Quality Control

Lucila B. Rabuco, PhD

Objectives of Laboratory Quality Assurance

OBJECTIVES OF LABORATORY QUALITY ASSURANCE

Primary Goal

the production of high quality data through measurement instruments measurement techniques that are accurate, reliable, & adequate for its intended purpose

Should be accomplished in a cost effective manner under a laboratory quality assurance program with the following objectives:

Objectives:
1. To measure the accuracy and precision of results within and between laboratories. 2. To continuously assess the reliability of data generated by the laboratory. 3. To detect training needs of the laboratory staff.

4. To identify weak methodology and provide a continuing source of research problems.

5. To provide a permanent record of instrument performance as a basis for validating data and projecting repair or replacement needs. 6. To upgrade the overall quality of laboratory performances. 7. To improve record keeping and report generation. 8. To ensure the integrity of the samples submitted to the laboratory. 9. To help ensure that the laboratory results will withstand legal scrutiny in regulatory actions.

DIMENTIONS OF QUALITY 1. Performance

2. Features 3. Reliability 4. Conformance to specifications

5. Durability
6. Serviceability 7. Perceive quality 8. Aesthetics

DEFINITIONS OF QUALITY
1. Quality is a distinctive inherent feature. 2. Quality is a distinguished attribute.

3. Quality is a degree of excellence.

4. Quality is the totality of features and characteristics of a product or service that bear on its ability to satisfy given needs. 5. Quality is fitness for use. 6. Quality is fitness for purpose. 7. Quality is freedom from deficiencies.

8. Quality is conformance to specifications.

9. Quality is conformance to requirements. 10. Quality is zero defects, 11. Quality is customer satisfaction. 12. Quality is uniformity around a target.

13. Quality is the opposing force to lower cost and higher productivity.
14. Quality is the loss imparted to society by products.

QUALITY CONTROL
Definition Process of monitoring laboratory analyses to ensure accuracy of results.

Good Quality Control Program

Monitors test performance

Helps identify problems

Helps in assessing reliability of results

Quality Assurance Encompasses every aspect of the laboratory operation from patient identification, sample acquisition to the clear reporting of the final laboratory result.

Specificity A measurement of the incidence of negative results in persons known to be free of disease (true negative)

Specificity =

TN

x 100

All w/o disease

( FP + TN )

Sensitivity
A measure of the incidence of positive results in persons known to have a condition ( true positive )

Sensitivity =

TP ( TP + FN )

x 100

All with disease

Basic quality control involves the analysis of specific control fluids (serum, urine, CSF) at the same time patient samples are analyzed for the constituents of interest

Terms used in Quality Control

Accuracy
An indication of how close the answer obtained to the true value

Precision
Indicates how close the single values are to one another

Interassay vs intra-assay reproducibility

Quality Control Materials

drawn from a pool either from human or animal source

marketed commercially or may be prepared in the laboratory; Freeze-dried for long term stability 2 levels : normal range
abnormal range may be obtained either assayed or nonassayed

Uses of quality control data

To identify if: 1. The assay is malfunctioning & no data obtained are reliable.

2. A problem with the assay is developing and needs to be corrected

Levy-Jennings Plot (Shewhart Plot)

Trend analysis of quality control data

Westgard Rules for Quality Control

A set of criteria developed to improve quality of monitoring, decrease subjectivity in data analysis, and provide some help in troubleshooting.
1. (2S) 2. (3S) One control value exceeds

2sd from the mean

One control value exceeds

3sd from the mean

3. 2 (2S) Two consecutive control values exceed the same limit, either 2sd
4. R (4S) The numerical difference between two control values within the same run exceeds 4sd 5. 4 (1S) Four consecutive values (control) exceed either 1sd 6. 10 (x) Ten consecutive results all lie on the same side of the mean

Relationship between accuracy and precision

The Levy Jennings Plot

Use of the Westgard rules

Violations of the 1 (2S) and 1 (3S) Westgard rules

Violation of the R (4S) Westgard rule.

Violations of the 2 (2S) and 4 (1S)

Westgard rules

Violation of the 10 () Westgard rule

Laboratory Quality Control

An Overview

Definitions (1)

Quality Control - QC refers to the measures that must be included during each assay run to verify that the test is working properly. Quality Assurance - QA is defined as the overall program that ensures that the final results reported by the laboratory are correct. The aim of quality control is simply to ensure that the results generated by the test are correct. However, quality assurance is concerned with much more: that the right test is carried out on the right specimen, and that the right result and right interpretation is delivered to the right person at the right time

Definitions (2)

Quality Assessment - quality assessment (also known as proficiency testing) is a means to determine the quality of the results generated by the laboratory. Quality assessment is a challenge to the effectiveness of the QA and QC programs. Quality Assessment may be external or internal, examples of external programs include NEQAS, HKMTA, and Qprobes.

