Internal compliance investigations can reduce government sanctions

An effective corporate compliance program is facilitated by three essential elements: a well-qualified compliance officer; a policy of immediate investigation of every report of potential fraud and abuse; and clearly defined roles for both corporate and outside counsel in conducting the investigations. A government agency is less likely to exercise the full extent of its powers when these elements are in place and three is evidence of a sincere compliance effort.

[Implementation of new Japanese GCP and the quality of clinical trials--from the standpoint of the pharmaceutical industry]

As a part of the amendment of the pharmaceutical law and regulations in Japan, the GCP has been revised and enacted into the law and regulations. The new GCP is based on ICH-GCP and aims at upholding the quality of the Japanese clinical trials to an internationally acceptable level. The roles of the people involved in clinical trials have been renewed. The sponsor is responsible for management of clinical trials. At the same time, the procedures for quality assurance and quality control have extensively been brought into the new GCP. Not only monitoring but also audit of clinical trials are now the obligations of the sponsor. In this article are described major responsibilities newly assigned to the sponsor, medical institutions and investigators as well as the matters to be tackled. Discussion was also made extending the theme to matters other than GCP for upholding the quality of clinical trials in Japan to the internationally acceptable level. It is evident that we will confront many difficulties to solve these matters, but the implementation of the new GCP should give us a good chance to improve the quality of clinical studies performed in Japan.

Rolling out the red carpet

Legions of lawyers, consultants and accountants are pulling in the big bucks helping providers stay on the right side of government regulations. Compliance is the trendiest buzzword in healthcare today, and it's creating some lucrative business opportunities. Compliance officers, like Roy Snell (left) of University of Wisconsin Medical Foundation, ride herd to make sure healthcare companies stay within the lines.

Implications of mandating amended reports following retrospective review of Papanicolaou smears

The Clinical Laboratory Improvement Amendments of 1988 requires a 5-year retrospective review of negative or normal smears in patients with diagnoses of high-grade squamous intraepithelial lesions or cancer, and amended reports are required when discrepancies that would affect current patient care are found. Notwithstanding the requirements of the Clinical Laboratory Improvement Amendments of 1988, one laboratory has been required by a State Department of Health to issue amended reports even when the discrepancy did not affect current patient care. The implications of notifying the patient and her physician of any discrepancy in a Papanicolaou smear may lead to media attention and litigation. This paper outlines how amended reports and/or correspondence to patients and physicians can be utilized to generate media attention and litigation and what laboratories can do to combat the litigation.

Papanicolaou smear 5-year retrospective review: what is required by the Clinical Laboratory Improvement Amendments of 1988?

Five-year retrospective review of negative or normal smears in patients with newly diagnosed high-grade squamous intraepithelial lesions or cancer is a federal regulation for all laboratories practicing gynecologic cytology under the Clinical Laboratory Improvement Amendments of 1988. Amended reports are required when significant discrepancies are found that would affect patient care. The focus of this regulation is current patient care. Two studies have found a retrospective discrepancy rate of about 10% when the threshold for discrepancy was at least dysplasia. Higher rates are reported when missed atypical cases are counted as discrepancies. Retrospective review highlights problem areas for laboratory education and quality improvement efforts, but liability concerns have been a detrimental consequence of this regulation. Clarification that amended reports be issued only when current patient care is affected should aid laboratories in complying with this regulation.

Health Care Financing Administration/American Society for Cytotechnology inspections: government assessment of cytology laboratory practice under the regulations of the Clinical Laboratory Improvement Amendments of 1988

Since 1988, the American Society for Cytotechnology has performed inspections of 206 cytology laboratories in the United States under contract to the Health Care Financing Administration. These surveys are conducted by a team of supervisory-qualified cytotechnologists, including a specially trained survey team leader. A board-certified anatomic pathologist is assigned to each team and is on call for each survey. Laboratories are assessed for compliance with the regulations of the Clinical Laboratory Improvement Amendments of 1988 and, in particular, the area of quality control in cytology. These surveys are unique in that a sample of at least 0.1% of a laboratory's annual case volume is reevaluated by the survey team. Of the 206 laboratories surveyed, 116 were found to be in substantial compliance with the regulations while 90 were found to have Condition level deficiencies. Of those with Condition level deficiencies, 8 have had their Clinical Laboratory Improvement Amendments of 1988 certificates limited for cytology, and 16 have been terminated from Medicare participation.

