ddgh-#12789-v1-2004 annual report · 2011-03-21 · 2004 annual report page 3 of 19 2.0. detailed...

AAnnnnuuaall RReeppoorrtt 22000044

Mission Statement The Regional Laboratory Program provides a community of co-operation and education to enhance the sharing of resources to improve quality and maximize the efforts of individual laboratories in providing a high level of services to our clients. Board of Directors

Robert Wilson Atikokan General Hospital Andrew Skene Dryden Regional Health Centre Mark Balcaen Lake of the Woods District Hospital Ken McGeorge Red Lake Margaret Cochenour Memorial Hospital Wayne Woods Riverside Health Care Facilities, Inc. Roger Walker Sioux Lookout Meno-Ya-Win Health Centre

Regional Office

Kenora-Rainy River Regional Laboratory Program, Inc. P.O. Box 3003

Dryden, ON P8N 2Z6 Phone: 807-223-8264 Fax: 807-223-7342

Chief Operating Officer: Andrew G. Skene Laboratory Director: Dr. J. Kerry MacDonald Regional Laboratory Consultant: Anna Robinson Program Assistant: Marilyn Dickey

Organizational Chart Appendix A.

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1.0. Executive Overview

The Kenora-Rainy River Regional Laboratory Program is a MOH-LTC-funded Corporation reporting to a Board of Directors comprising of six (6) C.E.O.’s representative of the laboratories in the Corporation. Since Incorporation, the Program has evolved into a strong regional entity in Ontario. The Program continues to act as a service provider offering well-researched information to assist laboratories in an ever changing environment. In addition, the Laboratory Director provides diagnostic and clinical consultations. The Program has developed a comprehensive Quality Management System for the laboratories, which includes a number of key indicators to assist in measuring current performance against accepted benchmarks. Our commitment to education continues to be an annual success responsive to the needs of medical and technical staff throughout this region and beyond. It is hoped that the scope will expand to include clinical placement training of 3rd year MLT students in our facilities to ease future recruitment concerns. The Program provides a collaborative environment, which facilitates the development of discipline-specific manuals and consensus achievement for equipment methodologies. To ensure the laboratories continue to provide the high level of patient care. the Program continues to monitor external quality assurance testing. This year has seen fewer errors than ever before confirming the commitment to technical excellence. Our Corporation continues to work with other laboratory service providers, lending leadership in regional initiatives.

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2.0. Detailed Description of Activities

2.1. Ontario Laboratory Accreditation (OLA) OLA continues to remain in the forefront of the Program’s endeavors. Using the Quality Manual and Total Quality Management Manual as developed in 2003, laboratories performed their first self-assessment measuring their quality program to the OLA requirements. The Program facilitated group meetings to determine major and minor non-conformances and identify gaps in processes. As an outcome of the review, revisions and additions were made to the manuals and recommendations were acted on to assist in the implementation of TQM in each facility. This project remains ongoing. Newsletters were developed to introduce the vision of Total Quality Management to the staff as sections of the manual were introduced. The self-assessments show a regional compliance of 80% - 90%. Since the self-assessment, regional laboratories have been notified of plans for an OLA peer assessment in 2005. The consultant has been requested to perform a mock assessment in each facility to identify non-conformances prior to the actual Accreditation visit. 2.2. Discipline-Specific Manuals The Program continued in this collaborative with the development of regional discipline-specific manuals. Final drafts are under review at each facility before implementation. These include Serology, Urinalysis, Coagulation, Hematology and IT. 2.3. Equipment Three (3) Chemistry analyzers in the region were highlighted for replacement in 2005. The Program, in collaboration with the Northshore District Laboratory Program (NDLP), prepared an RFP to seek critical information. Deliberation on the responses included meetings and teleconferences with the vendors, Laboratory Director, Laboratory Managers and C.E.O.’s. It was recommended by the Program Consultant and Laboratory Director to consider the purchase of the Vitros 350 analyzer should capital be available in 2005. In the region, two (2) of five (5) hospitals have purchased MTS technology for use in Transfusion Medicine. It is hoped DME funding will offset the capital costs.

