Review of the Evaluation Report

Review of proficiency testing results is an integral part of performing proficiency testing. Once you receive the evaluation, a thorough, critical review must be completed.

The first page or two (depending upon the number of tests the lab performs) will be the CLIA Overview (CMS Scorecard). This is the information that will be submitted to CMS or your accrediting agency. Only regulated analytes are on this portion of the report (see Regulated Analyte List in the CLIA Information section). Not only should you look for any unsatisfactory/unsuccessful scores, but also make sure that all of the regulated analytes appear on the Overview.

A successful performance is a minimum score of 80% for each regulated analyte (except for ABO, Rh and antibody screens, which require 100%) for the three events included on the Overview.

Note: Do not consider the evaluation review complete after having only reviewed the Summary. You must also review the individual results for each and every analyte performed in your lab.

To help in the process, first retrieve the photocopies you made of the Result Booklet. Review the report carefully to make sure that all of the results you submitted are contained within the report. If the error is correctable, you may submit a request for a corrected evaluation using the Corrected Evaluation Request Form (1-page PDF file; About PDFs). Next, look at the individual results for each specimen and analyte. A result of "Pass" clearly requires no additional follow-up.

Results of "Fail" or any form of "Not Graded" do require follow-up. The first thing to look for is a clerical error. A PT provider may not correct clerical errors on the part of the participant. If the AAFP-PT made the clerical error, it can be corrected. You will need to notify the AAFP-PT as quickly as possible in order to have the evaluation corrected. AAFP-PT allows approximately four weeks for corrected evaluation requests to be submitted. You should also check to see that the correct instrument/kit name appears on the report for each analyte; if it is incorrect, again, notify AAFP-PT.

If you should find that the clerical error was made in your office, you will need to determine what may have caused the problem and develop a corrective action plan that will keep the office from repeating that type of clerical error.

For example, perhaps the person recording results performed glucose testing but forgot to transfer the results to the Result Booklet. There are a number of different steps that could be considered for preventing repeat occurrences, including having a second person review the booklet for completeness or developing a checklist of what needs to be completed prior to mailing the results. Whatever you decide to do, document it! As the saying goes, if it is not written down, it did not happen. AAFP-PT provides you with the acceptable ranges whenever possible. You may use this information to self-evaluate your lab’s performance. Keep this information with your PT materials because many surveyors will ask to see documentation of self-evaluation.

Next, look for any of the specimens that have a "Not Graded" score. The CMS grading limits are applied to establish the acceptable range for the specimen/analytes. For "Not Graded" scores, compare your results to the acceptable ranges (either on the Evaluation Report or in the Event Summary). Your result should always be listed and the acceptable limits should also be listed for each analyte. Again, document what you have done and how you would have performed if the specimen had been graded.

Next, look for any of the specimens that are scored as "Fail". If you have first checked and determined that the failure was not due to a clerical error, it is now time to determine what type of testing error may have caused the problem.

First, check your records to find out how soon after receiving the kit that the test was performed. AAFP-PT recommends testing be completed within seven to ten days, particularly with the hematology specimens. The next step is to review your quality control results for the time period in which the proficiency testing was performed. Remember, just because your quality control results are in the acceptable range does not mean that you do not have an ongoing problem with the test. The quality control results should move back and forth around the mean. As you review each of these areas, be sure to document the steps you have taken.