THE LABORATORY QUALITY MANUAL Temp

QUALITY MANUAL
2023
White Crescent Hospital Laboratory
Rongai
Mark Kavai
0701114973
Written by Reviewed by Authorized by
Mark Kavai Mark Kavai
Date: 11/09/2023 Date:11/09/2023 Date:
Preface
A quality manual is required for implementing a quality management system. Such a system aims
primarily at achieving customer satisfaction by meeting customer requirements through application of
the system, continuous improvement of the system, and prevention of the occurrence of
nonconformities.
This quality manual is based on internationally-accepted standards and focuses on good quality
principles and best practices.
WCH/LQMS/D002 1
Quality Manual
Effective: August 2023
Next Review: August 2025
Version: Original
i. Abbreviations and acronyms
BSL Biosafety Level
CDC Centers for Disease Control and Prevention, USA
CLSI Clinical and Laboratory Standards Institute, Wayne, Pennsylvania, USA
EQA External Quality Assessment
ISO International Organization for Standardization
LIS Laboratory Information System
LQMS Laboratory Quality Management System
QC Quality Control
QM Quality Manual
QMS Quality Management System
QSE Quality System Essential
SOP(s) Standard Operating Procedure(s)
WHO World Health Organization
WCH/LQMS/D002
Quality Manual
2
Version: Original
ii. Table of Contents
Preface........................................................................................................................................2
i. Abbreviations and acronyms...................................................................................................3
ii. Table of Contents....................................................................................................................4
1. Introduction to the Quality Manual........................................................................................6
1.1 Overview of the organization............................................................................................................................................6
1.2 Mission statement..............................................................................................................................................................6
1.3 Vision statement................................................................................................................................................................6
1.4 Objectives.......................................................................................................................................................................... 6
1.5 Scope.................................................................................................................................................................................. 6
2. Quality Policy.........................................................................................................................7
3. QSE: Organization..................................................................................................................8
3.1 Organization policy............................................................................................................................................................8
3.2 Conflict of interest.............................................................................................................................................................8
3.3 Organization chart..............................................................................................................................................................8
3.4 Internal communication.....................................................................................................................................................8
3.5 Personnel responsibilities..................................................................................................................................................9
3.6 Supporting documents.....................................................................................................................................................10
4. QSE: Facilities and Safety....................................................................................................11
4.1 Policy............................................................................................................................................................................... 11
4.2 Facilities........................................................................................................................................................................... 11
4.3 Security............................................................................................................................................................................ 11
4.4 Working environment......................................................................................................................................................11
4.5 Waste disposal.................................................................................................................................................................11
5. QSE: Equipment...................................................................................................................13
5.1 Policy............................................................................................................................................................................... 13
5.2 Selection of equipment....................................................................................................................................................13
5.3 Installation and Acceptance Criteria................................................................................................................................13
5.4 Equipment Inventory and master file...............................................................................................................................13
5.5 Validation......................................................................................................................................................................... 13
5.6 Preventive maintenance and repair..................................................................................................................................14
5.7 Decommissioning............................................................................................................................................................14
6. QSE: Purchasing and Inventory............................................................................................16
6.1 Policy............................................................................................................................................................................... 16
6.2 Reagents and consumables management.........................................................................................................................16
6.3 Selection and evaluation of providers..............................................................................................................................16
6.4 Procurement.....................................................................................................................................................................17
6.4.1 Equipment procurement..........................................................................................................................................17
6.4.2 Reagents, consumables and materials.....................................................................................................................17
6.5 Stock management and inventory....................................................................................................................................17
6.6 Referral laboratories / subcontracting..............................................................................................................................17
7. QSE: Process Management...................................................................................................19
7.1 Policy............................................................................................................................................................................... 19
7.2 Sample management........................................................................................................................................................19
7.2.1 Specimen collection and transport...........................................................................................................................19
7.2.2 Specimen/sample receiving.....................................................................................................................................20
7.2.3. Specimen/sample handling, preparation and storage.............................................................................................20
WCH/LQMS/D002
Quality Manual
3
Version: Original
7.3 Method validation............................................................................................................................................................20
7.4 List of examinations.........................................................................................................................................................20
7.5 Restrictive list (if duty 24h/24)........................................................................................................................................20
7.6 Quality Control................................................................................................................................................................20
7.7 Reporting......................................................................................................................................................................... 21
7.8 Sample retention and disposal.........................................................................................................................................21
8. QSE: Assessments................................................................................................................23
8.1 Policy............................................................................................................................................................................... 23
8.2 Internal assessments.........................................................................................................................................................23
8.2.1 Internal Audits.........................................................................................................................................................23
8.2.2 Review and follow up of corrective actions............................................................................................................23
8.2.3 Quality indicators....................................................................................................................................................23
8.2.4 Staff suggestions......................................................................................................................................................23
8.2.5 Review of requests, methods and sampling requirements.......................................................................................24
8.3 External assessments........................................................................................................................................................24
8.3.1 External Quality Assessment/ Proficiency testing..................................................................................................24
8.3.2 Customer feedback..................................................................................................................................................24
8.3.3 External audits.........................................................................................................................................................24
9. QSE: Personnel.....................................................................................................................25
9.1 Policy............................................................................................................................................................................... 25
9.2 Recruitment......................................................................................................................................................................25
9.3 Personnel file / health file................................................................................................................................................25
9.4 Integration and clearance.................................................................................................................................................25
9.5 Training............................................................................................................................................................................ 25
9.6 Staff competency.............................................................................................................................................................26
9.7 Personnel performance appraisal.....................................................................................................................................26
9.8 Continuous education......................................................................................................................................................26
9.9 Non-permanent personnel................................................................................................................................................26
9.10 Supporting documents...................................................................................................................................................26
10. QSE: Customer Focus.........................................................................................................27
10.1 Policy............................................................................................................................................................................. 27
10.2 Customers satisfaction measurement.............................................................................................................................27
10.3 Claims management.......................................................................................................................................................27
11. QSE: Nonconforming Event Management.........................................................................28
11.1 Policy............................................................................................................................................................................. 28
11.2 Corrective Actions.........................................................................................................................................................28
12. QSE: Continual Improvement............................................................................................29
12.1 Policy............................................................................................................................................................................. 29
12.2 Quality indicators...........................................................................................................................................................29
12.3 Management review.......................................................................................................................................................29
12.4 Preventive action............................................................................................................................................................30
13. QSE: Documents and Records............................................................................................31
13.1 Policy............................................................................................................................................................................. 31
13.2 Documentation management.........................................................................................................................................31
13.3 Documents and records control.....................................................................................................................................31
13.4 Archiving....................................................................................................................................................................... 32
13.5 Review of contracts.......................................................................................................................................................32
WCH/LQMS/D002
Quality Manual
4
Version: Original
14. QSE: Information Management..........................................................................................33
14.1 Policy............................................................................................................................................................................. 33
14.2 Information system - Security........................................................................................................................................33
14.3 Confidentiality...............................................................................................................................................................33
15. Appendices..........................................................................................................................34
WCH/LQMS/D002
Quality Manual
5
Version: Original
1. Introduction to the Quality Manual
1.1 Overview of the organisation

