Pathology Quality

CP Audit Schedule

Month

QSE

Audit Topic

Jan

QSE 11 Assessments

Documentation of unscored/failure of Proficiency Testing review

Feb

QSE 4 Personnel

 

Laboratory Personnel Roster Audit &

Blue Folder Audit

QSE 8 Documents and Records

Master Control Sign-off for Outstanding Procedures and Training

 

Mar

QSE 8 Documents and Records

Critical Value Audit

Apr

 

 

May

QSE 5 Purchasing and Inventory

Clinical Engineering (Bio-Med) stickers on equipment

June

QSE 7 Process Management

IQCP documents complete (Quality Assessment Follow-up)

July

QSE 2 Customer Focus

Customer service assessment performed (Lab Ambassador Committee)

August

QSE 10 Nonconforming Events Management

Follow-up documentation on Patient Safety Reports (PSR)

September

QSE 3 Facilities and Safety

Emergency Preparedness Plan procedure (COOP)

 

QSE 8 Documents and Records

Critical Value Audit

October

QSE 6 Equipment

 

Manufacturer Reagent Insert process

QSE 12 Continual Improvement

Employee Engagement Efforts: New Employee Orientation

November

QSE 9  Information Management

IT Downtime procedure

December

QSE 11 Assessments

Follow-up on CAP citations

QSE 1 Organization

Organizational Charts available 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

Safety Checklist

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