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    STANDARD OPERATING PROCEDURES

    Al-Khidmat Diagnostic Networks Page 1

    STANDARD OPERATING

    PROCEDURES

    Al-Khidmat Diagnostic Networks

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    NOTE:

    This manual and SOPs have been prepared by HR/R&D Department with the

    conjunction of Healthcare and Diagnostics Department of Al-Khidmat FoundationPakistan.

    These standard operating procedures are being developed as a guide for our staff to

    maintain international standards in Healthcare. Users of this document are advised to

    suggest amendments that are relevant to their individual practices. All amendments

    (Endorsed by Manager Health & Diagnostics) with the consent of HR/R&D Department

    will be entered as Amendment # 1, Amendment #2 etc. at the end of SOPs in

    amendments section.

    All these amendments at the end of every calendar year with the consent of board shall

    become the permanent part of these SOPs.

    Prof. Dr. HafeezurRehman: _______________________________(President AKFP)

    Abdus Shakoor: _______________________________

    (Secretary General AKFP)

    Eng: Sabir Ahmed: ______________________________(Director Diagnostics Network)

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    STANDARD OPERATING PROCEDURES

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    Table of contents

    1. Goal .. 4

    2. Mission Statement 4

    3. Objectives 44. Organogram .. 5

    5. Introduction . 66. Classification of Diagnostic Network 6

    7. Basic Knowledge & Skills to perform investigations . 78. Analytical and Technical Process 8

    9. Personal Protective Equipment (PPE) ... 1010. Biohazard Warning Signs and Posting ... 1111. Biological Waste Disposal . 11

    12.Needles and Sharps Precautions 11

    13. Laboratory Code of Ethics .. 1214. Work Environment . 14

    15. Audit .. 15

    16. Procurement ... 1617. Recruitment Policy ..... 20

    18. Accreditation . 2119. Job Descriptions . 22

    20. Amendments ... 42

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    1. Goal

    Achieve a uniform protocol under a centrally developed guide lines and implement on all

    new and existing Al-Khidmat laboratories in the country.

    2. Mission Statement

    Al-Khidmat Diagnostic Network will particularly support the better Healthcare Services.

    It will be dedicated to the service of humanity in all parts of the country, welcoming the

    needy patients without any discrimination.

    3. Objective:

    To provide credible diagnostic services which includes Chemical Pathology,

    Hematology, Microbiology, Biochemistry, Histopathology, Blood Banking, Radiology

    and various scanning facilities to ailing humanity residing in Pakistan on affordable

    prices without compromising on local and international standards.

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    4. Diagnostic Lab Organogram:

    Director

    Lab Manager

    Asst. LabManager

    Accountant Receptionist

    Marketing

    Executive Mobilizer

    Driver Watchman

    Cleaner Peon

    Office Boy

    ManagerQuality Control

    Pathologist

    Technician

    Assistant

    Technician Phelabotamist

    Internee/Trainee

    Technologist

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    5. INTRODUCTION:

    The main purpose of Al-Khidmat Diagnostic Centers is to provide quality investigation/

    test services for the patients. We ensure laboratory production of valid test results andevidentiary data to achieve uniform and harmonized results and reporting. Al-Khidmat

    Diagnostic Network provide these services at economic/ competitive rates.

    Al-Khidmat Diagnostic Centres are providing world-class Pathology and Radiology

    services 24/7, combining state of the art technology with the network of experienced &

    highly skilled professionals. We offer a complete range of laboratory services including

    over 300 investigations/ laboratory tests.

    6. Classification of Diagnostic Network:

    Diagnosis is the process of identifying a medical condition or disease by its signs,

    symptoms, and from the results of various diagnostic procedures by using Biochemical,

    Radiological, Magnetic Resonance and Ultrasound methodologies. The conclusion

    reached through this process is called diagnosis. Diagnostic Centres are sub-divided into

    following 3 types.

    1. Collection Centre2. Model Diagnostic Centre

    3. Mega Diagnostic Centre

    6.1 Collection Centre:

    A Collection Centre is a platform through which specimen are collected and sent

    to the nearest Model or Mega Diagnostic Centre. These Collection Units are

    intended to facilitate the people by providing easiest accessibility.

    6.2 Model Diagnostic Centre:

    Model Diagnostic Centre is comprised of Semi-Automated Analyzers to bear

    normal work load.

