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The letter explores the use of sigma metrics in laboratory medicine, specifically examining the relationship between analytical imprecision and bias. Data from an external quality assurance program was used to analyze this correlation in participating laboratories. The study found that the correlation between 1/imprecision and sigma metric was stronger than that of bias and sigma metric, underscoring the significance of analytical imprecision in evaluating laboratory performance. The research emphasizes the importance of assessing both bias and imprecision separately to ensure accurate evaluation of laboratory methods for clinical use. [Extracted from the article]

This paper further explores the Sigma Metric (SM) and its application in clinical chemistry. It discusses the SM, assay stability, and control failure relationship.: SM is not a valid measure of assay stability or the likelihood of failure. When an out-of-control event occurs for an assay with a higher SM value, the same QC rule will have greater power to detect error than assays with a lower SM value. Thus, it is easier to prevent errors from happening for higher SM assays. This rationale encourages using more frequent QC events and more QC samples for a QC scheme of a low SM assay or simply more QC cost for low SM assays. A laboratory can have a high-precision instrument that frequently fails and a low-precision instrument that hardly ever fails. Parvin’s patient risk model presumes the bracketed continuous mode (BCM) testing workflow. If overlooked when designing QC schemes, this leads to the common misconception of the SM that one can save the cost of QC since assays with high SM require less frequent QC to ensure patient risk. There is no evidence that an assay’s precision is correlated with its failure rate. Schmidt et al., in a series of papers, showed that an assay with a higher Pf or shift in probability will have a higher expected number of unacceptable results. Incorporating Pf into the QC design process presents significant challenges despite the proactive quality control (PQC) methodology.Unfortunately, TEa Six Sigma, as widely practiced in Clinical Chemistry, is not based on classical Six Sigma mathematical statistics. Classical Six Sigma would facilitate comparing results across activities where the principles of Six Sigma are employed. [ABSTRACT FROM AUTHOR]

Clinical laboratories face limitations in implementing advanced quality control (QC) methods with existing systems. This study aimed to develop a web-based application to addresses this gap, and improve QC practices. QC Constellation, a web application built using Python 3.11, integrates various statistical QC modules. These include Levey-Jennings charts with Westgard rules, sigma-metric calculations, exponentially weighted moving average (EWMA) and cumulative sum (CUSUM) charts, and method decision charts. Additionally, it offers a risk-based QC section and a patient-based QC module aligning with modern QC practices. The codes and the web application links for QC Constellation were shared at https://github.com/hikmetc/QC%5fConstellation, and http://qcconstellation.com, respectively. Using synthetic data, QC Constellation demonstrated effective implementation of Levey-Jennings charts with user-friendly features like checkboxes for Westgard rules and customizable moving averages graphs. Sigma-metric calculations for hypothetical performance values of serum total cholesterol were successfully performed using allowable total error and maximum allowable measurement uncertainty goals, and displayed on method decision charts. The utility of the risk-based QC module was exemplified by assessing QC plans for serum total cholesterol, showcasing the application's capability in calculating risk-based QC parameters including maximum unreliable final patient results, risk management index, and maximum run size and offering risk-based QC recommendations. Similarly, the patient-based QC and optimization modules were demonstrated using simulated sodium results. In conclusion, QC Constellation emerges as a pivotal tool for laboratory professionals, streamlining the management of quality control and analytical performance monitoring, while enhancing patient safety through optimized QC processes. [ABSTRACT FROM AUTHOR]

The letter discusses the application of Six Sigma methodology in laboratory medicine, focusing on the calculation method of the Sigma Metric (SM) proposed by Westgard. It highlights the flaws in the equation proposed by Westgard, which leads to an underestimation of process performance and incorrect application to quality control rules. The letter emphasizes that the incorrect SM calculation method has contributed to confusion and hindered the successful implementation of Six Sigma in laboratory medicine. The authors suggest caution in using the flawed equation and propose alternative approaches for evaluating process performance accurately. [Extracted from the article]

The Sigma metric is widely used in laboratory medicine. [ABSTRACT FROM AUTHOR]

The sigma metric offers a quantitative framework for evaluating process performance in clinical laboratories. This study aimed to evaluate the analytical performance of automated analysers in haematology laboratories, using the sigma metric to choose the best analyser as an internal reference analyser. internal quality control (IQC) data were collected for 6 months from SNCS, and the sigma value was calculated for 9 haematology analysers in the laboratory. For the normal control level, a satisfactory mean sigma value ≥3 was observed for all of the studied parameters of all automated analysers. For the low control level, platelet (PLT) count by Instrument (Inst.) G performed poorly, with a mean sigma value <3. Inst. H, with all parameters' sigma values >4, performed best and was chosen as the internal reference analyser. The sigma metric can be used as a guide to choose the QC strategy and plan QC frequency. It can facilitate the comparison of the same assay performed by multiple systems. [ABSTRACT FROM AUTHOR]

Sigma metric can be calculated using a simple equation. However, there are multiple sources for the elements in the equation that may produce different Sigma values. This study aimed to investigate the importance of different bias estimation approaches for Sigma metric calculation.

