GEN-FORM-026- REFERRAL LABORATORY EVALUATION

Accreditation and Licensing Information:

Laboratory:
Accrediting Authority:
Certification number:
Expiry:

Laboratory Director:
Name:
Credentials:
Involvement:

Personnel:
Number of technologists: _____
Doctoral Level Pathologist(s): _____
Number of Full-time employees: _____
1. Does the laboratory have a qualified supervisor at all times? Yes No
2. Are the referral Laboratory Staff members cooperative? Yes No
3. Do the technologist’s expertise and qualifications satisfy your laboratory's needs? Yes No
4. Do the technologists receive continuing education on regular basis and is it documented? Yes No

Internal Quality Control Activities:

1. Is there documentation of a well written, comprehensive quality control Program? Yes No

2. Are all standard operating manuals complete for all the tests and reviewed annually? Yes No

3. Are all tests materials, including reagents, controls and calibrators,

appropriate for the tests performed and are used within their expiry dates? Yes No

4. Are all controls used in the appropriate frequency? Yes No

5. Are tolerance limits available for all procedures? Yes No

6. Is there a corrective action when it is exceeded? Yes No

7. Are statistical data adequate? Yes No

8. Are all instruments maintained properly? Yes No

GEN-FORM-026- Referral Laboratory Evaluation Version 1

Sharing folder\CAP\Lab Forms\General 01/12/2022
External Quality Assessment:

1. Is the referral laboratory enrolled in an external quality assessment program that covers their test menu? Yes No
2. If yes, are all proficiency testing results evaluated and documented? Yes No
3. For any deficiencies, are there investigations and corrective action taken? Yes No
4. Will the referral Laboratory agree to “split samples” with Jarallah German Specialized Clinic Laboratory? Yes No

Reputation:

1. Did the referral laboratory provide you with their client list? Yes No
2. Does the laboratory have a program to assess and assure client satisfaction? Yes No

Efficiency of Referral Service:

1. Does the laboratory offer a sufficient range of services to satisfy client? Yes No

2. Does the laboratory perform a sufficient volume for all procedures that the client will refer to as proficient? Yes No

3. Does the referral Laboratory clearly identifies the instructions for transportation and shipment of patient
specimens including preparation, packaging, labeling, storage and pick up times? Yes No

4. Does the referral laboratory provide a written statement for the expected turnaround time for every test performed? Yes No

5. Is there a clear agreement on the communication of inquiries, results between

the jarallah German Specialized Clinic Laboratory and the referral laboratory? Yes No

6. Does the referral laboratory provide a policy identifying the process of the critical values reporting,
the mechanism, and the timing? Yes No

7. Does the laboratory have a policy concerning dealing of compromised specimens? Yes No

8. Does the laboratory have a policy concerning corrected and amended reports? Yes No

9. Does the Jarallah German specialized Clinic Laboratory have an agreement with the referral laboratory

not to report results to patients without the Global Medical Clinic Laboratory director's consent? Yes No

Evaluated and Approved By:

Laboratory Director: Date:

GEN-FORM-026- Referral Laboratory Evaluation Version 1

Sharing folder\CAP\Lab Forms\General 01/12/2022