Quality Management Plans
Purpose
The Quality Management (QM) program is designed to continually evaluate the quality of clinical services generated throughout the Laboratory of Pathology (LP). This is accomplished by monitoring and evaluating quality improvement indicators for the LP and by assisting each individual laboratory with the QM plan. The LP QM Committee oversees the program.
2024 Quality Management Plan
General Requirements
The QM program is an LP-wide initiative, and quality indicators and reports cover all clinical areas. According to the College of American Pathologists, Laboratory General Checklist, v. 6/4/2020, the laboratory must have a written quality management program to systematically ensure the quality of laboratory services. In laboratories that are part of a larger institution (e.g. a hospital), the laboratory quality management program must be integrated with the institutional program. In accordance with the CAP standards, GEN.13806, GEN.20100, GEN.20208, GEN.20310, and GEN.20316, the laboratory has a written quality management program that covers the extent of all clinical services and establishes policies and procedures to identify and evaluate errors or issues that may interfere with patient care. The QM program includes monitoring key indicators of quality in the pre-analytic, analytic, and post-analytic phases.
A list of indicators is provided in the Quality Management Plan, which is reviewed, revised, and adopted by the Quality Management Committee and Medical Director annually. Some clinical sections can opt to devise additional QM plans to monitor and document a set of relevant indicators based on their section’s regulatory standards (e.g. CAP standards for turnaround times). Indicators for individual sections’ quality reports should include pre-analytical, analytical, and post-analytical variables.
QM Plan Overview
All clinical sections are given the opportunity to report their section specific quality plans and subsequent end-of-year reports to QM Committee to share quality initiatives across clinical sections.
In addition to the annual report for these sections, General Anatomic Pathology (AP): Autopsy and Histology Laboratory’s QA Sheets, and LP and the Clinical Center’s Environment of Care will be reviewed during each QM Committee meeting. Histology is the primary clinical processing laboratory, therefore monthly monitoring of quality issues is important to report to the QM committee.
The QM program must include a process to identify and evaluate errors, incidents, and other problems that may interfere with patient care services. LP staff have several mechanisms to identify and report any quality issues or concerns: a) LP currently participates in the Clinical Center’s Occurrence Reporting System (ORS), which is a mechanism to report hospital-related incidents to Clinical Center clinicians, nurses, and allied health professionals; b) LP’s internal Incident Reports, where LP staff reports internal and/or external quality concerns to the QM committee or Clinical Manager; and c) the Clinical Center has adopted a ‘Morning Huddle’ at 08:20 each weekday morning, which is attended by each clinical department, nursing units representatives, and support services representatives and is a forum for any healthcare professional to report on concerns that may benefit from other hospital departments. The overall objective is to identify and resolve consistent or recurrent complaints or incidents that affect all LP clinical laboratories.
In order to address best practices to improve the identification, communication, and correction of errors in a timely manner, all sections establish and define any incidents/complaints to address, monitor and report to QM Committee on a monthly basis. Action items will be addressed by the QM Committee.
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