2005 Annual Report
Mission Statement
The Program provides a community of cooperation and education to enhance the sharing of resources to improve quality and maximize the efforts of Regional Laboratory Services in providing a high level of services to our member hospitals and communities.
Values
Integrity
We act honestly, ethically and impartially at all times.
Professionalism
We encourage self-improvement and aim for scientific excellence.
Quality Assurance
We ensure that all our work is carried out in accordance with recognized standards.
Teamwork
We recognize the participation, initiative and cooperation of all the laboratories as being essential to our success.
Client Focus
We strive to recognize and anticipate the needs of clients by working openly and cooperatively to meet those expectations.
Board of Directors
Robert Wilson – Atikokan General Hospital
Wade Petranik – Dryden Regional Health Centre
Mark Balcaen – Lake of the Woods District Hospital
Janice Mullin – Red Lake Margaret Cochenour Memorial Hospital
Wayne Woods – Riverside Health Care Facilities, Inc.
Roger Walker – Sioux Lookout Meno-Ya-Win Health Centre
Organizational Chart
Appendix A.
Executive Summary
Medical Laboratories are in a state of on-going change. In addition to meeting the requirements laid out by Ontario Laboratory Accreditation (OLA) they have been impacted by the transformation to newer diagnostic tools responsive to the changes in medical practice.
The Program’s main objective this year was to assist 6 Laboratories in implementing a Quality Management System that was developed in 2003-2004. Extensive work and collaboration took place to meet accreditation. The Program is pleased that each facility was awarded a five-year certificate from OLA. From this, the Program has grown to meet future demands and has evolved into an enabler of change by focusing on continuous quality improvement and outcome measures. This will ensure that the laboratories can meet the current and future standards as laid out by accreditation.
The Program is pleased to announce the appointment of Dr. J. Kerry MacDonald, Laboratory Director, to the OLA Advisory Panel. This Committee reviews and adopts operational policies as well as approves laboratory accreditation recommendations. In addition, Anna Robinson, Regional Consultant, has agreed to fill the position vacated by Andrew Skene on the OHA Laboratory Advisory Committee. The mandate for this Committee is to work on human resource strategies as it relates to Laboratory Medicine.
These appointments help to create an environment that promotes excellence in performance and accountability as well as champion for training and development of the MLT workforce to meet organizational needs.
As of November 1st, 2005, the services of the Program were contracted for 1 year to assume defined administrative responsibilities of the Dryden Regional Health Centre Laboratory.
Despite the pressures to meet Accreditation requirements, the Program continues to meet its other goals. The commitment to education, regional manuals, equipment and quality assurance is on going. To transform Laboratory diagnostics into better health care for our clients we must continue to be responsive to the needs of medical and technical staff throughout this region.
Detailed Description of Activities
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Ontario Laboratory Accreditation (OLA)
In December, 2005 each facility in this region received notification of an OLA peer assessment scheduled for spring, 2006. Accreditation is a mandated process by which an organization demonstrates that it meets the standards established by professional regulators.
In preparation for the Peer Assessment, the Program Consultant performed simulated assessments to familiarize each laboratory in the process as well as identify non-conformances. Each on site visit was approximately 2-3 days as each process was examined to ensure compliance. A written report was supplied to each facility identifying areas of concern.
Following the OLA peer assessment the Program collaborated with each laboratory to address those non-conformances identified. The Program further developed and expanded on the comprehensive and systematic quality management system for laboratory implementation to meet the accreditation requirements.
Assisting in continual quality improvement of the Laboratories’ overall performance shall be a permanent objective of the Program. The aim is to provide a solution that would bring more assistance, resources and expertise to facilities in the Kenora-Rainy River Region that may be out of reach for these laboratories due to fiscal limitations and shortage of human resources.
The Program Consultant also provides service as a certified Assessor for OLA. In this capacity she has been called upon to act as a lead evaluator in two facilities this year. In addition, with the assistance of Tanya Knopf, Laboratory Manager Lake of the Woods Hospital, they performed a simulated assessment of Thunder Bay Regional Hospital to prepare that Laboratory for a peer assessment in December 2005. It is the intent of the Laboratory Director to take the OLA Assessor course in 2006.