ABSTRACTIntroduction The sigma metric offers a quantitative framework for evaluating process performance in clinical laboratories. This study aimed to evaluate the analytical performance of automated analysers in haematology laboratories, using the sigma metric to choose the best analyser as an internal reference analyser.Materials and Methods internal quality control (IQC) data were collected for 6 months from SNCS, and the sigma value was calculated for 9 haematology analysers in the laboratory.Results For the normal control level, a satisfactory mean sigma value ≥3 was observed for all of the studied parameters of all automated analysers. For the low control level, platelet (PLT) count by Instrument (Inst.) G performed poorly, with a mean sigma value 4, performed best and was chosen as the internal reference analyser.Conclusion The sigma metric can be used as a guide to choose the QC strategy and plan QC frequency. It can facilitate the comparison of the same assay performed by multiple systems.

• The underlying assumptions of conventional quality control (QC) are described. • The limitations of the application of the Sigma metric in calculating QC frequency are described. • An alternative, patient-based real-time quality control, is presented with its advantages and disadvantages. Effective Quality Control remains one of the pillars of Clinical Biochemistry. An understanding of the possible analytical errors that may occur, how to detect them efficiently and how to prevent them from causing patient harm are critical components of a Quality System. For some time, there have been questions about the theoretical basis of the models used to describe and detect analytical error. The current theory recognises two types of error, systematic and random and a system based on sampling the analytical process using a synthetic material to detect these errors. However, there are at least two other errors that are present. One is related to the QC material and the other, irregular errors. In this Opinion Piece, some of the underlying assumptions of Quality Control systems are described and analysed. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The aim of this study was to evaluate the analytical performances of various clinical biochemistry analytes by the sigma metrics method according to different total allowable error (TEa) targets and to determine the causes of errors that lead to low sigma score by using Quality Goal Index (QGI). METHODS: The study was carried out in the Central Laboratory of Bursa Karacabey State Hospital. Twelve analytes that were studied on the Roche Cobas c 501 autoanalyzer were included in the study. Internal (level 1 and 2) and external quality control data for the period March August 2020 were obtained retrospectively. The TEa targets were obtained from the Clinical Laboratory Improvement of 2019 (CLIA 2019), biological variation database (BVD), Rili-BAEK, and Turkish data. QGI was calculated for analytes with sigma score 6 were 7, 10, 6, and 18 according to TEa targets of CLIA, BVD, Rili-BAEK, and Turkey, respectively. When QGI was calculated, it was found that there was inaccuracy problem for albumin and chlorine L1 and imprecision for chlorine L2. DISCUSSION AND CONCLUSION: Laboratories should determine the appropriate TEa targets and use the sigma metrics method and QGI as a quality improvement tool. In the light of the obtained data, necessary quality improvements should be made, and the reliability of the results should be increased.

The application of Sigma metrics can be used for assessing the performance of diagnostic laboratories. Clinical laboratories are confronted with the trouble of having to select the best and suitable quality specifications that are required for quality planning. In this regard, our study aims at evaluating the performance of Sysmex XN-1000 hematology analyzer by using Sigma metrics based on different total allowable error (TEa) source and to determine the effects of these variations in Sigma metric evaluation.

Objectives: This study investigates the optimal number of quality control (QC) events per day in two scenarios: high-sensitive troponin, requiring three levels of QC materials, and creatinine, with two levels. The aim is to explore how different QC rules and sigma metric values affect the frequency of QC events, considering both analytical performance and the clinical impact of potential measurement errors as severity of harm., Methods: Risk-based QC calculations were performed using the QC Constellation tool. Four QC rule schemes (1-3 s, 1-3 s/2-2 s, 1-3 s/2-2 s/R-4 s, 1-3 s/2-2 s/R-4 s/4-1 s) were tested for high-sensitive troponin (catastrophic harm) and creatinine (serious harm). Sigma metric values from 3 to 6 were evaluated to determine maximum run sizes. QC event frequency was estimated for a hypothetical laboratory processing 1,000 samples daily., Results: Maximum run sizes decreased as sigma metric values declined. Correspondingly, the number of QC events per day increased as sigma metric values decreased. For high-sensitive troponin, with its catastrophic severity of harm related to potantial error, more frequent QC was necessary compared to creatinine., Conclusions: Analytical performance and severity of harm significantly influence the required frequency of QC events. Laboratories must consider both factors when designing QC strategies to balance patient safety with operational efficiency. For analytes with high severity of harm, achieving higher sigma metrics is critical to maintain feasible and cost-effective QC practices. A hybrid QC approach combining risk-based and patient-based methods may optimize QC strategies, but standardization of sigma metric calculations is still needed., Competing Interests: Declaration of competing interest The author declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