The White Crescent Hospital laboratory provides biochemistry, immunology, microbiology,
parasitology, haematology testing and other tests relevant to medicine and/or disease surveillance
to physicians, health care providers, and epidemiologists for the benefit of the patient and
population.
The laboratory has adopted a quality management system for the purpose of the effective and
efficient use of its resources. All employees are committed to the culture of quality. All staff
shares responsibility for identifying nonconformities or opportunities for improvement, recording
these instances so that corrective or preventive actions can be taken to ensure the laboratory meets
the needs of its customers.
1.2 Mission statement

To provide quality laboratory services in a timely, accurate and efficient manner to ensure
high-quality patient care and enhance patient health..
1.3 Vision statement

To be a successful, reputable, trusted and an environmental friendly laboratory that can provide
our customers with a wide range of laboratory testing, environmental monitoring, sampling and
surveying services.
1.4 Objectives
The objectives of the laboratory are to produce accurate, reliable and timely analyses' results,
achieve and maintain an effective quality management system and ensure compliance with
relevant statutory and safety requirements.
1.5 Scope
This quality manual describes the quality management system of the White Crescent Hospital
laboratory. Its scope is for:
 Internal use - to communicate to staff the laboratory’s quality policy and quality objectives, to
make the staff familiar with the processes used to achieve compliance with quality
requirements. This should facilitate the implementation of the quality management system as
well as ensure its maintenance and required updates during altering circumstances. This
should also allow effective communication and control of quality related activities and a
documented base for quality system audits.
 External use - to inform the White Crescent Hospital laboratory’s external partners about its
quality policy as well as its implemented quality management system and measures of
compliance with quality.
WCH/LQMS/D002 6
Quality Manual
Version: Original
2. Quality Policy
Senior management is dedicated to providing the resources necessary to maintain the laboratory
quality management system and to ensure the laboratory’s participation in the institutional quality
plan.
The laboratory is committed to continual improvement, meeting internal requirements and customer
requirements, and providing a basis for the establishment and review of the quality objectives.
Quality practices are communicated within the organization, understood and adhered to by all
employees.
The laboratory ensures a competent workforce to deliver quality results in a timely manner according
to the chosen internationally or nationally recognized standards.
11/09/2023
Mark KAVAI
Sign__M.K____________
WCH/LQMS/D002
Quality Manual
7
Version: Original
3. QSE: Organization
3.1 Organization Policy

The laboratory manager has the authority, competence and responsibility for the services provided.
Laboratory management ensures the following:

 there are no activities that could compromise laboratory performance;
 there are appropriate procedures to ensure ethical respect of patient samples and
confidentiality of patient information;
 duties and responsibilities of laboratory personnel are defined;
 appropriate communication is established within the laboratory;
 A quality manager biosafety officer are designated.
3.2 Conflict of interest

The White Crescent Hospital laboratory is not engaged in any activity that might influence its
technical judgment. The laboratory is not committed to any commercial, financial or other pressure
provided by any particular organization that could influence its technical judgment or affect its
competencies and trust.
3.3 Organization chart

The laboratory collaborates with other departments such as the human resources department, training
and education department, finance department, procurement department, as well as support services.
The laboratory internal organization consists of a team of 1 professional shown in the organizational
chart below:
Laboratory Director/Manager: Mark Kavai
Quality manager: Mark

