Quality Manual

/ Diagnostics Division
South Glasgow, Department of Haematology
Quality Manual / SG-MPOL-001
Version 3.0
Active Date: 4th January 2018
Author / M McBrearty / Authorised By / T Moffat / Page 1 of 49

QUALITY MANUAL

Current Version Number / 3.0
Date of initial version / 01/04/2008
Date of activation of current version / 04/01/2018
Review interval / Annually
Authorised by / Tom Moffat
Author / Maureen McBrearty

Contents

Abbreviations and Acronyms

1.Introduction

1.1.Overview of the organization

1.2.NHSGGC Mission statement

1.3.Objectives

1.4.Scope

2.Quality Policy Statement

3.Organisation and Management Responsibility (4.1)

3.1.Organisation (4.1.1. and 4.1.1.1.)

3.1.1.Legal Entity (4.1.1.2.)

3.1.2.Ethical Conduct (4.1.1.3.)

3.1.3.Laboratory Director (4.1.1.4.)

3.1.4.Organisational charts

3.2.Management responsibility (4.1.2.)

3.2.1.Management Commitment (4.1.2.1.)

3.3.Needs of Users (4.1.2.2)

3.3.1.Quality Policy (4.1.2.3.)

3.3.2.Quality Objectives and Planning (4.1.2.4.)

3.3.3.Responsibility, Authority and Interrelationships (4.1.2.5.)

3.3.4.Communication (4.2.1.6.)

3.4.Quality Manager (4.1.2.7)

4.Quality Management System (4.2)

4.1.Documentation (4.2.2.1)

4.2.Quality Manual (4.2.2.2.)

5.Document Control (4.3)

6.Service Agreements (4.4)

6.1.Establishment of Service Agreements (4.4.1, 4.4.2.)

7.Referral Laboratories (4.5)

7.1.Selection and Evaluation (4.5.1.)

7.2.Results from Referral Laboratories (4.5.1.)

8.External Services and Supplies (4.6)

9.Advisory Services (4.7)

10.Complaints (4.8)

11.Identification and Control of Nonconformities (4.9)

12.Corrective Action (4.10)

12.1.Root Cause Analysis (4.10b, 4.11b)

13.Preventative Action (4.11)

14.Continual Improvement (4.12)

15.Control of Records (4.13)

16.Evaluation and Audits (4.14)

16.1.Review of Requests, Procedures and Sample Requirements (4.14.2)

16.2.User Feedback (4.14.3)

16.3.Staff Suggestions (4.14.4)

16.4.Internal Audit (4.14.5)

16.5.Risk Management (4.14.6)

16.6.Quality Indicators (4.14.7)

16.7.Reviews by External Organisations (4.14.8)

17.Management Review (4.15)

17.1.Review Input (4.15.2)

17.2.Review Activities (4.15.3)

17.3.Review Output (4.15.4)

18.Personnel (5.1)

18.1.Personnel Qualifications (5.1.2)

18.2.Job Descriptions (5.1.3)

18.3.Personnel introduction to the organizational environment (5.1.4)

18.4.Training (5.1.5)

18.5.Competency Assessments (5.1.6)

18.6.Reviews of Staff Performance (5.1.7)

18.7.Continuing Education and Professional Development (5.1.8)

18.8.Personnel Records (5.1.9)

19.Accommodation and Environmental Conditions (5.2)

19.1.Laboratory and Office Facilities (5.2.2)

19.2.Storage Facilities (5.2.3)

19.3.Staff Facilities (5.2.4)

19.4.Patient Sample Collection Facilities (5.2.5)

19.5.Facility Maintenance and Environmental Conditions (5.2.6)

20.Laboratory Equipment Reagent and Consumables (5.3)

20.1.Equipment

20.1.1.Equipment Acceptance Testing (5.3.1.2)

20.1.2.Equipment Instructions for Use (5.3.1.3)

20.1.3.Equipment calibration and metrological traceability (5.3.1.4)

20.1.4.Equipment maintenance and repair (5.3.1.5)

20.1.5.Equipment adverse incident reporting (5.3.1.6)

20.1.6.Equipment Records (5.3.1.7)

