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Department of Laboratory Medicine AMNCHQUALITY POLICY

The Laboratory Medicine Department at The Adelaide and Meath Hospitalincorporating The National Children s Hospital (AMNCH) provides aconsultant led diagnostic pathology service 24/7 to a regional population of550,000 in the South and West Dublin, North Kildare and West Wicklowregions. Laboratory Medicine serves the 600 bed Voluntary UniversityTeaching Hospital at AMNCH which is attached to the University of Dublin,Trinity College; the community of General Practitioners supported by thehospital and other linked Health Care Institutions. AMNCH is part of theDublinMid-Leinster HSEnetwork.The hospital provides a comprehensive medical, surgical, paediatric,psychiatric and age related service to the community and also includesregional and national services such as Renal Dialysis, Trauma /Orthopaedics,and Urology. There is alarge adult andpaediatric Diabetes andEndocrinology serviceon site.Laboratory Medicine comprises the following specialities: Blood Transfusion,Cellular Pathology, Clinical Chemistry, Haematology and Microbiology. Thereis also an adult Phlebotomy service provided to patients.

The Department is committed to the pursuit of excellence in all itsactivitiesIn accordance with this commitment and the primacy of the patient, theDepartment aimsto implement theQuality Policyby

1. Setting clinical governance and quality objectives2. Operating a total quality management system that integrates values,

organisation, management, procedures, processes, practices andresources. Providing advice and implementing policies that ensure proper samplecollection, transport, preparation, identification, storageanddisposal.

4 Managing systems and securing resources that ensure accuracy andreliability of laboratory testing, and the harnessing of new technology toenhance the delivery of laboratory services.5 Careful attention to operations management and turnaround times, toensure timelyandconfidential reportingofaccurate results.6 Commitment to the provision of Blood Transfusion testing services,Haemovigilance and Traceability functions, operating to: ISO15189:2007

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Standards, Irish National Accreditation Board (INAB) / Irish MedicinesBoard 1MB) conditions, Minimum Requirements for Haemovigilance andTraceability,andcompliance with Irish Legislation onBlood Transfusion.

7. Providing data in a clear and clinically useful format, supplemented byConsultantClinical Pathologist reporting andadvice where appropriate8. Maintaining a prime focus on Health and Safety for staff, users, patients

and visitors and ensuring compliance with relevant Health and Safety atWorkandEnvironmental requirements

9. Sustaining a continuous improvement program.10. Monitoring and optimising laboratory services through participation in,

and review of, (i) assessment of user satisfaction; (ii) internal qualityaudit; (iii) external quality assessment, (iv) development of processes inthe parent organisation

11.Fostering an atmosphere in which the professional development andwellbeing of all staff is supported through education, training, respect forthe individual and staffwelfare in accordance with the Values and Visionoftheparent organisation.

12.Ensuring that thequality policy iscommunicated to all personneland thatthey are familiar with the contents of the Quality Manual and allprocedures relevant to their work.

13.Ensuring commitment to continuing compliance with laboratoryAccreditation systems (CPA (UK) Ltd ver 2.01 and ISO 15189:2007 asappropriate)

Authorisedby:-

M/JohnO CdnnellCEO (act) AMNCH

7Date of Authorisation

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