Facility Information for Initial Assessment

Laboratory Medicine - Community

Laboratory Medicine - Community

Laboratory Name:
Address:
Laboratory Phone No:
Projected Date of Facility Opening or Discipline Starting:
New Discipline(s) to be Accredited (Check all that apply)
Anatomic Pathology / Microbiology
Chemistry / Molecular Diagnostics
Cytogenetics / Point of Care Testing
Cytology / Sample Collection
Hematology / Transfusion Medicine
Other (List):
Are multiple disciplines consolidated into one area (core laboratory)? If so, indicate below.
Chemistry / Microbiology
Hematology / Transfusion Medicine
Laboratory Information
Organizational Chart – Please provide the Laboratory organizational chart:
Leadership / Name / Title / Email address / Location
Laboratory Medical Director:
Laboratory Administrative Director:
Laboratory Technical Leader:
Quality Manager:
Other Laboratory Leader(s):
Medical and Clinical Doctoral ScientistDirectors
First Name / Last Name / CPSBC No. / Discipline(s) / Location
Discipline-Specific Technical Laboratory Leaders
First Name / Last Name / Discipline(s) / Location
Total FTEs:
-Technologists (MLT):
-Pathologist’s Assistants (PA):
-Scientific personnel (BSc MSc):
-Combined Laboratory X-Ray Technologist (CLXT):
-Laboratory Assistants (MLA):
-Transcription and Clerical personnel:
Laboratory Contact Person for Accreditation Activities:
Name: / Title:
Address:
City: / Postal:
Phone No: / Email:
Cellular No:
Sample Collection (SCT)
Total FTEs:
-Technologists (MLT):
-Combined Laboratory X-Ray Technologist (CLXT):
-Laboratory Assistants (MLA):
-Clerical personnel:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated personnel or rotate through the area? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Number of phlebotomy chairs:
Projected number of samples collected daily:
Do non-laboratory personnel routinely collect samples? / Yes No
Are sample collection personnel responsible for performing pre-analytical sample processing? / Yes No
If no, who is?
Are sample collection personnel responsible for receiving referred in samples? / Yes- number per day No
If no, who is?
Are sample collection personnel responsible for preparing samples for transport? / Yes No
If no, who is?
Are cardiograms performed at this location? / Yes No
Is Holter monitoring available at this location? / Yes No
Off Site Collection Stations
SITE 1
Official Site Name:
Address:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Projected number of samples collected daily: / Number of collection chairs:
Are personnel responsible for performing pre-analytical sample processing at this site? / Yes No
Are personnel responsible for receiving referred in samples at this site? / Yes- number per day No
Is point of care testing performed at this location?
If yes, what point of care testing is performed? / Yes No
Are cardiograms performed at this location? / Yes No
Is Holter monitoring available at this location? / Yes No
SITE 2
Official Site Name:
Address:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Projected number of samples collected daily: / Number of collection chairs:
Are personnel responsible for performing pre-analytical sample processing at this site? / Yes No
Are personnel responsible for receiving referred in samples at this site? / Yes- number per day No
Is point of care testing performed at this location?
If yes, what point of care testing is performed? / Yes No
Are cardiograms performed at this location? / Yes No
Is Holter monitoring available at this location? / Yes No
SITE 3
Official Site Name:
Address:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Projected number of samples collected daily: / Number of collection chairs:
Are personnel responsible for performing pre-analytical sample processing at this site? / Yes No
Are personnel responsible for receiving referred in samples at this site? / Yes- number per day No
Is point of care testing performed at this location?
If yes, what point of care testing is performed? / Yes No
Are cardiograms performed at this location? / Yes No
Is Holter monitoring available at this location? / Yes No
SITE 4
Official Site Name:
Address:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Projected number of samples collected daily: / Number of collection chairs:
Are personnel responsible for performing pre-analytical sample processing at this site? / Yes No
Are personnel responsible for receiving referred in samples at this site? / Yes- number per day No
Is point of care testing performed at this location?
