Personal commentaryExternal quality assessment (EQA) in gynaecological cytology: radical rethinking required?

Accepted for publication 19 February 1999
THE PAST
The value of EQA in pathology, including proficiency testing in gynaecological cytology, has been the subject of much recent lively debate^1–6. In summary, the proven role of EQA in the monitoring of personal performance and ability is still uncertain. Furthermore, its potential to prevent critical incidents remains purely speculative. Also, whether EQA would be better replaced, for some or all professional groups, by other methods of quality assurance is unknown. Similarly, whether EQA can justify the considerable professional time, effort and expense involved has not been resolved.  

THE PRESENT

Not surprisingly, events at Kent & Canterbury Hospitals abruptly halted much of the debate about the foregoing issues⁷. Indeed, as a direct consequence of this and other incidents, the NHS Executive stipulated unilaterally that EQA is now mandatory within the NHS Cervical Screening Programme (CSP)⁸ and reinforced the necessity for all qualified laboratory staff to participate^8–10. A surprise, however, was the Executive's enlightened comments on EQA. First, and of greatest significance, that the principal function of EQA in pathology is to improve standards and advance quality through personal education. Second, that EQA should be seen to complement other QA systems for the early identification of potential problems which might affect patient care. Third, that the identification of individual poor performance through EQA will be exceptional and in essence is a by-product of the basic educational exercise. The latter conclusion was drawn, as far as one can judge, from previous experience with the NHS Breast Screening Programme (NHSBSP) EQA.  

THE FUTURE—PERSONAL SUGGESTIONS FOR OPEN DEBATE

     

The Yorkshire slide exchange external quality assessment (EQA) scheme

A slide circulation scheme measuring cervical screening performance of individual cytologists in 15 laboratories in Yorkshire Regional Health Authority is described. The advantages and disadvantages are compared with the current National Proficiency Testing (NPT) scheme. The results indicate that a slide circulation scheme can be successfully used in cervical cytology external quality assessment (EQA). Levels of participation are better than those currently achieved by regional variations of the NPT scheme, and the use of laboratory consensus in the selection of scoring slides appears to be no less valid than the use of a pre‐selected slide pool assembled by an expert panel. The volume of data accumulated in one round is considerably greater than that achieved by proficiency testing and the educational value is regarded as high. However, the scheme is very time consuming for participants and consequently expensive for laboratories. The lack of external supervision increases the risk of unfair practices within individual laboratories. Because of these problems, Yorkshire has now switched to an NPT scheme.     

Quality assurance in cervical cancer screening

Objectives. to examine the effectiveness of introducing External Quality Assessment (EQA) into all laboratories which undertake gynaecological cytopathology. to assess pathologists and cytotechnologists regularly for their competence to screen cervical smears, regardless of their standing in the laboratory hierarchy or their experience of gynaecological cytopathology.
Methods. Each participant was asked to screen and report on 10 slides during a 2 h period. the assessment was carried out by a facilitator under the direction of a specially appointed EQA Committee. A maximum score of 20 points was awarded for a completely correct set of answers. A minus score was awarded for a missed abnormal smear. Seventeen pathology laboratories in North West Thames Regional Health Authority participated; 146 cytologists were assessed.
Results. A pilot and four rounds of EQA have been completed and a total 5350 smears examined. Out of 2568 dyskaryotic (abnormal) smears screened, 0.7% were not identified correctly. of the 146 cytologists taking part in the assessment, 95% achieved a score of 17 or more. Three participants were identified who did not reach an acceptable level of competence and appropriate remedial action was taken.
Conclusion. the EQA scheme detected unacceptable levels of performance which can be quickly rectified. Participation of 100% has been maintained on a voluntary basis, and 4 years experience of the scheme confirms that a very high standard of screening prevails in the Region. the study illustrates that voluntary self-regulation is acceptable in the NHS, and the introduction of similar EQA schemes on a national scale will go a long way to establishing confidence in the cervical cancer screening programme.     

