2. Preparing for Accreditation Viki Massey, Quality Coordinator A Joint Venture of London Health Sciences Centre and St. Joseph’s Health Care London

3. What is Accreditation? Peer review assessment process –Cyclical –“For Cause” –Mandatory Process ensures that laboratories meet specific quality management criteria Gives formal recognition that the lab is competent to carry out examinations

4. Ontario Laboratory Accreditation Requirements Based on recognized Standards and Regulations –ISO 15189 –Laboratory Standards e.g. AABB, NCCLS –Accepted Laboratory Practices Over 500 requirements “Check list” format

5. LLSG Implementation Plan Quality Coordinator Discipline Task Teams Quality Team Develop Policies GAP analysis Map Processes Write procedures Quality Manual Communicate/Educate/Train Audit Accreditation

6. Where are We? Quality Team Quality policies- written Processes- identified/mapped Procedures –written Quality Manual Published Web site for documents (manuals) Web site for referral labs Document Management System- developed and training scheduled On line Occurrence Form- developed, pilot project completed and training scheduled

7. Where are We? Discipline Task Teams GAP analysis Implementation Plan –Pre-analytical –Analytical –Post Analytical –QC/QA –Equipment/Inventory –Facilities –Safety –LIS Processes mapped Procedures written Revisit requirements and close GAP

8. What’s Next? Quality Team to continue to address QSE Discipline Task Teams to complete sections of OLA requirements Training and implementation Self assessment or Peer assessment Accredited

9. Celebrate Success!

10. Web Sites Documents and Manuals http://www.lhsc.on.ca/priv/lab/policy/index.htm http://www.lhsc.on.ca/priv/lab/policy/index.htm Quality Manual http://www.lhsc.on.ca/lab/qmanual/index.htm http://www.lhsc.on.ca/lab/qmanual/index.htm Safety Manual http://www.lhsc.on.ca/priv/lab/policy/safety/techaids/e saf001.pdfhttp://www.lhsc.on.ca/priv/lab/policy/safety/techaids/e saf001.pdf OLA Compliance for Referral Labs http://www.lhsc.on.ca/lab/licen/licindex.htm http://www.lhsc.on.ca/lab/licen/licindex.htm Quality Management http://www.lhsc.on.ca/lab/qmanage/qmsys.htm