Kavai
Microbiology Biochemistry Haematology

department department department
WCH/LQMS/D002
Quality Manual
8
Version: Original
3.4 Internal communication
The management ensures appropriate communication takes place to keep staff members informed.
Monthly meetings are held for all personnel in the laboratory. During the meetings:
 activities of the month are reviewed and activities to be performed are defined
 All information on general organization, actions and projects is communicated.
Minutes (notes) are taken of meeting discussions, followed by a written report.
3.5 Personnel responsibilities
Laboratory director/manager
 designs, approves, implements and maintains the quality management system;

 ensures that the necessary human and material resources, as well as the necessary information,
are available to enable effective operation and control of the processes of the quality
management system;
 delegates tasks to qualified personnel;
 selects suppliers;
 manages contracts;
 ensures adequate training;
 Ensures internal and external communication.
Quality manager
 assesses the facilities, procedures, practices, and training of personnel involved in the
laboratory’s activities, in regard to the quality management system;
 reviews the quality plan annually and recommends any revisions needed to the laboratory’s
director/manager;
 seeks advice from different departments and specialists and may require assistance from
independent experts;
 establishes an internal audit program and informs the laboratory director/manager of audit
outcomes;
 ensures that the quality management system is managed and maintained;
 establishes and monitors all processes and procedures for the quality management system;
 resolves nonconformities;
 ensures that action is taken in order to obtain continuous improvement of processes/activities;
 Ensures all staff has up-to-date QMS training.
Supervisor
 plans and co-ordinates the work schedule;

 ensures stock management/material management;
WCH/LQMS/D002
Quality Manual
9
Version: Original
 ensures activities/processes included in the scope of the quality management system are
identified and performed in compliance with this manual;
 applies the necessary techniques and criteria in order to verify that established
processes/activities and their implemented controls are effective;
 evaluates and identifies new products.
Technologist
 manages, protects, and preserves stock;

 manages and maintains equipment;
 provides technical advice on laboratory quality procedures to personnel;
 reports to the supervisor any significant problems of which he/she becomes aware in daily
practice.
 performs the tests;
 controls and maintains equipment;
 reports to the technologist/head technician any significant problems of which he/she becomes
aware in daily practice;
 checks performance of internal quality controls to validate the tests.
3.6 Supporting documents
Processes ID Code
Communication
Conflict of interest
Review of the general organization
Procedures
Meetings management
Internal communication
Ethics and conflict of interest
Organization review
Forms/Logs
Meeting minutes
Conflict of interest and ethics form
WCH/LQMS/D002
Quality Manual
10
Version: Original
4. QSE: Facilities and Safety
4.1 Policy
The laboratory is provided with sufficient space and reliable infrastructure to perform its work, to
ensure the quality, safety and efficacy of the services provided.
The laboratory design provides an efficient and safe environment for the laboratory staff, other health
care personnel, patients, and the community.
Personnel are trained in the basics of safety and biorisk management issues.
4.2 Facilities
The laboratory has several rooms, each designated for specific uses; for example, offices, storage
facilities, washrooms, patient collection area, and laboratory working areas.
4.3 Security
The laboratory reception is clearly marked with the appropriate signage. Access to all facilities other
than reception is restricted to authorized personnel.
Access to the laboratory outside the opening hours is limited to laboratory management, technical staff
and to personnel on duty call.
A 24-hour security service is in effect.
The facilities and zones at risk are linked to an alarm system at the central post of security.
4.4 Working environment

All manipulation presenting a risk of contamination (for the operator, environment and/or sample) is
isolated from other activities.
Working areas are kept clean, dust free and are well maintained.
A complete and thorough description of safety rules is available and all personnel are trained in safety
and biorisk management issues when working with chemicals and samples. Further details can be
found in the safety manual.
4.5 Waste disposal

Waste (chemical, biological and other) is segregated and disposed according to national regulations on
waste disposal. People in charge of the waste disposal are trained to handle biohazardous waste.
WCH/LQMS/D002
Quality Manual
11
Version: Original
Processes ID Code
Facility maintenance
Security
Safe working environment
Waste disposal
Procedures
Safety manual (all specific safety procedures including biosafety)
Facility maintenance
Safe manipulation
Security
Waste disposal
Forms/Logs
Incident report form
Visitors log
Housekeeping log
WCH/LQMS/D002 12
Quality Manual
Version: Original
5. QSE: Equipment
5.1 Policy
The management of the laboratory ensures that equipment is properly selected, installed, validated,
maintained and disposed of according to established procedures and manufacturer's instructions to
meet the needs of the laboratory to perform quality diagnostic testing.
5.2 Selection of Equipment

This section is developed in chapter 6 Purchasing and Inventory.
5.3 Installation and acceptance Criteria

New instruments and equipment are installed, calibrated and documented by the vendor who assures
satisfactory performance.
The laboratory ensures space, ventilation, humidity and electricity meet specifications for satisfactory
performance.
The laboratory provides documentation that each instrument meets all the required criteria for its use
in the laboratory.
5.4 Equipment Inventory and master file

All equipment is uniquely identified (serial number and unique number developed by the laboratory).
An equipment file is maintained for inventory for all equipment
The inventory represents the list of all equipment, and persons in charge of the different pieces of
equipment. Updating of this inventory is ensured by the persons in charge of the equipment The same
for the attribution of the inventory number of each piece of equipment.
The following information is in the master file:

 name of the equipment
 brand (manufacturer)
 inventory number
 serial number
 model and year
 location
 cost
 date of purchase
 date of first use
 Type of maintenance (contract with an external company, in house, etc.)
 regular preventive maintenance to be performed, and frequency to perform these activities
 calibration activities
 record of preventive maintenance activities
 record of repairs
 parts of the equipment that have been changed or repaired.
WCH/LQMS/D002
Quality Manual
13
Version: Original
5.5 Validation
The laboratory validates each new piece of equipment.
The validation process depends on the type of equipment and its use in the laboratory. Reproducibility
and accuracy tests are performed, documented, reviewed and approved before the instrument is used in
the testing environment.
All equipment used for specific testing is the responsibility of staff in charge of that discipline.
The responsible staff conducts or delegates the required calibrations of the equipment and maintains
records of all interventions on the equipment.
Use and maintenance of each equipment is based on the manufacturer's instructions.
A standard operating procedure (SOP) on the use, maintenance and safety risks of the equipment is
accessible at the bench.
The operating manual of each piece of the equipment is available in the language spoken and
understood by the laboratory staff.
5.6 Preventive maintenance and repair

