| Quality essentials and cited non-conformities | Number of facilities with non-conformities | |||
| Q1 | Q2 | Q3 | Q4 | |
| Documents and records |
| |||
| SOPs not signed by relevant Lab personnel | 12 | 10 | 8 | 0 |
| Organization and personnel | ||||
| No organogram | 10 | 7 | 5 | 3 |
| No staff folders, job description, certificates of training and other relevant documents not found in staff folders | 11 | 9 | 5 | 6 |
| Internal and external quality control | ||||
| No internal quality control records and L-J chart not plotted | 20 | 16 | 12 | 10 |
| Non-participation in at least one External quality control CD4 count | 20 | 1 | 0 | 0 |
| Internal audit was not conducted by facility quality officer | 16 | 13 | 10 | 9 |
| No CAPA documentation of poor external quality control and internal quality control performance | 10 | 5 | 4 | 0 |
| Inventory control system | ||||
| Tally cards not updated for lab reagents and consumables | 14 | 6 | 4 | 3 |
| Ambient and refrigerating temperature not monitored | 14 | 0 | 2 | 4 |
| Equipment | ||||
| Operators' equipment daily maintenance charts not updated and reviewed | 19 | 6 | 6 | 5 |
| Facilities and safety | ||||
| PEP guideline with designated contact person not available | 10 | 5 | 2 | 4 |
| Signage/bench top references | ||||
| No food, no drink or no food, no drink picture format not t displayed | 10 | 8 | 10 | 9 |
| Unauthorized person not allowed sign not displayed | 11 | 7 | 10 | 9 |
| No separate sample collection/phlebotomy area | 10 | 7 | 5 | 5 |