Hong Kong Institute of Medical Laboratory Sciences Quality Assurance Programme Ltd.
Quality Assurance Programme
Cytopathology Microscopy Module
Objective of the Programme
1. To assess the screening and interpretative performance of cytotechnologist in examination of cytology smears.
2. To enhance the experience of cytotechnologist by providing interesting and relevant cytological material.
Three smears, which had been wet fixed and stained with Haematoxylin & Eosin or Papanicolaou stain, and case history are provided. All slides must be returned.
Make diagnosis on the slide.
Four times a year
Criteria for Participation
Any medical laboratory which provides cytology examination services is eligible to participate.
Return of Result
Participants identified by assigned confidentiality codes, are required to submit survey results using the Return Form by facsimile on day specified on the Return Form. (Please refer to the Time Schedule for the Year)
Participant returning result timely will be informed of preliminary result through email before the date for returning survey materials.
Return of Hard Copy of Survey Result Form and Cytology Smears:
· All cytology smears shall be returned on the day specified on the survey form (usually 16 calendar days after the dispatch of survey materials) in the original packaging.
· Arrangement has been made with DHL to collect the survey form and materials from participants back to HKIMLSQAP. Participant has to place order to DHL according to the Guide provided.
· To maintain the integrity of the smears during transportation foam-padded envelope will be provided.
· As the cytology slides are precious material, participants are requested to handle the cytological smears cautiously and keep them in safe custody.
· HKIMLSQAP reserve the right to claim indemnity if the cytological smears are broken due to mishandling or non-return due to lost.
Request for Replacement Samples
No replacement of survey materials requested by participants would be entertained except the slides were broken during dispatch to the laboratory.
Objective Criteria for Performance Evaluation of Cytology Examination
· The answer is in multiple-choice format and a “4-tier” scoring system is adopted.
· The assessment is based on the faxed result.
· No return or late return will be counted as not done and will be marked on the survey report.
· Performance assessment will be evaluated by the Cytopathology Panel with reference to target answer.
· The performance of the participant in cytopathology will be graded individually as yes, acceptable, barely acceptable or unacceptable according to the following grading system.
In agreement with
Slightly deviated from
Discrepancy ≤ 1 step
No significant impact on patient management
Borderline answer, grading in-between “Acceptable” and “Unacceptable”
· Final report will be issued and dispatched on the next round of survey exercise.
· Survey data will be compiled and displayed in table form.
· No return or late return of survey result will be counted as not done and will be marked as “ND” in the report.
· Explanatory note will be provided if appropriate.
· Performance of individual participant will be summarized in a report issued annually.
Certificate of Participation
A certificate of participation will also be issued indicating the number of survey results returned timely.
· Should there be any disagreement of the preliminary result, data discrepancy in the preliminary survey report or any disagreement with the performance evaluation; participant can appeal to the Chairman of HKIMLSQAP.
· The appeal shall be lodged by making a written submission providing the grounds of the appeal within four weeks from the date of receiving the preliminary survey report.
· The laboratory can apply for getting back the slides for further review. The laboratory is responsible for the extra cost of the delivery and return of the slides.
CME Points For the Cytopathology Microscopy Programme
Starting from November Survey (2021), the Hong Kong College of Pathology (HKCP) has approved 1.5 CME points for participation in each survey of Cytopathology Microscopy Module. Participant has to complete and return the CME/CPD Program Attendance Record for Quality Assurance and Audits (QA) by fax to 2124 2798 or email to email@example.com within the time stated in the instruction sheet dispatched along with the survey materials.
Should there be any enquiry on the survey; participants are requested to contact HKIMLSQAP for assistance.
Each participant is assigned with a laboratory code for submitting survey result. The key to decipher the identities of participants is limited to few authorized members of HKIMLSQAP Council, (Council Chairman, Hon. Secretary and Office Staff) who are forbidden to release the identities of the participants.
Accreditation body would access to participant’s performance during assessment, however, HKIMLSQAP keeps all details of participant’s identities confidential and will not disclose their identities to a third party unless required by legislation.