and non-hospital-based laboratories), Recollect and Non-registered exams, with failure rates of 2.70, 1.05 and 0.63%, respectively. The performance of the PBIL program participants was in line with the literature references, and allowed to identify benchmarks in the laboratory medicine market, target of PBIL, with best practices were observed for some indicators.

CONCLUSIONS

The results of the program demonstrate the importance of an ongoing program comparative performance-monitoring program for setting more robust goals and consequently reducing laboratory process failures. Even with these promising premises and results, the contextualized analysis of the program indicators, point to a still significant number of failures in our market, with possibilities for improvement in order aiming to ensure more robust and effective processes.

Quality Improvement in Critical Value Delivery at a Tertiary Care Center

BACKGROUND

Prompt notification of critical laboratory values to providers is essential for effective patient care. To improve the delivery of these critical values, a quality improvement project was initiated to determine the obstacles to prompt notification and to identify possible interventions to improve this process.

METHODS

Critical value call logs were retrieved, and delivery time, patient location, test name, and call time were abstracted and analyzed. All critical values with delivery times greater than 60 min were reviewed by 2 authors for 1 representative month in both the pre- and postintervention period.

RESULTS

Based on the results of the data review, a modification to the laboratory information system call center color-coded alerts was introduced to address delays attributable to the laboratory. The overall rate of calls greater than 60 min decreased from 3.4% ± 0.8% in the preintervention study period to 1.3 ± 0.3%, postintervention. The average number of values not delivered within 60 min decreased by 64% across all locations, following with an 82% decrease for values originating from inpatient locations, and a 39% decrease for outpatient values.

CONCLUSIONS

Low complexity interventions to critical value callback protocols can significantly increase the efficacy of communication between the laboratory and providers.

Six Sigma performance of quality indicators in total testing process of point-of-care glucose measurement: A two-year review

Objectives

The error rate in the total testing process (TTP) of point-of-care (POC) glucose measurement remains high although a total quality management system has been applied. Quality indicators (QIs) in the TTP of glucose meter were established via risk assessment. Their two-year Six Sigma values were reviewed for quality improvement.

Design

The TTP of POC glucose measurement was mapped to identify risks in key steps. The risks were assessed for their frequency and severity of impact on patient safety. Whenever possible, measurable data from the data management system and other sources was collected to establish QIs for risk monitoring. Average Six Sigma value of each QI in the last two years was calculated for acceptance and for determining corrective action.

Results

29 risks were identified in eight key steps of the TTP. Eight QIs were established for monitoring six risks and three QIs for two accepted risks were established for improving operator testing skill. The QIs had a good coverage to key steps. Two, five and four QIs showed Six Sigma values <3, 3-4 and >4 respectively. Six Sigma values of two QIs related to quality control (QC) testing were improved by using meters with accurate QC sample loading.

Conclusions

The establishment of QIs for glucose measurement by risk assessment with measurable data from the data management system and on Six sigma scale was effective, efficient, and manageable. Most of QIs’ Six Sigma values were between 3 and 5, which could be improved by using upgraded meters.

•

The total testing process of POC glucose measurement was assessed to identify all risks that might impact patient safety.

•

QIs that established from data management system monitored the risks related to all of the meters and operators.

•

Six Sigma values of QIs provided a straightforward acceptance in their performance evaluation.

•

Most of the Six Sigma values of QIs for glucose meters were between 3 and 5 under current total quality management system.

Errors within the total laboratory testing process, from test selection to medical decision-making - A review of causes, consequences, surveillance and solutions

Laboratory analyses are crucial for diagnosis, follow-up and treatment decisions. Since mistakes in every step of the total testing process may potentially affect patient safety, a broad knowledge and systematic assessment of laboratory errors is essential for future improvement. In this review, we aim to discuss the types and frequencies of potential errors in the total testing process, quality management options, as well as tentative solutions for improvement. Unlike most currently available reviews on this topic, we also include errors in test-selection, reporting and interpretation/action of test results. We believe that laboratory specialists will need to refocus on many process steps belonging to the extra-analytical phases, intensifying collaborations with clinicians and supporting test selection and interpretation. This would hopefully lead to substantial improvements in these activities, but may also bring more value to the role of laboratory specialists within the health care setting.

