Critical review of the Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA): suggestions for harmonization, implementation and improvement

Abstract

Objective  Clinical laboratories in low- and middle-income countries (LMIC) need fundamental improvement because quality laboratory services are essential for the decision-making capacity of clinicians, health workers and public health authorities. To this end, a tiered accreditation scheme Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) was developed by WHO-AFRO, CDC and others for clinical laboratories in LMIC. One to five stars are accredited to laboratories based on the level of compliance with a checklist. Our aim was to evaluate the quality and applicability of this accreditation scheme compared with international quality standards.

Methods  We performed a critical review of this scheme to formulate recommendations for implementation, harmonization and improvement. Two analyses were performed: one assessing its coverage of the ISO 15189:2007 standard and one to identify and evaluate priorities of the accreditation checklist.

Results  Although the content of the checklist covers all aspects of total quality management, it strongly prioritizes resource management activities. We recommend identifying critical requirements for each tier of accreditation to assure a certain level of quality for each tier or instead using a pass/fail approach towards accreditation. In addition, the checklist should include more questions for assessing proper management, ethics and continuous improvement to meet ISO 15189.

Conclusion  Launching accreditation schemes for laboratories in LMIC should be encouraged. After further optimization of SLIPTA, clinical laboratories may certainly benefit, leading to more correctly diagnosed patients and less waste of resources.

Objetivo:  Los laboratorios clínicos en países de rentas baja y media (PRBM) requieren de una mejora fundamental, ya que la calidad de sus servicios es esencial dentro de la capacidad de toma de decisiones de los clínicos, trabajadores sanitarios y autoridades de sanidad pública. Por ello la OMS-AFRO, CDC y otros han desarrollado un esquema de acreditación (SLIPTA) para laboratorios clínicos en PRBM. Nuestro objetivo era evaluar la calidad y aplicabilidad de este esquema de acreditación comparado con estándares de calidad internacionales.

Métodos:  Hemos realizado una revisión crítica del esquema para formular recomendaciones para su implementación, armonización y mejora. Se realizaron dos análisis: uno evaluando la cobertura que SLIPTA tiene del estándar ISO15189:2007 y otro para identificar y evaluar las prioridades de su lista de requisitos para la acreditación.

Resultados:  Aunque el contenido de la lista cubre todos los aspectos de manejo de la Calidad Total, prioriza principalmente las actividades de gestión de recursos. Nuestra recomendación es la de identificar los requerimientos críticos para cada nivel de acreditación, para asegurar un cierto grado de calidad en cada nivel, en vez de utilizar un enfoque de aprobado/suspendido para la acreditación. Adicionalmente, la lista debería incluir más preguntas para evaluar una gestión adecuada, la ética y la mejora continua, con el fin de alcanzar el ISO15189.

Conclusión:  El lanzamiento de esquemas de acreditación para laboratorio en PRBM se debería potenciar. Tras una optimización del SLIPTA, los laboratorios clínicos se podrían beneficiar, resultando en un mejor diagnóstico de los pacientes y un menor desperdicio de recursos.

Objectif:  Les laboratoires cliniques dans les pays à revenus faibles et intermédiaires (PFR-PRI) ont besoin d’amélioration fondamentale car les services de laboratoire de qualité sont essentiels pour la capacité décisionnelle des cliniciens, des agents de la santé et des autorités de santé publique. À cette fin, un schéma d’accréditation à plusieurs niveaux (SLIPTA) a été développé par l’OMS-AFRO, le CDC et d’autres partenaires pour les laboratoires cliniques dans les PFR-PRI. Notre objectif était d’évaluer la qualité et l’applicabilité de ce schéma d’accréditation par rapport aux normes internationales de qualité.

Méthodes:  Nous avons effectué une analyse critique de ce schéma afin de formuler des recommandations pour l’implémentation, l’harmonisation et l’amélioration. Deux analyses ont été effectuées: l’une évaluant sa couverture pour la norme ISO15189:2007 et l’autre pour identifier et évaluer les priorités sur la liste des vérifications pour l’accréditation.

Résultats:  Bien que le contenu de la liste couvre tous les aspects de la gestion totale de la qualité, elle place en grande priorité les activités de gestion des ressources. Nous recommandons l’identification des besoins essentiels pour chaque niveau d’accréditation afin d’assurer un certain degré de qualité pour chaque niveau, ou d’utiliser plutôt une approche de réussite/échec vers l’accréditation. En outre, la liste devrait inclure plus de questions pour évaluer la bonne gestion, l’éthique et l’amélioration continue pour satisfaire à la norme ISO15189.

