2012 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
Allan Katz – Riverside Health Care Facilities, Inc.
Dave Murray – Sioux Lookout Meno-Ya-Win 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 (up to Sept 2012) – Tanya Knopf (beginning Sept 2012)

Executive Assistant: Marilyn Rustan

Executive Summary:

The Kenora Rainy River Regional Laboratory Program (KRRRLP) exists to provide education and technical support to the six hospital laboratories in Northwestern Ontario. The program has been in existence for close to 30 years. A culture of cooperation between the six facilities has been the cornerstone of each individual laboratory’s success. The Program plays a key role in assisting the laboratories to constantly move forward with changes to improve the quality of laboratory service provided to the patients of Northwestern Ontario. 2012 marked a year of significant change for the Program itself and the laboratories associated with the Program.

Anna Robinson retired as Executive Director of the Program in September of 2012. Her years of dedicated service to the Program are evident throughout the region. Moving all six laboratories toward successful Ontario Laboratory Accreditation is one of her many outstanding achievements. Tanya Knopf replaced Anna, and she will endeavor to continue the quality improvement momentum throughout the region. Three new laboratory managers were also hired in the region in 2012.

The decision to purchase combined platform analyzers for chemistry and immunoassay has meant significant changes in workflow within the laboratories. Efficiencies in time and maintenance costs are being realized with a single analyzer replacing two analyzers. Quality assurance software for the monitoring of point-of-care testing (POCT) has provided a significant improvement in the laboratory’s ability to monitor operators and control access to POCT equipment.

The 2012 KRRRLP regional symposium, “Moving Forward – Back to the Basics” was a huge success with more than 50 delegates and vendors in attendance. The symposium continues to be the single biggest event of the year for the Program. Other educational activities include regular newsletters on current topics as well as presentations by the Laboratory Director,

A significant amount of time is spent travelling to each lab in addition to regular laboratory manager’s meetings and microbiology teleconferences. These visits and meetings provide a venue with which the laboratories can share their experiences and the Program can provide resources for the revision or implementation of quality processes in the individual laboratories.

All laboratories continue to participate in a wide variety of external quality assurance (EQA) programs. Every test is validated and monitored by comparing results with other laboratories. This year the six laboratories submitted more than 3300 data points for EQA, with only 1% of results flagged as discordant. This falls in line with the Quality Management Program-Laboratory Services (QMPLS) overall provincial rate for 2011. The flags initiate investigations to find the root cause and then corrective actions are put in place to reduce the risk of reoccurrence. The Program assists laboratories through this process, by providing expertise and resources.

Audits are an important part of continuous quality improvement initiatives. Each laboratory audits a variety of indicators within their own facility. The Program consolidates the results for those audits that are common to all laboratories. The results are reviewed as a group, and suggestions for improvement are coordinated by the Program.

Many projects that were started in 2012 are targeted for implementation and completion in 2013. As the years roll by, the laboratories continue to work together with the Program and constantly look for ways to improve the quality of laboratory services within this vast region.

Detailed Description of Activities

Equipment / Test Menus

The Program is cognizant of changes necessary to improve service delivery and operational efficiencies in addition to the clinician’s needs for accurate results to assist in the diagnosis, treatment, monitoring and prevention of disease.

In February 2012, the very long and complicated request for proposal (RFP) for chemistry and immunoassay analyzers was awarded to Siemens Healthcare Diagnostics for the EXL 200. The install of the new EXL 200 analyzers will provide an excellent opportunity for the laboratories to review their test menus and realize efficiencies. The EXL 200 is a combined platform analyzer that replaces both the general chemistry and immunoassay analyzers. Utilizing a single instrument for both types of analyses, decreases the resources required to maintain two analyzers. In addition, the highly sensitive troponin assay on the EXL 200 enables the laboratories to delete other, less sensitive cardiac tests from their test menu. Two of the five laboratories installed the EXL 200 in 2012. The remaining three are expected to install the EXL 200 in 2013. With the increase in antibiotic resistant organisms, and aminoglycoside testing costs very reasonable on the EXL 200, several laboratories are considering adding vancomycin and gentamycin to their test menu.

