Facility Information for Initial Assessment · Facility Information for Initial Assessment –...

College of Physicians and Surgeons of British Columbia300–669 Howe Street Vancouver BC V6C 0B4 www.cpsbc.ca

Telephone: 604-733-7758 Toll Free: 1-800-461-3008 (in BC) Fax: 604-733-3503

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DIAGNOSTIC ACCREDITATION PROGRAM

Revised November 8, 2018Facility/hospital/health centre name:

Facility Information for Initial AssessmentLABORATORY MEDICINE

FACILITY INFORMATION

Facility/hospital/health centre name:

Laboratory name (if different from above):

Corporate entity/health authority:

Health service area (if applicable):

Address:

City: Postal code:

Laboratory phone number:

Population of city:

Other towns or areas the laboratory serves:

Number of beds in hospital/health centre:

Projected date of facility opening or discipline starting:

CONTACT INFORMATION FOR ACCREDITATION ACTIVITIES

Name: Title:

Address:

City: Postal code:

Phone number: Cell phone number:

Email:

ORGANIZATIONAL LEADERSHIP

Complete the leadership appropriate for the organization.

Medical leadership First name Last name Title Email Location

Health authority vice president of medicine

Regional laboratory medical director

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College of Physicians and Surgeons of British ColumbiaFacility Information for Initial Assessment – Laboratory Medicine


Medical leadership First name Last name Title Email Location

Alternate laboratory medical director

Health service area laboratory medical director

Facility laboratory medical director

Administrative leadership First name Last name Title Email Location

Hospital/health centre COO/administrator

Regional laboratory administrative director

Health service area laboratory administrative director

Facility laboratory administrative/technical leader

Quality leadership First name Last name Title Email Location

Regional quality director

Facility quality lead

Other laboratory leadership First name Last name Title Email Location

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Other laboratory leadership First name Last name Title Email Location

PERSONNEL

Total FTEs

Technologists (MLT): Pathologist's assistants (PA):

Scientific personnel (BSc, MSc): Combined laboratory X-ray technologists (CLXT):

Laboratory assistants (MLA): Transcription and clerical personnel:

SCOPE OF SERVICES TO BE ACCREDITED (Check all that apply)

Anatomic pathology MicrobiologyChemistry Molecular diagnosticsCytogenetics Point of care testingCytology Sample collectionHematology Transfusion medicineOther (list):

Are multiple services consolidated into one area (core laboratory)? If so, indicate below.Chemistry MicrobiologyHematology Transfusion medicine

For each scope of service to be accredited, complete the corresponding section(s) below and the Scope of Accreditation and PT Enrolment form.

INFORMATION MANAGEMENT AND INFORMATICS (IMI)

Is there a laboratory information system (LIS)? Yes No

Name of system:

Is this part of a regional system? Yes No

Is there a telepathology system for diagnostic purposes? Yes No

Name of system:

Is this part of a regional system? Yes No

SAMPLE COLLECTION (SCT) ON-SITE

Does your facility perform mobile phlebotomy (see definition in accreditation manual)?

Yes No

Name of sample collection supervisor: Title:

Total FTEs

Technologists (MLT): Laboratory assistants (MLA):

Nurses: Combined laboratory X-ray technologists (CLXT):

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In-patient days and hours of operation:Monday 24 hours Other: to Tuesday 24 hours Other: to

Wednesday 24 hours Other: to Thursday 24 hours Other: to

Friday 24 hours Other: to Saturday 24 hours Other: to

Sunday 24 hours Other: to

Projected number of in-patient samples collected daily:

Outpatient days and hours of operation:Monday 24 hours Other: to Tuesday 24 hours Other: to




Projected number of outpatient samples collected daily:

SAMPLE COLLECTION SITES (OFF-SITE)

Sample collection site 1

Sample collection site name:

Address:

City: Postal code:

Phone:


Total FTEs



Days and hours of operation:Monday Hours: to Tuesday Hours: to

Wednesday Hours: to Thursday Hours: to

Friday Hours: to Saturday Hours: to

Sunday Hours: to

Projected number of patient samples collected daily:

Will point of care testing (POCT) be performed at this location? Yes No

If yes, what POCT will be performed?