20.2.Reagents and Consumables (5.3.2)

20.2.1.Reception and storage (5.3.2.2)

20.2.2.Acceptance testing (5.3.2.3)

20.2.3.Inventory management (5.3.2.4)

20.2.4.Instructions for use (5.3.2.5)

20.2.5.Adverse incident reporting (5.3.2.6)

20.2.6.Records (5.3.2.7)

21.Pre-examination Processes (5.4)

21.1.Information for patients and users (5.4.2)

21.2.Request form information (5.4.3)

21.3.Primary sample collection and handling (5.4.4)

21.3.1.Instructions for pre-collection activities (5.4.4.2)

21.3.2.Instructions for collection activities (5.4.4.3)

21.4.Sample transportation (5.4.5)

21.5.Sample reception (5.4.6)

21.6.Pre-examination handling, preparation and storage (5.4.7)

22.Examination Procedures (5.5)

22.1.Selection, verification and validation of examination procedures (5.5.1)

22.1.1.Verification of examination procedures (5.5.1.2)

22.1.2.Validation of examination procedures (5.5.1.3)

22.1.3.Measurement uncertainty of measured quantity values (5.5.1.4)

22.2.Biological reference intervals or clinical decision values (5.5.2)

22.3.Documentation of examination procedures (5.5.3)

23.Ensuring quality of examination results (5.6)

23.1.Quality Control (5.6.2)

23.1.1.Quality control materials (5.6.2.1)

23.1.2.Quality control data (5.6.2.2)

23.2.Interlaboratory comparisons (5.6.3)

23.2.1.Participation (5.6.3.1)

23.2.2.Alternative approaches (5.6.3.2)

23.2.3.Analysis of interlaboratory comparison samples (5.6.3.3)

23.2.4.Evaluation of laboratory performance (5.6.3.4)

23.3.Comparability of examination results (5.6.4)

24.Post-examination processes (5.7)

24.1.Review of results (5.7.1)

24.2.Storage, retention and disposal of clinical samples (5.7.2)

25.Reporting of results (5.8)

25.1.Report attributes (5.8.2)

25.2.Report content (5.8.3)

26.Release of results (5.9)

26.1.Automated selection and reporting of results (5.9.2)

26.2.Revised reports (5.9.3)

27.Laboratory information management (5.10)

27.1.Authorities and responsibilities (5.10.2)

27.2.Information system management (5.10.3)

Appendices

Appendix 1: Referenced Documents

Appendix2: Quality Policy

Quality Manual: This hard copy was printed on28/09/2018 07:16ELECTRONICversions of this document are “CONTROLLED”, all printed versions expire at midnight on the date of printing

/ Diagnostics Division
South Glasgow Department of Haematology
Quality Manual / SG-MPOL-001
Version 3.0
Active Date: 4th January 2018
Author / M McBrearty / Authorised By / T Moffat / Page 1 of 49

Abbreviations and Acronyms

AGM / Assistant General Manager
AMR / Annual Management Review
BSQR / Blood Safety and Quality Regulations
CPD / Continuing Professional Developement
EQA / External Quality Assessment
HCPC / Health and Care Professions Council
HSE / Health and Safety Executive
IQC / Internal Quality Control
ISO / International Organization for Standardisation
JD / Job Description
LIMS / Laboratory Information System
MHRA / Medicines and Healthcare Products Regulatory Authority
MSC / Managed Service Contract
NHS / National Health Service
NHSGGC / NHS Greater Glasgow and Clyde
QEUH / Queen Elizabeth University Hospital
QM / Quality Manual
QMS / Quality Management System
RCA / Root Cause Analysis
RF / Radio Frequency
RHC / Royal Hospital for Children
SLA / Service Level Agreement
SLM / Sector Laboratory Manager
SNBTS / Scottish National Blood Transfusion Service
SOP(s) / Standard Operating Procedure(s)
TP / Transfusion Practitioner
TSM / Technical Services Manager
UKAS / United Kingdom Accreditation Service
VACH / New Victoria Ambulatory Care Hospital

1.Introduction

This Quality Manual, together with the Policy and Procedure documents which are referenced, describes the Quality Management System of the Department of Haematology,South Glasgow Sector, NHSGGC. This Quality Manual has been created to meet with all the requirements of The International Standard ISO: 15189-2012 –Medical Laboratories-Requirements for Quality and Competence (and all associated documentation) (hence known as ISO:15189), Blood Safety and Quality Regulations (2005 and subsequent amendments) ( hence known as BSQR), and other appropriate national and international standards.

