RULES AND REGULATIONS OF CLINICAL LABORATORIES IN PH Flashcards
ORGANIZATION AND MANAGEMENT
• Updated organizational chart (with names, pictures, and designations) must be displayed in a conspicuous area
• The laboratory’s vision, mission, and goals and the DOH-LTO must also be displayed
• Written policy on management review and compilation of documented minutes of meeting
• Supporting documents for evaluation and monitoring of activities such as records, logbooks, checklist of supplies, inspection report, purchasing and procurement and acceptance of supplies, etc.
• Written policy and procedure for handling complaints/ client feedback
• Suggestion box must be visible to clients
• Updated organizational chart (with 3) must be displayed in a conspicuous area
names, pictures, and designations
• The laboratory’s(4) must also be displayed
vision, mission, and goals and the DOH-LTO
• Written policy on _____and compilation of documented_____
management review
minutes of meeting
Organizational chart should include:
Head: Pathologist
Chief MTs
Registered MTs
DOH LTO
Renewed every YEAR
Ngano need i document tanan?
For proof/ evidence if anything happens like kulang ang mga equipment, gamit, or if mag visit ang DOH then kumpleto ang papers
HUMAN RESOURCE MANAGEMENT
• Written policies and procedures on hiring, orientation, and promotion of personnel at all levels
• Written policies and procedures for staff development and training
• Proof of training through certificates, memos, budgetary allocations, written reports
• Written policies and procedures on discipline, suspension, demotion, and termination of personnel at all levels
• Written job description or duties and responsibilities of all laboratory personnel
• List of personnel with designation
• Areas of assignment indicated in the
Proof of training
Certificate
HEAD OF THE LABORATORY: THE PATHOLOGIST
Proof of supervisory________
OR_______
at least once a week for physical visit
once a month physical visit with at least twice a week of supervisory calls and or video conferencing
• For HOL of hospital-based laboratory: supervisory physical visit of…
at least once a week
• Proof of qualifications:
Updated resume
PRC certificate and valid PRC ID
Board Certificate and a Certificate of Good Standing from PSP
Notarized employment contract
Relevant training certificates
Proof of immunization
PSP
Philippine Society of Pathologists
PRC
Professional Regulation Commission
This certificate can be used as employment, business, or further proof of credibility and good moral character as a professional.
PRC CERTIFICATE OF GOOD STANDING
Clinical Laboratory
Primary
Secondary
Tertiary
Limited
Anatomic Laboratory
Molecular Laboratory
Genetics**
Immunohematology
Infectious
Anatomical Pathology
Surgical Pathology
Cytology
Immunonistopatholcay
Forensic Pathology
Autopsy
Clinical Pathology
Hematology
Immuno-serology
Immunohematology
Clinical Microscopy
Microbiology
Clinical Chemistry
Parasitology
Toxicology
Therapeutic Drug Monitoring
Headed by a Pathologist who is certified by the..
Philippine Board of Pathology
- Clinical Laboratory Law of 1966
Republic Act No. 4688
REGISTERED MEDICAL TECHNOLOGISTS
At least______ per assigned area
RMTs with designated assignments must have proof of trainings
1 competent RMT
: certificate of proficiency (SACCL)
rHIVda
(rHIVda)
rapid HIV diagnostic algorithm
NRL-SLH SACCL
STD AIDS Cooperative Center Laboratory
NRL for HIV
San Lazaro Hospital
AFB microscopy: certificate of training on
DSSM (NTRL)
Direct Sputum Smear Microscopy
is indicated for suspected cases of tuberculosis
AFB-microscopy
• Bacteriology: certificate of training in bacteriology
Research Institute for Tropical Medicine
• Malaria smear: certificate of training in malaria smear
RITM
• Biosafety and Biosecurity Officer: certificate of training
RITM and/or UP- NTCBB
Research Institute for Tropical Medicine
National Training Center for Biosafety and Biosecurity
STAFFING PATTERN FOR RMT ANALYSTS
- Clinical Laboratory for Clinical and Anatomic Pathology
- Clinical Laboratory for Anatomic Pathology - At least one RMT per section
- Clinical Laboratory for Molecular Pathology - Will depend on the services offered
Bio safety vs Biosecurity
Biosafety is about preventing accidental exposure to harmful biological agents through safe practices.
Biosecurity focuses on preventing the intentional misuse of biological materials, like theft or bioterrorism.
Shift hours in a day
8 hours
In tertiary lab, at least hm RMTs are needed in the first shift
6
In secondary laboratory, at least hm RMTs are needed for the first shift?
5
In primary laboratory, at least hm RMTs are needed in 1st shift?
4
Primary lab shifts
8 (7+1 reliever) without Microbiology
9 (8+1 reliever) for Government Facilities
Secondary lab shifts
12 (11+1 reliever)
Tertiary lab shifts
12 (11+1 reliever) without Histopathology
13 (12+1 reliever) for Hospital-Based
Written policy and program for the proper maintenance and monitoring of physical plant and facilities
Proposed schedule for…
preventive maintenance
Preventive maintenance vs Repair
Preventive maintenance involves regular, scheduled upkeep of laboratory equipment to prevent breakdowns and ensure reliable performance.
