# Presentation: 356788

## Dr.Mrs.Nalini Ramamurty
King Institute of Preventive Medicine, Chennai

- King Institute of Preventive Medicine, Chennai

- Quality assurance

## Quality is.....

- 			Invisible when GOOD
- 	  Impossible to ignore when BAD

## Quality assurance

- Definition
- It is the sum total of all lab activities that are undertaken to ensure generation of accurate and reliable results.
- What is the Objective?
- 	To ensure credibility of the lab and generate confidence in lab results

## Components of Quality assurance 

- Internal Quality control: IQC
- Nature: Concurrent
- performed by:  lab staff
- Objective: Reliable results on a daily basis
- External quality assessment: EQA
- Nature: Retrospective to evaluate IQC
- Performed by: Independent agency
- Objective: Ensure interlaboratory comparability

## Quality systems 

**	****Objectives**
- To prevent risks
- To detect deviations
- To correct errors
- To improve efficiency
- To reduce costs
**How**** : By establishing a quality manual defining**
- Organizational structure – Staff
- Responsibilities
- Procedures and processes
- Resources
- Documentation

## The 5M’s of Quality

- <date/time>

- Man
- Material
- _M__achinery_
- _M__anuals/Methodology ( SOP)_
- Motivation

## Factors influencing quality:

| Pre analytical | Analytical | Post analytical |
| --- | --- | --- |
| Right specimen | Laboratory professionals | Recording |
| Right collection | Reagents | Interpretation |
| Right labeling | Equipment | Turnaround time |
| Right quantity | Selection of test - SOP | Report to right user |
| Right transport | Records |  |
| Right storage | Bio-Safety |  |

## Quality Assurance

- Standard Operating Procedures

## STANDARD OPERATING PROCEDURE (SOPs)

**	**An authorized written procedure giving instructions for performing operations not necessarily specific to a given process, product or material (e.g. equipment operation, maintenance and cleaning; validation; cleaning of premises and environmental control; sampling and inspection).

## STANDARD OPERATING PROCEDURES (SOPs)

- Standard operating procedures describe in a detailed form the activities performed in the laboratory
- Provide uniformity, consistency and reliability in each of the activities performed in the laboratory
- Reduce systematic errors
- Provide training and guidance for new staff

## SOPs should be

- Written instructions that specify how a test or procedures is to be performed.
- How a piece of equipment is operated, maintained and calibrated.
- Describes “Standard” approved procedures.
- Revision ... when planned changes are made or annually

## SOPs should be (Cont..)

- Original – maintained in a central file.
- Copies – distributed to locations.
- Written by the person performing the procedure or who knows the procedure well.
- Supervisor review SOPs for completeness and content.
- QA or QC staff approval

## What should be covered under SOP

- General:Document Preparation (SOP for SOP)
- Preparation and maintenance of work area
- Washing and sterilization
- Decontamination
- Testing area
- Receipt of samples,
- Recording and labeling
- Storage and discarding
-                                                                .........cont

## ......What should be covered

**Laboratory operations**
- Receipt of reagents, standards, etc – storage
- Preparation of reagents – labeling and  storage
- Test procedures
- Reference material – identification,handling,storage and use
- Results – results, deviations, errors
- Reports – generation, distribution
- Archives maintenance
**Staff **– Training, GLP, staffing pattern
-                                                                       ...........cont

## ......What should be covered

- Equipments
**Indent, purchase, installation and validation**
**Maintenance**
- Daily checks and records
- Periodic calibration and validation
- Trouble shooting and action to be taken
- Annual maintenance
- In case of accidents – action to be taken
-                                                                        ......cont

## ......What should be covered

- _Deviations_
- Planned deviations
- Unplanned deviations
- Variance
- Errors
- Record of all the above – Action taken

## Format of an SOP

**Title** 		: descriptive
**Code** 		: Number relating to procedure and revisions
**Objective** 	: Aim of the procedure clearly described
**Scope** 	: The operating unit and field of application
**Definitions****	**: Meaning of principle terms used
**Description** : Operating instructions clearly 					  described without any ambiguity,  				  understood by all staff with flow diagrams
**Safety ****	**: Measures to be kept in mind when 				 executing  the SOP
**Documentation** : Protocol, Data sheets and measurements
**References** 	: Used to draw up the SOP

## Format on each page of SOP

- Logo and name of the organization
- Department or unit issuing the SOP
- Title and date of issue
- Signature of person who drew up the SOP
- Signature of person who reviewed it
- Signature of person who authorized it
- Duration of validity
- Date of review
- Code
- Page number and total number of pages in the document

## Eg

**National Polio Laboratory - Department of Virology,****  **
- Standard Operating Procedure  - 001
**RECEIPT OF STOOL SPECIMENS**
** **