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    Services:

    a. Biochemistry

    b. Hematology

    c. Serology & Immunology

    d. Clinical Pathology

    e. Sonology

    6.3 Mega Diagnostic Centre:

    Mega Diagnostic Centre is comprised of Fully-Automated Analyzers to bear

    heavy work load.

    Services:

    a. Biochemistry

    b. Hematology

    c. Serology & Immunology

    d. Clinical Pathology

    e. Microbiology

    f. Immunochemistry

    g. Molecular Biology

    h. Sonology

    i. Radiology (X-ray, CT-Scan, MRI)

    7. Basic Knowledge & Necessary Skills:

    Technician/ Technologists should know the test terminology, purpose, procedure,

    process and normal test reference values or results. The names of diseases are a

    convenient way of briefly stating the end point of a diagnostic process that begins with

    assessment of symptoms and signs and ends with knowledge of caution and detection of

    underlying disorders of structure and function. The staff should hold the relevant

    educational degree and investigation skills as well.

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    8. Analytical and Technical Processes

    8.1 All patients referred to Lab from different hospitals are received at reception.

    8.2 All Lab investigations will be done on payment except for those signed free byDirector/Lab Manager.

    8.3 All the investigations will be performed on economic prices

    8.4 Log register shall be maintained by receptionist

    8.5 Receptionist will guide the patient/ attendant/ guardian about the cost of the tests/

    investigations.

    8.6 The cost of the investigations shall be received in advance by receptionist

    8.7 The receptionist will provide a receipt with unique identity number

    8.8 The name and signature (or other means of identification and recording) of the Person

    delivering or transferring custody of the shipped Samples, the date, the time of

    receipt, and the name and signature of the laboratory representative receiving the

    Samples, shall be documented as part of the laboratory internal Chain of Custody

    record.

    8.9 The laboratory shall have a system to uniquely identify the Samples and associate

    each Sample with the collection document or other external chain of custody.

    8.10 The laboratory shall have laboratory Internal Chain of Custody procedures to maintain

    control of and accountability for Samples from receipt through final disposition of

    the Samples.

    8.11The laboratory shall observe and document conditions that exist at the time of

    receipt that may impact on the integrity of a Sample report. For example,

    irregularities noted by the laboratory should include, but are not limited to:

    8.11.1Sample tampering is evident.

    8.11.2 Sample is not sealed with tamper-resistant device or seal upon receipt.

    8.11.3 Sample is without a collection form (including sample identification code) or

    a blank form is received with the Sample.

    8.11.4Sample identification is unacceptable. For example, the number on the bottle

    does not match the Sample identification number on the form.

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    8.11.5Sample volume is extremely low

    8.12 The Laboratory should notify and seek advice from the Testing Authority regarding

    rejection and testing of Samples for which irregularities are noted.8.13 Sample collection will be done by aseptic standardized method

    8.14 All samples will be numbered immediately, ensuring it to be the right patient and

    slips. For urine sample, patient will be provided container and guided towards the

    toilet. Samples will be transported to the respective section by the lab attendant/

    Phlebotomist. Care will be taken to avoid wrong numbering, labeling of samples.

    8.15 Receptionist will ensure the timely delivery of investigation reports with the

    suggestion/ recommendation of technologists and pathologists

    Clinical Pathology:

    8.16 Technologist, Technician, Assistant technician will collect the samples from

    reception

    8.17 Technologist, Technician, Assistant technician will perform the investigation

    procedure

    8.18 Assistant Technician will ensure data entry (Hard copy and Soft Copy)

    8.19 Technician will present the investigation in-front of clinical pathologist

    8.20 Clinical pathologist will correlate the physical and chemical sign and symptoms

    8.21 After ensuring/ verifying all the procedures, He/ She will approve the investigation

    Radiology:

    8.22 Receptionist will give a token number to the patient for smooth functioning of the

    process

    8.23 After checking the prescribed forms patients are sent to waiting area and they are

    called for examination on turn by the Radiographer.

    8.24 After complete processing Dark room assistant will get these X-Rays checked by

    Radiologist for quality of X-Ray

    8.25 If the study / Procedure is satisfactory, patient is asked to leave the waiting area and

    collect the report on next day

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    8.26 The X-Rays are sent at the reception for labeling and audit of films to be supervised

    by Radiologist

    8.27 Reporting of X-Rays is done on next day by Radiologist and interesting anddifficult cases are discussed with Professor / Head of Radiology Department

    Research

    8.28 Laboratories are entitled to participate in research programs provided that the

    laboratory director is satisfied with the bona-fide nature and the programs have

    received proper ethical (e.g. human subjects) approval

    Controlled substances

    8.29 The Laboratories are expected to comply with the relevant national laws

    regarding the handling and storage of controlled (illegal) substances.

