SOP's AKFP Diagnostic Network PDF

STANDARD OPERATING PROCEDURES
STANDARD OPERATING
PROCEDURES
Al-Khidmat Diagnostic Networks
MONTH DAY YEAR
Place Photo Here,

Otherwise Delete Box
Page 1

NOTE:
This manual and SOPs have been prepared by HR/R&D Department with the
conjunction of Healthcare and Diagnostics Department of Al-Khidmat Foundation
Pakistan.
These standard operating procedures are being developed as a guide for our staff to
maintain international standards in Healthcare. Users of this document are advised to
suggest amendments that are relevant to their individual practices. All amendments
(Endorsed by Manager Health & Diagnostics) with the consent of HR/R&D Department
will be entered as Amendment # 1, Amendment #2 etc. at the end of SOPs in
amendments section.
All these amendments at the end of every calendar year with the consent of board shall
become the permanent part of these SOPs.
Prof. Dr. Hafeez ur Rehman:

(President AKFP)
_______________________________
Abdus Shakoor:
(Secretary General AKFP)
_______________________________
Eng: Sabir Ahmed:

(Director Diagnostics Network)
______________________________
Page 2
Table of contents
1. Goal .. 4
2. Mission Statement 4
3. Objectives 4
4. Organogram .. 5
5. Introduction . 6
6. Classification of Diagnostic Network 6
7. Basic Knowledge & Skills to perform investigations . 7
8. Analytical and Technical Process 8
9. Personal Protective Equipment (PPE) ... 10
10. Biohazard Warning Signs and Posting ... 11
11. Biological Waste Disposal . 11
12. Needles and Sharps Precautions 11
13. Laboratory Code of Ethics .. 12
14. Work Environment . 14
15. Audit .. 15
16. Procurement ... 16
17. Recruitment Policy ..... 20
18. Accreditation . 21
19. Job Descriptions . 22
20. Amendments ... 42
Page 3
1. Goal
Achieve a uniform protocol under a centrally developed guide lines and implement on all
new and existing Al-Khidmat laboratories in the country.
2. Mission Statement
Al-Khidmat Diagnostic Network will particularly support the better Healthcare Services.
It will be dedicated to the service of humanity in all parts of the country, welcoming the
needy patients without any discrimination.
3. Objective:
To provide credible diagnostic services which includes Chemical Pathology,
Hematology, Microbiology, Biochemistry, Histopathology, Blood Banking, Radiology
and various scanning facilities to ailing humanity residing in Pakistan on affordable
prices without compromising on local and international standards.
Page 4
4. Diagnostic Lab Organogram:
Director
Lab Manager
Manager
Quality Control
Asst. Lab
Manager
Pathologist
Technologist
Accountant
Receptionist
Technician
Marketing
Executive
Mobilizer
Assistant
Technician
Driver
Watchman
Internee/
Trainee
Cleaner
Peon
Phelabotamist
Office Boy
Page 5

5. INTRODUCTION:
The main purpose of Al-Khidmat Diagnostic Centers is to provide quality investigation/
test services for the patients. We ensure laboratory production of valid test results and
evidentiary data to achieve uniform and harmonized results and reporting. Al-Khidmat
Diagnostic Network provide these services at economic/ competitive rates.
Al-Khidmat Diagnostic Centres are providing world-class Pathology and Radiology
services 24/7, combining state of the art technology with the network of experienced &
highly skilled professionals. We offer a complete range of laboratory services including
over 300 investigations/ laboratory tests.
6. Classification of Diagnostic Network:

Diagnosis is the process of identifying a medical condition or disease by its signs,
symptoms, and from the results of various diagnostic procedures by using Biochemical,
Radiological, Magnetic Resonance and Ultrasound methodologies. The conclusion
reached through this process is called diagnosis. Diagnostic Centres are sub-divided into
following 3 types.
1. Collection Centre
2. Model Diagnostic Centre
3. Mega Diagnostic Centre
6.1 Collection Centre:

A Collection Centre is a platform through which specimen are collected and sent
to the nearest Model or Mega Diagnostic Centre. These Collection Units are
intended to facilitate the people by providing easiest accessibility.
6.2 Model Diagnostic Centre:
Model Diagnostic Centre is comprised of Semi-Automated Analyzers to bear
normal work load.
Page 6

Services:
a. Biochemistry
b. Hematology
c. Serology & Immunology
d. Clinical Pathology
e. Sonology
6.3 Mega Diagnostic Centre:

Mega Diagnostic Centre is comprised of Fully-Automated Analyzers to bear
heavy work load.
Services:
a. Biochemistry
b. Hematology
c. Serology & Immunology
d. Clinical Pathology
e. Microbiology
f. Immunochemistry
g. Molecular Biology
h. Sonology
i. Radiology (X-ray, CT-Scan, MRI)
7. Basic Knowledge & Necessary Skills:
Technician/ Technologists should know the test terminology, purpose, procedure,
process and normal test reference values or results. The names of diseases are a
convenient way of briefly stating the end point of a diagnostic process that begins with
assessment of symptoms and signs and ends with knowledge of caution and detection of
underlying disorders of structure and function. The staff should hold the relevant
educational degree and investigation skills as well.
Page 7

