Version 3.2 Document No. Q-POLICY-2
Last Updated: 22/08/2018 Approved by: Lee Luscombe, Pathology Service Manager
Scope of the service:
The Pathology Service aims to provide high quality Blood Science, Point of Care, Blood Transfusion, Microbiology, Andrology, Cellular Pathology (excluding gynae cytology), Mortuary, Bereavement and I.T services to users of the Northern Devon Healthcare Trust, GP Commissioners, the Devon Partnership Trust and other users where such arrangements have been made.
In order to provide these services which meet or exceed the needs and requirements of its users and patients, the laboratory management team is fully committed to compliance with ISO 15189:2012 and:-
Achieving continual quality improvement in all areas of the laboratory by:-
Continually developing and reviewing the effectiveness of the Quality Management System to allow improvements to all elements of the Pathology Service.
Regularly reviewing the past performance of the Pathology Service and subsequently setting quality indicators, quality objectives and planning for the future which will be implemented to comply with this Quality Policy.
Following Caldicott principles and complying with the standards set by external regulatory organisations and national legislation. Following advice and guidance from professional bodies such as the Royal College of Pathologists.
Taking all available opportunities for developing the pathology estate to provide upgraded, modern premises that are suitable for delivering a high quality service.
The health, safety, welfare and development of all pathology staff by:-
Providing a friendly working environment to encourage the retention and recruitment of highly professional staff, committed to excellent professional practice.
Regularly reviewing, by audit and inspection, compliance with the department’s health & safety procedures.
Analysing incidents, complaints, feedback and accident reports, applying remedial, corrective and/or preventative actions as appropriate and reviewing these actions for effectiveness.
Providing resources for staff training, education and development.
Providing the highest quality analytical pathology service by:-
Participating in the NHSi initiative of ‘Getting it Right First Time’ by promoting the department’s philosophy of ‘Clean in’ (There is a well-formulated clinical question: (a) with a prior understanding of the actions to be taken as a result of the answer, (b) and which incorporates an understanding of what is normal for the patient, (c) and of which the patient has sufficient understanding. The proposed tests are necessary and sufficient to answer the clinical question. The request arrives at the point of testing in a state that allows the question to be answered.) ‘Clean through’ (The consistency (or uncertainty) of the answer is described. The answer is available in time to answer the question). ‘Clean out’ (Results are meaningful and helpful; within the context of shared understanding of what matters to the patient and their lives).
Procuring and maintaining the most appropriate equipment and resources to enable the provision of quality examinations of specimens.
Upholding professional values and continuing commitment to good professional practice and conduct.
Giving advice on the collection and handling of all pathology samples, (to minimise uncertainty of results), allowing the production of quality assured results in a timely, confidential and clinically useful manner.
Optimising the available test repertoire, based on clinical evidence and in conjunction with users to reduce unnecessary testing and thereby reducing unnecessary further testing and investigation of patients.
Assessing the satisfaction of users and staff.
Participation in an internal audit cycle, external and internal quality assurance schemes.
Active involvement with the management and procurement of all Point of Care devices.
Treating all visitors and callers to the department with courtesy and respect by:-
Being helpful and polite and giving consideration to their health, safety and welfare whilst in the department.
Dr Tom Lewis, Laboratory Director