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quality_manual [2025/01/27 04:17] adminquality_manual [2025/02/06 06:24] (current) admin
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-=====Header===== +=====Header=====
 ^Name^Unique ID^Edition^Date of Edition^ ^Name^Unique ID^Edition^Date of Edition^
 |Quality Manual|LSSTH/A/Central/P/8.3/1| 1 | 01-03-2023|    |Quality Manual|LSSTH/A/Central/P/8.3/1| 1 | 01-03-2023|   
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 The information will include as appropriate: The information will include as appropriate:
   - The location(s) of the laboratory, operating hours and contact information;   - The location(s) of the laboratory, operating hours and contact information;
-  -  The procedures for requesting and the collection of samples;[[Test requisition procedure]] {{https://docs.google.com/document/d/1HjjBji_wm30je8T4nAxne6W3i9yGKCa9oLAJRBPcIKA/edit?usp=drive_link| Test requisition Procedure}}+  -  The procedures for requesting and the collection of samples;[[Test requisition procedure]] 
   -  The scope of laboratory activities and time for expected availability of results;   -  The scope of laboratory activities and time for expected availability of results;
   -  The availability of advisory services;   -  The availability of advisory services;
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 ===7.2.3.2 Oral requests=== ===7.2.3.2 Oral requests===
-The laboratory will have a procedure for managing oral requests for examinations, if applicable, that includes the provision of documented confirmation of the examination request to the laboratory, within a given time. [[https://drive.google.com/drive/folders/1WwogpahNgMQHALXXDk3PFEORIlOmtLk2?usp=drive_link|Procedure to manage Oral requests]] [[DP for Oral request]]+The laboratory will have a procedure for managing oral requests for examinations, if applicable, that includes the provision of documented confirmation of the examination request to the laboratory, within a given time.  [[DP for Oral request]]
  
 ===7.2.4 Primary sample collection and handling=== ===7.2.4 Primary sample collection and handling===
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 ===7.2.4.1 General=== ===7.2.4.1 General===
  
-The laboratory will have procedures for the collection and handling of primary samples. [[https://drive.google.com/drive/folders/1Tad23OEAFlS7A1R1dlKVi1eUmaFo-UzF?usp=drive_link|Sample collection manual]] [[Sample collection manual]]+The laboratory will have procedures for the collection and handling of primary samples.  [[Sample collection manual]]
 Information will be available to those responsible for sample collection. Any deviation from the established collection procedures will be clearly recorded. The potential risk and impact on the patient outcome of acceptance or rejection of the sample will be assessed, recorded and shall be communicated to the appropriate personnel. The laboratory will periodically review requirements for sample volume, collection device and preservatives for all sample types, as applicable, to ensure that neither insufficient nor excessive amounts of sample are collected, and samples are properly collected to preserve the analyte. Information will be available to those responsible for sample collection. Any deviation from the established collection procedures will be clearly recorded. The potential risk and impact on the patient outcome of acceptance or rejection of the sample will be assessed, recorded and shall be communicated to the appropriate personnel. The laboratory will periodically review requirements for sample volume, collection device and preservatives for all sample types, as applicable, to ensure that neither insufficient nor excessive amounts of sample are collected, and samples are properly collected to preserve the analyte.
  
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 ==7.2.6.1 Sample receipt procedure== ==7.2.6.1 Sample receipt procedure==
  
-The laboratory will have a procedure for sample receipt [[Procedure for sample receipt]][[https://drive.google.com/drive/folders/17vD_5aOE8zLqPGACr0P38_JQ0MuhBC5g?usp=drive_link|Procedure for sample receipt]] that includes:+The laboratory will have a procedure for sample receipt [[Procedure for sample receipt]]that includes:
   -  the unequivocal traceability of samples by request and labelling, to a uniquely identified patient and when applicable, the anatomical site;   -  the unequivocal traceability of samples by request and labelling, to a uniquely identified patient and when applicable, the anatomical site;
   -  Criteria for acceptance and rejection of samples;     -  Criteria for acceptance and rejection of samples;  
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 ==7.2.7.1 Sample protection== ==7.2.7.1 Sample protection==
-The laboratory will have procedures and appropriate facilities for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage. [[https://drive.google.com/drive/folders/1iaVE0R-T5RV1gJ9bNhXck3lKvoKG1-Qs?usp=drive_link|Documentary Procedures for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage]] [[Documentary Procedures for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage]]+The laboratory will have procedures and appropriate facilities for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage. [[Documentary Procedures for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage]]
 ==7.2.7.2 Criteria for additional examination requests== ==7.2.7.2 Criteria for additional examination requests==
 Laboratory procedures will include time limits for requesting additional examinations on the same sample. Laboratory procedures will include time limits for requesting additional examinations on the same sample.
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 ===7.3.1 General=== ===7.3.1 General===
  
