NHS Greater Glasgow and Clyde
North Glasgow Clinical Biochemistry Tests Database
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NHS Greater Glasgow and Clyde North Glasgow Clinical Biochemistry Tests Database |
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ANNUAL REPORT 2004 All Change During 2004, the Department experienced significant organisational change. At the end of March the existing Trusts in Greater Glasgow Health Board were formed into the North, South and Yorkhill Divisions. Currently, a pan-Glasgow strategic review of laboratory services and a multi-discipline equipment procurement are in progress. During the second quarter of the year, Dr Graham Beastall was appointed as the new Clinical Lead and trials manager. Mr David Cameron was appointed to the post of Laboratory Manager. Dr Beastall instigated an organisation and management review, the aim being to ensure that the group was capable of delivering effective and efficient management. Following the review, a planning subcommittee and a number of working groups were formed to take the various new developments forward including the review of laboratory services, equipment procurement, agenda for change and working time directive. There was also a new appointment to the chair of the audit subcommittee. Dr Anne Pollock, a member of the ACB National Audit Committee and chair of the Scottish Audit Group, continues the commitment to promote audit activity throughout the Department and participate in the audit of clinical effectiveness. NEEDS AND REQUIREMENTS OF USERS The Department's quality management system is now well established and this provides the integration of organisational structure, processes, procedures and resources needed to fulfil the quality policy and hence meet the needs and requirements of users. The quality manager is responsible for ensuring the quality management system (QMS) is implemented and maintained. The QMS is audited regularly to monitor effectiveness. The quality manager reports the audit findings to the management group at regular intervals. During 2004, the Department's subcommittees and groups worked steadily, both independently and in collaboration, to achieve the quality objectives. Most of the objectives have been delivered in good time, however a few have been deferred until the pan-Glasgow review of laboratory services has been completed.
Standardisation of the laboratory information system is almost complete (75%) Due to the pan-Glasgow review, three main objectives have not been achieved:
An audit of general practitioners was undertaken early in 2004 to identify service improvements. All general practitioners were given the opportunity to meet with a member of the Department to discuss specific issues. Only one has taken up the offer. Four main issues emerged following analysis of the data:
In response:
The questionnaire has recently been issued to users within the North Glasgow Hospital network. A GP liaison officer has been appointed at the West site to improve communication with users. Visits to practices are arranged to discuss specific issues. Should this prove to be an effective mechanism for improving communication and service quality it will be considered for adoption by the hospitals in the East and North. Two liaison officers provide support to the renal unit at the East site. This has proven to be an effective mechanism for facilitating improvement. The Department is currently seeking a Digoxin assay with improved sensitivity and is in the process of evaluating the precision of the current magnesium method at levels <0.5mmol/L in order to meet the needs of users. RESOURCE MANAGEMENT Effective management of the resources required to meet the needs and requirements of users remains a key objective of the Department. Personnel The Department recognises the importance of staff recruitment, training, development and retention at all times to provide a full and effective service to its users. One trainee Biomedical Scientist (BMS) has successfully completed her training and oral examination in 2004 and is now a member of the staff complement. Another trainee will complete her training early in 2005. The Department continues to fulfil its commitment to the training and development of clinical scientists and specialist registrars. One specialist registrar completed MRCPath in 2004 and a Grade A Clinical Scientist successfully completed her training. The professionalism and commitment exhibited by members of staff throughout the Department is exceptional. Without this dedication it would be impossible to achieve the level of productivity and overcome the day to day analytical challenges, yet still deliver a service of high quality. Premises and Environment The Department has a continuing commitment to provide an environment that is safe and appropriate for efficient working practices. Reconfiguration of the Macewen Building to improve storage and bench space, the functioning of equipment and facilities for specimen receipt remains an objective of the Department. Plans have been submitted for the reconfiguration at an estimated cost of £1.2 million. However, all major developments are 'on-hold' because of the strategic review of laboratory services across Glasgow. A number of laboratory configurations are being considered and funds will not be released until the review process has been completed. Environmental conditions have