Context.—The Q-Tracks program, created in 1999, is a quality monitoring subscription service offered by the College of American Pathologists.
Objective.—To establish benchmarks in quality metrics, monitor changes in performance over time, and identify practice characteristics associated with better performance.
Design.—The Q-Tracks program provides ongoing study of multiple metrics offered in most laboratory disciplines. The design enables measuring the effects of process changes and comparisons with other participating laboratories. Each laboratory Q-Tracks monitor has a primary quality indicator and additional secondary indicators.
Results.—To date, 19 Q-Tracks monitors have been offered, with 12 currently active monitors. Q-Tracks are primarily conducted in hospital-based laboratories in the United States, Canada, and 21 other countries. Common to most Q-Tracks monitors is a demonstration of performance improvement by subscribers with long-term participation. This finding was seen in preanalytic, turnaround time, and postanalytic measures. Q-Tracks monitors contribute to the overall demonstration and improvement of laboratory and hospital quality because they address core quality measures for the College of American Pathologists Laboratory Accreditation Program and multiple Joint Commission National Patient Safety Goals.
Conclusions.—The Q-Tracks program has established multiple benchmarks in most disciplines of the laboratory and has demonstrated significant performance improvement in benchmarks and individual laboratories over time.
In this article we celebrate 15 years of the Q-Tracks program. The Q-Tracks program was a natural addition to the Q-Probes program. Q-Probes studies are focused but in-depth studies that demonstrate gaps in practice. Although Q-Probes studies have explored many aspects of practice by associating current practices with measures of quality, they are time-limited studies. As Q-Probes studies proliferated, members of the College of American Pathologists (CAP) Quality Practices Committee postulated that most quality measures should improve over time. When Q-Probes studies were repeated, improvement in the quality measures was documented with various changes in practices. However, some measures improved without identifiable changes in practice. In a very general sense, Q-Probes studies provided benchmarks, but the benchmarks were only valid for the time period in which the study was done. Many laboratorians have noticed that benchmarks in laboratories with active quality improvement programs change, and typically for the better. The Q-Tracks program was developed as a tool with ongoing benchmarks. Indeed, multiple Q-Tracks monitors with stable participation over a prolonged period of time (5–10 years) have demonstrated a steady and sustained improvement in the relevant benchmark measures of quality. Although both Q-Probes studies and Q-Tracks monitors indicate how well laboratories are doing at a point in time compared with a cohort of their peers, Q-Tracks monitors also trend any changes in the measures over time.
The Q-Tracks program was launched in 1999 and became a mainstay of the CAP Quality Practices Committee activities. From its origin, Q-Tracks monitors focused on established quality measures with wide acceptance. Most Q-Tracks monitors evaluated preanalytic or postanalytic processes or turnaround time measures. The data collection of Q-Tracks monitors is streamlined, with periodic updates of demographic and other practice parameters. Importantly, in most instances Q-Tracks monitors demonstrate prolonged improvement in laboratory quality measures. Improvement occurs most dramatically in laboratories with the poorest initial quality, but it is also typically demonstrated for all laboratories as a group. Most Q-Tracks monitors have addressed the clinical laboratory, with a few studies addressing anatomic pathology. This article summarizes and highlights the successes of the Q-Tracks program.
MATERIALS AND METHODS
The Q-Tracks quality monitoring program is a subscription program offered by the CAP. The basic mechanisms of the program have been described previously.1,2 Briefly, each institution submits demographic and practice characteristic questionnaires. Institutions submit data on chosen monitors. Data typically are submitted to the CAP on a monthly or quarterly basis, and participants receive their summarized results on a quarterly basis with percentile rankings in comparison with other participants. At the end of each program year, an annual summary is provided to participants. A final discussion by the study's authors includes suggestions for improvement.
For this manuscript, a review of the literature was performed regarding the Q-Tracks program, and available documents warehoused at CAP were also evaluated. The SCOPUS citation index was used to quantify the number of times Q-Tracks studies were cited in the medical literature. Self-citations were included. Specific information was derived, including: (1) total number of studies, authors, participants, countries, publications, and citations; (2) highlights of important studies; (3) the studies' impact on medicine, such as the use of data and incorporation into regulatory documents (The Joint Commission, CAP checklists, editorials, The Journal of the American Medical Association abstracts, workshops, and presentations); (4) demonstrated improvements; (5) the most notable successes of the program; (6) the most significant and/or interesting information derived from Q-Tracks monitors.
Table 3 lists the Q-Tracks contributions to accrediting agencies and in publications. The Q-Tracks program supports in large measure the need for ongoing monitoring of the preanalytic and postanalytic phases of the test cycle. This information is cited in the checklist item GEN.20316 of the CAP Laboratory Accreditation Program. The Q-Tracks program also supports and substantiates two Joint Commission National Patient Safety Goals: (1) correctly identifying patients and specimens, and (2) improving communication between the laboratory and the medical staff. The Q-Tracks program has also contributed substantially to overall quality programs with publications beyond the Archives of Pathology & Laboratory Medicine.
