Carl D. Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs and Rehabilitation Associate Professor of Medicine - Mayo Clinic College of Medicine.

Carl D. Mottram, BA RRT RPFT FAARCCarl D. Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs and RehabilitationDirector - Pulmonary Function Labs and Rehabilitation

Associate Professor of Medicine - Mayo Clinic College of MedicineAssociate Professor of Medicine - Mayo Clinic College of Medicine

Carl D. Mottram, BA RRT RPFT FAARCCarl D. Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs and RehabilitationDirector - Pulmonary Function Labs and Rehabilitation

Associate Professor of Medicine - Mayo Clinic College of MedicineAssociate Professor of Medicine - Mayo Clinic College of Medicine

Quality Control of Exercise and Quality Control of Exercise and Gas Exchange EquipmentGas Exchange Equipment

Quality Control of Exercise and Quality Control of Exercise and Gas Exchange EquipmentGas Exchange Equipment

Exercise Testing GuidelinesExercise Testing GuidelinesExercise Testing GuidelinesExercise Testing Guidelines

• ACC/AHA Guidelines for Exercise ACC/AHA Guidelines for Exercise TestingTesting

• J Am Coll Cardiol 1997;30:260-315

• Updated in 2002 (www.americanheart.org)

• ATS/ACCP Statement on ATS/ACCP Statement on Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

• Am J Respir Crit Care Med Vol 167. pp 211–Am J Respir Crit Care Med Vol 167. pp 211–277, 2003277, 2003

• ACC/AHA Guidelines for Exercise ACC/AHA Guidelines for Exercise TestingTesting

• J Am Coll Cardiol 1997;30:260-315

• Updated in 2002 (www.americanheart.org)

• ATS/ACCP Statement on ATS/ACCP Statement on Cardiopulmonary Exercise TestingCardiopulmonary Exercise Testing

• Am J Respir Crit Care Med Vol 167. pp 211–Am J Respir Crit Care Med Vol 167. pp 211–277, 2003277, 2003

Exercise Testing GuidelinesExercise Testing GuidelinesExercise Testing GuidelinesExercise Testing Guidelines

• Guidelines for Exercise Testing in the Guidelines for Exercise Testing in the Pediatric Age GroupPediatric Age Group - Council on - Council on Cardiovascular Disease in the Young, American Cardiovascular Disease in the Young, American Heart AssociationHeart Association

• Reginald Washington MD et al (Reginald Washington MD et al (Circulation 90:2166-2179, Circulation 90:2166-2179, 1994) 1994)

• Guidelines for Methacholine and Exercise Guidelines for Methacholine and Exercise Challenge Testing (Challenge Testing (Am J Respir Crit Care Med Vol 161. Am J Respir Crit Care Med Vol 161. pp 309-329, 2000)pp 309-329, 2000)

• ATS Pulmonary Function Laboratory ATS Pulmonary Function Laboratory Management and Procedure Manual Management and Procedure Manual (updated 2005) (updated 2005)

• www. thoracic.orgwww. thoracic.org

• Guidelines for Exercise Testing in the Guidelines for Exercise Testing in the Pediatric Age GroupPediatric Age Group - Council on - Council on Cardiovascular Disease in the Young, American Cardiovascular Disease in the Young, American Heart AssociationHeart Association

• Reginald Washington MD et al (Reginald Washington MD et al (Circulation 90:2166-2179, Circulation 90:2166-2179, 1994) 1994)

• Guidelines for Methacholine and Exercise Guidelines for Methacholine and Exercise Challenge Testing (Challenge Testing (Am J Respir Crit Care Med Vol 161. Am J Respir Crit Care Med Vol 161. pp 309-329, 2000)pp 309-329, 2000)

• ATS Pulmonary Function Laboratory ATS Pulmonary Function Laboratory Management and Procedure Manual Management and Procedure Manual (updated 2005) (updated 2005)

• www. thoracic.orgwww. thoracic.org

Quality ModelsQuality ModelsQuality ModelsQuality Models

• Clinical and Laboratory Standards Clinical and Laboratory Standards Institute (formerly NCCLS)Institute (formerly NCCLS)

• ““Quality System Model for Healthcare” Quality System Model for Healthcare” HS-1 (ISO 9000)HS-1 (ISO 9000)

• Application of a Quality System Model Application of a Quality System Model for Respiratory Services” HS-4for Respiratory Services” HS-4

• Clinical and Laboratory Standards Clinical and Laboratory Standards Institute (formerly NCCLS)Institute (formerly NCCLS)

• ““Quality System Model for Healthcare” Quality System Model for Healthcare” HS-1 (ISO 9000)HS-1 (ISO 9000)

• Application of a Quality System Model Application of a Quality System Model for Respiratory Services” HS-4for Respiratory Services” HS-4

Application of a Quality System Application of a Quality System Model for Respiratory Services Model for Respiratory Services

Path of workflowPath of workflow

Application of a Quality System Application of a Quality System Model for Respiratory Services Model for Respiratory Services

Path of workflowPath of workflow

Cardiopulmonary Exercise Testing Cardiopulmonary Exercise Testing Path of WorkflowPath of Workflow

• Pre-testingPre-testing• Demographic information Demographic information • HistoryHistory

• Exercise limitations - orthopedic Exercise limitations - orthopedic considerationsconsiderations

• Laboratory results – Na, K, etc.Laboratory results – Na, K, etc.

