The SLIPTA (Stepwise Laboratory Improvement Process Towards Accreditation) baseline assessment for Raaso Primary Hospital has concluded, providing a comprehensive overview of its current Laboratory Quality Management System (LQMS) status. The assessment, conducted by the Somali Regional Public Health Laboratory and Research Center, revealed a "No Stars" rating with a compliance score of 37.6%.

Raaso Primary Hospital SLIPTA Score

37.6%

❌ No Stars ❌

This score indicates foundational gaps requiring urgent and comprehensive interventions.

Understanding the "No Stars" Rating

A "No Stars" rating signifies that the laboratory is operating below the minimum acceptable threshold for quality management systems as defined by the SLIPTA framework (less than 55% compliance). This outcome underscores the critical need for immediate and focused efforts to establish fundamental quality practices across various laboratory operations.

Key Strengths: Building Blocks for Future Progress

Despite the overall score, the assessment identified several areas where Raaso Primary Hospital demonstrates foundational strengths, which can serve as building blocks for future improvements:

  • Quality Document Accessibility (Section 1): Quality documents are accessible, indicating a potential for better document control implementation.
  • Organizational Chart & Laboratory Management (Section 3): The hospital has an organizational chart and a defined laboratory management structure, providing a framework for clear reporting lines and leadership.
  • Equipment Records & Maintenance (Section 5): Equipment inventory data is available, and some aspects of preventive and service maintenance are performed and documented. Obsolete equipment is appropriately handled.
  • Risk Management & EQA Participation (Section 6 & 8): The laboratory has a risk management program in place and actively participates in External Quality Assessment (EQA), demonstrating an awareness of external quality assurance.
  • Information Management (Section 9): Procedures for reporting and release of results, test result reporting system, and identification of testing personnel are largely in place, indicating a good starting point for data management.
  • Nonconforming Event Management (Section 10): Identification and management of nonconforming work is present, and resumption of testing is documented when halted.
  • Facilities & Safety (Section 12): Housekeeping, physical work environment, laboratory access, storage areas, laboratory safety manual, and handling of hazardous chemicals show good compliance, indicating a relatively safe working environment.

Critical Areas for Improvement: A Targeted Approach

The assessment highlighted several critical areas where Raaso Primary Hospital needs urgent and comprehensive intervention to establish a robust LQMS. These gaps are fundamental to ensuring reliable and safe laboratory services:

1. Documentation and Record Control (Section 1: 7/22)

  • Legal Entity & Policies: Lack of documentation for legal identity and fully communicated/understood management system policies.
  • Document Control System: Insufficient implementation of a comprehensive document control system, including tracking editions, distribution, and discontinuation of documents.
  • Data Archiving: Absence of systematic archiving for test results, technical, and quality records, hindering easy and timely retrieval.

2. Organization and Leadership (Section 2: 9/26)

  • Code of Conduct: No defined procedure or implementation records for organizational code of conduct.
  • Management Reviews: Lack of routine documented review of quality/technical records and formal management review meetings with required inputs and follow-up on action items.
  • Deputation: No process to ensure continuity of the QMS during key personnel absence.

3. Personnel Management (Section 3: 12/34)

  • Personnel Procedures: Absence of defined procedures for overall personnel management, authorization, training, competency assessment, performance review, and regular personnel meetings.
  • Training & Development: No formal program for continuous education and professional development.

4. Customer Focus (Section 4: 4/24)

  • Advisory Services & Complaints: No defined procedures for advisory services or systematic handling/resolution of complaints and feedback.
  • Patient Requirements: Lack of established process for treating patients' well-being and samples with due care and respect.
  • Service Agreements: No defined procedures or implementation records for service agreements.
  • Communication: Inadequate timely notification to users regarding service delays or changes.

5. Equipment Management (Section 5: 16/44)

  • Comprehensive Management: No defined procedure for overall equipment management (determining need, selection, procurement, acceptance, installation).
  • Validation & Verification: Absence of procedures and documentation for validation and verification of equipment after installation or repair.
  • Calibration: No defined procedure or implementation for equipment calibration and metrological traceability.
  • Adverse Incident Reporting: No process for reporting equipment adverse incidents.

6. Assessments (Section 6: 8/24)

  • Internal Audits: Lack of defined procedures, conduct, and follow-up for internal audits.
  • Risk Management: Absence of a defined procedure for overall risk management, and no use of evaluation tools to identify risks.
  • Quality Indicators: Monitoring of quality indicators is partial, and their outcomes are not fully utilized for process improvement.

7. Supplier and Inventory Management (Section 7: 17/27)

  • Supplier Management: No defined procedures for externally provided products/services or purchasing/inventory control.
  • Performance Review: Lack of monitoring for external supplier performance.
  • Management Review: No review and approval of laboratory requirements for externally provided products/services by management.

8. Process Management (Section 8: 15/71)

  • Contingency Planning: Absence of continuity and emergency preparedness planning.
  • Sample Handling: Inconsistent implementation of sample receipt procedures, and lack of defined process for referral laboratories.
  • IQC & EQA: No defined procedure for Internal Quality Control (IQC) or External Quality Assessment (EQA), despite EQA participation. Monitoring of QC performance is lacking.
  • Method Verification/Validation: No defined procedures or records for verification and validation of examination methods.
  • Measurement Uncertainty: No defined procedure or documented estimates for Measurement Uncertainty (MU).
  • Environmental Conditions: Environmental conditions are not consistently monitored or reviewed.

9. Continual Improvement (Section 11: 2/7)

  • Formal Procedure: No defined procedure for continual improvement activities.
  • Communication: Outcomes of continual improvement activities are not communicated to relevant stakeholders.

10. Facilities and Safety (Section 12: 28/54)

  • Safety Procedures: No defined procedure for overall laboratory safety.
  • Environmental Conditions: No defined procedure for facilities and environmental conditions.
  • Adequacy of Layout: No documented evaluation of laboratory size and layout for optimal workflow and risk reduction.
  • Fire Safety & Safety Audits: Lack of fire safety measures and regular, documented safety inspections/audits.
  • Personnel Vaccinations & Post-Exposure Prophylaxis: No program for personnel vaccinations or management of adverse incidents/injuries.
  • Biosecurity: Biosecurity policies and procedures are not implemented.

The Path Forward: A Commitment to Quality

The results of this baseline assessment provide a clear roadmap for Raaso Primary Hospital. The Somali Regional Public Health Laboratory and Research Center, in collaboration with EPHI, is committed to supporting Raaso Primary Hospital in addressing these identified gaps. A tailored action plan will be developed, prioritizing interventions to establish fundamental LQMS elements.

This comprehensive understanding of the hospital's current status is a critical first step. Through dedicated mentorship, targeted training, and consistent follow-up, Raaso Primary Hospital will embark on a structured journey towards achieving higher SLIPTA star ratings, ultimately ensuring the delivery of high-quality, reliable laboratory services vital for patient well-being and public health in the region.