Preventive maintenance is recorded in the instrument daily logbook.
Maintenance contracts and warranty service are documented and maintained
Defective or malfunctioning equipment is identified with label alerting that it is not in use.
Equipment requiring service due to a malfunction is decontaminated following manufacturers

requirements.
Serviced or repaired equipment is calibrated to ensure it meets the manufacturer’s performance

criteria.
5.7 Decommissioning
Obsolete equipment is decontaminated and removed from the laboratory.
Processes ID Code
Selection and acquisition of equipment (see chapter 6 Purchasing and Inventory)
Equipment installation
Equipment repair
Decommissioning
Equipment identification
WCH/LQMS/D002
Quality Manual
14
Version: Original
Procedures
Equipment selection (see chapter 6 Purchasing and Inventory)
Equipment validation
Equipment identification
Decontamination of laboratory equipment
Equipment decommission
Equipment SOPs (calibration, operation and maintenance of each piece of equipment)
Forms/Logs
Laboratory equipment disposal form
Checklist for decontamination
Service certification
WCH/LQMS/D002
Quality Manual
15
Version: Original
6. QSE: Purchasing and Inventory
6.1 Policy
The White Crescent Hospital laboratory ensures an uninterrupted supply of consumables and/or
services are available to perform all quality laboratory functions.
The laboratory maintains a list of vendors that meet the requirements for the product or service to be
purchased. The laboratory strives to purchase high quality reagents at a reasonable cost and without
bias.
The laboratory has a documented procedure for ordering, receiving, documenting, evaluating and
storing all consumables supplies.
The laboratory has an inventory management system.
The laboratory selects its referral laboratories and is responsible for all tests performed by these
laboratories.
6.2 Reagents and consumables management

The laboratory ensures that the procedures for the purchase, receipt and storage of all reagents
guarantee that the quality of testing is not compromised.
All new lots of reagents are crosschecked and documented with previous lots to ensure reproducibility.
Environmental conditions for the storage of all reagents and consumables are monitored and
documented.
The laboratory maintains a record of all laboratory supplies, including reagents and consumables. This
information includes:
 identity of the reagent or consumable;
 manufacturers name;
 contact information for the supplier or the manufacturer;
 date of receiving and date of entering into service;
 condition when received (e.g. acceptable or damaged);
 manufacturers’ instructions;
 records that confirmed the reagent's or consumables initial acceptance for use;
 Performance records that confirm the reagents or consumables ongoing acceptance for use.
6.3 Selection and evaluation of providers

The laboratory evaluates the providers for the reagents, consumables and equipment. The evaluation
should be conducted against defined criteria which may include:
 value for money
 post-delivery support
 availability
 in-country distribution
 registration of the provider.
WCH/LQMS/D002
Quality Manual
16
Version: Original
All the evaluations are recorded and a list of retained providers is established.
6.4 Procurement
6.4.1 Equipment procurement

The laboratory ensures that when purchasing, leasing or acquiring new equipment, it conforms to the
established requirements (for example testing capacities). See chapter 5 Equipment.
6.4.2 Reagents, consumables and materials

Purchasing orders
The orders for purchase of supplies (reagents, consumables and materials) are requested using a
specific form and submitted to the provision/purchasing department.
Receipt of orders
The laboratory confirms receipt of the supplies both for external and internal orders
The date of receipt is recorded.
The person in the laboratory taking receipt of the supplies crosschecks the information indicated on
the package and accompanying documents with the data of the order.
6.5 Stock management and inventory

The laboratory has a stock management system to ensure consumables are stored under correct
environmental conditions and are used prior to their expiration dates.
A regular inventory is performed.
6.6 Referral laboratories / subcontracting

The laboratory is responsible for all tests performed by another laboratory on patient samples that are
referred. The laboratory should select referral laboratories according to pre-defined criteria.
It will be the quality manager’s responsibility to designate the laboratories and/or companies with
whom they will subcontract tests or calibration. These will be listed and kept in a folder with all
documents referring to the subcontractors.
Subcontracting of samples may occur under any of the following circumstances:

 test not performed routinely by the laboratory
 instrument breakdown or reagents not available
 workload restrictions
 client requested turnaround time cannot be met.
Where a laboratory subcontracts any part of the calibration of equipment, this work is contracted with
a company complying with the requirements of this quality manual.
The laboratory ensures and can demonstrate that its subcontractor is competent to perform the
activities in question.
WCH/LQMS/D002
Quality Manual
17
Version: Original
WCH/LQMS/D002
Quality Manual
18
Version: Original
Processes ID Code
Selection and acquisition of equipment, reagents, consumables and service providers (see
chapter 5 Equipment)
Receipt of supplies
Stock and inventory management
Procedures
Selection
Purchasing
Receipt
Stock management
Inventory management
Forms/Logs
List of providers
List of referral laboratories
Stock log
Inventory log
WCH/LQMS/D002 19
Quality Manual
Version: Original
7. QSE: Process Management
7.1 Policy
The laboratory has processes for each phase of the sample processing: pre-examination, examination
and post-examination phases, to ensure accurate and reliable testing.
The laboratory has quality control measures to monitor the examination phase of testing (qualitative,
quantitative and semi-quantitative).
Processes following the path of workflow:
WCH/LQMS/D002
Quality Manual
20
Version: Original
7.2 Sample management
7.2.1 Specimen collection and transport