8. Analytical and Technical Processes
8.1 All patients referred to Lab from different hospitals are received at reception.
8.2 All Lab investigations will be done on payment except for those signed free by
Director/Lab Manager.
8.3 All the investigations will be performed on economic prices
8.4 Log register shall be maintained by receptionist
8.5 Receptionist will guide the patient/ attendant/ guardian about the cost of the tests/
investigations.
8.6 The cost of the investigations shall be received in advance by receptionist
8.7 The receptionist will provide a receipt with unique identity number
8.8 The name and signature (or other means of identification and recording) of the Person
delivering or transferring custody of the shipped Samples, the date, the time of
receipt, and the name and signature of the laboratory representative receiving the
Samples, shall be documented as part of the laboratory internal Chain of Custody
record.
8.9 The laboratory shall have a system to uniquely identify the Samples and associate
each Sample with the collection document or other external chain of custody.
8.10 The laboratory shall have laboratory Internal Chain of Custody procedures to maintain
control of and accountability for Samples from receipt through final disposition of
the Samples.
8.11 The laboratory shall observe and document conditions that exist at the time of
receipt that may impact on the integrity of a Sample report. For example,
irregularities noted by the laboratory should include, but are not limited to:
8.11.1 Sample tampering is evident.
8.11.2 Sample is not sealed with tamper-resistant device or seal upon receipt.
8.11.3 Sample is without a collection form (including sample identification code) or
a blank form is received with the Sample.
8.11.4 Sample identification is unacceptable. For example, the number on the bottle
does not match the Sample identification number on the form.
Page 8

8.11.5 Sample volume is extremely low
8.12 The Laboratory should notify and seek advice from the Testing Authority regarding
rejection and testing of Samples for which irregularities are noted.
8.13 Sample collection will be done by aseptic standardized method
8.14 All samples will be numbered immediately, ensuring it to be the right patient and
slips. For urine sample, patient will be provided container and guided towards the
toilet. Samples will be transported to the respective section by the lab attendant/
Phlebotomist. Care will be taken to avoid wrong numbering, labeling of samples.
8.15 Receptionist will ensure the timely delivery of investigation reports with the
suggestion/ recommendation of technologists and pathologists
Clinical Pathology:
8.16 Technologist, Technician, Assistant technician will collect the samples from
reception
8.17 Technologist, Technician, Assistant technician will perform the investigation
procedure
8.18 Assistant Technician will ensure data entry (Hard copy and Soft Copy)
8.19 Technician will present the investigation in-front of clinical pathologist
8.20 Clinical pathologist will correlate the physical and chemical sign and symptoms
8.21 After ensuring/ verifying all the procedures, He/ She will approve the investigation
Radiology:
8.22 Receptionist will give a token number to the patient for smooth functioning of the
process
8.23 After checking the prescribed forms patients are sent to waiting area and they are
called for examination on turn by the Radiographer.
8.24 After complete processing Dark room assistant will get these X-Rays checked by
Radiologist for quality of X-Ray
8.25 If the study / Procedure is satisfactory, patient is asked to leave the waiting area and
collect the report on next day
Page 9

8.26 The X-Rays are sent at the reception for labeling and audit of films to be supervised
by Radiologist
8.27 Reporting of X-Rays is done on next day by Radiologist and interesting and
difficult cases are discussed with Professor / Head of Radiology Department
Research
8.28 Laboratories are entitled to participate in research programs provided that the
laboratory director is satisfied with the bona-fide nature and the programs have
received proper ethical (e.g. human subjects) approval
Controlled substances
8.29 The Laboratories are expected to comply with the relevant national laws
regarding the handling and storage of controlled (illegal) substances.
9. Personal Protective Equipment (PPE):
The technicians, technologists and all other laboratory staff shall use personal protective
equipment before going to the lab restricted areas. Some of the PPEs are explained as
follows:
9.1 Gloves
9.2 Safety Glasses/ Goggles
9.3 Gowns/Aprons
9.4 Laboratory Coat
9.5 Tyvek Suits
9.6 Respiratory protection (fit test and medical clearance required)
9.7 Surgical Mask
9.8 Shoe Covers
9.9 Bonnets
9.10 Face Shields
Page 10

10. Biohazard Warning Signs and Posting
Each laboratory must clearly display a sign that provides safety information to visitors
and service personnel.
11. Biological Waste Disposal:

Proper structure of disposal of waste material should be introduced to provide clean and
healthy environment. To obtain these particular tasks we should adopt the following
procedures:
11.1 We shall use 3 baskets of different colors (White, Yellow and blue)
11.2 For cotton, bandage and tissue papers white basket shall be used
11.3 For plastic bags, syringes and any other plastic related materials, yellow basket shall
be used
11.4 For the particulars made of glass shall be disposed off in blue basket
11.5 Waste should be disposed off through proper biological waste collection
organizations
12. Needles and Sharps Precautions

