Transcript Preparing for Accreditation - London Health Sciences Centre

Preparing for Accreditation
Viki Massey, Quality Coordinator
A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London
What is Accreditation?
• Peer review assessment process
– Cyclical
– “For Cause”
– Mandatory
• Process ensures that laboratories meet
specific quality management criteria
• Gives formal recognition that the lab is
competent to carry out examinations
Ontario Laboratory
Accreditation Requirements
• Based on recognized Standards and
Regulations
– ISO 15189
– Laboratory Standards e.g. AABB, NCCLS
– Accepted Laboratory Practices
• Over 500 requirements
• “Check list” format
LLSG Implementation Plan
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Quality Coordinator
Discipline Task Teams
Quality Team
Develop Policies
GAP analysis
Map Processes
Write procedures
Quality Manual
Communicate/Educate/Train
Audit
Accreditation
Where are We?
Quality Team
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Quality policies- written
Processes- identified/mapped
Procedures –written
Quality Manual Published
Web site for documents (manuals)
Web site for referral labs
Document Management System- developed
and training scheduled
• On line Occurrence Form- developed, pilot
project completed and training scheduled
Where are We?
Discipline Task Teams
• GAP analysis
• Implementation Plan
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Pre-analytical
Analytical
Post Analytical
QC/QA
Equipment/Inventory
Facilities
Safety
LIS
• Processes mapped
• Procedures written
• Revisit requirements and close GAP
What’s Next?
• Quality Team to continue to address
QSE
• Discipline Task Teams to complete
sections of OLA requirements
• Training and implementation
• Self assessment or Peer assessment
• Accredited
Celebrate Success!
Web Sites
• Documents and Manuals
http://www.lhsc.on.ca/priv/lab/policy/index.htm
• Quality Manual
http://www.lhsc.on.ca/lab/qmanual/index.htm
• Safety Manual
• http://www.lhsc.on.ca/priv/lab/policy/safety/techaids/e
saf001.pdf
• OLA Compliance for Referral Labs
http://www.lhsc.on.ca/lab/licen/licindex.htm
• Quality Management
• http://www.lhsc.on.ca/lab/qmanage/qmsys.htm