O-8Detection of human telomerase gene (TERC) amplification in cervical neoplasia: a retrospective study of 50 patients with normal smears or mild or moderate dyskaryosis

Circulation E of the North West non gynaecological cytology EQA scheme was split into two with one half receiving conventional glass slides and the other half receiving digital images supplied by the SlidePath company over the web. More of the participants eligible participated in the slide half (43/65) than the digital half (17/41).
Similar results were obtained for seven out of ten of the scoring cases and for both the educational cases. However for one case eight of the digital participants could not obtain the images over the web. In the remaining three scoring cases the digital participants were less good at obtaining the correct answer compared to the slide based participants. The use of this virtual microscopy has shortened the circulation length considerably. The digital participants complained about the speed the digital slides appeared on their computers and whilst most agreed that this is the way forward they are still uncomfortable with their performance being marked on their digital submissions. Delegates will have the opportunity of viewing still images taken for each case from this circulation.     

Posters. P7 Development of a web‐based resource pack for cytology training officers

The NHSCSP Cervical Cytopathology Training Log and accompanying Workbook are central to the education and training of new recruits in cytology laboratories in the UK. These are currently available only in paper format and do not fully address the needs of training officers and trainees in Wales. A web‐based resource pack, which complements the NHSCSP training documents, has been developed by the Welsh Cytology Training School to address these problems. The pack consists of the following sections and has recently been posted on the Welsh intranet:

• ? guide for training officers;
• ? teaching aids, including handouts and ‘powerpoint’ tutorials;
• ? image library;
• ? worksheets; and
• ? competency sheets.

The electronic format allows for instant updating and simultaneous availability to all training officers in Wales. It has been devised in an effort to standardize the training of new cytology recruits in laboratories throughout Wales, thereby ensuring that all new trainees receive the same high‐quality education and training wherever they are employed. CPD modules in gynaecological and non‐gynaecological cytology are being developed. Samples from the resource pack will be presented.     

Quality assurance of human papillomavirus testing

The External Quality Assurance (EQA) in medical microbiology in the Czech Republic is well organized. It is coordinated by the Accreditation Department of the Centre of Epidemiology and Microbiology (AD-CEM) of the National Institute of Public Health in Prague. Since 1993 when the first samples were sent out the number of programmes and participating laboratories has been rapidly increasing. EQA for Human papillomavirus (HPV) has been available since 2000. As has been shown for other programmes, the EQA for HPV has proved to be useful, helping to improve the accuracy of analyses and contributing to the standardization of methods of HPV DNA testing. EQA for HPV has been well received by routine laboratories, demonstrated by a high number of these institutions voluntarily participating in EQA.     

ABC3 Part I: a review of the guidelines for terminology,classification and management of cervical cytology in England

J. H. F. Smith ABC3 Part I: a review of the guidelines for terminology, classification and management of cervical cytology in England The provision of guidance on cytology reporting and evaluation, first outlined in 1995 with the publication of Achievable Standards, Benchmarks for Reporting, and Criteria for Evaluating Cervical Cytopathology (ABC), and subsequently revised and expanded in a second edition in 2000, has been pivotal to the success of the National Health Service Cervical Screening Programme (NHSCSP), ensuring that standards are upheld, and that rigorous evaluation and quality assurance take place. In the last decade, major changes to the NHSCSP, notably the adoption of revised age ranges and screening intervals for all women in England, implementation of liquid‐based cytology and, most recently, the decision to introduce high‐risk human papillomavirus (HR‐HPV) testing for triage of low‐grade and borderline (equivalent to 'atypical') cytological abnormalities and test of cure after treatment of cervical intraepithelial neoplasia (CIN) determined that an updated version of ABC was required. The third edition of ABC recommends adoption, with minor modification, of the revised British Society for Clinical Cytology terminology and provides guidance on the management of abnormal cytology results linked to this terminology taking account of HR‐HPV testing. To accommodate these changes, expanded result codes, which are electronic codes used to transfer management information to central computers for follow‐up, call and recall of individual women, have been developed. Further guidance on specimen adequacy is also provided. Revised performance indicators are described and explained in a separate article by R. Blanks in this issue of Cytopathology. All the changes in ABC3 are designed to support the mission statement of the NHSCSP that ‘the objective of cervical screening is to reduce cervical cancer incidence and mortality by screening with a high sensitivity for the detection of CIN2 or worse, whilst maintaining a high specificity’.     