• MedicationsMedications• Digitalis, Digitalis, ββ – blockers, calcium – blockers, calcium

channel blockerschannel blockers



• Pre-Test (cont)Pre-Test (cont)• Pre-test instructionsPre-test instructions

• Appropriate shoes and clothingAppropriate shoes and clothing• Refrain from smoking (8 hours)Refrain from smoking (8 hours)• Light meal 2-4 hours prior to testingLight meal 2-4 hours prior to testing• Medication instructionsMedication instructions

• Appropriate orderAppropriate order• Type of exercise test, adjuncts (FV loops, Type of exercise test, adjuncts (FV loops,

ABG’s, etc.ABG’s, etc.

• Pre-Test (cont)Pre-Test (cont)• Pre-test instructionsPre-test instructions

• Appropriate shoes and clothingAppropriate shoes and clothing• Refrain from smoking (8 hours)Refrain from smoking (8 hours)• Light meal 2-4 hours prior to testingLight meal 2-4 hours prior to testing• Medication instructionsMedication instructions

• Appropriate orderAppropriate order• Type of exercise test, adjuncts (FV loops, Type of exercise test, adjuncts (FV loops,

ABG’s, etc.ABG’s, etc.


• TestingTesting• Patient instructionsPatient instructions

Understanding, effort & Understanding, effort & cooperationcooperation

• Technologist’s performance & trainingTechnologist’s performance & training• Equipment Equipment



• Technologist’s competencyTechnologist’s competency• Job qualificationsJob qualifications• Job descriptionsJob descriptions• OrientationOrientation• TrainingTraining• Competency assessmentCompetency assessment• Continuing educationContinuing education• Performance appraisalPerformance appraisal

• Technologist’s competencyTechnologist’s competency• Job qualificationsJob qualifications• Job descriptionsJob descriptions• OrientationOrientation• TrainingTraining• Competency assessmentCompetency assessment• Continuing educationContinuing education• Performance appraisalPerformance appraisal

Employee(s) identified

What Happens How It Happens How To Do It

Activities to be assessed

determined

Competency assessed

Performance satisfactory

?

Send completed job description /performance apprasel form to Human

Resources. Keep a copy in employee file

End

Training ProcessApp D

YesNo

· Develop observation schedules and send out peer review forms

· Refer to job description· Use job description/competency

assessment tool·

* Training manuals*Competency Program

Methods used:· Direct observation· Result comparison· Review 360 degree peer review feedback· Review of test results, worksheets,

quality control, preventive maintenance, proficiency test results

COMPETENCY ASSESSMENT PROCESS

Mayo Clinic - Pulmonary Function Laboratories and RehabilitationDepartment of Pulmonary and Critical Care Medicine

Rochester, MN 55905Purpose: This process describes how the competency assessment process happens and

provides guidance for how to do specific activities in this process..

QSE: Personnel (POL 012246)Appendix E version 001Effective date: 05.01.01

Page 1 of 1PathLabM/QAOffice/DRAFTQualityManual/Personnel/CompetencyAssessmentProcessAppE

Cardiopulmonary Exercise TestingCardiopulmonary Exercise TestingEquipment - ErgometersEquipment - Ergometers

• Calibration every 3-6 monthsCalibration every 3-6 months

• Cycle ergometersCycle ergometers• static-bar and weightsstatic-bar and weights• dynamic-calibratorsdynamic-calibrators

• TreadmillTreadmill• Speed: beat length, stopwatch (subject on Speed: beat length, stopwatch (subject on

TM)TM)• % Grade % Grade = = Length of the treadmillLength of the treadmill

vertical height of elevation vertical height of elevation

Cardiopulmonary Exercise TestingCardiopulmonary Exercise TestingEquipment – Flowmeter and analyzersEquipment – Flowmeter and analyzers

• ATS/ERS standard for flow-volume ATS/ERS standard for flow-volume devicesdevices

• 3 liter syringe3 liter syringe• ± 3.5% or ± 50 ml ± 3.5% or ± 50 ml

• Gas analyzersGas analyzers• Paramagnetic, infrared, mass spectrometerParamagnetic, infrared, mass spectrometer• Linearity: 2-pt. calibration over range testingLinearity: 2-pt. calibration over range testing

Cardiopulmonary Exercise TestingCardiopulmonary Exercise TestingEquipment –AnalyzersEquipment –AnalyzersCardiopulmonary Exercise TestingCardiopulmonary Exercise TestingEquipment –AnalyzersEquipment –Analyzers

• Phase/time delayPhase/time delay•Establish lab Establish lab mean and STD mean and STD

•Proctor DN. Proctor DN. BeckBeck KC. KC. Journal Journal of Applied Physiology. of Applied Physiology. 81(6):2495-9, 1996 Dec.81(6):2495-9, 1996 Dec.