INTRODUCTION: Sigma metric model is one of the most popular quality management system tools used for Six Sigma process improvement. This model provides three features that improve the results: low inaccuracy, less deviation, and correct performance of the analytical method. Internal quality control and external quality assessment programs are routinely carried out in all clinical laboratories to evaluate and continually improve the analytical quality. The Six Sigma model is a global quality management system that can also be applied in the determination of glycated hemoglobin (HbA1c). In recent years, this model has been supported by Quality Goal Index (QGI). In this study, we aimed to evaluate the analytical performances of Arkray HA8180V HbA1c analyzer according to internal and external quality Sigma metrics and QGI. METHODS: The data have been evaluated according to two internal control materials (Bio-DPC and KBUDEK External Quality Program) to calculate Sigma levels [Sigma=(TEa%-bias%)/CV%] and quality target indexes (QGI=bias/1.5×CV), where TEa is the total analytical error and CV is the coefficient of variation. QGI is a metric that can distinguish between techniques to deal with sensitivity and accuracy issues as well as calibrator lot changes. RESULTS: The mean Sigma levels for low and high quality control materials were found to be 5.17 and 2.51, respectively. QGI was found to be 0.8 1.2 for both levels. DISCUSSION AND CONCLUSION: The performance of HA8180V HbA1c analyzers was found to be acceptable compared to Sigma metrics. The values of OGI between 0.8 and 1.2 indicate inaccurate and inconsistent result. However, when evaluated as a whole with Sigma values, the results of the devices were found reliable.

Objectives: The aim of this study was to evaluate the analytical performances of various clinical biochemistry analytes by the sigma metrics method according to different total allowable error (TEa) targets and to determine the causes of errors that lead to low sigma score by using Quality Goal Index (QGI). Methods: The study was carried out in the Central Laboratory of Bursa Karacabey State Hospital. Twelve analytes that were studied on the Roche Cobas c 501 autoanalyzer were included in the study. Internal (level 1 and 2) and external quality control data for the period March–August 2020 were obtained retrospectively. The TEa targets were obtained from the Clinical Laboratory Improvement of 2019 (CLIA 2019), biological variation database (BVD), Rili-BAEK, and Turkish data. QGI was calculated for analytes with sigma score <3 according to CLIA. Results: According to the TEa goals of four different guides, different sigma scores were obtained. Three parameters with sigma scores <3 were determined according to TEa targets of CLIA, 8 according to BVD, and 6 according to RiliBAEK, while there were no parameters with sigma score <3 according to the TEa targets of Turkey. Number of parameters with sigma scores >6 were 7, 10, 6, and 18 according to TEa targets of CLIA, BVD, Rili-BAEK, and Turkey, respectively. When QGI was calculated, it was found that there was inaccuracy problem for albumin and chlorine L1 and imprecision for chlorine L2. Conclusion: Laboratories should determine the appropriate TEa targets and use the sigma metrics method and QGI as a quality improvement tool. In the light of the obtained data, necessary quality improvements should be made, and the reliability of the results should be increased. [ABSTRACT FROM AUTHOR]

