Day to Day Management of Quality Control Donna Walsh M.S. MT(ASCP) Deaconess Hospital Boston, MA.
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Transcript of Day to Day Management of Quality Control Donna Walsh M.S. MT(ASCP) Deaconess Hospital Boston, MA.
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Day to Day Management of Quality Control
Donna Walsh M.S. MT(ASCP)
Deaconess HospitalBoston, MA
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Why We Do Quality Control
Clients of laboratories services see the test results we produce as information and expect that information to be flawless, a very tall order. Statistical Quality Control practices is one of the tools of the trade utilized to approach reasonable levels of flawlessness.
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Why We Do Quality Control
We are all familiar with classical approaches to quality control and the frustrations involved when these approaches fail and we need to troubleshoot methodology before releasing results.
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Goal and Objective
This talk will review the basics of statistical quality control and some 'nuts and bolts' solutions to common QC problems.
Case studies will be used to illustrate effective strategies.
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Goals of those Attending Today
Improving Day to Day QC Decisions & Documentation and Review of QC
Trying to get the days work reported out
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Health Care Today
Emphasis today is on cost containment Laboratories have become cost centers as
opposed to revenue centers.» QC costs involve cost of QC material (special
controls can be very costly)» QC costs involve rework of out of control runs.
(labor, reagent and control cost)
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How Did We Get Here?
Levy-Jennings Plots were adapted from industrial use and have been in use to this very day since the 1960’s
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Classic Quality Control
Principles of Statistical QC» Control Solutions are used to make Control
Measurements» Control Measurements validate Unknown
Measurements» Statistical Measurements Provide Guidelines for
Acceptable Control Measurements
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Classic Quality Control
Example:
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trendshift
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Youden Plots
Looking at two controls at once
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low control
high
con
trol
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Ever Seen a QC Chart Like This?
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Dot chart of the
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Multi-rule Quality Control
Based on the concept that improved error detection is provided by selecting multi-rules over single-rule control procedures.
Widely used multi-rule control procedure is the one recommended by Westgard
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Westgard Multi-Rule Quality Control Scheme
control data
No
No No No No
No
Yes Yes Yes Yes Yes
IN-CONTROL ACCEPT RUN12s
13s22s R4s
41s 10X
OUT-OF-CONTROL REJECT RUN
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Available Options
Classic QC» very visual
» tedious manual record keeping
» often available as an on-line QC package for many automated systems
Multi-Rule» better error detection
» more cumbersome for operator
» easily adaptable to computer analysis
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Practical “Nuts & Bolts” Options
Include Analytical Performance in Control Parameter (mean & SD) Decisions» Use NCCLS EP-5 to evaluate precision.» Adapt Control Measurement Frequency to Testing Needs
Set Medically Useful Control Procedures» Controls Levels at Medical Decision Points
Consider Control Measurements Quality Checks» Keep track of lot numbers, calibrations & maintenance procedures » Use this procedural information to assign causes to failures of
quality checks
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Case Studies .... practical QC
Incorporating NCCLS EP-5 data into QC decisions
NCCLS EP- 5 data QC
Methodwithin run
% CV% of total variance
daily % CV
% of total variance
total % CV
% of total variance
% CV set @
Carotene @ 97 12.8% 23.0% 14.7% 30.0% 18.4% 47.0% 15.0%Carotene @ 228 7.6% 24.0% 8.5% 29.0% 10.8% 47.0% 10.1%IgA @ 121 1.1% 6.0% 2.9% 45.0% 3.0% 45.0% 5.5%IgA @ 359 1.1% 7.0% 2.7% 44.0% 2.8% 48.0% 5.8%
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Case Studies .... practical QC
Adapt Control Measurement Frequency to Testing Needs» NCCLS EP-5 calls for 2 replicates per run, 2 runs per day
for 20 day. Adapt to testing situation - Example: Stat Lab has three shifts and three controls for Oximetry
» Adopt CLIA definition of 24 hour = one run and assay 3 reps, for assay of new lot of control
» Implement different QC levels on each shift for periods of stable operation.
