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Thursday, September 19, 2013

Laboratory Proficiency: Closing the Gap?



Laboratory Proficiency: Closing the Gap?

I have written on the subject of proficiency testing as a measure of laboratory quality before, especially on the consistent reality that large laboratories have consistently and progressively out performed small laboratories for the last decade.  [see:  http://www.medicallaboratoryquality.com/2012/10/laboratory-size-complexity-and.html ]. 
In our program this was not always the case, and indeed in the early years, based upon our program structure, all the laboratories performed equally on their category appropriate challenges.
Note:  In our program, we have an approach that works on the premise that large complex university based or similar laboratories often receive complex samples from complex patients, while smaller outpost laboratories do not receive as many complex patients and as a result tend to not see as many complex samples.  Thus we send complex university based laboratories more complex proficiency testing challenges, and send more basic samples to the outpost laboratories. 
Note within the note:  We know this is not always true.  These days people on dialysis or on cancer chemotherapy drugs can live almost everywhere.

Over the last 10 years. In direct correlation with a national drive to reduce laboratory access through closures, we have seen a consistent drop in the quality of laboratory proficiency in all microbiology laboratories except the largest and most complex.  The large laboratories primarily found in large urban centres, and often associated with university teaching hospitals have consistently maintained a proficiency well above 90 percent.  On the other hand, the smaller laboratories have not fared as well, As the size and complexity lowers, so does their proficiency.  This is magnified because we do send them the less complex challenges, and some have considerable difficulty, with a mean proficiency much closer to 70 percent.  We argue that this is not about finding fault, other than of the ministries of health who under-funded and under-supported these laboratories with fewer (or none) opportunities for continual improvement or refresher programs, and reduced their supervision by microbiologists to a near non-existent level.  Given the choice between supporting these laboratories or killing them off, the ministries have strongly moved to the latter. 
This may be effective use of resources, but the physicians and patients who live in these areas have not been getting much of a fair shake. 
But this year, it appears that something has changed; for reasons unclear there has been a substantial improvement in the proficiency testing scores of the smallest laboratories. I am not sure why.
I know it is not an arithmetic error.  I know it is not a knowing shift in the degree of difficulty in the challenges. 
It may be a geographic shift in the sense that the number of C1 laboratories has increased and that most of the laboratories are in one province, and many of them are laboratories recently downgraded by their province.  Maybe more of these laboratories have a higher level of local support 


At the moment I cannot say if the improvement is a transient bleep or a heralding of better laboratory performance yet to come.
Only time will tell.
Fingers crossed.

M

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