Transcript Lab Strengthening Efforts in the USAPI

Lab Strengthening Efforts in the USAPI
Vasiti Uluiviti
PIHOA Regional Lab Coordinator
57th PIHOA Meeting: March 9th – 13th 2015
Palau
Overview of presentation
 2015 4th PIHOA-AUL Lab Network Meeting – Overview
of outcomes
 Lab quality management systems (LQMS) in the USAPI
 The USAPI medical laboratory workforce
 The USAPI laboratory surveillance of infectious diseases
 Guam Public Health Lab – Future expectations
 PIHOA Regional Lab Initiative Progress Highlights: 2005 2015
2015 4th PIHOA-AUL Lab Network Meeting –
Overview of outcomes
Representation (~ 40 people)
USAPI Lab managers/supervisors
USAPI Hospital/public health lab administrators
CDC, APHL, WHO, SPC
 US Naval Hospital, GMH, Guam Private labs, professional institutions (GMS,
GMA, PBMA)
Stakeholders meeting – 2 days
GPHL Assessment Report (APHL)
 Improving Level 1 (USAPI) testing capabilities
 Expectations of Level 2 (GPHL) testing capabilities
4th AUL Meeting – 1 day
 Election of new office bearers
 Completion of the AUL strategic plan
 Improve support of the PIHOA Reimbursable Fund (specimen transport)
Improving lab quality management
systems in the USAPI
PIHOA Board Resolution # 48 – 03
(April 2010)
“Concerning Lab Strengthening among PIHOA Member
States”
In support of:
World Health Organization (WHO) lab strengthening efforts through the Asian
Pacific Strategy for Strengthening Health Laboratory Services, 2010 to 2015,
which was endorsed by all Pacific countries and territories, including PIHOA
member states, at the 60th Regional Committee Meeting of the Western Pacific
Regional Office of the WHO in Hong Kong, China, September 2009;
Vision for the PIHOA Regional Lab Initiative: Laboratory
quality improvement and standards in the FAS (FedSM,
Palau, RMI)
Comply with Recognized Lab Standards
Lab inspection
& assessments
Identify and rectify
deficiencies
Goal:
By 2018 - 2019 at least 2 labs in
the freely-associated states of
Palau, FedSM and RMI are
accredited to a lab accrediting
institution (ISO/CLIAInternational/CAP-International)
Continuous lab improvements
Laboratory accreditation
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LQMS vs No LQMS
Implementing
Quality Management
does not
guarantee
an
ERROR-FREE
Laboratory
But it detects
errors that may
occur and
prevents them
from recurring
USAPI LQMS phases of improvement
Phase 5
Phase 4
Phase 3
Phase 1
1st
LQMS
assessment
Recommended
activities for
improvement
completed
2010
Phase 2
LQMS training
completed
Quality
manual
developed
2nd and 3rd
LQMS reassessments
Recommende
d activities
for
improvement
completed
Preaccreditatio
n audit
Prepare for
accreditatio
n
Phase 6
Accreditation
completed
2017 –
2018???
Overview of LQMS activities completed in the USAPI
Regional EQA Program
USAPI Lab Participation in the PPTC Proficiency Surveys
100%
100%
100%
100%
100%
90%
89%
88%
80% 77%
80%
69%
70%
63%
60%
50%
40%
30%
25%
20%
10%
 Increased participation
noticed - 4 laboratories
reaching 100% in 2014
 Inconsistent submission
by some laboratories –
no delegation/ QA
officer. Lack of
ownership -charge
technicians/ staff
 Room for
improvements in 2015
0%
2012
2013
2014
USAPI TB Lab EQA
I. Blind slide re-checking
 100% participation
II. AFB Proficiency Panel
 100% participation
Improving the USAPI medical
laboratory workforce
Vision for the USAPI Lab Workforce Development
Future lab workforce
Current lab workforce
Acquire baseline
MLT qualifications
Certificate/PPTC Diploma
Identify college
graduate
Bachelor in
Medical Lab Science
Licensure
Certification
Graduate studies
13
Vision for the USAPI Lab Workforce Development
Goal
By 2020:
1. At least ONE (local) or more medical lab scientist
employed in each USAPI lab
2. All USAPI lab staff to have acquired the minimum
MLT/MLS qualification
Medical Lab Workforce
- Statement of Need There is generally an essential and great need to increase the
number of the medical lab workforce in each USAPI lab;
increase the appropriate number with academic
qualifications in MLS; and sustain these trained & qualified
individuals with appropriate incentives. Why???
1. Workload in the each lab has generally increased over the years
with the same number of people performing the tests.
2. The need to improve delivery of quality lab services, thus, ensuring
quality patient care
3. Be able to perform much needed tests onsite with moderate –
higher complexity levels
Overview of USAPI lab workload vs Number of lab staff
USAPI lab staff capacity
USAPI lab workload
Lab Workload: Number of lab staff (ratio)
Q: IS THE RATIO ADEQUATE? DO WE NEED MORE
LAB STAFF?