Laboratory precision performance: state of the art versus operating specifications that assure the analytical quality required by clinical laboratory improvement amendments proficiency testing

OBJECTIVE

To estimate the percent of laboratories with precision performance sufficient to satisfy the operating specifications and guarantee the quality required by the proficiency testing criteria defined by the Clinical Laboratory Improvement Amendments of 1988 (CLIA).

DESIGN

Cumulative distributions that describe state-of-the-art laboratory imprecision were obtained for 1500 laboratories participating in the 1990 College of American Pathologists Quality Assurance Service. Allowable imprecision was estimated from the x-intercepts of charts of operating specifications prepared for commonly used single and multirule quality control procedures having two to four control measurements per run.

MAIN OUTCOME MEASURE

The derived values for allowable imprecision were imposed on the cumulative distributions to obtain graphical estimates of the percent of laboratories satisfying the operating specifications.

RESULTS

Up to 28% of laboratories achieve the imprecision allowable for albumin, up to 64% for total bilirubin, 52% for calcium, 35% for chloride, 48% for cholesterol, 28% for cortisol, 84% for creatinine, 9% for digoxin, 61% for glucose, 64% for high-density lipoprotein cholesterol, 88% for hemoglobin, 95% for potassium, 66% for total protein, 18% for sodium, 29% for thyroxine, 87% for triglycerides, 35% for urea nitrogen, and 81% for uric acid.

CONCLUSION

Improvements in precision are still needed for many laboratory tests to assure the analytical quality required by the CLIA proficiency testing total error criteria.

FDA audit of nonclinical studies

FDA is increasing its efforts to enforce regulations governing the conduct of nonclinical (animal) trials to support evidence of safety. Since the GLP regulations were promulgated in 1987, the incidence of deficiencies at these animal facilities has remained constant despite an increased number of issued warning letters. These warning letters constitute a serious breach of the FDA regulations and has resulted in certain cases in rejection of nonclinical study data, termination of the IND application, and disqualification of the facility as well as criminal prosecution of individuals involved in fraudulent practices.

Standard operating procedures (SOPs): reason for, types of, adequacy, approval, and deviations from and revisions to

Standard Operating Procedures (SOPs) are required in order to comply with the Good Laboratory Practice Standards (GLPS) as promulgated in the Federal Insecticide, Fungicide and Rodenticide Act (FIFRA) 40 CFR Part 160. Paragraph 160.81 (a) states: "A testing facility shall have standard operating procedures in writing setting forth study methods that management is satisfied are adequate to insure the quality and integrity of the data generated in the course of a study." Types of SOPs include administrative and personnel, analyses, substances, quality assurance and records, test system, equipment, and field related. All SOPs must be adequate in scope to describe the function in sufficient detail such that the study data are reproducible. All SOPs must be approved by a management level as described in a corporate organization chart. Signatures for SOP responsibility, authorship, and Quality Assurance review adds strength and accountability to the SOP. In the event a procedure or method is performed differently from what is stated in the SOP, an SOP deviation is necessary. As methods and procedures are improved, SOP revisions are necessary to maintain SOP adequacy and applicability. The replaced SOP is put into a historical SOP file and all copies of the replaced SOPs are destroyed.

