2014 Annual Report
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.
We act honestly, ethically and impartially at all times.
We encourage self-improvement and aim for scientific excellence.
We ensure that all our work is carried out in accordance with recognized standards.
We recognize the participation, initiative and cooperation of all the laboratories as being essential to our success.
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
Angela Bishop– Red Lake Margaret Cochenour Memorial Hospital
Allan Katz – Riverside Health Care Facilities, Inc.
Dave Murray – Sioux Lookout Meno-Ya-Win Health Centre
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: Tanya Knopf (up to Sept 2012) – Tanya Knopf (beginning Sept 2012)
Executive Assistant: Marilyn Rustan
In 2014 the Executive Director was absent for most of the year. A special thank-you goes out to Anna Robinson who came out of retirement to work part-time for a few months and oversee some of the necessary activities of the program. Also, the group of laboratory managers is to be commended for working together throughout this year to complete many on-going projects, including Ontario Laboratory Accreditation. As a result of these unusual circumstances, some of the non-critical activities that have normally occurred in previous year’s, were not fully realized in 2014.
The Kenora Rainy River Regional Laboratory Program (KRR RLP) is committed to providing quality education, expert advice and technical support to the six hospital laboratories in Northwestern Ontario. In collaboration with professional organizations and government agencies the Program delivers a solid foundation to assist the laboratories in achieving Ontario Laboratory Accreditation. KRRRLP is responsive to the healthcare needs of our communities by ensuring test platforms meet current and future needs.
The 2014 KRRRLP regional symposium, “Partners in Action” was a huge success with more than 70 delegates and vendors in attendance. The symposium continues to be the single biggest event of the year for the Program. Other educational activities included presentations by the Laboratory Director at the various sites on current topics.
The laboratory director spent time travelling to each lab in addition to participating in regular laboratory manager’s meetings. These visits and meetings provide a venue by 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 in the Province of Ontario. Any flags require an investigation to determine 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 any continuous quality improvement cycle. Each laboratory audits a variety of indicators within their own facility and the information is utilized to initiate quality improvement projects. The program is available to assist the laboratories with these initiatives. In addition, full internal audits of the quality management system are performed in each laboratory on a yearly basis. This year the Program supported the laboratories as they prepared for, and participated in, peer assessments by Ontario Laboratory Accreditation (OLA) and successfully achieved accreditation based on ISO 15189 standards.
Due to unforeseen circumstances some of the goals targeted for 2014 have not been fully implemented. As the program moves forward into 2015, with the Executive Director back at work, the laboratories are dedicated to moving forward on several outstanding projects.
Detailed Description of Activities
Equipment / Test Menus
The Program takes a futuristic approach to determine the most suitable analyzers for our laboratories to meet the demands of today and predict the needs of tomorrow.
In 2014, the Program issued a “Request for Proposal” (RFP) for new Hematology analyzers on behalf of 5 laboratories. There were three responses to the RFP and after many hours of deliberation, the laboratory managers agreed that the Beckman Coulter DxH 600 was the best fit for their laboratories. Most of the labs will be requesting the purchase of this analyzer either in this fiscal year (2014/2015) or the next (2015/2016).
The blood glucose monitor contract with Abbott expired in November 2014 for the six laboratories within our region. The Program, in cooperation with Thunder Bay Regional Health Sciences Centre and the Northwest Supply Chain, successfully negotiated to “piggyback” with the contract currently in place for the rest of the Northwestern Ontario labs. The contract extends out to 2017. In conjunction with this transition, the old PXP meters were replaced with new Freestyle meters which provide wireless connection to the quality assurance software. This will make the transfer of information in the meter more efficient, as the MLT’s will not have to physically plug the meters in to download data.
The laboratories continue to work with Siemens on the transition to the EXL chemistry analyzers. A “correction factor” was implemented for calcium in order to bring the results more in line with other hospitals in Ontario. A new reference range study was performed to account for the change in results obtained. In addition, Siemens continues to work with QMP-LS (IQMH) in regards to an apparent negative bias of creatinine values in the normal range. This is not considered a clinically relevant testing bias and so does not adversely affect patient care.
