Laboratory Quality Assurance Program

Role of College of Physicians & Surgeons of Saskatchewan (CPSS), Laboratory Quality Assurance Program (LQAP)

The CPSS is contracted by the Ministry of Health to operate the LQAP. As designated in the Medical Laboratory Licensing Act and Regulations, the LQAP is responsible for the requirements and standards of Medical Laboratories in the province. The purpose of assessing and accrediting laboratories is to evaluate and ensure compliance with established standards, identify areas of excellence and to provide recommendations for improvement.

LQAP Committees

The LQAP Committees consist of the Program Management Committee (PMC) and discipline specific Quality Assurance (QA) Committees for Anatomic Pathology, Chemistry, Hematology, Microbiology, and Transfusion Medicine. Committees are comprised of medical and technical experts in these disciplines. The QA Committees develop guidelines for laboratory practice in their specific disciplines; review facility assessment reports and proficiency testing deficiencies. The PMC is the oversight body for operations and decision making for the program. It is comprised of the chairs of the discipline specific committees along with representation from the Saskatchewan Association of Combined Laboratory and X-ray Technologists, Saskatchewan Medical Association, Saskatchewan Society of Medical Laboratory Technologists and a representative from the Ministry of Health.

Laboratory Accreditation Program Model

Medical laboratories are assessed on a four year rotation or earlier if PMC determines it’s necessary. The features of the CPSS accreditation model are as follows:

  • Assessments conducted:
    • On a 4 year rotation
    • By region

- Facility may be assessed prior to 4 year rotation if PMC determines that evidence of compliance was not adequate from assessment

  • Any facility holding a Medical Laboratory License is subject to assessment
  • Peer review conducted by assessment teams

- Trained team leaders – conduct interviews, conduct opening and summation conferences, assist in report and response review

- Trained assessors with subject matter expertise – selection based on scope of services

  • Region receives pre-assessment notification
  • Assessment teams are selected to ensure no direct conflict of interest
  • Facilities are not required to submit self-assessment documents
  • Facilities are required to provide test menu and staff lists prior to assessment
  • Facilities receive a verbal summation of key findings
  • All accreditation reports reviewed by QA and PMC Committees
  • Responses for non-conformance are due within 30 or 60 days of final report – including evidence of compliance
  • Facilities and assessors receive evaluation surveys after each assessment
  • Facilities and assessors are provided a training session prior to the assessment
  • PMC grants accreditation upon receiving acceptable evidence of compliance
  • All assessment findings are shared with the Ministry of Health
  • MOH receives bi-annual updates of accreditation status
About the Standards

The standards are secure documents, shared only with a facility's laboratory supervisor and approved designee. Laboratory supervisors further disperse these documents within their organization and manage the security features. To submit a proposed standards revision, complete the Stakeholders Standards Revision Form ensuring that:
  • the specific standards or section are identified
  • verifiable references (including link or attachment) are provided
  • the request applies to all diagnostic laboratory facilities (not limited to organization specific practice)
  • contact information is included
 

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