- Date of issue of this version:1/4/2003	                                                                                                                              Page Number 1/4

** **
**Objectives****	****:** Procedure to be followed for receiving and storing stool samples of AFP Cases.
**  **
**Scope****	****	****:** This document contains the procedure that is adopted when stool specimens are received from
- 		  cases of AFP from Tamilnadu, Andhra Pradesh,  Pondicherry, Andaman & Nicobar.
**  **
**Definition: **
- 		 Stool sample carrier – marked with red for stool samples only
- 		Deep freezer –20 (1) – preparation of ice pack
- 		Refrigerator No.3  – for pre processing storage of samples
- 	     	LRF – Lab request form.
-                  	AFP – Acute flaccid paralysis.
- Place of testing:
**Requirements**:

** **

** **

**Tech/Scientist incharge****	****                    Checked by                          Authorized by **
** **
** **
** **

## DOCUMENTATION

- Main objective
- 	to establish, monitor and record “Quality” for all aspects of Good Laboratory Practices and Quality Control”.
- Type of documents
- 	Standard operating procedures
- 	Protocols  of tests, results
- 	Reports

## “IF you have not documented it  you have not done it”

**Laboratory records**
- Description and identification of sample received
- Description of method of testing
- Record of all data secured in the course of the test
- Record of test results and how they compare with standards of identity, strength and quality
- Record of all deviations and modification of test
- Record of standardization of reference standards
- Record of calibration of equipments

##  A description of the sample received for testing with identification of source (that is, location from where sample was obtained), quantity, lot number, date sample was taken, and date sample was received for testing.

- Laboratory records shall include complete data derived from all tests necessary to assure compliance with established specifications and standards, including examinations and assays, as follows:
-  A description of the sample received for testing with identification of source (that is, location from where sample was obtained), quantity, lot number, date sample was taken, and date sample was received for testing.
- A statement of each method used in the testing of the sample. The suitability of all testing methods used shall be verified under actual conditions of use.
- A complete record of all data secured in the course of each test, including all graphs, charts, and spectra from laboratory instrumentation, properly identified to show the lot tested.

##  A record of all calculations performed in connection with the 	test, including    units of measure, conversion factors etc.

- <date/time>

-  A record of all calculations performed in connection with the 	test, including    units of measure, conversion factors etc.
-  Results of tests and how the results compare with  established 	standards of identity, strength, quality, and purity.
-  The initials or signature of the person who performs each test and 	the  date(s) the tests were performed.
-  The initials or signature of a second person showing review for 	accuracy, completeness, and compliance
-  Complete records shall be maintained of any modification of an   	established method employed in testing.
-  Complete records shall be maintained of any testing and 	standardization  of  laboratory reference standards,   	reagents, and standard solutions.
-  Complete records shall be maintained of the periodic calibration 	of   laboratory instruments and recording devices

## SOP for material and reference standards control

## Material Control

- Specification For Raw Materials
- Specification For Supplies/Disposables
- Inspection & Acceptance Criteria For Supplies/ Disposables/Raw Material.
- Inventory Control Procedures For Supplies/Disposables.

## SOP for Reagent and Standards Quality ControlThe accuracy and precision of test results and test methods is dependant on the reliability, authenticity and control over reference standards, reagents and stock solutions..  Similarly the retrospective testing of materials and product is dependant on the protection and storage of retention samples

- <date/time>

**SOP for Reagent and Standards Quality Control****The accuracy and precision of test results and test methods is dependant on the reliability, authenticity and control over reference standards, reagents and stock solutions..****  ****Similarly the retrospective testing of materials and product is dependant on the protection and storage of retention samples**

**Primary Standards**** may be obtained from**
**National reference labs**
**World Health Organisation (WHO) for biologicals**
**In House Secondary Standards**
**Standardised against primary standards using definitive methods**** ****	**

## SOP for control over Standards (reference material) 

**Register, Logging and Inventory System**
**Purchase****d**
**Supplied**
** ****Labelled**
**complete description (name, source, Lot number)**
**strength, activity and confidence interval**
**storage conditions **
**Protected ****(heat, light, humidity, irradiation, vibration)**
**Custodian of Standards**
**SOP for Standards Management**
**selection, standardisation, change, and control**
**Standard Lot Number must appear in testing record****	**
**	**

## SOP for Standard Solutions & Reagents

**QC Program for Incoming Lots of Reagents**
**Standard Procedure for Preparation (BP and USP)**
**Records of Standardisation**
**Storage and Protection Conditions**
**Validated expiry or re-standardisation  date**
**Complete labelling; each standard or stock solution must be labelled with:**
**Standard Name**
**Batch Number**
**Date of preparation**
**Date of expiry**
**Storage conditions **
**Strength****	**

