Wednesday, November 29, 2017

Quality Progress Taking Hold in African Countries

I was looking at some earlier files and presentations, going back to 2004-2005.  The subject from this retrospective “look-back” was my involvement in laboratory quality in African countries.  My introduction was through a senior partner group participating in the US President’s Emergency Program for AIDS Relief (PEPFAR) program set up by George W. Bush.  To the credit of the people responsible, they were able to see that establishing a program of monitoring for AIDS diagnostics was going to require the establishment of Africa based laboratories capable of Quality and Competent practices.  

Back then there was lots of evidence that this was going to be a major barrier.  Laboratories were working with at best rudimentary equipment, usually with out-dated reagents.  Samples all too frequently were being delivered to the laboratory not in typical sample container tubes, but more likely in repurposed medication vials.  Additives like heparin were being added by hand and pipette with little sense of precision.  In microbiology, critical samples such as blood cultures were a travesty,  with reliability closer to 30-40%; huge false positive results from contamination and false negative results from faulty media and terrible technology.  
When I think back to those days, my amazement of what is happening today is triple underlined and reinforced in gold.  

This week we are finishing off a 21-week on-line course that was put on for 15 Quality Assurance Officers.  This group has the same level of knowledge and sophistication about laboratory quality as peers almost anywhere in the world, and truly better than most.  Our discussions about things Quality, like internal audit, quality indicators, document control, quality control, inventory management, Lean, 5S, Six-Sigma, SIPOC would parallel or surpass many laboratories in much wealthier laboratories.   

So how did the laboratories get from then to now?  With a lot of work both from without and within.

Importantly governments from around the world, and US in particular, have spent a ton of tax-payer supported money, supporting laboratories, equipment, PEPFAR partners, mentors, and education.
But all that and a another dollar and a half would still not buy a Starbucks coffee were it not for a massive effort from the Africa Society for Laboratory Medicine (ASLM).  It was ASLM who with the support of World Health AFRO who introduced two programs; Strengthening Laboratory Management Toward Accreditation (SLMTA) and Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA).  SLMTA is an education program to promote education and knowledge about laboratory quality and SLIPTA is a graduated check-list that allows laboratories work at their own pace towards preparation for international accreditation. 

SLMTA and SLIPTA were introduced and implemented into some 1000-plus laboratories in near 50 different countries.

I know these programs were effective in moving the progress towards success because we had introduced earlier progenitor programs under the PEPFAR banner.  SLMTA and SLIPTA differed from what we did because they were Africa created, Africa taught and mentored, and Africa monitored.  

[To be honest, I am not sure that I see international accreditation as an important goal for many laboratories anywhere in the world, much less in Africa.  Most laboratories don’t do enough international work that then need to achieve accreditation to keep them in the international flow.  I do see the international documents a worthy goal, and a standard that states, provinces and countries everywhere can and should adopt in lieu of home-brew accreditations. 
But while that is a side digression, let me just say the next step to African laboratory quality is going to have to require African countries stepping up to the plate and demanding laboratories meet certain accreditation expectations for the sake of patient safety.]

To be fair and honest, many (most) laboratories in Africa that I have seen would not be able to function providing services in most developed countries, but that is NOT the fault of the laboratories.  The single biggest problem is that equipment and reagent distributors do not serve the laboratory community in Africa in the same way as they do in Europe or North America.  Part of this is money, and part is passivity, but the reality is that African population is around 1.2 billion people, and there is every reason they should be able to expect and demand better service.

But getting back to my original commentary.  Over the last 15 years we have seen monumental progress in medical laboratory performance and quality in many African countries.  
I would like to delude that I had a tiny role to play in this, but that would be grandiose thinking.

 African physicians are now in a position that they can actually make clinical decisions based on laboratory test results.  That was not the case a mere 15 years ago.

There clearly is more work to be done, but I NEVER would have imagined that we would see the levels of success that we are seeing today. 

Wednesday, October 4, 2017

A successful Quality conference

The Department of Pathology and Laboratory Medicine’s  Program Office for Laboratory Quality Management hosted its 6th October Quality Conference at the Paetzold Education Centre at the Vancouver General Hospital  from  October 1-3, 2017.  

The theme of Laboratory Quality in Challenging Times seemed to be appropriate.  While the reality of medical laboratories for the past twenty-five plus years, seems that it is always challenging, we seem to be reaching a capstone point with shrinking resources, fewer (and aging) staff, increasing customer expectations and demands, new sources of competition, and disruptor technologies.  Laboratory life is becoming a perpetual "Advil" moment.  On a more positive note, we are seeing new and thriving signs of inspiration and initiative and innovation.  

Tomorrow may yet be a better day!

The conference was attended by around 80 participants including students from the university and provincial institute of technology.  While most attendees were from my home province, there were also laboratorians from across Canada and from the United States.  Its good to have a base, but I will continue to push for a broader audience.

 For a Canadian conference on Quality I was very satisfied with the audience size.  It created a great opportunity for both individual and group participation in a way that larger conferences can't offer.  One example:  After each themed section with two or three speakers, there was a round-table discussion in which the audience, speakers, and moderators could discuss, challenge and debate for 20-30 minutes.  It was an energizing participatory exercise that created as many sparks as the presentations themselves.  Tough to do that with an audience of 500 or more..