The laboratory provides written instructions for specimen collection and transport.
The laboratory provides specimen containers.
Specimen transport follows national or international transport guidelines or regulations.
7.2.2 Specimen/sample receiving

The laboratory establishes written specimen/sample acceptance and rejection criteria for each test
offered and provides this information to its customers, as applicable. All specimens/samples are
inspected according to these acceptance/rejection criteria.
The laboratory rejects specimens/samples that are not suitable for processing. The requestor is notified
of the reason for rejection. If the specimen/sample is critical and cannot be rejected, the examination is
performed and a notation is made on the report.
In the case of critical specimens/samples, such as one of limited volume, the laboratory management
consults with the requestor to prioritize testing.
A unique registration number is assigned to each specimen/sample to be analysed.
All patient’s data is recorded in a laboratory register
7.2.3. Specimen/sample handling, preparation and storage

If the specimen needs to be shared for different tests throughout the laboratory and/or storage
purposes, each aliquot (sample) is labelled individually with the unique registration number.
Samples are stored under proper temperature and safety conditions.
7.3 Method validation

The laboratory is in charge of diagnostics in all laboratory departments
The methods developed in the laboratory have been through a documented validation process.
The methods used in the laboratory, that have been published in scientific reviews or transmitted by
national or international reference centers, have been verified and documented under the laboratory's
conditions and adapted when needed.
The methods and techniques used in the laboratory are described in the standard operating procedures
(SOPs) and associated documents
N/A
7.6 Quality Control

The laboratory has a Quality Control (QC) program with written policies and procedures.
WCH/LQMS/D002
Quality Manual
21
Version: Original
Laboratory technical staff is trained to review and take appropriate action regarding quality control
data.
Internal quality controls are required to ensure the results are valid.
The laboratory quality control program is a monitoring system that:

 first, provides immediate information for making the decision about the acceptability of
patient results;
 second, provides a method for evaluating data over time to help in making decisions about the
overall performance of the test procedure. These controls are run on both qualitative (result is
positive or negative) and quantitative (result is a number or value) tests. The resulting data is
recorded in such a way that trends are detectable and, where practicable, statistical techniques
are applied to the reviewing of the results.
Equipment calibration and servicing are monitored.
The examinations’ results are documented by the technologists on the corresponding records and
recorded in a computer system to create a permanent traceable record.
If QC results are not validated, patients’ examination results cannot be reported.
When problems occur the laboratory investigates, corrects and repeats sample testing (see chapter 11
Nonconforming Event Management).
7.7 Reporting
Examination results are reviewed by a laboratory quality manager and agreed upon before
transmission. If discrepancies occur the quality manager initiates corrective actions.
The quality manager contacts the clinician, ward or public health service for further clinical details, if
needed, or to transmit critical results.
Final reports are signed by the quality manager and released to the requestor.
7.8 Sample retention and disposal

Retention of the samples is done according to the laboratory’s policy and respects national regulations.
For disposal of samples, refer to chapter 4 Facilities and Safety.

Processes ID Code
Sample collection, transport, receipt, processing and storage
Method validation
Quality control
Reporting
Procedures
General sampling conditions
WCH/LQMS/D002
Quality Manual
22
Version: Original
Sample labelling
Sample rejection or acceptance
Sample transport
Sample storage and disposal
Analytical SOPs (procedure for each examination/test performed)
Results validation
Critical results reporting
Results reporting
Forms/Logs
Quality control logs
Test result form
List of examinations
Test request form
WCH/LQMS/D002
Quality Manual
23
Version: Original
8. QSE: Assessments
8.1 Policy
The laboratory performs ongoing quality assessments such as:
 periodic review of examination requests, suitable methods and sampling requirements;
 monitoring and evaluation of customer feedback, staff suggestions and impact of potential
failures on examination results and customer expectations;
 monitoring of determined quality indicators, corrective actions undertaken, and follow-up;
 participation in proficiency testing program and review of the corresponding reports;
 Participation in internal and external audits.
The laboratory strives to continuously improve the quality of laboratory performance, the
effectiveness of the quality management system and the reliability of test data.
The laboratory does its best to identify and resolve any nonconformity that may affect laboratory
performance and patient outcome.
8.2 Internal assessments
8.2.1 Internal Audits

During internal audits, information is gathered about:
 processes and operating procedures
 staff competence and training
 equipment
 environment
 handling of samples
 quality control and validation of results
 recording and reporting practices.
The findings are compared with the laboratory’s internal policies and to ISO 15989 .Any breakdown
in the system or departure from procedures should be identified.
Any gap or nonconformity in performance shows if the policies and procedures that the laboratory has
set require revision or are not being followed.
8.2.2 Review and follow up of corrective actions

All corrective actions undertaken in the laboratory will be reviewed and their follow up evaluated.
This is described in the chapter 11 Nonconforming Event Management.
8.2.3 Quality indicators

