Continuous Quality Improvement
Patient Care Laboratory Peer Review Program
The Laboratory Peer Review Program follows the guidelines in the JHML Certification checklist. This checklist was developed to include the CLIA regulations as well as Joint Commission and CAP guidelines.
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)
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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