Sunday, October 14, 2012

Laboratory Size, Complexity and Performance

Size Matters.

Tomorrow is our Annual General Meeting for CMPT, our proficiency testing program.  I have updated my meeting presentation to include all our review materials for the year that ended May 2012 (2011-2012). 

One subject that gets addressed in laboratory performance, not in the sense of finger pointing, but as a measure of our performance as a Quality Assessment program.

I have talked about this subject before, but obviously without particular effect.  To me it is a big deal.  Others may not see it that way, but I think they would be wrong.

We run CMPT which does proficiency testing in clinical and water bacteriology across Canada.  Proficiency testing programs structure themselves in one of two ways, either they give all laboratories the same challenges all the time, or they do not.  We do not.

When we started we stratified the laboratories into two groups.  The largest was category A are large complex laboratories that are expected to handle samples from all sorts of situation.  Often in addition to being large facilities with their own sample load, they also receive referral samples from smaller laboratories. The second group, category B, was large laboratories that tended to work at a lower complexity level.  They were less likely to receive cerebral spinal fluid samples or samples from severely immune compromised patients.  [Note: with the increase in homecare, and political will to ensure more services outside the core, the lines between categories A and B have blurred over time].  

As our program expanded we developed two additional categories; category C which are generally small rural laboratories, and category C1 are facilities whose primary function is to do sample set-up and then pack and ship.  The may be asked to so some basic tests which are defined to include preparing and examining Gram stained slides.  In my mind I would not call microscopic examination a basic procedure.

With 4 categories we decided from the get-go that large complex [A labs] would get a large volume of PT samples that include basic samples, complex samples, and very complex samples.  category B would get many of the same set, but would not get the very complex, largely because they would likely not see those samples often.  Similarly category C got fewer samples, and even less complexity, and category C1 received samples one-notch less.  If laboratories wanted to compare themselves [I hate that!], at least they could see themselves in a pool of comparable organizations.  The point was that we expect to see all laboratories performing well, if not perfect, as compared to others in their group.  

Unfortunately it doesn't work out that way.

Every year, the smaller the laboratory, the less well it performs, and over the decade the trend has never corrected and if anything continues to deteriorate.  This is not a good thing.  

Our best guess is that what this reflects is the relationship between size and complexity, and money, and opportunities for Quality.  The larger the laboratory, the more younger staff they can hire, the more continuing education they can support.  Money buys success.  The smaller laboratories have fewer staff, fewer fresh staff, less money for continuing education and fewer opportunities for Quality.  And the smaller the laboratory, the worse the situation.  

Proficiency testing should not be about inter-laboratory comparison in the sense of a competition.  That is an obsolete old notion retained mainly in the minds of bureaucrats.  But in this sense group to group comparison has value and merit.  

People living in small towns deserve to know that if they get a test done at a local medical laboratory they should have the assurance that the test should be received, set-up, performed and read, and interpreted accurately.  At least at a level higher than 70 percent.  I think that is part of the social contract.  It certainly is part of Patient Safety.

Maybe what is happening is they process all their regular sample work just fine; they only make their errors on the PT samples.  


But here is a scary thought.  Imagine what the graph would look like if we gave all the laboratories regardless of size or complexity the same challenge samples.

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