Substitute plastic-ware when possible
12.1 DO NOT bend, shear, break, recap or remove needle from syringe
12.2 Use sharps containers (dont fill more than full), which must be located as close to
work area as possible
12.3 Non-disposable sharps should be placed in a rigid container for transport to
appropriate area for decontamination, such as by autoclaving
12.4 Only needle-locking syringes or disposable syringe-needle units (needle is integral
to the syringe) should be used
12.5 Syringes that re-sheathe the needle, needleless systems, and other safety devices
may also be used
Page 11

12.6 Do not handle broken glass directly by hand. Use a mechanical device such as
forceps or protective gloves to pick up and dispose of glass in a glass box or sharps
container
13. Laboratory Code of Ethics:

13.1Basic Principles:
a. Each employee is responsible for the propriety and consequences of our
action
b. Each employee must conduct all aspects of Al-Khidmat Diagnostic Lab in
an ethical and lawful manner.
c. Each employee must hold high standards of honesty, integrity and fairness
in relationship to others.
d. Failure to comply with the Code or Standards will result in appropriate
disciplinary action, which may include termination of employment,
reimbursement to Al-Khidmat Diagnostic Lab for any resulting losses or
damages and in some circumstances may subject employees to civil or
criminal penalties.
e. Al-Khidmat Diagnostic Lab is obligated to fully and fairly investigate all
matters raised of unethical conduct.
13.2CONFLICT OF INTEREST:
13.2.1 Avoid situations that might involve a conflict of interest or even the appearance
of a conflict of interest. In general, avoid any actions that may appear to involve
a conflict of interest with Al-Khidmat Diagnostic Labs activities in carrying out
its mission. These include, but are not limited to: engaging in outside business
activities involving AL-Khidmat Diagnostic Labs suppliers, subcontractors,
government officials, cooperative research partners or other agencies.
13.2.2 Questionable activities may also include serving board of directors of the
organization doing business with Al-Khidmat Diagnostic Lab, significant
Page 12

ownership in the organization, or consulting with or working for a company or
failing to disclose outside business activities as required by Al-Khidmat
Diagnostic Labs policy.
13.2.3 Observe Al-Khidmat Diagnostic Labs ethical standards, as well as applicable
laws and regulations, when providing or accepting meals, entertainment or gifts
to or from people in business situations.
13.2.4 PROTECTION OF AL-Khidmat Diagnostic Labs:

13.2.5 Protect all data of Al-Khidmat Diagnostic Labs, property and funds under your
control against loss, theft and misuse. This includes proprietary information
belonging to Al-Khidmat Diagnostic Labs and its collaborators. Keep this
information confidential and be sure not make any of it available to unauthorized
personnel. Security procedures have been established to protect sensitive
information and many types of unclassified technical information.
13.2.6 Al-Khidmat Diagnostic Lab employees who handle such data are required to
know these procedures and strictly adhere to them at all times. The data may be
used for, property and funds only for their authorized, proper and intended
purposes. No use of such data or property may be made after termination of your
employment with Al-Khidmat Diagnostic Labs.
13.2.7 It is also imperative to make every effort to prevent the misuse of our assets
(Information, data, property) by any other person. Improper use includes selling,
loaning or giving away Al-Khidmat Diagnostic Labs property, destroying or
disclosing collaborator or Al-Khidmat Diagnostic Lab data.
13.2.8 Use of organizational property for personal or non-business purposes, other than
as specifically permitted as per the notification of Director Diagnostic Networks,
is considered to be improper conduct and is in violation of this Code of Ethics and
Standards of Conduct Confidentiality.
13.2.9 The heads of laboratories, their delegates and laboratory staff shall not discuss or
comment to the media on individual results prior to the completion of any
Page 13

adjudication without consent of the organization that supplied sample to the
laboratory and the organization that is asserting the Adverse Analytical Finding in
adjudication.
13.3
DATA, RECORDS AND REPORTS
13.3.1 It is the responsibility of Accounts & IT officer

13.3.2 To ensure the safe custody of all important documents as completely, honestly
and accurately as possible.
13.3.3 These records include timekeeping records, expense reports, accounting records,
test and progress reports, cost estimates, contract and grant proposals, and
presentations to clients, the public or AL-Khidmat Diagnostic Labs management,
and any representation, either written or oral, made by any AL-Khidmat
Diagnostic Labs employee or representative in the conduct of business shall be
factual, fully substantiated, and verifiable.
13.3.4 It is essential to maintain accurate timekeeping and expense records, making sure
to:
Record and allocate charges for time, materials and other business-related
expenses to the proper charge number.
Check all invoices and payments to customers, consultants and suppliers to
confirm the accuracy of information relating to products, services, prices and
terms of sale.
14. WORK ENVIRONMENT

a.
Use fairness, honesty, and comply with the law in all business relationships
with AL-Khidmat Diagnostic Labs stakeholders, collaborators, suppliers,
subcontractors, employees, and applicants, as well as with local, national and
international communities.
b.
Do not take unfair advantage of anyone through manipulation, concealment,

