Yusuf Abdullahi Primary Hospital Laboratory Assessment

Yusuf Abdullahi Primary Hospital CEO receiving 1-star SLIPTA assessment rating

Yusuf Abdullahi Primary Hospital Laboratory: Taking Steps to Improve Quality

Jijiga, Ethiopia – June 07, 2025

The Yusuf Abdullahi Primary Hospital Laboratory recently underwent a thorough assessment based on the SLIPTA (Stepwise Laboratory Quality Improvement Process Towards Accreditation) Framework. This crucial audit, conducted by Mr. Niman Tayib, Kadar Muse, and Ahmed Suane, offers a clear snapshot of the laboratory's current operational strengths and pinpoints significant opportunities for further enhancement in its pursuit of excellence.

Current Status: A Foundation for Progress

The Yusuf Abdullahi Primary Hospital Laboratory achieved an impressive overall score of 226 out of 367 possible points, which translates to a solid 61.5% compliance. According to the SLIPTA star rating criteria (Version 03), this places the laboratory at a 1 Star rating (206-240 pts or 55-64% compliance). This rating signifies a strong commitment to quality and sets a promising stage for continued advancements.

Noteworthy Strengths: Pillars of Performance

The assessment highlighted numerous areas where the Yusuf Abdullahi Primary Hospital Laboratory demonstrates robust practices and adherence to quality standards. Key strengths include:

• Strong Foundational Documentation: The laboratory maintains clear documentation of its legal identity and has a well-defined organizational code of conduct with good adherence to principles like impartiality and confidentiality.
• Effective Personnel Structuring: A comprehensive duty roster covering normal and after-hours is in place, alongside an up-to-date organizational chart. The laboratory is commendably directed by qualified personnel with specified authority and competency in leadership, budgeting, and stakeholder communication.
• Structured Personnel Management: Procedures for authorization, training, and competency assessment are well-defined and actively implemented for newly hired and assigned staff, with records properly retained.
• Patient-Centric Services: Procedures for providing advisory services to patients and users are established, as are clear processes for handling and resolving complaints and feedback.
• Diligent Equipment and Inventory Control: The laboratory adheres to proper equipment protocol, including unique labeling, and has defined procedures for validation, verification, and calibration of equipment. Routine user preventive maintenance is performed and recorded, and manufacturer’s operator manuals are readily available. Effective inventory control is demonstrated through comprehensive records, min/max level monitoring, and adherence to FEFO (First-Expiration-First-Out) practices.
• Proactive Quality and Risk Management: Defined procedures exist for internal audits and risk management, along with robust processes for externally provided products and services and purchasing and inventory control.
• Robust Process Management: The laboratory has defined procedures for continuity and emergency preparedness planning, pre-examination processes (including sample handling and test requests), documentation of examination procedures, and Internal Quality Control (IQC). Environmental conditions are diligently monitored and recorded daily. Procedures for External Quality Assessment (EQA), verification/validation of examination methods, and Measurement Uncertainty (MU) are also well-defined.
• Reliable Information and Safety Protocols: Clear procedures are in place for biological reference intervals and reporting and release of results, including a defined LIS procedure. Personnel vaccination and post-exposure prophylaxis policies are implemented, and a trained safety officer is designated.

These strengths underscore the laboratory's commitment to maintaining foundational elements of a strong quality management system.