Most of the Q-Tracks monitors have demonstrated significant improvement in laboratory performance over time. This is summarized in Table 4. An example of an important best practice finding of the Q-Tracks program (in QT2; Blood Culture Contamination) was the demonstration that blood culture contamination rates for institutions that have employees dedicated to collection of blood cultures specimens were significantly lower than for institutions that used nondedicated staff.3 Importantly, a greater decline in contamination was also observed with ongoing monitoring for 4 or 5 years. The frozen section–permanent section discordance Q-Tracks monitor (QT6; Intraoperative Consultation: Frozen Section Correlation) showed that for institutions participating in the monitor for 4 to 5 years, there was a mean decrease in discordance rates of 0.99%.4 These long-term participants made 1 error fewer per 100 frozen sections. In the Gynecologic Cytology Outcomes monitor, biopsy correlation performance demonstrated that long-term monitoring of cytology-histology correlation leads to a higher predictive value of a positive Papanicolaou test, higher sensitivity, and higher proportion of positive histologic diagnoses for a Papanicolaou test diagnosis of atypical squamous cells.5 Stat Test Turnaround Time Outliers monitor showed a continuous decline in the stat and routine outlier turnaround time with ongoing monitoring using Q-Tracks.6
Most Notable Q-Tracks Monitor
The first Q-Tracks monitor, Patient Identification Accuracy, first provided validation of the Q-Tracks approach to quality improvement. Prior to the initiation of the Q-Tracks program, 3 Q-Probes studies were used to study wristband errors (1991, 1993, and 1995).2,7 These Q-Probes and Q-Tracks studies predated the Institute of Medicine Report on medical errors and the 2002 initiation of the Joint Commission's National Patient Safety Goals.8,9 The first National Patient Safety Goal relates to accurate patient identification. The initial Q-Probes study established the extent and scope of the problem. The Q-Tracks monitor demonstrated steady improvement with monitoring. This is seen in the Figure. Subsequent to the landmark QT1 Patient Identification Accuracy study, multiple Q-Probes studies looking at specific identification items, such as identification errors (QP051), specimen labeling errors (QP072), blood bank specimen labeling (QP074), and mislabeling rates of surgical specimens, blocks, and slides (QP094), were performed.10–13
Notable Contributions of the Q-Track Program
Tables 5 and 6 list additional notable contributions of the Q-Tracks program. These contributions include the identification of laboratory practices that are associated with better performance, and a time-tested taxonomy of defects.
The Q-Tracks program represents a series of longitudinal studies of several essential measures of quality, patient safety, and resource management in the clinical laboratory. During the 15 years since the Q-Tracks program was initiated by the CAP in 1999, a total of 19 different measures of quality, patient safety, or resource management have been analyzed, and as of 2014, studies of 12 of these measures continue to be actively supported by the CAP.
The Clinical Laboratory Improvement Amendments of 1988 (CLIA 88) were written and enacted in order to improve laboratory quality. In Subpart K, the attributes of a quality system are outlined (Table 7).14 They include quality monitoring of all phases of the testing process in order to ensure continuous improvement and be appropriate for subspecialties of testing, services, and clients.
These attributes were the basis for development of the Q-Tracks program, namely, to maintain a quality system that monitors all phases of the test cycle, facilitates continuous improvement, and addresses the various components of the laboratory. The program provides multiple measures that can address all phases of the test cycle; for example, the preanalytic phase is addressed with patient and specimen identification. The analytic phase is investigated by measures such as cytology-histology correlation and frozen section correlation. The postanalytic phase is represented by monitoring of corrected reports and critical value reporting documentation.
The most notable achievement of the Q-Tracks program has been establishing that ongoing quality monitoring is associated with continuous improvement, clearly meeting the requirement of CLIA 88, subsection K, part B. This has been shown in most Q-Tracks studies. In addition to demonstrating that improvement continues over time, the performance of Q-Tracks subscribers has in many cases led to establishment of new, improved national benchmarks for many of the performance metrics monitored. A second important aspect of the Q-Tracks program has been the demonstrated use of core generic measures important in most sections or specialties of the laboratory and are valuable indicators of quality for any laboratory or hospital (F.A.M., unpublished data, March 2014). These measures are generic and can form the basis of a quality program in any section of the laboratory, fulfilling part C of subsection K of the CLIA 88. These key measures include preanalytic (patient/specimen identification, test order accuracy, specimen acceptability), turnaround time (stat test turnaround time), and postanalytic (corrected reports, critical value reporting) monitors.
The Q-Tracks program has also provided consistent, time-tested taxonomy of defects in multiple areas of laboratory and health care quality. Additional contributions and observations noted in Table 5 reaffirm basic principles of quality management; among these principles, that trained staff focused on a task (phlebotomy) perform better than others, monitoring a process usually improves that process, selective implementation of technology can improve a process, and implementation of basic quality assurance tools results in improvement. These improvements were documented within the Q-Tracks program using multiple measures, including some specific for transfusion medicine (blood product wastage), microbiology (blood culture contamination), cytology (biopsy correlation), surgical pathology (intraoperative consultation correlation), and result turnaround time for troponin.3,5,15
It is interesting to note in Table 4 and the Figure the level of improvement that has occurred over time. Indeed, these improvements should be celebrated, but we still realize that a great deal more progress is needed. If we aspire to other industry standards—Six Sigma, for instance—defect rates would need to fall to 3.4 per million. In the monitor of wristband errors, the current median rate is at 0.11%, or 1.1 per 1000. This is a level that is comparable to Three Sigma. A 1000-fold improvement must occur to reach Six Sigma.
In summary, the Q-Tracks program has proven to be a highly successful systematic process of continuous monitoring and improvement in laboratory performance and quality that meets CLIA requirements. The Q-Tracks program has been durable and has been shown to be associated with continuing performance improvement by subscribers during multiple years of participation. The program has brought forth evidence of improvement relative to basic quality assurance tools and has identified specific best practices in laboratory medicine.
The authors have no relevant financial interest in the products or companies described in this article.