HOSPITAL RAJA PERMAISURI BAINUN JALAN HOSPITAL 30990 IPOH PERAK DARUL RIDZUAN

05-2085000 Telefon: 05-208 Talian Terus: (Samb.) No. Faks: 05-2531541

Ruj. Kami: Tarikh:

1 Disember 2011

Pengarah Hospital; (up. Ketua Jabatan/Unit Patologi) Hospital Taiping/ Teluk Intan/ Seri Manjung/ Slim River/ Batu Gajah/ Kuala Kangsar/ Parit Buntar/ Kampar/ Tapah/ Sg Siput/ Selama/ Grik/ Changkat Melintang/ Bahagia, Ulu Kinta Tuan/Puan, LAPORAN PENCAPAIAN BAGI PROGRAM LABORATORY QUALITY ASSURANCE NATIONAL INDICATOR APPROACH (NIA) JAN DIS 2011 Adalah saya dengan hormatnya merujuk kepada perkara tersebut diatas. 2. Seperti sedia maklum setiap makmal hospital KKM di negeri Perak perlu menyediakan Laporan Pencapaian Program QAP-NIA sebanyak dua (2) kali dalam setahun iaitu pada bulan Januari dan Julai. Laporan tersebut perlu dihantar kepada Pakar Patologi Negeri untuk tujuan kompilasi dan dihantar ke Sekretariat QAP Kebangsaan. 3. Sehubungan dengan itu tuan/puan diminta menghantar laporan di atas bagi tahun 2011 menggunakan Borang QAP 1/2001, 2/2001 (jika ada SIQ) dan 5/2005 (contoh borang dikepilkan) sebelum 5 Januari 2012. Di samping itu, tuan/puan juga diminta menggunakan Borang QAP/ERR-1.1 untuk Indikator Transfusion Error Rate (Dilampirkan). Bersama ini juga disertakan indikator yang dipantau untuk rujukan. Laporan yang telah lengkap hendaklah dihantar kepada Ketua Jabatan Patologi, HRPB (up. Penyelaras QAP). Salinan softcopy hendaklah dihantar melalui email kepada zainura09@gmail.com atau seetha_lan@prk.moh.gov.my. Kerjasama tuan/puan dalam perkara ini didahului dengan ribuan terima kasih. Sekian dimaklumkan, terima kasih. "PENYAYANG, BEKERJA BERPASUKAN DAN PROFESIONALISMA ADALAH BUDAYA KERJA KITA "

BY EMAIL
.................................................... DATO DR. NORAIN KARIM
MBBS, MPath (Mal), FRCPath (UK), FRCPA(Aust), FICAP(USA), MIAC, FAMM Pakar Perunding Patologi dan Ketua Jabatan Patologi Hospital Raja Permaisuri Bainun, Ipoh. s.k.,

Pengarah Hospital, Hospital Raja Permaisuri Bainun, Ipoh Ketua Unit Anatomi Patologi, Hematologi, Mikrobiologi, Patologi Kimia, Transfusi, Jabatan Patologi HRPB. Sediakan laporan unit berkaitan

Fail: Laporan QAP Negeri Perak

Laboratory NIA Indicator

YEAR: .

QAP 1/2001

Trending of Performance DISCIPLINE: HOSPITAL:.. INDICATOR:. Standard:

MONTH January February March April May June SUB- TOTAL July August September October November December SUB-TOTAL TOTAL Standard Performance achieved

LABORATORY:

Is there a shortfall in Quality for this indicator?

Yes

No

Fail: Laporan QAP Negeri Perak

QAP 2/2001

Laboratory NIA Indicator

SHORTFALL IN QUALITY REPORTING FORMAT
DISCIPLINE: HOSPITAL:.. INDICATOR:. Standard: Actual performance achieved:
Reasons for Shortfall in Quality: e.g. mix-up of specimen, unsuitable specimen, and true quality problem. Structural factors: Process factors: e.g. staffing, facilities, training, equipment etc e.g. Procedures not followed, etc Any ACTION STRATEGIES for implementation to improve the situation? Yes/No If No, why not? ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________ If YES, why not? 1. Policy changes 2. Procedural changes 3. Equipment (changes in type of equipment used, installation of additional facilities. 4. Staffing training, education, number, reployment, credentialing. 5. Development of new systems of care. 6. Development of department specific clinical indicators. 7. Re-engineering of the processes. 8. Review of tests methods. 9. Introduction of procedures, work instruction. 10. Communication with customers clinicians, nurses etc 11. Developing guidelines on usage of laboratory services. 12. Initiation of awareness programs. 13. Process of receiving of specimens, dispatch of results etc reviewed. 14. Others (Please state) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ _______________________________________________________

LABORATORY:

CLOSING THE QA CYCLE Level of implementation

NO

ACTION STRATEGY

IMPLEMENTATION If No, why not?