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Practical ‘Nut & Bolts’ HINT
Many of today's testing procedures have much improved analytical performance. You can take advantage of this improved accuracy and precision in the design of your QC protocol.
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Case Studies .... practical QC
Set Medically Useful Control Procedures» Example: Digoxin
YTD n=
1430
target mean
target sd
target% CV
YTD mean
YTD sd
YTD % CV
level 1 0.51 0.15 29.4% 0.70 0.20 28.6%level 2 1.51 0.20 13.2% 1.69 0.20 11.8%level 3 3.30 0.25 7.6% 3.33 0.27 8.1%
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Case Studies .... practical QC
Set Medically Useful Control Procedures» Example: pH Reference Range is 7.37-7.44
(range = 0.07)
» Control Material A; standard deviation = 0.014; +/- 2 sd = 0.056
» Control Material B; standard deviation = 0.005; +/- 2 sd = 0.020
» Control Material B is more costly than Control material A
But it is costly to walk too fine a line...
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Practical ‘Nut & Bolts’ HINT
Set the % CV tight or use a control protocol that has improved precision at Clinically Significant Decision Levels
Or put differently, make sure you have an appropriate target for the situation.
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Case Studies .... practical QC
Consider Control Measurements Quality Checks» Keep track of lot numbers, calibrations
& maintenance procedures » Use this procedural information to assign
causes to failures of quality checks
» Best way to document assignable causes of mean & sd changes
lot numbers
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Case Studies .... practical QC
Example: Preventative Maintenance Appropriate for Workload» Drugs by Fluorescent Polarization
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Case Studies .... practical QC
Increase PM frequency
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Case Studies .... practical QC
Example: new lot number of reagent
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Case Studies .... practical QC
Example: new lot number of reagent» shift in QC values correlated with
change in lot of reagent.» check to see if there is a shift in
unknowns (samples) or standards» matrix effect if shift is only in control
samples» adjust QC mean to account for shift and
avoid unnecessary repeat work.
Lot numbers5-1-95 xx02265-15-95 xx0228
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66.0
69.0
72.0
75.0
78.0
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Case Studies .... practical QC
Long standing shifts may not be obvious until a lot change causes a shift out of control
Check Year to Date and
or lot to date QC for any shifts or
trends.lot change
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Case Studies .... practical QC
Example: Glucose - shift in current month away from year to date when new electrode used.
YTD n= 398
target mean
target sd
YTD mean
YTD sd
monthmean
monthsd
level 1 72 3.0 74.5 2.20 76.3 2.2level 2 261 7.0 257.5 5.80 260.1 6.7
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8.70
8.85
9.00
9.15
9.30
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Case Studies .... practical QC
Example: Change in QC post calibration of new lot of Calcium
calibration done
Lot related shift post cal
on 5-10. Recal on 5-20 due to bias in
pt. checks
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Case Studies .... practical QC
Example of shift with no assignable cause» Lithium by ISE
0.68
0.71
0.74
0.77
0.80
0.83
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Trouble shooting- new control- recalibration- new electrode- fresh reagents
NOTHING WORKED!!!
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Case Studies .... practical QC
Lithium Statistical QC information
YTD n = 274 mean sd % CV
target 0.78 0.03 3.8%YTD 0.77 0.02 2.6%monthly 0.74 0.06 8.1%
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Practical ‘Nut & Bolts’ HINT
Running control samples is a check on quality; they do not control quality. You must do that yourself.
REPORT RESULTS!
There is NO such thing as a
QC Crystal Ball
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Recommendations
View the test results we produce as information » Include Analytical Performance in Control Protocols» Set Medically Useful Control Procedures
Make use of on-line QC packages» facilitates statistical quality control calculations» provides visual dot charts for operators
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Recommendations
Consider Control Measurements Quality Checks» Keep track of information that could validate a
change in the statistical QC parameters» Change QC parameters promptly when the situation
warrents» Use Patient Check Data to help in QC decisions
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Benefits
Accurate and Reliable Reporting of Patient Test Data
Well Documented Quality Control Program Day to Day and Cumulative QC data will be more
useful.