    9. Personal Protective Equipment (PPE):

    The technicians, technologists and all other laboratory staff shall use personal protective

    equipment before going to the lab restricted areas. Some of the PPEs are explained as

    follows:

    9.1 Gloves

    9.2 Safety Glasses/ Goggles

    9.3 Gowns/Aprons

    9.4 Laboratory Coat

    9.5 Tyvek Suits

    9.6 Respiratory protection (fit test and medical clearance required)

    9.7 Surgical Mask

    9.8 Shoe Covers

    9.9 Bonnets

    9.10 Face Shields

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    10. Biohazard Warning Signs and Posting

    Each laboratory must clearly display a sign that provides safety information to visitors

    and service personnel.

    11. Biological Waste Disposal:

    Proper structure of disposal of waste material should be introduced to provide clean and

    healthy environment. To obtain these particular tasks we should adopt the following

    procedures:

    11.1 We shall use 3 baskets of different colors (White, Yellow and blue)

    11.2 For cotton, bandage and tissue papers white basket shall be used

    11.3 For plastic bags, syringes and any other plastic related materials, yellow basket shall

    be used

    11.4 For the particulars made of glass shall be disposed off in blue basket

    11.5 Waste should be disposed off through proper biological waste collection

    organizations

    12. Needles and Sharps Precautions

    Substitute plastic-ware when possible

    12.1 DO NOT bend, shear, break, recap or remove needle from syringe

    12.2 Use sharps containers (dont fill more than full), which must be located as close to

    work area as possible

    12.3 Non-disposable sharps should be placed in a rigid container for transport to

    appropriate area for decontamination, such as by autoclaving

    12.4 Only needle-locking syringes or disposable syringe-needle units (needle is integralto the syringe) should be used

    12.5 Syringes that re-sheathe the needle, needleless systems, and other safety devices

    may also be used

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    12.6 Do not handle broken glass directly by hand. Use a mechanical device such as

    forceps or protective gloves to pick up and dispose of glass in a glass box or sharps

    container

    13. Laboratory Code of Ethics:

    13.1Basic Principles:

    a. Each employee is responsible for the propriety and consequences of our

    action

    b. Each employee must conduct all aspects of Al-Khidmat Diagnostic Lab in

    an ethical and lawful manner.

    c. Each employee must hold high standards of honesty, integrity and fairness

    in relationship to others.

    d. Failure to comply with the Code or Standards will result in appropriate

    disciplinary action, which may include termination of employment,

    reimbursement to Al-Khidmat Diagnostic Lab for any resulting losses or

    damages and in some circumstances may subject employees to civil or

    criminal penalties.

    e. Al-Khidmat Diagnostic Lab is obligated to fully and fairly investigate all

    matters raised of unethical conduct.

    13.2CONFLICT OF INTEREST:

    13.2.1 Avoid situations that might involve a conflict of interest or even the appearance

    of a conflict of interest. In general, avoid any actions that may appear to involve

    a conflict of interest with Al-Khidmat Diagnostic Labs activities in carrying out

    its mission. These include, but are not limited to: engaging in outside business

    activities involving AL-Khidmat Diagnostic Labs suppliers, subcontractors,

    government officials, cooperative research partners or other agencies.

    13.2.2 Questionable activities may also include serving board of directors of the

    organization doing business with Al-Khidmat Diagnostic Lab, significant

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    ownership in the organization, or consulting with or working for a company or

    failing to disclose outside business activities as required by Al-Khidmat

    Diagnostic Labs policy.13.2.3 Observe Al-Khidmat Diagnostic Labs ethical standards, as well as applicable

    laws and regulations, when providing or accepting meals, entertainment or gifts

    to or from people in business situations.

    13.2.4 PROTECTION OF AL-Khidmat Diagnostic Labs:

    13.2.5 Protect all data of Al-Khidmat Diagnostic Labs, property and funds under your

    control against loss, theft and misuse. This includes proprietary information

    belonging to Al-Khidmat Diagnostic Labs and its collaborators. Keep this

    information confidential and be sure not make any of it available to unauthorized

    personnel. Security procedures have been established to protect sensitive

    information and many types of unclassified technical information.