A: ??????
WHO WISN TOOL
- Workload Indicators of Staffing Need (WISN)
The WISN Tool
 WISN is a tool and a method to adjust staffing levels to an optimal
distribution across health facilities.
 Analytical planning tool to:
• Determine how many health workers are required to cope with actual
workload in a given facility
• Estimate staffing required to deliver expected services of a facility
based on workload
• Calculate workload and time required to accomplish tasks of
individual staff categories
• Compare staffing between health facilities and administrative areas
The WISN Tool
• Understand workload of staff at a given facility
• Establish fair workload distribution among staff
• Assess workload pressure on staff
• Applicable to all personnel categories
• Medical staff
• Paramedical staff
• Non-medical staff
Medical Lab Science Training Institutions
Institutions
Fiji National University
 Bachelors in Medical Lab Science (4 years)
 Diploma in Clinical Lab Science (2 years)
 Certificate in Phlebotomy (6 months)
Pacific Paramedical Training Center, NZ
 Diploma in Medical Lab Technology (2 years) – WHO Pacific Open Health Learning Network (free)
 Lab discipline courses (microbiology, hematology, biochemistry, blood bank, serology, lab quality
management) – (onsite 3-months)
CDC
 Online short courses in microbiology (free)
Other institutions
Philippines
Taiwan
Type of financial support
Scholarships (AusAid, WHO, Local govt, other govts)
Pacific Paramedical Training Center
Wellington, NZ
Association of USAPI Labs (AUL) Recommendation
(Endorsed by the PIHOA Board in March 2014 – 54th PIHOA Meeting)
“PPTC Diploma in Medical Lab Science or equivalent
as the minimum qualification to be acquired by all
USAPI lab staff”
Status update:
Pacific Paramedical Training Center (PPTC) graduates –
Diploma in Medical Lab Technology (POHLN): 2006 – 2015
Status update:
Fiji National University
(Bachelors degree in Medical Lab Science)
Status update as of Jan 2015
Current number of USAPI lab staff vs % with MLS qualifications
Improving the USAPI laboratory
surveillance of infectious diseases
Diagnostic Capabilities of Outbreak-prone Infections
Goal:
Enhance Level 2 lab capabilities/capacity
at Guam Public Health Lab (GPHL)
Enhance microbiology diagnostic
capabilities at Level 1 USAPI labs
Specimen referral for confirmatory testing in the USAPI
Influenza & Other diseases
GPHL/Hawaii State Lab/NRL
– Australia/ Institut Pasteur,
New Caledonia/CDC Labs
Ebola
CDC Lab, Atlanta
PIHOA shipping mechanism
Influenza specimen transport financially supported by SPC
Other specimens supported by USAPI
USAPI Laboratories
ASA
CNMI
GUA
CHK
PNI
KOS
YAP
PAL
MAJ
EBE
27
CDC Labs (Atlanta/Fort
Collins, CO
CDC Labs (Puerto Rico)
Cairns
28
Specimen transport mechanism in the USAPI
The PIHOA Shipping Mechanism Replenishment
Hawaii State
Lab or
Diagnostic Lab
Services (DLS)
of PIHOA
Revolving Fund
CDC Labs,
Atlanta
CCH/TNT
charges PIHOA
account
Freight Forwarder
(Courier Corporation of
Hawaii/TNT-Guam)
(PIHOA
Revolving
Fund)
Airline Cargo
charges
PIHOA
account
Airline Cargo Station (United
Airlines/Hawaiian Airlines)
PIHOA
PIHOA seeks
reimbursement of
shipping costs from
institution concerned
Communicates
USAPI Lab
Shippers
PIHOA pays
shipping
invoices
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IATA Infectious substances shipping training
 Target: At least 3 certified
shippers in each USAPI lab at all
times
Training focused on most current
version of the IATA Dangerous
Goods Regulation (DGR)
(Class/Division 6.2 Infectious
substances)
 PIHOA facilitates purchase of most
current version of IATA DGR (biannually)
PIHOA conducts on-going infectious
substance shipping training
(certification & re-certification)
94 currently certified shippers in
the USAPI (as of Dec 31st 2014)
Total # certified shippers in the
USAPI labs (as of Dec 31st 2014) = 66
USAPI Lab
1
2
3
4
5
6
Guam
RMI - Majuro
RMI – Ebeye
FSM - Yap
FSM - Chuuk
FSM – Pohnpei
FSM - Kosrae
CNMI – Saipan
CNMI – Rota
CNMI - Tinian
A Samoa
Palau
CERTIFIED
(* # lab certified shippers)
5 (*5)
8 (*4)
5 (*4)
7 (*7)
7 (*4)
10 (*4)
3 (*3)
12 (*4)
2 (*0)
2 (*0)
25(*25)
8 (*5)
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CDC Influenza Lab (L4)
Guam Public
Health Lab –
Expectations as
a Level 2
Reference Lab
for the
Northern
Pacific
1. Conduct reference testing for HSLD
Hawaii State Lab (L3)
1. Conduct PCR and viral culture on all VTMs received.
2. Report PCR and viral culture results to GPHL.
3. Refer all positive viral cultures to CDC reference lab.
4. Pack and ship specimens (as a batch) with dry ice to CDC reference
lab.