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2.4. Education This year, the Program worked in collaboration with the Ontario Society of Medical Technologists to present a Fall Conference. It was well received regionally and interest has been expressed to repeat the venue in the future. Complete details are in Appendix B. The Laboratory Director continued to offer onsite education to a variety of health care providers. Topics included Lactate and Osmolality testing as well as blood utilization. Site dependant, physician interest remains variable in amount. Their reasons for failing to take advantage of offered education are varied. 2.5. Onsite Visits In addition to monthly teleconferences with the Laboratory Managers, onsite visits have occurred by the Laboratory Director and Program Consultant a minimum of four (4) times at each site this year. Appendix C. These exchanges continue to strengthen regional interaction and collaborative ventures between sites. In addition, this interaction creates an environment for laboratories to participate openly, actively and fairly using a consensus process regarding products and services. Onsite travel amounts to approximately 12,200 km, equaling 200 travel hours. 2.6. Recruitment The Program remains responsive to the concerns of future recruitment in the region. Discussions took place with Cambrian College (Sudbury) and Red River College (Winnipeg) to investigate opportunities for the provision of clinical placement and training for MLT students. At this time, the laboratory licenses have been forwarded to Red River College for their review to determine if the current laboratory menu meets the criteria listed in the student’s curriculum. If acceptable, the region will prepare to accept two (2) students as early as September 2005.

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2.7. EQA The performance of the laboratories as it relates to QMP-LS external quality assurance testing continues to be monitored. Participation in EQA and the Program’s inter-laboratory monthly QC program has assisted in identifying problems in analytical performance not always detectable by internal quality assurance activities. The Program notes improvement from last year in both Microbiology and Transfusion Medicine. Overall regional performance in 2004 has shown improvement in EQA testing. Appendix D1, D2, D3, & D4, 2.8. Laboratory Services Plan The Regional Coordinating Committee continues to have three (3) representatives from the KRR RLP. Information from these meetings flows to the North network to assist in broad spectrum healthcare planning.

3.0. Goals for 2005

3.1. Develop a regional antibiogram to assist physicians with empiric treatment of

infected patients. 3.2. Promote Osmolality testing in the region.

3.3. Assist the laboratories in the peer accreditation process schedule March/April

2005.

3.4. Examine current referral practices to determine if efficiencies can be found.

3.5. Develop a regional Chemistry and Specimen Collection manual.

3.6. Provide clinical instruction on the use of eGFR – MDRD for the early detection of renal disease and monitoring of the illness.

3.7. Promote compliance with the National Kidney Disease Education Program

(NKDEP) recommendations for laboratory services including proficiency goals.

3.8. Assist the Board in examining the Corporate By-Laws.

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AAppppeennddiixx AA

Organizational Chart

Board of DirectorsLaboratory Director

(6 Hospital CEO's)

Kenora Rainy River Regional Laboratory Program, Inc.

Regional Laboratory Consultant

Program Assistant

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AAppppeennddiixx BB

OOSSMMTT // KKRRRR RRLLPP FFaallll CCoonnffeerreennccee 22000044

Saturday, September 25

Speaker

Topic

Dr. Deborah Yamamura

Antibiotic Susceptibility Testing

Linda Crawford

OLA – How do we stack up so far?

Darcy Heron

Ortho Clinical Diagnostics

Technical Breakout Session

Vitros; Fusion; ECi

Dr. Carney Matheson

Medical Research and Technology

in the Paleo-DNA Laboratory

Dr. William G. McCready

Renal Dialysis and Related

Laboratory Testing

Dr. Frank Denson

Lakehead Psychiatric Hospital

Methadone: A Historical Perspective

and Modern Clinical Usage

Kathy Wilkie

CMLTO

10th Anniversary Salute to the RHPA:

A Practical Guide for Professional MLTs

Linda Diebold

Beckman Coulter Canada Inc.