Variables that affect the quality of results

The educational background and training of the laboratory personnel The condition of the specimens The controls used in the test runs Reagents Equipment The interpretation of the results The transcription of results The reporting of results

Errors in measurement

True value - this is an ideal concept which cannot be achieved.

Accepted true value - the value approximating the true value, the difference between the two values is negligible.
Error - the discrepancy between the result of a measurement and the true (or accepted true value).

Sources of error

Input data required - such as standards used, calibration values, and values of physical constants. Inherent characteristics of the quantity being measured - e.g. CFT and HAI titre. Instruments used - accuracy, repeatability. Observer fallibility - reading errors, blunders, equipment selection, analysis and computation errors.

Environment - any external influences affecting the measurement. Theory assumed - validity of mathematical methods and approximations.

Random Error

An error which varies in an unpredictable manner, in magnitude and sign, when a large number of measurements of the same quantity are made under effectively identical conditions.

Random errors create a characteristic spread of results for any test method and cannot be accounted for by applying corrections. Random errors are difficult to eliminate but repetition reduces the influences of random errors. Examples of random errors include errors in pipetting and changes in incubation period. Random errors can be minimized by training, supervision and adherence to standard operating procedures.

Random Errors
x

x x True Value x x x x x x x x x x x

Systematic Error

An error which, in the course of a number of measurements of the same value of a given quantity, remains constant when measurements are made under the same conditions, or varies according to a definite law when conditions change. Systematic errors create a characteristic bias in the test results and can be accounted for by applying a correction. Systematic errors may be induced by factors such as variations in incubation temperature, blockage of plate washer, change in the reagent batch or modifications in testing method.

Systematic Errors

x x True Value x x x x x x x

Internal Quality Control Program for Serological Testing

An internal quality control program depend on the use of internal quality control (IQC) specimens, Shewhart Control Charts, and the use of statistical methods for interpretation. Internal Quality Control Specimens IQC specimens comprises either (1) in-house patient sera (single or pooled clinical samples), or (2) international serum standards with values within each clinically significant ranges.

Shewhart Control Charts

A Shewhart Control Chart depend on the use of IQC specimens and is developed in the following manner:

Put up the IQC specimen for at least 20 or more assay runs and record down the O.D./cut-off value or antibody titre (whichever is applicable).

Calculate the mean and standard deviations (s.d.)

Make a plot with the assay run on the x-axis, and O.D./cut-off or antibody titre on the y axis. Draw the following lines across the y-axis: mean, -3, -2, -2, 1, 2, and 3 s.d. Plot the O.D./cut-off obtained for the IQC specimen for subsequent assay runs Major events such as changes in the batch no. of the kit and instruments used should be recorded on the chart.

Westgard rules

The formulation of Westgard rules were based on statistical methods. Westgard rules are commonly used to analyse data in Shewhart control charts. Westgard rules are used to define specific performance limits for a particular assay and can be use to detect both random and systematic errors. There are six commonly used Westgard rules of which three are warning rules and the other three mandatory rules. The violation of warning rules should trigger a review of test procedures, reagent performance and equipment calibration. The violation of mandatory rules should result in the rejection of the results obtained with patients serum samples in that assay.

Shewhart Chart
100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Antibody Units

+3 sd +2 sd +1 sd

Target value
-1 sd -2 sd -3 sd

16

Assay Run VZV IgG ELISA: Target Value = 49 U/ml

Warning rules

Warning 12SD : It is violated if the IQC value exceeds the mean by 2SD. It is an event likely to occur normally in less than 5% of cases. Warning 22SD : It detects systematic errors and is violated when two consecutive IQC values exceed the mean on the same side of the mean by 2SD.

Warning 41SD : It is violated if four consecutive IQC values exceed the same limit (mean 1SD) and this may indicate the need to perform instrument maintenance or reagent calibration.

Mandatory rules

Mandatory 13SD : It is violated when the IQC value exceeds the mean by 3SD. The assay run is regarded as out of control.

Mandatory R4SD : It is only applied when the IQC is tested in duplicate. This rule is violated when the difference in SD between the duplicates exceeds 4SD.
Mandatory 10x : This rule is violated when the last 10 consecutive IQC values are on the same side of the mean or target value.

Westgard Rules: 1 3SD

100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Antibody Units

+3 sd +2 sd +1 sd

Target value
-1 sd -2 sd -3 sd

16

Assay Run VZV IgG ELISA: Target Value = 49 U/ml

Westgard Rules: 10X

100 90 80 70 60 50 40 30 20 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Antibody Units

+3 sd +2 sd +1 sd

Target value
-1 sd -2 sd -3 sd

16

Assay Run VZV IgG ELISA: Target Value = 49 U/ml

Follow-up action in the event of a violation

There are three options as to the action to be taken in the event of a violation of a Westgard rule:

Accept the test run in its entirety - this usually applies when only a warning rule is violated. Reject the whole test run - this applies only when a mandatory rule is violated. Enlarge the greyzone and thus re-test range for that particular assay run - this option can be considered in the event of a violation of either a warning or mandatory rule.