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Continuous Quality Improvement Program
Patient Care Laboratory Peer Review Program
All areas of the laboratory are assessed for compliance with all pertinent regulations as well as J.H.M.I. (Johns Hopkins Medical Institutions) Standards. In addition, overall management of laboratory operations are reviewed to assess compliance with Good Laboratory Practice and to detect areas which could benefit from re-engineering practices to improve laboratory utilization and meet clinical needs.
AREAS OF REVIEW
Personnel
- Leadership
- Human Resources, Job descriptions
- Staffing
- Training/orientation
- Competency/credentialing
- Continuing Education
- Staff Conflict Policies
Documentation
- Management of Information/ back-up
- Record Retention
- Test Performance Tracking Data, Patient Test Management
- Worksheets, Requisitions Reports
- Equipment,QC, QA, PI records
- Confidentiality
- Supervisory Review
- Standard Operation Procedure Manual
- All procedures, protocols, policies governing the pre-analytical,
analytical, post-analytical process; human resources; safety; quality
assurance; ethics
- Reflects current Laboratory practice
- Changes in Methodologies
- Technical Supervisory Review
- References
- Established Format (NCCLS-PDF)
Proficiency Testing
- Validation of participation in a CLIA approved accredited program
for all regulated analytes.
- If no Standardized Program exists for the analyte, documentation of
how the Lab has assured accuracy and reliability.
- Records of Proficiency Testing / Technical Supervisory Review /Documentation
of Corrective actions.
Quality Control (QC)
- Documented Performance
- Appropriate Levels/ Frequency
- Statistical Evaluation
- Review as per Policy Corrective Action
Quality Assurance (QA)
- Documented Leadership, Staff Communications
- Documented Review of Personnel, Records, QC, Proficiency Testing,
Corrective Actions
- Method Evaluation/ Validation/ Review
- Clinical Correlation
Performance Improvement Initiatives (PI)
- Tie in with Departmental Initiatives
- Written Initiatives
- Bench Marks
- Monitoring Data
- Evaluation: How does this Improve Performance?
Safety
- Management of Laboratory Environment ( Chemical Storage, space, biological
safety cabinets, fume hoods, eye wash, sprinkler system,etc.)
- Personnel safety (fire, protective gear, training, MSDS)
- Surveillance, prevention and control of Infection. (training, practice)
Operations
- Work flow
- Overall management
- Laboratory utilization
- Clinical relevancy, redundancy of testing
- Lab Licensure
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