Three years' experience of quality monitoring program on pre-analytical errors in china

Background

Various errors in the procedure of specimen collection have been reported as the primary causes of pre‐analytical errors. The aim of this study was to monitor and assess the reasons and frequencies of rejected samples in China.

Methods

A pre‐analytical external quality assessment (EQA) scheme involving six quality indicators (QIs) was conducted from 2017 to 2019. Rejection rate was calculated for each QI. The difference of the rejection rates over the time was checked by Chi‐square test. Furthermore, the 25th, 50th, and 75th percentiles of the results from total laboratories each year were calculated as optimum, desirable, and minimum level of performance specifications.

Results

In total, 423 laboratories submitted data continuously for six EQA rounds. The overall rejection rates were 0.2042%, 0.1709%, 0.1942%, 0.1689%, 0.1593%, and 0.1491%, respectively. The most common error was sample hemolysed (0.0514%–0.0635%), and the least one was sample not received (0.0008%–0.0014%). A significant reduction in percentages was observed for all QIs. For biochemistry and immunology, hemolysis accounted for more than half of the rejection causes, while for hematology, the primary cause shifted from incorrect fill level to sample clotted. The quality specifications had improved over time, except for the optimum level.

Conclusion

The significant reduction in error rates on sample rejection we observed suggested that laboratories should pay more attention to the standardized specimen collection. We also provide a benchmark for QIs performance specification to help laboratories increase awareness about the critical aspects in the need of improvement actions.

How to meet ISO15189:2012 pre-analytical requirements in clinical laboratories? A consensus document by the EFLM WG-PRE

The International Organization for Standardization (ISO) 15189:2012 standard aims to improve quality in medical laboratories through standardization of all key elements in the total testing process, including the pre-analytical phase. It is hence essential that accreditation bodies, assessing laboratories against ISO15189:2012, pay sufficient attention to auditing pre-analytical activities. However, there are significant differences in how technical auditors interpret the pre-analytical requirements described in ISO15189:2012. In this consensus document, the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Pre-analytical Phase (WG-PRE) sets out to review pre-analytical requirements contained in ISO15189:2012 and provide guidance for laboratories on how to meet these requirements. The target audience for this consensus document is laboratory professionals who wish to improve the quality of the pre-analytical phase in their laboratory. For each of the ISO requirements described in ISO15189:2012, members of EFLM WG-PRE agreed by consensus on minimal recommendations and best-in-class solutions. The minimal consensus recommendation was defined as the minimal specification which laboratories should implement in their quality management system to adequately address the pre-analytical requirement described in ISO15189:2012. The best-in-class solution describes the current state-of-the-art in fulfilling a particular pre-analytical requirement in ISO15189:2012. We fully acknowledge that not every laboratory has the means to implement these best-in-class solutions, but we hope to challenge laboratories in critically evaluating and improving their current procedures by providing this expanded guidance.

Real-world use of key performance indicators for point-of-Care Testing network accredited by ISO 22870

Objective

We aimed to evaluate the results of key performance indicators (KPIs) for a period of over three years, as well as their effectiveness as an improvement tool, to provide information about Point-of-Care Testing (POCT) management system performance and quality assurance.

Design and methods

KPIs regarding the global POCT process, extra-analytical phase, quality assurance and staff training and competency were evaluated for blood gases, HbA1c, sweat test and non-connected and connected glucose in an ISO 22870 accredited network. We established the definition of every KPI and its corresponding target. The results of KPIs from all clinical settings were appraised every month during the study period, taking corrective actions when necessary.