ACL Troubleshooting and Introduction to D-Dimers

Connie Colavecchia Ortho Clinical Diagnostics

Transfusion Medicine

- Past, Present and Future

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Sunday, September 26

Speaker

Topic

Karen Scraba

BD Medical Systems

Best Practices in Blood Collection

Susan MacDonald BD Medical Systems

Understanding the Impact of Pre-analytical

Variables on Patient Outcomes

Cathie McCallum

Establishing a Point-of-Care Program

in Your Facility

Gianna Zecchini

Inter Medico


Immulite – Technical Update

Blanca McArthur

Ontario Society of Medical Technologists

Certification & Regulation for Lab

Assistants/Technicians

Dr. Dmitros Vergidis

Northwestern Ontario Regional Cancer Centre

Anticoagulant Therapy and

Non-Specific Inhibitors

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OSMT / KRR RLP Fall Conference

Summary

The OSMT / KRR RLP Fall Conference was held September 24 – 26, 2004 at the Travelodge Hotel Airlane in Thunder Bay. In attendance were 105 delegates of which thirty-two(32) were from our own region. Delegates included technologists and technicians as well as one Laboratory Director. Included were delegates from Ottawa, North Bay and the greater Toronto area. Excluded from these statistics were the Conference Committee, OSMT Board of Directors and Exhibitors. The breakdown of delegates from our region include:

• Atikokan General Hospital: 3 • Dryden Regional Health Centre 3 • Lake of the Woods District Hospital 4 • Red Lake MC Memorial Hospital 2 • Riverside Health Care Facilities, Inc. 8 • Sioux Lookout Meno-Ya-Win Health Centre 10 • KRR RLP 2

The educational format consisted of 12 guest speakers who provided presentations relating to laboratory management and medicine. In addition, three (3) technical breakout sessions ran concurrently with vendor exhibition hours to provide valuable user information on analyzers presently in use in our region. The exhibition itself included 21 vendors. The main social event was a candlelight tour of Fort William Historical Park. The cost to the KRR RLP is as follows:

Registration for 32 Delegates: $4,665.20

Hotel Accommodation: 3,490.73

Travel: 1,606.42

Reimbursements: $1,255.02

Total Cost to KRR RLP: $8,886.33

A profit was realized and the KRR RLP received one-half of the next proceeds as compensation for its efforts in arranging the conference. This amounted to approximately $3,900.00.

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The delegates were asked to complete an evaluation prior to leaving the Conference. The findings were:

Evaluation Form - Delegates

Organization: Unsatisfactory Excellent1 2 3 4 5

Registration Process 3% 26% 71%Schedule of Sessions & Events 6% 44% 50%Facilities: Meeting Rooms & AV 18% 44% 38% Food 3% 3% 9% 47% 38% Service & Accommodation 3% 21% 44% 32%

Program: Unsatisfactory Excellent1 2 3 4 5

Selection of Session Topics 7% 13% 20% 27% 33%Speakers (Saturday) 6% 44% 50%Speakers (Sunday) 6% 35% 59%Annual General Meeting 14% 0% 86% 0%Trade Show & Exhibits 9% 47% 44%

Overall Value: Low Value High Value1 2 3 4 5

Educational Value 3% 9% 26% 62%Social Value 3% 35% 62%

Social Events: Not Enjoyable Very Enjoyable1 2 3 4 5

President's Reception 8% 12% 27% 54%Banquet 10% 45% 45%Fort William Historical Park Tour 19% 6% 38% 38%

Unsatisfactory Excellent1 2 3 4 5

Overall Rating of Conference: 3% 41% 56%

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AAppppeennddiixx CC

MMeeeettiinnggss aanndd VViissiittss

2004 Meetings

Board of Directors

Regional Laboratory

Managers

Regional Co-Ordinating

Committee (R.C.C.)