If yes, what point of care testing is performed? / Yes No
Are cardiograms performed at this location? / Yes No
Is Holter monitoring available at this location? / Yes No
Anatomic Pathology (ANP) / Discipline Not Applicable
Scope of Service
General Anatomic Pathology / Yes No / Frozen Sections Only / Yes No
Gross examination / Yes No / Is this a specialized or separate section? / Yes No
Microscopic examination / Yes No / Is this a specialized or separate section? / Yes No
Intraoperative examination / Yes No / Is this a specialized or separate section? / Yes No
Immunohistochemistry / Yes No / Is this a specialized or separate section? / Yes No
Electron microscopy / Yes No / Is this a specialized or separate section? / Yes No
Autopsy / Yes No / Is this a specialized or separate section? / Yes No
Total FTEs:
-Technologists (MLT): Combined Laboratory X-Ray Technologist (CLXT):
-Pathologist’s Assistants (PA): Laboratory Assistants (MLA):
-Transcriptionists / Clerical personnel:
Is there a dedicated supervisor for Anatomic Pathology? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Anatomic Pathology laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Anatomic Pathology Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Chemistry (CHE) / Discipline Not Applicable
Scope of Service
General Chemistry including urinalysis and blood gases / Yes No
TDM & Drug screening / Yes No / Is this a specialized or separate section? / Yes No
Sweat Chloride examinations / Yes No / Is this a specialized or separate section? / Yes No
Radioimmunoassay / Yes No / Is this a specialized or separate section? / Yes No
HPLC / GC / MS / ICP-MS / Yes No / Is this a specialized or separate section? / Yes No
Electrophoresis / Yes No / Is this a specialized or separate section? / Yes No
Prenatal screening / Yes No / Is this a specialized or separate section? / Yes No
Maternal screening / Yes No / Is this a specialized or separate section? / Yes No
Total FTEs:
-Technologists (MLT):
-Scientific personnel (BSc MSc):
-Combined Laboratory X-Ray Technologist (CLXT):
-Laboratory Assistants (MLA):
Is there a dedicated supervisor for Chemistry? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Chemistry laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Chemistry laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Chemistry Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Cytogenetics (CYG) / Discipline Not Applicable
Scope of Service
General Cytogenetics / Yes No
FISH / Yes No
Microarray / Yes No
Total FTEs:
-Genetic Technologists (MLT):
-Scientific personnel (BSc MSc):
-Laboratory Assistants (MLA):
-Transcriptionists / Clerical personnel:
Is there a dedicated supervisor for Cytogenetics? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Cytogenetics Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Cytology (CYT) / Discipline Not Applicable
Scope of Service
Non-gynecological cytology / Yes No
Gynecological cytology / Yes No
Total FTEs:
-Cytotechnologists (MLT):
-Laboratory Assistants (MLA):
-Transcriptionists / Clerical personnel:
Are cytotechnologists screening and/or reporting out cases? Yes No
Is there a dedicated supervisor for Cytology? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Cytology is located:
Within Anatomic Pathology
Adjacent to Anatomic Pathology
Distinct department
Cytology Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Hematology (HEM) / Discipline Not Applicable
Scope of Service
General hematology and coagulation / Yes No
Fluid & CSF examinations / Yes No / Is this a specialized or separate section? / Yes No
Special coagulation / Yes No / Is this a specialized or separate section? / Yes No
Blood parasites / Yes No / Is this a specialized or separate section? / Yes No
Bone marrow examinations / Yes No / Is this a specialized or separate section? / Yes No
Hemoglobinopathy examinations / Yes No / Is this a specialized or separate section? / Yes No
Semen examinations / Yes No / Is this a specialized or separate section? / Yes No
Flow cytometry / Yes No / Is this a specialized or separate section? / Yes No
Total FTEs:
-Technologists (MLT):
-Scientific personnel (BSc MSc):
-Combined Laboratory X-Ray Technologist (CLXT):
-Laboratory Assistants (MLA):
Is there a dedicated supervisor for Hematology? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Hematology laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Hematology laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Hematology Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Microbiology (MIC) / Discipline Not Applicable
Scope of Service
General Microbiology / Yes No / Gram Stains only / Yes No
MALDI-TOF / Yes No / Is this a specialized or separate section? / Yes No
Susceptibility testing / Yes No / Is this a specialized or separate section? / Yes No
Mycobacteriology / Yes No / Is this a specialized or separate section? / Yes No
Mycology / Yes No / Is this a specialized or separate section? / Yes No
Parasitology / Yes No / Is this a specialized or separate section? / Yes No
Virology / Yes No / Is this a specialized or separate section? / Yes No
Molecular Microbiology / Yes No / Is this a specialized or separate section? / Yes No
Immunology & Serology / Yes No / Is this a specialized or separate section? / Yes No
Total FTEs:
-Technologists (MLT):
-Scientific personnel (BSc MSc):
-Combined Laboratory X-Ray Technologist (CLXT):
-Laboratory Assistants (MLA):
Is there a dedicated supervisor for Microbiology? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Microbiology laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Describe each specialized section that is separate from the general Microbiology laboratory.