## SOP for Laboratory Control

- Record Review : Quality Monitors
- Review & Trending Of Error Reports
- Review Of Field Complaints
- Review Of Quality Control Data
- Internal Audits : Review Trends

## Quality Assurance is a dynamic process

**It is a journey **
**towards the destination**

## Thank you

## Quality assurance

*Equipment Management*

## How does good equipment management affect Quality assurance

**Ensures reliable test results and customer satisfaction thus credibility of the lab**
**Reduces interruption of services and delays in reporting due to breakdowns **

## Quality assurance Equipment Criteria	

- Selection
- Purchase / Acquisition
- Installation
- Calibration /Validation
- Maintenance - Service and repair
- Replacement

## Selection - design & purchase

- Specify what you need the machine to do.
- Specify accuracy and  precision
- Specify details of installation site.
- Get the machine you specify.
- 	Sales personnel are trained to sell a refrigerator to an eskimo, so beware.
- 			check the fine print!!!
- check the firms reputation & its service backup.

## .....Selection Criteria

**Use - Matching equipment with service**
** ****Performance characteristics and safety **
**Facility requirements - - Availability of space, accessibility**
**Cost**
**Supply of reagents**
**Ease of operation**
**Warranty**
**Availability of manufacturer technical support**
**Service Contracts**

**Notes:**
Performance characteristics 
	accuracy
	precision
	sensitivity
	specificity
Physical requirements
	electrical, re-wiring, drains, plumbing
Supply of reagents
	Access to reagents
	Alternative sources
Full support from manufacturers in terms of training, installation, service and repair are key points when checking the selection criteria.

## Acquiring Equipment

**Purchase, Lease, or Rent**
**Central acquisition**
**Bulk procurement**
**Donor provided**
**Conditions of contract**
**Parts Manual**
**Installation**
**Operators’ Manual**
**Trial period**
**Contents of service contracts**

**Notes:**
Pros and Cons of Purchase or Rent
Pro Purchase		VS		Against Purchase
Ownership				Total Responsibility

## INSTALLATION

- The equipment should be checked for all its design parameters.Ensure you got what you wanted.
- Confirm responsibility for installation
- Check the Performance of equipment under adverse conditions
- A number of check runs of known samples may be necessary to validate the equipment.

## Post Installation

**Establish inventory record**
**Define conditions**
**Develop and implement SOP for calibration, performance verification, and operating procedures**
**Establish maintenance program**
**Provide training for all operators – trouble shoot**

## PERFORMANCE CHECKS

- Equipment performance degrades over time.
- Check the equipment regularly for its performance – daily, weekly, monthly etc.
- Eg; Autoclave: Daily use -  autoclave indicator tapes
-                             - Monthly validation by BI
- Performance checks must be conducted after repair of equipment before putting it into routine use.
- Ensure a cleaning programme after each use
- Determine frequency of routine calibration

## Economics of maintenance

- Maintenance is a costly activity.
- How much maintenance is needed?
- Extent of the maintenance facilities and strength of maintenance squad.
- When and how often ??
- Is centralized maintenance desirable? or
- - Should maintenance be done only by out side contractors.

## Equipment Management program

**Assign responsibilities for all activities**
**Routine maintenance**
**Preventive maintenance**
**Train **_***all***_** personnel**** ****on equipment management **
**Develop standard operating procedures**** ****for maintenance**
**Maintain history card and **** ****logbooks**
**Monitor equipment management activities**** : **
**Routinely reviewing all records**
**Ensuring all procedures are followed **

**Notes:**
Training of laboratorians and monitoring of equipment are also important roles of the equipment manager.

## PREVENTIVE MAINTENANCE

**Options**
**In house service of small equipment, e.g., microscopes, washers, pipettes**
**Team of biomedical service technicians or AMC by manufacturer**
- Regular  schedule is usually provided by the firm.
- Ensure strict compliance of the schedule.
- Ensure all jobs have been performed as per checklist.
- Verify the quality of job performed by the firm.

## 	Equipment Maintenance : 	Documents and records 

- Equipment History card** :****A record for  equipment  inventory**
**Name, Model #, Serial #**
**Location in lab**
**Date purchased**
**Manufacturer and vendor contact information**
**Warranty, expiration date**
**Spare parts**
**	****For each piece of equipment:**
**Establish routine maintenance plan**
**Establish required function checks**
**Develop a list of spare parts **

## Equipment Maintenance : Documents and records

**Develop written procedures**** for all equipment   **
**Concise step-by-step instructions**
**Establish maintenance record**** to track:**
**function checks and routine maintenance**
**calibration**
**manufacturer’s service**
**Nature of Records**
**Charts and graphs **
**Logs**
**Checklists**
**Service Reports**