been improved at Glasgow Royal Infirmary (GRI) and Stobhill. The air conditioning units at GRI have been upgraded and local units have been installed at Stobhill. Equipment and Diagnostics Procurement The Department is committed to the proper procurement and maintenance of equipment to ensure continued service provision. NHS Greater Glasgow is currently pursuing a pan-Glasgow, cross discipline equipment procurement. The tender process is at an advanced stage and it is anticipated the equipment should be commissioned by mid 2005. The Department has successfully commissioned a new specific protein analyser, a GCMS (Drug Investigation Unit) and a haematoflurometer for zinc protoporphyrin (trace element unit). HEALTH AND SAFETY The Department affords respect and due consideration to health, safety and welfare matters to its staff and others and follows environmentally safe procedures. The Department's Health and Safety (H&S) Control books have been audited by the Division's Health and Safety adviser and have been accepted as compliant with the standard. The H&S subcommittee has ensured compliance with National and European H&S legislation. The H&S subcommittee has also been pro-active in seeking resolution to the various environmental and security issues throughout the Department. However, due to financial constraints, attempts to improve the security arrangements at the Macewen Building have been unsuccessful. QUALITY MANAGEMENT User Satisfaction and Complaints A total of 7 complaints were registered in 2004. This represents a >50% reduction from the previous year. Turnaround time was compromised due to a sustained period of analyser failure (ADVIA 1650). The eventual replacement of the faulty equipment has resolved the issue of unsatisfactory turnaround. Solutions have been sought to maximise the electronic transfer of results to the laboratory information system (LIS) in order to reduce transcription errors. Complaints unique to individual service users will be reviewed should they become issues for others. Internal Audit The Department has conducted regular internal audits of its quality management system to ensure that the system has been effectively established, implemented and maintained. The Department also audits its examination processes to ensure that they are being conducted according to agreed procedures. External Quality Assessment The Department participates in External Quality Assessment (EQA) schemes to provide evidence of the quality of their repertoire of services. During 2004, the Department found it necessary to review three assays that were identified as having unsatisfactory performance. The progesterone assay experienced a method shift due to a reagent lot switch. Assay performance is once again satisfactory. Two instances of a-typical B score were reported for the cortisol assay. Intervention by the manufacturer's service engineer has improved the assay performance. The assay continues to be monitored closely. The Free T4 assay was outside acceptable limits for one return. Re-analysis of the material gave the correct values and patient results were unaffected. Performance has been satisfactory since the event. Unfortunately, the cause remains unidentified. Audit A diverse range of staff are now involved in audit activity within the Department. There has been a 100% increase in the number of technical audits performed this year. Staff of all grades attended an audit seminar held in June and several members of the Department presented data. An impressive total of sixteen audits have been completed and reported during 2004 including five turnaround audits and a number of clinical audits. The Department has also participated in a total of five National audits. A newsletter is circulated that provides information about Departmental audit activity and audit reports are available on the NGUHD network (Stobhill domain). Incident Recording The Department has procedures in place for incident recording to facilitate continuing quality improvement. Incident recording during the last 12 months has enabled the Department to identify and implement a number of improvements. Wherever possible, the Department has pursued the electronic transfer of results to the LIS. A number of procedures have been revised to minimise the release of incorrect results. PID errors have been reduced following the roll out of electronic requesting. The vast majority of incidents recorded necessitated re-affirming that procedures must be followed and that care and attention is required at all times when carrying out day to day duties. It is, therefore, appropriate to emphasise that the Department's workload has increased (19% increase in GP workload alone) in 2004, but the staff complement has remained the same. FUTURE KEY OBJECTIVES AND PRIORITIES The Department's objectives for 2005 were set following the review of the individual subcommittee reports and by taking into account any issues raised by the various mechanisms for identifying quality improvements (internal audit, monitoring complaints and satisfaction and external reports). An action plan, designed to achieve our key objectives, is available for 2005. The plan will be reviewed by the Management Group regularly throughout the year to ensure the key objectives, listed below, are on target for completion. Key Objectives
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Last Updated: 16 December 2008 |