Evidence from 617 laboratories in 47 countries for SLMTA-driven improvement in quality management systems

Preparedness of district clinical laboratories towards ISO 15189: 2012 accreditation scheme in Lake Zone, Tanzania (a descriptive cross-sectional study)

Introduction

diagnosis, prevention, and surveillance of diseases relies on high quality laboratory services. However, accessibility and availability of the quality laboratory services among healthcare facilities remains a serious challenge among sub-Saharan African countries. This study investigated the preparedness of district clinical laboratories for ISO 15189: 2012 accreditation scheme using Stepwise Laboratory Quality Improvement Process towards Accreditation (SLIPTA) checklistin Lake Zone, Tanzania.

Methods

this descriptive cross-sectional study was conducted from September 2018 to August 2019 among clinical laboratories at district hospitals and council designated hospitals in Lake Zone regions of Tanzania. Data were collected using the verified WHO-SLIPTA checklist. In each laboratory, either the laboratory manager, quality officer or safety officer was interviewed.

Results

a total of 10 health laboratories affiliated to 6 districts and 4 councils designated hospitals were enrolled. Six laboratory managers and four quality officers were interviewed. Six (60%) and 4 (40%) laboratories were under government ownership and private ownership, respectively. The majority (70%, n=7) of medical district laboratories in Lake Zone-Tanzania were not registered for WHO-SLIPTA.

Conclusion

about two third of district and council designated hospital laboratories in Lake zone are not registered for WHO-SLIPTA indicating unpreparedness towards ISO 15189: 2012 accreditation.

From benchmarking to best practices: Lessons from the laboratory quality improvement programme at the military teaching hospital in Cotonou, Benin

BACKGROUND

In 2015, the Army Teaching Hospital-University Teaching Hospital (HIA-CHU [Hôpital D'instruction des Armées de Cotonou Centre Hospitalier et Universitaire]) laboratory in Benin launched a quality improvement programme in alignment with the World Health Organization Regional Office for Africa's Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA). Among the sub-Saharan African laboratories that have used SLIPTA, few have been francophone countries, and fewer have belonged to a military health system. The purpose of this article was to outline the strategy, implementation, outcomes and military-specific challenges of the HIA-CHU laboratory quality improvement programme from 2015 to 2018.

INTERVENTION

The strategy for the quality improvement programme included: external baseline SLIPTA evaluation, creation of work plan based on SLIPTA results, execution of improvement projects guided by work plan, assurance of accountability via regular meetings, training of personnel to improve personnel competencies, development of external stakeholder relationships for sustainability and external follow-up post-SLIPTA evaluation.

LESSONS LEARNT

Over a period of 3 years, the HIA-CHU laboratory improved its SLIPTA score by 29% through a quality improvement process guided by work plan implementation, quality management system documentation, introduction of new proficiency testing and internal quality control programmes, and enhancement of personnel competencies in technical and quality management through training.

RECOMMENDATIONS

The programme has yielded achievements, but consistent improvement efforts are necessary to address programme challenges and ensure continual increases in SLIPTA scores. Despite successes, military-specific challenges such as the high mobility of personnel have hindered programme progress. The authors recommend that further implementation research data be shared from programmes using SLIPTA in under-represented settings such as military health systems.

Clinical Referral Laboratory Personnel's Perception of Challenges and Strategies for Sustaining the Laboratory Quality Management System

OBJECTIVES

To explore challenges explaining the decrease in quality performance and suggest strategies to improve and sustain laboratory quality services.

METHODS

Twenty key informants' interviews from laboratory personnel were conducted in five laboratories. Four had previously shown a decrease in quality performance. Interviews were transcribed verbatim and analyzed using inductive thematic analysis.

RESULTS

Two themes emerged: (1) insufficient coordination and follow-up system towards accreditation, where lack of coordination, follow-up, and audits explained the decrease in performance; (2) inadequate resource optimization, where insufficient knowledge in Laboratory Quality Management System (LQMS), ownership by laboratory workforce, and insufficient stakeholders' communication contributed to low-quality performance.

CONCLUSIONS

The coordination, follow-up, and assessments of LQMS, in conjunction with training of laboratory workforce, would establish an institutional culture of continuous quality improvement (CQI) towards accreditation and sustainment of quality health care. To achieve CQI culture, routine gap checking and planning for improvement using a system approach is required.

Strengthening Quality of Tuberculosis Laboratories Toward Accreditation in Viet Nam

OBJECTIVES

Early diagnosis of tuberculosis (TB) and multidrug-resistant TB (MDR-TB) is a priority for Viet Nam's National TB Control Programme. In many laboratories, quality systems are weak; few have attained accreditation. We implemented a structured training and mentoring program for TB laboratories and measured impact on quality.

