The Kabridahar General Hospital Laboratory recently underwent a comprehensive assessment using the SLIPTA (Stepwise Laboratory Improvement Towards accreditation) , a vital tool for evaluating laboratory quality management systems. The audit, conducted by Mr. Niman Tayib, Kadar Muse, and Ahmed Suane, provided valuable insights into the laboratory's current operational strengths and identified key areas for advancement.

Current Standing: A Foundation for Growth

The Kabridahar General Hospital Laboratory achieved an overall score of 206 out of 367 possible points, translating to 56% compliance. This score, according to the SLIPTA star rating criteria (Version 03), places the laboratory at a 1 Star rating (206-240 pts or 55-64% compliance). This indicates a solid foundation and a clear path for further development.

Commendable Strengths: Building on Success

The assessment highlighted numerous areas where the Kabridahar General Hospital Laboratory excels, demonstrating a commitment to structured processes and quality. Key strengths include:

• Robust Management Systems: Well-defined procedures are in place for organizational code of conduct, deputization, budgetary projections, management reviews, and personnel management. This shows a strong administrative backbone.
• Comprehensive Personnel Practices: The laboratory boasts effective procedures for personnel training, competency assessment, and performance reviews, ensuring a skilled workforce.
• Patient-Centric Approaches: Procedures for advisory services and handling complaints and feedback are well-established, indicating a focus on patient and user satisfaction.
• Efficient Equipment and Inventory Management: Strong protocols are noted for equipment management, calibration, preventive maintenance, and inventory control, including the effective use of FEFO (First-Expiration-First-Out) practices to minimize waste.
• Preparedness and Safety: A defined procedure for continuity and emergency preparedness planning is in place, alongside a readily available laboratory safety manual and proper waste disposal practices.
• Quality Control in Testing: The laboratory demonstrates proficiency in pre-examination processes, monitoring environmental conditions, and having procedures for External Quality Assessment (EQA) and verification/validation of examination methods.

These strengths serve as a testament to the dedication of the laboratory staff and management in upholding essential quality standards.

Areas for Enhancement: Paving the Way for Excellence

While many positives were observed, the assessment also pinpointed crucial areas requiring immediate attention to elevate the laboratory's services and achieve higher SLIPTA ratings. These include:

• Strengthening Documentation and Consistency: A recurring theme across various sections is the need for more consistent recording, archiving, and implementation of established procedures, particularly regarding quality and technical records, and management review outcomes.
• Enhanced Personnel Development: There's a clear need for a more comprehensive and consistently implemented program for training, continuing education, and competency assessment, especially for new and reassigned personnel. Ensuring all personnel sign job descriptions is also critical.
• Improving Customer Focus Implementation: While procedures exist, their consistent implementation in areas like providing advisory services to patients and conducting satisfaction surveys needs bolstering. Establishing a process for the treatment of patients' well-being and samples with due care and respect is also a key recommendation.
• Optimizing Equipment Practices: Critical gaps were identified in the consistent documentation of equipment verification, calibration scheduling and recording, and routine service maintenance by qualified engineers. Ensuring all operators have assigned authorization and recorded training is also vital.
• Deepening Assessment and Risk Management: The report highlights a significant need for consistent internal auditing, overall risk management tool development and implementation, and the use of quality indicators to drive continuous improvement.
• Refining Process Management: Critical areas include the consistent implementation of the continuity and emergency preparedness plan, meticulous recording of patient sample collection activities, and a formal procedure for referral laboratories. More robust Internal Quality Control (IQC) and Measurement Uncertainty (MU) practices are also essential.
• strengthening Information Management and Nonconformance Handling: Ensuring authorized personnel consistently release results with signatures, maintaining comprehensive laboratory report logs, and improving LIS system verification and maintenance records are crucial. Furthermore, the identification and management of nonconforming work require more thorough documentation and root cause analysis.
• Prioritizing Facilities and Safety: This emerged as a critical area for improvement, with a strong emphasis on establishing a documented procedure for overall laboratory safety. Significant enhancements are needed in the physical work environment, installation and verification of emergency showers and fire alarms, and the purchase and proper management of biosafety cabinets. A fully defined and implemented overall safety program encompassing hazardous materials, fire safety, and regular safety inspections is paramount. Biosecurity policies also need to be implemented.

Moving Forward: A Commitment to Quality

The Kabridahar General Hospital Laboratory's SLIPTA assessment provides a clear roadmap for advancing its quality management system. By diligently addressing the identified areas for improvement, particularly those flagged as "critical," the laboratory can significantly enhance its operational efficiency, accuracy, and overall service delivery. This commitment to continuous improvement is vital for providing the highest standard of healthcare to the community it serves and progressing towards a higher SLIPTA star rating.

What are your thoughts on how vital laboratory assessments are for improving healthcare services? Share your insights below!