Guam Public Health Lab (L2)
1. Store VTMs at -70oC.
2. Conduct PCR testing on VTM specimens
3. Report PCR test results to USAPI labs.
4. Refer all positive and negative VTMs to HSLD.
5. Pack and ship specimens (as a batch) with dry ice to HSLD.
6. Report HSLD lab results to USAPI labs.
Proposed
future
algorithm for
the regional
influenza
testing in the
USAPI at
GPHL
Other USAPI Labs (L1)
1. Perform Influenza Rapid Test (IFA/Test kit).
2. Document test results.
3. Refer 2 specimens to GPHL (1 nasopharyngeal swab in alcohol & 1 nasopharyngeal swab in VTM.
4. Pack and ship specimens to GPHL with gel ice packs.
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GPHL Microbiology Skill-up Enhancement Training
Goal: Strengthen Level 2 reference lab testing of infectious diseases at GPHL
Objectives:
Conduct microbiology skill-up training at GPHL between 2015 – 2016
2015
• Phase 1 (1st Q)– Microbiology skills
• Phase 2 (2nd Q) – Microbiology skills
• Phase 3 (3rd Q) – Lab surveillance/Antibiotic resistance patterns
• Phase 4 (4th Q) – Food microbiology
2016
• Phase 5 (1st Q) – Water microbiology
• Phase 6 (2nd Q) – Bacterial agents of bioterrorism
• Types of assistance:
• SPC  Financial & Training delivery/co-facilitation
• PIHOA  Training delivery/co-facilitation
USAPI Microbiology Skill-up Enhancement Training
(if or when funding is available)
Goal:
I. Strengthen Level 1 lab surveillance of infectious diseases
II. Enhance Level 1 diagnostic microbiology testing capabilities and
infection control
Objectives:
Conduct microbiology skill-up training in the USAPI labs
Incorporate lab infection control training modules
Challenges
MAJOR CHALLENGES FACED IN LQMS IMPLEMENTATION
THROUGHOUT THE PACIFIC REGION INCLUDING THE USAPI
 Lack of Quality Culture.
 Lack of priority or urgency for Laboratory issues. Inadequate resources and
infrastructure.
 Lack of Quality champions.
 Poor and ineffective management.
 Lack of support by Ministries of health
 Accuracy, reliability, timeliness of lab services are questionable.
 Weak area of Human resources and capacity.
 No urgency in LQMS implementation.
 Little incentive for staff, small salaries, 2nd jobs, little recruitment.
 Isolated and remote islands.
 No Lab Information systems (LIS) generally.
 No formal qualification internationally recognised. PPTC/FSM
 Inadequate transport and referral to Reference Labs.
Major challenges vs Suggested Solutions
Challenges
 Slow progress in the
implementation of LQMS
recommended activities for
improvement in USAPI labs
(especially with the FAS).
Suggested solutions
 Appointment of a Lab Quality
Officer in each USAPI Lab
U
Injection of $2,000 - $3,000 into
the PIHOA Reimbursable Fund
by each USAPI Lab
npaid shipping invoices – slow
replenishment of the PIHOA
Reimbursable Fund.
PIHOA Regional Lab Initiative Progress Highlights:
2005 - 2015
Survival of the PIHOA Lab Initiative (on-going funding
by APHL/CDC, ASTHO, DLS-TB Program)
Effective use of the PIHOA Reimbursable Fund
Successful use of the PIHOA Shipping Mechanism
Shipping
Continuous re-certification of shippers: 25 (2006) vs
94 (2015)
Successful specimen transport
PIHOA Regional Lab Initiative Progress Highlights:
2005 - 2015
TB Lab Network
Active USAPI TB Lab Network
USAPI TB Lab EQA -100% participation
AUL
Active Association of USAPI Labs (AUL)
LQMS
LQMS activity implementation
LQMS improvements noted but slow
PIHOA Regional Lab Initiative Progress Highlights:
2005 - 2015
Medical lab workforce
 Continuous professional development of lab staff
GPHL
GPHL improvements with the ‘BT suite’
Increased testing capabilities (Genexpert Influenza,
Genepert Chlamydia & Gonorrhea, PCR Influenza typing
(H1, H3, H5, H7), Leptospirosis, Measles/Rubella)
Dengue PCR: soon in late 2015
Chuuk, FedSM: Nov – Dec 2014
Chuuk, FedSM: Nov – Dec 2014
Thank you!!!
Questions???