The sections of this Quality Manual are arranged so that they equate with the sections in ISO:15189. After the title of each section or sub section, the relevant standard is referenced in brackets (X.X.X.). In each section there is a brief description of the way in which the Department seeks to comply with the particular standard, and references are given to appropriate documents using their QMS reference number [SG-ABC -XXX]. The full title of the document can be found in the appendices. All referenced documents can be found on the department’s QMS Q-Pulse. All the policies and procedures referenced are mandatory within the Department of Haematology, South Glasgow Sector.

1.1.Overview of the organization

As part of the diagnostic services of NHSGGC,the Department of HaematologySouth Glasgow Sectorprovideshaematologyservicesrelevant to service users for the benefit of the patients and population.

The laboratory has implemented 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 shareresponsibility 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.NHSGGC Mission statement

Deliver effective and high quality health services, to act to improve the health of our population and to do everything we can to address the wider social detriments of health which cause health inequalities.

1.3.Objectives

The objectives of the laboratory are to produce accurate, reliable and timely analyses' results, achieve and maintain an effective quality management system and to ensure compliance with relevant statutory and safety requirements.

The department senior management, through the quality manager, contributes to the implementation of the quality management system to achieve the defined objectives.

1.4.Scope

This quality manual describes the quality management system of the Department of Haematology, South Glasgow Sector.

Its scope is:

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 will facilitate the implementation of the quality management system aswell 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 service usersabout its quality policy as well as its implemented quality management system and measures of compliance with quality.

2.Quality Policy Statement

Senior management are dedicated to providing the resources necessary to maintain the laboratory quality management system.

The laboratory is committed to continual improvement, meeting internal and service user requirements, and providing a basis for the establishment and review of the quality objectives.

Quality practices are communicated within the organisation, understood and adhered to by all employees. The laboratory ensures a competent workforce to deliver quality results in a timely manner according to ISO:15189 and the BSQR. The laboratory ensures that each section participates in and records internal quality control and assurance activity. The laboratory ensures that each section participates in appropriate External Quality Assurance schemes with evidence of performance review. The laboratory ensures that each section is routinely active in addressing Health & Safety, Staff training and development, appropriate equipment maintenance and internal audit.

3.Organisationand Management Responsibility (4.1)

3.1.Organisation (4.1.1. and 4.1.1.1.)

The laboratory ensures to deliver quality results in a timely manner according to ISO:15189 and the BSQR.

3.1.1.Legal Entity (4.1.1.2.)

The laboratories of the Department of Clinical and Laboratory Haematology, South Glasgow Sector, NHSGGC, are a constituent of the Diagnostics Division of the Acute Services of NHS Greater Glasgow and Clyde. The department provides routine and specialised haematology services, together with Blood Transfusion, from QEUH as well as a limited repertoire of tests at the VACH (latter open Mon-Fri 08:45-17:00 only)

QEUH Address: Department of Haematology and Blood Transfusion

Level 1

Laboratory Medicine and FM Building

Queen Elizabeth University Hospital

1345 Govan Road

Glasgow

G51 4TF

Telephone: 0141-354-9100Fax: 0141-232-7982

VACH Address: Laboratories

Clinic P, 1st Floor

Grange Road,

Glasgow G42 9LF

Telephone: 0141-347-8141

3.1.2.Ethical Conduct (4.1.1.3.)

The Department of Haematology is not engaged in any activity that might influence its technical or clinical judgment. The laboratory is not committed to any commercial, financial or other pressure provided by any particular organisation that could influence its technical or clinical judgment or affect its competencies and trust.