The future of cytology laboratories

1. NHSCSP Annual Review 2006. Patnick J (ed.). Sheffield, UK, NHSCSP; 2007.
2. Dowie R, Stoykova B, Crawford D. et al . Liquid-based cytology can improve efficiency of cervical smear readers: evidence from timing surveys in two NHS cytology laboratories. Cytopathology 2006; 17(2):65–72.
3. Williams AR. Liquid-based cytology and conventional smears compared over two 12-month periods. Cytopathology 2006; 17(2):82–85.
4. Gregory LS, Dudding N, Smith JHF. The impact of introducing liquid based cytology into a routine screening laboratory. Cytopathology 2006; 17(S1):24.
5. Lord Carter of Coles. Report of the Review of NHS Pathology Services in England 2006. Department of Health.
6. Kardos TF. The focal point system: focal point slide profiler and focal point GS. Cancer 2004; 102(6):334–39.
7. Biscotti CV, Dawson AE, Dziura B. et al. Assisted primary screening using the automated ThinPrep Imaging System. Am J Clin Pathol 2005; 123(2):281–87.
8. Eltoum IA, Roberson J. Impact of HPV testing, HPV vaccine development and changing screening frequency on national Pap test volume: projections from the National Health Interview Survey (NHIS). Cancer 2007; 111(1):34–40.
9. Kohli M, Ferko N, Martin A. et al. Estimating the long-term impact of a prophylactic human papillomavirus 16/18 vaccine on the burden of cervical cancer in the UK. Br J Cancer 2007; 96(1):143–50.
10. Franco EL, Cuzick J, Hildesheim A, de Sanjose S. Chapter 20: issues in planning cervical cancer screening in the era of HPV vaccination. Vaccine 2006; 24 (Suppl. 3):S171–S177.
11. Peto J, Gilham C, Fletcher O, Matthews FE. The cervical cancer epidemic that screening has prevented in the UK. Lancet 2004; 364(9430):249–56.     

External Quality Assessment for Tuberculosis Diagnosis and Drug Resistance in the European Union: A Five Year Multicentre Implementation Study

BackgroundExternal quality assurance (EQA) systems are essential to ensure accurate diagnosis of TB and drug-resistant TB. The implementation of EQA through organising regular EQA rounds and identification of training needs is one of the key activities of the European TB reference laboratory network (ERLTB-Net). The aim of this study was to analyse the results of the EQA rounds in a systematic manner and to identify potential benefits as well as common problems encountered by the participants.MethodsThe ERLTB-Net developed seven EQA modules to test laboratories’ proficiency for TB detection and drug susceptibility testing using both conventional and rapid molecular tools. All National TB Reference laboratories in the European Union and European Economic Area (EU/EEA) Member States were invited to participate in the EQA scheme.ResultsA total of 32 National TB Reference laboratories participated in six EQA rounds conducted in 2010–2014. The participation rate ranged from 52.9% - 94.1% over different modules and rounds. Overall, laboratories demonstrated very good proficiency proving their ability to diagnose TB and drug-resistant TB with high accuracy in a timely manner. A small number of laboratories encountered problems with identification of specific Non-tuberculous Mycobacteria (NTMs) (N = 5) and drug susceptibility testing to Pyrazinamide, Amikacin, Capreomycin, and Ethambutol (N = 4).ConclusionsThe European TB Reference laboratories showed a steady and high level of performance in the six EQA rounds. A network such as ERLTB-Net can be instrumental in developing and implementing EQA and in establishing collaboration between laboratories to improve the diagnosis of TB in the EU/EEA.     

