Quality Assurance and Quality Improvement

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Quality processes, products, and people are the cornerstones upon which the quality system of the Department of Pathology and Ancillary Laboratory Services (DPALS) is built. DPALS’s Quality Management Plan is organized to monitor processes and operations in the laboratory through the performance of self-assessment inspections, self-assessment audits, error management, and customer feedback. DPALS adheres to high standards for quality by conforming to accreditation requirements established by the Joint Commission (TJC), the College of American Pathologists (CAP), the American Association of Blood Banks (AABB), the Food and Drug Administration (FDA), and other peer-review organizations.

The Department of Pathology Quality Assurance Committee meets monthly to discuss and assess quality assurance, quality improvement and performance improvement issues as part of the department’s quality improvement plan. The focus of this committee is toward the prevention of problems in addition to the identification and resolution of existing problems using a Total Quality Management approach of employee involvement and customer satisfaction. DPALS uses the FOCUS-PDCA process to identify, analyze, and find solutions for performance improvement. The following three programs are examples of the continuous, ongoing quality assessment and improvement measures in place at DPALS:

• Quality Control - Quality Control checks are performed on every test system according to the recommended guidelines of the manufacture and accrediting agencies.
• CAP Proficiency Testing Program – CAP’s external proficiency testing program challenges the laboratory with unknown samples to demonstrate the laboratory's proficiency.
• Peer Review – An internal program developed to monitor individual section performance in areas such as test turn-around-times, phlebotomy wait time, and surgical/cytological case turn-around-times. Critical performance areas are identified, goals and standards are set, and periodic review conducted.

The Department of Pathology is fully accredited by:

• The College of American Pathologists (CAP)
• American Association of Blood Banks (AABB)
• Food and Drug Administration (FDA)