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. (SG-MPOL-005,SG-MPOL-012,SG-EXT-G019, SG-REF-G009)
Duties and responsibilities of laboratory personnel are defined.
Appropriate communication is established within the laboratory.
Aquality managerand a health and safety officer aredesignated.
Quality, continual improvement and user satisfaction are the personal responsibility of all departmental staff.

3.1.3.Laboratory Director (4.1.1.4.)

There is one lead clinician for South Sector, and they report to the head of service. Each clinician may have additional duties as outlined in their job description/job plan.

The table on the following page details the responsibilities as detailed in Section 4.1.1.4 of the ISO15189 standard and to whom those duties may be delegated.

Duty / Responsibility / Comment
Provide effective leadership of the medical laboratory service, including budget planning and financial management, in accordance with institutional assignment of such responsibilities. / Lead clinician, TSM, SLM and laboratory management team. / Through HMT and MSC budget meetings.
Relate and function effectively with applicable accrediting and regulatory agencies, appropriate administrative officials, the healthcare community, and the patient population served, and providers of formal agreements, when required. / Lead clinician, TSM, SLM, Quality Manager and TPs / Senior laboratorystaff deal directly with UKAS and MHRA. User meetingsand SLA’s with outside service users.
Ensure that there are appropriate numbers of staff with the required education, training and competence to provide medical laboratory services that meet the needs and requirements of the users / Medical staff – Regional management team.
Lab staff – Diagnostic management team. / Training and education records kept for all staff.
Ensure the implementation of the quality policy. / Lead clinician, TSM, SLM, and Quality Manager / Controlled document in QMS.(SG-MPOL-035)
Implement a safe laboratory environment in compliance with good practice and applicable requirements. / TSM, SLM, and Health and Safety Officer. / H&S committee, relevant items raised at staff meetings and daily huddles.
[SG-MPOL-009]
Serve as a contributing member of the medical staff for these facilities served, if applicable and appropriate. / Lead Clinician / Detailed in this document
Ensure the provision of clinical advice with respect to the choice of examinations, use of the service and interpretation of examination results. / All Consultant medical and registrarstaff. / Medical staff are available 24 hours a day.
Select and monitor laboratory suppliers / Diagnostic management team. / Controlled through managed service contract.
Select referral laboratories and monitor the quality of their service. / TSM, SLM, Technical Leads and Quality Manager / All referral labs are asked to complete evaluation form annually. [SG-FORM-G034]
Duty / Responsibility / Comment
Provide professional development programmes for laboratory staff and opportunities to participate in scientific and other activities of professional laboratory organisations. / TSM, SLM, and Quality/Training Manager / All staff complete mandatory training, NEQAS, CPD, and attend scientific meetings
Define, implement and monitor standards of performance and quality improvement of the medical laboratory service and services. / Lead clinician, TSM, SLM, Technical leads, Quality Manager, Transfusion practioner / Defined through quality manual and monitored via balanced scorecard monthly at HMT. [SG-MPOL-001]
Monitor all work performed in the laboratory to determine that clinically relevant information is being generated. / Lead clinician, TSM, SLM, Technical Leads and Quality Manager. / Audit module in QMS, Laboratory Non Conformance Log Spreadsheet, Incident, quality and HTC meetings.
Address any complaint, request or suggestion from staff and/or users of laboratory services. / Lead clinician, TSM, SLM, Quality manager and Technical Leads / Audit module in QMS, Incident, quality, staff, HMT,HTC meetings and Daily Huddles
Design and implement a contingency plan to ensure that essential services are available during emergency situations or other conditions when laboratory services are limited or unavailable. / Lead clinician, TSM, SLM, and Technical Leads / [SG-MPOL-034]
(SG-EXT-G018)
Plan and direct research and development, where appropriate. / Lead clinician, TSM, SLM, and Technical Leads.

This section is deliberately blank, see next page

3.1.4.Organisational charts

The laboratory collaborates with other departments including the human resources department, Education and Learning department, finance department, procurement department, Facilities as well as other support services.

