UAMS PATHOLOGY AND LABORATORY SERVICES

        PERFORMANCE IMPROVEMENT PROGRAM

        Implemented:    February 18, 2000

          Revised:    January 9, 2004

I. FUNCTION:

As part of the hospital wide quality improvement/assurance program, the quality and appropriateness of pathology and clinical laboratory services are monitored and evaluated on an ongoing and systematic basis. This program is designed employing ISO9000 standards to objectively and systematically assess aspects of are, to pursue opportunities to improve patient care, and to identify and correct problems as they arise. Monitoring and evaluation are accomplished through routine and periodic internal and external audits outlining corrective measures. Follow-up assessment evaluates the effectiveness of the corrective action. All of these functions are documented and reported to the Hospital Performance Improvement Department on a quarterly basis.

II. GOALS:

The goal of the Performance Improvement Program is to strive for the highest quality health care for the patients and other customers we serve. This goal shall be achieved by cooperation of all members of the laboratory team and the interaction between the laboratory and other departments of the hospital in identifying aspects of care and working together to improve the quality of these aspects.

III. RESPONSIBILITY:

The Laboratory Director has the ultimate responsibility for implementation of the Performance Improvement program. Under this direction, the Performance Improvement Committee has been formed to carry out the objectives of the plan. The Laboratory Performance Improvement Committee consists of:

IV. SCOPE OF SERVICE:

The University Hospital includes a full-service clinical laboratory that operates twenty four hours of every day and provides a wide range of routine and specialized laboratory services. The laboratory performs over a million diagnostic and therapeutic procedures each year in the sections of Chemistry, Hematology, Endocrinology/Immunology, Flow Cytometry, Toxicology, Microbiology, Point of Care Testing, Transfusion Service, Therapeutic Apheresis, Stem Cell Apheresis, Bone Marrow Laboratory, Cell Therapy Lab, Cytogenetics, Histology and Cytology. In addition we provide limited inpatient and extended outpatient phlebotomy and inpatient and outpatient therapeutic phlebotomy services.

In addition to the main laboratory, we operate a Pediatric Stat Lab adjacent to the nursery and Labor and Delivery, blood draw stations in the Outpatient Diagnostic Center, Community Women's Health Center and Freeway Medical building.

V. KEY ASPECTS OF PATIENT CARE

The key aspects of patient care for the clinical laboratory include:

VI. METHODOLOGY

The laboratory Quality Improvement Committee will meet monthly (on the third Thursday at 2:00 p.m. in the Clinical Laboratory Library) to review the continuously collected data regarding the quality indicators and determine if the designated thresholds have been exceeded and to address specific problems as they arise. If thresholds have been exceeded, or problems are identified by regular assessment or other means, and the section Supervisor or Manager has been unable to correct the deviation form SOP, the Committee will ascertain the reason(s) and take action to correct the problem.

These actions may include:

VII. QI PLAN

A written report prepared by the Laboratory Performance Improvement Committee is composed of agendas, meeting minutes, and a narrative evaluation documenting each audit, corrective measures taken, and follow-up required to resolve any deviation from SOP.

An annual report is distributed to all section managers to disseminate to staff, and is sent to the Hospital QI Department with appropriate documentation.

VI. SIGNATURES:

**Policy review dates and signatures are available and on file in the laboratory.

 

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