In 2012, all laboratories upgraded their blood gas analyzers to the GEM Premier 3500 which improves the sampling process through updated software. This upgrade was facilitated by Instrumentation Laboratories (Canada) Ltd., who installed the new analyzers in conjunction with a new warranty agreement rather than a capital purchase.

In an effort to comply with strict OLA regulations for the monitoring of POCT operators, Sioux Lookout Meno Ya Win Health Centre has purchased new Status Plus urinalysis analyzers and will host the RapidComm quality assurance software for the region. Over the next year all sites will be looking to purchase these analyzers and will connect with the RapidComm software. This will allow the laboratories to electronically monitor the operators and test results for POCT urinalysis.

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.

The 21st Annual Fall Symposium, “Moving Forward-Back to the Basics”, was held Sept 18, 19, and 20th, 2012 at the Best Western Plus, in Dryden, Ontario. The educational format consisted of five (5) guest speakers who provided presentations relating to laboratory management and medicine. Unfortunately, due to illness, Evelyn Kokoskin was unable to attend and present her session on Malaria. Fortunately, Dennis Ernst was prepared with a third presentation on the “10 Commandments of Phlebotomy”. The 31 delegates from all of the hospitals in the region were very understanding of the situation. The exhibition itself included 15 booths from various laboratory product companies with 21 vendors in attendance. See the detailed program 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. See Appendix C.

The Laboratory Director provided education to a variety of health care providers, including physicians, nurses and pharmacists during his on-site visits. The presentations included topics such as Novel Anticoagulants. Evaluation forms were developed for the presentations as a mechanism to elicit feedback from the participants and to assist the Program in creating presentations that are of value to facility staff.

Onsite Visits

The Laboratory Director and the Executive Director travelled to each site in the region two or three times this past year. These visits provide an opportunity for the Laboratory Director to meet with the individual Laboratory Managers to discuss site specific issues and to review EQA and quality management documentation. See Appendix D.

The Laboratory Managers meet as a group with the Laboratory Director and Executive Director bi-annually 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 addition, monthly or bi-monthly teleconference meetings with the managers are held to discuss on-going issues. Major topics of discussion in 2012 included the Chemistry/Immunoassay RFP, Heparin testing, POCT urinalysis, data loggers for monitoring temperature during transportation, and malaria procedures.

A regional Microbiology Committee actively meets by teleconference 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 in individual operations and the regional manuals. This year, topics of discussion included new antimicrobial sensitivity reporting protocols, expanded polymerase chain reaction (PCR) testing, extended spectrum beta lactimase (ESBL) testing, and EQA testing results.

Recruitment

Recruitment, retention and succession planning of qualified staff have historically been a challenge for the laboratories of this region. The hard work and concerted effort in this area was rewarded this past year. In 2012, a new Executive Director, and three new laboratory managers were hired within the region. In addition, several frontline laboratory staff were hired or promoted.

After almost 15 years as Executive Director of the Program, Anna Robinson retired in September 2012. Her dedication to the Program, her expertise in Quality Management and her experience in the field of laboratory medicine has been a significant benefit to the Program and to the laboratories of this region. A “Happy Retirement” celebration was held in Dryden following the symposium with many friends, co-workers and family in attendance. She will be missed, but we wish her all the best in her retirement.

Tanya Knopf was hired to replace Anna as Executive Director of the Program in September 2012. Tanya has worked as an MLT in the region for almost 30 years; the last 12 years as laboratory manager at Lake of the Woods District Hospital (LWDH). Tanya is working from her home in Kenora four days a week and travelling to the Dryden office one day a week. Lori Hoppe was hired at LWDH to replace Tanya as laboratory manager.