The laboratory and the Diagnostics Division organisation is shown in the organisational charts below:

3.1.4.1.Diagnostics Division

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3.1.4.2.Department of Haematology

Quality Manual: This hard copy was printed on28/09/2018 07:16ELECTRONICversions of this document are “CONTROLLED”, all printed versions expire at midnight on the date of printing

/ Diagnostics Division
South Glasgow Department of Haematology
Quality Manual / SG-MPOL-001
Version 3.0
Active Date: 4th January 2018
Author / M McBrearty / Authorised By / T Moffat / Page 1 of 49

3.2.Management responsibility (4.1.2.)

3.2.1.Management Commitment (4.1.2.1.)

The Laboratory management is committed to the developmentand implementation of the quality management system and continually improves its effectiveness by:

Communicating to laboratory personnel the importance of meeting the needs and requirements of users [SG-MREC-037]

Communicating the regulatory and accreditation requirements[SG-MREC-037 and SG-MREC-039]
Establishing the quality policy [SG-MPOL-035]
Ensuring that quality objectives and planning are established[SG-MPOL-041]
Defining responsibilities, authorities and interrelationships of all personnel [SG-MPOL-001]
Establishing communication processes[SG-MREC-051] [SG-MREC-036]
Appointing a quality manager, however named
Conducting management reviews [SG-MPOL-006]
Ensuring that all personnel are competent to perform their assigned activities [SG-MPOL-008]
Ensuring availability of adequate resources to enable the proper conduct of pre-examination,examination and post-examination activities

3.3.Needs of Users (4.1.2.2)

The needs of the users of the department are translated into requirements, which form the focus of objective setting and planning. The needs of the users are kept under constant review, achieved through periodic meetings [SG-MREC-048] [SG-MREC-050],[SG-MREC-046] informal discussion and communication, and from user surveys (when deemed necessary).

Assessment of user satisfaction and complaints is conducted on a regular basis and consideration of the findings form part of the annual management review.

3.3.1.Quality Policy (4.1.2.3.)

The Quality policy [SG-MPOL-035] of the Haematology department is in appendix 2 of this quality manual.

3.3.2.Quality Objectives and Planning (4.1.2.4.)

The quality objectives [SG-MPOL-041] for the Directorate are discussed, agreed and documented at the Annual Management Review meeting between the senior management team in Haematology and the Clinical Lead and senior Diagnostics Directorate staff. The Laboratory Management Team defines the quality objectives of the laboratory and is responsible for ensuring that plans are made to meet these objectives.

3.3.3.Responsibility, Authority and Interrelationships (4.1.2.5.)

Clinical Head of Service: Dr Edward Fitzsimons (Deputised by fellow Consultants).

General Manager: Isobel Neil.

Assistant GeneralManager: Jane Gibb, reports to general manager.

Lead Clinician: Dr Ian MacDonald (Deputised by Dr Rajesh Gottipati) reports to clinical head of service

Technical Services Manager (TSM):Tom Moffat (Deputises for AGM as approriate) reports to assistant general manager (Jane Gibb).

Sector Manager (SLM):Claire McKie, (Deputises for TSM & QM) reports to TSM.

Training, Quality and Point of Care Manager (QM):Maureen McBrearty, reports to SLM, accountable to TSM.

Haemoglobinopathy Manager: Mr Iain Fergus: Named deputy- Miss Jacqueline Fellowes.

Sector Lead Clinician / The Sector Lead Clinician has overall clinical responsibility for the Department, and specific responsibility for medical staff recruitment.
Consultant Medical Staff / Consultant Medical Staff have responsibilities for Clinical and Laboratory Haematology services and as defined in Job Plans, are accountable to the Sector Lead Clinician.
Technical Services Manager / The Technical Services Manager has specific accountability for laboratory operations of the Department. In addition, in conjunction with the General and Assistant General Manager, the Technical Services Manager has accountability for financial operations of the Department.
In the absence of the Technical Services Manager, the Sector Laboratory Manager shall assume responsibilities.[SG-EXT-G020]
Sector Laboratory Manager / Responsibilities of the Sector Laboratory Manager are defined in [SG-EXT-G021
Quality, Training and POCT Manager / Responsibilities of the Quality, Training and POC manager are defined in [SG-EXT-G022
Haemo-globinopathy Manager / Responsibilities of the Haemoglobinopathy manager are defined in[SG-EXT-G023]