Department of Microbiology Quality Manual / Policy QORMI03001.10 / Page 2 of 3
Section: Organization / Subject Title: Quality Assurance Committee – Terms of Reference

Purpose:

In keeping with the mission of the Mount Sinai Hospital and the University Health Network and the management of the Department of Microbiology this committee ensures the continuous improvement in the provision of Microbiology services in order to enhance the delivery of quality patient care.

Objective:

·  Review incident reports from all sections of the department and identify corrective action.

·  Review proficiency testing results.

·  Review issues and implement changes in the laboratory procedure manual and practice.

·  Design quality assurance audits.

·  Identify quality improvement indicators.

·  Perform QI indicator measurements as required.

·  Monitor QI program efficiency.

Chairmanship:

Bacteriology/Mycology Section: Dr. S. Poutanen (alternate: P. Lo)

Virology/Serology Sections: Dr. T. Mazzulli (alternate: K. Wong)

Membership:

Bacteriology/Mycology Section: Ed Cudek, Nancy Beresford, Pauline Lo, Suzie Ho, Barbara Willey, Katherine Wong, Medical Microbiology Resident(s)

Virology/Serology Sections: Ed Cudek, Nancy Beresford, Pauline Lo, John Ng, Suzie Ho, Katherine Wong, Medical Microbiology Resident(s)

Meeting Frequency:

·  Bacteriology/Mycology QA Committee meets monthly

·  Virology/Serology QA Committee meets monthly

Meeting Format:

Committee meetings will discuss:

·  Clients’ complaint/issues.

·  Incident reports by Charge Technologist of each section.

·  LIS issues and outstanding orders report by LIS Officers.

·  Proficiency testing results report

·  Quality Improvement indicators

Reporting:

This committee reports to the Departmental Senior Management Committee.

Related Document:

Quality System Organization Chart / QORMI03000
UHN LMP Quality Management Committee Terms of Reference / QMC Terms of Reference
Quality Improvement Working Group Terms of Reference / QORMI03002
Process Improvement Process / QPIMI01000


Record of Edited Revisions

Manual Section Name: Organization

Page Number / Item / Date of Revision / Signature of Approval
Annual Review / March 5, 2005 / Dr. T. Mazzulli
Annual Review / April 24, 2006 / Dr. T. Mazzulli
Annual Review / May 2, 2007 / Dr. T. Mazzulli
Annual Review / June 16, 2008 / Dr. T. Mazzulli
Annual Review / June 16, 2009 / Dr. T. Mazzulli
Annual Review / June 30, 2010 / Dr. T. Mazzulli
Annual Review / May 31, 2011 / Dr. T. Mazzulli
Annual Review / May 31, 2012 / Dr. T. Mazzulli
Annual Review / May 31, 2013 / Dr. T. Mazzulli
Update of Membership / August 7, 2013 / Dr. T. Mazzulli
Annual Review / May 8, 2014 / Dr. T. Mazzulli

UNIVERSITY HEALTH NETWORK/MOUNT SINAI HOSPITAL, DEPARTMENT OF MICROBIOLOGY

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