QAP and QC

CLINICAL LABORATORY
Outline
1. Quality assurance program
2. Quality control
a. QC parameters
b. Types of QC
c. QC materials/reagents
d. QC statistics and calculations
e. Types of QC chart
f. Levey-Jennings chart
Learning outcomes
At the end of this topic the student should be able to;
1. Define Quality assurance program
2. Describe the quality control as part of quality assurance
3. Know the different terminologies and components of QA
4. Create a Levey-Jennings chart using a Microsoft excel.
QUALITY ASSURANCE (QA)
• A systematic process to ensure quality, means accurate and precise
laboratory results.
• It consist of laboratory policies, processes, procedures and resources.
• It is planning, monitoring, documenting, and implementing set
guidelines through out the laboratory analysis.
QUALITY ASSURANCE (QA)
Covers the entire laboratory process
1. Pre-analytical phase
2. Analytical phase
3. Post analytical phase
QUALITY ASSURANCE
Pre analytical phase
1. Patient identification and preparation.
2. Specimen collection and labelling.
3. Specimen rejection criteria.
4. Specimen handling (preservation and transportation).
QUALITY ASSURANCE
Analytical phase
1. Test report completeness.
2. Quality control.
3. Proficiency.
4. Machine and reagent maintenance.
QUALITY ASSURANCE
Post analytical phase
1. Accurate and reliable report system.
2. Timely reporting of results.
3. Storage and retrieval of results
4. Waste management
QUALITY CONTROL (QC)
QUALITY CONTROL (QC)
• A part of Quality assurance program (internal quality control).
• It evaluates the validity of laboratory results before reporting.
• Aims to identify and correct errors to ensure accuracy and precision.
 QA
Pre analytical Analytical Post analytical

QC
Parameters of quality control
1. Accuracy
2. Precision
3. Analytical sensitivity and specificity
4. Diagnostic sensitivity and specificity
5. Reference interval
6. Reportable range
Quality control parameters
ACCURACY PRECISION/REPRODUCIBILITY
refers to closeness of measured the degree of closeness or
value of an analyte to its true agreement among values between
value. repeated measurements.
 Accuracy and Precision

Accuracy can be verified using samples with known values (controls, calibrators, proficiency samples).

Precision cab be verified by repeated testing the sample on the same day or different days to see how close the results
are.
Accuracy and Precision
Quality control parameters
Analytical sensitivity Analytical specificity
• Also known as detection limit. • Ability of test method to
• The lowest concentration of measure only the target analyte
substance that can be detected and not the other related
by test method. substances.
• High sensitivity decrease false (-) • High specificity decreases false
(+) and cross reactivity.
• Desirable for screening test
• Desirable for confirmatory test.
Quality control parameters
Diagnostic sensitivity Diagnostic specificity
proportion of population with proportion of population without
disease who will be positive for disease who will be negative for
result. result.
Also known as true POSITIVE Also known as TRUE NEGATIVE
RATE. RATE.
Calculation of diagnostic sensitivity and
specificity
Disease
Test Positive (+) Negative (-)
Positive (+) True positive (TP) False positive (FP)
Negative (-) False negative (FN) True negative (TN)

Formula
Sensitivity = TP/ (TP + FN) X 100
Specificity= TN/(TN + FP) X 100
Calculation of sensitivity and specificity
Disease
Test Positive (+) Negative (-)
Positive (+) 95 (TP) 5 (FP)
Negative (-) 75(FN) 25 (TN)

What is the sensitivity and specificity of newly developed test kit for Monkeypox?