Conclusion:  Le lancement des schémas d’accréditation pour les laboratoires dans les PFR-PRI doit être encouragé. Après une optimisation plus poussée du SLIPTA, les laboratoires cliniques pourraient effectivement en bénéficier, conduisant à plus de patients correctement diagnostiqués et moins de ressources gaspillées.

Introduction

Strengthening of health systems in low- and middle-income countries (LMIC) is essential to achieve Millennium Development Goals four (reduce child mortality rates), five (improve maternal health) and six (combat HIV/AIDS, malaria and other diseases) (Gershy-Damet et al. 2010; Ravishankar et al. 2009). International Health Regulation core capacity eight requires WHO member states to ‘establish mechanisms to provide reliable and timely laboratory diagnosis of infectious agents and other hazards potentially causing public health emergencies of national and international concern’ (Masanza et al. 2010). Since the beginning of this century, health systems funding has increased dramatically, mainly through considerable initiatives such as the U.S. President’s Emergency Fund for AIDS relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the Global Health Initiative and the World Bank (McCoy et al. 2009). Considering that laboratories form a crucial link in the healthcare chain, the clinical laboratory sector has long been neglected in health systems-strengthening activities (Clinton 2003; Gayle 2003; Nkengasong et al. 2010; Petti et al. 2006; Okeke 2006; Bates & Maitland 2006; Muula & Maseko 2006; Berkelman et al. 2006).

In 2008 and 2009, several international meetings focused on laboratory strengthening in LMIC. Many of these meetings formulated strategies for laboratory quality improvement (WHO 2008; Ndihokubwayo et al. 2010; WHO Regional Office for Africa 2008). In the summer of 2009, this led to the launch of a stepwise accreditation scheme for clinical and public health laboratories by the WHO-AFRO in cooperation with, among others, the Centers of Disease Control and Prevention (CDC), the American Society for Clinical Pathology (ASCP) and the Clinton Health Access Initiative. In June 2011, the name of this scheme was officially established as ‘Stepwise Laboratory Improvement Process Towards Accreditation’ (SLIPTA).

Stepwise Laboratory Improvement Process Towards Accreditation is currently being used by many laboratories throughout Africa. The most important element of this scheme is a checklist (WHO Regional Office for Africa 2009). However, the checklist that is used is still a draft version as no accreditation governing board is in place to provide an official ‘stamp of approval’ for the checklist to be used in assessing laboratories for the purpose of accreditation (personal communication: G.D. Cross, CDC, 2010). The African Society for Laboratory Medicine (AFSLM), launched in Ethiopia in March 2011, may be assigned to fulfil this task (AFSLM 2011).

The WHO-AFRO accreditation scheme: the SLIPTA

WHO-AFRO recognized the gap between the current state of laboratories in Africa and the requirements of ISO 15189, noting that many laboratories would require an interim accreditation as the ISO 15189 accreditation is out of reach. The SLIPTA is meant to fill this gap and is not aimed at replacing the ISO 15189 accreditation standard (Gershy-Damet et al. 2010).

The SLIPTA follows a stepwise approach rather than a binary pass/fail system as is used for most international standards. Accreditation is given in five tiers, awarded in the form of stars. The aim is to achieve full five-star accreditation, and, where deficient, prioritize efforts to improve the accreditation rating in a timely manner. SLIPTA documents are available free of charge (AFSLM 2011;WHO Regional Office for Africa 2009).

The checklist

The requirements of the SLIPTA accreditation are formulated in the form of questions in its checklist. The number of stars being awarded to a laboratory depends on the level of compliance to the checklist. The checklist consists of 110 questions (totalling 250 points) subdivided over 12 sections. For each positively answered question, points are allocated (2, 3 or 5); partially positive answers are awarded 1 point. Five stars are awarded when 237–250 points are scored (>95% compliance), four stars for 212–236 points (85–94%), three stars for 186–211 points (75–84%), two stars for 161–185 points (65–74%) and one star for 138–160 points (55–64%); 137 points or less (<55%) yield no accreditation.

