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)

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;

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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???

Overview of LQMS activities completed in the USAPI

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

Improving the USAPI medical laboratory workforce

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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

Overview of USAPI lab workload vs Number of lab staff

USAPI lab workload USAPI lab staff capacity

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

Status update:Fiji National University

(Bachelors degree in Medical Lab Science)

Status update as of Jan 2015Current 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

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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

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CDC Labs (Atlanta/Fort Collins, CO

CDC Labs (Puerto Rico)

Cairns

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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

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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 (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)

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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

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).

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

Chuuk, FedSM: Nov – Dec 2014

Chuuk, FedSM: Nov – Dec 2014

Thank you!!!

Questions???