METHODS

Six TB culture laboratories implemented the Strengthening TB Laboratory Management Towards Accreditation (TB SLMTA) program, consisting of three training workshops and on-site mentoring between workshops to support improvement projects. Periodic audits, using standardized checklists, monitored laboratories' progress toward accreditation readiness.

RESULTS

At baseline, all six laboratories achieved a zero-star level. At exit, five laboratories attained three stars and another one star. Overall checklist scores increased by 44.2% on average, from 29.8% to 74.0%; improvements occurred across all quality system essentials.

CONCLUSIONS

The program led to improved quality systems. Sites should be monitored to ensure sustainability of improvements and country capacity expanded for national scaleup.

Diagnosis of Human Immunodeficiency Virus Infection

HIV diagnostics have played a central role in the remarkable progress in identifying, staging, initiating, and monitoring infected individuals on life-saving antiretroviral therapy. They are also useful in surveillance and outbreak responses, allowing for assessment of disease burden and identification of vulnerable populations and transmission "hot spots," thus enabling planning, appropriate interventions, and allocation of appropriate funding. HIV diagnostics are critical in achieving epidemic control and require a hybrid of conventional laboratory-based diagnostic tests and new technologies, including point-of-care (POC) testing, to expand coverage, increase access, and positively impact patient management. In this review, we provide (i) a historical perspective on the evolution of HIV diagnostics (serologic and molecular) and their interplay with WHO normative guidelines, (ii) a description of the role of conventional and POC testing within the tiered laboratory diagnostic network, (iii) information on the evaluations and selection of appropriate diagnostics, (iv) a description of the quality management systems needed to ensure reliability of testing, and (v) strategies to increase access while reducing the time to return results to patients. Maintaining the central role of HIV diagnostics in programs requires periodic monitoring and optimization with quality assurance in order to inform adjustments or alignment to achieve epidemic control.

Clinical Referral Laboratories in Rwanda

Objectives

We investigated the quality system performance in Rwandan referral laboratories to determine their progress toward accreditation.

Methods

We conducted audits across five laboratories in 2017, using the Stepwise Laboratory Quality Improvement Process Towards Accreditation checklist. Laboratories were scored based on the World Health Organization grading scale (0-5 stars scale) and compared with earlier audits.

Results

Between 2012 and 2017, only one laboratory progressed (from four to five stars). Four of the five laboratories decreased to one (three laboratories) and zero (one laboratory) stars from four and three stars. Management reviews, evaluation, audits, documents, records, and identification of nonconformities showed a low performance.

Conclusions

Four of five laboratories are not moving toward accreditation. However, this target is still achievable by energizing responsibilities of stakeholders and monitoring and evaluation. This would be possible because of the ability that laboratories showed in earlier audits, coupled with existing health policy that enables sustainable quality health care in Rwanda.

Laboratory medicine in Africa since 2008: then, now, and the future

The Maputo Declaration of 2008 advocated for commitment from global stakeholders and national governments to prioritise support and harmonisation of laboratory systems through development of comprehensive national laboratory strategies and policies in sub-Saharan Africa. As a result, HIV laboratory medicine in Africa has undergone a transformation, and substantial improvements have been made in diagnostic services, networks, and institutions, including the development of a competent workforce, introduction of point-of-care diagnostics, and innovative quality improvement programmes that saw more than 1100 laboratories enrolled and 44 accredited to international standards. These improved HIV laboratories can now be used to combat emerging continental and global health threats in the decades to come. For instance, the unprecedented Ebola virus disease outbreak in west Africa exposed the severe weaknesses in the overall national health systems in affected countries. It is now possible to build robust health-care systems in Africa and to combat emerging continental and global health threats in the future. In this Personal View, we aim to describe the remarkable transformation that has occurred in laboratory medicine to combat HIV/AIDS and improve global health in sub-Saharan Africa since 2008.

Evaluation of the WHO laboratory quality stepwise implementation tool

OBJECTIVES

To introduce the Laboratory Quality Stepwise Implementation (LQSI) tool and provide data about its roll-out, usage and effectiveness in assisting laboratories with quality improvement.

METHODS

The LQSI tool, a freely available stepwise guide, was developed by WHO to assist laboratories with efficiently implementing a quality management system.

RESULTS

Since the tool's launch in 2014, it has been accessed by 130 986 unique users from 195 of 206 listed states. Of 35 respondents to a survey, 12 (34%) indicated that their laboratory had been able to achieve accreditation/certification/licensing as a result of using the tool.

CONCLUSIONS

The LQSI tool, currently being used worldwide and available in English, French, Russian, Spanish, Arabic and Turkish, positively impacts the quality of services provided by clinical and public health laboratories, leading to improved clinical care and disease surveillance capacity as required by the IHR (2005) and envisioned by the Global Health Security Agenda.

