The Accreditation Standards 2015 – Laboratory Medicine document has been reviewed and accredited by the International Society for Quality in Health Care (ISQua).
- Accreditation Standards 2015 – Laboratory Medicine (effective February 1, 2017)
Medical laboratories in the province are required to participate in proficiency testing (PT) programs and alternative assessment procedures that reflect their range of accredited services. The DAP maintains its own records of laboratory PT performance, including the outcomes of investigations and subsequent corrective actions. PT performance history will be a factor considered when determining the overall accreditation award. Medical laboratories are required to investigate and comment on unacceptable performance in writing to the DAP within a designated time-frame. Corrective actions that are initiated by the laboratory require monitoring to ensure they are effective.
What is proficiency testing?
Proficiency testing (PT) is an evaluation of participant performance against pre-established criteria by means of interlaboratory comparison. A PT program is a quality assessment tool that provides a retrospective measure of technical quality. To be most effective, PT must be used in conjunction with the laboratory’s internal quality control program and be a part of the quality management system. The objectives of the PT program for the DAP are to:
- provide objective evidence of laboratory competence through continual monitoring
- identify trends in acceptable PT results and flag unacceptable PT results requiring investigation
- monitor the outcomes of investigations and subsequent corrective actions
- provide laboratories the opportunity to identify issues related to systemic error, imprecision, or human error; potentially unrecognized issues if PT is not fully incorporated into the quality management system
- consider laboratory PT performance during the assessment and accreditation process using a combination of data collected through the PT monitoring process and evidence provided during onsite assessment
Forms and resources
- Laboratory Medicine Proficiency Testing Manual
- Available Proficiency Testing Providers
- Mandated Measurands by Service
- Proficiency Testing Attestation Form
- Proficiency Testing Enrolment Form
- Proficiency Testing Investigation and Exception Response Form
- Proficiency Testing Investigation: Sources of Error Form
For new laboratory medicine facilities
All new facilities and services within an already accredited facility must proceed through the initial assessment process prior to service delivery or patient testing.
- Accreditation Standards 2015 for Initial Assessment – Laboratory Medicine
- Facility Information for Initial Assessment Form – Laboratory Medicine – Health Authority
- Facility Information for Initial Assessment Form – Laboratory Medicine – Community
- Notification of Significant Change in Service Form – Laboratory Medicine (for facilities/services that are accredited but are undergoing significant changes in service)
For relocating laboratory medicine facilities
All facilities relocating to a new address or within their existing building (e.g. facility is rebuilt on the same site) must proceed through the relocation assessment process prior to service delivery or patient testing. Please note that the DAP is currently in the process of developing relocation accreditation standards.