Biosystems User Training Program

QC Module

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What is Quality Control ?

1. An statistical process to monitoring and evaluate the analytical process that produces patient results.
2. It requires regular testing (throughout the control products) along with patient samples and comparison of QC results
to specifical statistical limits (ranges included in IFU sheets)
3. QC results are used to validate whether the instrument is operating within pre-defined specifications, inferring that
patient results are reliable.
4. A QC product is a patient-like material ideally made from human serum, urine or other matters. It is composed of one
(monocontrol) or more constituents (multicontrol) of known concentration. Control products should be tested in the
same manner as patient samples.
5. GLP rules require testing normal and abnormal controls for each test at least daily to monitor the analytical process. If
the test is stable for less than 24h or some change has occurred which potentially affects the test stability (i.e. an
intervention of technical service), controls should be assayed more frequently.

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Calculation and Use of QC Statistics

The statistics and ranges calculated from the data collected from a QC product are specific for each level of control and reflect the behaviour of
the test at specific concentrations (or values around these)
The Mean

The mean is the calculation for the average of all the data collected for one QC level. It is determined by the sum of all the values obtained from
QC processing divided by the number of values collected.
The Standard Deviation [s]

Standard Deviation is a statistic that quantifies how close numerical values are in relation to each other. The term precision or repeatability is
often used interchangeably with its statistic. Thus, imprecision is used to express how far apart numerical values are from each other. The
repeatability of a test may be consistent (low sd, low imprecision) or inconsistent (high sd, high imprecision). Inconsistent repeatability may be
due to the chemistry involved or to a malfunction. It is desirable to get repeated measurements of the same specimen as close as possible.
To calculate sd :
Where N = number of results
xi = Result number i
= Mean of the results
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Calculation and Use of QC Statistics

The Standard Deviation [s]

Investigation of the test system is necessary and the following questions

should be asked:

1. Has the reagent or reagent lot changed recently? (S.E.)

2. Has maintenance been performed routinely and on schedule? (R.
E.)
3. Are the reagent and sample tips operating correctly? (R.E.)
4. Is there any change in reagent formulation that can affect its
behaviour and requires a reprogrammation of the test? (S.E.)

S.E.: Systematic Error

R.E.: Random Error

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Calculation and Use of QC Statistics

Coefficient of Variation [CV]

The Coefficient of Variation [CV] is the ratio of the sd to the mean and it is expressed as a percentage.

Since sd typically increases as the concentration of the analyte increases, the CV can be regarded as a statistical equalizer. If the technician is
comparing precision for two different methods and uses only sd, he or she can be easily misled. For example, a comparison between hexoquinase
and glucose oxidase (two different methods for assaying glucose) is required. The sd for HK method is 4.8 and it is 4.0 for glucose oxidase. If the
comparison only uses sd, it can be incorrectly assumed that glucose oxidase method is more precise that the HK method. If, however, a CV is
calculated, it might show that both methods are equally precise. Assume that the mean for the HK method is 120 and the glucose oxidase mean is
100. Then CV for both methods is 4%. They are equally precise.

HK (4.8/120) x 100 = 4%

Oxidase (4.0/100) x 100 = 4%

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Calculation and Use of QC Statistics

Coefficient of Variation [CV]

The CV can also be used when comparing instrument performance. Consider Table 1: In the example, both instruments have similar
precision for calcium and glucose, but
Instrument #1 demonstrates much better
Table 1: Imprecision differences due to instrument or reagent precision than Instrument #2 for phosphorus.
Because the precision was calculated from
Normal Control lot X Normal Control lot X data for the same lot number and level of
control, the differences in precision are likely
Instrument #1 / Reagent #1 CVs Instrument #2 / Reagent #2 CVs due to the instrument or reagent.
Lack of regular maintenance could be one
Calcium 6.1 % 5.9 % source of imprecision if differences in CV
would appear on almost every test between
Phosphorus 5.2 % 9.9 % two identical instruments.

Glucose 4.4 % 4.2 %

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Calculation and Use of QC Statistics

Comparative Evaluations

There are several sources that provide performance expectations to which the laboratory can compare its sd:

1. Instrument Manuals & Test Method Descriptions (IFU sheet): Instrument manuals and test method descriptions publish expectations
for between-run and within-run precision. These expectations are determined by the manufacturer through repetitive testing and may
reflect ideal conditions. However, even a less precision alarm appears and before any final assessment is made, the laboratory should
compare its results to a interlaboratory QC program (like PREVECAL), which is more indicative of ‘real world’ experience.
2. Interlaboratory QC Programs: In an interlaboratory comparison program, labs submit monthly data
collected for each control product tested. These data are combined with data from other laboratories which use the same instrument and
provide statistical analysis in order to determine how is the level of precision of each of them.

