A tale of two accreditations


On Thursday last week, LMP woke to surprise visits from both the College of American Pathologists (CAP) and the American Association of Blood Banks (AABB) to conduct biennial laboratory accreditations of LMP’s molecular and cytogenetics labs, and the transfusion laboratory respectively.

“Both organizations schedule windows of time for assessments to take place – but it’s always a bit of  a surprise when they show up,” says Mary Fountas, Manager, Quality and Safety System, LMP. “We have incredible staff and work to maintain an effective quality system keeping us well prepared and thoroughly organized for unannounced assessments.”

After assessors completed the necessary privacy training – they toured the labs and then hit the books (LMP quality/safety and technical manuals) looking to ensure our lab practices matched our procedures.

The CAP team was able to complete their assessment in one day, and accredited the labs with a 99.9 per cent conformance rate (830 requirements, 1 minor non-conformance). They described the labs as having highly dedicated and experienced staff who are accomplishing very complex testing and making successful strides in implementing the newest technologies in rapidly changing fields.

It took two days for AABB to visit and assess all three UHN transfusion laboratories, but in keeping with LMP standard – the transfusion labs were accredited with a 99+ per cent conformance rate (368 requirements, 2 minor non-conformance) and assessors remarked at the size and scope of the department.

Additionally, both organizations emphasized the mutual learning that comes from peer assessment – and for every recommendation they gave to further improve our quality system, they also took something away that stands to benefit other North American laboratories.

“Our accreditation results bear testimony to the outstanding work the respective teams perform on a daily basis,” says Dr. Runjan Chetty, Interim Medical Director, LMP. “A sincere congratulations to all staff involved.”



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