The specific actions needed to comply with the requirements of the checklist are formulated in an additional job task list. In this document, a distinction is made between tasks for four different levels of laboratories based on their position in the health system (community level, district level, regional or provincial level and central level). The tasks are tailor-made for each level, ensuring that staff of lower level laboratories is not burdened with complicated procedures that may only be necessary in higher level laboratories. This job task list is part of another element accompanying the checklist, namely the Strengthening Laboratory Management Towards Accreditation (SLMTA) training and mentoring toolkit on implementation of a quality management system (QMS), developed by the CDC, WHO-AFRO, ASCP and the Clinton Foundation (Masanza et al. 2010).

Although SLIPTA’s value and suitability in practice have not yet been measured, this article provides early suggestions for its harmonization with international quality standards to increase its applicability and effectiveness. To that aim, we compared the set of SLIPTA requirements with those of the ISO 15189:2007 international standard to determine where the SLIPTA is more or less demanding. The purpose of this article is to contribute to the public discussion on accreditation strategies for laboratories in LMIC to accelerate effective implementation of quality management systems for ensuring accurate and timely clinical laboratory results.

Methods

Two separate analyses were completed. The first analysis aimed to identify whether the content of the SLIPTA checklist covered the complete set of requirements described in the international quality standard for medical laboratories, ISO 15189:2007 (International Organization for Standardization 2007), by linking each question of the SLIPTA checklist to similar ISO 15189 requirements. This provided insight into which ISO articles are covered by the SLIPTA checklist and which not. The second analysis was performed to evaluate the accreditation structure used in the SLIPTA checklist. The SLIPTA divides the quality management system into 12 elements. For each of these 12 elements, a certain number of points can be scored, the total of which determines the accreditation level (Table 1). For such a system it is important that it encourages laboratories to invest equal effort in all 12 elements to give meaning and value to interim accreditation levels. For example: a standardized reporting system complying with all the requirements has no value if the examination process is not controlled because the laboratory has not yet invested any efforts in the process control requirements. If this laboratory is accredited with a number of stars, these stars have no meaning as the quality of laboratory results is still not assured.

Table 1.   Analysis results of the SLIPTA checklist

Sections in our suggested order	No. of questions	Maximum points	Process stage	Technical/managerial elements	Order in the current checklist
RM, Resource Management; PM, Process Management; IM, Improvement management; SLIPTA, Stepwise Laboratory Improvement Process Towards Accreditation. *Organization is managerial, personnel is technical of nature.
1. Facilities and safety	20	40	RM	T	12
2. Organization and personnel	8	20	RM	M/T*	3
3. Equipment	15	30	RM	T	5
4. Purchasing and inventory	15	30	RM	M	7
5. Process control, IQA and EQA	18	43	PM	T	9
6. Information management	7	14	PM	T	8
7. Documents and records	11	25	PM	M	1
8. Client management and customer service	4	8	PM	M	4
9. Management reviews	4	12	IM	M	2
10. Internal audit	2	10	IM	M	6
11. Occurrence management and process improvement	2	10	IM	M	11
12. Corrective action	4	8	IM	M	10

By analysing and comparing the number of points scored in each element of the SLIPTA checklist, an insight in priorities and neglected elements of the quality management system was obtained. For this, an analysis framework was adapted from ISO 9000: Quality Management Systems – Fundamentals and Vocabulary and ISO 9001: Quality Management Systems – Requirements (International Organization for Standardization 2005, 2008). This framework is shown in Figure 1.

Figure 1.  Analysis framework used for analysis of the point distribution. The quality cycle can be divided into three stages starting with resource management, followed by process management and improvement management. To each stage, four sections of the SLIPTA checklist were allocated. Adapted from: International Organization for Standardization (2000, 2008).

A QMS is a continuous cycle of activities needed to maintain and continuously improve the quality of laboratory processes. Our framework represents this quality cycle, which consists of three stages: resource management, process management and improvement management. Every element of the SLIPTA checklist was allocated to one stage of this quality cycle, yielding an indication in which stage of the cycle SLIPTA has put its priorities (Figure 2).

Figure 2.  Relative point distribution of the SLIPTA checklist over different sections, subdivided over the three quality cycle stages.