Results

Annual global results were generally acceptable. However, some clinical areas displayed deviations in specific months. The monitoring of these KPIs allowed us to detect the deviations immediately and identify their causes. These included errors in patient identification, consumables, strips, reagents, analyzers, calibration, internal and external quality control, sample management, connectivity, and operator identification strategy, among others.

Conclusions

The evaluation of these KPIs over time has shown their appropriateness. This set of quality indicators could be a useful tool for laboratory medicine leading POCT networks for better and safer patient care.

The use of preanalytical quality indicators: a Turkish preliminary survey study

OBJECTIVES

The utilization of reliable quality indicators (QIs) proven to be suitable for monitoring and improvement tools is one of the best choices to minimize of the risk of errors in all laboratory processes called as total testing process (TTP). In 2008, a Working Group "Laboratory Errors and Patient Safety" (WG-LEPS) established by International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) developed the Model of Quality Indicators (MQI) complying with requirements of the ISO 15189:2012 standard for laboratory accreditation. They have also been dealing with harmonizing the QIs in most laboratories worldwide since then. The present study was set out to investigate the frequency of using IFCC WG-LEPS' pre-QIs by Turkish laboratories and to assess the conformity of them, by taking into account Turkey's conditions.

METHODS

A survey consisting nine questions was applied in 81 laboratories using SurveyMonkey.

RESULTS

According to the survey results, most of the laboratories reported they have used pre-QIs in the quality standards of health prepared by Turkish Ministry of Health (MOH). A part of IFCC WG-LEPS' pre-QIs were being utilized by more than 80% of the laboratories, the rest of which only used by 10% of laboratories.

CONCLUSIONS

The majority of the medical laboratories have been using the pre-QIs included in the guidelines of Quality Standards prepared by the MOH. The pre-QIs are partially compatible with IFCC WG-LEPS' pre-QIs. The definitions of IFCC WG-LEPS' pre-QIs may also be revised to make them more clear and understandable by IFCC WG-LEPS. The insufficiency of Health Information Management Systems (HIMS) limits the use of pre-QIs proposed by IFCC WG-LEPS. Finally, the education of relevant personnel about the use of HIMS and pre-QIs is very crucial to harmonize and to extend the use of IFCC WG-LEPS' pre-QIs in Turkish medical biochemistry laboratories.

Measurement uncertainty as a universal concept: can it be universally applicable in routine laboratory practice?

Measurement uncertainty (MU) of results is one of the basic recommended and accepted statistical methods in laboratory medicine, with which analytical and clinical evaluation of laboratory test quality is assessed. Literature data indicate that the calculation of MU is not a simple process, but that its assessment in daily laboratory practice should be reduced to routine and simple presentation, understandable to both laboratory professionals and physicians. In order to achieve this, it is necessary to understand the purpose of the test for which MU is to be determined. Various suggestions have been given for presentation of MU as a quantitative indicator of the quality of the final measurement result in the medical laboratory. Although MU refers to the final measurement result, this metrological concept reflects the entire laboratory measurement process. The data on estimated MU is used to interpret the measured numerical result, and represents quantitatively the quality of the measurement itself, i.e. how different are the results of multiple measurements of the analyte of interest in the same sample, as well as whether the method of determination itself is subjected to significant random and systematic deviation. Initially, in the metrological concept, the MU is viewed in relation to the true value of the analyte of interest. However, the true value of the analyte measured in the biological fluid matrix of the study population cannot be known. It is therefore considered the closest value obtained by the perfect method, for which the bias and inaccuracy, as measures of systematic and random error, are equal to zero, which is practically impossible to achieve in routine laboratory practice. Although current standards require accredited medical laboratories to estimate MU, none of these guidelines provide clear guidance on how this can be achieved in daily laboratory work. This review examines literary data and documents dealing with MU issues, but also highlights what additional terms and data should be considered when interpreting MU. This paper ultimately draws attention, and once again points out, that a simpler solution is needed for this universal concept to be formally and universally applicable in routine laboratory medicine practice.

