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Preparing for Accreditation

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

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Preparing for Accreditation

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  1. Preparing for Accreditation VikiMassey, Quality Coordinator A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London

  2. 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

  3. 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

  4. LLSG Implementation Plan • Quality Coordinator • Discipline Task Teams • Quality Team • Develop Policies • GAP analysis • Map Processes • Write procedures • Quality Manual • Communicate/Educate/Train • Audit • Accreditation

  5. Where are We? Quality Team • 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

  6. Where are We? Discipline Task Teams • GAP analysis • Implementation Plan • Pre-analytical • Analytical • Post Analytical • QC/QA • Equipment/Inventory • Facilities • Safety • LIS • Processes mapped • Procedures written • Revisit requirements and close GAP

  7. 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

  8. Celebrate Success!

  9. 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/esaf001.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

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