O-12The use of control samples in the PAPANICOLAOU technical external quality assessment scheme

Technical external quality assessment (TEQA) in Wales is based on NHSCSP publication 19, which sets out policy and procedures for the scheme. The purpose of EQA is to sustain and improve the quality of patient care by promoting a high standard of performance. Following the introduction of liquid base cytology (LBC) technical limitations, particularly in assessing counterstaining, have been noted. LBC provides the means to address these limitations - As part of a development plan for TEQA in Wales, a control sample procedure was introduced to the scheme. A pooled control sample was composed, containing residual material from six 'matched' negative samples, re-suspended in collection fluid. Aliquots of this sample were distributed for processing and staining, to the 13 laboratories registered with the scheme. The slides produced were assessed at a scheduled TEQA assessment in accordance with the standard criteria. Initial overall scoring for these control samples produced acceptable levels of staining for 12 of the laboratories - one laboratory produced a marginal score. Repeat distributions have shown maintained or improved results. This method provides a prospective quality assessment tool, which counters the emphasis on slide selection and eliminates potential selection bias, whilst introducing consistency and improving comparability across participant laboratories. The method may also prove helpful in identifying technical inconsistencies such as equipment or handling errors that may occur during sample processing prior to or during staining. The control process, which is now used routinely in the Welsh TEQA scheme; is considered complimentary to, and not a replacement for, the selection process established in NHSCSP #19. However, we feel that this development could be considered as a new initiative in the National TEQA scheme. The control process is applicable to all LBC systems in current use.     

P‐15COMPARISON OF RESULTS FOR A NON‐GYNAECOLOGICAL CYTOLOGY EQA SCHEME

The problems encountered with a glass slide circulation are legion but timely circulation is a major problem and is an inherent deficiency of our Non‐gynaecological EQA scheme. This applies not only to consultants but also to specialist registrars (SpRs) and technical staff that are not formally included in the circulation list. In 2005 only 7 technical staff and 4 out of 47 SpRs took part on a formal basis, their participation being dependant on access to slides during their cytology attachment. The results for the 2005 circulation have been analysed and despite the small numbers of participating technical staff and SpRs their answers concur with the consultant body. To address the issues of timeliness and circulation problems a pilot teaching set has been developed by SlidePath into a virtual microscope web based circulation and sent to all SpRs in our region. They have recorded their answers and been given immediate access to the consensus consultant opinion with illustrations of follow up histology. A questionnaire was completed to evaluate the scheme. The facility of immediate feedback of consultant consensus is particularly pertinent to the educational element of the scheme and use of virtual microscopy addresses the issue of timely circulation. If further funding was made available technical staff could also be given the opportunity to try this web‐based circulation.     

美国国家植物基因组计划资助情况分析

美国植物基因组计划（National Plant Genome Initiative,NPGI）于1998年正式启动,该计划在美国国家科学基金会（NSF）的支持下,成立了由美国农业部（USDA）、能源部（DOE）、国立卫生研究院（NIH）、国家科学基金会（NSF）、科学与技术政策办公室（OSTP）、管理与预算办公室（OMB）和美国国际开发署（USAID）等组成的植物基因组跨机构工作组（Interagency Working Group on Plant Genomes,IWG）,IWG每5年制定一项5年计划来指导协调基因组研究工作。对1998～2009年期间,美国国家科学基金会（NSF）资助国家植物基因组计划（NPGI）的目标、经费、项目变化情况进行了分析,以期得到某些启示和借鉴。     