Background: Sigma metrics is a quantitative management tool. This study assessed the Six Sigma score for 26 chemistry analytes, compared scores with different total allowable errors (TEa) and use of scores for internal quality control (IQC) rules in 4 Laboratories in Kwa-Zulu Natal, South Africa. Methods: Utilizing 6 months of IQC SD, CV, and bias data on albumin, alkaline phosphatase, alanine aminotransferase, amylase, aspartate aminotransferase, bicarbonate, calcium, total cholesterol, creatine kinase, chloride, creatinine, gamma glutamyl transferase, glucose, HDL-cholesterol, potassium, lactate dehydrogenase, magnesium, sodium, inorganic phosphate, direct bilirubin, total bilirubin, triglycerides, total protein, urea nitrogen, uric acid, and C-reactive protein (CRP) Six Sigma scores were calculated using Microsoft Excel 2016 and ideal IQC rules were determined. Six Sigma scores using Ricos et al. 2014, Royal College of Pathologists Australasia, and Clinical Laboratory Improvement Amendments TEas were compared. Results: For levels 1, 2, and 3 respectively, analytes scoring >3 sigma was 9 (35%), 12 (46%), and 14 (54%) in Laboratory A; Laboratory B had 15 (58%), 19 (73%), and 17 (65%); Laboratory C had 12 (46%), 13 (50%), and 15 (58%); and Laboratory D had 13 (50%), 18 (69%), and 18 (69%). Albumin, calcium, sodium, magnesium, bicarbonate, and chloride scored <3; CRP scored >6 for all. In Laboratories A, B, C, and D, 7 (27%), 7 (27%), 6 (23%), and 8 (31%) analytes, respectively, required only 1 IQC rule. One of 21 analytes for Laboratories C and D, 3 for Laboratory A, and 0 for Laboratory B had the same sigma score with all 3 databases. Conclusion: Despite South Africa being a developing nation, many analytes are able to achieve >3 sigma. [ABSTRACT FROM AUTHOR]

Objectives: Sigma metric model is one of the most popular quality management system tools used for Six Sigma process improvement. This model provides three features that improve the results: low inaccuracy, less deviation, and correct performance of the analytical method. Internal quality control and external quality assessment programs are routinely carried out in all clinical laboratories to evaluate and continually improve the analytical quality. The Six Sigma model is a global quality management system that can also be applied in the determination of glycated hemoglobin (HbA1c). In recent years, this model has been supported by Quality Goal Index (QGI). In this study, we aimed to evaluate the analytical performances of Arkray HA8180V HbA1c analyzer according to internal and external quality Sigma metrics and QGI. Methods: The data have been evaluated according to two internal control materials (Bio-DPC and KBUDEK External Quality Program) to calculate Sigma levels [Sigma=(TEa%-bias%)/CV%] and quality target indexes (QGI=bias/1.5×CV), where TEa is the total analytical error and CV is the coefficient of variation. QGI is a metric that can distinguish between techniques to deal with sensitivity and accuracy issues as well as calibrator lot changes. Results: The mean Sigma levels for low and high quality control materials were found to be 5.17 and 2.51, respectively. QGI was found to be 0.8-1.2 for both levels. Conclusion: The performance of HA8180V HbA1c analyzers was found to be acceptable compared to Sigma metrics. The values of OGI between 0.8 and 1.2 indicate inaccurate and inconsistent result. However, when evaluated as a whole with Sigma values, the results of the devices were found reliable. [ABSTRACT FROM AUTHOR]

Introduction: Sigma metric offers a quantitative framework for evaluating process performance in clinical laboratories. This study aimed to evaluate the analytical performance of automated analyzers in hematology unit of Alexandria Main University Hospital using the sigma metric approach. Materials and Methods: Quality control data were collected for 6 months, and sigma value was calculated from hematology analyzers SYSMEX (XN 1000, XT 1800i), ADVIA (2120i, 2120), and coagulation analyzers SYSMEX CA 1500 (3610, 6336). Results: For the normal control level, satisfactory mean sigma value ≥3 was observed for all of the studied parameters by all analyzers. For the high control level, red blood cell count by ADVIA 2120, and hematocrit by ADVIA (2120i and 2120) performed poorly with a mean sigma value <3. For the low control level, red blood cell count by ADVIA (2120i and 2120), hemoglobin by ADVIA 2120, hematocrit by ADVIA (2120i and 2120) and SYSMEX XN 1000, platelet count by the SYSMEX XT 1800i also performed poorly with a mean sigma value <3. Satisfactory mean sigma value of ≥3 was observed for prothrombin time and activated partial thromboplastin time for both normal and pathological control levels and analyzers. Conclusion: Sigma metrics can be used as a guide to make QC strategy and plan QC frequency and can facilitate the comparison of the same assay performance across multiple systems. Harmonization for TEa source is recommended to standardize sigma value calculation. [ABSTRACT FROM AUTHOR]