Looking forward, the program has been working with the microbiology laboratories to investigate the feasibility of Maldi-Tof technology. This technology allows for the identification of pathogenic organisms much quicker than the conventional ID systems, and provides a more complete identification for many isolates. A presentation at the Fall Symposium about this technology was enthusiastically received by all in attendance. Feasibility and business case studies are planned for 2015.
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 23nd Annual Fall Symposium, “Partners in Action”, was held at the Best Western Lakeside Inn, in Kenora, on September 23, 24 & 25, 2014. The educational format consisted of nine (9) guest speakers who provided presentations relating to laboratory management and medicine. The 2014 Symposium was attended by 44 delegates from all of the hospitals in the region. The exhibition itself included 19 booths from various laboratory product companies with 28 vendors in attendance.
See the detailed program in Appendix B.
Due to the absence of the Executive Director in 2014, the program was unable to produce a series of newsletters for physicians and technologists. The newsletter series is expected to resume in 2015.
The Laboratory Director provided educational “lunch’n learn” presentations to a variety of health care providers, including physicians, nurses and pharmacists, during his onsite visits. The presentations included the topics of C.Difficile and Normal Flora.
Onsite Visits and Meetings
The Acting Executive Director and/or the Laboratory Director travelled to each site in the region a couple of 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 met as a group with the Laboratory Director and the acting Executive Director several times throughout the year 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 primary focus of this year’s meetings was Ontario Laboratory Accreditation, ensuring all laboratories had the tools and information available for the peer assessments in May/June of 2014. Following the peer assessments, the Program met with the Laboratory Managers to assist labs in completing corrective actions to achieve successful accreditation in all six laboratories.
The regional Microbiology Committee did not meet in 2014, but is expected to resume their quarterly teleconferences in 2015.
Laboratory Medicine is a service and often we think we have no control on our workload such as the number of laboratory tests performed or the number of call backs in a given week. Dr. MacDonald continues to work closely with two of the smaller sites to find solutions to ease call back burden and staff shortages.
Recruitment, retention and succession planning of qualified staff continues to be a challenge for the laboratories of this region. The hard work and concerted effort to recruit has netted some new technologists. Several laboratories are clinical training sites for Cambrian College and Confederation College in an effort to ensure a pool of potential employees. Those sites involved with clinical training have found the experience very rewarding. Graduates have reported their overall training as a positive experience.
The Institute for Quality Management in Healthcare (IQMH), formally Quality Management System – Laboratory Services (QMP-LS), and OneWorld Accuracy 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.
Each discordant result is followed up by a root cause analysis. The discordant results may have more than one root cause. The results are as follows
Statistical/method bias/matrix effect – 40
Technical -misinterpretation of results, calculation errors, QC limits sample mix-up, random error – 4
Materials – defective reagents/unsupported reagents, mishandling QMP-LS samples – 5
Failure to follow SOP – 0
Equipment function – 1
Organizational Factors- communication, training , missing SOP information – 9
Transportation Issue – 7
Unexplained 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.
Overall, in 2014, the laboratories rate of non-conformance was 1.1%. This rate is slightly higher than in previous years, but still in line with the provincial average of 1%. The increase is primarily related to the new EXL Chemistry analyzers. The laboratories have worked closely with Siemens in researching these non-conformances and corrective actions have been put in place where applicable. It is expected that the rate of non-conformance in chemistry will significant drop in the upcoming year.
Accreditation and Audits
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)
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 2013:
- Implement RapidComm for monitoring POCT Urinalysis – Not completed; alternate program being investigated
- Implement Ant-Factor Xa (Heparin) testing – Completed in 3 of 6 sites
- 2014 Fall Symposium “Partners in Action” – Complete
- Develop RFP for hematology Analyzer – Complete
- Research Maldi-Tof for microbiology testing – In Progress
- OLA – develop and implement corrective actions from finding of peer assessments – Complete
Goals Set for 2013:
- 2015 Fall Symposium, Dryden
- Recruitment of New Executive Director, KRR RLP
- Implementation of POCT interfaces to Meditiech
- Update to POCT quality assurance software (pWeb)
- Develop RFP for Maldi-Tof analyzers in cooperation with St Joseph’s Group
- Implementation of Risk Management software for quality control (Mission Control)
- Implement CRP testing in place of ESR testing.