The utility of measurement uncertainty in medical laboratories

The definition and enforcement of reference measurement systems, based on the implementation of metrological traceability of patient results to higher-order (reference) methods and/or materials, together with a clinically acceptable level of measurement uncertainty (MU), are fundamental requirements to produce accurate and equivalent laboratory results. The MU associated with each step of the traceability chain should be governed to obtain a final combined MU on clinical samples fulfilling the requested performance specifications. MU is useful for a number of reasons: (a) for giving objective information about the quality of individual laboratory performance; (b) for serving as a management tool for the medical laboratory and in vitro diagnostics (IVD) manufacturers, forcing them to investigate and eventually fix the identified problems; (c) for helping those manufacturers that produce superior products and measuring systems to demonstrate the superiority of those products; (d) for identifying analytes that need analytical improvement for their clinical use and ask IVD manufacturers to work for improving the quality of assay performance and (e) for abandoning assays with demonstrated insufficient quality. Accordingly, the MU should not be considered a parameter to be calculated by medical laboratories just to fulfill accreditation standards, but it must become a key quality indicator to describe both the performance of an IVD measuring system and the laboratory itself.

National surveys on 15 quality indicators for the total testing process in clinical laboratories of China from 2015 to 2017

Background As effective quality management tools, quality indicators (QIs) are widely used in laboratory medicine. This study aimed to analyze the results of QIs, identify errors and provide quality specifications (QSs) based on the state-of-the-art. Methods Clinical laboratories all over China participated in the QIs survey organized by the National Health Commission of People' Republic of China from 2015 to 2017. Most of these QIs were selected from a common model of QIs (MQI) established by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). All participants were asked to submit general information and original QIs data through a medical quality control data collection system. The results of QIs were reported in percentages and sigma, except turnaround time (TAT) which was measured in minutes. The 25th, 50th and 75th percentiles were, respectively, calculated as three levels of QSs, which were defined starting from the model proposed during the 1st Strategic Conference of the EFLM on "Defining analytical performance 15 years after the Stockholm Conference on Quality Specification in Laboratory Medicine". Results A total of 76 clinical laboratories from 25 provinces in China continuously participated in this survey and submitted complete data for all QIs from 2015 to 2017. In general, the performance of all reported QIs have improved or at least kept stable over time. Defect percentages of blood culture contamination were the largest in the pre-analytical phase. Intra-laboratory TAT was always larger than pre-examination TAT. Percentage of tests covered by inter-laboratory comparison was relatively low than others in the intra-analytical phase. The performances of critical values notification and timely critical values notification were the best with 6.0σ. The median sigma level of incorrect laboratory reports varied from 5.5σ to 5.7σ. Conclusions QSs of QIs provide useful guidance for laboratories to improve testing quality. Laboratories should take continuous quality improvement measures in all phases of total testing process to ensure safe and effective tests.

Enhance the effectiveness of clinical laboratory critical values initiative notification by implementing a closed-loop system: A five-year retrospective observational study

BACKGROUND

Accurate and timely clinical laboratory critical values notification are crucial steps in supporting effective clinical decision making, thereby improving patient safety.

METHODS

A closed-loop laboratory critical value notification system was developed by a multidisciplinary team of clinicians, laboratorians, administrators, and information technology experts. All the laboratory critical values that occurred at Beijing Tsinghua Changgung Hospital (BTCH, Beijing, China) from 2015 to 2019 were analyzed and studied retrospectively.

RESULTS

The total number (ratio) of institutional laboratory critical values to all reported items at BTCH from 2015 to 2019 was 38 020/7 706 962 (0.49%). Percentage distribution points of critical value boundaries based on patients' test reports are 0.007% ~ 6.04% for low boundaries and 71.70% ~ 99.99% for high boundaries. After the intervention, the timely notification ratio, notification receipt ratio, and timely notification receipt ratio of critical values of ED, IPD, and total patients had increased, with a significant difference (P < .001). Five quality indicators, such as notification ratio, timely notification ratio, notification receipt ratio, timely notification receipt ratio, and clinician response ratio over a 5-year period, were 100%, 94%, 97%, 92%, and 99%, respectively.