Note: Ensure all POCT examinations and location of POCT testing is listed in the scop of accreditation report.



Address:

City: Postal code:

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Phone:


Total FTEs






Sunday Hours: to







Address:

City: Postal code:

Phone:


Total FTEs






Sunday Hours: to







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Address:

City: Postal code:

Phone:


Total FTEs






Sunday Hours: to





ANATOMIC PATHOLOGY (ANP)

Days and hours of operation:Monday 24 hours Other: to Tuesday 24 hours Other: to




Scope of service

Intraoperative consultations (frozen sections) Yes No

Indicate location:

Gross examination Yes No

Tissue processing, embedding, microtomy, staining Yes No

Autopsy Yes No

Immunohistochemistry Yes No

Is this a specialized or separate section? Yes No

If yes, indicate location and supervisor name:

Other ancillary examinations Yes No

In-situ hybridization (ISH)

Immunofluorescence microscopy

Electron microscopy

Are any specialized or separate sections? Yes No

If yes, indicate location and supervisor name:

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CHEMISTRY (CHE)





Scope of service

General chemistry Yes (core lab) Yes (non-core lab area) No

Urinalysis Yes (core lab) Yes (non-core lab area) No

Blood gases Yes (core lab) Yes (non-core lab area) No

Therapeutic drug monitoring (TDM) and drug screening Yes (core lab) Yes (non-core lab area) No

Sweat chloride examinations Yes (core lab) Yes (non-core lab area) No

Gas chromatography (GC)/High-performance liquid chromatography (HPLC)/Thin layer chromatography

Yes (core lab) Yes (non-core lab area) No

Radioimmunoassay (RIA) Yes (core lab) Yes (non-core lab area) No

Atomic absorption Yes (core lab) Yes (non-core lab area) No

Mass spectrometry (MS) Yes (core lab) Yes (non-core lab area) No

Inductively coupled plasma—mass spectrometry (ICP—MS) Yes (core lab) Yes (non-core lab area) No

Electrophoresis Yes (core lab) Yes (non-core lab area) No

Prenatal screening Yes (core lab) Yes (non-core lab area) No

Newborn screening Yes (core lab) Yes (non-core lab area) No

CYTOGENETICS (CYG)





CYTOLOGY (CYT)





HEMATOLOGY (HEM)



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MICROBIOLOGY (MIC)





MOLECULAR DIAGNOSTICS (MOL)





POINT OF CARE (POC) TESTING

Point of care (POC) testing is performed near or at the site of a patient and is typically performed by non-lab personnel.

Note: If POC equipment is used in a traditional medical laboratory, operated by qualified medical laboratory personnel, complete the service-specific sections of this form.Is there a multidisciplinary POCT management group for point of care testing? Yes No

If yes, indicate location:

Who is responsible for laboratory oversight of point of care testing (see POC 1.1.2 to 1.1.5)?

Name: Location:

Who monitors employee training for point of care testing?

Name: Location:

Who monitors ongoing employee competency assessment for point of care testing?

Name: Location:

Who monitors point of care testing equipment and maintenance?

Name: Location:

Who monitors point of care testing quality control?

Name: Location:

Who monitors point of care proficiency testing?

Name: Location:

TRANSFUSION MEDICINE (TRM)



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ADDITIONAL INFORMATION

Other information you wish to add:

Email completed form to [email protected].

The information in this form is collected under the authority of part 5, section B of the Bylaws under the Health Professions Act, RSBC 1996, c.183. If you have any questions about the collection and use of this information, please contact the College at 300–669 Howe Street, Vancouver, BC, V6C 0B4 or by phone at 604-733-7758 or 1-800-461-3008 (toll free in BC).

