As demonstrated by measurable improvements in quality management at our 12 supported sites , our training and mentoring approach in Cambodia made a positive impact in participating laboratories and correlates with similar reports in the region . With the addition of this study, we found reasonable evidence that regular laboratory mentoring, supported by needs based training and inter-laboratory collaboration enhances laboratory quality improvement when it impresses actionable needs-based planning, peer learning in a practical and supportive environment, and collaborative problem solving. It was evident in the implementation of our program that customizing the mentoring and training program for the local environment is more effective than a preconceived and rigid “one size fits all” approach, and that taking an adaptive approach to teaching practice based skills is critical for rapid improvement .
Best practices within CamLQMS gap assessments and action planning
Our model of best practices presents how our adaptive approach was received in the context of Cambodia. Multiple comments from participants recognized the adaptive role of CamLQMS gap assessments in their LQMS improvement progress, for example, which is to identify gaps in LQMS conformity and direct improvement plans to address deficiencies. Participants also recognized the part of action planning, which led to specific, measurable, attainable, relevant, and timely goals. Although not corroborated by participant feedback, we further observed a clear benefit from immediate feedback and corrective action by auditors during audits, and from auditors engaging the attention of both hospital leadership and government stakeholders where they otherwise were less engaged. Further research may help to confirm these observations where participant feedback did not recognize the contribution of these practices to improvement.
Best practices within formal LQMS training
In support of our use of a needs-based design of curriculum, 58 participant comments suggested knowledge gain due to training activities, 22 of which referred to concepts specific to the needs-based curriculum such as management review and equipment validation. Additionally, peer learning and collaboration was remarked highly by participants, who often requested more activities where participants of different labs could share ideas and experiences, learning from each other and collaborating to troubleshoot and solve practical LQMS improvement challenges.
Our program was designed specifically to utilize peer learning among a set of other dynamic, hands-on, and interactive adult-learning strategies implemented as adaptive drivers of change. Such strategies have been shown to be effective within healthcare professional training [14, 18], and participants gave a positive response to many of these training activities, for which we recommend them within our model of best practices. Our program further emphasized a focus on patient safety, which we observed to motivate participants during training, though only one participant comment supports the practice in this study.
Participants expressed considerable preference for on-site training activities, mentioning specifically the practical and experiential learning as important for participant improvement. Theoretically, one of the key benefits to this method is the advanced training and improvement opportunity that it gave to higher performing laboratories, which had the opportunity to present their own quality management systems for critical observation by their peer participants from other laboratories. Lower performing laboratories, meanwhile, were able to learn from the best practices of their peers. This practice addressed the need to match training content to benefit all ranges of participant experience. Participants were also able to acquire practical skills through direct hands-on participation during the experience. “I think practice is better than theory”, one participant suggested. Finally, although our trainers strived to conduct all training in the local language wherever possible as a best practice, feedback from participants expressed strong critique for translators where information was not translated clearly enough. It was apparent that the training curriculum required further strengthening to meet the language needs of participants.
Best practices of In-person LQMS mentoring
In-person mentor visits, which participants agreed most highly to be important to the progress experienced in their laboratories, are purposefully designed to complement training, providing supplementary training and taking the time to answer questions for participants within the context of their own laboratories. Participant feedback appreciated the mentors’ effort to answer those questions and demonstrate how to apply information learned in formal training. Participants also appreciated follow-up from mentors regarding quality improvement plans, driving action and holding participants accountable. Even more feedback appreciated the problem-solving function of mentors, identifying and discussing problems on-site with participants and collaborating to overcome challenges to improvement.
Participants also suggested that face-to-face visits from mentors served to improve the professional mentor-mentee working relationship, and further comments remarked mentor visits to help engage other important leading stakeholders such as hospital directors and MoH regulators in laboratory improvement. One participant addressed both factors, stating “Regular periodic visits from trainers is important because it makes an important connection between the training institute and the laboratory staff. An in-person trainer visit is also important to increase the credibility of the laboratory staff to the lab director.” When mentors visit laboratories, MoH personnel and laboratory directors are invited to meet with mentors and laboratory quality assurance staff to discuss current and past improvement efforts, garnering support for laboratory improvement efforts; This engagement of leadership is critical.