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Additional QC Control Statistics

Coefficient of Variation Ratio [CVR]

One way a laboratory can determine whether the precision of a specific test is acceptable is to compare its precision to that of another laboratory
performing the same test on the same instrument using the same reagents (laboratory peer group).
Any ratio less than 1.0 indicates that precision is better than the peer group. Any score greater
CVR = Within Laboratory CV / Peer Group CV than 1.0 indicates that imprecision is larger. Ratios greater than 1.5 indicate a need to
investigate the cause of imprecision and any ratio of 2.0 or greater usually indicates need for
troubleshooting and corrective action. Something in the test system is causing the increased
imprecision and patient test results may not be entirely reliable.

Standard Deviation Index [SDI]

The Standard Deviation Index [SDI] is a peer-based estimate of reliability.

The target SDI is 0.0 which indicates a perfect comparison with the peer
SDI = ( Lab
- Group
) / SGroup group.
➔ 1.25 or less is considered acceptable.
➔ 1.25 - 1.49 is considered acceptable to marginal performance.
2014/09 ➔ 1.5 - 1.99 is considered marginal performance. Version 1.0
➔ 2.0 or greater is generally considered to be unacceptable.
 Biosystems User Training Program

Levey-Jennings Charts & Westgard Rules

Creating a Levey-Jennings Chart

Standard deviation is commonly used for preparing Levey-Jennings (L-J or LJ) charts. The L-J chart is used to graph successive (run-to-run or day-to-day) quality
control values. A chart is created for each test and level of control. The decision limits for the chart are defined by one, two or three sd. This is the mean plus or
minus one sd, the mean plus or minus twice one sd or the mean plus or minus three times one sd. When we have a representation of the frequency every value
goes close to the mean, one sd, two sd or three sd, we obtain a Gauss-like or bell-shaped distribution.

When an analytical process is within control, approximately 68% of all QC values fall
within ±1 sd. Likewise 95.5% of all QC values fall within ±2 sd of the mean. About 4.5%
of all data will be outside the ±2 sd limits when the analytical process is in control.
Approximately 99.7% of all QC values are found to be within ±3 sd of the mean. As
only 0.3% will fall outside, any value that goes out from ±3 sd is considered to be
associated with a significant error condition and patient results should not be
reported.
CAUTION !!: Some labs consider any QC value goes outside ±2 sd limits to be out
of control. Approximately 4.5% of all valid QC values will fall somewhere between ±2
and ±3 sd limits. Labs that use a ±2 sd limit frequently reject good runs. That means
patient samples are repeated unnecessarily, labor and materials are wasted, and
patient results are unnecessarily delayed.
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Levey-Jennings Charts & Westgard Rules

2
Using a Levey-Jennings Chart to Evaluate Run Quality

The laboratory needs to document that QC materials are assayed and the
QC results have been inspected to assure the quality of the analytical run.
This documentation is accomplished by maintaining a QC log and using the
L-J chart on a regular basis. The QC log is maintained on the software of the
instrument as well as could be maintained on a QC special designed 1
4 5 3
software of the host (by uploading the results obtained in the instrument).
The log should identify the name of the test1, the instrument2, units3, the
date the test is performed4 and the results for each level of control
assayed5. Once the QC results are entered into the QC log, they will be
plotted on the L-J chart. When the results are plotted, an assessment can
be made about the quality of the run, so the technician should look for S.E.
and R.E.
Systematic Error
S.E. is evidenced by a change in the mean of the control values. The change Fig.1: A QC log from BA400 instrument.
in the mean may be gradual and demonstrated as a trend in control values
or it may be abrupt and demonstrated as a shift in control values.
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Levey-Jennings Charts & Westgard Rules
Systematic Error & Sources
Trend
A trend indicates a gradual loss of reliability in the test system.
Trends are usually subtle. Causes of trending may include:
➔ Deterioration of the instrument light source (in case of
halogen lamp and if trending affects all the BQ tests).
➔ Gradual accumulation of debris in sample/reagent tubing or
on electrode surfaces (if we talk about ISE module). This
usually also affects all tests of the analyser.
➔ Aging of reagents.
➔ Gradual deterioration of control materials.
➔ Gradual deterioration of incubation temperature only in
case of enzymes.
➔ Gradual deterioration of light filter integrity.
➔ Gradual deterioration of calibration.
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Shift
Abrupt changes in the control mean are defined as shifts. Shifts in QC
data represent a sudden and dramatic positive or negative change in
test system performance. Shifts may be caused by:
➔ Sudden failure or change in the light source.
➔ Change in reagent formulation.
➔ Change of reagent lot.
➔ Major instrument maintenance with no post-calibration.
➔ Sudden change in incubation temperature (enzymes only).
➔ Change in room temperature or in humidity.
➔ Failure in the sampling system or/and in reagent dispense
system.
➔ Inaccurate calibration/recalibration.
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Levey-Jennings Charts & Westgard Rules

