Pathology Quality Policy 6th Ed

Gwent Healthcare NHS Trust
Owner: Directorate of Pathology

Department of: Pathology
Q-pulse No. QP0001

Edition No. 6
Printed copy is controlled only on date printed 25/07/2008
Pathology Quality Policy
Status: Operational
Issue Date: 2nd June 2008
Review Date: June 2009
Page 1 of 6

Q-pulse No. QP0001

Edition No. 6
SOP Policy Document

(Pathology Quality Policy)
Test Code: N/A
Q-Pulse Number QP0001
EDITION No:
Six
OPERATIVE DATE:
2nd June 2008
REVIEW DATE:
June 2009
REPLACES:
Edition 5
LOCATION:
All Pathology Departments
AUTHOR:
Signature:
Date:
AUTHORISED BY:
Signature:
Date:
Tim Von Pokorny
Dr Neil Carbarns
DOCUMENT HISTORY
Edition No Operative Comment
Date
1.
March
Up dated 26/11/04
2004
2.
26/11/2004 Document reviewed March 2005 and no
amendments were identified
3.
27/11/2005 Document reviewed November 2005.
Amendments made to sections 2.3, 3, 4 & 6
4.
19/05/2006 Document reviewed and amendment made to
section 3. Additional bullet point added (7thfrom top)
re. H&S legislation.
5.
23/10/07
Incorporation of new CPA standards (V2).
19th November 2007 minor amendment made; Name
and position of persons signature on quality policy
statement added under signature to meet non
conformance from RGH CPA surveillance visit.
6.
02/06/08
Dr Grant Robinson replaced with Dr Neil Carbarns.
Scope of service added to statement of policy.
7.
Status: Operational
Page 2 of 6

Q-pulse No. QP0001

Edition No. 6
CONTENTS
1.
2.
3.
4.
5.
6.
Executive summary
1.1.
Purpose of policy
1.2.
Target Audience
1.3.
Implementation
Introduction
Statement of Policy
Aims and objectives
Responsibilities
Further information
Status: Operational
Page 3 of 6
4
4
4
4
5
6
6
6

1.
Q-pulse No. QP0001

Edition No. 6
EXECUTIVE SUMMARY
1.1
Purpose of policy
This policy specifies the approach to quality in the Directorate of
Pathology, Gwent Healthcare NHS Trust.
1.2
Target Audience
1.21
1.22
1.3
Staff working within The Trusts Directorate of Pathology.

Users of the Trusts Pathology services.
Implementation
The Directorate must:

1.3.1
1.3.2
1.3.3
1.3.4
1.3.5
1.3.6
1.3.7
1.3.8
Display the Quality Policy in public areas of the laboratory.

Regularly assess user satisfaction.
Identify a member of staff in each department to take a lead in quality issues who
will be responsible for accurate document and record maintenance.
Ensure that each department partakes in and documents internal quality assurance
activity.
Ensure that each department belongs to and participates in appropriate External
Quality Assurance schemes with evidence of performance review.
Ensure that each department is routinely active in addressing Health & Safety,
Staff training/development, appropriate equipment maintenance and internal audit.
Ensure that the handling of all specimens facilitates the correct performance of
laboratory examinations.
Ensure that the reporting of results is timely, accurate and clinically useful.
INTRODUCTION
2.1
2.2
2.3
2.4
2.5
2.6
The Quality Policy of the laboratory reflects the Quality Policy of Gwent Healthcare
NHS Trust.
The Directorate of Pathology is committed to providing a service of the highest
quality and shall be aware and take into consideration the needs and requirements
of its users.
Quality, continual improvement and user satisfaction are the personal responsibility
of all Pathology staff.
The National Pathology accrediting body, CPA (UK) Ltd, requires the Directorate of
Pathology to produce a Quality Policy.
The Laboratory Quality Management group sets the Laboratory Quality Policy and
Objectives.
In order to achieve Quality Improvement goals the laboratories quality performance
is continually reviewed.
Status: Operational
Page 4 of 6