Results and discussion

The SLIPTA checklist vs. ISO 15189

WHO-AFRO encourages laboratories to enrol in an ISO 15189 accreditation scheme once five-star accreditation has been obtained. When comparing the SLIPTA checklist with ISO 15189, the coverage was found to be high: the SLIPTA checklist covers most paragraphs and requirements of the ISO 15189 standard, only in much less detail (Table 2). Only the ISO 15189 paragraph on preventive actions was not covered. This is surprising as preventive action, in addition to corrective action, is crucial for continuous improvement, which is vital to a properly functioning QMS. We therefore strongly recommend including requirements on preventive action in the SLIPTA checklist.

Table 2.   The coverage of ISO 15189 by the SLIPTA checklist per ISO paragraph*

ISO 15189 paragraph	No. of requirements covered by the SLIPTA checklist/Total no. of requirements
ISO, International Organization for Standardization; SLIPTA, Stepwise Laboratory Improvement Process Towards Accreditation. *Chapters 1–3 and Annex A of the ISO 15189 standard do not contain requirements and are therefore not included in this table.
4.1 Organization and management	2/6
4.2 Quality management system	5/5
4.3 Document control	2/2
4.4 Review of contracts	1/5
4.5 Examination by referral laboratories	1/4
4.6 External services and supplies	4/4
4.7 Advisory services	1/1
4.8 Resolution of complaints	1/1
4.9 Identification and control of non-conformities	2/3
4.10 Corrective action	3/4
4.11 Preventive action	0/2
4.12 Continual improvement	2/5
4.13 Quality and technical records	1/3
4.14 Internal audits	1/3
4.15 Management review	1/4
5.1 Personnel	4/13
5.2 Accommodation and environmental conditions	7/10
5.3 Laboratory equipment	6/14
5.4 Pre-examination procedures	9/14
5.5 Examination procedures	2/6
5.6 Assuring quality of examination procedures	4/7
5.7 Post-examination procedures	1/2
5.8 Reporting of results	10/16
Annex B Recommendations for protection of laboratory information systems (LIS)	19/41
Annex C Ethics in laboratory medicine	0/23

The ISO 15189 standard also contains two annexes, one with recommendations for laboratory information systems (LIS) and one for ethics in clinical laboratory practice. Of the annex on LIS, only the parts related to maintenance and security of hardware and software are covered by the SLIPTA checklist. The ethics annex is not covered at all. In our view, ethics is highly important in clinical laboratory practice. Including questions on ethical behaviour may also be a valuable contribution to the SLIPTA checklist. This suggestion is not specific for the SLIPTA accreditation scheme, as most national and international quality management standards lack requirements and recommendations on ethics.

Point distribution analysis

From the point distribution, it is clear that the SLIPTA prioritized resource management, which is the initial stage of the quality cycle: Figure 2 shows that 48% of the points can be earned at this stage. Little emphasis (16% of all points) is placed on the improvement management stage, even though this stage is of prime importance for sustaining the continuous improvement cycle. By awarding few points to the improvement management stage, the laboratory is less stimulated to invest effort in improvement management.

Stepwise Laboratory Improvement Process Towards Accreditation accreditation is solely provided based on the percentage of compliance with checklist questions. In the current SLIPTA accreditation scheme, it is theoretically possible that a two-star laboratory fully complies with five checklist elements (facilities and safety; organization and personnel; equipment; purchasing and inventory; process control), while the other seven sections are completely neglected. It is questionable whether such a laboratory is able to assure the quality of their results. For example: can the laboratory deliver the results correctly to the customer without a fixed reporting form and standardized reporting system (part of information management)?

Strengths and weaknesses

The launch of the SLIPTA accreditation scheme in itself may already sensitize policy makers to the importance of quality laboratory services and shows laboratory managers the existence and importance of quality management (QM) (Gershy-Damet et al. 2010). This may facilitate more efficient and faster uptake and implementation of QM in the (clinical) laboratory field in LMIC.

In the past, various disease-specific standards and guidelines were published by WHO for use in LMIC. Examples are the WHO Polio checklist for accreditation (WHO 2003a) and the WHO tuberculosis laboratory assessment tool (WHO 2003b). A strong aspect of the SLIPTA accreditation scheme is that it is compatible with different disciplines within clinical laboratory practice. This is in accordance with the Dakar decision that accreditation schemes should no longer be field specific (Gershy-Damet et al. 2010). The SLIPTA accreditation scheme is unique as it is not disease specific and designed explicitly for implementation in multiple LMIC as most LMIC do not have national laboratory accreditation schemes, both a reason for and a consequence of neglect of the laboratory sector.

