Quality Improvement Metrics Q4 2017

INTRODUCTION

The National Reference Laboratory, NRL, part of Mubadala’s network of world-class healthcare providers, and managed by Laboratory Corporation of America Holdings, LabCorp, became the largest laboratory network to be accredited by the College of American Pathologists, CAP, in the Middle East in July 2017.  The CAP inspection process included a first time inspection for  Imperial College London Diabetes Centre in Zayed Sports City and Etihad Airways Medical Centre thus bringing the number of CAP accredited NRL laboratories to eight.

In addition to achieving such an oustanding recognition, NRL initiated a systems inspection approach for the first time in fourth quarter of 2017.  In September and November 2017, over a period of ten days, seven of the laboratories within the NRL network were successfully inspected by ISO 15189 United Kingdom inspectors.  This initiative will continue with the CAP inspections in 2018 and for all accrediting bodies in subsequent years.  A system wide inspection will further enhance development and monitoring of  NRL’s standardization and integration  processes as well as provide cost and operational efficiencies for inspection preparedness to include time management and logistic arrangements. The specific outcomes anticipated as a result of a system wide inspection include the following:

  • Improve standardization of administrative, operational and quality management policies and procedures
  • Single, central management team and resources resulting in continuity of oversight
  • Enhance the current implementation process for on-going quality improvement and safety programs within the network

An overview of NRL’s record breaking 14 inspections throughout 2017 are summarized below:

STRATEGIC QUALITY METRIC

1.Sharing Best Practices Within the Region

Purpose:

Sharing best practices with healthcare professionals in the area of laboratory medicine is a core theme of NRL’s mission. The on-going innovation and advancements in laboratory testing and technology are remarkable, and it is one of our goals and responsibilities to educate laboratory professionals, physicians and patients about these exciting changes. These advancements serve to facilitate faster diagnoses for more accurate treatment decisions, which ultimately increase the quality of care for patients in the region.

Action/Outcome:

NRL is reinforcing its commitment to raise laboratory quality excellence in the region through collaborations with CAP. NRL sponsored a CAP Laboratory Inspectors Training Program on November 4th, 2017 in Abu Dhabi. The program was a first in the region and welcomed over 250 professionals from CAP-accredited laboratories in the UAE and the Middle East.

Dr. Bharati Jhaveri, Chair of the CAP Council on Accreditation, stated, "This achievement marks an important step for NRL as it continues to expand its network of CAP-accredited laboratories, addressing the region’s unique healthcare challenges and raising the standard of laboratory services, an integral component in the delivery of world-class healthcare."

A complete list of  the events NRL hosted and/or participated in during the second half of the year are highlighted below:

Date - Q3 2017

Event

Topic

Speaker

Aug 17, 2017

Al Jalila Children’s Specialty Hospital in Dubai

"Sample Collection and Phlebotomy" Hands-on seminar

Abigail Baguio and Dr. Vladimir Sashkov, from BD

Aug 24, 2017

Nation Hospital in Abu Dhabi

"Sample Collection and Phlebotomy" Hands-on seminar

Abigail Baguio and Dr. Vladimir Sashkov, from BD

Date - Q4 2017

Event

Topic

Speaker

Nov 4, 2017

CAP Inspection Training hosted by NRL

"Point of Care Testing"

Edna Parker

Nov 16 - 17, 2017

ASCP Pathology Update 2017 - Abu Dhabi

"Non Fasting Lipids"

Dr. Jay Murthy

"Hemaglobinopathies Overview and Interesting Case Discussion"

Dr. Shereen Atef

"Serum Protein Electrophoresis Workshop"

Dr. Shereen Atef

"Investigation of Hypercoagulation Disorders"

Michael Taylor

"Quality Toolbox 101 and Inspection Preparedness"

Edna Parker

"Modern Approaches to Quality Control Practices"

Faisal Ibrahim

Dec 16, 2017

3rd Emirates Surgical Pathology Conference

"Diagnostic Challenges in Prostate Pathology"

Dr. Basel Altrabulsi

"Diagnostic Challenges in Bladder Pathology"

Dr. Suhaila Alameeri


2.New Test Integration

Purpose:

Test menu expansion to achieve enhanced patient, quality care and business growth is an area that must be monitored for appropriate management. Patient and client impact and the cost to integrate new tests and sustain the current test menu are key considerations in this endeavor.  NRL collects all relevant data before an assay is added to the test compendium to ensure quality of care and operational processes.

Action/Outcome:

During Q4 2017 the following tests were integrated into NRL’s test menu and are now offered to all clients. 

Order Code

Order Code Name

162388

Anti-Neutrophil Cytoplasmic Antibodies (ANCA) by IFA

162388

ANCA Profile

10095

Free Kappa Light Chains, Free Lambda Light Chains, and Kappa/Lambda Ratio

9924055

Acid Fast (Mycobacteria) Smear

9924063

Acid Fast (Mycobacteria) Smear and Culture with Reflex to ID and Susceptibility

9924061

Acid Fast (Mycobacteria) Smear and Culture with Reflex to ID

9924057

Acid Fast (Mycobacteria) Culture and Identification

9924059

Acid Fast (Mycobacteria) Antibiotic Susceptibilities


NRL’s Anatomic Pathology department continues to validate and expand the Immunohistochemistry (IHC) stains offered.  Currently, 160 different IHC stains are available; more than any other reference laboratory in the UAE.

