Pathology Quality

AP Audit Schedule

Month

QSE

Audit Topic

January

QSE 11 Assessments

Documentation of Unscored and PT Failure Review

February

QSE 8 Documents and Records

Laboratory Personnel Roster and Blue Folder Audit

Master Control Sign-off for Outstanding Procedures and Training

March

QSE 6 Equipment

Dictation Equipment Downtime and Repair Documentation

Yellow Tag Audit

April

QSE 4 Personnel

SOP and Resident Training for Specimen Identification Documentation Complete

 

May

QSE 3 Facilities and Safety

Employee/Laboratory Spaces Security Measures Reevaluation

June

QSE 10 Non-Conforming Event Management

Follow-up Documentation on Patient Safety Reports

July

QSE 2 Customer Focus

Customer Satisfaction Survey

August

QSE 7 Process Management

OR Specimen Hand-offs SOP and Education Complete

 

September

QSE 5 Purchasing and Inventory

Inventory Management

October

 

Employee Engagement Efforts

PDCA Cycle on Previous Project

November

QSE 9 Information Management

Validation of Homegrown Data Sources Documentation

December

QSE 11 Assessments

Follow-up on CAP Citations

QSE 1 Organization

Organizational Charts Available and Up-to-Date for Sections of the Lab and Pathology Administration

     
QSE 3 Facilities and Safety Audits – To be performed by Safety Committee Members

January

Facilities and Safety

 

Chemical Inventory Available Submitted

Personal Protective Equipment worn per lab policy

February

Facilities and Safety

 

Annual Safety Audit

http://www.med.umich.edu/i/Safety/CommitteesNetworks/Documents/SafetyChecklist.pdf

March

Facilities and Safety

 

Biohazard and other warning signs are on doors and refrigerators

Spill kits are appropriate for lab, in-date (dated), and staff can locate them.

April

Facilities and Safety

 

Waste is labeled and  disposed according to safety and recycling requirements

Records of accidents are being maintained

May

Facilities and Safety

  

Storage - <18” from ceiling and not in halls or blocking egress

No floor storage

Lab prepared chemicals dated and labeled

June

Facilities and Safety

Chemical Exposure monitoring is being performed if needed

Staff can identify the new SDS  & chemical labeling

July

Facilities and Safety

 

Safety Scavenger Hunt

Ergonomics-

August

Facilities and Safety

 

Specimen transport

Engineering Controls

September

Facilities and Safety

Personal Protective Equipment worn per lab policy

Facilities and Safety

Check glassware for cracks and chips

October

Facilities and Safety

Eyewash and Showers are operable; staff know how to use them

Inoperable equipment is tagged and unplugged

November

Facilities and Safety

Compressed gas tanks are chained

Facilities and Safety

Lab specific procedures in Master Control

December

Facilities and Safety

Fire Drill Participation Report Completed

SDS Sheets are up to date