4 CHAPTER IV: RESULTS
4.3 Qualitative analysis
4.3.1 Specific objective 4: Determination of the role laboratory workers and managers think proficiency testing plays as a quality assessment technique
4.3.1.2 Perception of laboratory staff towards proficiency testing
Quality assurance/Quality control programmes in laboratories
All respondents except one agreed that standard operating procedures were available in all TB laboratories. All responders except one mentioned that quality assurance/quality control was performed regularly in their laboratory.
Most responders (80%) indicated that proficiency testing slides were processed by the same people processing routine TB specimens. However, one laboratory encourages all
microscopists to read proficiency testing slides and record their results. The proficiency testing slides are then checked by a senior medical technologist. It can be assumed from this that the results were discussed or even debated before they were sent back to the reference laboratory. The advantage of this is that all microscopists were given the
opportunity to read the slides and was mentored. In reality routine patient specimens are not treated in such a manner and patients do not have the luxury of having their sputum
examined by several microscopists. The disadvantage is that the proficiency testing results sent to the reference laboratory would be biased.
One respondent mentioned that proficiency testing slides were not always processed by the same person performing TB microscopy routinely. He felt that there was a perception among laboratory staff that proficiency testing was a punitive measure and that if someone read slides incorrectly then they would be punished. Therefore a small number may have treated proficiency testing slides in a 'special way'.
All respondents except one felt that proficiency testing was a valuable exercise and not a waste of time. One microscopists at facility level mentioned that she felt that proficiency testing was 'good practice and not waste of time, it gives us an idea of how we are working and it encourages us to read slides properly; I like QC\ One laboratory manager mentioned that 'it is very valuable and ensures that correct, reliable and accurate results are released'.
One respondent felt that blinded re-reading would be more valuable than proficiency testing. He felt that people knew that they were being tested and therefore asked friends to assist or spent more time reading proficiency testing slides.
Processing of proficiency testing slides
Five respondents agreed to some extent that some laboratory managers get the best person to process proficiency testing slides or even process it themselves. However this was not a widespread phenomenon as one laboratory manager mentioned 'this could be true but not in most labs'. This would also depend on the size of the laboratory as some laboratories have only one staff. Proficiency testing results would be biased in laboratories where laboratory mangers punish staff for producing poor results. In these laboratories staff would be pressured to produce correct results and therefore would resort to seeking assistance when reading slides.
Six (60%) of the respondents felt that proficiency testing was effective enough to detect errors in microscopy technique. One respondent felt that it was effective to a certain extent, while another felt that it was effective provided that slides were read in duplicate. This might be to confirm results of the first reading by the second reader. However, this would also bias the proficiency testing results.
Two respondents felt that proficiency testing was not effective enough to detect errors in microscopy technique. One respondent mentioned 'they don't tell us anything about over- decolourising or staining. Hence we introduced rechecking to supplement proficiency testing. Proficiency testing is the minimum requirement by WHO'. It is a concern that some laboratory staff did not regard the proficiency testing exercise as effective enough.
However, it is encouraging to note that another method of quality assurance (slide re- checking) was explored. Blinded rechecking is considered the best method for evaluating performance and providing motivation to staff for improvement. [11]
The time spent reading slides varies between laboratories and depend, to a large extent, on workload of the laboratory and on the individual. Five respondents mentioned that about five minutes are spent on reading each slide, one respondent mentioned 5- 10 minutes and another mentioned about 30 seconds for positive slides. Three respondents were doubtful and implied that much less than the recommended five minutes are spent reading each slide due to the high workload. One microscopist mentioned that she would seek assistance when she encountered problems reading slides. Two respondents expressed that low positives are missed when microscopists do not spend adequate time reading slides.
Feedback
Respondents indicated that feedback was inconsistent from both the KwaZulu-Natal
reference laboratory as well as the National Health Laboratory Service reference laboratory.
This could be due to several reasons. Some of the reasons mentioned were: proficiency testing results could be going to unit business managers and was not filtering through to the microscopists, communication between reference laboratories and the peripheral
laboratories were poor and all TB coordinators except for one was removed from the programme.
Standard operating procedures
Nine (90%) of the respondents were convinced that standard operating procedures were available in the, laboratories. However one respondent felt that standard operating
procedures might not be available in all smaller laboratories in KwaZulu-Natal, whereas all National Health Laboratory Service laboratories had standard operating procedures.
Training
Many respondents (60%) felt that microscopists are adequately trained but many (40%) of them also expressed doubt. The level of training depended on whether microscopists attended a formal training course or whether they were trained at a laboratory. There is a perception that medical technologists and microscopists that attended a formal training
course was better trained than microscopists that trained at a laboratory with a high workload.
Training was provided in 2006 for TB microscopists in all districts. In addition 46 new TB microscopists were employed in almost all districts in the province. Other categories of staff were also employed in the laboratories.
Problems experienced with proficiency testing.
Quality assurance/Quality control programmes in laboratories
• Some laboratory managers get the best people to process proficiency testing slides or even process it themselves
• Proficiency testing does not assess quality of stains or the staining process Processing of proficiency testing slides
• Some laboratory managers punish staff for producing substandard proficiency testing results.
• High workload prevented people from spending the recommended amount of time on each slide.
• Low positives are missed when less than the recommended amount of time is spent on reading slides. However, failure to correctly diagnose low positives (low false negative results) may be due to other causes as well (see table 17).
Feedback
• Feedback from the reference laboratories was inconsistent
• Poor communication between the reference laboratory and the peripheral laboratory.
• Poor communication between the laboratory management and staff.
• Standard operating procedures may not be available in all laboratories Training
• There was doubt as to whether all TB microscopists were adequately trained.
• Refresher training was conducted in 2006 in all districts.