Beth Israel Deaconess Medical Center Laboratory Manual

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We continually monitor the quality of our laboratory services, including traditional laboratory parameters (such as quality control and proficiency testing) as well as newer areas of focus (such as competency testing). In addition, all processes, procedures and programs are standardized, and compliance with all external regulatory agencies is coordinated for the entire division (both east and West campuses).

We also look at "key performance measures" of the entire process. Some examples are:

Specimen Acceptability	Specimens which are considered inappropriate for testing (e.g. improperly labeled) are reviewed.
Turnaround Times	Various tests are chosen to represent different clinical situations and different sections of the laboratory. The time it takes for us to receive, process, analyze, and report these test results is closely monitored and any major problems are investigated.
Critical Values	Timely call back of critical values is monitored to ensure prompt notification to health care providers.
Test Orders	Data elements required for complete log in and billing (e.g., responsible physician, ICD9 codes) are reviewed and accuracy of log-in is monitored.
Compliance	Point-of-care testing sites are monitored for compliance with policies and procedures established by the Clinical Laboratory. Audits of the administration of blood products are performed to ensure proper documentation of the process. In both examples, follow up is provided to the appropriate sites.
Changed Results	Any test result which is entered into our Laboratory Information System and then changed (for whatever reason) is included on a daily report which is reviewed by a laboratory supervisor.
Safety	We review any accidents or needlestick events along with any plans to eliminate barriers to a safe work environment.

Whenever a complaint about laboratory services is received, whether written or oral, the person receiving the complaint notifies the Operations Director and prompt follow-up is provided.

To contact us about a complaint, a suggestion for improvement, or any quality-related issues, call Gina McCormack at 617-667-2342.