Bhagirathi Neotia Woman and Child Care Centre, New

Town (A unit of Park Hospitals)

(Department of laboratory Services)
List of Quality Indicators of the laboratory
FORMAT NO: BNWCCC/FM/24
Sl. Phase Indicators Name Target
No
01 Pre Analytical Sample Rejections in laboratory < 5 in a Month
Needle Stick Injury 0 in a month

02 Analytical 6 Monthly CV% Evaluation < 10% in a Month

EQAS 1. For Biochemistry

parameter: ≤ 2 Z-score
2. For Hematology : ≤ 2 Z-
score
3. Microbiology: ≥80%
4. Molecular: <0.5log10

03 Post Analytical Wrong reporting of results < 5in a Month

04 General TAT < 5 hrs in a month

(Average Time)
Complaint < 5 in a month
 Testing
 General
Machine down time (Each Machine) < 120 hours in a year

Non Conformance < 5 in a Month

Adverse Incident < 2 in a Month

Prepared By: Approved By:

Date: 10.10.2020
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
IMPROVEMENT ACTION PLAN
Format No: BNWCCC/FM/23 Page 1 of 4
REMARKS
AREA AGENDA PLAN OBJECTIVE PROGRESS

PRE-ANALYTICAL PHASE

Sample Sample The patient is identified at To reduce sample Continuous

collection and Identification the reception during test identification error.
identification registration and name
checked by phlebotomist
and compared with
particulars printed on the
sticker on vials
Improper Vial Improper Vials are To reduce incorrect Continuous
rejected and documented reporting of test result.
in sample rejection
register. Trend analysis to
be done.
Improper Phlebotomist will be given To reduce incorrect Induction training for new
Collection of periodical training on reporting of test result joiner & for existing
collection of patient .and for trend analysis.
Sample sample.
routine training as per
training schedule
Inadequate Patient information To reduce pre-analytical Patient information
Patient booklet including details errors booklet prepared
of patient preparation is
Preparation provided to the
receptionist for proper
guidance to patient party.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE:
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
IMPROVEMENT ACTION PLAN
Format No: BNWCCC/FM/23 Page 2 of 4
REMARKS
AREA AGENDA PLAN OBJECTIVE PROGRESS

Transportation Sample transport Sample will be To maintain integrity of Continuous

and processing in sample transported in sample the sample
collection box with proper
transportation label and ice pack
box.

ANALYTICAL PHASE

Quality of Daily Internal QC Commercial controls to be To check performance of Continuous

analysis & run as per Quality Control equipment and reagent
Personnel Plan quality
Competency
Calibration of Calibration is done as per To ensure proper As & when required as per
Equipment calibration plan functioning of calibration plan
equipment.
Competency Competency evaluation of To ensure the technical Every time after
Evaluation of laboratory personnel will competency of evaluation
be done regarding the laboratory personnel.
Technicians Technical awareness.

Training of An annual training plan To updated knowledge of As per training plan

Laboratory will be prepared based on laboratory personnel.
the training need of the
personnel. laboratory personnel.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE:
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
IMPROVEMENT ACTION PLAN
Format No: BNWCCC/FM/23 Page 3 of 4
REMARKS
AREA AGENDA PLAN OBJECTIVE PROGRESS

Equipment Deep freezer to be To improve the storing Procured

procured. efficiency & capacity of
controls, calibrators.

Uncertainty of CV % calculation for all the To check the precision of Continuous

measurements parameters are done the equipment.
monthly and the results
(monthly % CV) are satisfactory

Performance of The Laboratory is To ensure external Continuous

EQAS participating in following proficiency testing
EQAS programs :
1. Biorad :Clinical Bio-
Chemistry
2. AIIMS: Haematology
3. IAMM: Microbiology &
Infectious diseases
serology
4. RML Lucknow:
Histopathology

For non EQAS & EQAS

Outlair parameters are
send for ILC with NABL
accredited lab

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE:
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
IMPROVEMENT ACTION PLAN
Format No: BNWCCC/FM/23 Page 4 of 4
REMARKS
AREA AGENDA PLAN OBJECTIVE PROGRESS

POST ANALYTICAL

Reporting of Monitoring of To monitor TAT parameter To check the promptness Continuous

result & Turnaround time wise, based on which TAT of the laboratory in
handling of may be improved. respect of release of test
customer result.
complain.
Clinical co-relation is done To assure quality of test Continuous
Clinical co- as and when required result.
relation of patient
sample.
Interfacing of all analyzers. To reduce transcriptional Continuous
Transcriptional error.
Error
OTHERS
Customer Number of complaints is to To check the Continuous
Complain. be reviewed at regular performance and
intervals. monitor non
conformances
Laboratory Hospital has decided to To ensure smooth Continuous
Information improve laboratory functioning and make it
information system. user friendly and time
System saving. Better analytics &
added features

