Quality Management System
The Department of Laboratory Medicine and Pathology (DLMP) has a strong commitment to continually improving the performance of its laboratories. Our laboratories are accredited by the College of American Pathologists and are part of the Hamad Medical Corporation which is accredited by the Joint Commission International. Additionally, our transfusion medicine services have accreditation from the Association for the Advancement of Blood and Biotherapies and our immunology services from the American Society for Histocompatibility and Immunogenetics
We have a fully implemented quality management system (QMS) for an integrated systematic approach to quality throughout all of our laboratories. This enables us to consistently deliver high quality, cost effective and patient oriented laboratory services focused on the following outcomes:
- Ability to reduce or eliminate error through managing risks
- Meeting customer expectations
- Effective and efficient operations
- Sustainable attainment of quality objectives
- Successful regulatory and accreditation assessments.
The QMS has been built in line with the Clinical and Laboratory Standards Institute (CLSI) model and is comprised of 12 Quality Safety Essentials (QSEs)
- Organization and Leadership: The DLMP defines its mission, vision, values, goals and objectives and organizational structure in accordance with its scope of service and the strategic objectives and plans of Hamad Medical Corporation.
- Customer focus: The DLMP determines the expectations and needs of its customers on an on-going basis and strives to ensure it has sufficient resources to meet them.
- Facilities and Safety Management: The DLMP ensures all laboratory facilities are designed and/or maintained in accordance with applicable regulatory and accreditation safety requirements. Our aim is to provide a safe and pleasant working environment for all our staff and ensure the safety of all visitors to our laboratories.
- Personnel: The DLMP ensures its services are delivered by highly qualified, trained and competent staff who satisfy all accreditation requirements. This is supported by an on-going training and competency program for all staff.
- Supply and Inventory Management: The DLMP has processes in place to procure all necessary and required equipment and instrumentations, materials and consumables in order to deliver a high-quality service.
- Equipment: The DLMP ensures its state-of-the -art equipment undergoes the necessary validations and/or verifications on installation and is maintained to a good working standard throughout its lifetime.
- Process Management: The DLMP has documented policies, processes and standard operating procedures for its pre-examination, examination and post-examination activities that are regularly audited for their effectiveness.
- Documents and Records Management: The DLMP has an electronic Document Management System which complies with all applicable local and accreditation requirements.
- Information Management: The DLMP maintains confidentiality of protected health information and security of data access for all its activities.
- Non-conforming Event Management: The DLMP has a comprehensive system for the management of occurrences, variances from expected practice and accidents (OVA) and/or any complaints received. This includes investigation of the OVA/compliant, root cause analysis of sentinel events, implementation of effective corrective actions where needed and the monitoring of trends.
- Assessments: The DLMP uses external and internal assessments as well as internal monitoring systems to verify that all laboratory processes meet requirements and that all processes are functioning as expected.
- Continual Improvement: The DLMP regularly reviews its performance, identifies opportunities for improvement and acts to remove root causes of problems such as a process that does not meet performance expectations
