Lab Strengthening Efforts in the USAPI
Vasiti UluivitiPIHOA Regional Lab Coordinator
57th PIHOA Meeting: March 9th – 13th 2015Palau
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/supervisorsUSAPI Hospital/public health lab administratorsCDC, 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)
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;
6
Vision for the PIHOA Regional Lab Initiative: Laboratory quality improvement and standards in the FAS (FedSM,
Palau, RMI)
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/CLIA-International/CAP-International)
Comply with Recognized Lab Standards
Identify and rectify deficiencies
Lab inspection & assessments
Continuous lab improvements
Laboratory accreditation
ImplementingQuality Management
does notguarantee
anERROR-FREE
Laboratory
But it detects errors that may occur and prevents them from recurring
LQMS vs No LQMS
Phase 5 Pre-accreditation audit Prepare for accreditation
Phase 4 2nd and 3rd LQMS re-assessments Recommended activities for improvement completed
Phase 3 Quality manual developed
Phase 2LQMS training completed
Phase 11st LQMS assessmentRecommended activities for improvement completed
Phase 6 Accreditation completed
USAPI LQMS phases of improvement
2010
2017 – 2018???
Regional EQA Program
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
Average Palau Ebeye Majuro Yap Pohnpei Kosrae Chuuk A/Samoa0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0.80.77
0.89
1
0.88
1 1
0.25
0.63
0.69
1USAPI Lab Participation in the PPTC Proficiency Surveys
2012 Series2 2013 Series4 2014
USAPI TB Lab EQA
I. Blind slide re-checking 100% participation II. AFB Proficiency Panel
100% participation
13
Vision for the USAPI Lab Workforce Development
Current lab workforce Future lab workforce
Identify college graduate
Acquire baseline MLT qualifications
Certificate/PPTC Diploma
Bachelor in Medical Lab Science
Graduate studies
CertificationLicensure
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 care3. Be able to perform much needed tests onsite with moderate –
higher complexity levels
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 InstitutionsInstitutionsFiji 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 institutionsPhilippinesTaiwan
Type of financial support Scholarships (AusAid, WHO, Local govt, other govts)
Pacific Paramedical Training CenterWellington, 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
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
27
Specimen referral for confirmatory testing in the USAPI
PIHOA shipping mechanismInfluenza specimen transport financially supported by SPC
Other specimens supported by USAPI
Influenza & Other diseasesGPHL/Hawaii State Lab/NRL – Australia/ Institut Pasteur,
New Caledonia/CDC Labs
EbolaCDC Lab, Atlanta
GUA
USAPI Laboratories
CNMI KOSCHK PNI YAP MAJASA EBEPAL
29
Specimen transport mechanism in the USAPIThe PIHOA Shipping Mechanism
Airline Cargo charges PIHOA
account
Hawaii State Lab or
Diagnostic Lab Services (DLS)
Freight Forwarder(Courier Corporation of
Hawaii/TNT-Guam)
Airline Cargo Station (United Airlines/Hawaiian Airlines)
USAPI Lab Shippers
PIHOA pays shipping invoices
PIHOA(PIHOA
Revolving Fund)
CCH/TNT charges PIHOA
account
PIHOA seeks reimbursement of
shipping costs from institution concerned
CDC Labs, Atlanta
Replenishment of PIHOA
Revolving Fund
Communicates
30
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 (bi-annually)
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 CERTIFIED(* # lab certified shippers)
1 Guam 5 (*5)2 RMI - Majuro 8 (*4) RMI – Ebeye 5 (*4)3 FSM - Yap 7 (*7) FSM - Chuuk 7 (*4) FSM – Pohnpei 10 (*4) FSM - Kosrae 3 (*3)4 CNMI – Saipan 12 (*4) CNMI – Rota 2 (*0) CNMI - Tinian 2 (*0)5 A Samoa 25(*25)6 Palau 8 (*5)
31
CDC Influenza Lab (L4)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 specimens3. 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.
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.
Proposed future algorithm for the regional influenza testing in the USAPI at GPHL
Guam Public Health Lab – Expectations as a Level 2 Reference Lab for the Northern Pacific
GPHL Microbiology Skill-up Enhancement TrainingGoal: Strengthen Level 2 reference lab testing of infectious diseases at GPHLObjectives: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 diseasesII. Enhance Level 1 diagnostic microbiology testing capabilities and
infection control
Objectives:Conduct microbiology skill-up training in the USAPI labsIncorporate lab infection control training modules
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).
U
npaid shipping invoices – slow replenishment of the PIHOA Reimbursable Fund.
Suggested solutions Appointment of a Lab Quality
Officer in each USAPI Lab
Injection of $2,000 - $3,000 into the PIHOA Reimbursable Fund by each USAPI Lab
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 FundSuccessful use of the PIHOA Shipping MechanismShippingContinuous re-certification of shippers: 25 (2006) vs
94 (2015)Successful specimen transport
PIHOA Regional Lab Initiative Progress Highlights: 2005 - 2015
TB Lab NetworkActive USAPI TB Lab NetworkUSAPI TB Lab EQA -100% participation AULActive Association of USAPI Labs (AUL)LQMSLQMS activity implementation LQMS improvements noted but slow
PIHOA Regional Lab Initiative Progress Highlights: 2005 - 2015
Medical lab workforce Continuous professional development of lab staffGPHLGPHL 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