Q-pulse No. QP0001

Edition No. 6
3 STATEMENT OF QUALITY POLICY

The scope of service provided by the Pathology Directorate is an in house routine diagnostic
service for Haematology/Blood Transfusion, Biochemistry, Microbiology (supplemented by an
emergency 24 hour on-call facility) and Cellular Pathology (Histology/Cytology). The department
also provides mortuary and post mortem facilities serving the Trusts hospitals as well as for the
coroner acting as a public mortuary.
The Pathology Directorate is committed to providing a service of the highest quality and shall be
aware and take into consideration the needs and requirements of its users.
In order to ensure that the needs and requirements of users are met, the Pathology Directorate will:
Operate a quality management system to integrate the organisation, procedures, processes

and resources. (A4)
Set quality objectives and plans in order to implement this quality policy. (A5)
Ensure that all personnel are familiar with this quality policy to ensure user satisfaction. (A3.1c)
Ensure that personnel are familiar with the contents of the quality manual and all procedures
relevant to their work. (A3.1d)
Commit to the health, safety and welfare of all its staff. (C5)
Ensure that visitors to the department will be treated with respect and due consideration will be
given to their safety while on site. (C3 & C5)
Uphold professional values and be committed to good professional practice and conduct.
(A3.1e)
To keep advised of and to implement, where applicable, all current legislation relating to the
Health and Safety of staff and visitors.
Commit to comply with all the relevant environmental legislation.
Conform to confidentiality in accordance with The Data Protection Act and Caldicott Guidelines.
The Pathology laboratory will comply with standards set by the CPA (UK) Ltd. accreditation system,
The Blood Safety and Quality Regulations, The Human Tissue Authority and is committed to:
Staff recruitment, training, development and retention at all levels to provide a full and effective
service to its users. (B2, B7, B9)
The proper procurement and maintenance of the equipment and other resources needed for
the provision of the service. (D1)
The collection, transport and handling of all specimens in such a way as to ensure the correct
performance of laboratory examinations. (E3)
The use of examination procedures that will ensure the highest achievable quality of all tests
performed. (F2)
Reporting results of examinations in ways which are timely, confidential, accurate and clinically
useful. (G1)
The assessment of user satisfaction (H2), in addition to internal audit (H3 & H4), external
quality assessment (H5), benchmarking and identification and control of non-conformities (H7)
in order to produce continual quality improvement. (H6).
Signed on behalf of the

Directorate of Pathology
Dr Neil Carbarns
Pathology Chief of Staff
Date 02nd June 2008
Status: Operational
Page 5 of 6

4.
Q-pulse No. QP0001

Edition No. 6
AIMS AND OBJECTIVES

The aim of the Pathology Department at Gwent Healthcare NHS Trust is to provide
clinically useful information through the laboratory analysis of samples from patients, taking
into account the requirements of the laboratories users. The reported data should be
reliable and their uncertainties should be in accordance with the clinical needs and the
appropriate technical standards of the profession. Quality records will be maintained to
document effective implementation of the Quality Management System and provide
evidence of conformity to CPA (UK) Ltd standards. When problems occur in a process,
outputs, the quality management system or when user complaints are received, the
appropriate corrective action is taken.
5.
RESPONSIBILITIES
5.1
5.2
6.
This policy must be communicated, understood, available and implemented

throughout the laboratory.
All staff working within the Directorate of Pathology.
FURTHER INFORMATION
ISO 14050:1998
ISO/DIS 15189:2002
ISO/IEC DIS 17011
ISO/IEC 17025:2000
ISO 14001:2000
Status: Operational
Page 6 of 6
ISO/DIS 9001:2000
EC4 Essential Criteria
ISO 9000:2000
CPA(UK)Ltd Standards

Pathology Quality Policy 6th Ed

Загружено:

Сведения о документе

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

Pathology Quality Policy 6th Ed

Загружено:

Авторское право:

Доступные форматы

Gwent Healthcare NHS Trust

Owner: Directorate of Pathology

Q-pulse No. QP0001