An audit of cervical cytology in HIV‐positive women

O. E. O. Hotonu, J. Hussey, M. S. T. Basta, V. Wadehra, P. Cross and M. L. Schmid
An audit of cervical cytology in HIV‐positive women Objective: To investigate whether a cohort of human immunodeficiency virus‐positive (HIV+) women were having annual cervical cytology as recommended by the English National Health Service cervical screening programme (NHSCSP) guidelines. Methods: An audit of cervical cytology in an HIV+ cohort of 187 women by obtaining their last cervical cytology result and recall from local cytology services. Results: Of the 187 women in the audit, two were ineligible, leaving 185 women, 167 (90.3%) of whom were aged 25–64 years and eligible for screening. Of the 185 women, 126 (68.1%) had a cytology history, 50 (27%) had never had cervical cytology and nine (4.9%) had inadequate details to ascertain whether or not they had a cytology history. Of the 126 with a cytology record, 34 (27%) had a current cytological abnormality, which was low grade in 25 (19.8%) and high grade in nine (7.1%). Among women aged 25–64 years attending the clinic, these percentages were significantly higher than expected for England as a whole (P < 0.001). Of 126 women with a cytology record, 29 (23%) were overdue for their recall date and of these the previous test was abnormal in 14 (48.3%). Cytology tests were taken within the community setting in 61 (48.4%), whereas 65 (51.6%) were seen either at an HIV sexual health clinic or were under colposcopy follow‐up. Of 91 women with negative cytology only 50 (54.9%) were recommended for repeat in 12 months. Conclusion: This audit demonstrates a high rate of cytological abnormalities among HIV+ women compared with the screening population at large. Implementation of NHSCSP guidelines has been difficult and requires improved care pathways between HIV clinics, primary care and laboratories.     

Liquid‐based cytology: is this the way forward for cervical screening?

Liquid-based cytology (LBC) is currently being marketed as an alternative methodology to replace the conventional PAP smear in cervical cytology. A substantial body of literature exists in support of LBC, some of which is at least partially sponsored by product manufacturers. The majority of published literature in support of LBC employs Bethesda reporting terminology. In this study we have analysed published raw data and presented this in NHSCSP terminology. Claims relating to sensitivity, specificity and smear adequacy have then been considered with reference to this data. Our analysis of existing data does not support the nationwide implementation of LBC at present. Further studies are recommended in order to evaluate the place of this technology within the NHSCSP.     

Risk of significant gynaecological pathology in women with ?glandular neoplasia on cervical cytology

A. Talaat, D. Brinkmann, J. Dhundee, Y. Hana, J. Bevan, R. Irvine, S. Bailey and R. Woolas
Risk of significant gynaecological pathology in women with ?glandular neoplasia on cervical cytology Objective: To review the risk of pre‐invasive and invasive gynaecological pathology in women referred with cervical cytology reporting ?glandular neoplasia. Methods: Review of the case notes of all women referred with cervical cytology reported as ?glandular neoplasia between January 1999 and December 2008 at two UK hospitals: Portsmouth Hospitals NHS Trust and Queen Mary’s Hospital Sidcup. The category of ‘borderline nuclear change in endocervical cells’, result code 8 according to the national health service cancer screening programme (NHSCSP), was excluded from the study. Results: A total of 200 women were identified using the hospitals’ pathology computer systems. Invasive carcinoma was found in 48 women (24%): 28 endocervical adenocarcinomas, eight squamous cell carcinomas (SCC), ten endometrial and two ovarian adenocarcinomas. Pre‐invasive neoplasia was found in 115 (57.5%), including 14 cervical glandular intraepithelial neoplasia (CGIN), 31 cervical intraepithelial neoplasia (CIN) grade 2/3 and 70 concomitant CGIN and CIN2/3. CIN1/HPV was found in 25, simple endometrial hyperplasia in three and no histological abnormality in three. Thirty‐four (70.8%) of 48 invasive carcinomas (of which 23 were endocervical adenocarcinomas) were in asymptomatic women investigated for abnormal cytology. Fourteen of 34 (41.4%) of those with ?glandular neoplasia thought to be endometrial were CGIN or CIN2/3. Colposcopic appearances were normal in 47.6% of women with pure cervical glandular neoplasia (adenocarcinoma or CGIN) compared with 12.8% with squamous cell lesions (CIN2/3 or SCC): P = 0.0001. Thus, colposcopy was more sensitive for detecting squamous cell abnormalities than their glandular counterparts. Although cervical adenocarcinomas are less amenable to prevention by screening than cervical SCC, in our study cervical cytology predominantly detected these abnormalities at their early asymptomatic stages. Conclusion: At least CIN2 was found in 81.5% in women referred with cervical cytology reporting ?glandular neoplasia. A thorough evaluation of the whole genital tract is needed if colposcopy is negative.     