    13.2.6 Al-Khidmat Diagnostic Lab employees who handle such data are required to

    know these procedures and strictly adhere to them at all times. The data may be

    used for, property and funds only for their authorized, proper and intended

    purposes. No use of such data or property may be made after termination of your

    employment with Al-Khidmat Diagnostic Labs.

    13.2.7 It is also imperative to make every effort to prevent the misuse of our assets

    (Information, data, property) by any other person. Improper use includes selling,

    loaning or giving away Al-Khidmat Diagnostic Labs property, destroying or

    disclosing collaborator or Al-Khidmat Diagnostic Lab data.

    13.2.8 Use of organizational property for personal or non-business purposes, other than

    as specifically permitted as per the notification of Director Diagnostic Networks,is considered to be improper conduct and is in violation of this Code of Ethics and

    Standards of Conduct Confidentiality.

    13.2.9 The heads of laboratories, their delegates and laboratory staff shall not discuss or

    comment to the media on individual results prior to the completion of any

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    adjudication without consent of the organization that supplied sample to the

    laboratory and the organization that is asserting the Adverse Analytical Finding in

    adjudication.

    13.3 DATA, RECORDS AND REPORTS

    13.3.1 It is the responsibility of Accounts & IT officer

    13.3.2 To ensure the safe custody of all important documents as completely, honestly

    and accurately as possible.

    13.3.3 These records include timekeeping records, expense reports, accounting records,

    test and progress reports, cost estimates, contract and grant proposals, and

    presentations to clients, the public or AL-Khidmat Diagnostic Labs management,

    and any representation, either written or oral, made by any AL-Khidmat

    Diagnostic Labs employee or representative in the conduct of business shall be

    factual, fully substantiated, and verifiable.

    13.3.4 It is essential to maintain accurate timekeeping and expense records, making sure

    to:

    Record and allocate charges for time, materials and other business-related

    expenses to the proper charge number.

    Check all invoices and payments to customers, consultants and suppliers to

    confirm the accuracy of information relating to products, services, prices and

    terms of sale.

    14. WORK ENVIRONMENT

    a. Use fairness, honesty, and comply with the law in all business relationships

    with AL-Khidmat Diagnostic Labs stakeholders, collaborators, suppliers,subcontractors, employees, and applicants, as well as with local, national and

    international communities.

    b. Do not take unfair advantage of anyone through manipulation, concealment,

    abuse of privileged information, misrepresentation of material facts or any

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    15.3 Performance Audit:

    15.3.1 Performance Audit is the responsibility of Program Manager Al-Khidmat

    Diagnostic Network under the supervision of Director Diagnostic NetworkAl-Khidmat Foundation Pakistan.

    16 Procurement:

    16.1 Procurement policy of Diagnostic Network Al-Khidmat Foundation Pakistan

    will be based on following principals:

    16.1.1 Transparent

    16.1.2 Impartial and unbiased

    16.1.3 Cost effective

    16.1.4 Technically Competitive

    16.1.5 Technically Comparative

    16.1.6 Customized and Adoptable

    16.1.7 Centrally devised and Monitored

    16.2 The classification of the procurement policy will be as follows

    16.2.1 Pre-qualification

    16.2.2 Tender

    16.2.3 Quotations

    16.3 The areas of and procurement are classified as follows

    16.3.1 Instrument & Equipment

    16.3.2 Kits, Chemicals and consumables

    16.3.3 Furniture & Fixtures

    16.3.4 Renovation & Construction Materials

    16.3.5 Computers & Electronic items

    16.3.6 Stationary, office utensils and printing materials

    16.4 Procurement Procedures:

    Based on main principals mentioned above all companies interested to supply for

    Diagnostic Network Al-Khidmat Foundation Pakistan must be pre-qualified through pre-

    qualification tender published in highly circulated newspapers mainly in the following

    areas of laboratory working separately.

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    1. Pathology

    2. Radiology3. Sonology

    4. Any other area deemed necessary in future

    The prequalification of the companies shall be based on following rules:

    1. Company/ supplier technical strength and reputation

    2. Company/ supplier supply network

    3. Company/ supplier financial strength

    4. Product technical strength

    5. After sales services back up network

    All pre-qualified companies shall be allowed to participate in various tenders published in

    newspapers by AKF time to time. During the pre-qualified tenure no other company will

    allow to participate in the tender proceedings until/ unless the National director will have

    sufficient reasons for the benefit of overall Diagnostic Network Al-Khidmat Foundation

    Pakistan upon imposing a penalty amount for the onetime special pre-qualification to

    allow them to participate in subject tender.

