2010 Annual Report

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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 service 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

Executive Summary

The excellence of the Kenora Rainy River Regional Program and the importance of its mission has remained constant over time. It exists to provide administrative and technical advice, consultative, educational and quality support services. The Program lends its expertise in the delivery of laboratory services consistent with best practices and established standards to ensure accuracy and reliability of test results.

The results are evident. After 3 weeks of scrutiny, the laboratory services of all six hospitals achieved the highest recognition from the Ontario Laboratory Accreditation (OLA) program, receiving a four-year certificate. Laboratory accreditation applies rigorous standards based on ISO requirements, national and provincial laws and best practice documents. extraordinary creativity, commitment and hard work demonstrated by our Laboratories’ exceptional workforce.

Regional educational activities are driven by the Program as a commitment to lifelong learning. Besides the annual Fall Symposium the Program continues to develop Newsletters to share information with both Laboratory and non-Laboratory professionals.
The KRRRLP has traditionally promoted sound quality assurance practices and reviews proficiency testing program results to monitor laboratories’ performance level, accuracy and competency. With the development of quality audits, the Program maintains a process of systematic examinations to assess the quality system carried and acts as an external quality auditor. Auditing an important part of laboratories’quality management system and is a key element in the ISO quality system standard, ISO15189
The Laboratory Director continues to sit on the OLA Advisory Committee and the Executive Director( E.D.) of the Program remains a Council member for CMLTO. The E.D. was elected President of CMLTO for 2010.

Detailed Description of Activities

  • Equipment / Test Menus

The Program is responsive to the Clinician’s needs for analyses to assist in the diagnosis, treatment, monitoring and prevention of disease. It is also cognizant of changes necessary to improve service delivery and operational efficiencies. As a result one site adopted molecular testing to improve bed utilization.

Point-of-care testing (POCT) remains in the forefront of the Program’s plans for several sites noting it has the potential to significantly reduce call backs and enhance the quality of care.

Almost every patient that comes into one of our hospital is served by the Laboratory Medicine Department, with 1.37 million patient tests every year. These laboratories provide high quality test results to facilitate rapid diagnostic processes and treatment in the Emergency Room, as well as for ambulatory and hospitalized patients.

Measuring the uncertainty of test results was a huge undertaking this year. It required that each measurand (analyte) where possible be assessed using a series of complex equations to express the test result of a measurement as a best estimate of the measurand along with an associated measureable uncertainty.

The sustainability of APTT testing in our facilities for the purpose of the therapeutic monitoring of intravenous unfractionated heparin is under scrutiny.  This is in response to recommendations issued by the Quality Management Services Laboratory Services (QMP-LS) for the validation of the APTT therapeutic range of unfractionated heparin (UFH). In small hospitals this will be overwhelming, if not technically unfeasible.  Many small labs do not have sufficient numbers of patients receiving UFH, dedicated staffing resources or instrumentation/test platform to conduct many of these studies. Alternative testing methods are being investigated.

  • Education

The Program organizes continuing medical and technical education in a variety of forums: conferences, teleconferences, workshops, presentations and lectures. It is committed to helping the medical and technical personnel be the best they can be.

Details of this year’s Symposium are outlined in Appendix B.

This year the Program continued in its educational commitment by producing a series of newsletters for physicians and technologists to provide authoritative information, advice and instruction on the utility of specific laboratory tests. Appendix C.

The Laboratory Director continues to provide onsite education to a variety of health care providers. The presentations included topics such as Octaplex.

The time given to provide these resource activities and support its users is extensive.

  • Onsite Visits

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.

  • Education

In addition to monthly or bi-monthly teleconference meetings with the Laboratory Managers, onsite visits have occurred in the region by the Laboratory Director and/or the Executive Director, 3 times. Appendix D.

The Laboratory Managers also meet with the Laboratory Director and Executive Director 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.

In preparation for OLA, the Executive Director visited each site to perform a simulated assessment of their Quality Management Systems. Non-conformances to the requirements were documented allowing Laboratories enough time prior to their Peer Assessment to correct any non-conformances.

A regional Microbiology Committee actively meets to provide a forum for technologists working in this discipline to connect with their peers and discuss related issues. This has led to quality improvements to individual operations and the regional manuals.

An Immunohaematology Committee was formed this year to deal with particular OLA requirements and perform a review of the manual in consultation with an external consultant. This work was completed October 2010.

  • Recruitment

The Program is committed to the training students pursuing a career as medical laboratory technologists (MLT). Staff members at LWDH worked closely with Cambrian College by helping to train students in their clinical year. LWDH, RHCF and SLMHC will be receiving students in 2011. The Executive Director of the Program sits on the Professional Advisory Committee (PAG) for Cambrian College.

The Executive Director is the Chair of the PAG for the MLA/T Program at Confederation College. The six facilities in the KRRRLP have agreed to work collaboratively with the College to provide students with the training needed to transition them into a MLA/T career path hopefully within North Western Ontario.

The Pathologists also provided training to a fifth year Pathology resident.

  • EQA Challenges

The Quality Management System – Laboratory Services (QMP-LS) and DigitalPT provide external quality assurance programs specifically designed for Ontario laboratories. The goal is to provide a confidential assessment by which a laboratory can compare its internal test results to those of other laboratories.

A Regional review of EQA challenges has revealed improvement in performance when compared to previous years. Appendix E.

  • Audits

Audits are an essential OLA management tool to be used for verifying objective evidence of processes, to assess how successfully processes have been implemented, for judging the effectiveness of achieving any defined target levels, to provide evidence concerning reduction and elimination of problem areas.  As a result and for the benefit of four sites without a Quality Coordinator, the Program lead quality auditing to globally assess evidence, detemine non-conformances and participate in the implementation of corrective actions.

Approximately 30 audits were performed by each site in 2010.  The statistical data from these audits were submitted by the Laboratory Manager as part of a Management Review to Senior Administration so are not part of this Report.

In summary, the Laboratories are meeting defined target levels.  Any corrective action items have been acted on expeditiously and again the Laboratories are in position to meet the OLA requirements.

Goals for 2010:

  1. Assist Laboratories in achieving a 4-year accreditation. Act on areas of non-conformance. Complete
  2. BNP and POC testing: continue from 2009. Ongoing
  3. Measurement of Uncertainty: Fully measure analytical bias on appropriate tests and have available for clinical use. Complete
  4. Succession Planning: Pursue the development of Lab personnel in the region to fill the position of Executive Director. Ongoing
  5. Provide Clinical presentations on Reversal of Warfarin and Hemolytic Anemias Complete
  6. Establish an Immunohaematology Committee Complete

Goals for 2011:

  1. Implement anti-Factor Xa testing
  2. Transition Laboratories to Ontario Laboratory Accreditation Version 5.0
  3. Prepare RFP for Chemistry, Immunoassay and Transfusion Medicine equipment replacement
  4. Identify educational opportunities using regional staff surveys and QMPLS patterns of practice ie. Malaria

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