Building and Rebuilding: The National Public Health Laboratory Systems and Services Before and After the Earthquake and Cholera Epidemic, Haiti, 2009-2015

Before the 2010 devastating earthquake and cholera outbreak, Haiti’s public health laboratory systems were weak and services were limited. There was no national laboratory strategic plan and only minimal coordination across the laboratory network. Laboratory capacity was further weakened by the destruction of over 25 laboratories and testing sites at the departmental and peripheral levels and the loss of life among the laboratory health-care workers. However, since 2010, tremendous progress has been made in building stronger laboratory infrastructure and training a qualified public health laboratory workforce across the country, allowing for decentralization of access to quality-assured services. Major achievements include development and implementation of a national laboratory strategic plan with a formalized and strengthened laboratory network; introduction of automation of testing to ensure better quality of results and diversify the menu of tests to effectively respond to outbreaks; expansion of molecular testing for tuberculosis, human immunodeficiency virus, malaria, diarrheal and respiratory diseases; establishment of laboratory-based surveillance of epidemic-prone diseases; and improvement of the overall quality of testing. Nonetheless, the progress and gains made remain fragile and require the full ownership and continuous investment from the Haitian government to sustain these successes and achievements.

Developing a customised approach for strengthening tuberculosis laboratory quality management systems toward accreditation

Background

Quality-assured tuberculosis laboratory services are critical to achieve global and national goals for tuberculosis prevention and care. Implementation of a quality management system (QMS) in laboratories leads to improved quality of diagnostic tests and better patient care. The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme has led to measurable improvements in the QMS of clinical laboratories. However, progress in tuberculosis laboratories has been slower, which may be attributed to the need for a structured tuberculosis-specific approach to implementing QMS. We describe the development and early implementation of the Strengthening Tuberculosis Laboratory Management Toward Accreditation (TB SLMTA) programme.

Development

The TB SLMTA curriculum was developed by customizing the SLMTA curriculum to include specific tools, job aids and supplementary materials specific to the tuberculosis laboratory. The TB SLMTA Harmonized Checklist was developed from the World Health Organisation Regional Office for Africa Stepwise Laboratory Quality Improvement Process Towards Accreditation checklist, and incorporated tuberculosis-specific requirements from the Global Laboratory Initiative Stepwise Process Towards Tuberculosis Laboratory Accreditation online tool.

Implementation

Four regional training-of-trainers workshops have been conducted since 2013. The TB SLMTA programme has been rolled out in 37 tuberculosis laboratories in 10 countries using the Workshop approach in 32 laboratories in five countries and the Facility-based approach in five tuberculosis laboratories in five countries.

Conclusion

Lessons learnt from early implementation of TB SLMTA suggest that a structured training and mentoring programme can build a foundation towards further quality improvement in tuberculosis laboratories. Structured mentoring, and institutionalisation of QMS into country programmes, is needed to support tuberculosis laboratories to achieve accreditation.

External quality assurance for HIV point-of-care testing in Africa: A collaborative country-partner approach to strengthen diagnostic services

It is important to consider the role of diagnostics and the critical need for quality diagnostics services in resource-limited settings. Accurate diagnostic tests play a key role in patient management and the prevention and control of most infectious diseases. As countries plan for implementation of HIV early infant diagnosis and viral load point-of-care testing, the London School of Hygiene & Tropical Medicine has worked with countries and partners with an interest in external quality assurance to support quality point-of-care testing on the continent. Through a series of collaborative consultations and workshops, the London School of Hygiene & Tropical Medicine has gathered lessons learned, tools, and resources and developed quality assurance models that will support point-of-care testing. The London School of Hygiene & Tropical Medicine is committed to the continued advancement of laboratory diagnostics in Africa and quality laboratory services and point-of-care testing.

Implementation research: a mentoring programme to improve laboratory quality in Cambodia

OBJECTIVE

To implement a mentored laboratory quality stepwise implementation (LQSI) programme to strengthen the quality and capacity of Cambodian hospital laboratories.

METHODS

We recruited four laboratory technicians to be mentors and trained them in mentoring skills, laboratory quality management practices and international standard organization (ISO) 15189 requirements for medical laboratories. Separately, we trained staff from 12 referral hospital laboratories in laboratory quality management systems followed by tri-weekly in-person mentoring on quality management systems implementation using the LQSI tool, which is aligned with the ISO 15189 standard. The tool was adapted from a web-based resource into a software-based spreadsheet checklist, which includes a detailed action plan and can be used to qualitatively monitor each laboratory's progress. The tool - translated into Khmer - included a set of quality improvement activities grouped into four phases for implementation with increasing complexity. Project staff reviewed the laboratories' progress and challenges in weekly conference calls and bi-monthly meetings with focal points of the health ministry, participating laboratories and local partners. We present the achievements in implementation from September 2014 to March 2016.