An audit of colposcopy appointment processes in women with abnormal cervical cytology

C. Kietpeerakool, M. Manopunya, P. Phuprasertsak, T. Jaijit and J. Srisomboon An audit of colposcopy appointment processes in women with abnormal cervical cytology Objectives: This study was conducted to audit the waiting times and default rates of colposcopy using the standard requirements of the National Health Service Cervical Screening Programme (NHSCSP) 2004 guidelines. Methods: The records of 291 women with abnormal cervical smears referred to the colposcopy clinic between January and December 2008 at Chiang Mai University Hospital, Thailand, were reviewed. Results: The proportion of women with abnormal cervical smears of any grade receiving colposcopy appointments within 8 weeks of referral (96.9%) achieved the minimum requirements (≥ 90%). However, the waiting times for women with high‐grade squamous intraepithelial lesion, glandular cell abnormality and invasive lesion smears were longer than recommended by NHSCSP guidelines. The default rate of 15.8% in this study was slightly higher than recommended by the guidelines (< 15%). Having no health insurance, being known to have HIV infection and waiting times longer than 4 weeks were independent predictors of default from an initial colposcopy appointment. Conclusion: The waiting times for colposcopy among women with high‐grade smear abnormality and the default rate failed to meet standard requirements. Designing an effective protocol for colposcopy appointment processes is warranted.     

Development of a technical external quality assurance scheme in non‐gynaecological cytology in UK

Technical external quality assurance (EQA) schemes are well established for histopathology and cervical cytology but, to date, sadly lacking for diagnostic cytology (DC). This timely review redresses the balance by describing the development and evaluation of a technical EQA scheme for DC available to the UK, Europe and beyond.     

Food safety through the meat supply chain

Food poisoning in humans can be caused by many different bacterial genera. While the incidence of food poisoning in England, Wales and Scotland from Salmonella has reached a plateau, there has been an increase in the incidence from Campylobacter. The incidence from Escherichia coli O157:H7 rose to 1997 but declined slightly in 1998 (data from the Public Health Laboratory Service and the Scottish Centre for Infection and Environmental Health). This organism has a high virulence in humans and a very low infective dose. Infection can produce a wide range of responses, including death. The low infective dose presents a major threat. The organism is relatively heat-sensitive and the cooking of food products to achieve a centre core temperature of 70 degrees C for 2 min is sufficient to destroy it. It is relatively acid-tolerant and will survive for several weeks at pH 4.2. Several foodstuffs, as well as water, have been implicated in world-wide outbreaks. The E. coli O157:H7 food-borne outbreak in Lanarkshire in 1996 led to 21 fatalities. The Pennington Group report, issued in April 1997, reported on the circumstances leading to this outbreak, the implications for food safety and the lessons to be learnt. Four areas covered within the Pennington Group report specific to meat hygiene are reviewed in this paper. On-farm practices must ensure the presentation of clean animals for slaughter. There is a requirement for the development and introduction of risk assessment techniques based upon Hazard Analysis of Critical Control Points in abattoirs, and the Meat and Livestock Commission (MLC) is producing a manual for use by the abattoir sector. The Pennington report stated that there was a need for research into the potential use of end-process treatments such as steam pasteurization. The MLC is involved in evaluating such a system. Meat production premises and butchers' shops in England are introducing HACCP through an MLC scheme funded by the Department of Health. At the point of consumption, food safety is improved by the provision of practical guidelines regarding the handling of meat and meat products. These are distributed at retail outlets and communicated to secondary schools via MLC's educational publications.     