Preparing for and handling the results of regulatory inspections of biomedical facilities

Although there have been numerous presentations on how to conduct and survive a government inspection, it appears that these sessions do not always adequately include suggestions from those who have been the subjects of regulatory inspections. This paper will include comments from the experience of one of the regulated. Remarks apply to experience with U.S. regulatory authorities, principally the U.S. Food and Drug Administration (FDA) and the U.S. Environmental Protection Agency (EPA). This paper attempts to give guidance on how to prepare for an inspection and what to do at the debriefing and after the inspector(s) leave your facility.

Strategic partnership: the successful contract laboratory-sponsor relationship

Contract laboratory. These two words often trigger a number of concerns for a sponsor, concerns that range from timing and cost considerations to issues of technical and regulatory capability. From a contract laboratory perspective, the best way to address these concerns is for the sponsor to consider the contract laboratory as a strategic partner, a provider of needed services. In many ways, the lab should function as an extension of the sponsor's own technology group. This partnership approach should foster effective communication so that the contract laboratory understands both the technical and regulatory objectives of the sponsor as well as any unique factors that could impact the study. A team approach will ensure an understanding of the role of each participant, approaches to be used in problem solving, and details of the sponsor/laboratory interaction, such as protocol input/development, technical updates/reviews, quality assurance audits, and final report format and approval process. This presentation will share perspectives from one contract laboratory on strategic partnerships for good science, with compliance, remembering that for the sponsor, the successful study is done on time, on budget, and is accepted by the agency.

Removal of standard setting requirements for medical and nonmedical facilities where SSI recipients reside--HHS. Final rule

This notice removes from the Code of Federal Regulations the provisions on standard setting requirements for medical and non-medical facilities where Supplemental Security Income recipients reside. These standard setting requirements implement the requirements of the Keys Amendment, Section 1616(e) of the Social Security Act, as amended. This action is necessary because, as of March 31, 1995, Federal responsibility for the Keys Amendment will be assumed by the independent Social Security Administration as required by statute.

Those who do not remember the past

A foundation stone for quality assurance is the ability to document past actions. The celebration of the 10th Annual Meeting of the Society of Quality Assurance allows all of us, who were somehow intimately involved in its beginnings, to reflect on the past actions of our industries and to contemplate what this history bodes for the future. The exciting expectations of global and regulatory agency harmonization beckon us into the 21st century. We eagerly rush to embrace the concepts of total quality management and to establish an international dimension for our Society. Just as the retrospective audit of the science we regulate is an integral part of our daily activities, however, so must the reflection on whence we came (and why) be an integral part of our planning for the future. There is a dark side to the history of why the Society persists to celebrate this 10th anniversary. What lessons of yesterday remain to help guide us all into tomorrow?

The development and implementation of a quality assurance Master Audit Plan

As a quality assurance (QA) department for a clinical research organization, QA conducts audit activities for clinical trials managed by our organization and acts as an independent QA group for several other companies. A quality assurance/regulatory compliance Master Audit Plan is developed for each study or each audit if the audit is an independent task. The Master Audit Plan designed for a specific clinical study consists of a combination of several QA activities designed to ensure quality and regulatory compliance, to define timelines, and to identify personnel. These activities may include the review of the regulatory documents for each investigative site prior to the shipping of test article (test article release), review of informed consent, review of internal sponsor study files, and clinical site audits. Results of audit activities conducted under the Master Audit Plan for several clinical studies have been compiled for three of the major QA tasks. These include test article release, informed consent review, and site audits. A review of regulatory document files for test article release indicated that 13% required additional documents or correction of submitted documents. A review of informed consents found that 32% required revision. Site audit activities indicated that the clinical sites were, in general, adhering to Federal regulations and GCP guidelines. Observations noted at sites tended to fall into the categories of test article accountability issues, regulatory document additions or revisions, and quality control issues.

Perspectives on the U.S. FDA Bioresearch Monitoring Program

An overview is presented of the U.S. FDA Bioresearch Monitoring Program from the field perspective. The presentation includes current insight as to how FDA conducts field audits in various program areas and observations regarding shared responsibilities for ensuring both quality data and patient safety during the preclinical and clinical investigation processes.