FINDINGS

As of March 2016, the 12 laboratories have completed 74-90% of the 104 activities in phase 1, 53-78% of the 178 activities in phase 2, and 18-26% of the 129 activities in phase 3.

CONCLUSION

Regular on-site mentoring of laboratories using a detailed action plan in the local language allows staff to learn concepts of quality management system and learn on the job without disruption to laboratory service provision.

Driving hospital transformation with SLMTA in a regional hospital in Cameroon

Background

Inspired by the transformation of the Regional Hospital Buea laboratory through implementation of the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme, hospital management adapted the SLMTA toolkit to drive hospital-wide quality improvement.

Objective

This paper describes changes in the hospital following the quality improvement activities in hygiene and sanitation, the outpatient waiting area and the surgical and maternity wards.

Methods

In March 2011, hospital management established a quality improvement task force and created a hospital-wide quality improvement roadmap, following the SLMTA model. The roadmap comprised improvement projects, accountability plans, patient feedback forms and log books to track quality indicators including patient wait time, satisfaction level, infection rates, birth outcomes and hospital revenue.

Results

There was steady improvement in service delivery during the 11 months after the introduction of the quality improvement initiatives: patient wait time at the reception was reduced from three hours to less than 30 minutes and patient satisfaction increased from 15% to 60%. Treatment protocols were developed and documented for various units, infrastructure and workflow processes were improved and there was increased staff awareness of the importance of providing quality services. Maternal infection rates dropped from 3% to 0.5% and stillbirths from 5% to < 1%. The number of patients increased as a result of improved services, leading to a 25% increase in hospital revenue.

Conclusion

The SLMTA programme was adapted successfully to meet the needs of the entire hospital. Such a programme has the potential to impact positively on hospital quality systems; consideration should be made for development of a formal SLMTA-like programme for hospital quality improvement.

Innovative strategies for a successful SLMTA country programme: The Rwanda story

Background

In 2009, to improve the performance of laboratories and strengthen healthcare systems, the World Health Organization Regional Office for Africa (WHO AFRO) and partners launched two initiatives: a laboratory quality improvement programme called Strengthening Laboratory Management Toward Accreditation (SLMTA), and what is now called the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA).

Objectives

This study describes the achievements of Rwandan laboratories four years after the introduction of SLMTA in the country, using the SLIPTA scoring system to measure laboratory progress.

Methods

Three cohorts of five laboratories each were enrolled in the SLMTA programme in 2010, 2011 and 2013. The cohorts used SLMTA workshops, improvement projects, mentorship and quarterly performance-based financing incentives to accelerate laboratory quality improvement. Baseline, exit and follow-up audits were conducted over a two-year period from the time of enrolment. Audit scores were used to categorise laboratory quality on a scale of zero (< 55%) to five (95% – 100%) stars.

Results

At baseline, 14 of the 15 laboratories received zero stars with the remaining laboratory receiving a two-star rating. At exit, five laboratories received one star, six received two stars and four received three stars. At the follow-up audit conducted in the first two cohorts approximately one year after exit, one laboratory scored two stars, five laboratories earned three stars and four laboratories, including the National Reference Laboratory, achieved four stars.

Conclusion

Rwandan laboratories enrolled in SLMTA showed improvement in quality management systems. Sustaining the gains and further expansion of the SLMTA programme to meet country targets will require continued programme strengthening.

A comprehensive review of the SLMTA literature part 2: Measuring success

Background

Since its introduction in 2009, the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme has been implemented in 617 laboratories in 47 countries.

Objective

We completed a systematic review of the published literature on SLMTA. The review consists of two companion papers; this article examines quantitative evidence presented in the publications along with a meta-analysis of selected results.

Methods

We identified 28 published articles with data from SLMTA implementation. The SLMTA programme was evaluated through audits based on a standard checklist, which is divided into 12 sections corresponding to the 12 Quality System Essentials (QSEs). Several basic service delivery indicators reported by programmes were also examined. Results for various components of the programme were reviewed and summarised; a meta-analysis of QSE results grouped by the three stages of the quality cycle was conducted for 126 laboratories in 12 countries.

Results

Global programme data show improved quality in SLMTA laboratories in every country, with average improvements on audit scores of 25 percentage points. Meta-analysis identified Improvement Management as the weakest stage, with internal audit (8%) and occurrence management (16%) showing the lowest scores. Studies documented 19% – 95% reductions in turn-around times, 69% – 93% reductions in specimen rejection rates, 76% – 81% increases in clinician satisfaction rates, 67% – 85% improvements in external quality assessment results, 50% – 66% decreases in nonconformities and 67% increases in staff punctuality.

Conclusions

The wide array of results reported provides a comprehensive picture of the SLMTA programme overall, suggesting a substantive impact on provision of quality laboratory services and patient care. These comprehensive results establish a solid data-driven foundation for program improvement and further expansion.