abuse of privileged information, misrepresentation of material facts or any
Page 14

other unfair dealing practice.
c.
Observe Human Resources management practices including, but not limited to,
those
regarding
recruitment,
selection,
job
assignment,
transfer,
promotion/demotion, layoff, return from layoff, discipline (including

termination), training, education, tuition, social and recreational programs,
compensation and benefits.
d.
Do not engage in or permit harassment of AL-Khidmat Diagnostic Labs

employees for any reason by other employees, vendors, collaborators or
anyone else with whom AL-Khidmat Diagnostic Labs employees come into
contact in the course of their business activities.
e.
Honor the prohibition from possessing, using, distributing, manufacturing,

purchasing, dispensing or selling illegal substances. Because these actions are
illegal and counterproductive to our business interests, they will not be
tolerated on AL-Khidmat Diagnostic Labs premises either during scheduled
work periods or at any time while conducting Lab business.
f.
Alcohol abuse will not be tolerated, either on AL-Khidmat Diagnostic Labs

premises during scheduled work periods or at any time while conducting
Company business.
15. Audit:
15.1 Internal Audit:
i.
Internal Audit will be the responsibility of District President AlKhidmat Foundation
ii.
Internal Audit should ensure after every 6 months.
15.2 External Audit:

External Audit will be the responsibility of Regional President Al-Khidmat
Foundation Pakistan.
15.2.1
External Audit of a calendar year (July to June) should be completed before
30th August of every year.

Page 15

15.3 Performance Audit:
15.3.1
Performance Audit is the responsibility of Program Manager Al-Khidmat

Diagnostic Network under the supervision of Director Diagnostic Network
Al-Khidmat Foundation Pakistan.
16 Procurement:
16.1
Procurement policy of Diagnostic Network Al-Khidmat Foundation Pakistan

will be based on following principals:
16.1.1 Transparent
16.1.2 Impartial and unbiased
16.1.3 Cost effective
16.1.4 Technically Competitive
16.1.5 Technically Comparative
16.1.6 Customized and Adoptable
16.1.7 Centrally devised and Monitored
16.2 The classification of the procurement policy will be as follows

16.2.1 Pre-qualification
16.2.2 Tender
16.2.3 Quotations
16.3 The areas of and procurement are classified as follows
16.3.1 Instrument & Equipment
16.3.2 Kits, Chemicals and consumables
16.3.3 Furniture & Fixtures
16.3.4 Renovation & Construction Materials
16.3.5 Computers & Electronic items
16.3.6 Stationary, office utensils and printing materials
16.4
Procurement Procedures:
Based on main principals mentioned above all companies interested to supply for
Diagnostic Network Al-Khidmat Foundation Pakistan must be pre-qualified through prequalification tender published in highly circulated newspapers mainly in the following
areas of laboratory working separately.
Page 16

1.
2.
3.
4.
Pathology
Radiology
Sonology
Any other area deemed necessary in future
The prequalification of the companies shall be based on following rules:

1.
2.
3.
4.
5.
Company/ supplier technical strength and reputation

Company/ supplier supply network
Company/ supplier financial strength
Product technical strength
After sales services back up network
All pre-qualified companies shall be allowed to participate in various tenders published in

newspapers by AKF time to time. During the pre-qualified tenure no other company will
allow to participate in the tender proceedings until/ unless the National director will have
sufficient reasons for the benefit of overall Diagnostic Network Al-Khidmat Foundation
Pakistan upon imposing a penalty amount for the onetime special pre-qualification to
allow them to participate in subject tender.
Tender Proceedings:
All pre-qualified companies will be eligible to participate in tender bids without any
tender fees. The quoted price by the bidders will be effective for one year (prequalification period of the company). The finalization process of tender will be as
follows:
1. Comparative statement will be prepared
2. Quoted prices will be negotiated by National Director with the help of Program
Manager
3. All negotiated prices will be presented with the priority list of Diagnostic
Network Al-Khidmat Foundation Pakistan purchase committee
4. After approval of purchase committee, the final price list will be issued to regions
Purchase Order:
Based on final negotiated prices regions directly or with the help of Program Manager
will issue the purchase order to the respective companies for the procurement of
subjected items.
Page 17

All purchase orders must follow the following rules:
1.
2.
3.
4.
Name of equipment / item

Place of supply
Date of supply requested
5% earnest money requirement for the instrument warranty period having worth
of rupees 100,000 or more.
5. Payment procedures after the supply and installation followed by installation
report signed by Lab Manager and company representative
Note: The above mentioned policy will be implemented on classification # 1 & 2 and will
be applied on all other areas on gradual basis.
16.5 Other Methods of procurement:
Goods or services may be acquired other than tender process shall be followed by the
following criteria:
16.5.1 Direct Purchase:
a. Procurement (less than Rs. 10,000) should be approved by Lab Manager
b. Purchases less than Rs. 10,000 may be purchased to best advantage without
quotations subject to the following conditions;
i. Rates should be reasonable and consistent with normal market rates for
items of same nature.
ii. Requirements should not be split into components or succession of orders
for the same goods or services for the purpose of enabling the goods or
services to be obtained under the limit of Rs. 10,000.
16.5.2 Written Quotation:
1) For purchases greater than Rs.10,000 but less than 25,000 should be
approved by Lab Manager and at least three written quotation should be
obtained subject to the following conditions;
a. Rates should be reasonable and consistent with normal market rates
for items of similar nature.
b. Requirements should not be split into components or succession of
orders for the same goods or services for the purpose of enabling the
goods/services to be obtained under limit of Rs. 25,000.
Page 18

