2004 Annual Report
1.0. Executive Overview
The Kenora-Rainy River Regional Laboratory Program is a MOH-LTC-funded Corporation reporting to a Board of Directors comprising of six (6) C.E.O.’s representative of the laboratories in the Corporation.
Since Incorporation, the Program has evolved into a strong regional entity in Ontario.
The Program continues to act as a service provider offering well-researched information to assist laboratories in an ever changing environment. In addition, the Laboratory Director provides diagnostic and clinical consultations.
The Program has developed a comprehensive Quality Management System for the laboratories, which includes a number of key indicators to assist in measuring current performance against accepted benchmarks.
Our commitment to education continues to be an annual success responsive to the needs of medical and technical staff throughout this region and beyond. It is hoped that the scope will expand to include clinical placement training of 3rd year MLT students in our facilities to ease future recruitment concerns.
The Program provides a collaborative environment, which facilitates the development of discipline-specific manuals and consensus achievement for equipment methodologies.
To ensure the laboratories continue to provide the high level of patient care. the Program continues to monitor external quality assurance testing. This year has seen fewer errors than ever before confirming the commitment to technical excellence.
Our Corporation continues to work with other laboratory service providers, lending leadership in regional initiatives.
2.0. Detailed Description of Activities
2.1. Ontario Laboratory Accreditation (OLA)
OLA continues to remain in the forefront of the Program’s endeavors. Using the Quality Manual and Total Quality Management Manual as developed in 2003, laboratories performed their first self-assessment measuring their quality program to the OLA requirements. The Program facilitated group meetings to determine major and minor non-conformances and identify gaps in processes.
As an outcome of the review, revisions and additions were made to the manuals and recommendations were acted on to assist in the implementation of TQM in each facility. This project remains ongoing.
Newsletters were developed to introduce the vision of Total Quality Management to the staff as sections of the manual were introduced.
The self-assessments show a regional compliance of 80% – 90%. Since the selfassessment, regional laboratories have been notified of plans for an OLA peer assessment in 2005.
The consultant has been requested to perform a mock assessment in each facility to identify non-conformances prior to the actual Accreditation visit
2.2. Discipline-Specific Manuals
The Program continued in this collaborative with the development of regional discipline specific manuals. Final drafts are under review at each facility before implementation. These include Serology, Urinalysis, Coagulation, Hematology and IT.
2.3. Equipment
Three (3) Chemistry analyzers in the region were highlighted for replacement in 2005. The Program, in collaboration with the Northshore District Laboratory Program (NDLP), prepared an RFP to seek critical information.
Deliberation on the responses included meetings and teleconferences with the vendors, Laboratory Director, Laboratory Managers and C.E.O.’s. It was recommended by the Program Consultant and Laboratory Director to consider the purchase of the Vitros 350 analyzer should capital be available in 2005.
In the region, two (2) of five (5) hospitals have purchased MTS technology for use in Transfusion Medicine. It is hoped DME funding will offset the capital costs.
2.4. Education
This year, the Program worked in collaboration with the Ontario Society of Medical Technologists to present a Fall Conference. It was well received regionally and interest
has been expressed to repeat the venue in the future. Complete details are in Appendix B.
The Laboratory Director continued to offer onsite education to a variety of health care providers. Topics included Lactate and Osmolality testing as well as blood utilization. Site dependant, physician interest remains variable in amount. Their reasons for failing to take advantage of offered education are varied.
2.5. Onsite Visits
In addition to monthly teleconferences with the Laboratory Managers, onsite visits have occurred by the Laboratory Director and Program Consultant a minimum of four (4) times at each site this year. Appendix C. These exchanges continue to strengthen regional interaction and collaborative ventures between sites. In addition, this interaction creates an environment for laboratories to participate openly, actively and fairly using a consensus process regarding products and services. Onsite travel amounts to approximately 12,200 km, equaling 200 travel hours.
2.6. Recruitment
The Program remains responsive to the concerns of future recruitment in the region. Discussions took place with Cambrian College (Sudbury) and Red River College (Winnipeg) to investigate opportunities for the provision of clinical placement and training for MLT students.
At this time, the laboratory licenses have been forwarded to Red River College for their review to determine if the current laboratory menu meets the criteria listed in the student’s curriculum. If acceptable, the region will prepare to accept two (2) students as early as September 2005.
2.7. EQA
The performance of the laboratories as it relates to QMP-LS external quality assurancetesting continues to be monitored.
Participation in EQA and the Program’s inter-laboratory monthly QC program has assisted in identifying problems in analytical performance not always detectable by internal quality assurance activities.
The Program notes improvement from last year in both Microbiology and TransfusioMedicine. Overall regional performance in 2004 has shown improvement in EQA testing. Appendix D1, D2, D3, & D4,
2.8. Laboratory Services Plan
The Regional Coordinating Committee continues to have three (3) representatives from the KRR RLP. Information from these meetings flows to the North network to assist in broad spectrum healthcare planning.
3.0. Goals for 2005
3.1.
Develop a regional antibiogram to assist physicians with empiric treatment of infected patients.
3.2.
Promote Osmolality testing in the region.
3.3.
Assist the laboratories in the peer accreditation process schedule March/April 2005.
3.4.
Examine current referral practices to determine if efficiencies can be found.
3.5.
Develop a regional Chemistry and Specimen Collection manual.
3.6.
Provide clinical instruction on the use of eGFR – MDRD for the early detection of renal disease and monitoring of the illness.
3.7.
Promote compliance with the National Kidney Disease Education Program (NKDEP) recommendations for laboratory services including proficiency goals.
3.8.
Assist the Board in examining the Corporate By-Laws.