Lab name or description:
Name of supervisor if different: / Title:
Are personnel dedicated or rotate from the general lab? / Dedicated Rotate
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Microbiology Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Molecular Diagnostics (MOL) / Discipline Not Applicable
Scope of Service
Restriction Endonucleases / Yes No
Sangar Sequencing / Pyrosequencing / Yes No
Next Generation Sequencing / Yes No
Electrophoresis & PCR / Yes No
Microarray / Yes No
ISH / Yes No
Total FTEs:
-Technologists (MLT):
-Scientific personnel (BSc MSc):
-Laboratory Assistants (MLA):
-Transcriptionists / Clerical personnel:
Is there a dedicated supervisor for Molecular Diagnostics? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Molecular Diagnostics Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Point of Care Testing (POC) / Discipline Not Applicable
Scope of Service
Examination (check all that apply) / Equipment or Method / Location(s)Performed
Glucose
CBC / Hemoglobin
PT/INR
Activated Clotting Time
Urinalysis
Urine Pregnancy Examinations
Urine Drug Screening
Blood Gases/Co-oximetry
Electrolytes/Urea/Creatinine
Fecal Occult Blood
Hemoglobin A1c
Lactate
Other(specify):
Is there a multidisciplinary POCT management group for point of care testing? Yes No
Location:
Who is responsible for laboratory oversight of point of care testing (see POC 1.1.2-5)?
Location:
Who monitors point of care testing quality control?
Location:
Who monitors point of care proficiency testing?
Location:
Who monitors point of care testing training?
Location:
Who monitors point of care testing competency?
Location:
Who monitors point of care testing equipment and maintenance?
Location:
Transfusion Medicine (TRM) / Discipline Not Applicable
Scope of Service
Receive and Issue only / Yes No
Storage blood or blood products / Yes No
Group and screen / Yes No
Antibody investigation / Yes No
Compatibility examinations / Yes No
Neonatal transfusions / Yes No
Modification (washing, pooling, irradiation, aliquoting) / Yes No
Transfusion reaction investigation / Yes No
Total FTEs:
-Technologists (MLT):
-Combined Laboratory X-Ray Technologist (CLXT):
-Laboratory Assistants (MLA):
Is there a dedicated supervisor for Transfusion Medicine? / Yes No
Name: / Title:
Days and hours of operation:
MON / TUE / WED / THU / FRI / SAT / SUN
24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to / 24 hrs. or
to
Transfusion Medicine Examination Menu
List allexaminationsperformed. A separate spreadsheet may be submitted if insufficient space here.
Examination / Methodology / Instrument / Kit / Method
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Automated Manual
Information Management & Informatics (IMI)
Is there a laboratory information system (LIS)?
Name of system:
Is this part of a regional system? / Yes No
Yes No
Is there document control software?
Name of software:
Is this part of a regional system? / Yes No
Yes No
Is therea telepathology system for diagnostic purposes?
Disciplines telepathology is utilized:
Name of system:
Is this part of a regional system? / Yes No
Yes No
Medical Director’s Signature
______Date: ______
Any additional information you wish to add:
Please return form by:
Mail: College of Physicians and Surgeons of British Columbia
Diagnostic Accreditation Program
300-669 Howe Street
Vancouver BC V6B 0B4 / Email:
Fax:604.733.3503