Laboratory Services in Lesotho: A Journey to Quality

Capstone Project Presentation

Barbara Chase McKinney,M.D.

May 1, 2007

Acknowledgements American Society for Clinical Pathology (ASCP) Ministry of Health and Social Work / Laboratory

Services, Lesotho World Health Organization (WHO) The Centers for Disease Control (CDC) The Clinton Foundation Johns Hopkins Bloomberg School of Public

Health Gilbert Burnham, MD, PhD

Today’s Journey Context

The Country and the Healthcare System MOHSW / Laboratory Services

My Assignment Assessment Findings Quality Assurance Program Plan Training Progress

Lesotho at a glance Independent Kingdom Completely surrounded by South Africa Area – 30,355 sq km (slightly smaller than Maryland) Population: 2,022,331 HIV/AIDS Prevalence Rate: 28.9% PLWHA: 500,000 including 16,000 children

Lesotho Healthcare SystemHealth Service Areas

Laboratory Services in Lesotho GoL Initiates Large Scale

ART (2004) Laboratories essential to

diagnosing HIV and monitoring ART

Increased testing volume (>200%)

Expanded range of services offered

New high technology equipment Added demands for highly

accurate and reliable results

“Know your Status” Campaign (2005)

ART Scale Up

My AssignmentTechnical Assistance to the MOHSW / Laboratory

Services of Lesotho

Quality Assurance Program

Letter from MOHSWLaboratory Director

“We are in the process of setting up our quality assurance programme and basically we will be starting from scratch…” Kekeletso Mosisili

My Trips to LesothoJune 20 to July 7, 2006

September 18 to October 6, 2006

Today’s Journey Context My Assignment Assessment

Assessment tools Laboratories Assessed

Findings Quality Assurance Program Plan Training Progress

Assessment Tools Direct Observation Questionnaire Interviews - Stakeholder Analysis

Laboratory Personnel Laboratory Clients – Patients, Physicians, Nurses, Hospital Administrators Laboratory Stakeholders

Donors/Funding Agencies Governmental Non-governmental

Documents Job Descriptions Laboratory Statistics Lesotho National HIV/AIDS Strategic Plan, 2006-2011 MOHSW Summary Operational Plan 2005/2006 MOHSW Memorandum of Understanding with Health Partners

Laboratories Assessed June / July 2006 Butha-Buthe Leribe Mafeteng Mahale’s Hoek Queen Elizabeth II Scott Hospital *

September / October 2006 Maluti Adventist Hospital* Berea Mantsonyane – St. James * Roma – St. Joseph’s * Qacha’s Nek – Maatebeng

Hospital Tebellong Hospital *

* CHAL Hospitals

Facilities

Findings Infrastructure

Facilities Space Safety

Equipment Consumables -

Reagents Purchasing & Inventory

Human Capacity Culture of Quality

Today’s Journey Context My Assignment Assessment Findings Quality Assurance Program Plan Training Progress

What is to be done? Quick Fixes Must Be Done For the Long Term

Quick FixesCulture of Quality Quality Champion from

each lab to form a national Quality Team

Principles of quality to all laboratorians – QA Seminar

QA newsletter Equipment monitoring

initiated Hand washing

Quick FixesEnvironment

Inventory all equipment and remove all non-functioning equipment from the laboratory premises

“House Cleaning” Remove old

paperwork, manuals, and receipts

Quick FixesRecognition

Make it rewarding! Develop a laboratory

recognition program Criteria for excellence Plaque Recognition ceremony Presented by

prominent official Publish it in the

newspaper

Must Be DoneCulture of Quality Daily QC

Internal & External Controls Standard Operating Procedures (SOPs) for all

procedures performed Documentation & Record keeping

Statistics tallied, recorded, and reported monthly Equipment

Maintenance logs Temperature monitoring for all refrigerators and blood bank

transport

Must Be DoneCulture of Quality Improvement must be

measured Balanced scorecard for

each lab or section Compare divisions

graphically Post graphs in each

laboratory Publish the results in the

QA newsletter0

102030405060708090

Jul Aug Sep Oct

HemeChemMicro

For the Long TermEquipment Basic equipment in

every lab Equipment logs

Maintenance & routine service (Service contracts purchased with equipment)

Repair - communication with service personnel

Safety policies & protocols

For the Long TermConsumables Assure reliable

reagent supply Budgeting Inventory Control Consider strategies to

make the laboratory sustainable

Consider cost recovery

For the Long TermHuman Capacity People are an investment in

the future Establish a culture of quality Training for all laboratorians

Test-specific Management

Organizational structure of responsibility and authority

Career advancement Competency assessment Hire clerks

Today’s Journey Context My Assignment Assessment Findings Quality Assurance Program Plan Training Progress

Quality Assurance Seminar October 1, 2006 - Lancer’s Inn Maseru

Seminar Topics1. Principles of Quality

Assurance2. Specimen

Management3. Internal & External

Quality Control4. Standard Operating

Procedures5. Documentation and

Record Keeping

Seminar Statistics 39 Attendees of 40 Invitees Educational Evaluation

38 total pretests, 24 matched pre and post tests statistically evaluated Matched Pre-test Score Mean – 17.5

(Confidence Interval 16.53-18.47) Matched Post-test Score Mean – 19.1

(Confidence Interval 18.31-19.94) Paired t-test t = .003, p >0.2 Change in Individual Scores – All individuals showed improvement

Satisfaction Evaluation Overall meeting rated 3.87 out of 4.0 by participants Based on 21 point assessment

Planned 3 month follow-up Internal Assessment with Checklist

Training MOHSW Laboratory Training Plan (CHAI)

Pre-service ASCP Evaluation of NHTC

Lesotho, November 2006 Test-specific technical training

ASCP Chemistry, Hematology & CD4 Lesotho, July 2007

Clinic-laboratory relations Laboratory Management Training

ASCP Module Development Chicago, March 2007

Mentoring Program

Progress Infrastructure Reagents & Consumables Human Capacity Culture of Quality

Culture of Quality QA Representatives forming a National QA Team QA Newsletter Quality Manual

Mission, Vision & Values Quality Standards National Quality Management System Standard Operating Procedures Laboratory Handbook for Users

National Accreditation EQA / Proficiency testing for the laboratories EQA for Rapid HIV Testing

New position for managing EQA for rapid testing

The Journey Continues…June 4-20, 2007

Discussion