Facility Information
Laboratory Medicine - Health Authority
Facility Information
Laboratory Medicine - Health Authority
Hospital/Health Centre Name:Health Authority:
Laboratory Name:
Address:
Laboratory Phone No:
Projected Date of Facility Opening or Discipline Starting:
New Discipline(s) to be Accredited (Check all that apply)
Sample Collection, Transport, Accessioning and Storage / Point of Care Testing
Hematology / Chemistry
Transfusion Medicine / Microbiology
Anatomic Pathology / Cytology
Cytogenetics / Molecular Genetics
Other – Please List:
Laboratory Contact Person for Accreditation Activities:
Name: / Title:
Address:
City: / Postal:
Phone No: / Fax No:
Cellular No: / Email:
Hospital/Health Centre Information
Number of beds:
Other major services that the Hospital/Health Centre provides:
Population of town:
What other town’s or areas does the Laboratory serve?
Are there any distinct patient population demographics?
Are there any geographic considerations that affect service delivery?
Laboratory Information
Organizational Chart – Please provide the Laboratory organizational chart:
Leadership / Name / Title / Location
Regional Laboratory Administrative Leader:
Regional Laboratory Medical Leader:
Health Service Area, Laboratory Administrative Leader:
Health Service Area, Laboratory Medical Leader:
Administrative Leader:
Medical Leader of Laboratory:
Technical Leader of Laboratory: (e.g. Chief Technologist/Manager)
Other Individuals appointed to leadership positions: (e.g. Professional Practice Leader)
Hospital Health Centre COO/Administrator:
Medical or Clinical Laboratory Leaders
First Name / Last Name / #CPSBC / Discipline / Location
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
POCT / Hem / Chem / TM
Micro / AP / Other
Cytogenetics / Molecular Genetics
Medical and Clinical (e.g. PhD) Laboratory Staff
Name / Discipline / Location
Medical and Clinical (e.g. PhD) Laboratory Staff
Name / Discipline / Location
Number of:
- Technologists:
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Laboratory Assistants:
- Other Clerical Staff:
Sample Collection Transport and Accessioning
Number of technical staff (FTE):
Number of staff working on each shift:
- Laboratory Assistants:
- Technologists:
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Projected number of in-patient samples collected daily:
Projected number of out-patient samples collected daily:
Projected number of referred in samples daily:
Is there a unit or ward where non-laboratory staff routinely collects blood samples? (e.g. ER, ICU, Renal Unit) / Yes No
If yes, please indicate unit(s) or ward(s):
Is there a phlebotomy team? / Yes No
Off Site Collection Stations
Site 1:
Official Site Name:
Location:
Days and hours of operation:
Is Point of Care Testing performed at this location? / Yes No
If yes, what Point of Care Testing is performed?
Are Cardiograms performed at this location? / Yes No
Is Holter Monitoring available at this location? / Yes No
Site 2:
Official Site Name:
Location:
Days and hours of operation:
Is Point of Care Testing performed at this location? / Yes No
If yes, what Point of Care Testing is performed?
Are Cardiograms performed at this location? / Yes No
Is Holter Monitoring available at this location? / Yes No
Site 3:
Official Site Name:
Location:
Days and hours of operation:
Is Point of Care Testing performed at this location? / Yes No
If yes, what Point of Care Testing is performed?
Are Cardiograms performed at this location? / Yes No
Is Holter Monitoring available at this location? / Yes No
Site 4:
Official Site Name:
Location:
Days and hours of operation:
Is Point of Care Testing performed at this location? / Yes No
If yes, what Point of Care Testing is performed?
Are Cardiograms performed at this location? / Yes No
Is Holter Monitoring available at this location? / Yes No
Point of Care Testing (POCT)
Discipline Not Applicable
Scope of Service
Number of glucose meters in use:
Location(s):
Who monitors Point of Care Testing glucose QC?
Location:
What other tasks does the laboratory perform related to Point of Care Testing?
Actual Patient Testing
QC
Proficiency Testing
Maintenance
User Training
Other, please indicate:
Other POCT and Equipment (Other than Glucose Meters)
Please indicate test and name of equipment used and location where POCT is performed (including urine dipstick testing):
Test / Equipment / Location
E.g. Hemoglobin / HemoCue / O.R.
Hematology
Discipline Not Applicable
Number of technical staff (FTE):
Number of staff working on each shift:
- Technologists:
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Laboratory Assistants:
- Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Are there Hematology tests that are only performed by specialized technologists? / Yes No
Are bone marrow samples collected at this site?
Are bone marrow samples analyzed at this site? / Yes No
Yes No
Test Menu
Tests performed: Include test menu with information on analyzer and methodology if applicable.
Test / Methodology
(Automated/Manual) / Instrument
(Manufacturer and Model) / Year
E.g. aPTT / Automated / Coag-A-Mate MTX II / 2004
E.g. Fluid Cell Count / Manual
List commercial kits used in the laboratory including vendor (e.g. Mono, Malaria, d Dimer):
Test / Kit / Vendor
E.g. Mono / SeraTest / Remel
Instruments/Equipment
Who is responsible for the maintenance of diagnostic equipment:
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Chemistry
Discipline Not Applicable
Number of technical staff (FTE):
Number of staff working on each shift:
- Technologists:
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Laboratory Assistants:
- Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Are there Chemistry tests that are only performed by specialized technologists? / Yes No
If yes, please list:
Test Menu
Tests performed: Include test menu with information on analyzer and methodology if applicable.