2) For the purchases greater than Rs. 25,000;
a. A minimum of three written quotations must be obtained by
administration department.
b. Quotations must be based on written outline of specifications which
has been provided to the suppliers.
c. The purchase committee will approve such type of purchasing.
d. Purchase committee will consist of Lab Manager, Accounts Manager,
Pathologist and Regional Health Director.
e. Such Quotations must be on a printed format document/letter head
containing
1. Suppliers Name and full Address
2. Land line phone number
3. NTN/CNIC for withholding Tax Purpose
f. The best and competitive quotation will be suggested by Manager
Administration, on a comparative statement prepared for approval by
purchase committee.
3) For the purchases greater than Rs. 100,000;

a. For purchases greater than Rs.100,000 should be approved by
Director Diagnostic Network Al-Khidmat Foundation Pakistan.
16.6 Benefits of a procurement policy
As a consequence of adhering to this policy, Al-Khidmat Diagnostic Lab will;
16.6.1 Obtain the best value for its purchases, in both cost and quality terms.
16.6.2 Have a fast and efficient purchasing process; demonstrate financial probity and
accountability to its stakeholders and public interest.
16.6.3 Successfully manage and prevent the potential for conflicts of interest.
16.6.4 Monitor and evaluate performance in purchasing and procurement. Be protected
from complaints and legal actions mounted by potential suppliers who believe
they have not received fair treatment.
16.7 Ethical guidelines

16.7.1 No matter how transparent or fool proof an arrangement may be; its success lies
in the behavior of the officer(s) in-charge and his or her intention in following laid
down procedure and regulations. The set of rules laid below can serve as a
guideline for any purchasing officer.
Page 19

16.7.2 Shift In-charge and Technician will ensure the availability of stock (Each and
every instrument, chemicals, reagent, kits and consumable etc.) after every 15
days.
16.7.3 Emergency purchasing will not be appreciated however if required; it shall be
requested by shift in-charge and technician with the recommendation of
Pathologist/ Radiologist and then approved by Lab Manager.
16.7.4 The best value for the organizations goods and services must be sought.
16.7.5 There will be a documented process for all purchases; which allows for
transparency of decisions and review of purchases.
16.7.6 The conduct of procurement is subject to continuous auditing by the organization
and by external bodies such as the board, auditor and stake holders.
16.7.7 Staff will ensure that they are not, or are not perceived to be in a conflict of
interest with any supplier.
16.7.8 Those staff who have, or may be perceived to have a vested interest in outcome of
a purchase should disclose any conflict to their supervisor and discuss whether
they should exclude themselves from any role in the purchase.
16.7.9 Staff will be suitably skilled and qualified to attend the completion of their
purchasing and contracting role(s).
17 Recruitment Policy:
17.1 Objectives:
The objectives of this policy are to:
Acquire the services of the appropriate and qualified personnel when and
where needed.
Ensure the transparency and fairness without any bias, favoritism and
discrimination in hiring process.
17.2 Selection Board
Selection Board will be constituted by Director Diagnostic Network Al-Khidmat
Foundation Pakistan which may be consist of District President, Regional Health
Director, Senior Pathologist, Lab Manager
17.3 Approval
Selection Board of Al-Khidmat Diagnostic Labs shall approve all the vacancies.
Page 20

17.4 Appointments
17.4.1 The Pathologist, Lab Managers, Technicians of Al-Khidmat Diagnostic Labs will
be appointed by Selection Board of Al-Khidmat Diagnostic Network.
17.4.2 Receptionist, Supporting staff, Mobilizer will be appointed by a committee
consist of Lab Manager, Pathologist and District President.
17.5
Procedure
Lab Manager will be responsible for all the appointments according to the
following criteria:
17.5.1 Lab Manager will disseminate the Employment Requisition Form to all Heads of
Departments (Pathology, Radiology, Sinology)
17.5.2 Lab Manager will make proper advertisement to fill the vacant positions of all
levels.
17.5.3 All appointments will be made according to the set criteria (i.e. Academic Record,
Test, and Interview.)
17.5.4 Keeping in view the laid down criteria, short listing will be done, if needed.
Selection Board/ Committee will conduct interviews and made final selection.
17.5.5 Letter of appointment will be issued by Project Director addressing to the
appointee and a personal file of each and every employee will be maintained.
17.5.6 Two or more close blood relations will not be appointed in the same department
however, may be appointed with the approval of Director/Lab Manager.
18 Quality Control
18.1
18.1.1
18.1.2
18.1.3
18.1.4
18.1.5
Laboratory quality control is designed to detect, reduce, and correct deficiencies

in a laboratory's internal analytical process prior to the release of patient results,
in order to improve the quality of the results reported by the laboratory.
Developed Internal Quality Control mechanism in each laboratory
One guide line shall be followed for internal quality control.
All quality control result & charts shall be posted regional coordinator and he will
send to central office to monitor and harmonies our system
External quality control mechanism shall be adopted under central guide lines
Accreditation with local and international bides will be executed.
Page 21