Repair is the process of fixing equipment after it has already malfunctioned or failed.
Preventive maintenance vs Repair
Which is more important?
Preventive maintenance is generally more important because it helps avoid equipment failures, ensures consistent performance, and extends the lifespan of laboratory instruments. It reduces the likelihood of costly repairs and downtime, keeping the lab running smoothly.
MOA
Memorandum of Agreement
Policy on disposal of wastes that conform with______ and____
Healthcare Waste Management Manual
RA 6969 Toxic Substances and Hazardous and Nuclear Wastes Control Act of 1990)
, this program of the DENR-EMB covers the sound and proper management of industrial chemicals and hazardous wastes in all aspects of its life cycle, from importation, manufacture, distribution, transportation, use and disposal.
RA 6969 Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990
A Memorandum of Agreement (MOA) is crucial in the disposal of laboratory wastes because….
it clearly outlines the responsibilities and protocols for handling and disposing of hazardous materials. It ensures that all parties involved follow legal and safety guidelines, minimizing the risk of environmental contamination and ensuring compliance with regulations
EQUIPMENT/INSTRUMENTS
List of available and functional laboratory equipment
Regular schedule including frequency of preventive maintenance and calibration
Record of repair reports
Written policy on contingency plan in case of equipment breakdown
When should PM be done?
Daily/Weekly: Basic checks, like cleaning, calibration, and quality control tests.
Monthly/Quarterly: More thorough inspections and servicing, such as replacing worn parts or filters
FDA certification is important because…
it ensures that medical devices, pharmaceuticals, and other health-related products meet safety, efficacy, and quality standards.
This certification helps protect public health by ensuring that products are reliable and have been thoroughly evaluated before reaching the market.
It also facilitates regulatory compliance and can enhance consumer trust and product credibility.
Temperature monitoring records should include:
- Date and Time of each reading.
- Temperature Reading.
- Location of measurement.
- Name of the person monitoring.
- Action Taken if temperatures are outside the acceptable range.
Documented procedure for the retention of records which follows DOH standards
Laboratory logbooks:
Laboratory results:
Laboratory requests:
dispose 2 years after the last entry provided that no item is subiect of a medico-legal case
must be disposed after 15 years
dispose 1 year after the release of the result
In hematology dapat…
2 RMTs mag agree sa results
Purpose of QC
The purpose of Quality Control (QC) is to ensure that laboratory tests and processes are accurate, reliable, and consistent by systematically monitoring and maintaining high standards throughout the testing process. QC helps identify and correct errors, ensure compliance with regulations, and enhance the overall quality of laboratory results.
How to perform QC
To perform QC in a clinical laboratory using high, low, and normal controls, regularly run these control samples alongside patient tests. High controls test the accuracy at the upper limit, low controls at the lower limit, and normal controls at expected values. Compare the results of these controls to their expected ranges to ensure that the testing system is functioning correctly. Document the results and take corrective actions if any controls fall outside the acceptable ranges.
* Regularly run control samples with known values to check if test results fall within acceptable ranges.*
(QAP)
Quality Assurance Plan
Purpose of management review
Minimize errors and achieve quality services
Written policy and procedure for handling know complaints/ client feedback
○ Available forms
○ Records and action taken
HUMAN RESOURCE MANAGEMENT
● Written policies and procedures on ____,_____, and ______of personnel at all levels
● Written policies and procedures for staff____ and _____
● Proof of training through_____, memos, budgetary allocations, written reports
● Written policies and procedures on (4) of personnel at all level
● Written_____ and _____ of all laboratory personnel
● List of personnel with designation
● Areas of______ indicated in the posted work schedule
hiring, orientation, and promotion
development and training
certificates
discipline, suspension, demotion, and termination
job description or duties and responsibilities
assignment
Types of Lab
Clin chem lab
Anatomic lab
Molecular lab
Tests in anatomic lab
Surgical pathology and cytology
Autopsy
Frozen section
Clinical Pathologist
Clin chem lab
Molecular lab
Anatomic pathologist
Anatomic laboratory
Autopsy
Surgical patho
Frozen section
Laboratory ____ and ______are accessible to the public
services and corresponding prices
● __________of laboratory services in each section/area
Documented and updated policies and procedures
Laboratory report forms bearing the…
name
original digital signature
PRC ID number
of the head of the laboratory and the RMT analysts
Certificate of Performance in_____
EQAP with passing rate
● Documented procedures on referral and outsourcing of examinations to another________
● Written policy on______ in case of equipment breakdown
● Records of______(in the event of machine breakdown)
●_____ on test referrals
●______ of referral testing laboratory
DOH-licensed clinical laboratory
contingency plan
outsourced examinations
Notarized MOA
DOH-LTO
All documented policies, protocols, and procedures are _________by the_____
signed and approved
head of the laboratory