Clinical

Diagnostics
Science for a Safer World

Defining Calibration Verification, Analytical

Measurement Range (AMR), and Linearity

In this white paper, we will explore the defining variations between laboratory testing bodies, Clinical
Laboratory Improvement Amendments (CLIA) and The College of American Pathologists
(CAP). Defining calibration verification, Analytical Measurement Range (AMR), and Linearity enables
laboratories to ensure their results are accurate, timely, and reliable.

The United States, Congress passed the Clinical Laboratory Improvement Amendments in 1988
establishing authority to disseminate standards for certain laboratory testing to ensure the accuracy,
reliability, and timeliness of test results regardless of where or by whom the test is performed1.

The College of American Pathologists (CAP), began offering Accreditation Programs for
laboratories to achieve CAP accreditation and maintain regulatory compliance in the mid-1960s. At a
minimum, CAP Accreditation meets the standards set forth by CLIA, but varies in its description of key
terms and compliance criteria.

In the United States, Congress passed the Clinical

Laboratory Improvement Amendments (CLIA) in 1988,
establishing authority to disseminate standards for certain
laboratory testing to ensure the accuracy, reliability, and
timeliness of test results regardless of where or by whom
the test is performed1.

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Science for a Safer World

CLIA defines calibration as a process of testing and adjusting an instrument or test system to
establish a correlation between the measurement response and the concentration or amount of the
substance that is being measured by the test procedure3. CAP’s description diverges, as the set of
operations that establish, under specified conditions, the relationship between reagent
system/instrument response and the corresponding concentration/activity values of an analyte4.

Calibration verification, which is separate from calibration, is listed by CLIA as the assaying of
materials of known concentration in the same manner as patient samples to substantiate the
instrument or test system’s calibration throughout the reportable range for patient test results 3.
Likewise, CAP discusses calibration verification as the process of confirming that the current
calibration settings for each analyte remain valid for a test system4.

Perhaps the most important distinction between CLIA and CAP is how each entity refers to reportable
range. CLIA utilizes the term within calibration verification to refer to the span of test result values
over which the laboratory can establish or verify the accuracy of the instrument or test system
measurement response3. Conversely, CAP uses the term analytical measurement range (AMR) to
describe the range of analyte values that a method can directly measure on the specimen without any
dilution, concentration, or other pretreatment not part of the usual assay process4.

Furthermore, CAP segments AMR from calibration verification requirements through a

separate AMR verification process while CLIA captures both requirements within calibration
verification. An important concept in verifying the reportable range is that a plot of measured values
from test samples versus their actual (or expected) concentration, or relative concentrations, must be
linear within defined acceptance criteria4. As such, linearity, is defined as the relationship between the
final analytical result for a measurement and concentration of the analyte being measured2. This
distinction is relevant because a plot of analyte concentration versus measurement signal from the
instrument may not be linear.

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For laboratories to meet the minimum requirements set

forth by CLIA for calibration verification, they must perform
and document verification procedures, including analyzing
three samples in duplicate, that span the reportable range
of the assay.

Alignment between CLIA and CAP is most notable in their requirements regarding when to perform
calibration verification3,4. They are outlined as follows:

● At least every six months

● Whenever there is a complete change in the set of reagents to a new lot
● There is major preventative maintenance or replacement of critical parts of the instrument
● Quality control data shows a trend, shift, or is outside of acceptable limits
● When recommended by the manufacturer

For laboratories to meet the minimum requirements set forth by CLIA for calibration verification, they
must perform and document verification procedures, including analyzing three samples in duplicate,
that span the reportable range of the assay. The samples must include a value near the lower
limit, a midpoint value, and a value near the upper limit of the reportable range. The source of
materials, in addition to the acceptability criteria for accepting or rejecting tests during calibration
verification, are determined by the laboratory director. Patient samples may be used as long as they
sufficiently challenge the upper and lower ends of the reportable range and are of acceptable quality
and stability2. Commercial calibration verification kits are also available, which reduces the need to
source patient samples and challenge the reportable range through a more widely accepted five
levels.

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Science for a Safer World

CAP requires that each laboratory maintain a written policy defining the method, frequency, and limits
of acceptability of calibration for each instrument/test system and records of calibration verification at
their defined frequency4. If the manufacturer provides a calibration validation or verification process, it
should be followed. Other acceptable techniques include, assay of the current method calibration
materials as unknown specimens, determination that the correct target values are recovered, and
assay of matrix-appropriate materials with target values that are specific for the method4.

As previously mentioned, CAP segments AMR verification from calibration verification and requires at
a minimum that matrix-appropriate materials, which include the low, mid-, and high concentration or
activity ranges of the AMR and recovering appropriate target values, are within defined acceptance
criteria are utilized4. Records of AMR verification must be available.

As a best practice, CAP recommends that AMR verification demonstrate a linear relationship, within
defined acceptance criteria, between measured concentrations of analytes and expected values for a
set of four or more matrix-appropriate samples that cover the AMR4. AMR verification may be
accomplished through the calibration procedure when the calibration of an assay includes calibrators
that span the full range of the AMR, with low, midpoint and high values (i.e. three points) included. A
one-point or two-point calibration does not include all of the necessary points to validate the AMR 4.
CAP requires that AMR verification be performed when initially introducing a new method,
independent of the calibration process, and when the criteria for performing calibration verification is
met4. Commercially available calibration verification kits also meet CAP requirements and are
available through third-parties.

Learn more about these important practices and find out

how calibration verification can improve your laboratory’s
proficiency testing by talking with an LGC Maine
Standards’ expert at +1 800.377.9684.
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Science for a Safer World

References:

1. CLIA Brochure
2. Calibration Verification and Linearity Regulatory Requirements
3. CLIA ‘88
4. CAP 2016 Chemistry and Toxicology Checklist - CAP Accreditation Program