 A coterie of excellent speakers from our department, from across Canada and international spoke to the theme of Laboratory Quality in Challenging Times, touching on topics including Patient-Centred Care, Laboratory Leadership, Improvement, Evolution of International Standardization, “Take-Away Tools”, Quality Initiatives, and the Opportunities for Quality Specialists.  Speaking to the collaborative program between POLQM and the International Training and Education Center for Health (I-TECH), currently in conjunction with the  American International Health Alliance, and the Ministry of Health Zambia,  Dr. Lucy Perrone, University of Washington and Directory of   I-TECH Laboratory Strengthening Program spoke of the International Opportunities in Quality and Dr. Michael Noble spoke to training in Quality through the Program Office’s  on-line Continuing Professional Development course.  

We were not surprised, but were still pleased to see that the participants scored the conference for its content.  It was clear that we hit all the relevant key-points for a Quality conference. 


In the on-line satisfaction survey, responses were received from more than 50 percent of the participants.  Significantly and consistent with human-sized conferences the conferences was rated highly for networking opportunities.  

Overall, the conference was rated at an impressive average score of 86/100 (median score  89 and mode score 90).

Planning for our next October Quality Conference (2018) will be starting soon.  

For those interested the presentations are available at

Tuesday, September 26, 2017

Motivation and Inspiration in Quality Teaching

I have a personal story about my quality adventure.  I have mentioned it before, but it is worth repeating. 

 In 2002 I was shamed into pursuing international recognition for CMPT, my proficiency testing program by a laboratory technologist who accused me and others associated with laboratory oversight as being FRAUDS because we exerted our authority over laboratories making performance demands while at the same time requiring no similar demands on ourselves.  She was disturbingly  but absolutely correct because back then neither my province nor my country required or expected either  accreditation bodies or proficiency testing bodies to demonstrate competence through objective oversight.
In the absence of an established credible laboratory quality standard (at the time) we immediately started our process towards have our quality system developed and certified to ISO9001:2000. 

[Note: while ILAC guide 25 for testing laboratories and ILAC guide 43 for proficiency testing bodies existed, there were no Canadian bodies that would assess against either guideline at the time. There were however Canadian certification bodies that could assess against ISO9001].

In order to implement our voluntarily imposed quality system, we hired a quality consultant but things were not going well.  One day he called me aside and pointed out that when he was around, I would work with him on the QMS.  When he was NOT around I would STOP working.  Josef made it clear: “This was NOT his QMS, and was NOT his laboratory.  If I wanted this to actually happen, I would have to take ownership and get my act in gear”.  Again, he was right and I was definitely wrong.
With the appropriate well placed kick, we got ourselves going, completed our certification and have maintained it ever since, most recently to ISO9001:2015. 
By every measure CMPT improved substantially and has grown from being a local program to a national and now international EQA provider.  In 2014 we extended our commitment to quality and added international accreditation (ISO/IEC17043:2010).

The reason that I recount this story is because it is a very personal good example of a general truth: the impetus and inspiration to Quality can come from the most unexpected of places, but the drive and motivation to Quality must come from within.   

The story has relevance for me because over the years we taken that same passion and commitment and put it into creating our Certificate Course in Laboratory Quality Management.  We have now trained close to 400 people.  Most have come from Canada or the United States or some of the wealthy developed countries in the middle East.  Some have come from much less wealthy regions. 

While about 95 percent do well enough to earn their certificate and by survey enjoy what we offer, by my estimate less than half leave the course with the sort of commitment and drive to make an inspired career in the Quality arena.   

We occasionally get folks that folks who come uninspired and leave uninspired.  Recently we had a person, very senior in laboratory hierarchy, who paid the tuition money, started the course but hardly ever participated and then quit showing up after about a month and then just disappeared.  I wonder how the employer felt about frittered money. 

I will tell you that every once in a while, we get a note that something has happened and they were unable to continue. Sometimes we can offer a rebate, or an invitation to come back and continue next year.  In this situation, they didn’t ask and we didn’t offer.

But because we are aware of  and pay attention to those who don’t move forward, we spend a lot of time and energy focusing on course improvements and the changing picture of quality.  We promote leadership and innovation and their impact on culture of quality and the development of quality tools.  We focus as much (or more) attention on challenging participants to look for and find positive and progressive opportunities for improvement as we charge them to monitor and identify and remediate and correct findings of non-conformities.

And sometimes we get our special rewards for the effort when we receive letters and notes from the enthusiastic participants who tell us about how our course inspired them to take their laboratory quality to the next level.  

So here is the point that I am making.  Despite our efforts at continual improvement and promoting communication and participation and learning and teaching new skills, taking our course can not guarantee to imbue all participants with the drive and motivation to engage in quality passionately, but I sure am pleased that we have been able to provide more than our fair share with the impetus and drive (and in some instances, passion) to help make laboratories better.

There is much to be gained being committed to providing quality Quality education.