- 1. The laboratory will select and use examination methods which have been validated for their intended use to assure the clinical accuracy of the examination for patient testing. {{ https://docs.google.com/document/d/1QkzqMP7idMa_3amw7eqs30m1ZNoxcUdcTGquEuF41Do/edit?usp=drive_link | Documentary Procedure for Validation & Verification of  examination methods }} + 1. The laboratory will select and use examination methods which have been validated for their intended use to assure the clinical accuracy of the examination for patient testing.
- +
  
 **NOTE:** Preferred methods are those specified in the instructions for use of in vitro diagnostic medical devices or those that have been published in established/authoritative textbooks, peer-reviewed texts, or journals, or in international and national consensus standards or guidelines, or national or regional regulations. **NOTE:** Preferred methods are those specified in the instructions for use of in vitro diagnostic medical devices or those that have been published in established/authoritative textbooks, peer-reviewed texts, or journals, or in international and national consensus standards or guidelines, or national or regional regulations.
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 ===7.3.2 Verification of examination methods=== ===7.3.2 Verification of examination methods===
 +[[DP for Verification of examination methods]]
   - The laboratory will have a procedure to verify that it can properly perform examination methods before introducing into use, by ensuring that the required performance, as specified by the manufacturer or method, can be achieved.   - The laboratory will have a procedure to verify that it can properly perform examination methods before introducing into use, by ensuring that the required performance, as specified by the manufacturer or method, can be achieved.
   - The performance specifications for the examination method confirmed during the verification process will be those relevant to the intended use of the examination results.   - The performance specifications for the examination method confirmed during the verification process will be those relevant to the intended use of the examination results.
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 Biological reference intervals and clinical decision limits will be defined, and their basis recorded, to reflect the patient population served by the laboratory, while considering the risk to patients. {{https://docs.google.com/spreadsheets/d/14EYVZZ319vrkWjglrR6lMTO9gY5H101K/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true| Biological Reference Interval}} Biological reference intervals and clinical decision limits will be defined, and their basis recorded, to reflect the patient population served by the laboratory, while considering the risk to patients. {{https://docs.google.com/spreadsheets/d/14EYVZZ319vrkWjglrR6lMTO9gY5H101K/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true| Biological Reference Interval}}
 +[[Biological Reference Interval]]
 **NOTE:** Biological reference values, provided by the manufacturer can be used by the laboratory, if the population base of these values is verified and deemed acceptable by the laboratory **NOTE:** Biological reference values, provided by the manufacturer can be used by the laboratory, if the population base of these values is verified and deemed acceptable by the laboratory
  
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 {{https://drive.google.com/drive/folders/1HoEjDwAo4eTkVXzHEW3cRDpikJcD3lPX?usp=drive_link| LJ Semi, Electrolyte, ABG}} {{https://drive.google.com/drive/folders/1HoEjDwAo4eTkVXzHEW3cRDpikJcD3lPX?usp=drive_link| LJ Semi, Electrolyte, ABG}}
 {{https://docs.google.com/spreadsheets/d/1-nPoy9GocIFE-uPgR7dhmIscpc2_u4Cq/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true| Abbott Calibration File}} {{https://docs.google.com/spreadsheets/d/1-nPoy9GocIFE-uPgR7dhmIscpc2_u4Cq/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true| Abbott Calibration File}}
 +[[Documentary Procedure for validation of examination of result]]
 a) The laboratory will have an IQC procedure for monitoring the ongoing validity of examination results, according to specified criteria, that verifies the attainment of the intended quality and ensures validity pertinent to clinical decision making. a) The laboratory will have an IQC procedure for monitoring the ongoing validity of examination results, according to specified criteria, that verifies the attainment of the intended quality and ensures validity pertinent to clinical decision making.
  
