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Internal proficiency testing for hematology.

In-house PT is an inexpensive, nonthreatening way to draw the staff's attention to testing errors while reinforcing laboratory protocol.

Our 900-BED HOSPITAL hematology lab participates in the hematology survey program of the College of American Pathologists. While these exercises monitor testing well, they have limitations; for instance, the surveys do not evaluate the accuracy of white blood cell differentials. Like HCFA in the rules for CLIA '88, CAP wants labs to treat PT specimens like regular patient specimens. Thus only one or two technologists can participate in any individual survey.

CAP's Hematology and Clinical Microscopy Resource Committee recently added two questions to the hematology inspection checklist. The 1992 guidelines state that hematology laboratories must have a written system in place to insure that all personnel report microscopic morphology consistently on both blood and body fluid differentials. Thanks to the program we'll describe in this article, we had such a system in place already.

Four years ago, our hematopathologist asked us to develop an in-house manual differential proficiency program for staff members on all three shifts. Such a program could help us to determine our strengths and weaknesses regarding testing procedures, to evaluate uniformity among the staff in following laboratory protocol, and to plan future in-services. It was suggested that after the program started, we should place the proficiency instructions and other materials in a training packet for new employees and residents.

Because we lacked a computerized statistics program and the personnel necessary to perform manual calculations at that time, our first attempt at in-house PT lasted less than six months. The acquisition of word processing and computer spreadsheet programs and the dedication of a motivated staff made our second effort a success.

* Testing procedures. As partners in this project, the two of us contribute equal time to keeping it running efficiently and effectively. One of us selects and prepares the materials to be examined; the other tabulates results and prepares reports. Besides the testing of manual white blood cell differentials, our proficiencies include reticulocyte counts, hematology analyzer histogram reviews, and differentials and hemacytometer cell count calculations for body fluids. Working with an expanded menu of critical hematology procedures provides an opportunity to review and rectify critical reporting mistakes, introduce new instrumentation and procedures, update existing protocols, and establish more effective methodologies.

Our PT program tests peripheral blood smear scans for our new "diff-if" protocol, too. Techs must decide whether to perform a manual differential or report the automated five-part differential based on whether they observe certain preestablished morphologic abnormalities when scanning a smear with a 25-power oil objective for 30 to 60 seconds.

A new proficiency exercise is posted on our department bulletin board every month. Each assignment consists of two to four smears, protected by coverslips; a specially designed worksheet, accompanied by histograms and relevant information; and instructions. Figure 1 displays our worksheet on peripheral blood differentials. We limit the number of smears, calculations, and histogram reviews so that the staff will be able to complete the testing within 30 minutes during regular work hours.

Typically about 38 technologists, representing all shifts, take part. Participation is mandatory for everyone who rotates through hematology. We evaluate employees' involvement on their annual performance appraisals.

Both full-time and part-time employees are instructed to work independently and to report findings according to department protocol, indicating any additional testing that may be necessary. They are given two weeks to submit their answers.

* Types of proficiencies. Our first formal proficiency test consisted of manual differentials on two peripheral blood smears. We deliberately chose normal smears to relieve our employees' anxiety over the new program. The second test was designed to make believers out of the skeptics who doubted the accuracy of the differential and flagging system in our new five-part differential hematology analyzer. The staff had to do two manual differentials on blood smears with neutrophilia and compare the results with the 8,000-cell WBC scatterplots generated by the analyzer for the same smears. (They were convinced.)

The next three proficiency tests each included two blood smears and their scatterplots. We used the results to evaluate employees' understanding of our "diff-if" protocol.

Subsequent proficiency tests have included benign and malignant body fluid differentials, hemacytometer cell count calculations on body fluids, manual reticulocyte counts, and blood smear scans for WBC and PLT interferences such as platelet clumping, nucleated red blood cells, and cryoglobulins. Our bone marrow techs have been asked to produce leukocyte alkaline phosphatase scores. We are planning to have these employees perform acid elution fetal cell counts and bone marrow differentials in the near future.

* Analyzing results. Once the majority of technologists have handed in their results for a particular proficiency, we prepare a computer spreadsheet that lists everyone's test data and computes the group mean for all numerical results. Among the results compared: the percentage of neutrophils, lymphocytes, and monocytes as well as outstanding findings such as RBC morphology and WBC inclusions. We note the participant's initials in the left margin of the spreadsheet next to his or her results. When an assignment is submitted late, those results are written at the bottom of the printout. Employees who turned in their results after the deadline can therefore compare them with those of their colleagues, although their findings are not included in the group mean.