Best practices of LQMS tele-mentoring
Participant feedback addressing tele-mentoring activities reveals an apparent contradiction from a concurrent study that has found a correlation between participation time spent in Zoom teleconferencing activities and improved conformity to CamLQMS checklist standards. While this association suggests tele-mentoring may be a potentially significant driver of improvement, participant feedback ranked Zoom teleconferencing activities lower than all other primary activities. Participant feedback was critical of group teleconferencing activities in particular, commonly referring to “too much talk” and distraction among participants. This feedback did not, however, critique one-on-one tele-mentoring between mentors and a single laboratory and its staff, which was also common.
Positive feedback demonstrated that tele-mentoring activities fulfilled the same primary aims as in-person mentoring. Participants noted knowledge gained from telementor trainings, appreciated regular feedback from mentors, and again praised the ability to collaborate with both peers and mentors, sharing experience and knowledge. Participants further praised the ready access to mentors, being able to ask questions and get a response immediately, which was an important practice of our mentors, who set regular hours for participants to call for guidance. Further feedback emphasized again the importance of training in the local language, and one comment appreciated the cost effectiveness of telementor training, not just for the implementing organization, but for participants as well, saving them time and money. For these reasons, we recommend that telementor activities be designed to integrate the essential components of continued learning, peer accountability, and collaborative learning and problem solving, implemented cost effectively and in the local language wherever possible. We further recommend that mentors work with smaller groups or individual laboratories as much as possible during tele-mentoring activities for best results, maintaining firm control and structure, limiting back-and-forth between participants to set question and answer periods to make the best use of participant time.
Best practices of LQMS auditee training program
The auditee training was a combination of tele-conferencing and on-site audit training based on auditee assessment of the laboratory using the CamLQMS checklist. In essence, the ITECH auditor trainer feedback and taught on the gaps for improvement at the site of the audited laboratory. The training program had components of the training tools such as the technique of asking objective questions, observations of laboratory process and evidence of LQMS documents at site and ability to rate correctly on the checklist questionnaire. Trainees evaluated the auditor training positively and had learned the skill to rate their own laboratories on the Internal Audit of the QSE element effectively. In summary, the auditor training program was successful in providing MOH with a group of 12 auditors who would be able to assist in the collection of objective evidence, thus permitting an informed judgement about the status of the laboratory quality system that would be audited efficiently.
Because most of these best practice themes are derived first from implementing staff observations, this study may be influenced by positive biases toward the implemented activities and practices, missing potentially useful practices not observed by either staff or participants. Data from program participants too is limited by positive response bias from participants, and is further limited to written feedback only, which is limited to short answer responses. Extensive interviews of participants or key stakeholders may provide richer data in following studies.
Program evaluation responses were further limited by language barriers among participants, who had varying abilities to respond clearly to the surveys in English, which resulted in some unclear or truncated responses. Feedback from training evaluations, which were responded to in either English or Khmer, contains the potential for translation error and bias as responses were translated into English by mentors rather than professional translators.
Recommendations and conclusion
This study gives further information to explain how an adaptable package of needs-based planning, training, and mentoring can lead to improved laboratory quality management systems via an informed, trained, and empowered workforce. Our model of best practices serves as a guide for future programs, emphasizing the importance of needs based training and informed planning. Themes from participant feedback highlight the usefulness of on-site training and peer learning, and highly support regular contact with experienced laboratory professionals who can mentor theory and practical skills in the laboratory setting, hold participants accountable to goals, and provide collaboration to identify and solve problems in the laboratory. Tele-mentoring activities appear to be associated with improved outcomes in one concurrent study  and in our Auditee Training program suggest that scale up practices for laboratory medicine would be a worthwhile investment, therefore we recommend careful planning and management of these activities to assure effective knowledge uptake and minimum distraction among participants. We further recommend that in-person mentoring be maintained to some degree in such programs, due to its perceived value among mentors and participants in the improvement process.