Finnish cytotechnologists' views on the competencies of newly graduated biomedical scientists in clinical cytology

Objective

This study asked 40 cytotechnologists for their views on the competencies of newly graduated biomedical scientists in clinical cytology during the national conference of the Finnish Association of Cytotechnologists in November 2015.

Methods

The questionnaire mainly consisted of statements that were scored on a five‐point Likert‐scale, where 1 was not important and 5 was very important. It covered five sections of clinical cytology: sampling and techniques, gynaecological screening, non‐gynaecological screening, safety and quality management, and miscellaneous.

Results

Of the 40 delegates approached to complete the questionnaire, 37 (92.5%) agreed. Respondents felt that important sampling and technique competencies were specimen fixation, with a mean score of 4.9 out of 5.0, types of specimens (4.7), Papanicolaou smear collection (4.7), Papanicolaou smear request information (4.7) and evaluation of specimen sufficiency (4.6). Less important competencies were examining FNAs (2.0) and nasopharyngeal specimens (2.2). The respondents had many expectations about how education in cytology could be developed, for example more theoretical lessons, more practice in microscope use, and consistent criteria for training and cooperation between cytology laboratories and universities of applied sciences.

Conclusions

The cytotechnologists who took part in our survey expected newly graduated biomedical scientists to have basic competencies in cytology. These were sampling and techniques, laboratory safety and quality management, specimen adequacy and identifying normal cells taken during gynaecological screening. They were also keen to develop education in cytology.     

The BSCC Code of Practice – exfoliative cytopathology (excluding gynaecological cytopathology)

Exfoliative cytopathology (often referred to as non‐gynaecological cytology) is an important part of the workload of all diagnostic pathology departments. It clearly has a role in the diagnosis of neoplastic disease but its role in establishing non‐neoplastic diagnoses should also be recognised. Ancillary tests may be required to establish a definitive diagnosis. Clinical and scientific teamwork is essential to establish an effective cytology service and staffing levels should be sufficient to support preparation, prescreening, on‐site adequacy assessment and reporting of samples as appropriate. Routine clinical audit and histology/cytology correlation should be in place as quality control of a cytology service. Cytology staff should be involved in multidisciplinary meetings and appropriate professional networks. Laboratories should have an effective quality management system conforming to the requirements of a recognised accreditation scheme such as Clinical Pathology Accreditation (UK) Ltd. Consultant pathologists should sign out the majority of exfoliative cytology cases. Where specimens are reported by experienced biomedical scientists (BMS), referred to as cytotechnologists outside the UK, this must only be when adequate training has been given and be defined in agreed written local protocols. An educational basis for formalising the role of the BMS in exfoliative cytopathology is provided by the Diploma of Expert Practice in Non‐gynaecological Cytology offered by the Institute of Biomedical Science (IBMS). The reliability of cytological diagnoses is dependent on the quality of the specimen provided and the quality of the preparations produced. The laboratory should provide feedback and written guidance on specimen procurement. Specimen processing should be by appropriately trained, competent staff with appropriate quality control. Microscopic examination of preparations by BMS should be encouraged wherever possible. Specific guidance is provided on the clinical role, specimen procurement, preparation and suitable staining techniques for urine, sputum, semen, serous cavity effusion, cerebrospinal fluid, synovial fluid, cyst aspirates, endoscopic specimens, and skin and mucosal scrapes.