After reviewing the spreadsheet data and worksheets, we prepare feedback reports. To do this, we write comments at the bottom of the spreadsheet, focusing on such aspects as prominent smear findings and the patient's history and diagnosis, often known by reviewing the original lab report or bone marrow report or by asking a resident to look at the patient's chart. We add notes on the accuracy of the original lab report in adhering to protocol: Is the terminology correct? Has a finding been reported too high or too low? Finally, we summarize the results we had anticipated. We then attach a copy of the original laboratory report to the spreadsheet for comparison. If significant discrepancies are found between the original report and the group results, we perform the laboratory assay ourselves, noting our results on the report.

We generate two copies of our feedback report. The version containing participants' initials is stored in a confidential file. An anonymous copy is photocopied and distributed to participants so that they can compare their results (which are highlighted) with the group mean, the original lab report, and their coworkers' results. If someone has missed a pertinent finding, we circle the error in red on his or her copy and attach a note. If the result is markedly off target, the employee must review the slide with a supervisor. We later document the date on which this review was conducted.

Once our feedback report has been handed out, worksheets are filed in a notebook for one year. Employees are thus able to review their work again whenever they wish. PT slides (stored in slide holders) remain on the bulletin board for about a week and then are filed in a slide box indefinitely.

* Benefits. Our program has enabled us to uncover and rectify procedural errors. We discovered that employees were spending too long examining blood smear scans, looking for features that were not clinically significant. Some laboratorians were overcalling morphologic findings such as platelet clumping and giant platelets. Too often they were recommending time-consuming and unnecessary corrective procedures such as manual WBC and platelet counts. We held a staff meeting to clarify our reporting protocols for RBC morphology and giant platelets and to present a new protocol for reporting clumped platelets. The number of unnecessary manual corrections dropped substantially within a few weeks.

Besides alerting staff to strengths and weaknesses in their testing techniques beyond those routinely evaluated by external PT, our program has several advantages:

* It costs virtually nothing to implement. Histograms, body fluid smears, blood smears, and reticulocyte smears can be taken from the regular workload.

* It provides inexpensive continuing education experiences from which all the technologists benefit. Our employees accrue half an hour of CE credit for every proficiency completed. This helps our full-time techs meet their minimum in-house requirement of 10 CE hours per year.

* It is less intimidating for technologists than an external program since results are not graded and are seen only within the laboratory.

* It reinforces morphology protocols for all employees, particularly for those who do not routinely work in hematology.

* Drawbacks. Like any program, ours has had, glitches to correct. At first, because smears were selected from our regular workload, we seldom made duplicate slides. It has happened that a slide handled by many technologists broke before everyone had a chance to review it. We now usually make extra smears.

In addition, it can take up to three hours of a supervisor's time per month to select and coverslip smears, retrieve original lab reports and (if applicable) scatterplots, and prepare and post worksheets and directions. Compiling, analyzing, and distributing results can take another two days per month--roughly 10% of a supervisor's time.

The actual time necessary to run such a program depends on how extensive supervisors want the testing to be. Smaller labs might limit their requirements to one proficiency exercise, consisting or one or two slides, per quarter.

* Tips for success. Our proficiency testing program, now in place for two years, has been well received by our lab staff. When asked for a critique, the majority of employees have confirmed that our program is an excellent way to keep the lines of communication open among employees from all shifts, supervisors included.

For readers who would like to start a similar program, we offer the following suggestions.

* Make sure your technologists understand up front that the program is meant to be a learning experience, not a hand-slapping exercise.

* Begin with normal specimens to ease employees into the program and allay any anxiety about participating. A gradual introduction to the process will promote greater enthusiasm down the road.

* View the problems that surface as opportunities to clarify, reinforce, or change your laboratory protocol as well as to familiarize your staff members with new instruments and procedures.

* Enhancing accuracy. Today's sophisticated hematology analyzers enable laboratorians to process large numbers of specimens with remarkable precision and accuracy--and minimal manipulation of specimens. Still, this technology does not insure error-free testing. While an internal PT program like ours provides no guarantees, it reduces the likelihood of encountering serious problems by identifying weaknesses in the laboratory chain before they can weaken the chain itself.

Ferrence-Ramirez is assistant hematology supervisor and clinical hamatology instructor in the medical technology program and Procopio is hematology supervisor at William Beaumont Hospital, Royal Oak, Mich.
COPYRIGHT 1992 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1992 Gale, Cengage Learning. All rights reserved.

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Author:Ferrence-Ramirez, Nancy E.; Procopio, Noelle A.
Publication:Medical Laboratory Observer
Date:Dec 1, 1992
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