• Sensitivity = TP/ (TP + FN) X 100

• Specificity= TN/(TN + FP) X 100
Quality control parameters
REFERENCE interval (normal values)
• a set of values with upper and lower limits based on a healthy
individual (120 person).
• Can be vary from different population (age, gender, race). Slightly
different in every laboratory
• Use to compared with patient value for laboratory interpretation.
• Manufacture’s reference range or laboratory’s own reference range
can be used if suitable for their patient population.
• E.g. glucose hexokinase test ( 3.5 - 5.0 mmol/L)
Quality control parameters
Reportable range
Also known as LINEARITY.
Range of values over which lab can verify accuracy of the test system.
Provided by the manufacturer and verify by testing 20 normal samples.
Other components of quality assurance
program
Delta check- comparison of patient data with previous result. It
determine if the changes is due to medical or lab error.

Critical values- test value that considered as life threatening. Glucose,

electrolytes, total bilirubin and blood gases are list typically. Immediate
notification to health care personnel should be done.
Types of quality control
Intralab QC Interlab QC
• External quality control
• Internal quality control
• Testing of proficiency sample with
• Part of analytical phase of QA unknown concentration.
• the testing of control together • Participated by different laboratories.
with the patient sample. • Maintain long term accuracy of the
analytical method.
• Monitors the accuracy and • The gold standard for proficiency testing is
precision of analytical method the College of American pathologist (CAP).
on a daily basis and detects any
error
Note: Quality control check the stability of the instrument/machine, quality
of reagent, and technical error.
QC materials/reagents
QC materials/reagents
• STANDARD-a solution with precise known concentration
used to identify and determine the concentration of the
sample. Not serum or plasma based.

• CALIBRATOR- a solution or device with known

concentration or activity that is used to calibrate, adjust
, or graduate measurement of an instrument to match a
known input. Serum or plasma based.

Both measure accuracy.

QC materials/reagents
CONTROL
• a patient-like material made from human
serum.
• Used to run with patient samples.
• Used to monitor the performance of an
instrument after calibration.
• Measure precision/reproducibility
• They can be assayed (mean and SD are given )
or un-assayed (determine mean and SD).
CONTROLS
Can be liquid or lyophilized ( freeze dried)
products and composed or 1 or more analytes
with known concentration

TYPES OF CONTROL
1. Normal- contains normal levels of analyte
being tested (level I)
2. Abnormal- contains above or below the
normal level of analyte being tested (level II).
Qc statistics and calculations
Qc statistics and calculations
QC statistics are calculated from the QC Data base collected by regular
testing of controls.

1. Mean
2. Standard deviation (SD)
3. QC limits
4. Coefficient variation (CV)
5. Coefficient variation ratio (CVR)
6. Standard deviation index (SDI)
Qc statistics and calculations

Mean (average)
Sum of all observation divided by
the # of observations.

Mean is related to accuracy or

systematic error.

.
Qc statistics and calculations
STANDARD DEVIATION (SD)
• Statistics that quantifies how close QC values
to each other.
• It shows the dispersion of values around the
mean.
• SD is related to imprecision or random error.
• High SD means high IMPRECISION and vice
versa.
• 20 or more control values are to be needed
to get the SD.
Standard deviation
Data: 2,5,9,3,5,7,4
Mean: 5
SD: 2.4
• Subtract the mean from all the values
• Square the difference
• Add the difference
• Divide by the number of data minus 1
• Find the square root.
Qc statistics and calculations
Control limits
• Range within the control values must fall for assay to be
considered valid.
• Determine if the process is in control or out control.
• Calculated for interpretation using Westgard rule.
• Control limits: ±1s, ±2s and ±3s.
• Formula : Mean +/- (control limit X SD)
Control limit calculation
Mean- 4.1 mmol/L
SD- 0.1 mmol/L
Formula: Mean +/– (SD X control limit)
Upper control limit Lower control limit (-) Range
(+)
1s 4.1+ (0.1) (1)= 4.2 4.1- (0.1) (1)= 4.0 4.0- 4.1 mmol/L

