(6) Corrective training
From the slide-checking results, TB coordinator would know who needs a corrective training or on the job training. If over-all false readings do not exceed 10%, no special action is necessary to be taken. However, if the false reading rate exceed 20%, immediate corrective training should be followed. If the poor smear preparation and staining exceed over 40%, it must be stressed to the worker responsible for sputum collection 2nd smear preparation and staining.
E. QC by unblinded slide-checking (supervisory visit)
Blinded slide-checking is an objective evaluation of PMC smear microscopy but corrective action and on the job training are not possible because the laboratory expert does not visit the PMC. Therefore, if the laboratory services are well organized, it is desirable to entrust QC of smear microscopy to the supervisor (or expert) of higher level laboratory. Laboratory expert makes a periodical supervisory visit to PMC and review overall performances in smear microscopy, for example, quanity and quality of specimens, smear preparation, staining and reading, maintenance of microscope, management of laboratory reagents and logistics, recording and reporting of the smear microscopy results before slide-checking. Slide-checking will be made in a unblinded fashion on the spot but in a blinded fashion if the selected slides brought in the higher level laboratory by the supervisor. This system makes it possible to find and correct on the spot which procedures should be improved to solve the problem if any and to provide a continuous good quality services.
If the selected slides are rechecked during the visit, the results should be feedback on the spot in order to let PMC microscopist to know of their performances. However it may not be possible to recheck all slides on the spot and so the slides will be brought in the higher level laboratories where they will be rechecked and feedback the results later by mail. Supervisor may not be able to recheck all slides that he brought from supervisory visit, thus he may distribute them to his entrusted deputies for rechecking. Supervisor, however, should check the slides shown disagreement between his deputies and PMC microscopists.
The frequency of supervisory visits must be same as mentioned in 4.
F. Proficiency evaluation
Proficiency of newly recruited PMC microscopists in smear microscopy should be evaluated with a set of stained or unstained know positive and negative slides at the end of training. Proficiency evaluation can also be performed for higher level laboratory workers, especially who are charged in slide-checking from time to time. The slides for this purpose usually consist of 10 negative slides and 5 slides of 1+, 3 slides of 2+, and slides of 3+.
G. QC of new batches of stains
Quality of new batches of staining solutions and a possible mycobacterial contamination in carbol-fuchsin must be checked with known positive and negative slides.
? TRAINING OF LABORATORY PERSONNEL
All the laboratory procedures must be performed only by trained personnel. Newly recruited workers should be trained at central laboratory as soon as possible, otherwise you cannot expect an accurate and reliable laboratory results. Supposing TB worker has been replaced with a new one and there is no fellow worker who have experience in TB smear microscopy, then TB laboratory services in this center will be jeopardized. In this case immediate preservice training in smear microscopy could be performed by the supervisor of intermediate higher level laboratory, irrespecively with his or her qualifications and experience in other field.
Training should be stressed on the accuracy and reliability of the particular laboratory procedure rather than the variety of techniques, especially for the peripheral HC workers.
Planning of training programme should be directed to ensure adequate theoretical and practical training through which all trainess would know what to do, how to do, and why it has to be done in a particular way, of every laboratory techniques they learn. Training course should not be tending to become academic.
An hour or so should be allocated for epidemiology in order to make them aware of the magnitude of TB problem in the country such as annual risk of infection, prevalence or incidence of bacteriologically confirmed TB cases, and high risk groups, etc. A few hours should be allocated to the principles of NTP and it's implementation with operational details.
