Virtual assessment, training, and evaluation of clinical laboratory technologists amidst peak Covid-19 pandemic: An observational study

Medical technologists are considered a neglected group when it comes to academic interventions. We developed and implemented an educational intervention and assessment for the technologists based on an online questionnaire as a pre-test consisting of questions related to knowledge (n=5), attitude (n=3), and practices (n=4) of daily internal quality control (QC) monitoring via Google Docs survey tool. This study served multiple purposes. It allowed keeping the technologists engaged during the peak of the COVID-19 pandemic while also improving the knowledge, attitude, and practices about the internal quality control using Bio-Rad Unity Real Time (URT) QC software. Subjects were graded based on the scores they received out of 100 (0-60 = poor; 61-79 = good; 80-100 = excellent). Training materials, i.e., a set of 5 videos every week via e-mail, were circulated. A voice-over PowerPoint presentation was also shared for easy comprehension. This activity was repeated after one month. A post-test was administered to assess the improvement. The study results show significant improvement in the technologists' performance after the intervention.


Summary
Medical technologists are considered a neglected group when it comes to academic interventions. We developed and implemented an educational intervention and assessment for the technologists based on an online questionnaire as a pre-test consisting of questions related to knowledge (n=5), attitude (n=3), and practices (n=4) of daily internal quality control (QC) monitoring via Google Docs survey tool. This study served multiple purposes. It allowed keeping the technologists engaged during the peak of the COVID-19 pandemic while also improving the knowledge, attitude, and practices about the internal quality control using Bio-Rad Unity Real Time (URT) QC software. Subjects were graded based on the scores they received out of 100 (0-60 = poor; 61-79 = good; 80-100 = excellent). Training materials, i.e., a set of 5 videos every week via e-mail, were circulated. A voice-over PowerPoint presentation was also shared for easy comprehension. This activity was repeated after one month. A post-test was administered to assess the improvement. The study results show significant improvement in the technologists' performance after the intervention.
Klju~ne re~i: kontrola kvaliteta, tehni~ar, COVID-19, Unity Real Time, laboratorija, klini~ka hemija The utility of medical technologists in the laboratory has been well-established since the 1930s (1). Specifically, in clinical pathology, medical technologists play a much more important role than anatomical and other aspects of pathology (1). A quality medical laboratory is an important part of the healthcare system, and quality control (QC) is one of the most pivotal pillars of laboratory testing (2,3). Historically, technologists are often neglected in terms of training and academic progression (4).
Dissemination of new knowledge to medical technologists is an integral part of laboratory practice (5). Educational interventions in the field of laboratory management have proven to be effective. However, the effect of intervention disappears over time unless additional interventions are provided to sustain performance (6). The management of internal QC of the College of American Pathologists (CAP) accredited Clinical Chemistry laboratory at the Aga Khan University Hospital (AKUH) has been evaluated to promote an efficient and comprehensive process of internal QC management. Bio-Rad Unity Real Time (URT) QC software is used to monitor internal QC. The URT software is configured and consolidated in the hospital's Integrated Laboratory Management System (ILMS). URT software provides statistical review, documentation, and analysis across all facets of the laboratory. It is networkable to include all areas of the laboratory. The software analyses the QC data for laboratory staff to complete their QC tasks as required and also allows for external peer-group analysis (7). However, substantial differences and deficiencies were encountered repeatedly on review by the sectional QC coordinator.
The Coronavirus Disease 2019 (COVID-19) impacted healthcare delivery at all levels (8). Specific focus and resources have been applied to diminish the effects on physicians, patients, and healthcare systems with little attention to delineating and addressing the issue of medical technologists (9).
This study aims to assess the knowledge and practice of medical technologists by online QC monitoring using Bio-Rad Unity Real Time Software (URT) and to keep the technologists engaged during the peak of the COVID-19 pandemic.
The study was performed at the Section of Clinical Chemistry, Aga Khan University Hospital (AKUH), Karachi, Pakistan, from June to September 2020. The study participants comprised three tiers of clinical scientists working in the laboratory, ranging from the senior-most cadre of charge technologists, senior technologists, and technologists. A total of 20 lab technologists were randomly selected with equal gender distribution, and the functional grades covering different tiers of laboratory staffing are enlisted in Table I.