Quality indicators have been determined for a month to monitor the quality objectives of the
laboratory.
This monitoring is detailed in chapter 12 Continual Improvement.
WCH/LQMS/D002
Quality Manual
24
Version: Original
8.2.4 Staff suggestions
All staff is encouraged to offer suggestions for improvement of any aspect of the laboratory. These
suggestions are recorded, evaluated and implemented if useful. Feedback on the suggestions
implemented is provided to the staff.
8.2.5 Review of requests, methods and sampling requirements

Requests are systematically reviewed to evaluate the appropriateness of the methods used for the test
required.
The required sample volume and general sampling requirements are also reviewed every biannually to
ensure that samples are collected properly and in the correct volume needed for the best performance
of the test.
8.3 External assessments
8.3.1 External Quality Assessment/ Proficiency testing

Proficiency testing serves as a tool for quality improvement in the laboratory. One of the major
benefits is identifying performance issues and correcting them.
List of the External Quality Assessment (EQA) programmes in which the laboratory participates in:
……
..
8.3.2 Customer feedback

Customer feedback is collected and reviewed on a regular basis. This is described in the chapter 10
Customer Focus.
8.3.3 External audits
Assessment reports are shared with all staff. Corrective actions are undertaken accordingly.
Processes ID Code
Internal and external audits
Quality indicators
EQA programmes selection
See chapters 10 Customer Focus, 11 Nonconforming Event Management, and 12
Continual Improvement
Procedures
Internal audit
WCH/LQMS/D002
Quality Manual
25
Version: Original
Preparing for external audit
Follow up staff suggestion
EQA review
Forms/Logs
Audit checklist
Staff suggestion form
List of EQA programmes
WCH/LQMS/D002
Quality Manual
26
Version: Original
9. QSE: Personnel
9.1 Policy
The laboratory recognizes that its most important resource is its personnel.
The laboratory management defines staff educational requirements and competency qualifications
necessary for conducting laboratory procedures.
The laboratory management strives to ensure recruitment is unbiased.
The laboratory works with the Human Resources department to ensure education qualifications and
references of job applicants are checked and to ensure legal contracts/agreements are signed by all
parties prior to employment or within a month.
The laboratory has a documented procedure for personnel management.
All personnel (temporary, permanent, students, etc.) sign a confidentiality agreement.
All laboratory personnel respect the laboratory rules concerning health, safety and security.
The laboratory provides training to its staff according to its needs.
9.2 Recruitment
The manager submits a completed staff recruitment form to the human resources department describes
the appropriate education, training, experience, and skills needed for the available position. The dates
of the position are clearly stated. Interviews are arranged by the Human Resources department.
9.3 Personnel file / health file

An individual administrative file is established for each staff member (temporary, permanent, trainee,
etc.) that contains documents concerning the staff qualifications (degree, diplomas, CV, training
certificate, etc.). Certain documents may be managed and stored by the Human Resources department
The orientation record, competency assessments, training records, continuing education, job
descriptions are stored in the laboratory in a controlled access area and updated regularly by the
quality manager.
Each new staff member or trainee requires a medical check-up within 30 days of arrival. The capacity
certificate for the given activities is stored in the staff's individual file along with the list of applicable
vaccinations.
9.4 Integration and clearance

Staff orientation of all new employees is to be completed within 30 days of hire.
Safety orientation occurs before an employee is assigned to duties.
All newly hired employees are trained comprehensively on all policies and procedures in the
department that apply to their job description and assignments (see 9.6 Staff competency, below).
WCH/LQMS/D002
Quality Manual
27
Version: Original
9.5 Training
The laboratory provides training for all personnel, which includes the quality management system,
assigned work processes and procedures, the laboratory information system, health and safety, ethics
and confidentiality.
The effectiveness of the training program is periodically reviewed.
9.6 Staff competency

Staff competencies cover technical and practical skills and general knowledge.
Competency of each new employee is assessed and verified before permitting to perform testing and
report results.
All employees are assessed for competency on an annual basis.
9.7 Personnel performance appraisal

Each staff is given the opportunity for an annual interview with the laboratory director/manager.
9.8 Continuous education

A continuing education program is available for the professional development of staff. Expectations
for staff participation are communicated for those education sessions that are deemed mandatory.
9.9 Non-permanent personnel

Non-permanent personnel such as students, post doctorates and trainees follow the general laboratory
orientation procedures for integration in the laboratory.

Processes ID Code
Orientation, training and competency
Recruitment
Continuing education
Performance appraisals
Personnel record maintenance
Procedures
Orientation
Internal training
Competency assessment
Personnel handbook (group of procedures)
Recruitment
Forms/Logs
WCH/LQMS/D002
Quality Manual
28
Version: Original
Orientation checklist
Competency assessment checklist
Competency assessment logbook
Performance appraisal form
Training logs
WCH/LQMS/D002
Quality Manual
29
Version: Original
10. QSE: Customer Focus
10.1 Policy
The White Crescent Hospital laboratory management is dedicated to providing quality and timely
service to all customers, both internal and external. The laboratory management commits to providing
adequate resources to meet customers’ requirements and to provide an on-going program for continual
improvement.
10.2 Customer satisfaction measurement

Customer surveys are implemented. The objective is to assess the satisfaction of the main customers:
patients, clinicians and public health institutes.
The analysis of survey results leads to implementation of corrective actions where needed.
10.3 Claims management