CONCLUSIONS

We enhanced the effectiveness of clinical laboratory critical values initiative notification by implementing a closed-loop system and intervening. Clinical critical values and quality indicators should be analyzed and monitored to avoid adversely affecting patient care.

European survey on preanalytical sample handling - Part 1: How do European laboratories monitor the preanalytical phase? On behalf of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE)

Introduction

Compared to other activities of the testing process, the preanalytical phase is plagued by a lower degree of standardization, which makes it more vulnerable to errors. With the aim of providing guidelines and recommendations, the EFLM WG-PRE issued a survey across European medical laboratories, to gather information on local preanalytical practices. This is part one of two coherent articles, which covers all practices on monitoring preanalytical quality except haemolysis, icterus and lipemia (HIL).

Materials and methods

An online survey, containing 39 questions dealing with a broad spectrum of preanalytical issues, was disseminated to EFLM member countries. The survey included questions on willingness of laboratories to engage in preanalytical issues.

Results

Overall, 1405 valid responses were received from 37 countries. 1265 (94%) responders declared to monitor preanalytical errors. Assessment, documentation and further use of this information varied widely among respondents and partially among countries. Many responders were interested in a preanalytical online platform, holding information on various aspects of the preanalytical phase (N = 1177; 87%), in a guideline for measurement and evaluation of preanalytical variables (N = 1235; 92%), and in preanalytical e-learning programs or webinars (N = 1125; 84%). Fewer responders were interested in, or already participating in, preanalytical EQA programs (N = 951; 71%).

Conclusion

Although substantial heterogeneity was found across European laboratories on preanalytical phase monitoring, the interest in preanalytical issues was high. A large majority of participants indicated an interest in new guidelines regarding preanalytical variables and learning activities. This important data will be used by the WG-PRE for providing recommendations on the most critical issues.

Managing inappropriate utilization of laboratory resources

Background The inappropriate use of laboratory resources, due to excessive number of tests not really necessary for patient care or by failure to order the appropriate diagnostic test, may lead to wrong, missed or delayed diagnosis, thus potentially jeopardizing patient safety. It is estimated that 5-95% of tests are currently used inappropriately, depending on the appropriateness criteria, thus significantly contributing to the potential of generating medical errors, the third leading cause of death in the US. Content In this review, we discuss the reasons as well as the medical and financial consequences of inappropriate utilization of laboratory tests. We then provide demand management (DM) tools as a means for overcoming this issue and also discuss their benefits, challenges, limitations and requirements for successful implementation. Summary and outlook When based on current evidence, adapted to local conditions and developed in close collaboration with clinicians, DM is a reasonable strategy for progressing toward better management of over- and underuse of laboratory resources.

Blood sample quality

Several lines of evidence now confirm that the vast majority of errors in laboratory medicine occur in the extra-analytical phases of the total testing processing, especially in the preanalytical phase. Most importantly, the collection of unsuitable specimens for testing (either due to inappropriate volume or quality) is by far the most frequent source of all laboratory errors, thus calling for urgent strategies for improving blood sample quality and managing data potentially generated measuring unsuitable specimens. A comprehensive overview of scientific literature leads us to conclude that hemolyzed samples are the most frequent cause of specimen non-conformity in clinical laboratories (40-70%), followed by insufficient or inappropriate sample volume (10-20%), biological samples collected in the wrong container (5-15%) and undue clotting (5-10%). Less frequent causes of impaired sample quality include contamination by infusion fluids (i.e. most often saline or glucose solutions), cross-contamination of blood tubes additives, inappropriate sample storage conditions or repeated freezing-thawing cycles. Therefore, this article is aimed to summarize the current evidence about the most frequent types of unsuitable blood samples, along with tentative recommendations on how to prevent or manage these preanalytical non-conformities.