January 30

January 8

(via teleconference)

March 30

February 13

Annual Meeting (via teleconference)

No Quorum

February 10


October 5

February 27


March 29


February 27

Annual Meeting (via teleconference)

May 13 & 14

May 25

June 23


October 29

September 8


October 27 & 28

November 10


December 9


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2004 Onsite Visits

AGH Atikokan

DRHC Dryden

RL MCMH Red Lake

RHCF

Fort Frances

SLMHC

Sioux Lookout

March 25

February 12

March 26

March 4

April 1

June 17

June 24

July 8

May 28

July 15

September 30

October 8

October 7

October 20

October 14

December 1

December 8

November 30

November 23

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AAppppeennddiixx DD11

Labs Total Participating Laboratories Total Provincial Letters Ontario Average Per Lab KRR RLPPrediction

1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003 1999 2000 2001 2002 2003

Chemistry 6 227 222 215 212 206 200 137 157 150 140 0.9 0.6 0.7 0.7 0.7 5.3 3.7 4.4 4.2 4.1

Drug Monitoring 6 168 171 167 168 169 123 50 79 94 92 0.7 0.3 0.5 0.6 0.5 4.4 1.8 2.8 3.4 3.3

Endocrinology 3 129 125 126 126 123 168 61 67 63 60 1.3 0.5 0.5 0.5 0.5 3.9 1.5 1.6 1.5 1.5

Enzymes 6 214 210 226 205 198 52 69 56 56 37 0.2 0.3 0.2 0.3 0.2 1.5 2.0 1.5 1.6 1.1

Lipids 1 160 155 148 144 135 57 70 74 127 58 0.4 0.5 0.5 0.9 0.4 0.4 0.5 0.5 0.9 0.4

POCT 6 196 0 0.0 0.0 0.0 0.0 0.0 0.0

Hematology 6 244 236 227 223 217 84 76 53 86 50 0.3 0.3 0.2 0.4 0.2 2.1 1.9 1.4 2.3 1.4

Coagulation 6 230 222 212 207 200 50 32 47 24 50 0.2 0.1 0.2 0.1 0.3 1.3 0.9 1.3 0.7 1.5

Morphology 6 236 228 218 214 206 136 70 70 126 40 0.6 0.3 0.3 0.6 0.2 3.5 1.8 1.9 3.5 1.2

Transfusion Medicine 6 179 179 179 177 176 112 139 156 147 221 0.6 0.8 0.9 0.8 1.3 3.8 4.7 5.2 5.0 7.5

Bacteriology *** 3 111 137 127 118 114 342 301 289 384 218 3.1 2.2 2.3 3.2 3.2 9.2 6.6 6.8 9.6 9.6

Cytology 1 84 84 90 86 88 41 51 43 3 0 0.5 0.6 0.5 0.0 0.0 0.5 0.6 0.5 0.0 0.0

Totals 1982 1969 1935 1880 2028 1365 1056 1091 1260 966 8.8 6.5 6.9 8.1 7.5 35.7 25.8 28.0 32.8 31.5

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QMP-LS Correspondence Per Discipline

Regional Laboratories

1999 2000 2001 2002 2003 2004Chemistry 10 5 4 8 1 6Drug Monitoring 0 0 1 2 5 2Endocrinology 0 0 0 0 0 2Enzymes 1 1 0 3 2 0Lipids 0 0 1 1 0 0POCT 2 1 1 0 0 0Hematology 3 3 1 3 0 0Coagulation 0 0 1 0 1 0Morphology 3 3 1 3 0 0Transfusion Medicine 1 1 5 7 6 1Bacteriology * 14 12 8 6 5 3Cytology 0 0 0 0 0 0

Totals 34 26 23 33 20 14

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Actual Number of QMP-LS Correspondence Per Laboratory

Regional Laboratories

1999 2000 2001 2002 2003 2004

Atikokan General Hospital 2 3 3 3 3 0

Dryden Regional Health Centre 7 2 1 0 3 2

Lake of the Woods District 8 8 7 7 6 3

Red Lake MC Memorial 3 1 3 4 2 0

Riverside Health Care Facilities 5 3 4 7 2 6

SL Meno-Ya-Win Health Centre - 7th Avenue Site 7 6 2 6 3 3

Totals 32 23 20 27 19 14

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QMP-LS Correspondence – Error Assessment

January – December 2004

Site

Memos / Letters

Lesser Error

Significant

Error

On Site

Total

QMP-LS Atikokan General Hospital

0

Dryden Regional Health Centre

2

2 Lake of the Woods District Hospital

3

3

Red Lake M.C. Memorial Hospital

0

Riverside Health Care Facilities, Inc.