    Tender Proceedings:

    All pre-qualified companies will be eligible to participate in tender bids without any

    tender fees. The quoted price by the bidders will be effective for one year (pre-

    qualification period of the company). The finalization process of tender will be as

    follows:

    1. Comparative statement will be prepared

    2. Quoted prices will be negotiated by National Director with the help of Program

    Manager

    3. All negotiated prices will be presented with the priority list of Diagnostic

    Network Al-Khidmat Foundation Pakistan purchase committee

    4. After approval of purchase committee, the final price list will be issued to regions

    Purchase Order:

    Based on final negotiated prices regions directly or with the help of Program Manager

    will issue the purchase order to the respective companies for the procurement of

    subjected items.

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    All purchase orders must follow the following rules:

    1. Name of equipment / item

    2. Place of supply3. Date of supply requested

    4. 5% earnest money requirement for the instrument warranty period having worth

    of rupees 100,000 or more.

    5. Payment procedures after the supply and installation followed by installation

    report signed by Lab Manager and company representative

    Note: The above mentioned policy will be implemented on classification # 1 & 2 and will

    be applied on all other areas on gradual basis.

    16.5 Other Methods of procurement:

    Goods or services may be acquired other than tender process shall be followed by the

    following criteria:

    16.5.1 Direct Purchase:

    a. Procurement (less than Rs. 10,000) should be approved by Lab Manager

    b. Purchases less than Rs. 10,000 may be purchased to best advantage withoutquotations subject to the following conditions;

    i. Rates should be reasonable and consistent with normal market rates for

    items of same nature.

    ii. Requirements should not be split into components or succession of orders

    for the same goods or services for the purpose of enabling the goods orservices to be obtained under the limit of Rs. 10,000.

    16.5.2 Written Quotation:

    1) For purchases greater than Rs.10,000 but less than 25,000 should be

    approved by Lab Manager and at least three written quotation should be

    obtained subject to the following conditions;

    a. Rates should be reasonable and consistent with normal market rates

    for items of similar nature.

    b. Requirements should not be split into components or succession oforders for the same goods or services for the purpose of enabling the

    goods/services to be obtained under limit of Rs. 25,000.

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    2) For the purchases greater than Rs. 25,000;

    a. A minimum of three written quotations must be obtained by

    administration department.

    b. Quotations must be based on written outline of specifications whichhas been provided to the suppliers.

    c. The purchase committee will approve such type of purchasing.d. Purchase committee will consist of Lab Manager, Accounts Manager,

    Pathologist and Regional Health Director.

    e. Such Quotations must be on a printed format document/letter head

    containing1. Suppliers Name and full Address2. Land line phone number

    3. NTN/CNIC for withholding Tax Purpose

    f. The best and competitive quotation will be suggested by Manager

    Administration, on a comparative statement prepared for approval bypurchase committee.

    3) For the purchases greater than Rs. 100,000;

    a. For purchases greater than Rs.100,000 should be approved by

    Director Diagnostic Network Al-Khidmat Foundation Pakistan.

    16.6 Benefits of a procurement policy

    As a consequence of adhering to this policy, Al-Khidmat Diagnostic Lab will;

    16.6.1 Obtain the best value for its purchases, in both cost and quality terms.

    16.6.2 Have a fast and efficient purchasing process; demonstrate financial probity and

    accountability to its stakeholders and public interest.

    16.6.3 Successfully manage and prevent the potential for conflicts of interest.

    16.6.4 Monitor and evaluate performance in purchasing and procurement. Be protectedfrom complaints and legal actions mounted by potential suppliers who believe

    they have not received fair treatment.

    16.7 Ethical guidelines

    16.7.1 No matter how transparent or fool proof an arrangement may be; its success lies

    in the behavior of the officer(s) in-charge and his or her intention in following laiddown procedure and regulations. The set of rules laid below can serve as a

    guideline for any purchasing officer.

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    16.7.2 Shift In-charge and Technician will ensure the availability of stock (Each and

    every instrument, chemicals, reagent, kits and consumable etc.) after every 15

    days.

    16.7.3 Emergency purchasing will not be appreciated however if required; it shall berequested by shift in-charge and technician with the recommendation of

    Pathologist/ Radiologist and then approved by Lab Manager.

    16.7.4 The best value for the organizations goods and services must be sought.

    16.7.5 There will be a documented process for all purchases; which allows fortransparency of decisions and review of purchases.

    16.7.6 The conduct of procurement is subject to continuous auditing by the organization

    and by external bodies such as the board, auditor and stake holders.