Background: Urine reagent strip test (URST) results are semi-quantitative; therefore, the precision of URSTs is evaluated as the proportion of categorical results from repeated measurements of a sample that are concordant with an expected result. However, URSTs have quantitative readout values before ordinal results challenging statistical monitoring for internal quality control (IQC) with control rules. This study aimed to determine the sigma metric of URSTs and derive appropriate control rules for IQC. Methods: The URiSCAN Super Plus fully automated urine analyzer (YD Diagnostics, Yongin, Korea) was used for URSTs. Change in reflectance rate (change %R) data from IQC for URSTs performed between November 2018 and May 2020 were analyzed. Red blood cells, bilirubin, urobilinogen, ketones, protein, glucose, leukocytes, and pH were measured from 2-3 levels of control materials. The total allowable error (TEa) for a grade was the difference in midpoints of a predefined change %R range between two adjacent grades. The sigma metric was calculated as TEa/SD. Sigma metric-based control rules were determined with Westgard EZ Rules 3 software (Westgard QC, Madison, WI, USA). Results: Seven out of the eight analytes had a sigma metric >4 in the control materials with a negative grade (-), which were closer to the cut-offs. Corresponding control rules ranged from 12.5s to 13.5s. Conclusions: Although the URST is a semi-quantitative test, statistical IQC can be performed using the readout values. According to the sigma metric, control rules recommended for URST IQC in routine clinical practice are 12.5s to 13.5s. [ABSTRACT FROM AUTHOR]

In laboratory medicine, mathematical equations are frequently used to calculate various parameters including bias, imprecision, measurement uncertainty, sigma metric (SM), creatinine clearance, LDL-cholesterol concentration, etc. Mathematical equations have strict limitations and cannot be used in all situations and are not open to manipulations. Recently, a paper "Bias estimation for Sigma metric calculation: Arithmetic mean versus quadratic mean" was published in Biochemia Medica. In the paper, the author criticized the approach of taking the arithmetic mean of the multiple biases to obtain a single bias and proposed a quadratic method to estimate the overall bias using external quality assurance services (EQAS) data for SM calculation. This approach does not fit the purpose and it should be noted that using the correct equation in calculations is as important as using the correct reagent in the measurement of the analytes, therefore before using an equation, its suitability should be checked and confirmed. [ABSTRACT FROM AUTHOR]

Variability in analytical performance of some analyte indicated the need of evaluation of quality plan of our laboratory. We tried to put the same degree of effort into our quality metrics as we put into the laboratory processes themselves. Application of six sigma methodologies improve the quality by focusing on the root causes of the problems in performance and analyzing by flowcharts, fishbone diagrams and other quality tools. Sigma metric was calculated for laboratory parameters for a period of 8 months during 2018–19. The analytes with poor sigma metric were free Thyroxine (FT3, FT4), Sodium, Calcium and Magnesium. Sigma metric of free Thyroxine (FT3, FT4), Sodium, Calcium and Magnesium were below 3. A road map for process improvement was designed with DMAIC (Define-Measure-Analyze-Improve-Control) model to solve the issue. Possible causes for low analytical performance of the particular analytes were depicted in Fishbone diagram. The Fishbone analysis identified the water quality issues with electrolyte analysis while high ambient temperature was culprit for poor assay performance of free Thyroxine. Sigma metric of the analytical performance was assessed once again after root cause analysis. Sigmametric showed marked improvement in control phase. Identification of problems led to reduction in non value added work leading to adequate resource utilization by addressing the priority issue. Therefore, DMAIC tool with Fish bone model analysis can be recommended as a well suited method for troubleshooting in poor performance of laboratory parameter. [ABSTRACT FROM AUTHOR]

Introduction: Laboratories minimize risks through quality control but analytical errors still occur. Risk management can improve the quality of processes and increase patient safety. This study aims to use the failure mode and effect analysis (FMEA) to assess the analytical performance and measure the effectiveness of the risk mitigation actions implemented. Materials and methods: The measurands to be included in the study were selected based on the measurement errors obtained by participating in an External Quality Assessment (EQA) Scheme. These EQA results were used to perform an FMEA of the year 2017, providing a risk priority number that was converted into a Sigma value (sFMEA). A root-cause analysis was done when sFMEA was lower than 3. Once the causes were determined, corrective measures were implemented. An FMEA of 2018 was carried out to verify the effectiveness of the actions taken. Results: The FMEA of 2017 showed that alkaline phosphatase (ALP) and sodium (Na) presented a sFMEA of less than 3. The FMEA of 2018 revealed that none of the measurands presented a sFMEA below 3 and that sFMEA for ALP and Na had increased. Conclusions: Failure mode and effect analysis is a useful tool to assess the analytical performance, solve problems and evaluate the effectiveness of the actions taken. Moreover, the proposed methodology allows to standardize the scoring of the scales, as well as the evaluation and prioritization of risks. [ABSTRACT FROM AUTHOR]