All laboratory staff in the region were saddened by the sudden passing of Patti Johnson in July 2012. Patti had been the laboratory manager at Riverside Healthcare Facilities (RHCF) for many years and was a dear friend and co-worker to many staff in the area. We offer our sincere condolences to her family, friends and the staff at Riverside. Toni Benning has been hired to replace Patti as laboratory manager

Karen Parent, long time laboratory manager at Sioux Lookout Meno-Ya-Win Health Centre took on a senior management position at that facility early in 2012. Brenda Voth was hired to replace Karen as laboratory manager.

The Program is committed to the training students pursuing a career as medical laboratory technologists (MLT). This is a direct strategy to recruit MLT’s to the region; if they come for training, and become familiar with the area, they may be willing to stay. This year Riverside Healthcare Facilities and Dryden Regional Health Centre, 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 the MLT program at Cambrian College and the MLA/T Program at Confederation College.

EQA Challenges

The Quality Management System – Laboratory Services (QMP-LS) and DigitalPT provide external quality assurance (EQA) 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 is performed annually to assess performance to previous years. See Appendix E.

This year there were 20 letters received for 34 discordant data points:

Non-Conformances

Statistical/method bias – 7

Technical -misinterpretation of results, calculation errors, QC limits sample mix-up, random error – 5

Materials – defective reagents/unsupported reagents, mishandling QMP-LS samples – 1

Failure to follow SOP – 1

Equipment function – 0

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

Random Error – 5

A significant number of the discordant results were as a result of bias associated with a specific method. These required communication with the vendor and are not within the control of the individual laboratories. Some technical errors required changes to process and/or procedure while others required education and/or training of staff. In 2012 there were no discordant findings in Microbiology. This is of particular significance due to the small size of the microbiology labs in this region and the knowledge required to successfully process the very complex EQA samples.

EQA Challenges

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.

In keeping with the Program’s cycle of laboratory assessment, each site performed a self-assessment of their Quality Management System in 2012. Non-conformances to the requirements were submitted to Ontario Laboratory Accreditation (OLA) and corrective actions were implemented in preparation for the next full internal audit by the Program in 2013.

Audits are an intrinsic part of quality management and an essential 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. In areas where the laboratories are encountering common problems, the Program will assist in collating audit results from all of the sites, analyzing the data and determining corrective actions as required.

Audits at each site may include:

  • 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
  • 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 the sites in 2012. The statistical data from these audits were submitted by the Laboratory Manager to Senior Administration as part of a Management Review so are not part of this Report.

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

Goals Set for 2012:

  • Meet OLA self-assessment – Results submitted and corrective actions completed by each site.
  • Develop a Competency based program for all disciplines to meet OLA – Procedures completed and distributed to each site for implementation.
  • Develop a Competency based program for pathologist/lab manager – In development; target completion 2013
  • Examine IT solutions for monitoring POCT to meet OLA – Sioux Lookout installed; other laboratories submitting for capital equipment and software purchases; target 2013
  • Assess Blood Gas Analyzers (warranty vs replacement) – Procedures and staff training in progress; target full implementation 2013
  • Implement Anti-Factor Xa (Heparin) testing – Cancelled due to budgetary constraints
  • Establish an EQA program for Malaria – All laboratories to move forward with program early 2013
  • Recruitment of Executive Director, KRRRLP – Complete September 2012.

Goals Set for 2013:

  • Complete Internal Audits for all 6 sites
  • Prepare for January 2014 OLA Peer Assessments (submission of information)
  • Implement EXL Chemistry/Immunoassay analyzers at 5 of 6 facilities
  • Implement Malaria EQA program
  • Implement RapidComm for monitoring POCT Urinalysis
  • Implement Ant-Factor Xa (Heparin) testing
  • Implement Competence Assessment for Managers/Pathologists
  • Develop procedures for result comparability
  • 2013 Symposium, Fort Frances, ON, “Safety First”

Click here to download the full Annual Report