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College of Physicians and Surgeons of British Columbia

300–669 Howe Street

Vancouver BC V6C 0B4

www.cpsbc.ca

Telephone: 604-733-7758 Toll Free: 1-800-461-3008 (in BC) Fax: 604-733-3503

of

DIAGNOSTIC ACCREDITATION PROGRAM

Revised November 8, 2018

of

College of Physicians and Surgeons of British Columbia

Facility Information for Initial Assessment – Laboratory Medicine

Revised November 8, 2018

Facility Information for Initial Assessment

LABORATORY MEDICINE

FACILITY INFORMATION

CONTACT INFORMATION FOR ACCREDITATION ACTIVITIES

ORGANIZATIONAL LEADERSHIP

Complete the leadership appropriate for the organization.

Medical leadership

First name

Last name

Title

Email

Location

Health authority vice president of medicine

Regional laboratory medical director

Alternate laboratory medical director

Health service area laboratory medical director

Facility laboratory medical director

Administrative leadership

First name

Last name

Title

Email

Location

Hospital/health centre COO/administrator

Regional laboratory administrative director

Health service area laboratory administrative director

Facility laboratory administrative/technical leader

Quality leadership

First name

Last name

Title

Email

Location

Regional quality director

Facility quality lead

Other laboratory leadership

First name

Last name

Title

Email

Location

PERSONNEL

Total FTEs

SCOPE OF SERVICES TO BE ACCREDITED (Check all that apply)

Are multiple services consolidated into one area (core laboratory)? If so, indicate below.

For each scope of service to be accredited, complete the corresponding section(s) below and the Scope of Accreditation and PT Enrolment form.

INFORMATION MANAGEMENT AND INFORMATICS (IMI)

Is there a laboratory information system (LIS)?

Is this part of a regional system?

Is there a telepathology system for diagnostic purposes?

Is this part of a regional system?

SAMPLE COLLECTION (SCT) ON-SITE

Does your facility perform mobile phlebotomy (see definition in accreditation manual)?

Total FTEs

In-patient days and hours of operation:

Outpatient days and hours of operation:

SAMPLE COLLECTION SITES (OFF-SITE)


Total FTEs

Days and hours of operation:

Will point of care testing (POCT) be performed at this location?



Total FTEs





Total FTEs





Total FTEs




ANATOMIC PATHOLOGY (ANP)


Scope of service

Intraoperative consultations (frozen sections)

Gross examination

Tissue processing, embedding, microtomy, staining

Autopsy

Immunohistochemistry

Is this a specialized or separate section?

Other ancillary examinations

Are any specialized or separate sections?

CHEMISTRY (CHE)


Scope of service

General chemistry

Urinalysis

Blood gases

Therapeutic drug monitoring (TDM) and drug screening

Sweat chloride examinations

Gas chromatography (GC)/High-performance liquid chromatography (HPLC)/Thin layer chromatography

Radioimmunoassay (RIA)

Atomic absorption

Mass spectrometry (MS)

Inductively coupled plasma—mass spectrometry (ICP—MS)

Electrophoresis

Prenatal screening

Newborn screening

CYTOGENETICS (CYG)


CYTOLOGY (CYT)


HEMATOLOGY (HEM)


MICROBIOLOGY (MIC)


MOLECULAR DIAGNOSTICS (MOL)


POINT OF CARE (POC) TESTING

Point of care (POC) testing is performed near or at the site of a patient and is typically performed by non-lab personnel.

Note: If POC equipment is used in a traditional medical laboratory, operated by qualified medical laboratory personnel, complete the service-specific sections of this form.

Is there a multidisciplinary POCT management group for point of care testing?

Who is responsible for laboratory oversight of point of care testing (see POC 1.1.2 to 1.1.5)?

Who monitors employee training for point of care testing?

Who monitors ongoing employee competency assessment for point of care testing?

Who monitors point of care testing equipment and maintenance?

Who monitors point of care testing quality control?

Who monitors point of care proficiency testing?

TRANSFUSION MEDICINE (TRM)


ADDITIONAL INFORMATION

Other information you wish to add:

Email completed form to [email protected].

The information in this form is collected under the authority of part 5, section B of the Bylaws under the Health Professions Act, RSBC 1996, c.183. If you have any questions about the collection and use of this information, please contact the College at 300–669 Howe Street, Vancouver, BC, V6C 0B4 or by phone at 604-733-7758 or 1-800-461-3008 (toll free in BC).

11.0.0.20130303.1.892433.887364

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