Building an AP Quality Management System in Uganda: My Month on the Inaugural ASCP Trainee Global Health Fellowship

Makerere University sits atop a hill in the lush green center of Kampala, Uganda. It has a storied history—its medical school was founded in 1922, and in the heady post-independence days of the mid-twentieth century it was an intellectual powerhouse attracting theorists, economists, and writers from North America, Europe, and Asia. It was in Makerere University’s Pathology Building where a certain Dr. Burkitt described a strange new lymphoma that appeared to affect East African children. The current pathology department boasts 13 qualified pathologists (out of 28 in the entire nation), and nine residents, and handily takes care of some 6,000 surgical specimens, performs 4,000 forensic and 500 hospital autopsies, and undertakes some 500 FNAs. It was a thrilling, illustrious place to be hosted for a month as the inaugural ASCP Trainee Global Health Fellow.

In my experience as a longtime watcher of the international aid and medical volunteerism community, most doctors who volunteer overseas come in three flavors. The first are the clinicians who go global with the specific goal of working clinically in their specialties. For us pathologists, that means seeing cases, assisting with procedures, double-scoping, and teaching residents. The pathologist gains experience with local entities, and imparts some teaching or case-specific knowledge to the host pathologists in return. The second group are the researchers—those who venture abroad hoping to answer specific questions, via formal case-based or epidemiological research. Reciprocity here comes via research collaboration, publication credits, and (ideally) monetary compensation for the department’s time and resources. And lastly, there’s a small group interested in logistics and everything that falls under the nebulous heading of “capacity-building.”

Map of Kampala, Uganda

Drawer of filed and organized blocks

The first histology QC in East Africa

I’m firmly in the last group. I’m like that here in the US too—much more interested in systems rather than individual cases (the ink on my new job contract is dry: otherwise I’d never admit that publicly in case Future Boss gets the wrong idea).

On my second day on the ground, the African Society of Laboratory Medicine conducted the first formal AP lab inspection in East Africa, using the SLIPTA-Afro (Stepwise Laboratory Improvement Process towards Accreditation in the African Region) checklist developed by the World Health Organization for African laboratories as a means of encouraging labs to progress towards accreditation. A lab needs 275 points to fully qualify and apply for accreditation. Thanks to many diligent efforts by the Head of Department prior to my arrival, our baseline number of marks was 62, placing the lab in the “0 stars” category. In order to progress out of the category of “Zero stars” to “1 star,” a lab needs 150 marks. We set an ambitious goal to climb to 1-star status by the end of the month.

Therefore, in my time there, we:

• Hand-digitized 4,000 cases from 2016 to 2018, creating the department’s first searchable database. This will permit research, pathology history correlation, the tabulation of TAT statistics, and epidemiological queries into the laboratory’s case mix, most common diagnoses made, etc.
• Wrote the first Makerere University Pathology Department clinician handbook, including detailed sections on how to jerry-rig an adequate specimen container.
• Wrote the first Makerere University Pathology Department policy manual, which comprehensively lays out the department’s policies on absolutely everything from purchasing to personnel.
• Wrote the first lab safety manual, which is a comprehensive general, chemical, biohazard, and hazardous material safety manual, and came up with a good fire-suppression plan in a laboratory space that is currently without reliable water supply.
• Instituted the very first histology quality control in East Africa, developing our own in-house slide quality measures.
• Instituted a new pathology quality assurance weekly conference.
• Organized more than 6,000 blocks, comprising the entirety of cases from 2017 and 2018, labeling them, and filing them for the first time, using these beautiful enormous well-constructed solid hardwood drawers in the lab space. Each drawer can hold over 800 blocks!
• Organized all grossed tissues and operationalized newly written policies regarding tissue retention.
• Conducted the first quality audit in the department from the newly digitized database, calculating discrepancy rates and TAT for the first time.
• Developed a histotechnology competency assessment tool which was locally appropriate.
• Started an in-house laboratory information system, based on Microsoft Excel (database) and Google Drive (document storage and prospective accessioning, case results, and statistics warehousing). Lab staff were trained in its usage.
• Developed a new, internationally standard report format and trained clerical staff to use it.
• Transitioned accessioning to a digital process, via the new database.

After all that, the lab is now firmly (by our count) above the 150-point threshold. It’s not official, but we think we’re the first 1-star histopathology lab in East Africa, outside possibly the Aga Khan in Nairobi.

As you can tell from the ebullient tone of this article, it was a thrilling, challenging, career-defining month. I thank ASCP most sincerely for sending me.

If you think you’d be interested in an international rotation, there are two ways to get there as a resident/fellow trainee: 1) apply for an ASCP Subspecialty Grant, administered by the Resident Council; or 2) apply this November to be a 2019 ASCP Trainee Global Health Fellow, as selected by the ASCP Center for Global Health.