Systematic Error

Fig.2: A clear example of trending. Fig.3: Shifting at the fifth run has been corrected from
the eighth run.
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Levey-Jennings Charts & Westgard Rules

Random Error

Technically, R.E. is any deviation away from an expected result. For QC

results, any positive or negative deviation away from the calculated mean is
defined as random error. There is acceptable (or expected) random error as
defined and quantified by standard deviation. There is unacceptable
(unexpected) random error that is any data point outside the expected
population of data (i.e. a data point outside the ±3 sd limits).

Fig.4: Two points out of limits in a random distribution.

(With no tendency)

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Levey-Jennings Charts & Westgard Rules

Westgard Rules

In 1981, Dr. James Westgard of the University of Wisconsin, published an article on laboratory quality control that set the basis for evaluating
analytical run quality for medical laboratories (Westgard algorithm)
There are six basic rules in the Westgard scheme that they can be used individually or in combination to evaluate the quality of analytical runs.
Most of the quality control rules can be expressed as NL, where N represents the number of control observations to be evaluated and L represents
the statistical limit for evaluating the control observations. Thus, 13s represents a control rule that is violated when one control observation
exceeds the ±3 sd control limits.

The relationship between this value and other control

RULE
results within the current and previous analytical runs
12S
must be examined. If no relationship can be found and
no source of error can be identified, it must be
assumed that a single control value outside the ±2 sd
limits is an acceptable random error. Patient results
can be reported.

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Levey-Jennings Charts & Westgard Rules

Westgard Rules

This rule identifies unacceptable random error or RULE 13S

RULE 22S
RULE
possibly the beginning of a large systematic error. Any
13S
QC result outside ±3 sd violates this rule.

This rule identifies systematic error only. The criteria

RULE 22S for violation of this rule are:
Two consecutive QC results + Greater than 2s + On the
same side of the mean.
There are two applications to this rule:
Across runs
➔ Within-run (affects all control results obtained
for the current analytical run, i.e. in two
different levels of controls).
➔ Across runs (affects the same level between
results not processed at the same run)
RULE 22S
Within-run

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Levey-Jennings Charts & Westgard Rules

Westgard Rules

This rule identifies random only and is applied only

RULE R4S within the current run. It is violated when exists a
difference at least of 4 sd between control values, i.e.
of different levels.

The criteria for violation of this rule are:

RULE 41S Four consecutive QC results + Greater than 1s + On the
same side of the mean.
There are two applications to this rule:
➔ Within-run (indicate systematic bias in a single
area of the method curve). RULE R4S
➔ Across runs (indicates systematic error over a
broader concentration).
RULE 41S

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Levey-Jennings Charts & Westgard Rules

Westgard Rules RULE 10Xm

The criteria for violation of this rule are:

RULE 10Xm
Ten consecutive QC results + On the same side of the
mean regardless of the specific standard deviation in
which they are located.
There are two applications to this rule:
➔ Within-run (indicate systematic bias in a single
area of the method curve).
➔ Across runs (indicates systematic error over a
broader concentration).
Across runs

Within-run

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Some examples….
RULE 12S

RULE 13S

RULE 22S

RULE R4S

RULE 10Xm

Fig.6: The lack of same number of results in both levels of QC, the
extremely wide distribution of results in blue and the violation of
Fig.5: A good performance in QC.
almost all Westgard rules are enough arguments to discard all the
results of the test from run 4th till the end.
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Guide for Interpretation and Resolution of Internal Quality Control series results in Clinical Laboratory
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08030 BARCELONA (SPAIN)
Tel. +34 933 110 000
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biosystems@biosystems.es

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