Foreword xv Preface xvii Acknowledgments xix About the Author xxi List of Abbreviations xxiii Part I Getting Started: Regulatory Oversight and Laboratory Accreditation 1 1 Clinical Laboratory Improvement Amendments (CLIA) and Regulatory Oversight 3 How is "clinical laboratory" defined? 3 What is CLIA? 4 What is the Code of Federal Regulations (CFR)? 5 What roles do the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the U.S. Food and Drug Administration (FDA) play in regulating clinical laboratories? 5 What is an FDA-cleared or FDA-approved test? 6 What is a laboratory developed test (LDT)? 7 What does the FDA final rule mean for my laboratory? 8 What is Emergency Use Authorization (EUA)? 14 What is test complexity? 15 Is there a list of tests categorized by complexity? 17 References 17 2 Clinical Laboratory Improvement Amendments (CLIA) Certificates 21 Which laboratories need a CLIA certificate? 21 Which laboratories are NOT required to obtain a CLIA certificate? 21 What are the types of CLIA certificates? 21 What procedures are categorized as provider-performed microscopy (PPM) procedures? 22 How does a laboratory obtain a CLIA certificate? 23 How many laboratories can be on one CLIA certificate? 24 Can one location have multiple CLIA certificates? 24 How many CLIA certificates can one laboratory director have? 25 How long is a CLIA certificate effective, and how does a laboratory renew a CLIA certificate? 25 What are the laboratory specialties and subspecialties? 25 Which states have CLIA-exempt laboratory programs? 26 When can a laboratory begin testing? 26 Who should be notified if there are changes in the laboratory, and when? 26 What happens if a laboratory is out of compliance with CLIA requirements? 27 References 28 3 Waived Testing 29 What are waived tests? 29 Is there a list of tests that are waived? 30 Is my laboratory subject to inspection if we perform waived testing? 30 What are the personnel qualifications for performing waived testing in clinical laboratories? 30 Are there compliance exemptions for laboratories performing waived testing? 30 References 31 4 Laboratory Accreditation 33 What is laboratory accreditation? 33 What are the current CMS-approved accrediting agencies? 33 How can my laboratory become accredited? 34 How does my laboratory maintain accreditation? 35 What happens during a laboratory inspection? 35 How does a laboratory respond when cited for deficiencies? 36 How is laboratory noncompliance addressed by CMS? 36 Can I become a laboratory inspector? 36 What is "ISO certification/accreditation" and does my laboratory need it? 37 I need some help with terms! 38 References 39 Part II Going Live: Verification and Validation of Test Systems 41 5 Verification and Validation 43 What are verification and validation? 43 When should a laboratory perform a verification or validation study? 43 If our laboratory complies with the FDA final rule for LDTs, do we still need to perform a validation study for our LDTs? 44 What is a test system? 45 What counts as a modification to a test system? 45 Who is responsible for designing and implementing a verification or validation study? 46 Can the company who made the instrument perform the verification study? 46 What performance characteristics should be assessed for a verification study? 46 What performance characteristics should be assessed for a validation study? 47 Is verification/validation necessary for point of care and other CLIA-waived assays? 47 My laboratory is moving an instrument. Is a verification/validation necessary? 47 My laboratory has five of the same instruments running the same assay. Do we have to run a verification/validation on each instrument? 48 My laboratory has multiple high-complexity laboratories across the health system that run the same assays on the same platform. Does a verification/validation need to be performed at each location? 48 My laboratory stopped running a particular assay. Is verification/validation necessary to resume testing with this assay? 48 My laboratory is running a test under Emergency Use Authorization (EUA). Is verification/ validation required? 49 Which laboratory personnel are involved in a verification/validation study? 49 References 49 6 Performance Characteristic: Precision 51 What is precision? 51 How many and what types of samples should be used to assess precision? 52 How does a laboratory assess precision for qualitative assays? 52 How does a laboratory assess precision for quantitative assays? 53 What calculations should be used for precision? 54 How can precision be assessed for matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification systems? 55 How can precision be assessed for antimicrobial susceptibility test (AST) systems? 57 How can precision be assessed for multiplex molecular systems? 57 References 62 7 Performance Characteristic: Accuracy/Agreement 65 What is accuracy? 65 How many and what types of samples should be used to assess accuracy? 66 What calculations should be used for accuracy? 67 What calculations should be used for agreement? 68 How does disease prevalence affect test performance? 69 How can accuracy be assessed for matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification systems? 69 How can accuracy be assessed for antimicrobial susceptibility test (AST) systems? 70 How can accuracy be assessed for multiplex molecular systems? 73 References 77 8 Performance Characteristic: Reportable Range 79 What is reportable range? 79 How many and what types of samples should be used to assess reportable range? 80 How does a laboratory assess reportable range for quantitative assays? 81 How does a laboratory assess reportable range for qualitative assays? 81 How can reportable range be assessed for matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification systems? 84 How can reportable range be assessed for antimicrobial susceptibility test (AST) systems? 84 How can reportable range be assessed for multiplex molecular systems? 84 References 85 9 Performance Characteristic: Reference Interval 87 What is a reference interval? 87 How many and what types of samples should be used to assess the reference interval? 87 How does a laboratory assess the reference interval? 88 What calculations should be used for reference interval? 88 How can the reference interval be assessed for matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification systems? 89 How can the reference interval be assessed for antimicrobial susceptibility test (AST) systems? 89 How can the reference interval be assessed for multiplex molecular systems? 89 References 89 10 Performance Characteristic: Analytical Sensitivity 91 What is analytical sensitivity? 91 How many and what types of samples should be used to assess analytical sensitivity? 92 How does a laboratory assess analytical sensitivity? 92 What calculations should be used for analytical sensitivity? 93 How can analytical sensitivity be assessed for matrix-assisted laser desorption ionization- time of flight (MALDI-TOF) identification systems? 93 How can analytical sensitivity be assessed for antimicrobial susceptibility test (AST) systems? 93 How can analytical sensitivity be assessed for multiplex molecular systems? 94 References 94 11 Performance Characteristic: Analytical Specificity 95 What is analytical specificity? 95 How many and what types of samples should be used to assess analytical specificity? 95 How does a laboratory assess analytical specificity? 96 What should we do if cross-reactivity or interfering substances are identified? 97 How can analytical specificity be assessed for matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification systems? 97 How can analytical specificity be assessed for antimicrobial susceptibility test (AST) systems? 98 How can analytical specificity be assessed for multiplex molecular systems? 98 References 98 12 Additional Performance Characteristics 99 What additional performance characteristics could be considered, and how are they assessed? 99 References 100 13 Unacceptable Results and Resolution 101 What should we do if there are significant discrepancies between our new assay and the comparator assay? (Accuracy) 101 We are using a less sensitive method as our comparator method, and our new test is showing poor agreement and increased "false positives.

" What should we do? (Accuracy) 101 Our assay shows significant cross-reactivity with a particular organism. What should we do? (Analytical specificity) 102 References 103 14 Documentation for Verification and Validation Studies 105 What documentation is necessary for a verification or validation study? 105 What should be included in a verification/validation plan? 105 What should be included in a.