Quality Management & Patient Safety
Quality is the foundation for everything at DSM. Our Quality Management System is thorough and full of checks and balances to help ensure that the results we report to doctors and health care providers are accurate and timely. But patients and their families also have a role to play in quality; safety comes from asking questions and accessing information related to your health care journey. That’s why DSM has committed to helping Manitobans understand the processes at work behind their diagnostic care; the information that follows on this page provides a high level picture of different aspects of the quality system we use at DSM, but if you are looking for information more closely tied to your own health care journey, for instance – what to expect when you come to a lab or imaging department or how you can learn about safety, please visit the “Know Your Lab and Imaging” patient portal of our site.
Learn more about Quality of Care and Patient Safety at DSM by watching the video below. You can also keep reading to learn about the key components of DSM’s Quality Management System.
[Note: The video features interviews with Paul Penner, former Chief Operating Officer with DSM, and Marie Perchotte, former Chair of the DSM Board of Directors. While these individuals are no longer with DSM, their explanations and viewpoints remain current for DSM.]
DSM’s Quality Management System
Below is a snapshot of the key components of DSM’s Quality Management System (more detail is available where indicated — or use the navigation on the left menu bar under Quality Assurance & Patient Safety to see topical areas with more in depth information):
1. Organization and Strategy
DSM’s commitment to quality and patient safety begins with a Strategic Vision that makes Quality the paramount ingredient in all the diagnostic services we provide to Manitobans, no matter where they live in the province. DSM’s Board of Directors has made quality and safety one of its five strategic priorities – so it convened a Quality and Patient Safety Committee to provide guidance and oversight in this area. From there, a culture that places utmost value on quality and patient safety permeates through the entire organization. Every person who works for DSM knows that quality is the single most important factor in what we do.
The primary evidence that DSM has achieved high standards of quality is its ongoing commitment to accreditation by third party agencies that evaluate and measure DSM’s overall performance. This commitment is the foundation for our strategic plan and keeps harmony with the Manitoba Government’s legislation for health authority accreditation.
DSM uses two main third party accreditation agencies: the Manitoba Quality Assurance Program (MANQAP) and College of American Pathologists (CAP). CAP is one of the highest ranked accreditation agencies for medical laboratories in the world and we’re proud that our largest medical laboratory sites at Health Sciences Centre and St Boniface General Hospital) and other pathology laboratories are CAP accredited. The remainder of our laboratories and diagnostic imaging facilities across Manitoba that require accreditation are accredited by MANQAP, which is run by the College of Physicians and Surgeons of Manitoba.
For more information on Accreditation or to see the Accreditation Certificates for DSM sites, click here.
3. External Proficiency Testing
External Proficiency Testing (EPT) is a fundamental piece of the Quality System at DSM and helps to ensure all of DSM’s analytical systems are performing appropriately when compared to similar systems in other labs. DSM participates in EPT programs that are offered by various laboratory organizations in Canada, the United States and Britain. Through these programs, we can assess our performance on thousands of tests across all the medical laboratory disciplines several times per year.
For more information on External Proficiency Testing and DSM’s performance in these programs, click here.
4. Internal Audits
DSM routinely conducts its own audits of sites to ensure compliance with standards. Since the goal is to be “accreditation ready” at all times, the audits may be scheduled or unannounced. Audits may be completed by:
- DSM Quality
- DSM Discipline Teams and associated scientific personnel
- DSM Occupational Health and Safety
- Operational peers
The goal is for our sites to maintain compliance with standards, and be ‘accreditation ready’ at all times. As such these audits can be scheduled or performed on an unannounced basis.
5. Equipment Installation, Validation, and Maintenance
DSM has established systems to work with vendors to install equipment and ensure that all equipment is operating at optimum levels. Discipline teams who are responsible for equipment selection regularly monitor equipment and validate results to ensure that equipment is properly calibrated and maintained. There is a Standard Operating Procedure for each piece of equipment and system used in DSM laboratories and imaging facilities.
6. Occurrence Management & Critical Incidents
The purpose of occurrence management is to record and analyze information when situations affecting quality occur so that DSM can look for trends, determine root problems and identify system-wide solutions. Occurrences can be relatively minor incidents that are immediately corrected to significant issues that have impacted patient safety and well-being. When patients are harmed or nearly harmed, the incident is called a Critical Incident.
For more information on occurrence management and critical incidents, click here.
7. Process Control & Improvement
Diagnostics involves several medical/scientific disciplines. Each of these disciplines defines all the processes for its particular operations through detailed policies. These are used by staff to ensure consistency in performance. This level of process control enables us to detect potential errors as well as prevent errors altogether.
Even with these controls in place, there is need for continuous improvement. Sources of information used to improve our Quality Systems include each of the components being described here, as well as other sources such as literature reviews, turn-around time audits, and patient and physician feedback. DSM analyzes all the feedback and information and looks for ways to enhance or improve the Quality Management System.
8. Document Control
DSM has thousands of operating procedure documents, as well as a host of other policies, process descriptions, forms, and other information relevant to ongoing operations. To ensure that all of these documents are maintained, they are regularly reviewed and shared with the appropriate audiences. The control system even includes a “sign-off” mechanism so DSM can monitor readership, which is especially important when policies and procedures are updated.
9. Human Resources
DSM’s Human Resources department has clear processes for recruitment, orientation, training and performance evaluation to help ensure that highly qualified people are in the right positions and to monitor the competency and performance of staff. From medical and scientific staff to technologists to transcriptionists – DSM’s HR program makes sure that people have the right qualifications to do their jobs, as well as the ongoing training, support, and evaluation needed for them to meet DSM expectations of quality.
10. Procurement & Vendor Relationships
Critical supplies and services must be identified through vendors. DSM’s procurement department helps DSM to establish quality criteria for vendors and manages relationships with vendors
11. Client Services
DSM’s Client Services department advocates on behalf of the patients we serve and accepts feedback from patients, their families and their physicians with respect to the service received from DSM. The department works to resolve complaints and to improve quality with respect to the service being provided.
12. Partnerships & Safety
Another important measure of quality for DSM comes from our health care partners. For instance, doctors and health care providers regularly communicate with DSM technical staff and radiologists offer feedback about the quality of images captured by our equipment and staff. DSM also works closely with all of the Health Authorities in Manitoba, which provides us with the opportunity to understand the needs and challenges of our frontline health care partners. Finally, DSM works with CancerCare Manitoba’s Radiation Protection and Safety Program to ensure that diagnostic imaging equipment is working within expected parameters and that patients and staff are not exposed to unsafe radiation levels.