Practical recommendations for managing hemolyzed samples in clinical chemistry testing

We suggest here a pragmatic approach for managing results of clinical chemistry testing in hemolyzed samples collected from adults/older children, attempting to balance the need to produce quality laboratory data with clinical urgency of releasing test results. Automatic measurement of the hemolysis index (H-index) in serum or plasma is highly advisable, whilst low-quality assessment of this test remains less good than a visual inspection. Regarding its practical use, when the H-index value does not generate an analytically significant bias, results can be released, whilst when the value is associated with analyte variation in a range between analytically and clinically significant bias (i.e. variation does not exceed the reference change value [RCV]), results of hemolysis-sensitive tests can be released in association with a comment describing the direction in which data are potentially altered, suggesting the need to collect another sample. When the H-index is associated with analyte variation exceeding clinically significant bias (i.e. variation exceeds the RCV), results of hemolysis-sensitive tests should be suppressed and replaced with a comment that biased results cannot be released because the sample is preanalytically compromised and advising the recollection of another sample. If H-index values reach an even higher critical cut-off (i.e. H-index corresponding to a cell-free hemoglobin concentration ≥10 g/L), all laboratory data may be unreliable and should hence be suppressed and replaced with a comment that all data cannot be released because the sample is grossly hemolyzed, also suggesting the recollection of another sample. Due to inaccuracy and imprecision, the use of corrective formulas for adjusting data of hemolysis-sensitive tests is discouraged.

Diabetes alert dogs: a narrative critical overview

Owing to their virtually incomparable olfactory apparatus and the mutual loving relationship with man, the use of dogs for assisting humans in many activities has become commonplace. Dogs have been used for long for livestock herding, hunting and pulling. More recently, they have been employed for servicing or assisting people with disabilities, for rescuing, for pet therapy and, last but not least, for detecting a vast array of volatile organic compounds related to drugs, narcotics, explosives and foods. Although cancer detection seems the most distinguished use of “man’s best friends” in science and medicine, increasing emphasis is being placed on their capacity to perceive chemical changes or human expressions associated with harmful, even life-threating, blood glucose variations. The evidence available in the current scientific literature attests that diabetes alerting dogs (DADs) have a heterogeneous efficiency for warning owners of episodes of hypoglycemia or hyperglycemia, with sensitivities and specificities ranging between 0.29–0.80 and 0.49–0.96, respectively. Although the adoption of DADs seems effective for improving the quality of life of many diabetics patients, some important drawbacks can be highlighted. These typically include adoption and keeping expenditures, lack of certification or accreditation of dog providers, poor harmonization of training procedures, significant inter-breed, intra-breed and intra-dog variabilities, wide-ranging alert behaviors, ability of owners to identify dog’s alerts, as well as lack of quality assessment of a dog’s “diagnostic” performance. Overcoming many of these limitations shall probably make DADs more efficient tools for improving diabetes management.

Preanalytical challenges – time for solutions

The European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for the Preanalytical Phase (WG-PRE) was originally established in 2013, with the main aims of (i) promoting the importance of quality in the preanalytical phase of the testing process, (ii) establishing best practices and providing guidance for critical activities in the preanalytical phase, (iii) developing and disseminating European surveys for exploring practices concerning preanalytical issues, (iv) organizing meetings, workshops, webinars or specific training courses on preanalytical issues. As education is a core activity of the WG-PRE, a series of European conferences have been organized every second year across Europe. This collective article summarizes the leading concepts expressed during the lectures of the fifth EFLM Preanalytical Conference “Preanalytical Challenges – Time for solutions”, held in Zagreb, 22–23 March, 2019. The topics covered include sample stability, preanalytical challenges in hematology testing, feces analysis, bio-banking, liquid profiling, mass spectrometry, next generation sequencing, laboratory automation, the importance of knowing and measuring the exact sampling time, technology aids in managing inappropriate utilization of laboratory resources, management of hemolyzed samples and preanalytical quality indicators.