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE:
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
PREVENTIVE ACTION PLAN
Format No: BNWCCC/FM/22

AREA AGENDA PLAN PROPOSED RESPONSIBILITY PROGRESS

ACTION

PRE-ANALYTICAL

Patient Sample Collection of sample Phlebotomists are Quality Manager and Laboratory Director & Continuous
Collection trained on sample Laboratory Director are Quality Manager
collection, order of draw given the responsibility
and only then they are to see that newly
allowed to draw patient appointed
sample. phlebotomists are well
trained and after
evaluation of their
competency, they are
allowed to draw patient
samples.
Patient Preparation Patient information Laboratory director & Laboratory Director & Done
booklet, training of Quality Manager have Quality Manager
receptionist been given the
responsibility to train
receptionists on patient
preparation and make
the patient information
booklet available

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE: 01.02.2021
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
PREVENTIVE ACTION PLAN
Format No: BNWCCC/FM/22

AREA AGENDA PLAN PROPOSED RESPONSIBILITY PROGRESS

ACTION

ANALYTICAL

Equipment Reduction of Breakdown CMC & AMC with LD & Quality Manager LD & Quality Manager Continuous
Maintenance Machine supplier have been given the
and responsibility to ensure
Performance that all equipment used
in the laboratory are
under AMC contract

Training of Laboratory Quality Manager & Quality Manager & Continuous

Manpower Departmental I/Cs to Departmental I/Cs
ensure that all
technicians handling
equipment are provided
with equipment
handling training.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE: 01.02.2021
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
PREVENTIVE ACTION PLAN
Format No: BNWCCC/FM/22

AREA AGENDA PLAN PROPOSED RESPONSIBILITY PROGRESS

ACTION

Machine measurement Calibration of the Quality Manager & Quality Manager & As & when required
performance and Equipment Departmental I/Cs are Departmental I/Cs
establishing traceability to ensure that all
of the measurement. equipment are
calibrated as per the
calibration plan
Calibration records are
maintained Use of non-
calibrated equipment
must be prevented.

Daily preventive Quality Manager & Quality Manager & Daily

maintenance Departmental I/Cs are Departmental I/Cs
to ensure that
technicians carry out
daily PM of the
equipment as per
manufacturer’s
instruction.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE: 01.02.2021
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
PREVENTIVE ACTION PLAN
Format No: BNWCCC/FM/22

AREA AGENDA PLAN PROPOSED RESPONSIBILITY PROGRESS

ACTION

Reduction of equipment Checking of electrical Electrical dept. Should Electrical Dept. Continuous
performance error earthing by licensed ensure that the
Electrician electrical earthing of the
laboratory is optimal for
equipment
performance.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE: 01.02.2021
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
PREVENTIVE ACTION PLAN
Format No: BNWCCC/FM/22

AREA AGENDA PLAN PROPOSED RESPONSIBILITY PROGRESS

ACTION

Accuracy of Test Quality in test results Quality control program Quality Manager & Quality Manager & Continuous
results is initiated, departmental I/Cs departmental I/Cs
1. Using available should review the QC
commercial data & perform
control appropriate root cause
2. Replicate & analysis wherever
Retesting outlier is identified.
3. Correlation of Accordingly corrective
results action to be taken.
4. Participation in
External Quality
Assurance
program
5. Interlaboratory
testing
POST ANALYTICAL

Test Report Reduction of Interfacing of all IT department has been IT Department Continuous
Typographical Error analyzers given the responsibility
to ensure that LIS
system is interfaced.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE: 01.02.2021
 Bhagirathi Neotia Woman and Child Care Centre, New Town (A unit of
Park Hospitals)
(Department of laboratory Services)
PREVENTIVE ACTION PLAN
Format No: BNWCCC/FM/22

AREA AGENDA PLAN PROPOSED RESPONSIBILITY PROGRESS

ACTION

GENERAL

Safe work Human safety 1) Training on Sample Quality manager is to Quality Manager As per Schedule
Environment handling ensure that all
laboratory personnel
are trained.
2) Immunization Quality manager is to Quality Manager As per Schedule
ensure that all
laboratory personnel
are immunized.
3) Personal protective Quality manager is to Quality Manager As per Schedule
gears like gloves apron ensure that all personal
etc protective gears are
available.
4) Training of Quality manager is to Quality Manager As per Schedule
Laboratory Personnel on ensure that all
control & prevention of laboratory personnel
Adverse incidence. are trained.

PREPARED BY: APPROVED BY: PREPARED DATE: 10.10.2020

EVALUATION DATE: 01.02.2021