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Quality Management & Patient Safety

The Quality Management System for diagnostic services 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. 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 we have 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 systems in place. For further information on your own health care journey, please visit the Know Your Lab and Imaging

Quality Management System

Below is a snapshot of the key components of Shared Health’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

Shared Health is commitment to quality and patient safety and creating a culture that places utmost value on quality and patient safety permeates through all of our operations.

2.    Accreditation

Two main third party accreditation agencies, the Manitoba Quality Assurance Program (MANQAP) and College of American Pathologists (CAP), evaluate our diagnostic services to ensure quality and safety is continuously at the forefront of all operations. 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 Shared Health diagnostic services sites, click here.

3.    External Proficiency Testing

External Proficiency Testing (EPT) is a fundamental piece of the Quality System of Shared Health’s diagnostic services and helps to ensure all of our analytical systems are performing appropriately when compared to similar systems in other labs. Shared Health 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 Shared Health diagnostic services performance in these programs, click here.

4.    Internal Audits

Shared Health diagnostic services 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:

  • Shared Health diagnostic services quality
  • Shared Health diagnostic services discipline teams and associated scientific personnel
  • Shared Health diagnostic services occupational health and safety
  • Operational peers

5.    Equipment Installation, Validation, and Maintenance

Shared Health diagnostic services 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 Shared Health’s 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 Shared Health diagnostic services 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. Shared Health diagnostic services analyzes all the feedback and information and looks for ways to enhance or improve the Quality Management System.

8.    Document Control

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. Shared Health diagnostic services analyzes all the feedback and information and looks for ways to enhance or improve the Quality Management System.

9.    Human Resources

Shared Health’s human resources department has clear processes for recruitment, orientation, and 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 – this program ensures that people have the right qualifications to do their jobs, as well as the ongoing training, support and evaluation needed for them to meet Shared Health’s expectations of quality.

10.   Procurement & Vendor Relationships

Critical supplies and services must be identified through vendors. Shared Health’s procurement department helps establish quality criteria for vendors and manages relationships with vendors.

11.   Client Services

Shared Health’s client services department advocates on behalf of the patients we serve and accepts feedback from patients, their families and their physicians. 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 is derived from our health care partners. Shared Health works closely with all of our health care partners and the Health Authorities in Manitoba, in order to create opportunities to understand the needs and challenges of our front line health care partners.