18.1.6 All quality control results shall be forwarded by Program Manager to Director
Diagnostic on monthly basis to ascertain deviations (if any) and for expert opinion
for ongoing quality issues
19 Accreditation:
Accreditation is a process in which certification of competency, authority or credibility is
presented. Organizations that issue credentials or certify third party against official
standards are themselves formally accredited by accreditation bodies such as UKAS.
The accreditation process ensures that the practices / investigations / environment /
standards are acceptable, typically meaning that the organization is competent to perform
investigation by ensuring quality.
Al-Khidmat Diagnostic Labs shall adopt all possible international standards procedures
and certify our labs with the following accreditation bodies:
19.1 National Accreditation Bodies:
19.1.1 Pakistan Accreditation Council
19.1.2 AFIP (Armed Force Institute of Pathology)
19.1.3 Agha Khan
19.2 International Accreditation Bodies:
19.2.1 RIQAS
19.2.2 UKAS
20 Job Descriptions:
A job description is a list that a person might use for general tasks or functions and
responsibilities of a position. It may often include to whom the position reports,
specifications such as the qualifications or skills needed by the person in the job.
Page 22

Al-Khidmat Diagnostic Network
JOB TITLE: Director
JOB PURPOSE:
The purpose of this job is to ensure the smooth functioning of the Lab, support operations by
supervising staff, planning, organizing, and implementing administrative systems.
KEY RESPONSIBILITIES:
To meet standard criteria in clinical lab, implement & maintain technical operations in
accordance with standard international guidelines
To guide/ direct administration and other supervisors to carry out & monitor standard
operating procedures at Clinical Lab
Implement and ensure quality assurance procedures
To plan, prepare and implement Lab accreditation protocols
To monitor progress of work assigned to administrative officers and supervisors in
clinical lab
To plan and design training programs for receptionist, phlebotomist, technician and
technologist according to requirement
To arrange refresher courses & workshops for clinical pathologist & radiologist
Director will report to Regional Health Director
To perform any other task assigned by competent authority
Working Conditions:
Working conditions include office work. Most of the time Director needs to deal with multiple
tasks at one time which may causes stress. Ability to manage work load will be the key.
I.T Skills:
1. Microsoft Office
(Word, Excel, Power Point)
Page 23

Knowledge, Skills and Abilities:
Ability to handle work load efficiently

Ability to handle all queries/ technical questions
Ability to work cooperatively
Ability to research and analyze technology problems and issues
Knowledge of database management system
Ability to work individually and as a team member
Ability to handle stress
Good written/verbal communication skills
Good presentation skills
Qualification/ Experience:
Director must have 5 years of experience with having MBBS degree and specialization in Clinical
Pathology/ Hematology/ Molecular Biology/ Endocrinology, Radiology or other relevant field.
________________________
_______________________
Director
Regional Health Director
Page 24

Al-Khidmat Foundation Pakistan
JOB TITLE: Pathologist/ Radiologist
JOB PURPOSE:
The purpose of this job is to provide specialize services of technical support/ advise for
investigations.
To facilitate Director in managing technical and administrative issues

To monitor sample processing steps
To finalize technical verification of lab investigations
To finalize verification of lab reports
To deal with consulting Physician/Surgeon for technical advice.
Monitor service and maintenance procedure of instruments.
To perform any other task assigned by the competent authorities
To ensure Quality of investigations
To supervise all Technical Staff
Report to Director of Lab
Working Conditions:
Working conditions include office work. Most of the time Pathologist/ Radiologist deal with
multiple tasks at one time which may causes stress. Ability to manage work load will be the key.
I.T Skills:
Microsoft Office
Page 25

Knowledge about investigations /reports

Pathologist/ Radiologist r must have 2 years of experience with having MBBS degree and
specialization in Clinical Pathology/ Hematology/ Molecular Biology/ Endocrinology, Radiology
or other relevant field.
________________________
_______________________
Pathologist
Director
Page 26

JOB TITLE: Lab Manager
JOB PURPOSE:
The purpose of this job is to support operations by supervising staff, planning, organizing, and
implementing administrative systems.
To ensure emergency supplies

To ensure all purchasing/ procurement
To coordinate regional administration issues
To complete special projects by organizing and coordinating information and
requirements; planning, arranging, and meeting schedules
To achieve financial objectives by anticipating requirements, submitting information for
budget preparation, scheduling expenditures, monitoring costs, analyzing variances etc
To ensure the secure filing of official documents
To ensure the office security
Contributes to team effort by accomplishing related results as needed
To manage all the events of Laboratory
Working Conditions:
Working conditions include office work. Most of the time Lab Manager needs to deal with
I.T Skills:
Microsoft Office
Page 27