Perceptions and attitudes toward SLMTA amongst laboratory and hospital professionals in Ethiopia

Background

Strengthening Laboratory Management Toward Accreditation (SLMTA) is a competency-based management training programme. Assessing health professionals’ views of SLMTA provides feedback to inform program planning, implementation and evaluation of SLMTA's training, communication and mentorship components.

Objectives

To assess laboratory professionals’ and hospital chief executive officers’ (CEOs) perceptions and attitudes toward the SLMTA programme in Ethiopia.

Methods

A cross-sectional descriptive survey was conducted in March 2013 using a structured questionnaire to collect qualitative data from 72 laboratory professionals and hospital CEOs from 17 health facilities, representing all regions and two city administrations in Ethiopia. Focus groups were conducted with laboratory professionals and hospital administration to gain insight into the strengths and challenges of the SLMTA programme so as to guide future planning and implementation.

Results

Ethiopian laboratory professionals at all levels had a supportive attitude toward the SLMTA programme. They believed that SLMTA substantially improved laboratory services and acted as a catalyst for total healthcare reform and improvement. They also noted that the SLMTA programme achieved marked progress in laboratory supply chain, sample referral, instrument maintenance and data management systems. In contrast, nearly half of the participating hospital CEOs, especially those associated with low-scoring laboratories, were sceptical about the SLMTA programme, believing that the benefits of SLMTA were outweighed by the level of human resources and time commitment required. They also voiced concerns about the cost and sustainability of SLMTA.

Conclusion

This study highlights the need for stronger engagement and advocacy with hospital administration and the importance of addressing concerns about the cost and sustainability of the SLMTA programme.

The impact of SLMTA in improving laboratory quality systems in the Caribbean Region

Background

Past efforts to improve laboratory quality systems and to achieve accreditation for better patient care in the Caribbean Region have been slow.

Objective

To describe the impact of the Strengthening of Laboratory Management Toward Accreditation (SLMTA) training programme and mentorship amongst five clinical laboratories in the Caribbean after 18 months.

Method

Five national reference laboratories from four countries participated in the SLMTA programme that incorporated classroom teaching and implementation of improvement projects. Mentors were assigned to the laboratories to guide trainees on their improvement projects and to assist in the development of Quality Management Systems (QMS). Audits were conducted at baseline, six months, exit (at 12 months) and post-SLMTA (at 18 months) using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist to measure changes in implementation of the QMS during the period. At the end of each audit, a comprehensive implementation plan was developed in order to address gaps.

Results

Baseline audit scores ranged from 19% to 52%, corresponding to 0 stars on the SLIPTA five-star scale. After 18 months, one laboratory reached four stars, two reached three stars and two reached two stars. There was a corresponding decrease in nonconformities and development of over 100 management and technical standard operating procedures in each of the five laboratories.

Conclusion

The tremendous improvement in these five Caribbean laboratories shows that SLMTA coupled with mentorship is an effective, user-friendly, flexible and customisable approach to the implementation of laboratory QMS. It is recommended that other laboratories in the region consider using the SLMTA training programme as they engage in quality systems improvement and preparation for accreditation.

Decentralised facility-based training as an alternative model for SLMTA implementation: The Cameroon experience

Background

The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme is designed to build institutional capacity to help strengthen the tiered laboratory system. Most countries implement the SLMTA three-workshop series using a centralised model, whereby participants from several laboratories travel to one location to be trained together.

Objectives

We assessed the effectiveness and cost of conducting SLMTA training in a decentralised manner as compared to centralised training.

Methods

SLMTA was implemented in five pilot laboratories in Cameroon between October 2010 and October 2012 by means of a series of workshops, laboratory improvement projects and on-site mentorship. The first workshop was conducted in the traditional centralised approach. The second and third workshops were decentralised, delivered on-site at each of the five enrolled laboratories. Progress was monitored by repeated audits using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist.

Results

Audit scores for all laboratories improved steadily through the course of the programme. Median improvement was 11 percentage points after the first (centralised) training and an additional 24 percentage points after the second (decentralised) training. The estimated per-laboratory cost of the two training models was approximately the same at US$21 000. However, in the decentralised model approximately five times as many staff members were trained, although it also required five times the amount of trainer time.

Conclusion

Decentralised SLMTA training was effective in improving laboratory quality and should be considered as an alternative to centralised training.

SLIPTA e-Tool improves laboratory audit process in Vietnam and Cambodia

Background

The Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist is used worldwide to drive quality improvement in laboratories in developing countries and to assess the effectiveness of interventions such as the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme. However, the paper-based format of the checklist makes administration cumbersome and limits timely analysis and communication of results.

