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 MenoYaWin Health Centre

Regional Office

Kenora-Rainy River Regional Laboratory Program, Inc.
P.O. Box 3003, Dryden, ON    P8N 2Z6
Phone:  807-223-8264      Fax:  807-223-7342

Chief Operating Officer: Wade Petranik
Laboratory Director: Dr. J. Kerry MacDonald
Executive Director: Anna Robinson
Executive Assistant: Marilyn Rustan

Organizational Chart

(See Appendix A)

Executive Summary

The Kenora –Rainy River Regional Laboratory Program (KRR RLP) exists to provide leadership in all aspects of Laboratory Medicine, including service and education with the pursuit of excellence, encouragement of innovation and adherence to regulatory and professional standards.  The mission of the Program shall be supportive of the missions of the participating hospitals.

This year marked the introduction of a new three-year plan. As a result the Program is pleased to report that through a series of RFPs the following has been accomplished:

• Acquisition of a suitable Hematology analyzer for all sites
• Placement of PCR equipment into one site

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.  This year, in response to a regional request, the Program also arranged a workshop in effective communication.

Medical Laboratories are in a state of on-going change.  In part this is due to the new requirements laid out by Ontario Laboratory Accreditation (OLA).  One of the Program’s objectives was to assist 6 Laboratories in their preparations for Peer Assessments by OLA in 2010.  Extensive work and collaboration took place and the Laboratories should be positioned to achieve a four-year accreditation.

In the absence of a Quality Coordinator at four sites the Program took the lead with orchestrating and reviewing Quality audits performed by each facility. The audits were performed at predefined time intervals with clearly-defined measureables allowing for the opportunity to implement effective action plans.

The Program updated its reference library to include current additions of paticular textbooks as well as an internet library.  This allowed for preparation and introduction of updated regional manuals in October 2009.

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

When one considers that 70% of diagnostic and treatment decisions are based on laboratory tests, it is easy to see the crucial role laboratory medicine plays in patient care in our hospitals.  In 2009, the region performed 1,300,000 laboratory tests.  This is a decrease of 100,000 tests over the last 3 years.  The decrease is attributed to streamlined menus, use of more appropriate tests and clinical education.

Site specific, the Program worked in collaboration to prepare business plans for Point of Care Testing and PCR.   Point-of-care testing (POCT) remains in the forefront of the Program’s plans noting it has the potential to significantly reduce call backs and enhance the quality of care.  Additional research is needed to identify the best methods for integrating POCT into daily clinical processes and monitoring its use as required by Ontario Laboratory  Accreditation.  As well, additional man hours would be needed to train and recertify operators in the proper use of POCT devices.

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.  This year it was the only Regional Program to host an annual Conference in Ontario outside of a provincial initiative.

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 community acquired MRSA and cognitive error.

At the request of the Laboratory Managers, a workshop was hosted on communication strategies in order that staff could be more effective as trainers.  Jim Lees, a Counselor and Coordinator of Student Services Confederation College, provided a one day workshop to ten (10) participants.

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

Onsite Visits

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.

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.

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.

Recruitment

The Program is committed to the training students pursuing a career as medical laboratory technologists (MLT).  Staff members at LOWH worked closely with Cambrian College by helping to train students in their clinical year.  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.

This year there were 15 letters of non-conformance received:

Non-conformances

Statistical/method bias – 5

Technical -misinterpretation of results, calculation errors, QC limits sample mix-up, random error – 3

Materials – defective reagents/unsupported reagents, mishandling QMP-LS samples – 2

Failure to follow SOP – 1

Equipment function – 0

Organizational Factors- communication, training, missing SOP information – 4

Random Error – 0

Corrective actions for the most part included re-education and training of staff, and contacting manufacturers regarding problems with materials or analytical performance.

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 2009.  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 2009:

• Revisit BNP testing: deferred until a regional decision is made for POCT testing
• Evaluate the availability of Octaplex on site: newsletters circulated to introduce the product. Availability on site is at the discretion of the hospital pending a re-distribution plan to prevent outdating of the product.
• RFP–PCR testing in three sites. Implemented in 1 site. Chromogenic media to be implemented in 2 sites.
• RFP -POCT-examine other testing available for small hospital laboratories: RFP complete and shortlisting has occurred. Will be revisited following OLA Accreditation.
• Roll out Regional benchmarks to assist in compliance with the OLA requirements. Twenty-two audits were performed to measure performance against established benchmarks. Audits ongoing to monitor quality improvement activities.
• Act as unbiased third party in monitoring laboratory quality processes. Audits collated and examined regionally to prevent bias. Ongoing activity.

Goals for 2010:

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

Appendix A

Organizational Chart

Appendix B

Annual Fall Symposium
2009

Summary

The 18th Annual Fall Symposium, “Striving for Excellence”, was held September 15, 16 and 17 2009, at laPlace Rendezvous in Fort Frances

Twenty-eight delegates attended this year’s Symposium:

• Atikokan General Hospital: 4
• Dryden Regional Health Centre: 1
• Lake of the Woods District Hospital: 8 (Includes Laboratory Director)
• Red Lake MC Memorial Hospital: 1
• Riverside Health Care Facilities: 8
• Sioux Lookout Meno-Ya-Win Health Centre: 5
• KRR RLP: 2

The educational format consisted of five (5) guest speakers who provided presentations relating to laboratory management and medicine.

The exhibition itself included 16 Booths with 22 vendors.

2009 Fall Symposium
at a glance

Appendix C

Newsletters

Reducing Errors in Specimen Labeling and Ordering – 2009-01

Protocol for Reporting Laboratory Test Results - 2009-02

Lab Results and What They Mean:  A Primer for Nursing Personnel and Collection Staff - 2009-03

Expectorated Sputum – 2009-04

Specimen Packaging and Transport – 2009-05

Treatment of Uncomplicated UTI – 2009-06

Guideline for Investigation of Suspected Transfusion Transmitted Bacterial  Contamination - 2009-07

Why is there never enough O Rh-negative blood? – 2009-08

Appendix D

Regional Meetings
2009

Onsite Visits
2009

QMP-LS Non-Conformances per Discipline

QMP-LS Non-Conformances per Laboratory

Appendix E

Explanation of Discordant Results 2009