Areas for Improvement: Opportunities for Advancement

While significant strengths were identified, the assessment also highlighted critical areas that require immediate and sustained attention to further elevate the laboratory's services and achieve higher SLIPTA ratings. These include:

• Enhancing Documentation and Leadership Oversight: There's a crucial need to fully develop and conspicuously post laboratory objectives, strengthen the master list for document control, and improve archiving of all patient, quality, and technical records for timely retrieval. Critically, routine documented review of quality and technical records by the Quality Officer is lacking, and management review meetings need to consistently cover all required inputs and outputs, with findings and actions clearly recorded, communicated, and followed up.
• Strengthening Personnel Management Implementation: Critical gaps exist in consistently documenting personnel authorization (e.g., signed job descriptions). A comprehensive program for training, continuing education, and professional development needs to be established and recorded. The absence of a documented procedure for personnel performance review is a key deficiency, and personnel meetings need to be regular with recorded progress.
• Deepening Customer Focus: While procedures exist, consistent implementation of advisory services by qualified personnel is needed. Critically, a formal process for the treatment of patients' well-being, samples, and remains with due care and respect is missing. Official service agreements require more consistent implementation, and laboratory handbooks/information for clients need to be more widely available. Communication policies for notifying patients about delays must be strengthened, and customer feedback utilization needs to be systematized.
• Improving Equipment Verification and Maintenance Records: Critical non-conformities include the inconsistent recording and archiving of equipment verification (for new, repaired, and maintained equipment) and the inconsistent scheduling, recording, and archiving of calibration for measuring equipment. Routine service maintenance by qualified external engineers is also not consistently documented or archived.
• Addressing Assessment and Risk Management Deficiencies: Internal auditing is not consistently completed annually with documented findings and follow-up. A significant weakness lies in the implementation of risk management and assessment tools, with action plans for identified risks not consistently developed, implemented, or monitored for effectiveness. Quality indicator outcomes are also not consistently used to improve processes.
• Rectifying Extensive Process Management Gaps: The continuity and emergency preparedness plan requires full implementation, review, and communication. Critically, records for patient sample collection activities (identity verification, pre-examination requirements, labeling) are largely missing, as is the consistent recording of timeframe and temperature for transported samples. A formal procedure and process for referral laboratories and technical consultants is missing, along with systems to ensure their competence. Consistent verification of new reagent preparations and lots is needed. Internal Quality Control (IQC) performance monitoring (biases, trends, Levy-Jennings charts) is critically inconsistent, as is comparability of examination results with different methods/equipment. Validation of examination methods (especially non-standard or in-house) is also not consistently performed or documented. Crucially, Measurement Uncertainty (MU) is not consistently performed or documented for quantitative tests.
• Strengthening Information Management and Data Integrity: While LIS procedures exist, consistent verification and confirmation of test results against patient identity is needed. Ensuring authorized lab personnel consistently release results with signatures and that the laboratory report log/book fulfills all required items is also vital. Consistent traceability of sample results and secure retention and access control for archived patient data are areas for improvement. Critically, verification of the LIS system after upgrades and comprehensive records of LIS maintenance, failures, and security measures are largely missing.
• Enhancing Nonconforming Event Management and Continual Improvement: Full capture of identification and management records for nonconforming work is needed, along with consistent documentation for authorization to resume testing. Corrective actions need to be consistently effective. The implementation of continual improvement activities is inconsistent, with outcomes not regularly communicated.
• Addressing Major Facilities and Safety Deficiencies: This section reveals critical gaps. A documented procedure for overall laboratory safety is missing. The adequacy of the physical work environment needs significant improvement (clutter, ventilation, climate control, wiring, backup power, space, signage). Critical needs include the installation and regular verification of emergency showers and fire alarms, and the purchase and proper management of biosafety cabinets. The overall safety program needs to be fully defined and implemented across all elements (hazardous chemicals, fire safety, inspections, safety equipment, adverse incident management, personnel training). Critically, biosecurity policies, processes, and procedures are not implemented.

Looking Ahead: A Path to Higher Standards

The SLIPTA assessment provides the Yusuf Abdullahi Primary Hospital Laboratory with a detailed roadmap for strategic improvements. By diligently addressing these identified areas, especially the critical non-conformities, the laboratory can significantly enhance its quality management system, improve operational efficiency, and ultimately deliver even higher quality and safer healthcare services to the community. This commitment to continuous improvement is crucial for the laboratory's journey towards achieving higher SLIPTA star ratings.

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