Development of e-Tool

In early 2012, the SLMTA team in Vietnam developed an electronic SLIPTA checklist tool. The e-Tool was pilot tested in Vietnam in mid-2012 and revised. It was used during SLMTA implementation in Vietnam and Cambodia in 2012 and 2013 and further revised based on auditors’ feedback about usability.

Outcomes

The SLIPTA e-Tool enabled rapid turn-around of audit results, reduced workload and language barriers and facilitated analysis of national results. Benefits of the e-Tool will be magnified with in-country scale-up of laboratory quality improvement efforts and potential expansion to other countries.

Translating a National Laboratory Strategic Plan into action through SLMTA in a district hospital laboratory in Botswana

BACKGROUND

The Ministry of Health (MOH) of Botswana adopted Strengthening Laboratory Management Toward Accreditation (SLMTA), a structured quality improvement programme, as a key tool for the implementation of quality management systems in its public health laboratories. Coupled with focused mentorship, this programme aimed to help MOH achieve the goals of the National Laboratory Strategic Plan to provide quality and timely clinical diagnoses.

OBJECTIVES

This article describes the impact of implementing SLMTA in Sekgoma Memorial Hospital Laboratory (SMHL) in Serowe, Botswana.

METHODS

SLMTA implementation in SMHL included trainings, improvement projects, site visits and focused mentorship. To measure progress, audits using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist were conducted at baseline and exit of the programme, with scores corresponding to a zero- to five-star scale. Turnaround times, customer satisfaction, and several other health service indicators were tracked.

RESULTS

The laboratory scored 53% (zero stars) at the baseline audit and 80% (three stars) at exit. Nearly three years later, the laboratory scored 85% (four stars) in an official audit conducted by the African Society for Laboratory Medicine. Turnaround times became shorter after SLMTA implementation, with reductions ranging 19% to 52%; overall patient satisfaction increased from 56% to 73%; and clinician satisfaction increased from 41% to 72%. Improvements in inventory management led to decreases in discarded reagents, reducing losses from US $18 000 in 2011 to $40 in 2013.

CONCLUSION

The SLMTA programme contributed to enhanced performance of the laboratory, which in turn yielded potential positive impacts for patient care at the hospital.

Laboratory system strengthening and quality improvement in Ethiopia

Background

In 2010, a National Laboratory Strategic Plan was set forth in Ethiopia to strengthen laboratory quality systems and set the stage for laboratory accreditation. As a result, the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme was initiated in 45 Ethiopian laboratories.

Objectives

This article discusses the implementation of the programme, the findings from the evaluation process and key challenges.

Methods

The 45 laboratories were divided into two consecutive cohorts and staff from each laboratory participated in SLMTA training and improvement projects. The average amount of supportive supervision conducted in the laboratories was 68 hours for cohort I and two hours for cohort II. Baseline and exit audits were conducted in 44 of the laboratories and percent compliance was determined using a checklist with scores divided into zero- to five-star rating levels.

Results

Improvements, ranging from < 1 to 51 percentage points, were noted in 42 laboratories, whilst decreases were recorded in two. The average scores at the baseline and exit audits were 40% and 58% for cohort I (p < 0.01); and 42% and 53% for cohort II (p < 0.01), respectively. The p-value for difference between cohorts was 0.07. At the exit audit, 61% of the first and 48% of the second cohort laboratories achieved an increase in star rating. Poor awareness, lack of harmonisation with other facility activities and the absence of a quality manual were challenges identified.

Conclusion

Improvements resulting from SLMTA implementation are encouraging. Continuous advocacy at all levels of the health system is needed to ensure involvement of stakeholders and integration with other improvement initiatives and routine activities.

Maximising mentorship: Variations in laboratory mentorship models implemented in Zimbabwe

Background

Laboratory mentorship has proven to be an effective tool in building capacity and assisting laboratories in establishing quality management systems. The Zimbabwean Ministry of Health and Child Welfare implemented four mentorship models in 19 laboratories in conjunction with the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme.

Objectives

This study outlines how the different models were implemented, cost involved per model and results achieved.

Methods

Eleven of the laboratories had been trained previously in SLMTA (Cohort I). They were assigned to one of three mentorship models based on programmatic considerations: Laboratory Manager Mentorship (Model 1, four laboratories); One Week per Month Mentorship (Model 2, four laboratories); and Cyclical Embedded Mentorship (Model 3, three laboratories). The remaining eight laboratories (Cohort II) were enrolled in Cyclical Embedded Mentorship incorporated with SLMTA training (Model 4). Progress was evaluated using a standardised audit checklist.

Results

At SLMTA baseline, Model 1–3 laboratories had a median score of 30%. After SLMTA, at mentorship baseline, they had a median score of 54%. At the post-mentorship audit they reached a median score of 75%. Each of the three mentorship models for Cohort I had similar median improvements from pre- to post-mentorship (17 percentage points for Model 1, 23 for Model 2 and 25 for Model 3; p > 0.10 for each comparison). The eight Model 4 laboratories had a median baseline score of 24%; after mentorship, their median score increased to 63%. Median improvements from pre-SLMTA to post-mentorship were similar for all four models.