The global demand for effective utilization of both humans and machinery is increasing due to wastage incurred during product manufacturing. Excessive waste generation has made entrepreneurs find it difficult to breakeven. The development of dynamic error-proof Overall Equipment Effectiveness (OEE) model for optimizing a complex production process is targeted at minimizing/eradicating operational wastes/losses. In this study, the error-proof sigma metric was integrated into the extended traditional OEE factors (availability, performance, quality) to include losses due to waste and man-machine relationships. Error-proof sigma statistics enabled continuous corrective measures on unsatisfactory or low-level OEE resulted from process output variations (quantity delivered or expected), which were mapped into sigma statistical standards (one- to sixsigma). Application of the model in a processing company showed that errors of the process were reduced by 78% and 42% respectively for traditional OEE and the new Error-Proof OEE (OEE-EP). The results revealed that the OEE-EP model is better than the other existing schemes in terms of losses elimination in the production process. [ABSTRACT FROM AUTHOR]

Introduction: Laboratories minimize risks through quality control but analytical errors still occur. Risk management can improve the quality of processes and increase patient safety. This study aims to use the failure mode and effect analysis (FMEA) to assess the analytical performance and measure the effectiveness of the risk mitigation actions implemented. Materials and methods: The measurands to be included in the study were selected based on the measurement errors obtained by participating in an External Quality Assessment (EQA) Scheme. These EQA results were used to perform an FMEA of the year 2017, providing a risk priority number that was converted into a Sigma value (σFMEA). A root-cause analysis was done when σFMEA was lower than 3. Once the causes were determined, corrective measures were implemented. An FMEA of 2018 was carried out to verify the effectiveness of the actions taken. Results: The FMEA of 2017 showed that alkaline phosphatase (ALP) and sodium (Na) presented a σFMEA of less than 3. The FMEA of 2018 revealed that none of the measurands presented a σFMEA below 3 and that σFMEA for ALP and Na had increased. Conclusions: Failure mode and effect analysis is a useful tool to assess the analytical performance, solve problems and evaluate the effectiveness of the actions taken. Moreover, the proposed methodology allows to standardize the scoring of the scales, as well as the evaluation and prioritization of risks. [ABSTRACT FROM AUTHOR]

The Six Sigma methodology has been widely implemented in industry, healthcare, and laboratory medicine since the mid-1980s. The performance of a process is evaluated by the sigma metric (SM), and 6 sigma represents world class performance, which implies that only 3.4 or less defects (or errors) per million opportunities (DPMO) are expected to occur. However, statistically, 6 sigma corresponds to 0.002 DPMO rather than 3.4 DPMO. The reason for this difference is the introduction of a 1.5 standard deviation (SD) shift to account for the random variation of the process around its target. In contrast, a 1.5 SD shift should be taken into account for normally distributed data, such as the analytical phase of the total testing process; in practice, this shift has been included in all type of calculations related to SM including non-normally distributed data. This causes great deviation of the SM from the actual level. To ensure that the SM value accurately reflects process performance, we concluded that a 1.5 SD shift should be used where it is necessary and formally appropriate. Additionally, 1.5 SD shift should not be considered as a constant parameter automatically included in all calculations related to SM. [ABSTRACT FROM AUTHOR]

Mass spectrometry analysis has been applied in many important diagnostic fields of laboratory medicine. However, there is little literature to guide quality management systems for LC-MS/MS methods. In this study, LC-MS/MS 25-hydroxyvitamin D (25(OH)D) was used as an example to establish internal quality control strategies to ensure the accuracy of clinical vitamin D results. A total of 141 batches of samples were analyzed. Sample internal standard peak area variability, ion pair ratio, and physical examination population data were monitored as quality control strategies for 25(OH)D results. The analytical performance was evaluated by calculated Sigma metrics. Applying our quality control strategies, several abnormal data were monitored in the routine analysis. The daily peak area CV of 25(OH)D fluctuated within a certain range. By selecting P99 CV as the control target, two abnormal batches were found. The ratio of 25(OH)VD3 ion pairs was relatively stable. Among them, batch20230120 had a high CV value, which may be due to the bias caused by the limited number. According to the physical examination data, batch20220913 and batch20220919 exceeded the alarm limit. Sigma level of 25(OH)VD3 in the laboratory was 6.52, which achieved "excellent" performance. In conclusion, we established comprehensive quality control strategies for the determination of 25(OH)D by LC-MS/MS, which has high analytical performance and can provide more accurate reports for the clinic. • Monitoring internal standard peak area and ion pair ratio help detect abnormalities. • Physical examination of population data can be a supplement to daily quality control. • Analytical performance of 25(OH)VD3 conformed to Six Sigma level with high quality. [ABSTRACT FROM AUTHOR]