2s 4.1 + (0.1) (2)= 4.3 4.1- (0.1) (2)= 3.9 3.9- 4.2 mmol/L

3s 4.1+ (0.1) (3)= 4.4 4.1- (0.1) (3)= 3.8 3.8-4.4 mmol/L
Other control statistics
• COEFFICIENT VARIATION (CV %)- the ratio of the standard deviation to
the mean, expressed in percentage (%).
• CV is used to evaluate overall precision of 2 different methods or
instruments and reagents.
• Formula: (SD/MEAN)X 100
• The lower the CV % = the greater precision
Analyte Method SD mean CV %
Glucose Oxidase 4.8 100

Hexokinase 4 100
COEFFICIENT VARIATION (CV %)
Which of the 2 methods for glucose determination has greater
precision?
Formula: (SD/MEAN)X 100
Analyte Method SD mean CV %
Glucose Oxidase 4.8 100

Hexokinase 4 100
Other control statistics
COEFFICIENT VARIATION RATIO (CVR)- used to determine the
precision of a specific test by comparing its precision to that of
another laboratory.

CVR= CV ( within the lab)

CV( peer group)
• 1.0 or less- better precision
• >1.0- imprecision
• >1.5- need investigation
• >2.0- need trouble shooting and correction
Other control statistics
STANDARD DEVIATION INDEX (SDI)
Is a peer based estimate of reliability

SDI- MEAN LAB - MEAN GROUP

SD GROUP

Score or 0.0 indicates perfect comparison of group

< 1.25- acceptable
1.25-1.49- borderline
1.5-1.99- marginal performance, need investigation
>2.0- unacceptable performance, remedial action is required.

Note: SDI is used in external quality assessment program or a proficiency testing

program.
STANDARD DEVIATION INDEX (SDI)
Group mean: 8
Group SD: 2

Laboratory Laboratory mean SDI

A 13
B 10

Formula: SDI- MEAN LAB - MEAN GROUP

SD GROUP

0.0 indicates perfect comparison of group

< 1.25- acceptable
1.25-1.49- borderline
1.5-1.99- marginal performance, need investigation
>2.0- unacceptable performance, remedial action is required.
Types of Quality control chart
1. Gaussian normal distribution graph
2. Cumulative sum graph
3. Youden/twin plot
4. Shewhart Levey-Jennings chart
Types of QC chart
Gaussian curve ( bell shape curve)
• Population probability distribution
that is symmetric about the mean.
• Also known as normal distribution
curve.
Types of QC chart
Cumulative sum graph (CUSUM)
• It identifies the consistent problem
and requires computer for
implementation.
• This plot is indicator of systemic error
(trend) and can be used with the 1s
rule.
• Results are out of control when slopes
exceeds 45 degrees.
Types of QC chart
Youden/twin plot
• Used to compare results obtained on a high
and low control serum from different
laboratories.
• Display the results of the analyses by
plotting the mean value for one specimen
on the y-axis and the other specimen for x-
axis.
• Points falling at the center within a 45
degree line- proportional error.
• Points falling at center outside of 45 degree-
constant error
Shewhart Levey-Jennings chart
Shewhart Levey-Jennings chart
• The most widely used QC chart
• Illustrate the overall distribution of QC values for interpretation.
• Used to graph successive/ day to day control values. At least 20 measurements

Note: LJ chart is a representation of vertically oriented Gaussian curve.

Shewhart Levey-Jennings chart
Empirical rule- approximation of distribution within
a normal distribution.
• 68% of the observations will lie within +/- 1 SD
from the mean
• 95% of the observations will lie within +/- 2 SD
from the mean
• 99.7% of the observations will lie within +/- 3 SD
from the mean

Note: empirical rule used to forecast data and

applies only in normal distribution (symmetrical
bell curve)
Shewhart Levey-Jennings chart
• Mean is located at the center-
accuracy.
• Mean is off the center- inaccuracy.
• Well rounded bell curve- precision.
• Wide bell curve, data points were
too spread- imprecision.
Shewhart Levey-Jennings chart
Other terminologies
• Median- the midpoint or middle value of a distribution. To determine
arrange the data in numerical order (ascending order).
• Mode- is the frequent observation in a data set.
• Range- expression of spread or distribution. To determine subtract
the highest data to lowest data.