Conclusion

Several mentorship models can be considered by countries depending on the available resources for their accreditation implementation plan.

A comprehensive review of the SLMTA literature part 1: Content analysis and future priorities

Background

Since its introduction in 2009, the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme has been implemented widely throughout Africa, as well as in the Caribbean, Central and South America, and Southeast Asia.

Objective

We compiled results from local, national and global studies to provide a broad view of the programme and identify directions for the future. The review consists of two companion papers; this paper focuses on content analysis, examining various thematic components of the SLMTA programme and future priorities.

Methods

A systematic literature search identified 28 published articles about implementing the SLMTA programme. Results for various components of the SLMTA programme were reviewed and summarised.

Results

Local and national studies provide substantial information on previous experiences with quality management systems; variations on SLMTA implementation; building human resource capacity for trainers, mentors and auditors; the benefits and effectiveness of various types of mentorship; the importance of management buy-in to ensure country ownership; the need to instill a culture of quality in the laboratory; success factors and challenges; and future directions for the programme.

Conclusions

Local, national and global results suggest that the SLMTA programme has been overwhelmingly successful in transforming laboratory quality management. There is an urgent need to move forward in four strategic directions: progression (continued improvement in SLMTA laboratories), saturation (additional laboratories within countries that have implemented SLMTA), expansion (implementation in additional countries), and extension (adapting SLMTA for implementation beyond the laboratory), to lead to transformation of overall health systems and patient care.

Weighing the costs: Implementing the SLMTA programme in Zimbabwe using internal versus external facilitators

Background

In 2010, the Zimbabwe Ministry of Health and Child Welfare (MoHCW) adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme as a tool for laboratory quality systems strengthening.

Objectives

To evaluate the financial costs of SLMTA implementation using two models (external facilitators; and internal local or MoHCW facilitators) from the perspective of the implementing partner and to estimate resources needed to scale up the programme nationally in all 10 provinces.

Methods

The average expenditure per laboratory was calculated based on accounting records; calculations included implementing partner expenses but excluded in-kind contributions and salaries of local facilitators and trainees. We also estimated theoretical financial costs, keeping all contextual variables constant across the two models. Resource needs for future national expansion were estimated based on a two-phase implementation plan, in which 12 laboratories in each of five provinces would implement SLMTA per phase; for the internal facilitator model, 20 facilitators would be trained at the beginning of each phase.

Results

The average expenditure to implement SLMTA in 11 laboratories using external facilitators was approximately US$5800 per laboratory; expenditure in 19 laboratories using internal facilitators was approximately $6000 per laboratory. The theoretical financial cost of implementing a 12-laboratory SLMTA cohort keeping all contextual variables constant would be approximately $58 000 using external facilitators; or $15 000 using internal facilitators, plus $86 000 to train 20 facilitators. The financial cost for subsequent SLMTA cohorts using the previously-trained internal facilitators would be approximately $15 000, yielding a break-even point of 2 cohorts, at $116 000 for either model. Estimated resources required for national implementation in 120 laboratories would therefore be $580 000 using external facilitators ($58 000 per province) and $322 000 using internal facilitators ($86 000 for facilitator training in each of two phases plus $15 000 for SLMTA implementation in each province).

Conclusion

Investing in training of internal facilitators will result in substantial savings over the scale-up of the programme. Our study provides information to assist policy makers to develop strategic plans for investing in laboratory strengthening.

Training-of-trainers: A strategy to build country capacity for SLMTA expansion and sustainability

Background

The Strengthening Laboratory Management Toward Accreditation (SLMTA) programme uses a training-of-trainers (TOT) model to build capacity for programme scale-up. The TOT strategy is designed to maximise utilisation of its graduates whilst minimising inconsistencies and ensuring high programme quality during global expansion.

Objectives

To describe the SLMTA TOT programme approach.

Methods

The two-week training, led by carefully selected and trained master trainers, enables effective and authentic implementation of the curriculum by its graduates. The teachback methodology used allows participants to practise teaching the curriculum whilst learning its content. A trainer’s toolkit provides all the materials necessary for teaching and must be followed faithfully during training. Two surveys were conducted to assess the effectiveness of the TOT strategy: one sent to 316 TOT graduates in 25 countries and the other sent to the programme leaders in 10 countries.

Results

By the end of 2013, 433 SLMTA trainers had been trained who, in turn, taught more than 1900 people to implement SLMTA in 617 laboratories in 47 countries. Ninety-seven percent of the 433 TOT graduates and 87% of the 38 master trainers are based in developing countries. Ninety-two per cent of the graduates have been utilised at least once in programme implementation and, as of August 2013, 87% of them were still actively involved in programme activities. Ninety-seven per cent of the graduates stated that the TOT workshop prepared them well for training or other programme tasks.