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Discipline-Specific Manuals
The Program continues to work with the Laboratories in the development of regional discipline specific manuals. To date Quality Management, Transfusion Medicine, Microbiology, Serology, Urinalysis and Information Technology manuals have been reviewed and implemented. Draft manuals for Hematology, Coagulation, Chemistry and Specimen Collection await review before implementation. These manuals are generic in nature allowing each laboratory the opportunity to manipulate the documents to the culture of their facility while adhering to the researched procedures that meet specific requirements.
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Equipment/Test Menus
Through a series of RFPs developed by the Program the laboratories have been successful at acquiring a variety of new instrumentation. These include 6 MTS systems for Transfusion Medicine, 3 Vitros 350 Chemistry analyzers, 5 Osmometers, 1 Vitek Microbiology analyzer and 1 LH 500 Hematology analyzer.
Site dependant, Point of Care testing expanded to include hCG in the Emergency Unit and an I-Stat in a satellite health care facility.
The Program examined population needs and national recommendations. As a result, eGFR reporting was added for the early detection of Chronic Kidney Disease. This region led the way in Ontario for providing this result. Site dependant, lactate testing was also implemented.
Work is on going to determine the feasibility and practicality of performing lipid profiles and thyroid studies on site versus referral to an external testing facility.
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Education
This year the Program hosted its Annual Fall Symposium in Fort Frances Ontario. Complete details Appendix B.
The venue provided an afternoon workshop followed by 2 full days of thought provoking speakers for Laboratorians to enhance their competency skills, knowledge and experience. Like past Symposiums this has allowed them to freely share their own knowledge and expertise while discussing problems and issues with their peers. Again the Program ensured vendor representation as part of the mix allowing for the exchange of information and development of consumer relationships that are critical to our operations.
The Laboratory Director continued to provide onsite education to a variety of health care providers. The topics included Lactate, Osmolality, eGFR and Fetal Fibronectin testing. Facility dependent he is also an active member of the Point of Care and Transfusion Medicine Committees.
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Onsite Visits
In addition to monthly teleconference meetings with the Laboratory, on site visits have occurred in the region by the Laboratory Director and/or the Laboratory Consultant 24 times. Appendix C. The Laboratory Managers also meet with the Laboratory Director and Program Consultant bi-annually for 2-day sessions to deal with strategic planning, new initiatives and complex projects. These meetings provide guidance to the Laboratories in order to meet the clinical needs and established goals in each facility.
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Recruitment
In 2005 the Board approved of sending Program representatives to the National Congress that will be hosted in Winnipeg, June 2006. It is to that end that the Program hopes to promote the region by renting booth space for use to highlight career opportunities within our own communities. It is also hoped that this tool will advertise the Annual Fall Symposium by attracting additional delegates and vendor support.
Negotiations are on-going with Cambrian College in Sudbury to investigate opportunities for the provision of clinical placements and training for MLT students. It is unfortunate that progress was not made with Red River College as they remained unresponsive to our offer. The Program Consultant shall also act on behalf of the Region by participating as a member on the OHA Laboratory Advisory Committee. In this role she will participate with peers in the development of a provincial health human resources strategy.
Quality Assurance
The Program has expanded its role as it relates to quality assurance. It continues to monitor QMP-LS testing as a result of External quality assessment (EQA). In addition it has provided tools to measure quality with an aim of quality improvement in Laboratory services.
External quality assessment (EQA) refers to a system in which laboratory test results are scrutinized objectively by an outside agency to determine inter-laboratory comparability. Patterns of practice surveys also provide a general impression of laboratory practice. As this assessment is retrospective, a laboratory is notified about a discrepant finding after submission of the data. The strength of EQA is thus not to achieve day-to-day consistency but to help establish comparability of results between laboratories and between techniques.
Quality management requires the laboratories and senior management to commit to the development of a culture, which recognizes the importance of quality, and quality assurance, in their work. To achieve this, the Program and Laboratory Managers developed and implemented a strategy for the continuous enhancement of quality. Now Laboratories in the region have formal mechanisms for the approval, periodic review and monitoring of their quality management systems. This includes regular audits to collect, analyse and use that relevant information for the effective management of their departments. At this time, some hospital laboratories have limited human resources to dedicate the time necessary to achieve the expectations as laid out in particular requirements and standards.