The SLIPTA accreditation scheme aims to overcome the lack of certain national regulations. Safety requirements, for example, are elaborate and detailed in the accreditation checklist, whereas the ISO 15189 standard merely includes the statement that national or regional safety regulations should be followed (International Organization for Standardization 2007). These national or regional safety regulations are indeed present in high-income countries, but in LMIC, these are often absent or still in their infancy.

A general disadvantage of checklists including the SLIPTA checklist is that they may be practical for laboratory assessors but not for laboratory managers who need to establish a quality management system: checklist questions generally lack an explanation on why and how to deal with the topic covered by the question. An example is the checklist question: ‘Is there a system for competency assessment of staff (both new hires and existing staff) and does it include planning and documentation of retraining and reassessment, when indicated?’ With this question, the laboratory manager does not receive any guidance on how to perform staff performance appraisals and to what end. This information can be found in the SLMTA training toolkit, but if the checklist is also used for establishing a quality management system (instead of for assessment), it may be necessary to include an explanation for each question, similar to the College of American Pathologists (2007) checklists for accreditation of laboratories.

The SLIPTA accreditation scheme does not include a roadmap that informs the laboratory manager in which order compliance to the checklist questions should be achieved. We found that the twelve elements are not structured in a way that could be useful for laboratory managers just beginning with establishing a QMS. We therefore suggest a logical order for implementing a QMS step-by-step (see Table 1, first column).

Suggestions on alternative strategies to accreditation

One can argue whether a stepwise accreditation scheme or a binary pass/fail system is preferable. A strong argument against the stepwise approach is that quality cannot be assured when incomplete compliance to the checklist is in place (see methods). The SLIPTA checklist does not indicate critical requirements per accreditation level. We recommend using a system that forces compliance with a set of critical requirements for each star to ensure the presence of at least a certain level of quality before accreditation for that tier can be achieved. To facilitate this, a roadmap may be developed that indicates which checklist questions have highest priority and should thus be complied with initially, and which questions could be complied with at later stages.

Accreditation schemes in high-income countries use a binary approach. For LMIC, the Thai national accreditation scheme could be used as an example of a binary approach. This scheme provides a checklist in addition to a standard. The percentage of compliance with this checklist gives laboratories an indication where they are on the road to accreditation and identifies gaps still present. Accreditation to the Thai national standard (which is not as demanding as international standards) is only provided when the laboratory fully complies with the checklist (Wattanasri et al. 2010). Identical to the SLIPTA checklist, laboratories can see in the Thai system where they are on the road to accreditation and the checklist results show points for improvement, but there is only one form of accreditation: complete compliance with the checklist. This overcomes the risk that laboratories with 3-star accreditation are incorrectly perceived as fully and correctly functioning laboratories that are only less extensive than 5-star accredited laboratories (as one could see a 3-star hotel offering less luxury than a 5-star hotel while still providing all necessary services).

Another option would be to distinguish between levels of laboratories with separate standards for each level, for example, a standard for peripheral laboratories, one for provincial/regional laboratories and one for national laboratories (this one may be equal or similar to ISO 15189). Each laboratory level would have different requirements suitable for their span of activities and responsibilities. These types of laboratories can then all be accredited to their own standard using a pass/fail system. Each standard should cover the complete quality cycle enabling a correctly functioning and continuously improving QMS. This makes it impossible for a laboratory to receive accreditation when complying with only half of the requirements to a proper functioning quality cycle.

Conclusion

By launching the SLIPTA, WHO-AFRO emphasized the necessity of QM in clinical laboratories in LMIC to policy makers and laboratory managers. The SLIPTA checklist is tailor-made for these laboratories as it overcomes the absence of national regulations, and it is applicable in multiple countries.

After analysing the SLIPTA checklist, some remarks and suggestions for improvement can be made mainly related to the skewed point distribution through which the resource management stage of the quality cycle of a laboratory is prioritized, the structure of the checklist, the scarcity of questions on management, ethics and continuous improvement. Another recommendation is to identify critical requirements for each tier of accreditation to assure a certain level of quality for each tier. After further optimization of SLIPTA, clinical laboratories may certainly benefit, leading to more patients correctly diagnosed and less waste of resources.

Acknowledgements

We thank Mirjam Engelberts and Coosje Tuijn for useful discussions and Dr. Emily Adams for critically reading the manuscript. Ingeborg Nagel is thanked for provision of useful documentation.