    16.7.7 Staff will ensure that they are not, or are not perceived to be in a conflict of

    interest with any supplier.16.7.8 Those staff who have, or may be perceived to have a vested interest in outcome of

    a purchase should disclose any conflict to their supervisor and discuss whether

    they should exclude themselves from any role in the purchase.

    16.7.9 Staff will be suitably skilled and qualified to attend the completion of their

    purchasing and contracting role(s).

    17 Recruitment Policy:

    17.1 Objectives:

    The objectives of this policy are to:

    Acquire the services of the appropriate and qualified personnel when and

    where needed.

    Ensure the transparency and fairness without any bias, favoritism and

    discrimination in hiring process.

    17.2 Selection Board

    Selection Board will be constituted by Director Diagnostic Network Al-Khidmat

    Foundation Pakistan which may be consist of District President, Regional Health

    Director, Senior Pathologist, Lab Manager

    17.3 Approval

    Selection Board of Al-Khidmat Diagnostic Labs shall approve all the vacancies.

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    17.4 Appointments

    17.4.1 The Pathologist, Lab Managers, Technicians of Al-Khidmat Diagnostic Labs will

    be appointed by Selection Board of Al-Khidmat Diagnostic Network.

    17.4.2 Receptionist, Supporting staff, Mobilizer will be appointed by a committee

    consist of Lab Manager, Pathologist and District President.

    17.5 Procedure

    Lab Manager will be responsible for all the appointments according to the

    following criteria:

    17.5.1 Lab Manager will disseminate the Employment Requisition Form to all Heads of

    Departments (Pathology, Radiology, Sinology)17.5.2 Lab Manager will make proper advertisement to fill the vacant positions of all

    levels.

    17.5.3 All appointments will be made according to the set criteria (i.e. Academic Record,

    Test, and Interview.)

    17.5.4 Keeping in view the laid down criteria, short listing will be done, if needed.

    Selection Board/ Committee will conduct interviews and made final selection.

    17.5.5 Letter of appointment will be issued by Project Director addressing to the

    appointee and a personal file of each and every employee will be maintained.

    17.5.6 Two or more close blood relations will not be appointed in the same department

    however, may be appointed with the approval of Director/Lab Manager.

    18 Quality Control

    18.1 Laboratory quality control is designed to detect, reduce, and correct deficiencies

    in a laboratory's internal analytical process prior to the release of patient results,

    in order to improve the quality of the results reported by the laboratory.

    18.1.1 Developed Internal Quality Control mechanism in each laboratory

    18.1.2 One guide line shall be followed for internal quality control.

    18.1.3 All quality control result & charts shall be posted regional coordinator and he will

    send to central office to monitor and harmonies our system

    18.1.4 External quality control mechanism shall be adopted under central guide lines

    18.1.5 Accreditation with local and international bides will be executed.

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    18.1.6 All quality control results shall be forwarded by Program Manager to Director

    Diagnostic on monthly basis to ascertain deviations (if any) and for expert opinion

    for ongoing quality issues

    19 Accreditation:

    Accreditation is a process in which certification of competency, authority or credibility is

    presented. Organizations that issue credentials or certify third party against official

    standards are themselves formally accredited by accreditation bodies such as UKAS.

    The accreditation process ensures that the practices / investigations / environment /

    standards are acceptable, typically meaning that the organization is competent to perform

    investigation by ensuring quality.

    Al-Khidmat Diagnostic Labs shall adopt all possible international standards procedures

    and certify our labs with the following accreditation bodies:

    19.1 National Accreditation Bodies:

    19.1.1 Pakistan Accreditation Council

    19.1.2 AFIP (Armed Force Institute of Pathology)

    19.1.3 Agha Khan

    19.2 International Accreditation Bodies:

    19.2.1 RIQAS

    19.2.2 UKAS

    20 Job Descriptions:A job description is a list that a person might use for general tasks or functions andresponsibilities of a position. It may often include to whom the position reports,specifications such as the qualifications or skills needed by the person in the job.

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    STANDARD OPERATING PROCEDURES

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    Knowledge, Skills and Abilities:

    Ability to handle work load efficiently

    Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Ability to research and analyze technology problems and issues

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Director must have 5 years of experience with having MBBS degree and specialization in Clinical

    Pathology/ Hematology/ Molecular Biology/ Endocrinology, Radiology or other relevant field.