• Phase/time delayPhase/time delay•Establish lab Establish lab mean and STD mean and STD

•Proctor DN. Proctor DN. BeckBeck KC. KC. Journal Journal of Applied Physiology. of Applied Physiology. 81(6):2495-9, 1996 Dec.81(6):2495-9, 1996 Dec.

Cardiopulmonary Exercise TestingCardiopulmonary Exercise TestingEquipment – Biological QCEquipment – Biological QC

• Laboratory personnelLaboratory personnel• 1-2 individuals: 100 watts cycle or 4.0 mph 1-2 individuals: 100 watts cycle or 4.0 mph

treadmill or below their anaerobic thresholdtreadmill or below their anaerobic threshold• Establish mean and confidence limits (95% Establish mean and confidence limits (95%

CI) for VOCI) for VO2, 2, VCOVCO2, 2, VVEE

• Perform at regular intervals depending on Perform at regular intervals depending on machine use or whenever data integrity are machine use or whenever data integrity are questionedquestioned

Cardiopulmonary Exercise TestingCardiopulmonary Exercise TestingEquipment – Biological QCEquipment – Biological QC

BioQC - 100 watts

VO2

1.2

1.25

1.3

1.35

1.4

1.45

1.5

1.55

1.6

1.65

1.7

Date

VO2

+2STD

-2STD

Cardiopulmonary Exercise Testing Cardiopulmonary Exercise Testing Path of Workflow - TestingPath of Workflow - Testing

Cardiopulmonary Exercise Testing Cardiopulmonary Exercise Testing Path of Workflow - TestingPath of Workflow - Testing

• ProtocolsProtocols• Cycle or treadmillCycle or treadmill• Steady state, incremental, rampSteady state, incremental, ramp• Defined (e.g. Bruce) or ad hocDefined (e.g. Bruce) or ad hoc

• ReferenceReference• Adult: Jones, Wasserman, Blackie, Zavala, Adult: Jones, Wasserman, Blackie, Zavala,

BruceBruce• Pediatric: James, Cooper, Cumming Pediatric: James, Cooper, Cumming

• ProtocolsProtocols• Cycle or treadmillCycle or treadmill• Steady state, incremental, rampSteady state, incremental, ramp• Defined (e.g. Bruce) or ad hocDefined (e.g. Bruce) or ad hoc

• ReferenceReference• Adult: Jones, Wasserman, Blackie, Zavala, Adult: Jones, Wasserman, Blackie, Zavala,

BruceBruce• Pediatric: James, Cooper, Cumming Pediatric: James, Cooper, Cumming


• Post- testingPost- testing•Data analysis and Data analysis and selectionselection•Report reviewReport review

•DemographicDemographic•DataData•InterpretationInterpretation



• Information managementInformation management•Timely posting of the data Timely posting of the data to the medical record or to the medical record or Information system Information system (HIS/LIS)(HIS/LIS)

• Turn-around time: Turn-around time: ATS PFL Registry ATS PFL Registry Abstract AARC 2005Abstract AARC 2005

•Average TRT: <1 day (15%), Average TRT: <1 day (15%), 1-2 d (30%), 3-4 d (27%), 5-6 d 1-2 d (30%), 3-4 d (27%), 5-6 d (15%), >7 d (3%)(15%), >7 d (3%)

• Information managementInformation management•Timely posting of the data Timely posting of the data to the medical record or to the medical record or Information system Information system (HIS/LIS)(HIS/LIS)

• Turn-around time: Turn-around time: ATS PFL Registry ATS PFL Registry Abstract AARC 2005Abstract AARC 2005

•Average TRT: <1 day (15%), Average TRT: <1 day (15%), 1-2 d (30%), 3-4 d (27%), 5-6 d 1-2 d (30%), 3-4 d (27%), 5-6 d (15%), >7 d (3%)(15%), >7 d (3%)

http://mayoweb.mayo.edu/id-imagearchive/images/TPH1072538-324.jpg

What is Quality?What is Quality?What is Quality?What is Quality?

““Doing the Doing the RightRight thing” thing”

““Doing the Doing the RightRight thing thing Right!!!”Right!!!”Kathleen Sazama MD, JDKathleen Sazama MD, JD

M.D. Anderson Cancer CenterM.D. Anderson Cancer Center

““Doing the Doing the RightRight thing” thing”

““Doing the Doing the RightRight thing thing Right!!!”Right!!!”Kathleen Sazama MD, JDKathleen Sazama MD, JD

M.D. Anderson Cancer CenterM.D. Anderson Cancer Center

Carl D. Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs and Rehabilitation Associate Professor of Medicine - Mayo Clinic College of Medicine.

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