A pilot study for establishing quality indicators in molecular diagnostics according to the IFCC WG-LEPS initiative: preliminary findings in China

Background

Quality indicators (QIs) are crucial tools in measuring the quality of laboratory services. Based on the general QIs of the Working Group “Laboratory Errors and Patient Safety (WG-LEPS)” of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), specific QIs have been established in order to monitor and improve the quality of molecular diagnostics, and to assess the detection level of associated disease.

Methods

A survey was conducted on 46 independent commercial laboratories in China, investigated using questionnaires and on-site inspections. Specific QIs established were mainly based on the specific laboratory work-flow for molecular diagnoses. The specific QI results from three volunteer laboratories were collected and used to validate their effectiveness.

Results

Of the 46 laboratories participating in the study, 44 (95.7%), conducted molecular diagnostics. Of 13 specific established QIs, six were priority level 1, and seven, priority level 3. At pre-evaluation of data from the three volunteering laboratories, it was found that the newly classified specific QIs had outstanding advantages in error identification and risk reduction.

Conclusions

Novel specific QIs, a promising tool for monitoring and improving upon the total testing process in molecular diagnostics, can effectively contribute to ensuring patient safety.

Clinical laboratory: bigger is not always better

Laboratory services around the world are undergoing substantial consolidation and changes through mechanisms ranging from mergers, acquisitions and outsourcing, primarily based on expectations to improve efficiency, increasing volumes and reducing the cost per test. However, the relationship between volume and costs is not linear and numerous variables influence the end cost per test. In particular, the relationship between volumes and costs does not span the entire platter of clinical laboratories: high costs are associated with low volumes up to a threshold of 1 million test per year. Over this threshold, there is no linear association between volumes and costs, as laboratory organization rather than test volume more significantly affects the final costs. Currently, data on laboratory errors and associated diagnostic errors and risk for patient harm emphasize the need for a paradigmatic shift: from a focus on volumes and efficiency to a patient-centered vision restoring the nature of laboratory services as an integral part of the diagnostic and therapy process. Process and outcome quality indicators are effective tools to measure and improve laboratory services, by stimulating a competition based on intra- and extra-analytical performance specifications, intermediate outcomes and customer satisfaction. Rather than competing with economic value, clinical laboratories should adopt a strategy based on a set of harmonized quality indicators and performance specifications, active laboratory stewardship, and improved patient safety.

Effectiveness of Practices to Support Appropriate Laboratory Test Utilization: A Laboratory Medicine Best Practices Systematic Review and Meta-Analysis

Objectives

To evaluate the effectiveness of practices used to support appropriate clinical laboratory test utilization.

Methods

This review followed the Centers for Disease Control and Prevention (CDC) Laboratory Medicine Best Practices A6 cycle method. Eligible studies assessed one of the following practices for effect on outcomes relating to over- or underutilization: computerized provider order entry (CPOE), clinical decision support systems/tools (CDSS/CDST), education, feedback, test review, reflex testing, laboratory test utilization (LTU) teams, and any combination of these practices. Eligible outcomes included intermediate, systems outcomes (eg, number of tests ordered/performed and cost of tests), as well as patient-related outcomes (eg, length of hospital stay, readmission rates, morbidity, and mortality).

Results

Eighty-three studies met inclusion criteria. Fifty-one of these studies could be meta-analyzed. Strength of evidence ratings for each practice ranged from high to insufficient.

Conclusion

Practice recommendations are made for CPOE (specifically, modifications to existing CPOE), reflex testing, and combined practices. No recommendation for or against could be made for CDSS/CDST, education, feedback, test review, and LTU. Findings from this review serve to inform guidance for future studies.