Administration manager must have 4 years of experience with having master degree in
Management or any other management related field.
________________________
_______________________
Lab Manager
Director
Page 28

JOB TITLE: Asst. Lab Manager
JOB PURPOSE:
The purpose of this job is to support Lab Manager to organizing, and implementing
administrative systems.
To Assist Lab Manager

To ensure emergency supplies
To ensure all purchasing/ procurement
To manage all attendance record of Lab Staff
To complete special projects by organizing and coordinating information and
requirements; planning, arranging, and meeting schedules
To ensure the secure filing of official documents
To ensure the office security
To manage all the events of Laboratory
To deal with purely administrative issues
To perform any other task assigned by Director/Lab Manager
Working Conditions:
Working conditions include office work. Most of the time Asst. Lab Manager needs to deal with
I.T Skills:
Microsoft Office
Page 29


Asst. Lab Manager must have 2 years of experience with having bachelor degree in Management
or any other management related field.
________________________
_______________________
Asstt Lab Manager
Director
Page 30

JOB TITLE: Manager Quality Control
JOB PURPOSE:
The purpose of this job is to provide specialize services of technical support/ advise for
investigations.
To facilitate Director/Pathologist in managing Technical and Quality Control issues

To monitor sample collection steps
To monitor processing steps
To ensure Internal Quality Control (IQC) mechanism
To finalize technical verification of lab investigations
To maintain all data of IQC
To send all IQC data to regional office for monitoring and compilation
To ensure hygienic environment
To develop opportunities for different Accreditation Programs
Monitor service and maintenance procedure of instruments.
Report to Director/Pathologist of Lab
To perform any other task assigned by the Director/Pathologist/Lab Manager
Working Conditions:
Working conditions include office work. Most of the Technologist deal with multiple tasks at one
time which may causes stress. Ability to manage work load will be the key.
I.T Skills:
Microsoft Office
Page 31


Manager Quality Control must have 2 years of experience after completion of Master degree in
the relevant field.
________________________
_______________________
Manager Quality Control
Director
Page 32

JOB TITLE: Technologist
JOB PURPOSE:
The purpose of this job is to provide specialize services of technical support/ performing
investigations.
To facilitate Pathologist in managing technical issues

To supervise Technician/Asstt Technician/Trainee
To perform lab investigations
To ensure IQC with colaboration of Quality Control Manager
To finalize lab reports
To present reports to Pathologist for verification
To discuss abnormal results with Pathologist
Monitor service and maintenance procedure of instruments
Report to Director/Pathologist/Lab Manager of Lab
To perform any other task assigned by the Director/Pathologist/Lab Manager
Working Conditions:
Working conditions include office work. Most of the Technologist deal with multiple tasks at one
time which may causes stress. Ability to manage work load will be the key.
I.T Skills:
Microsoft Office
Page 33


Technologist must have 3 years experience after completion of MSc in relevant field.
________________________
_______________________
Technologist
Director
Page 34

JOB TITLE: Technician
JOB PURPOSE:
The purpose of this job is to perform investigations by adopting standard procedures and facilitate
technologists and pathologist/ radiologist.
To perform investigations by adopting all formal (standard) procedures

To ensure safety of samples
To perform lab investigations
To ensure IQC under supervision of Quality Control Manager
To finalize lab reports
To present reports to Pathologist for verification
To discuss abnormal results with Technologist/Pathologist
To maintain reporting log register
To ensure the quality reporting of investigations and quality results of investigating
machines
To liaison with receptionist for timely delivery of reports to patients/ clients
To ensure the cleanliness in investigation area
To ensure availability of stock of equipments for performing investigations
Working Conditions:
Working conditions include office work. Most of the time technician needs to deal with multiple
tasks at one time which may causes stress. Ability to manage work load will be the key.
I.T Skills:
Microsoft Office
Page 35

Ability to perform investigations

Technician must have 3 years of experience in relevant field with having minimum a diploma
certificate in Medical Technology.
________________________
________________________
Technician
Director
Page 36

JOB TITLE: Receptionist
JOB PURPOSE:
The purpose of this job is to provide the patients with proper guideline related with the function
of lab and the investigations performed by Al-Khidmat Diagnostic Network. Receptionist will
take investigation fee and provide the patient with receipt.
To maintain record of all official asset

To manage all attendance record of employees
To perform refunds / cancellation of slip procedure
To ensure maintenance of record through daily & monthly return
To maintain daily return of test and patients
Monitor statistics of all test requested and no. of patients with their Bio-Data
Maintain record of training and other events
Coordinate with other departments of Al-Kdidmat Diagnostic Lab for day to day issues
concerned with lab reporting.
He / She will directly report to Lab Manager
Working Conditions:
Working conditions include office work. Most of the time Receptionist needs to deal with
I.T Skills:
Microsoft Office
Page 37