    ________________________

    Director

    _______________________

    Regional Health Director

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    STANDARD OPERATING PROCEDURES

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    Al-Khidmat Diagnostic Network

    JOB TITLE: Lab Manager

    JOB PURPOSE:

    The purpose of this job is to support operations by supervising staff, planning, organizing, and

    implementing administrative systems.

    KEY RESPONSIBILITIES:

    To ensure emergency supplies

    To ensure all purchasing/ procurement

    To coordinate regional administration issues

    To complete special projects by organizing and coordinating information andrequirements; planning, arranging, and meeting schedules

    To achieve financial objectives by anticipating requirements, submitting information for

    budget preparation, scheduling expenditures, monitoring costs, analyzing variances etc

    To ensure the secure filing of official documents

    To ensure the office security

    Contributes to team effort by accomplishing related results as needed

    To manage all the events of Laboratory

    To perform any other task assigned by competent authority

    Working Conditions:

    Working conditions include office work. Most of the time Lab Manager needs to deal with

    multiple tasks at one time which may causes stress. Ability to manage work load will be the key.

    I.T Skills:

    Microsoft Office

    (Word, Excel, Power Point)

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    Knowledge, Skills and Abilities:

    Ability to handle work load efficiently

    Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Ability to research and analyze technology problems and issues

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Administration manager must have 4 years of experience with having master degree in

    Management or any other management related field.

    ________________________

    Lab Manager

    _______________________

    Director

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    Al-Khidmat Diagnostic Network

    JOB TITLE: Asst. Lab Manager

    JOB PURPOSE:

    The purpose of this job is to support Lab Manager to organizing, and implementing

    administrative systems.

    KEY RESPONSIBILITIES:

    To Assist Lab Manager

    To ensure emergency supplies

    To ensure all purchasing/ procurement

    To manage all attendance record of Lab Staff To complete special projects by organizing and coordinating information and

    requirements; planning, arranging, and meeting schedules

    To ensure the secure filing of official documents

    To ensure the office security

    Contributes to team effort by accomplishing related results as needed

    To manage all the events of Laboratory

    To deal with purely administrative issues

    To perform any other task assigned by Director/Lab Manager

    Working Conditions:

    Working conditions include office work. Most of the time Asst. Lab Manager needs to deal with

    multiple tasks at one time which may causes stress. Ability to manage work load will be the key.

    I.T Skills:

    Microsoft Office

    (Word, Excel, Power Point)

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    STANDARD OPERATING PROCEDURES

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    Knowledge, Skills and Abilities:

    Ability to handle work load efficiently Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Asst. Lab Manager must have 2 years of experience with having bachelor degree in Management

    or any other management related field.

    ________________________

    Asstt Lab Manager

    _______________________

    Director

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    STANDARD OPERATING PROCEDURES

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    Al-Khidmat Foundation Pakistan

    JOB TITLE: Manager Quality Control

    JOB PURPOSE:

    The purpose of this job is to provide specialize services of technical support/ advise for

    investigations.

    KEY RESPONSIBILITIES:

    To facilitate Director/Pathologist in managing Technical and Quality Control issues

    To monitor sample collection steps

    To monitor processing steps

    To ensure Internal Quality Control (IQC) mechanism

    To finalize technical verification of lab investigations

    To maintain all data of IQC

    To send all IQC data to regional office for monitoring and compilation

    To ensure hygienic environment

    To develop opportunities for different Accreditation Programs

    Monitor service and maintenance procedure of instruments.

    Report to Director/Pathologist of Lab

    To perform any other task assigned by the Director/Pathologist/Lab Manager

    Working Conditions:

    Working conditions include office work. Most of the Technologist deal with multiple tasks at one

    time which may causes stress. Ability to manage work load will be the key.

    I.T Skills:

    Microsoft Office

    (Word, Excel, Power Point)

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    STANDARD OPERATING PROCEDURES

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    Knowledge, Skills and Abilities:

    Knowledge about investigations /reports Ability to handle work load efficiently

    Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Ability to research and analyze technology problems and issues

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Manager Quality Control must have 2 years of experience after completion of Master degree in

    the relevant field.

    ________________________

    Manager Quality Control

    _______________________

    Director

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    Al-Khidmat Diagnostic Networks Page 34

    Knowledge, Skills and Abilities:

    Knowledge about investigations /reports Ability to handle work load efficiently

    Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Ability to research and analyze technology problems and issues

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Technologist must have 3 years experience after completion of MSc in relevant field.