Background: A pilot external quality assurance (EQA) survey for the free light chain (FLC) assay was developed and implemented in Korea. Methods: Survey data over 6 years (2010–2015) were collected retrospectively and Sigma metrics were calculated for method-specific peer groups. Results: Nineteen to 29 laboratories participated in the EQA survey, and nephelometric (20%) and turbidimetric (80%) methods were used. Using a previously published clinically relevant reference change value (RCV) of 54.5% as the tolerance limit, the method-specific median Sigma metrics of kappa (κ) and lambda (λ) FLC achieved greater than Three-Sigma for 86–97% of all EQA distributions, and Five-Sigma for 48–72% of all distributions. Conclusions: This EQA analysis of FLC assay applied clinically relevant quality specifications using Sigma metrics. During the 6-year EQA survey, we found that most of the results from participating laboratories meet clinically relevant quality specifications. In addition, method-specific differences were noted for λ FLC, at FLC concentrations above the initial measuring range that require a sample dilution. [ABSTRACT FROM AUTHOR]

Six Sigma methodology has been used successfully in industry since the mid-1980s. Unfortunately, the same success has not been achieved in laboratory medicine. In this case, although the multidisciplinary structure of laboratory medicine is an important factor, the concept and statistical principles of Six Sigma have not been transferred correctly from industry to laboratory medicine. Furthermore, the performance of instruments and methods used in laboratory medicine is calculated by a modified equation that produces a value lower than the actual level. This causes unnecessary, increasing pressure on manufacturers in the market. We concluded that accurate implementation of the sigma metric in laboratory medicine is essential to protect both manufacturers by calculating the actual performance level of instruments, and patients by calculating the actual error rates. [ABSTRACT FROM AUTHOR]

A zero defects goal was implemented in the clinical laboratory settings using a six-sigma model. Daily Internal Quality Control (IQC) and external quality control data from April-September 2023 was extracted to calculate the sigma metrics of 21 biochemical analytes based on Total Error Allowable (TEa), % bias and co-efficient of variation percent (CV%). A retrospective comparative study was conducted in the department of Clinical Biochemistry at Kanva Diagnostic Services Pvt. Ltd, Bengaluru, India. The analytical performance of the 21 biochemical analytes was tested on Cobas 6000 and C311 analyzers. Quality Goal Index (QGI) and root cause analysis was calculated to infer the reason for the deviation of six sigma. Method decision charts were plotted to show the comparison of the problem analytes on both the analyzers. On Cobas 6000 at level 1 IQC, out of 21 analytes, 10 analytes showed σ>6 and 10 analytes showed σ 3-6 and on C311, 15 analytes which showed σ>6 and 6 analytes that showed σ 3-6. On Cobas 6000 at level 2 IQC, out of 21 analytes, 12 analytes showed σ>6 and 8 analytes showed σ 3-6 and on C311 17 analytes showed σ>6 and 4 analytes showed σ 3-6. Creatinine failed to meet minimal sigma performance at both levels of IQC on Cobas 6000., Competing Interests: There is no conflict of interest between the authors., (© 2023 Biomedical Informatics.)

Abstract Objectives The Abbott Alinity family of chemistry and immunoassay systems recently launched with early adopters contributing imprecision and bias data, which was consolidated to assess the performance of Alinity assays across multiple sites using the Sigma metric. Multi-site Sigma metrics were determined for 3 ion-selective electrodes, 12 photometric assays, and 3 immunoassays across 11 independent laboratory sites in 9 countries. Methods Total allowable error (TEa) goals followed a previously defined hierarchy that used CLIA as the primary goal. Bias was calculated against the Abbott ARCHITECT system using Passing-Bablok regression analysis using individual site data or pooled aggregate data. Sigma metrics were calculated as (%TEa - |% bias|)/%CV. For individual-site analysis, the Sigma metrics for each assay were compared using the individual-site and the pooled biases. For multi-site analysis, the average CV and the pooled bias were used to generate a Pooled Sigma metric encompassing the global performance for a given assay. Results A total of 97 individual-site and 18 Pooled Sigma metrics were calculated for available assays. Individual Sigma metrics varied across sites, with 90% of assays performing 4 Sigma or higher, and 17 of 18 Pooled Sigma metrics indicated performance greater than 4 Sigma. Sigma metrics were significantly improved in 16 assays when using pooled bias rather than individual-site bias. Conclusions This multi-center study applies a novel application of Sigma metrics to the first Alinity users and reveals analytical performance of greater than 4 Sigma for vast majority of assays. Laboratories with limited resources can leverage larger data sets for Pooled Sigma metric analysis, providing a tool to assess the consistency of analytical performance from multiple sites. Highlights • The Pooled Sigma metric is a composite metric of global performance for a given assay. • A Pooled Sigma metric can be used to assess inter-instrument analytical performance. • Pooled method comparison data overcomes the limitations of single-site bias estimates. • This multi-site study applies Pooled Sigma metrics to the first Abbott Alinity users. • 17 of 18 Alinity assays had Pooled Sigma metrics with performance >4 Sigma. [ABSTRACT FROM AUTHOR]

The article focuses on a study on the extra-analytical phase, no information is provided regarding the counted (discrete) variables and portion of extra-analytical phase variables consist of counted data. It mentions Sigma metric (SM) is reflected in defects per million opportunity (DPMO) and extra-analytical phase might follow a binomial rather than a normal distribution. It also mentions normal distribution is one of the most frequently used distribution types.

