By Jane Gun-Munro, Director, External Quality Assessment
QMP–LS is pleased to introduce a new EQA report, the performance summary report. This report will be issued to participants annually and, unlike other survey reports, this report is multidisciplinary, encompassing all QMP–LS discipline surveys for which the laboratory is a participant. It is intended for use by laboratory management to understand overall performance of the laboratory and to identify areas for improvement. It is also a useful document for management review or quality assurance purposes.
An accurate assessment of laboratory performance in EQA requires responses to be measured over time. The introduction of performance scores in 2008–9 facilitated objective assessment of performance that could be measured. It also allowed QMP–LS to introduce cumulative reports by survey, to track performance over time and identify patterns or trends e.g., method bias, continued problems in testing for antimicrobial resistance etc., as well as understand whether or not corrective action had been effective.
To provide supervisors and managers with a summary of performance for each discipline, performance scores could not be used, since the type of performance score (PAD or Q) varies according to discipline and type of survey. Instead, performance is tracked by action codes which are common to all surveys and, based on score, indicate to participants whether or not corrective action is required. Table 1 provides a description of action codes.
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Table 1: Description of Action Codes
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Action Code
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Description
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Required Action
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Acceptable performance
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No action
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W1
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Warning or suboptimal performance in a single survey
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Investigate and retain internal discordant finding documentation
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A1
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Suboptimal/unacceptable performance in a single survey
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Investigate and submit completed discordant findings investigation form to QMP–LS
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A2
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Repeated/unacceptable performance in a single survey
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Investigate and submit completed discordant findings investigation form to QMP–LS
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A3
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Repeated unacceptable performance in two of three consecutive surveys
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Investigate and submit completed discordant findings investigation form to QMP–LS
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Level of concern: W1<A1<A2<A3
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The performance summary reports use these action codes to identify performance issues requiring corrective actions by survey, by discipline, and also indicate the analyte, parameter or test involved.
Figure 1 provides information on the number and type of action codes this laboratory received for its chemistry surveys during the 2010 calendar year. Detailed information for any of the individual surveys would need to be obtained from the survey-specific reports. The performance summary report also provides similar information for surveys in other disciplines. It should be noted that interpretive surveys, such as cytology, bone marrow and genetics, that are currently not scored, do not have cumulative reports and will not be included in these new reports.
Since these reports are multidisciplinary, they will be filed in their own folder on QViewTM (Figure 2).
This report will be filed in each laboratory’s QViewTM file during June 2011 at which time an email notification will be issued. The report will summarize performance in all surveys from April 1, 2010 to March 31, 2011.
If you would like additional information or wish to discuss any concerns regarding these reports, please contact Jane Gun-Munro at gunmunro@qmpls.org.