    ________________________

    Technologist

    _______________________

    Director

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    Al-Khidmat Foundation Pakistan

    JOB TITLE: Technician

    JOB PURPOSE:

    The purpose of this job is to perform investigations by adopting standard procedures and facilitate

    technologists and pathologist/ radiologist.

    KEY RESPONSIBILITIES:

    To perform investigations by adopting all formal (standard) procedures

    To ensure safety of samples

    To perform lab investigations

    To ensure IQC under supervision of Quality Control Manager

    To finalize lab reports

    To present reports to Pathologist for verification

    To discuss abnormal results with Technologist/Pathologist

    To maintain reporting log register

    To ensure the quality reporting of investigations and quality results of investigating

    machines

    To liaison with receptionist for timely delivery of reports to patients/ clients To ensure the cleanliness in investigation area

    To ensure availability of stock ofequipments for performing investigations

    To perform any other task assigned by competent authority

    Working Conditions:

    Working conditions include office work. Most of the time technician needs to deal with multiple

    tasks at one time which may causes stress. Ability to manage work load will be the key.

    I.T Skills:

    Microsoft Office

    (Word, Excel, Power Point)

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    Knowledge, Skills and Abilities:

    Ability to perform investigations

    Ability to handle work load efficiently

    Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Ability to research and analyze technology problems and issues

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Technician must have 3 years of experience in relevant field with having minimum a diploma

    certificate in Medical Technology.

    ________________________

    Technician

    ________________________

    Director

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    Al-Khidmat Foundation Pakistan

    JOB TITLE: Receptionist

    JOB PURPOSE:

    The purpose of this job is to provide the patients with proper guideline related with the function

    of lab and the investigations performed by Al-Khidmat Diagnostic Network. Receptionist will

    take investigation fee and provide the patient with receipt.

    KEY RESPONSIBILITIES:

    To maintain record of all official asset

    To manage all attendance record of employees

    To perform refunds / cancellation of slip procedure

    To ensure maintenance of record through daily & monthly return

    To maintain daily return of test and patients

    Monitor statistics of all test requested and no. of patients with their Bio-Data

    Maintain record of training and other events

    Coordinate with other departments of Al-Kdidmat Diagnostic Lab for day to day issues

    concerned with lab reporting.

    He / She will directly report to Lab Manager

    Contributes to team effort by accomplishing related results as needed

    To perform any other task assigned by competent authority

    Working Conditions:

    Working conditions include office work. Most of the time Receptionist needs to deal with

    multiple tasks at one time which may causes stress. Ability to manage work load will be the key.

    I.T Skills:

    Microsoft Office

    (Word, Excel, Power Point)

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    STANDARD OPERATING PROCEDURES

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    Al-Khidmat Foundation Pakistan

    JOB TITLE: Marketing Manager

    JOB PURPOSE:

    The purpose of this job is to design, develops, implements and manages a series of marketing

    initiatives. These initiatives include, but not limited to the development of strategic alliances and

    promotion activities, the establishment of enabling networks.

    KEY RESPONSIBILITIES:

    To assist in the creation, development and implementation of creative marketing

    strategies that will make an impact and support the functions of Lab

    To develop Annual Marketing /Media Plan

    To develop Marketing kit (Profile, Brochure, flyer, Presentations, Calendar,

    Documentary)

    To manage Donor Data (E-mail, Phone, Postal Address)

    To produce innovative and cost-effective promotions tools (SMS, Social Media).

    To assist in Campaign development, implement and feedback.

    To manage different Event for promotion, and image building.

    To provide occasional secretarial, recruitment or administrative support and backup to the

    Lab Manger Media where requested To perform any other task assigned by competent authority

    Working Conditions:

    Working conditions include both field work and office work. Most of the time Marketing

    Manager needs to deal with multiple tasks at one time which may causes stress. Ability to

    manage work load will be the key.

    I.T Skills:

    Microsoft Office

    (Word, Excel, Power Point)

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    STANDARD OPERATING PROCEDURES

    Knowledge, Skills and Abilities:

    Ability to handle work load efficiently

    Ability to handle all queries/ technical questions

    Ability to work cooperatively

    Ability to research and analyze technology problems and issues

    Knowledge of database management system

    Ability to work individually and as a team member

    Ability to handle stress

    Good written/verbal communication skills

    Good presentation skills

    Qualification/ Experience:

    Marketing Manager must have 2 years of experience with having master degree in Marketing or

    any other related with marketing field.

    ________________________

    Marketing Manager

    ________________________

    Director

    21 Amendments: