CORE LABORATORY QA PROGRAM. Why have a QA Program? JCAHO Standard PI.1.10: The organization collects data to monitor its performance. Standard PI.2.10:

Slides:

Advertisements

Similar presentations

Developing a Comprehensive POCT Competency Assessment Program

Advertisements

CAP/POCT 2003 Carol Riley-Hunte, RRT Senior Education Specialist Bayer HealthCare.

The COLA Quality Management Systems Program. 2 Introduction COLA Quality Management Systems Program An ISO 15189:2003 Accreditation Program.

Medication Management

QUALITY CONTROL IN HEMATOLOGY

Dr. Hamda Qotba, M.D,MFPH,FFPH

Conducting Patient Safety Rounds with Staff. First Steps Set the stage –Unit and Hospital Leadership Support –Identify a “champion(s)” for each unit where.

Quality Data for a Healthy Nation by Mary H. Stanfill, RHIA, CCS, CCS-P.

A Quality Improvement and Patient Safety project for Kaleida Health April 2010.

Risk Management / CQI Nutr 564: Management Summer 2002.

1 1 Chapter 1 Specimen Management Professor A. S. Alhomida Disclaimer The texts, tables and images contained in this course presentation (BCH 376) are.

EVOLVING ASPECTS OF QUALITY ASSURANCE IN LABORATORY TESTING Patrick St.Louis, PhD, Dip Clin Chem Sainte-Justine Hospital Montreal, Canada Congress SCPC,

1 The aim…. ‘to enable assessors to objectively assess a laboratory’s compliance with the new standards’

This teaching material has been made freely available by the KEMRI-Wellcome Trust (Kilifi, Kenya). You can freely download, adapt, and distribute this.

Drug Utilization Review (DUR)

Laboratory Personnel Dr/Ehsan Moahmen Rizk.

Dr Samah Kotb Lecturer of Biochemistry 1 CLS 432 Dr. Samah Kotb Nasr El-deen Biochemistry Clinical practice CLS 432 Dr. Samah Kotb Nasr.

1 Assessment: Audits. Assessment: Audits - Module 9 2 Learning Objectives At the end of this activity, you will be able to: Develop a process to prepare.

Department of Patient RelationsMeasuring to Achieve Patient Safety General Information Session.

The Diagnostic Testing Process

Developing a Quality Management System Viki Massey Quality Coordinator A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London.

Laboratory Management - 1

This teaching material has been made freely available by the KEMRI-Wellcome Trust (Kilifi, Kenya). You can freely download,

Quality Assurance in the clinical laboratory

Module 5 Postanalytical Phase of Laboratory Testing.

Ireland Army Community Hospital CLSI Quality Series.

QUALITY ASSURANCE Shree Baboolal 12 th February, 2005.

Unit #7 - Basic Quality Control for the Clinical Laboratory

Introduction to the Principles of Laboratory Medicine Photos by Theresa Kristopaitis, MD.

Performance Improvement in Microbiology Laboratory

JCAHO UPDATE June The Bureau of Primary Health Care is continuing to encourage Community Health Centers to be JCAHO accredited. JCAHO’s new focus.

1 Accreditation and Certification: Definition  Certification: Procedures by which a third party gives written assurance that a product, process or service.

“Crosswalking” Hospitals for a Healthy Environment (H2E) & the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) Catherine Zimmer,

National Patient Safety Goals 2011

Occurrence Reports. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs.

This teaching material has been made freely available by the KEMRI-Wellcome Trust (Kilifi, Kenya). You can freely download, adapt, and distribute this.

Implementing QI Projects Title I HIV Quality Management Program Case Management Providers Meeting May 26, 2005 Presented by Lynda A. O’Hanlon Title I HIV.

PSO Overview for Executives (Presenter) (Date) Center for Patient Safety Toolkit for PSO Participation, Section 4.

Quality Assurance Positive Outcomes for Negative Events Quality Assurance monitors operational systems:Pre-analytical AnalyticalPost-analytical Tools Used:

P1 External Quality Assessment (EQA) Proficiency Testing.

CHAPTER 1 The Nursing Process and Drug Therapy Mosby items and derived items © 2007, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.

Step What happens?. Who is responsible? Procedures needed?

Phlebotomy Positive Patient ID

Dispensary and Administration Site Information Presentation.

Biochemistry Clinical practice CLS 432 Dr. Samah Kotb Lecturer of Biochemistry 2015 Introduction to Quality Control.

VERIFICATION OF BLOOD COLLECTION SYSTEM GIAN LUCA SALVAGNO, MD, PhD University of Verona, Italy.

Quality control & Statistics. Definition: it is the science of gathering, analyzing, interpreting and representing data. Example: introduction a new test.

Department of Patient RelationsMeasuring to Achieve Patient Safety Safety Observer’s Orientation.

CBER Common Problems on Source Plasma Inspections Judy Ellen Ciaraldi BS, MT(ASCP)SBB, CQA(ASQ) CBER, OBRR, DBA September 16, 2009.

Office of Human Research Protection Georgia Health Sciences University.

Module Three: Identifying your Patient in SIS. Introduction – Search for 1 st T Specimen The Search for 1 st T Specimen screen is used to access your.

Pre- analytic Analytic Post- analytic  S pecimen collection  Specimen transport  Specimen quality  Result accuracy  Clerical.

Effectiveness of risk management process towards error reduction in the laboratory at Sakra World Hospital AUTHORS: Dr. Shabnam Roohi Mr. Deepak Agarkhed.

Soarian Orders Update: ► Type and Screen ► Crossmatch ► Transfusions Implementation Date: Nov 6, 2012 Oct 2012.

Clinical Utility of EQA Dr. Angela Amayo UON27/11/2008.

Department of Pathology and Laboratory Medicine Strong Memorial Hospital SMS Visit Registration: Register patient visits using FLOWCAST Log: Log all tests.

RT Erasmus. Introduction Pathology laboratories regularly inspected by various accreditation bodies such as CPA, SANAS, CAP which use ISO standards. Many.

Introduction to Quality Assurance. Quality assurance vs. Quality control.

Quality Assurance.

Lesson 1-9 Quality Assessment.

Governing Body QAPI 2013 Update for ASC

Measuring to Achieve Patient Safety

Unit #6 - Basic Quality Control for the Clinical Laboratory

What is the Clinical Laboratory?

QUALITY MANAGEMENT Suzanne Kamel-Mohamed PhD, MBA, MT (ASCP) Associate

Complying With CLIA Competency Requirements

Shaimah Al-Failakawi Al Amiri Hospital Laboratory Quality Manager

Quality Assurance in Clinical Trials

Postanalytical Phase of Laboratory Testing

Presentation transcript:

CORE LABORATORY QA PROGRAM

Why have a QA Program? JCAHO Standard PI.1.10: The organization collects data to monitor its performance. Standard PI.2.10: Data are systematically aggregated and analyzed. Standard PI.3.10: Information from data analysis is used to make changes that improve performance and patient safety and reduce the risk of sentinel events.

Why have a QA Program? CLIA ’88 Standard : a-The laboratory must establish written policies and procedures for ongoing mechanism to monitor, assess and correct problems identified in the general laboratory systems requirements. b-The general laboratory systems quality assessment must include a review of the effectiveness of corrective actions taken to resolve problems, revisions of policies and procedures necessary to prevent recurrence of problems. c-The laboratory must document all general laboratory systems quality assessment activities.

Monitor Operational Systems Pre-analytical: test orders, collection, transportation, preparation for analysis Pre-analytical: test orders, collection, transportation, preparation for analysis Analytical: test analysis Analytical: test analysis Post-analytical: availability of results (TAT), test reports, transmission of results, comments and interpretations, notification of critical results Post-analytical: availability of results (TAT), test reports, transmission of results, comments and interpretations, notification of critical results

Quality Assurance (QA) Monitors Taking A Pulse Monitor all operational systems. Define a target. Identify failures. Revise, delete, add monitors as identified. Multi-departmental, as needed.

Taking Pulses Pre-analytical 1-Requisition entry monitor- 1% of reqs entered in each area by each shift. 2-AM Phlebotomy TAT- time last floor is drawn for both rounds and % patients drawn. 3-Unlabeled/mislabeled specimens- overseen by hospital committee. 4-Urine Cancellations- shared specimens between Microbiology and Core Lab.

Taking Pulses Pre-analytical 5-Phlebotomy Error Rate- number of PSN events. 6-Phlebotomy Scripting- quarterly measure of phlebotomist competency. 7-Pneumatic Tube Performance- monitor tube failures. 8-Phlebotomy Cancellations- % AM and POE requests cancelled due to action by phlebotomy.

Taking Pulses Analytical TAT; Process to Result: 1-AM Blood Drawing- CMP,H8ED,PTT 2-Core Lab Stat- CMP,H8ED, PTT 3-Core Lab Superstats- Heme-8, PTT 4-Stats from Weinberg- H8ED,PTT 5-Pre-Op Superstats- PTT,K,HCG

Taking Pulses Analytical TAT; Process to Result: 6-Weinberg Outpatients- H8ED,H8,Diff, Plt Estimates 7-Critical Care Lab- K 8-Adult ED Lab- CMP,ABG,HCG, Troponin,H8ED,PTT, UDip, Rapid Strep 9-Affiliate Stats- CMP,H8ED,PTT 10-Inpatient Routines- CMP,H8ED,PTT 11-Outpatient Routines- CMP,H8ED,PTT

Taking Pulses Post-analytical 1-Critical Action Value Read Back- read back of result and patient name. 2- Critical Action Value TAT- time of initial result to initial call to clinician. 3- BMS Specimen Cancellations- % specimens cancelled. 4- Antibiotic Cancellations- number of test without dosage information.

Taking Pulses Post-analytical 5-Coagulation Patient Safety- number of patients with 3 consecutive CAV PTT 6-Communication Errors- add-on errors, result errors, etc. 7-PDS Result Review- comments, interpretations, reference ranges, etc. 8-Patient Result Review- accuracy of results in patient’s medical record.

Performance Improvement Changes/improvements to current services. Failures/problems identified. Compliants from customers. QA Monitor identified failure. Implementation of new services.

Performance Improvement PDSAPlanDoStudyAct

PDSA Plan: Set a goal- what is the aim, what are we trying to accomplish? Focus Group- who should be on the Team to make PDSA happen? Measures- what data needs to be collected, who will collect data, how is data obtained, what is the frequency of data collection? Choose one small change- make a change in current process.

PDSA Do: Document what actually happened after a change was made, including any problems or unexpected outcomes. Document Observations- are the data telling us what we need to know?

PDSA Study: Complete analysis of data- what have we learned? Compare data analysis to expected outcomes- did original outcomes improve?

PDSA Act: Change Successful- how will the change be implemented, how is the change communicated? Implement QA Monitor to ensure change remains effective.

PDSA Act: Change Unsuccessful- what was the source of failure, how should we proceed (next steps)? Implement next PDSA cycle. Implement next PDSA cycle.