An online questionnaire-based pre-test consisting of questions related to knowledge (n=5), attitude (n=3), and practices (n=4) of daily internal QC monitoring via URT was administered via Google Docs survey tool as shown in Table II. Electronic consent for participation was acquired at the start of the survey. The study was approved by the sectional and departmental Quality Management Committee, Department of Pathology and Laboratory Medicine, AKUH (CA-01/2020). One laboratory medicine consultant and a QC in charge at the section designed the questionnaire which was validated as a pilot with 2 postgraduate trainees who were part of this initiative team. Keeping the hectic bench side work schedule that had vastly exalted during the peak of the pandemic and inherent time constraints in mind, the questionnaire was structured in such a way that it did not consume more than 15 minutes of a participant's time. Subjects were graded based on the scores they received out of 100 (0-60 = poor; 61-79 = good; 80-100 = excellent).
Training materials, i.e., a set of 5 videos every week via e-mail, were circulated. A voice-over PowerPoint presentation was also shared for easy comprehension. This activity was repeated after one month. A post-test was administered to assess the improvement.
Statistical analysis was performed using Microsoft Excel 2013 and Statistical Package of Social Sciences (SPSS) version 19. Frequency and percentages were calculated for gender and designation. Paired Samples t-test was performed to evaluate whether there is statistical evidence that the mean difference between paired observations between pretest and post-test with an intervention administered between the two time points is significantly different. Two-tailed p-values < 0.05 were considered significant.
The mean pre-test score + standard deviation (SD) was 42.5+14.82. The grades received in pretest were Excellent (n=0), Good (n=1), Poor (n=19).  The mean post-test score + SD was 81.5+15.31. The grades received in the post-test were Excellent (n=15), Good (n=1), Poor (n=4). A statistically significant difference was noted between the pre and post-test results (p<0.001). The results and the differences in pre-and post-test performance are detailed in Table III.
The results of our study demonstrated significant improvement in medical technologists' performance post-intervention. Medical technologists are essential members of the overall healthcare provision team. The knowledge of modern laboratory techniques is volatile and rapidly evolving (5). Periodic educational interventions are necessary to ensure better QC and also equip technologists with the latest information in their specific field. When it comes to academic growth and development, medical technologists are a neglected group amongst healthcare professionals (4). It is prudent to design educational interventions specific to medical technologists to meet their precise educational requirements.
The possible reasons for the poor pre-test performance can be lack of preparation for the virtual assessment, lack of hands-on activity earlier, especially for the junior cadre staff, and lack of periodic assessments on the usage of URT to keep them updated. The intervention based on synchronous and asynchronous activities proved fruitful, as depicted by the post-test scores using the same questionnaire. This highlights the utility of virtual platforms to supplement total quality management in the clinical laboratory.
Though COVID-19 affected all occupations with financial and emotional difficulties, medical technologists suffered from unprecedented challenges and fear due to the pandemic, including dissatisfaction about the measures taken by the management during the outbreak (10).
Hence, it is imperative to engage the historically neglected group with such interventions. This study provided an opportunity to engage medical technologists in pedagogy during challenging times while also improving the overall educational status as well as the laboratory's QC. In this regard, the administration of this education and evaluation intervention served a twin purpose during extraordinary times for healthcare professionals.
There were certain limitations to this study. The sample size was small and was also carried out at a single institute. However, this study was a first-of-itskind attempt to develop a refresher course for laboratory technologists in the region. The web-based assessment offered an inexpensive, self-administered tool with a rapid turnaround time and a high level of participation. Periodic conduction of such interventions will result in engagement, academic improvement, and better QC by the technologists hospitalwide.
The transition to synchronized online teaching and learning during the COVID-19 pandemic paved the path with a promising potential for the future of medical education for the overly occupied clinical laboratory scientists. This learning method is user-friendly, time-saving, and effective, as demonstrated by the results of this study.

Authors' Contribution
Sibtain Ahmed conceived the idea, designed the project, methodology, and research plan, searched the literature and drafted the manuscript. Muhammad Abbas Abid performed the data analysis and  write-up of the work. Farhat Jahan developed the questionnaire, Google Forms, data collection and contributed to the intervention phase by conducting educational activities. Tomris Ozben provided supervision to the project and contributed to the discussion of the results and review and amelioration of the draft. All authors participated in the data discussion and revised the manuscript. All the authors have accepted responsibility for the entire content of this submitted manuscript and approved submission.

Conflict of interest statement
All the authors declare that they have no conflict of interest in this work.