5

1

6

Sioux Lookout Meno-Ya-Win Health Centre

1

2

3

Totals

1

12

1

0

14

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Explanation of EQA Errors

Laboratory

Survey

Reference Lab

Result

Laboratory Result

Root Cause

Corrective Action Plan

Atikokan General

Hospital (AGH)

- - - - No EQA Errors - - - -

Drugs - 0405

Cannabinoids pos

Cannabinoids neg

Concentration of

analyte near the cut-off threshold

None

Dryden Regional

Health Centre (DRHC)

Chem - 0401

Calcium 4.23 mmol/L

Calcium 4.66 mmol/L

Positive bias onboard

?? stability of ?? testing material

Test samples immediately

Enzymes - 0403

Vial 1 Total CK-2 16

ug/L

Vial 2 Total CK-2 1 ug/L

Vial 3 Total CK-2

7 ug/L


Vial 1 Total CK-2 3

ug/L

Vial 2 Total CK-2 <0.7 ug/L

Vial 3 Total CK-2

1 ug/L


CK-2 test not performed.

Troponin results

transcribed into LIS.

Implement clerical checks of manually transcribed data.

Chem – 0404

Blood Gas

pC02 65 mmHg

56 mmHg

pC02 sensor defective

pC02 sensor replaced

Lake of the Woods

District Hospital (LOWH)

Chem – 0408

Blood Gas

Ionized Ca 0.47

mmol/L

0.54 mmol/L

Calcium sensor

defective

Calcium sensor

replaced including additional maintenance

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Laboratory

Survey

Reference Lab Result

Laboratory Result

Root Cause


Red Lake Margaret

Cochenour Memorial Hospital

(RLMCMH)

- - - No EQA Letters - - -

Enzymes - 0403


U/L

Vial 2 Total CK-2 91 U/L

Vial 3 Total CK-2

148 U/L



U/L


Vial 3 Total CK-2

123 U/L


Defective reagent

slides.

Replace slides.

TMed – 0405

Vial 1 – 1+ reaction

Vial 2 –

transfusion not compatible

Vial 3 – transfusion

not compatible

Vial 1 – negative

Vial 2 –

transfusion compatible

Vial 3 – transfusion

compatible

Methodology not

sensitive enough to detect the antibody in

question.

Pursue purchase of

MTS system.

Riverside Health Care

Facilities, Inc. (RHCF)

Bact - 0409

Staphylococcus

schleiferi

Staphylococcus

hemolyticus

Analyzer not capable of identifying S. schleiferi.

Refer out questionable

staph species.

2004 Annual Report

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Laboratory

Survey

Reference Lab Result

Laboratory Result

Root Cause


Drug-0410

Vial X

Methadone + Vial Y

Methadone -

Vial X

Methadone - Vial Y

Methadone +

Specimens mixed up at

testing

Technologist required to

review process for specimen identification.

Riverside Health Care

Facilities, Inc. (RHCF)

Chem-0410

Vial A: 71 g/L Vial B: 71 g/L Vial C: 71 g/L

Vial A: 63 g/L Vial B: 65 g/L Vial C: 63 g/L

Calibration drift

Participate in an

external QC program.

Enzymes – 0401

LD 1224.5 U/L

177 U/L

Transcription error.

Implement clerical

checks.

Chem – 0404

Blood Gas

pH 7.65

pH 7.60

Random error

Monitor performance

Sioux Lookout

Meno-Ya-Win Health Centre

(SLMHC)

Bact - 0404

- - - Letter of Clarification - - -

None.

ddgh-#12789-v1-2004 annual report · 2011-03-21 · 2004 annual report page 3 of 19 2.0. detailed...

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