## Spare Parts

**Establish and maintain an inventory of most frequently used spare parts.  Include in record of inventory: **
**Spare parts per equipment**
**Part number**
**Average use**
**Minimal # of items to be stored **
**Cost and date of ordering**
**Dates of entry and issuance of part from inventory stock **
**Balance of items remaining in inventory **

## When in problem what needs to be done 

- _Do NOT use the equipment _
**Options for testing:**
**Refer samples to nearby laboratory**
**Obtain backup instrument from central stores**
**Store samples appropriately **
**Seek help from manufacturer or other technical expert **
**Place a malfunction notice on equipment**

## When in problem what needs to be done?  TROUBLE SHOOT

**Does the equipment display any error messages.**
**Check manufacturers instruction**
**Could you identify the cause to the problem - a fluctuation in power supply, temperature, water, reagent problem, sample problem etc - MAKE ONE CHANGE AT A TIME)**
**Inform the maintenance department / firm giving all details**
**Have the engineer prepare a detailed service report **
**After rectification have all performance checks done.**

##               Documentation of problems

**	****Develop a  problem log record for each piece of equipment**
**Date problem occurred, removed from service**
**Reason for breakdown or failure**
**Corrective action taken**
**Date returned to use**
**Change in maintenance or function checks**

## Retiring Equipment / Disposal

**When? ****	**
**When experts indicate not repairable or outmoded , or spares not available **
**Why?**
**Prevent inaccurate test results**
**Free up valuable space**
**How?**
** ****Consider biohazard, follow **
**	****safety disposal procedures**

## Benefits of a Maintenance Program

**Greater confidence in the  results**
**Safety**
**Fewer interruptions of work**
**Lower repair costs**
**Elimination of premature replacement**
**Reduction of variation in test results**

## Quality Assurance is responsibility of....

- All Staff

## COMMON LABORATORY EQUIPMENT

**REFRIGERATORS**
**FREEZERS**
**WALK-IN FREEZERS AND COLD ROOMS**
**INCUBATORS**
**CARBON DIOXIDE INCUBATORS**
**WALK-IN INCUBATORS**
**STERILIZERS (HOT AIR AND STEAM)**
**MICROSCOPES**
**BIO-SAFETY CABINETS**
**pH METERS**
**WATER BATHS**
**BALANCES**
**CENTRIFUGES**

## MAINTENANCE OF REFRIGERATORS, FREEZERS AND WALK IN COLD ROOMS.

- Maintain daily record of temperature
- Ensure regular defrosting of the cabinets.
- Fans of walk in cold rooms need to be regularly oiled and cleaned.
- Check the compressors for unusual sound or over heating and report it to the firm (even though the equipment is performing).
- Do not over pack the refrigerators or freezers

## INCUBATORS, WALK IN INCUBATORS, CARBON DIOXIDE INCUBATORS

- Maintain daily temperature record
- Clean regularly
- Water used to maintain humidity may become contaminated. should be changed regularly.
- Record the CO2 concentration daily. Check pressure in CO2  cylinder
- Do not overload

## STEAM STERILIZERS

- Use only distilled water for steam generation
- Ensure valves and door gasket are not leaking.
- Special attention needs to be given to the drain line and the steam trap.
- Do not over pack. Allow free circulation of steam
- Open the autoclave only after the pressure drops.
- Use separate autoclaves for decontamination and sterilization or use at different times for each.
- check the sterilizer regularly with Biological indicators – spore strips/ampoules.

## BIOLOGICAL SAFETY CABINETS

- Do not overcrowd the cabinet
- Switch on the airflow 15 mins prior to use. Check the manometer reading and record
- Ensure the cabinet is cleaned and disinfected at the end of each use.
- Maintain log book and record the daily usage.
- Entrust the maintenace to an AMC. HEPA filters are to be checked at regular intervals for their efficiency and replaced when indicated.
- Record the use of UV light and replace regularly

## .......BIOLOGICAL SAFETY CABINETS  

**Primary or pre-filters are changed when the cabinet air flow is low or uneven**
**Decontaminate the cabinet before changing the filters or any work on motor or fans by fumigation.**
**A notice showing  “cabinet decontaminated and not to be used” should be displayed.**
**Used filters are sealed by placing in plastic or tough paper bags and discarded.**
**Do not attempt to change filters with unskilled work force it is a specialized job.**
**Ensure certification and validation after each replacement – DOP and sterility tests**

## MICROSCOPE & BALANCE

- These equipment are susceptible to dust, and humidity- Keep covered when not in use
- Balances are also susceptible to vibration - Place on stable table top.
- voltage fluctuations should be the checked
- Periodically calibrate the balance with standards.
- Sophisticated microscopes and balances should be placed under AMC and thoroughly checked and cleaned every 6 months.