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 ==7.3.7.3 External quality assessment (EQA)== ==7.3.7.3 External quality assessment (EQA)==
- 
-{{https://docs.google.com/document/d/1BzHs1ThpIlcTcWFsVWP9M-ZH1mta6zg8GxWjFm-UHuI/edit?usp=drive_link|7.3.7.3 Procedure for Storage, Preparation, Analysis, Result submission, RCA & Modification in EQAS}} 
  
 {{https://drive.google.com/file/d/1xqAM5lQqi_sbLSHGOd-uRU_Q_12nHv9w/view?usp=drive_link| EQAS Evaluation Criteria}} {{https://drive.google.com/file/d/1xqAM5lQqi_sbLSHGOd-uRU_Q_12nHv9w/view?usp=drive_link| EQAS Evaluation Criteria}}
  
 {{https://drive.google.com/drive/folders/1Ooqpnp3e8XUepdRu39WEJSbR960ozkEK?usp=drive_link| RIQAS Results}} {{https://drive.google.com/drive/folders/1Ooqpnp3e8XUepdRu39WEJSbR960ozkEK?usp=drive_link| RIQAS Results}}
 +[[Procedure for Storage, Preparation, Analysis, Result submission, RCA & Modification in EQAS]]
 a) The laboratory will monitor its performance of examination methods, by comparison with results of other laboratories. This includes participation in EQA programmes appropriate to the examinations and interpretation of examination results, including POCT examination methods. a) The laboratory will monitor its performance of examination methods, by comparison with results of other laboratories. This includes participation in EQA programmes appropriate to the examinations and interpretation of examination results, including POCT examination methods.
  
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 ==7.4.1.2 Result review and release== ==7.4.1.2 Result review and release==
  
-Results will be reviewed and authorized prior to release. The laboratory will ensure that authorized personnel review the results of examinations and evaluate them against IQC and, as appropriate, available clinical information and previous examination results. Responsibilities and procedures for how examination results are released for reporting, including by whom and to whom, will be specified.{{https://docs.google.com/document/d/12V1VO7GpjHiwejVVpq6KjYYXb4uS_6flw7-tfHMWMv8/edit?usp=drive_link|Procedure for review & release of reports}}+Results will be reviewed and authorized prior to release. The laboratory will ensure that authorized personnel review the results of examinations and evaluate them against IQC and, as appropriate, available clinical information and previous examination results. Responsibilities and procedures for how examination results are released for reporting, including by whom and to whom, will be specified.[[Procedure for review & release of reports]]
  
 ==7.4.1.3 Critical result reports== ==7.4.1.3 Critical result reports==
  
-{{https://docs.google.com/document/d/1eIJ7Q0NoeO6lga92Gta9-jlC-ERzU5fa/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true|Critical values}}{{https://docs.google.com/document/d/1nqDQwiSYg6gbMLmVhjP51DZwi13jqchU/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true|Format Critical value register}}+ [[7.4.1.3_critical_values|]]{{https://docs.google.com/document/d/1nqDQwiSYg6gbMLmVhjP51DZwi13jqchU/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true|Format Critical value register}}
  
 When examination results fall within established critical decision limits: When examination results fall within established critical decision limits:
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 === 7.4.2 Post-examination handling of samples === {{ https://docs.google.com/document/d/1U0GBhJRDIfjrt5WAh3MOM6mDulwYAFah2F_NLIGZOOk/edit?usp=drive_link | Documentary Procedures for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage === 7.4.2 Post-examination handling of samples === {{ https://docs.google.com/document/d/1U0GBhJRDIfjrt5WAh3MOM6mDulwYAFah2F_NLIGZOOk/edit?usp=drive_link | Documentary Procedures for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage
- }}+ }}[[Documentary Procedures for securing patient samples, ensuring sample integrity and preventing loss or damage during, handling, preparation and storage]]
  
 The laboratory will specify the length of time samples are to be retained following examination and the conditions under which samples are to be stored. The laboratory will ensure that after the examination, the The laboratory will specify the length of time samples are to be retained following examination and the conditions under which samples are to be stored. The laboratory will ensure that after the examination, the
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 ====7.5 Nonconforming work==== ====7.5 Nonconforming work====
  
-The laboratory will have a process for when any aspect of its laboratory activities or examination results do not conform to its own procedures, quality specifications, or the user requirements (e.g. equipment or environmental conditions are out of specified limits, results of monitoring fail to meet specified criteria). The process will ensure that: {{ https://docs.google.com/document/d/1jbMgfHFwHZB3wfQDqZFGZj4n0DgRO3ki/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true | Documentary Procedure for Identification and Control of Non-Conformities }}+The laboratory will have a process for when any aspect of its laboratory activities or examination results do not conform to its own procedures, quality specifications, or the user requirements (e.g. equipment or environmental conditions are out of specified limits, results of monitoring fail to meet specified criteria). The process will ensure that: {{ https://docs.google.com/document/d/1jbMgfHFwHZB3wfQDqZFGZj4n0DgRO3ki/edit?usp=drive_link&ouid=105726813387160537689&rtpof=true&sd=true | Documentary Procedure for Identification and Control of Non-Conformities }} [[Documentary Procedure for Identification and Control of Non-Conformities]]