Complaints are managed in order to lead to corrective or preventive actions (also refer to chapter 11
Nonconforming Event Management, and chapter 12 Continual Improvement).
The objective is to ensure continuous improvement of the quality system by taking into account the
customers' concerns. The claim management will facilitate tracking and investigating potential non-
satisfaction of customers.
Processes ID Code
Customer satisfaction
See chapters 11 Nonconforming Event Management, and 12 Continual Improvement
Procedures
Customer survey
Customer complaint
Forms/Logs
Customer survey form/questionnaire
Customer complaint logbook
Incident report
WCH/LQMS/D002
Quality Manual
30
Version: Original
11. QSE: Nonconforming Event Management
11.1 Policy
The White Crescent Hospital laboratory is committed to the identification, documentation, correction,
and prevention of nonconforming events in all aspects of the quality management system including
pre-examination, examination and post-examination processes. Procedures are in place that:
 designate the individuals responsible and actions necessary for handling nonconformities;
 ensures that each nonconforming event is documented, recorded, and reviewed at identified
intervals, a root cause analysis performed, and that corrective action is taken and documented;
 define when testing procedures and data reporting will be withheld due to nonconformities
and when, and under what conditions, examination can resume;
 defines the steps taken when examination data resulting from a nonconforming event has
already been released.
11.2 Corrective Actions

All nonconforming events (from occurrence reports, claims, audit reports, patient/customer
complaints, failed proficiency testing, etc.) are recorded, tracked, trends identified, and root cause
analysis performed. The appropriate corrective actions are taken.
The results of an occurrence assessment are communicated to management and become part of
periodic management review.
The objective is to ensure continuous improvement of the quality system.
Processes ID Code
Documentation, review of nonconforming events and corrective actions
Nonconforming event resolution
See chapters 7 Process Management, and 10 Customer Focus

Procedures
Handling nonconformities
Nonconforming event management
Corrective actions
Forms/Logs
Incident report
Corrective actions
WCH/LQMS/D002
Quality Manual
31
Version: Original
12. QSE: Continual Improvement
12.1 Policy
The laboratory continuously improves the effectiveness of its quality management system and its
processes, as stated in its quality policy and quality objectives.
A management review is performed annually to evaluate the laboratory’s quality management system,
evaluation activities, corrective actions and preventive actions.
The laboratory develops an action plan according to improvement needs every 3 months and monitors
the effectiveness of the actions undertaken.
12.2 Quality indicators

The laboratory establishes quality indicators to monitor and evaluate performance of its processes
every 3 months period of time.
These indicators are regularly monitored as for their concordance with the defined objectives and the
activities established in the laboratory. These indicators are presented during the annual management
review.
12.3 Management review

The annual management review ensures that the organization and the activities of the laboratory
remain appropriate and efficient. Therefore, it allows the evaluation and continuous improvement of
the efficiency of the quality system of the laboratory.
The elements reviewed are related to the quality system management.
Elements of entry of the management review:

 quality objectives of the past year
 quality indicators
 occurrences and nonconforming events recorded
 customer complaints reports
 customer satisfaction survey reports
 internal audit reports
 proficiency testing reports
 corrective/preventive actions and follow up
 changes in work load or type of work
 all pertinent factors: resources, future activities, etc.
Elements of output of the management review:

 actions for improvement
 definition of the quality objectives for the next year
 establishment of new quality indicators in concordance with the new quality objectives
 improvement of the quality management system.
WCH/LQMS/D002
Quality Manual
32
Version: Original
12.4 Preventive action
The laboratory reviews the data and implements preventive actions allowing the laboratory to
anticipate eventual nonconforming events in its activities. A follow up of the actions implemented for
improvement is ensured in the same way as described in chapter 11 Nonconforming Event
Management.

Processes ID Code
Continual review
Quality indicators
Management review
See chapters 8 Assessments, and 11 Nonconforming Event Management
Procedures
Quality indicators (including management and use)
Management review
Evaluation activities (see chapter 8 Assessments)
Forms/Logs
Review logs
Preventive actions
WCH/LQMS/D002
Quality Manual
33
Version: Original
13. QSE: Documents and Records
13.1 Policy
The laboratory ensures that documents and records are managed from creation and receipt to archival
and destruction, according to national laws, local regulations and international standards.
13.2 Documentation management

The four levels of documentation are represented in the pyramid below.
Policies
Processes
Procedures (SOPs)
Records (evidence)
The quality manager reviews and approves all requests for amendments to existing documents and the
development of new procedures, processes, and policies.
Staff is not permitted to make temporary amendments to documentation without the prior consent of
the quality manager.
When new or modified policies, processes and procedures are instituted, staff requires retraining.
The quality manual is reviewed annually. All laboratory procedures are reviewed on an annual basis.
The responsibility for the annual review lies with the document manager or quality manager.
The document manager or quality manager is responsible for the distribution of new documents,
retrieval of old documents and maintenance of records of amendments.
13.3 Documents and records control

All documents are uniquely identified. Date of issue, revision version, total number of pages and
authorizing signatories are included in the document.
Documents are signed as a paper copy or authorized electronically.