Test / Methodology
(Automated/Manual) / Instrument
(Manufacturer and Model) / Year
E.g. Carotene / Manual
E.g. HbA1C / Automated / Roche Cobas Integra 800 / 2008
Instruments/Equipment
Who is responsible for the maintenance of diagnostic equipment:
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Transfusion Medicine
Discipline Not Applicable
Number of technical staff (FTE):
Number of staff working on each shift:
- Technologists:
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Laboratory Assistants:
- Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Are there Transfusion Medicine tests that are only performed by specialized technologists? / Yes No
Scope of Service
Provide Information on the Testing Performed
Receive and Issue Only (No testing) / Yes No
Storage of Blood and Blood Products in the facility / Yes No
If yes, please provide a list of storage locations and storage equipment used:
Location / Storage equipment used
Component Preparation / Irradiation
Hospital based donation program / Other - Please List:
Test Menu
Tests performed: Include test menu with information on analyzer and methodology if applicable.
Test / Methodology
(Automated/Manual) / Instrument
(Manufacturer and Model) / Year
E.g. Group and Screen / Manual
E.g. DAT / Manual
E.g. Antibody Screen / Automated / Ortho BioVue / 2005
Is computer assisted crossmatch utilized?
Do you perform pre-transfusion testing of neonates (<4 months of age)?
Instruments/Equipment
Who is responsible for the maintenance of diagnostic equipment:
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Microbiology
Discipline Not Applicable
Number of technical staff (FTE):
Number of staff working on each shift:
- Technologists:
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Laboratory Assistants:
- Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Are there Microbiology tests that are only performed by specialized technologists? / Yes No
Test Menu
Tests performed: Include test menu with information on analyzer and methodology if applicable.
Test / Methodology
(Automated/Manual) / Instrument
(Maufacturer and Model) / Year
E.g. Gram Stain / Manual
E.g. Identification / Automated / bioMérieux vitek 2
E.g. Identification / Manual / API 20NE
List commercial kits used in the laboratory including vendor (e.g. Mono, Malaria, d-Dimer):
Test / Kit / Vendor
E.g. RSV / QuickVue / Quidel
Instruments/Equipment
Are you using a non-automated system to monitor blood cultures (i.e. Oxoid Signal Blood Culture System)? / Yes No
Who is responsible for the maintenance of diagnostic equipment:
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Anatomic Pathology (including Cytology)
Discipline Not Applicable
Number of technical staff (FTE):
Number of staff working on each shift:
- Technologist
-Qualified Not Registered (QNR):
-Combined Laboratory X-Ray Technologist (CLXT):
- Laboratory Assistants:
- Medical Transcriptionists:
- Other Clerical Staff:
- Other:
Are there supervisors for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Are there AP tests that are only performed by specialized technologists (i.e. Cytology, Immunohistochemistry, Electron Microscopy)? / Yes No
If yes, please list the tests:
Scope of Service
Is Gross Pathology performed on site? / Yes No
Is Microscopic Examination and Interpretation performed on site? / Yes No
Are Frozen Sections performed on site? / Yes No
Are Autopsies performed on site? / Yes No
Does the laboratory have any responsibilities for the morgue? / Yes No
Are fine needle aspirates collected at this site?
Are fine needle aspirates analyzed at this site? / Yes No
Yes No
Is cytology performed on-site?
If yes, types of samples (i.e. urine, sputum): / Yes No
Do cytotechnologists sign out cases? / Yes No
Test Menu
Tests performed: Include test menu with information on analyzer and methodology if applicable.
Test / Methodology
(Automated/Manual) / Instrument
(Maufacturer and Model) / Year
E.g. Tissue Processing / Automated / HMP300 HistoPro / 2006
E.g. H&E Stain / Automated / Sakura Tissue-Tek Prisma / 2005
E.g. GMS Stain / Manual
E.g. ER / Automated / Ventana NexES IHC
Instruments/Equipment
Who is responsible for the maintenance of diagnostic equipment:
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Cytogenetics
Discipline Not Applicable
Number of staff (FTE):
Number of staff working on each shift:
- Geneticists:
- Cytogenetics Technologists:
- Other Technologists:
- Laboratory Assistants:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Days and hours of operation:
List testing performed:
Test Menu
Tests performed: Include test menu with information on analyzer and methodology if applicable.
Test / Methodology
(Automated/Manual) / Instrument
(Maufacturer and Model) / Year
E.g. Chromosome Analysis / Nikon Genikon / 2007
E.g. FISH / Nikon Genikon / 2007
Instruments/Equipment
Who is responsible for the maintenance of diagnostic equipment:
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Molecular Genetics
Discipline Not Applicable
Number of technical staff (FTE):
Number of staff working each shift:
- Geneticists:
- Technologists:
- Other:
Is there a dedicated supervisor for this area? / Yes No
If yes, please provide name(s) and title(s):
Dedicated staff or rotate through the area? / Dedicated Rotate
Days and hours of operation:
Test Menu, Analyzer, Methodology
Test Performed / Methodology
Equipment
Who is responsible for the maintenance of diagnostic equipment:
Please indicate type and name of major equipment used:
Type / Name
Please indicate any new instrumentation/analyzers placed into service and date placed into service:
Has any existing equipment been recently relocated within the laboratory: / Yes No
If yes, list equipment:
Laboratory Informatics
There is no computer system (LIS) in place
There is a computer system (LIS) in place:
Name of system:
Date of Installation:
If applicable, date of last major upgrade to the existing LIS:
There are dedicated LIS support staff on-site
There are dedicated LIS support staff off-site
There is manufacturer support
Other:
Is there a Regional LIS? / Yes No
Additional Hospital/Health Centre Information
Are any renovations planned that will impact the laboratory? / Yes No
If yes, please provide information:
If possible please provide a laboratory floor plan.
Does the Hospital have a Medical Advisory Committee? / Yes No
Medical Directors 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
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Revised: May 12, 2014