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Chapter 14.1 : Quality Assessment and Improvement (Quality Assurance)

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Abstract:

QA is a process of monitoring the functional components of a system and correcting defects when unacceptable performance is identified. Quality is characteristically assessed by specifying performance indicators and setting targets (thresholds) for acceptable proficiency. Limits may be set so that action is taken only when the number of deficiencies exceeds a specified threshold, or a limit may be defined as a sentinel event that requires review and action whenever it is encountered. The functional attributes of a QA plan are listed in Table 14.1-1 .

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Figures

Image of Figure 14.1-1
Figure 14.1-1

Differences between QC and quality improvement QA objectives are met by continuously monitoring a process, identifying defects, and correcting them. Quality improvement objectives are met by analyzing and understanding how a process works so that adjustments can be made to prevent defects from occurring.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1-2
Figure 14.1-2

Fishbone diagram of bacterial meningitis diagnosis. A fishbone diagram displays important components of a process and their interrelationships. Examination of a process from this perspective helps demonstrate potential weaknesses and reveals how improvements in the process might be achieved.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1-3
Figure 14.1-3

Pareto chart of solitary blood cultures. On the horizontal axis, the Pareto chart displays specific categories or groupings, beginning with the most prevalent type of event and continuing with other events in descending order of prevalence. The absolute numbers in each category are shown on the left vertical axis, and cumulative distributions (from 0 to 100%) are displayed on the right vertical axis. Making a change in the most prevalent category will have the most significant impact on overall improvement. Displaying quantitative relationships between groups in this way facilitates anticipation of the most likely sources of difficulty and sets priorities for improvement ( ).

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1-4
Figure 14.1-4

Computerized trend analysis of culture results for the identification of clusters that may have epidemiologic significance (courtesy of Misys Healthcare [Sunquest Information Systems], Tucson, AZ). Analysis of positive culture results may be employed to identify clusters of related infections that might signify an infection control problem. This requires analysis of positive-culture rates over an extended period. In this example from a commercial software program, a potential cluster is flagged as a positive-culture rate for a specific species, recovered in respiratory cultures at more than twice the running monthly baseline. Although patient identifier information has been deleted from this example for confidentiality purposes, the report includes the following information on each patient from whom this organism was recovered in culture: collection date (in chronological order), history number, name, sex, location, sample accession number, specimen type, and antimicrobial agents to which the isolate was resistant. This information can be used to detect potential outbreaks at a very early stage.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1-1
Figure 14.1.1-1

Diagram of the FOCUS summary of process improvement.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1-2
Figure 14.1.1-2

Strategy: diagram of the plan-do-check-act cycle for process improvement. (From M. Brassard, Goal/QPC, Salem, NH, 1998.)

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1-A1
Figure 14.1.1-A1

Outline of a typical process improvement project.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A1
Figure 14.1.1.2-A1

The project title describes the process improvement project.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A2
Figure 14.1.1.2-A2

The aim allows the team to focus on the goal of the process improvement project.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A3
Figure 14.1.1.2-A3

The team is assembled to establish its purpose, process, and measures of team progress.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A4
Figure 14.1.1.2-A4

Flowchart of process.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A5
Figure 14.1.1.2-A5

The cause-and-effect fishbone diagram allows team members to find and cure causes, not symptoms. This allows a team to identify, explore, and graphically display, in increasing detail, all of the possible causes related to a problem or condition to discover its root causes(s).

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A6
Figure 14.1.1.2-A6

Data from a process are summarized and graphically presented.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A7
Figure 14.1.1.2-A7

The intervention describes what action will be taken to improve the process.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A8
Figure 14.1.1.2-A8

The actions for process improvement are documented each month.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A9a
Figure 14.1.1.2-A9a

The control chart is a graphic display of the data as the process change evolves over time

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A9
Figure 14.1.1.2-A9

The control chart is a graphic display of the data as the process change evolves over time

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A9c
Figure 14.1.1.2-A9c

The control chart is a graphic display of the data as the process change evolves over time

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A10
Figure 14.1.1.2-A10

The impact statements describe the process change.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Image of Figure 14.1.1.2-A11
Figure 14.1.1.2-A11

The process improvement is observed over time to maintain the change.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Tables

Generic image for table
Table 14.1-1

Attributes of a QA plan

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table
Table 14.1-2

Roles of personnel in quality management organization

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table
Table 14.1-3

Examples of quality indicators for medical microbiology

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table
Table 14.1-4

Example of results from sputum quality monitor

SEC, squamous epithelial cells; LPF, low-power field.

These units need more intensive instruction on specimen collection or indications for sputum culture.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table
Table 14.1-5

Examples of indications for restricting microbiology testing

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table
Table 14.1-6

QA issues examined by CAP interlaboratory Q-Probes program with application to microbiology in years 1989 to 1991

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

These recommendations should be used as empirical guidelines only until specific antimicrobial susceptibility testing results are available. If additional or more specific information is required, contact the microbiology lab at XXX-XXX-XXXX or the microbiology director at XXX-XXX-XXXX.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

•Clavulanic acid, ceftazidime, cefoxitin, and imipenem are all strong inducers of class C β-lactamases in many nosocomial gram-negative organisms.

•Antibiotics demonstrating in vitro activity against <70% of all isolates of a given bacterial species are shaded in the table to underscore less than optimal activity.

•22% of pneumoccocci at Magnanimous Medical Center now display high-level resistance to penicillin (MIC ≥ 2.0 lg/ml), and 31% are macrolide resistant.

•In serious or deep-seated infections (such as pneumonia, meningitis, osteomyelitis, or sepsis) with spp., spp., spp., spp., and treatment with two antibiotics (e.g., a β-lactam plus an aminoglycoside or a fluoroquinolone) should be considered to increase clinical efficacy and decrease the chances for the development of resistance.

•Deep-seated enterococcal infections (e.g., endocarditis) should be treated with ampicillin or vancomycin plus low-dose (e.g., peak 3 to 5 μg/ml) gentamicin or streptomycin.

•55% of all isolates recovered from inpatients are now resistant to oxacillin and nafcillin (MRSA).

These recommendations should be used as empirical guidelines only until specific antimicrobial susceptibility testing results are available. If additional or more specific information is required, contact the microbiology lab at extension X-XXXX.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Table 14.1-A1

Procedures for quality assessment of urine specimen examinations

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Table 14.1-A2

Summary of data for urine specimen examinations

UA, urinalysis.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
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If time is not recorded, mark the box "ND" for no data.

If microorganisms are seen on Gram smear, record the time that doctor ordered antimicrobial agent(s); otherwise, leave blank.

TAT, turnaround time.

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1
Generic image for table

Citation: Garcia L. 2010. Quality Assessment and Improvement (Quality Assurance), p 538-582. In Clinical Microbiology Procedures Handbook, 3rd Edition. ASM Press, Washington, DC. doi: 10.1128/9781555817435.ch14.1

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