Conclusion

The SLMTA TOT strategy is effective in building local capacity for global programme expansion whilst maintaining programme quality.

Building local human resources to implement SLMTA with limited donor funding: The Ghana experience

BACKGROUND

In 2009, Ghana adopted the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme in order to improve laboratory quality. The programme was implemented successfully with limited donor funding and local human resources.

OBJECTIVES

To demonstrate how Ghana, which received very limited PEPFAR funding, was able to achieve marked quality improvement using local human resources.

METHOD

Local partners led the SLMTA implementation and local mentors were embedded in each laboratory. An in-country training-of-trainers workshop was conducted in order to increase the pool of local SLMTA implementers. Three laboratory cohorts were enrolled in SLMTA in 2011, 2012 and 2013. Participants from each cohort attended in a series of three workshops interspersed with improvement projects and mentorship. Supplemental training on internal audit was provided. Baseline, exit and follow-up audits were conducted using the Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist. In November 2013, four laboratories underwent official SLIPTA audits by the African Society for Laboratory Medicine (ASLM).

RESULTS

The local SLMTA team successfully implemented three cohorts of SLMTA in 15 laboratories. Seven out of the nine laboratories that underwent follow-up audits have reached at least one star. Three out of the four laboratories that underwent official ASLM audits were awarded four stars. Patient satisfaction increased from 25% to 70% and sample rejection rates decreased from 32% to 10%. On average, $40 000 was spent per laboratory to cover mentors' salaries, SLMTA training and improvement project support.

CONCLUSION

Building in-country capacity through local partners is a sustainable model for improving service quality in resource-constrained countries such as Ghana. Such models promote country ownership, capacity building and the use of local human resources for the expansion of SLMTA.

The SLMTA programme: Transforming the laboratory landscape in developing countries

Background

Efficient and reliable laboratory services are essential to effective and well-functioning health systems. Laboratory managers play a critical role in ensuring the quality and timeliness of these services. However, few laboratory management programmes focus on the competencies required for the daily operations of a laboratory in resource-limited settings. This report provides a detailed description of an innovative laboratory management training tool called Strengthening Laboratory Management Toward Accreditation (SLMTA) and highlights some challenges, achievements and lessons learned during the first five years of implementation (2009–2013) in developing countries.

Programme

SLMTA is a competency-based programme that uses a series of short courses and work-based learning projects to effect immediate and measurable laboratory improvement, while empowering laboratory managers to implement practical quality management systems to ensure better patient care. A SLMTA training programme spans from 12 to 18 months; after each workshop, participants implement improvement projects supported by regular supervisory visits or on-site mentoring. In order to assess strengths, weaknesses and progress made by the laboratory, audits are conducted using the World Health Organization’s Regional Office for Africa (WHO AFRO) Stepwise Laboratory Quality Improvement Process Towards Accreditation (SLIPTA) checklist, which is based on International Organization for Standardization (ISO) 15189 requirements. These internal audits are conducted at the beginning and end of the SLMTA training programme.

Conclusion

Within five years, SLMTA had been implemented in 617 laboratories in 47 countries, transforming the laboratory landscape in developing countries. To our knowledge, SLMTA is the first programme that makes an explicit connection between the performance of specific management behaviours and routines and ISO 15189 requirements. Because of this close relationship, SLMTA is uniquely positioned to help laboratories seek accreditation to ISO 15189.

Improving quality in national reference laboratories: The role of SLMTA and mentorship

Background

The Nigerian Institute of Medical Research houses two reference laboratories: the virology and tuberculosis laboratories. Both were enrolled in the Strengthening Laboratory Management Toward Accreditation (SLMTA) programme.

Objective

To describe the impact of SLMTA and discuss factors affecting the results, with an emphasis on mentorship.

Methods

The SLMTA programme was implemented from April 2010 through November 2012. Participants attended three workshops and executed quality improvement projects; laboratory auditors evaluated performance using a standard checklist. The virology laboratory did not receive mentorship; however, the tuberculosis laboratory had an international mentor who visited the laboratory four times during the programme, spending two to four weeks embedded within the laboratory during each visit.

Results

There was an overall improvement in the performance of both laboratories, with the virology laboratory increasing 13% (from 80% at baseline to 93% at exit audit) and the tuberculosis laboratory increasing 29% (from 66% to 95%). These scores were maintained nine months later at the surveillance audit.

Conclusion

The SLMTA programme resulted in improved and sustained quality management performance for both laboratories. Mentoring was a possible factor in the substantial improvement made by the tuberculosis laboratory and should be considered in order to augment the training received from the SLMTA workshops.