Quality Improvement Unit (QIU)

Policy

In an effort to promote OHRPP program accountability and optimize processes, the UCLA Office of the Human Research Protection Program monitors and measures the effectiveness and quality of its human research protection program. Based on the results of these measurements, necessary plans and improvements to the program are considered for implementation.

Overall Description and Goals

The primary purpose of the Quality Improvement Unit (QIU) is to provide post-approval monitoring and internal oversight, education and training to research professionals to assure that all OHRPP operations effectively support UCLA’s mandate to protect the rights and welfare of research participants. This includes compliance with institutional policies and procedures, and applicable federal, state and local laws pertaining to the protection of human subjects in research. The program consists of the following components:

• On-site Review of Human Research Studies
• Post-Approval Quality Assurance (QA) and Quality Improvement (QI)
• Handling of Complaints and Concerns About Human Subjects Research or the OHRPP
• Review and Assessment of OHRPP Operations and Procedures
• Assessment of IRB Members and OHRPP Staff
• Review of Research Participants’ Survey of Study Experience

Specific Components of the OHRPP QI Unit

Post Approval Monitoring of Human Research Studies

Routine (not for-cause) and for-cause reviews of on-site research records provide measures of investigator understanding and compliance with laws, regulations and policies governing the conduct of human subject research. These reviews also provide a measure of the effectiveness of investigator resources, quality and timeliness of Investigator/IRB communication, and access to and awareness of OHRPP policies, education and available training opportunities.

For example, the QIU might evaluate the following as indications that research teams understand and execute their responsibilities:

• Adequacy of resources to conduct the study (number of studies per PI; complexity of protocols)
• Qualifications and training of key personnel
• Regular communication between the PI and research team about the protocol and updates
• Enrolled subjects met the eligibility criteria
• Consent is being obtained appropriately
• Access to on-site and electronic research data is controlled
• Study drug is controlled and dispensed according to UCLA Research Drug Information Pharmacy policy
• Proper assessment of events and deviations in order to understand relevance and determine appropriate reporting

Review findings are provided to the IRBs for review and follow up as needed. Follow up may include a corrective action plan and/or a recommendation for additional education and training. For additional information see OHRPP Guidance and Procedure: Post Approval Monitoring.

Post-Approval Quality Assurance and Quality Improvement

An important element of quality assurance review of clinical research activities is performed by the QIU through the processing and review of all post-approval reports submitted to the IRB. Research study reports include adverse events, protocol deviations and incidents, as well as any updated study safety information. This review enables the IRBs to identify potential significant new risks, re-evaluate the risks and benefits of the research, ensure that adequate safeguards are in place, and determine whether subjects should be informed of new information.

Complaints and Concerns Regarding Human Subjects Research or the OHRPP

The QIU is responsible for the processing, review and inquiry into all complaints and concerns that are brought to the attention of the OHRPP/IRB regarding human subjects research conducted at UCLA and/or by UCLA OHRPP personnel. Complainants may include, but are not limited to subjects (past, present or potential), subject family members, investigators, other research staff, or any person with concerns.

Review and Assessment of OHRPP Operations & Procedures

Review and Assessment is based upon:

• Feedback from investigators regarding satisfaction with the IRB review process and services.
• Audits of the IRB files to measure compliance with OHRPP and other institutional policies and procedures, as well as applicable federal, state and local laws.
• Statistics showing IRB activities and timelines
• Feedback on educational and training programs and materials.

Assessment of IRB Members and OHRPP Staff

IRB Members are assessed on an annual basis based upon meeting participation, preparedness, quality of review, and knowledge of UCLA policies and federal regulations. Individual educational needs are identified and forwarded to the OHRPP Education Program.

OHRPP Staff receive annual evaluations, constructive feedback, and individual educational needs are identified with their supervisor.

Internal Audits:
The QIU routinely conducts internal audits of OHRPP/IRB records. These audits involve sampling records based on particular themes, for example whether certain standard sections of the informed consent form (such as injury or costs) are included when expected and without unauthorized alteration, or that management plans from the Conflict of Interest Review Committee have been accounted for in the IRB review, and that relevant changes are made to the IRB application and to the consent form.

The sampling of records is representative of the five IRBs and allows the QIU to assess the rate of compliance or proper documentation of exceptions.

The QIU may also conduct for cause audits of OHRPP/IRB records.

Results and feedback of audits are provided to the Director, Associate/Assistant Directors and OHRPP staff for further action, which is in turn monitored and revisited.

Statistics:
OHRPP leadership receives regular reports for monitoring turnaround times and volumes. These are analyzed for indications that a team or individual staff members may not be meeting benchmarks for various types of actions.

OHRPP leadership is collaborating with Office of Research Information Systems to validate the quality of data in reports and to experiment with different metrics in order to better understand the flow of business, the research portfolio of the University and internal productivity.

UCLA also participates in a group of the 5 University of California campuses with health systems which aims to harmonize data collection and analysis in order to identify best practices and develop cross-campus benchmarks.

Research Participants’ Survey of Study Experience

Direct feedback from research participants provides an opportunity for the OHRPP to review and assess subjects’ considered opinions and assessment of their experience at UCLA and whether they believe that their rights and welfare were protected in accordance with federal regulations and institutional policies governing the conduct of human subject research.

Annual Reporting

The OHRPP QIU prepares an annual report of its activities. The report includes an evaluation of the previous year’s activities and describes planned improvement initiatives. The report will be forwarded to the Human Research Policy Board and the IRB Chairs and members for review and comment.