2011 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

Doug Moynihan – Atikokan General Hospital
Wade Petranik – Dryden Regional Health Centre
Mark Balcaen – Lake of the Woods District Hospital
Paul Chatelain – Red Lake Margaret Cochenour Memorial Hospital
Wayne Woods – Riverside Health Care Facilities, Inc.
Dave Murray– Sioux Lookout MenoYaWin Health Centre

Executive Summary

Health care is a complex field. With each passing year, new discoveries, new technologies, new specialties and new treatments seem to increase this complexity. It is our responsibility to enhance our knowledge and ability to deal with these ongoing challenges.

Regardless of change, the Kenora Rainy River Regional Program is committed to the pursuit of quality by providing exceptional support services to our Laboratories. This means a culture of continuous improvement in planning and building a cohesive Laboratory network, where individuals, teams and the right technologies are in place to meet patient needs. Success requires a common vision, shared values, innovation and a collective buy-in by all Laboratory staff to deliver diverse services, expertise and programs.

The key enabler to the Program’s success is its unique culture. It’s a culture derived from the commonality of history, six Hospitals and the values they espoused in delivering Laboratory Services back in 1992. This culture continues to inspire innovation, excellence and foster collaboration – between individuals, teams, programs, health authority partners, governments and others – to ensure new knowledge and Laboratory solutions can be applied as widely and effectively as possible.

As evidence of the Program’s commitment to quality, the Executive Director oversees compliance with the OLA requirements of the quality management system and acts an independent resource by providing an unbiased assessment bi-annually of each Laboratory’s processes. The Program also monitors the appropriateness and cost effectiveness of our services.

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 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 re- elected President of CMLTO for 2011.

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.

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. Anti-factor Xa continues to be evaluated for monitoring unfractionated heparin in patients.

An RFP was developed in April to secure a Chemistry/Immunoassay analyzer for each of 5 Laboratories. This was an enormous project taking up a huge amount of HR hours to prepare, circulate, respond to questions and collate findings for presentations. The contract was awarded in February 2012.

Almost every patient that comes into one of our hospitals is served by the Laboratory Medicine Department, with more than 1 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.
< h3>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

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 keeping with the Program’s cycle of external peer assessment, the Executive Director visited each site to perform an assessment of their Quality Management Systems. Non-conformances to the requirements were documented allowing Laboratories enough time prior to their Self Assessment with Ontario Laboratory Accreditation (OLA) requirements 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.
Both the Laboratory Director and Executive Director participate, site specific, on an Immunohaematology Committee as per OLA requirements to provide assistance with any transfusion medicine issues.

Recruitment

The Program is committed to the training students pursuing a career as medical laboratory technologists (MLT). This year LWDH, RHCF and SLMHC each accepted a MLT student from Cambrian College for clinical training. In addition, some sites also accepted an MLA/T student from Confederation College. To date, each site has rated this experience as being most positive.

The Executive Director of the Program sits on the Professional Advisory Committee (PAG) for Cambrian College. The Executive Director is also the Chair of the PAG for the MLA/T Program at Confederation College.

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

EQA Challenges

The Program is committed to the training students pursuing a career as medical laboratory technologists (MLT). This year LWDH, RHCF and SLMHC each accepted a MLT student from Cambrian College for clinical training. In addition, some sites also accepted an MLA/T student from Confederation College. To date, each site has rated this experience as being most positive.

The Executive Director of the Program sits on the Professional Advisory Committee (PAG) for Cambrian College. The Executive Director is also the Chair of the PAG for the MLA/T Program at Confederation College.

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

Non-conformances

Statistical/method bias – 0

Technical -misinterpretation of results, calculation errors, QC limits sample mix-up, random error – 6

Materials – defective reagents/unsupported reagents, mishandling QMP-LS samples – 6

Failure to follow SOP – 1

Equipment function – 1

Organizational Factors- communication, training, missing SOP information – 1

Unexplained Error – 3

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

Audits

The Laboratories continue to strive for excellence in the most efficient and cost effective manner. Continuous improvement is achieved by planning for quality, measuring the effectiveness and continuously improving our processes and outcomes.

Audits are an intrinsic part of quality management and 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 leads quality auditing to globally assess evidence using key Quality Indicators

These metrics include, but are not limited to:

  • Test and patient volumes
  • Patient wait times
  • Turnaround times for operational processes
  • Quality assurance metrics, for example rejected specimen rates, edited report rates, external proficiency testing results, blood culture contamination rates.
  • Customer satisfaction – customer satisfaction assessment surveys and complaint
  • Specimens received by the laboratory unlabelled or mislabeled, inadequate or incomplete specimens received by the laboratory, failure to follow collection process (e.g. collection procedure not followed.
  • Patient identification
  • Failure or delay to receive laboratory test results (e.g. delayed specimen receipt, delayed testing, reports not sent to physician, lost reports.)

Approximately 30 audits were performed by each site in 2011. 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 2011:

  • Implement anti-Factor Xa testing (deferred to 2012)
  • Transition Laboratories to Ontario Laboratory Accreditation Version 5.1(complete)
  • Prepare RFP for Chemistry, Immunoassay and Transfusion Medicine equipment replacement (completed Feb. 2012)
  • Identify educational opportunities using regional staff surveys and QMPLS patterns of practice ie. Malaria (complete)

Goals for 2012:

  • Meet OLA self assessment
  • Develop a Competency based program for all disciplines to meet OLA
  • Develop a Competency based program for pathologists
  • Examine IT solutions for monitoring POCT to meet OLA
  • Assess Blood Gas Analyzers (warranty versus replacement)
  • Implement anti-Factor Xa testing
  • Establish an EQA program for Malaria
  • Recruitment of Executive Director, KRR RLP

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