Laboratory Services Plan
The Regional Coordinating Committee continues to have three (3) representatives from the KRR RLP. The Committee met in Thunder Bay April 20, 2005. At that time the Committee was updated on the OLIS project with an aim to secure early adopters.
Goals for 2005:
- Develop a regional antibiogram to assist physicians with empiric treatment of infected patients. (Ongoing. Requires a review, annually.)
- Promote Osmolality testing in the region. (Implementation Complete. Education extended into 2006.)
- Assist the laboratories in the peer accreditation process schedule March/April 2005. (Complete)
- Examine current referral practices to determine if efficiencies can be found. (RFP circulated. Decision expected March 2006.)
- Develop a Regional Chemistry and Specimen Collection manual. (Complete pending regional review.)
- Provide clinical instruction on the use of eGFR – MDRD for the early detection of renal disease and monitoring of the illness. (Complete. Ongoing evidence requires education be extended into 2006.)
- Promote compliance with the National Kidney Disease Education Program (NKDEP) recommendations for laboratory services including proficiency goals. (Compliant. Certification received by all sites. Proficiency testing ongoing.)
- Assist the Board in examining the Corporate Bylaws. (Not complete. Expected completion June 2006.)
Many goals set for 2005 have been met. Those goals identified as on going have evolved into common practice therefore may not be mentioned in future reports unless they impact on strategic plans.
Goals for 2006:
- Investigate, educate and implement FFN, TSH, Lipid profile, PSA and Factor Xa testing on site if appropriate. Delete AST and LDH from all laboratory licenses.
- Secure access to liquid based pap smear cytology for all women in the region.
- Review frequency of callbacks to determine additional POCT strategies to relieve this burden. Expand POCT menu at satellite facilities.
- Secure a Quality Coordinator or FTE equivalent for all sites. Ensure a fully audited Total Quality Management System (including IT compliance)
- Prepare, circulate and review RFPs for equipment replacement or expansion in POCT. Make recommendations for purchase. See Appendix E.
Appendix A
Kenora-Rainy River Regional Laboratory Program, Inc.
Organizational Chart
Appendix B1
KRR RLP Fall Conference
Summary
The Symposium was held September 13, 14 & 15, 2005 at laPlace Rendez-Vous, in Fort Frances.
In attendance were thirty-four (34) delegates of which twenty-eight (28) were from our own region. Delegates included technologists and technicians as well as one Laboratory Director.
The breakdown of delegates from our region include:
- Atikokan General Hospital: 1
- Dryden Regional Health Centre: 2
- Lake of the Woods District Hospital: 8 (includes Laboratory Director)
- Red Lake MC Memorial Hospital: 1
- Riverside Health Care Facilities: 10
- Sioux Lookout Meno-Ya-Win Health Centre: 4
- KRRRLP 2
The educational format consisted of 6 guest speakers who provided presentations relating to laboratory management and medicine. The exhibition itself included 18 vendors. The main social event was a humorous rendition of the Ontario Laboratory Accreditation process as presented by “Actors Without Borders”.
Appendix B2
The delegates were asked to complete an Evaluation, prior to leaving the Conference.
Appendix B3
Appendix C
Meetings and Visits
2005 Meetings:
Appendix C2
2005 Onsite Visits:
Appendix D1
QMP-LS Correspondence Per Discipline
* Includes Blood Gases
** Includes Drugs of Abuse
Appendix D2
Actual Number of QMP-LS Correspondence Per Laboratory
Appendix D3
Explanation of EQA Errors
Appendix E
2006
Instrument Replacement Plan
Priority Ranking:
1. Urgent Replacement
• Current analyzer / equipment / methodology results in poor or questionable quality
results.
• Analyzer parts / service no longer available
2. Scheduled Replacement
Rationale includes:
• limited test menu
• old methodology
• upgrade required to meet services
• improvement in efficiency and workflow
3. Replacement
Rational includes:
• standardizing test platform
•provide regional service
4. Backup Replacement
- Back-up instrument / equipment required in facility.
Rationale includes:
• POCT
• Small platform analyzers
5. New Initiatives
- Required to meet services.