WCH/LQMS/D002
Quality Manual
34
Version: Original
A document control log is maintained identifying the current valid versions and their distribution.
A secure master file is maintained of all documents to prevent unauthorized access, loss or damage.
13.4 Archiving
The document manager or quality manager is responsible for the proper archiving of documents and
records.
The laboratory respects the national regulations or legislations concerning the retention time of all
records.
A copy of an obsolete document is kept to provide a means for review if the situation arises.
13.5 Review of contracts

Refer to section 6.6
Processes ID Code
Identification and control of documents and records
Creation, edit, review and approval of documents
(Example: Internal documents management)
Archive and retention of documents
Contract review
Procedures
SOP management
Document management
Short term archiving
Long term archiving
Document control
Contract review
Forms/Logs
Document control logbook
WCH/LQMS/D002
Quality Manual
35
Version: Original
14. QSE: Information Management
14.1 Policy
The White Crescent Hospital laboratory has access to the data and information needed to provide a
service that meets the needs and requirements of internal and external customers. The laboratory
information system (LIS) provides for the collection, processing, recording, storage, and retrieval of
data, and has documented procedures in place to ensure the confidentiality of patient information and
the security of the data during each step of the process.
14.2 Information system - Security

The information management system used in the laboratory is managed by the informatics department.
This department is in charge of installing on each computer a backup and antivirus system and has
procedures in place to meet national and international requirements for data protection and to restrict
unauthorized access.
14.3 Confidentiality
The personnel (temporary, permanent, student, etc.), whatever the duration of their contract, will sign
a confidentiality agreement.
The laboratory has a secure process for archiving and/or data disposal; refer to chapter 13 Documents
and Records.
Processes ID Code
Information security and confidentiality
Selection of an information management system (see chapter 6 Purchasing and Inventory)
LIS down-time
Procedures
Transmission of results
Informatics system maintenance
Back up
LIS down-time
Retrieval of data (manual or computerized)
Forms/Logs
LIS down-time log
Back up log
WCH/LQMS/D002
Quality Manual
36
Version: Original
15. Appendices
Appendix 1: SOP: Meetings management
Appendix 2: SOP: Safe manipulation
Appendix 3: Process: Equipment installation
Appendix 4: Process: Equipment repair
Appendix 5: SOP: Decontamination of laboratory equipment; Forms: Checklist for decontamination,

Certification for service
Appendix 6: SOP: Equipment decommission; Form: Laboratory equipment disposal
Appendix 7: SOP: General sampling conditions
Appendix 8: SOP: Sample labelling; Form: Test request
Appendix 9: SOP: Sample rejection or acceptance
Appendix 10: SOP: Sample transport
Appendix 11: SOP: Results validation
Appendix 12: SOP: Critical results reporting
Appendix 13: SOP: Internal audit
Appendix 14: Form: Orientation checklist
Appendix 15: SOP: Internal training
Appendix 16: SOP: Competency assessment; Forms: Competency assessment checklist, Competency
assessment logbook
Appendix 17: SOP: Customer survey
Appendix 18: SOP: Customer complaint
Appendix 19: SOP: Nonconforming event management
Appendix 20: Process: Internal documents management
Appendix 21: SOP: SOP management
Appendix 22: SOP: Document management
Appendix 23: SOP: Short term archiving
Appendix 24: SOP: Document control; Form: Document control logbook
WCH/LQMS/D002 37
Quality Manual
Version: Original

THE LABORATORY QUALITY MANUAL Temp

Uploaded by

Copyright:

Available Formats

THE LABORATORY QUALITY MANUAL Temp

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

THE LABORATORY QUALITY MANUAL Temp

Uploaded by

Copyright:

Available Formats

QUALITY MANUAL

Written by Reviewed by Authorized by

Mark Kavai Mark Kavai

Date: 11/09/2023 Date:11/09/2023 Date:

BSL Biosafety Level

CDC Centers for Disease Control and Prevention, USA

CLSI Clinical and Laboratory Standards Institute, Wayne, Pennsylvania, USA

EQA External Quality Assessment

ISO International Organization for Standardization

LIS Laboratory Information System

LQMS Laboratory Quality Management System

QMS Quality Management System

QSE Quality System Essential

SOP(s) Standard Operating Procedure(s)

WHO World Health Organization

Next Review: August 2025

Next Review: August 2025

Next Review: August 2025

Next Review: August 2025

1.1 Overview of the organisation

1.2 Mission statement

1.3 Vision statement

Next Review: August 2025

3.1 Organization Policy

Laboratory management ensures the following:

3.2 Conflict of interest

3.3 Organization chart

Laboratory Director/Manager: Mark Kavai

Quality manager: Mark

Microbiology Biochemistry Haematology

Next Review: August 2025

Minutes (notes) are taken of meeting discussions, followed by a written report.

3.5 Personnel responsibilities

 designs, approves, implements and maintains the quality management system;

 plans and co-ordinates the work schedule;

Next Review: August 2025

 manages, protects, and preserves stock;

3.6 Supporting documents

Next Review: August 2025

A 24-hour security service is in effect.

4.4 Working environment

4.5 Waste disposal

Next Review: August 2025

5.2 Selection of Equipment

5.3 Installation and acceptance Criteria

5.4 Equipment Inventory and master file

An equipment file is maintained for inventory for all equipment

The following information is in the master file:

Next Review: August 2025

Use and maintenance of each equipment is based on the manufacturer's instructions.

5.6 Preventive maintenance and repair

Maintenance contracts and warranty service are documented and maintained

Equipment requiring service due to a malfunction is decontaminated following manufacturers

Serviced or repaired equipment is calibrated to ensure it meets the manufacturer’s performance

5.8 Supporting documents

Next Review: August 2025

Next Review: August 2025

The laboratory has an inventory management system.