New IHC Stains Offered

Order Code Name

Clone

CPT Code

Clinical Application

ACTH

Polyclonal

88342

Marker used in classification of pituitary adenomas

Prolactin

Polyclonal

88342

Marker used in classification of pituitary tumors and the study of pituitary disease.

SV-40

13B10

88342

SV40 is associated with brain tumors, bone cancers, non-Hodgkin lymphoma, and malignant mesothelioma.

   Hepatocyte/                   

     Hep Par1

OCH1E5

88342

Useful for the differential diagnosis of hepatocellular tumors in general, for the differentiation of clear cell HCC from other clear cell malignancies, and for the distinction of hepatoblastoma, especially the embryonal type, from other small, round-cell tumors of childhood.

Beta-Catenin

14

88342

For identification of desmoid tumors, colorectal cancer and colon adenoma

Inhibin

R1

88342

For identification of ovarian sex cord and stromal tumors such as granulosa cell tumor. Other positive tumors include complete hydatiform mole, gynandroblastoma and adrenal cortical adenocarcinoma.

CK17

SP96

88342

For staining of cytokeratin (CK 17) in myoepithelial cells of human complex epithelia found in various carcinomas such as pancreatic adenocarcinoma and squamous cell carcinoma of the lung

Uroplakin

SP73

88342

For the specific identification of urothelial carcinomas in patients with metastases of unknown primary site.

Actin, Muscle Specific

HHF35

88342

For identification of soft tissue tumors with muscle differentiation, i.e. leiomyoma, leiomyosarcoma and rhabdomyosarcoma.

KEY PERFORMANCE INDICATORS

1.Specimen Rejection Rate

Purpose:

Maintaining specimen quality at all points of the laboratory path of workflow is critical for the accurate analysis and reporting of patient results. This indicator monitors the total number of specimens rejected for testing. Rejected specimens data are used to educate clients, staff and vendors to ensure quality specimens are received into the laboratory. Identifying the number of specimens that are inadequate for testing  is a critical area for improvement to ensure accurate patient results, optimum operational efficiencies and sustained financial stability.

Target: < 0.3% rejection rate for all NRL departments

Action/Outcome:

NRL departments met the acceptable average percent rejection rate of < 0.3% in Q4 2017.

Specimen Rejection Rate – 2017

2.Quality Concerns/Non-Conformities Monitoring

Purpose:

The investigation, review and monitoring of nonconformities is an important component of NRL’s Quality Management System (QMS). Utilizing the Corrective Action Preventive Action (CAPA) module in NRL’s electronic, document control management system, the QA department is able to identify, track and control nonconformities which are referred to as Quality Concerns.  There are two types of Quality Concerns:  Internal and External.  Internal concerns are identified by staff within the organization.  External concerns are raised by clients and customers for necessary follow-up and resolution.  Identifying the root cause of non-conformities is essential for continuous quality improvement.  

Monthly Quality Concern Meetings are held with representatives from all departments including management, finance/insurance, business development, technical operations and information technology. The meetings focus on data review and analysis for associated improvement.  Their mission is to:

  • enhance NRL’s level of service provided to clients
  • detect potential errors internally and identify educational opportunities
  • identify the root cause of non-conformities and formulate corrective and preventive action plans
  • monitor quality concern data and key performance indicators

Target: < 0.2% of total monthly test volumes

Action/Outcome:

The rate of internal and external quality concerns raised and addressed during Q4 2017 are performing well below the 0.2% threshold. 

Overall rate of Quality Concerns in 2017

Quality Projects Summary for 2017:

National Reference Laboratory has had a successful year and the following quality strategic projects were implemented and completed in 2017:

  • System ISO Inspection for 7 sites:
    • 4 surveillance audits (ICAD, ICLDC AD, ICLDC AA, HP)
    • 1 reaccreditation (Dubai)
    • 2 initial accreditations (ICLDC ZSC and EAMC)
  • 5 CAP inspections  
    • 3 reaccreditations (Dubai, HP, CCAD AP)
    • 2 initial accreditations (ICLDC ZSC and EAMC)
  • 2 HAAD inspections
    • ICAD – OSHAD renewal certificate audit
    • HP - Post Relocation Audit
  • Completion of Auto verification (AV) project; scope included:
    • HP – Coagulation, Chemistry and Hematology
    • Dubai - Coagulation, Chemistry, Immunoassay and Hematology
    • ICLDC AD/AA/ZSC  - Chemistry, Immunoassay/Serology and Hematology
    • ICAD – Coagulation, HIV, and Hematology
  • Completion of Technical SOP Project
    • Phase 1: Total of 231 SOPs reviewed (100% completion)
    • Phase 2: Total of 174 SOPs reviewed (100% completion)
  • The Quality Assurance department is actively working with Al Jalila Children’s Hospital Laboratory to prepare for CAP accreditation
  • Quality Management System Implementation for 2 new sites
    • EAMC
    • ICDLC ZSC
  • 132 QA verifications performed for all sites throughout the year to ensure inspection readiness
  • Continuous oversight of the incident reporting process and document management system
  • Quality and safety management oversight including quarterly submissions to HAAD
  • Key Performance Indicator monitoring and the facilitation of Quality Circle and Quality Concern Meetings

NRL QUALITY DASHBOARD - Q4 2017