• Performance specifications based on biological variation are too stringent for analytes under strict homeostatic control like sodium. • Sodium measurement clearly fulfills a clinical need, even if it underperforms according to current models. • An outcome based model could be better suited in the case of sodium, and this mightapply to other analytes that are under strict homeostatic control. When increasing the quality in clinical laboratories by decreasing measurement uncertainty, reliable methods are needed not only to quantify the performance of measuring systems, but also to set goals for the performance. Sigma metrics used in medical laboratories for documenting and expressing levels of performance, are evidently totally dependent on the "total permissible error" used in the formulas. Although the conventional biological variation (BV) based model for calculation of the permissible (or allowable) total error is commonly used, it has been shown to be flawed. Alternative methods are proposed, mainly also based on the within-subject BV. Measurement uncertainty models might offer an alternative to total error models. Defining the limits for analytical quality still poses a challenge in both models. The aim of the present paper is to critically discuss current methods for establishing performance specifications by using the measurement of sodium concentrations in plasma or serum. Sodium can be measured with high accuracy but fails by far to meet conventional performance specifications based on BV. Since the use of sodium concentrations is well established for supporting clinical care, we question the concept that quality criteria for sodium and similar analytes that are under strict homeostatic control are best set by biology. [ABSTRACT FROM AUTHOR]

In clinical laboratories, the performance of a process as Sigma Metric ( SM) is calculated by the equations derived by Westgard. In the present study, we found that the Westgard equations do not reflect the real performance of the process and that the SM calculated using these equations is lower than the real SM. We measured the substance concentration of ten analytes (glucose, urea, creatinine, cholesterol, calcium, magnesium, phosphorus, LDH, sodium, and potassium) in serum and calculated the SM for each using the Westgard equations and z transformations. The SM values for the same measurand using the Westgard equations based on either the absolute or the relative (percentage) results were not equal to each other, and those related to calcium and sodium were even lower than 0. The SM obtained from the z transformation was higher than that from the Westgard equations, and none were lower than 0. We concluded that the equations suggested by Westgard to calculate the SM do not cover all of the data produced by the process and do not reflect reality. From our research, the z transformation was the optimum method of calculating the actual SM for the process. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Evaluation of the performance of INDEXOR® in the archive unit of a clinical laboratory: a step to Lean laboratory" by Abdurrahman Coskun and colleagues in the previous issue.

A letter to the editor in response to the article "To err is human, Building a safer health system," By L. Kohn and colleagues in the previous issue is presented.

Background: Urine reagent strip test (URST) results are semi-quantitative; therefore, the precision of URSTs is evaluated as the proportion of categorical results from repeated measurements of a sample that are concordant with an expected result. However, URSTs have quantitative readout values before ordinal results challenging statistical monitoring for internal quality control (IQC) with control rules. This study aimed to determine the sigma metric of URSTs and derive appropriate control rules for IQC., Methods: The URiSCAN Super Plus fully automated urine analyzer (YD Diagnostics, Yongin, Korea) was used for URSTs. Change in reflectance rate (change %R) data from IQC for URSTs performed between November 2018 and May 2020 were analyzed. Red blood cells, bilirubin, urobilinogen, ketones, protein, glucose, leukocytes, and pH were measured from 2-3 levels of control materials. The total allowable error (TE a ) for a grade was the difference in midpoints of a predefined change %R range between two adjacent grades. The sigma metric was calculated as TE a /SD. Sigma metric-based control rules were determined with Westgard EZ Rules 3 software (Westgard QC, Madison, WI, USA)., Results: Seven out of the eight analytes had a sigma metric >4 in the control materials with a negative grade (-), which were closer to the cut-offs. Corresponding control rules ranged from 1 2.5s to 1 3.5s ., Conclusions: Although the URST is a semi-quantitative test, statistical IQC can be performed using the readout values. According to the sigma metric, control rules recommended for URST IQC in routine clinical practice are 1 2.5s to 1 3.5s .