IQMH Q&A with Mary Fountas + update


The assessment team from IQMH wrapped up their week long accreditation process on November 18, and LMP staff were left with a lot to be proud of.

The assessment, which spanned across LMP sites and departments went as successfully as anyone had hoped. There was an exceptional amount of positive feedback on the things we do right, and we’ve been made aware of the few things we need to improve on. As was said at the beginning of the accreditation process – external quality assessments are meant to be a good thing, non-conformances and all.

Assessed against over 1900 requirements, LMP labs received a conformance rate of over 99 per cent, which was touted with much praise from the IQMH assessment team. Assessors credited all areas of the labs for the impressive results, and acknowledged a drive and passion in every area they visited.

The IQMH accreditation results reflect our commitment to exemplary patient care and safety. It speaks to the amazing staff across LMP labs, the outstanding Laboratory Information Systems team, and the quality teams present throughout the program. Congratulations to all on the success of the accreditation and the things staff do daily to deliver the best possible patient care.





During the week of November 14-18, LMP and all of its labs will undergo a peer review assessment by the Institute for Quality Management in Healthcare (IQMH).

The assessment is a familiar process for many LMP staff as Ontario labs are required to renew their accreditation every four years, but for newer staff there can be a lot of unknowns. To shine some light on IQMH, the purpose of the assessment and what LMP staff can expect we asked Mary Fountas, LMP Quality and Safety Manager a couple of key questions. So if you’d like to learn more, read the Q&A below!


  1. What’s the purpose of IQMH accreditation?

Successful IQMH accreditation is all about showing patients, clients, and ourselves that we are meeting our commitment to safe and effective patient care, and continually improving our practices.

  1. How has LMP scored in past IQMH assessments?

In the past we’ve received very few citations in IQMH assessments. In 2012 we actually had zero majors and zero repeat citations. Though, it’s important to point out that receiving citations isn’t necessarily a bad thing, in fact I think it’s often a reminder that there’s always room to improve how we do things.

  1. What does it mean to receive citations from IQMH?

You know how in your house you stop seeing things that other people might notice at first glance? A lot of the time citations are just like that. That’s what makes it an important practice. If there’s anything we’re doing incorrectly or anything we can improve on we want to receive that citation, so we can address the issue and make our practice better for everyone.

  1. As an LMP staff member, what role do I play in the assessment process?

Your primary role is the same as it is on any other day, and you just continue to perform your work as it’s documented to be done. If an assessor from the IQMH team asks you a question, answer them to the best of your ability and try to show evidence in Paradigm or lab documents to support your answer. If you’re unsure what the assessor means or what they are looking for, ask a colleague or manager for assistance.

  1. What types of things will assessors look for as they tour our labs?

You can expect the IQMH team to look for records or evidence showing that we meet the requirements set in our quality management system. Assessors will also follow along in our work and ‘buddy’ with staff at the bench to see the process we use to conduct a particular test or activity.

  1. Is there anything we need to do to prepare our lab space?

As someone who specifically focuses on quality and safety, it’s always a good time to tidy up your workspace and check to make sure you know where specific documents and records are kept. If you see anything out of place or of possible concern, notify your manager or supervisor.

  1. What do we hope to learn from this assessment?

When it comes down it – we want to confirm what we’re doing right, and learn what areas we can improve on.

  1. Any other thoughts you’d like to share as we get closer to our assessment dates?

I think the most important point to make is that the IQMH team is not here to assess you, but here to assess our facility and how our quality management system supports you in your work. It should be taken as a positive to have this type of peer-review assessment and it ties in with our commitment to Caring Safely and becoming a High Reliability Organization.


Stay tuned for more details on LMP’s upcoming IQMH assessment in the weeks to come!


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