YES/NO

Any, re-audit performed AFTER IMPLEMENTATION OF CHANGES? WHEN? MONTHLY PERFORMANCE AFTER IMPLEMENTATION OF CHANGES.

Fail: Laporan QAP Negeri Perak

QAP 5/2005 Laboratory NIA Indicator LAB : ___________________________ YEAR : ___________________________ NATIONAL PERFORMANCE FOR: PERIOD : 1 January to 31 June / 1 July to 31 December
Performance Achievement Action Taken

Indicators

Standard

Comment

a. Chemical Pathology Indicators

1. 2. 3. Average Analytical Performance for routine Clinical Biochemistry The turn around time (TAT) of BUSE urgent tests The turn around time (TAT) of Bilirubin (Paeds) urgent tests Accuracy Score: 0-5 TAT < 90 mins LTAT < 45 mins TAT < 90 mins LTAT < 45 mins

b. Medical Microbiology
1. 2. 3. 4. 5. Performance in Lab Diagnosis Tuberculosis Microscopy Performance in Antinuclear Antibody testing (ANA) using EIA/IF Performance in Medical Bacteriology Performance in HIV Antibody Testing TAT of CSF results Correctness Correctness Correctness Correctness TAT< 3 hrs LTAT<1 hr

c. Transfusion / Haematology Indicators

1. 2. 3. 4. 5. 6. Crossmatch Transfusion (C:T ratio) Expiry rate of red cell Transfusion Error Rate Rate of Laboratory Error in HbsAg screening test Rate of Laboratory Error in antiHCV screening test TAT of urgent full blood count Efficiency Blood inventory Safety Accuracy and Precision Accuracy and Precision 90% should be reported within 60 mins 90% should be reported within 90 mins

7.

TAT of urgent PT & APTT

Fail: Laporan QAP Negeri Perak

QAP 5/2005 cont.. Laboratory NIA Indicator LAB : ___________________________ YEAR : ___________________________ NATIONAL PERFORMANCE FOR: PERIOD : 1 January to 31 June / 1 July to 31 December
Performance Achievement Action Taken

Indicator 8. 9. 10. 11. External QA Blood Banking a) ABO and Rh Grouping b) Antibody Screening c) Antibody identification NEQAP in Haematology External QA for Haemostasis Performance in immunophenotyping: T cell subset enumeration. Performance in Histopathology (General Diagnostic) Performance in Histopathology (Technical) TAT of thyroidectomy specimen TAT of urgent biopsies Adequacy of Histopathology report for mastectomy specimen % of CIN diagnosed by HPE on all colposcopic biopsies Performance in Cytopathology (Gynae) Performance in Cytopathology (General) Performance in Cytopathology (FNAC) Histo-Cytopathology correlation for FNAC of breast lesion Accuracy of reporting Gynaecology Smear: Percentage of cytologyhistopathology correlation

Standard Correctness Correctness Correctness Correctness

Comment

d. Histopathology & Cytology Indicators

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Correctness Correctness LTAT- 80% within 10 days LTAT - 80% within 72 hrs 100% correctness 90% show CIN Correctness Correctness Correctness 90% agreement

11.

Minimum 65% agreement

Fail: Laporan QAP Negeri Perak

QAP/ERR-1.1 INDICATOR: TRANSFUSION ERROR RATE HOSPITAL: .................................... Month Sampling Error STATE: Blood Bank Error YEAR: . Total Number of Errors Actual Error Near Miss (Wrong Blood Transfused)

Error Assoc With Admin Of Blood

Jan Feb Mac Apr May Jun Total (Jan-June) July Aug Sept Oct Nov Dec Total (Jul-Dec)

Grand Total

Is there a Shortfall In Quality (SIQ) for this Indicator? If Yes P, please complete form QAP 2/2009

Yes (

No ( )

Fail: Laporan QAP Negeri Perak