Find the mean, median, mode, and range for the following list of
values: 13, 18, 13, 14, 13, 16, 14, 21, 13
Empirical rule (68-95-99 )
Glucose level 1
# of observation/data: 22
Mean- 4.15
SD- 0.55

1. What is the range of observation that falls

within 68 %
2. How many % of observations fall from mean
to + 2SD?
3. What is the % of observation of data ranging
from 3.6 to 4.15?
Interpretation of Shewhart L-J chart
Detection of error
SYSTEMATIC ERROR RANDOM ERROR
Presence of shift and trend Due to human error such as
due to • dirty glassware
• pipetting error
• instrument malfunction
• improper mix of samples and
• poor instrument calibration reagent
• reagent or control deterioration. • Mis-labeling
Result to inaccuracy. • drug and anticoagulant interference.
Result to imprecision
Detection of error
Systemic error Random error
1. Impurity of the calibrator 1. Incorrect pipetting
2. contaminated standard 2. Improper mixing of samples
3. Unstable blanks 3. Lack of temperature stability
4. Poorly written procedures 4. Improper timing regulation
5. Faulty instrument 5. Temperature fluctuation
6. Poor calibrated pipets and
instruments.
Systematic error
Shift (bias)- sudden change in data Trend- 6 or more values move
for several days. 6 or more continuously in one direction.
consecutive values are observed Hard to notice because it looks
only on one side of the mean. The like a shift. Main cause is reagent
main cause is improper calibration deterioration.
of instrument.
Shift
Upward shift Downward shift
Causes Causes
• Improperly prepared standard • Increase concentration of
• Inaccurate timer standard and reagent
• Dirty test tubes • Contaminated reagents
• Overheating in temperature • Under heating
• Dirty test tubes
detection of error
Outlier
Any value outside established limit (+/-3s). It is significant if occurs
more than once in 20 successive runs, caused by systematic or random
error.
Outlier
Causes
1. Specimen contamination
2. Incorrect dilution of test
WESTGARD RULES
Developed by: Dr. James Westgard, University of Wisconsin. 1981

Rule Explanation Specimen

12s a single value is outside ±2s limits. Indicate a systematic or random error. Accept (warning)
13s any value outside ±3s limits. Indicates a random error Reject
22s 2 consecutive values outside the ±2s limits. Indicates systemic error. Reject
R4s there is at least 4 differences between control values within a single run. Reject
Indicates a random error only.
31s 3 consecutive values outside ±1s limits. Systematic error Reject

41s 4 consecutive values outside ±1s limits. Systematic error Reject

10x 10 control results on the same side of the mean regardless of SD which Reject
they are located. Systematic error.
WESTGARD RULES
Accept- accept the test run in its completeness.

Reject- reject the whole test run.

• Don’t report the results
• Identify and correct the problem
• Retest the patient sample and control
WESTGARD RULES
Single rule system
• Uses a single criterion or single set of control limits
• +/- 2 standard deviations or +/- 3 standard deviations
• The rules are assessed individually to check for random and
systematic errors.
WESTGARD RULES VIOLATION
WESTGARD RULES VIOLATION
WESTGARD RULES VIOLATION
WESTGARD RULES VIOLATION

7T rules= TREND 6x rule- SHIFT

 Multi rule system

Uses two or more control rules to evaluate

the QC data, and then rejects a run if any
one of these is present.

Advantage: minimizes false rejection and

higher chance of error detection of an
analytical test/run.
Reference
• Bishop, Michael. 2018. Clinical Chemistry:Principles and Procedures,
8th ed. C and E Publishing Inc.

• Henry, John. 2002. Clinical Diagnosis and Management by Laboratory

Methods, 22th ed. Merriam and Webster Inc.
• Tumamao, Aldrin. 2019. Clinical Chemistry Notes