Receptionist must have 1 years of experience with having minimum degree of F.Sc pre Medical.
________________________
_______________________
Receptionist
Director
Page 38

JOB TITLE: Accounts Officer
JOB PURPOSE:
The purpose of this job is to facilitate Director / Lab Manager to keep up to date record of each
and every transaction.
To prepare all types of vouchers (BRV/CRV/CPV/BPV/JV) on daily basis

To prepare staff salaries and process for payment on monthly basis
Preparation of Donors/Vendors Reconciliations
To prepare cheques regarding payments to vendors/regions/other parties
To reconcile accounts of donors/vendors on monthly basis
To handle bank transactions on daily basis
To manage withholding tax statements of vendors/suppliers and employees
Any duty assigned by Director / Lab Manager
Working Conditions:
Working conditions include office work. Majority of financial officers usually work under stress
and work load. Ability to manage work load will be the key.
I.T Skills:
Microsoft Office
Accounting Softwares
Online cash handling
Page 39

Ability to handle accounting softwares

Ability to handle work load
Good written communication skills
Accounts Officer must have 2 years of experience with having graduate degree in Finance or any
other finance related field.
________________________
________________________
Accounts Officer
Director
Page 40

JOB TITLE: Marketing Manager
JOB PURPOSE:
The purpose of this job is to design, develops, implements and manages a series of marketing
initiatives. These initiatives include, but not limited to the development of strategic alliances and
promotion activities, the establishment of enabling networks.
To assist in the creation, development and implementation of creative marketing
strategies that will make an impact and support the functions of Lab
To develop Annual Marketing /Media Plan
To develop Marketing kit (Profile, Brochure, flyer, Presentations, Calendar,
Documentary)
To manage Donor Data (E-mail, Phone, Postal Address)
To produce innovative and cost-effective promotions tools (SMS, Social Media).
To assist in Campaign development, implement and feedback.
To manage different Event for promotion, and image building.
To provide occasional secretarial, recruitment or administrative support and backup to the
Lab Manger Media where requested
Working Conditions:
Working conditions include both field work and office work. Most of the time Marketing
Manager needs to deal with multiple tasks at one time which may causes stress. Ability to
manage work load will be the key.
I.T Skills:
Microsoft Office
Page 41


Marketing Manager must have 2 years of experience with having master degree in Marketing or
any other related with marketing field.
________________________
________________________
Marketing Manager
Director
21 Amendments:
Page 42

SOP's AKFP Diagnostic Network PDF

Загружено:

Сведения о документе

Исходное описание:

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

SOP's AKFP Diagnostic Network PDF

Загружено:

Авторское право:

Доступные форматы

STANDARD OPERATING PROCEDURES

Al-Khidmat Diagnostic Networks

Place Photo Here,

STANDARD OPERATING PROCEDURES

Prof. Dr. Hafeez ur Rehman:

Eng: Sabir Ahmed:

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

4. Diagnostic Lab Organogram:

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

6. Classification of Diagnostic Network:

6.1 Collection Centre:

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

6.3 Mega Diagnostic Centre:

STANDARD OPERATING PROCEDURES

STANDARD OPERATING PROCEDURES

STANDARD OPERATING PROCEDURES

STANDARD OPERATING PROCEDURES

11. Biological Waste Disposal:

12. Needles and Sharps Precautions

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

13. Laboratory Code of Ethics:

STANDARD OPERATING PROCEDURES

13.2.4 PROTECTION OF AL-Khidmat Diagnostic Labs:

STANDARD OPERATING PROCEDURES

DATA, RECORDS AND REPORTS

13.3.1 It is the responsibility of Accounts & IT officer

14. WORK ENVIRONMENT

Do not take unfair advantage of anyone through manipulation, concealment,

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

promotion/demotion, layoff, return from layoff, discipline (including

Do not engage in or permit harassment of AL-Khidmat Diagnostic Labs

Honor the prohibition from possessing, using, distributing, manufacturing,

Alcohol abuse will not be tolerated, either on AL-Khidmat Diagnostic Labs

Internal Audit will be the responsibility of District President AlKhidmat Foundation

Internal Audit should ensure after every 6 months.

15.2 External Audit:

External Audit of a calendar year (July to June) should be completed before

30th August of every year.

STANDARD OPERATING PROCEDURES

Performance Audit is the responsibility of Program Manager Al-Khidmat

Procurement policy of Diagnostic Network Al-Khidmat Foundation Pakistan

16.2 The classification of the procurement policy will be as follows

STANDARD OPERATING PROCEDURES

The prequalification of the companies shall be based on following rules:

Company/ supplier technical strength and reputation

All pre-qualified companies shall be allowed to participate in various tenders published in

STANDARD OPERATING PROCEDURES

Name of equipment / item

Al-Khidmat Diagnostic Networks

STANDARD OPERATING PROCEDURES

3) For the purchases greater than Rs. 100,000;

16.7 Ethical guidelines

STANDARD OPERATING PROCEDURES