Saturday, May 21, 2011


This entry is linked to specimen rejection, but not exactly in a linear fashion.

By way of circumstance I was invited to attend a meeting in eastern Europe with 5 other “EQA Experts” to assist and advise an initiative to develop a new national EQA program in a country looking to improve its quality monitoring and improvement of medical microbiology laboratories.  The meeting went as anticipated, some presentations (all well received), a lot of discussion with a lot of agreement points, along with some ongoing barriers, mostly of a “small-p” political nature.  At this point there was general sense that none of the barriers were insurmountable.

But that is not what I want to talk about.

What was interesting to me was to see how differently very established EQA programs can be at some very basic fundamental philosophical levels.  All of our programs were of a similar age (25-35 years) and all in developed countries.  All of us, while not being wealthy (NOBODY gets rich on EQA!) all of the programs were financially stable, and had well established infrastructure.  All the programs were headed by either senior experienced staff with similar backgrounds with university affiliations and clinical laboratory experience and expertise.  Some had more patient experience than others.  

So you would not be surprised that there was a lot in common with the programs.  Everyone recognized that EQA and Accreditation often worked hand-in-hand as Quality Partners, each with their independent mandate.  Everyone saw that given a choice, EQA was best focused on education and improvement rather than on laboratory censure or closure.  We all saw EQA much more as a CARROT than as a STICK.

But there was a core difference with essentially half the group on one side and half the group on the other.  One side (I will call them the “technical” or "archaic" group) perceived EQA as a tool only to address measurement of technical competency, while the others (I will call us the “progressive” or “clinical competency” group) saw EQA as a broader measure with a mandate to monitor to the extent possible, the delivery of clinically relevant and timely accurate information. [We recognize that timeliness is probably the hardest attribute to measure, but as on-line systems improve, timeliness is likely to become a part of the assessment process sooner rather than later.]

While we all develop tools to measure examination phase  microbial identification and susceptibility testing or serological or toxin testing positive/negative testing, the technical group stopped at this point  There might be an inclusion of a brief clinical history statement, but it was there mostly to provide some context for interest.  

On the other hand, the clinical competency group integrated the clinical context much more deeply and introduced pre-examination and post-examination variables into the laboratory monitoring process.  Factors such a patient age and clinical circumstance are integrated into the history as factors to be taken into consideration in the investigation of the sample.  Pre-examination variables may be added in.  Post-examination issues such as interpretation, and report construction, and inclusion of informative or cautionary notes, and clinical vocabulary are included in the report process.
In this approach the laboratory is expected to distinguish between known or probable pathogens from contaminants or normal resident flora.  Susceptibility testing needs to take into consideration age, and wound location.  Do the laboratories report relevant information of public health or infection control.  

The point is that over the last 25 years, microbiology laboratories have progressive become more like biochemistry and haematology laboratories.  The technical aspects, which used to depend on technologist knowledge and skill have been overtaken by machines.  EQA technical testing is no longer a challenge of laboratorian skill, it is more an extension or variation of quality control and the use of control materials.  The human skill now lies far more in the areas of clinical relevancy, sample acceptability (I mentioned before the link to rejection criteria) and the appropriateness of the information that the laboratory provides to the clinician.  
And that is the area upon which we need to focus our education and improvement energies.

If EQA wants to remain relevant to the laboratory and continue to play a role in improving patient care, then it is time for all programs to move on.  

Adapt or die.

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