CVPH QMS Manual 2016

Policy
COMPOSTELA VALLEY PROVINCIAL Number

HOSPITAL
Department of Laboratories Effective
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Manual of Standards
on
Quality Management Systems
in the
Clinical Laboratory
Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Pathologist
Verified by: Ferdinand Anthony C. Soberano, MD, FPSMS

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
TABLE OF CONTENTS
POLICY NUMBER PAGE NUMBER
Group of Standards No. 1 Management Responsibility
GLD-0001 Laboratory Management
GLD-0002 Legal & Regulatory Requirements
GLD-0003 Professional Ethics and Conduct
GLD-0004 Quality & Strategic Planning
GLD-0005 Budget
GLD-0006 Management Review
Group of Standards No. 2 Resource Management
GLD-0007 Human Resource Management
GLD-0008 Responsibilities

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
GLD-0009 Personnel Orientation
GLD-0010 Work Schedule, Leave of Absence
GLD-0011 Staff Training & Development
GLD-0012 Staff Meetings
GLD-0013 Sanctions & Violations
GLD-0014 Physical Facilities
GLD-0015 Equipment & Instruments
GLD-0016 Contingency Plan
GLD-0016A Disruption of Laboratory Services due to Problems in the Physical
Facility
GLD-0016B Contingency Plan for Equipment Breakdown
GLD-0016C Preventive Maintenance
GLD-0016D Reagents & Supplies
GLD-0017 Reagents, Controls, Standards, Glassware, and Supplies
Group of Standards No. 3 Service Delivery
GLD-0018 Customer Needs & Requirement

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
General Guidelines
Pre Examination Phase
A. Request Form (In and Out Patient)
B. Request from In Patient
C. Time when to forward Blood Chemistry request
D. STAT Cases
E. Request from Out Patient
F. Collection
G. Criteria for Rejection of Sample
Post Examination
A. Reporting of Result
B. Releasing of Result Out Patient and In Patient
GLD-0019 Issuance of Second Copy
GLD-0020 Send Out & Received Sample
GLD-0021 Clinical Consultative Services
GLD-0022 Laboratory Charges

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
GLD-0023 Point of Care Testing
GLD-0024 Turn Around Time
Group of Standards No. 4 Monitoring Performance
GLD-0025 Quality Assurance System
GLD-0026 Internal Quality Control Program
GLD-0027 External Quality Control Program
GLD-0028 Factors affecting Quality of Laboratory Results
Group of Standards No. 5 Quality Improvement Activities
GLD-0029 Continuing Quality Improvement
Group of Standards No. 6 Information Management
GLD-0030 Information System
GLD-0031 External and Internal Communication
GLD-0032 Document and Record Control
GLD-0033 Laboratory Information System
Group of Standards No. 7 Environmental Management and Biosafety
GLD-0034 Housekeeping and Working Condition

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
GLD-0035 Preventive Safety Measure
GLD-0036 Aseptic Technique
GLD-0037 Orderliness and Labeling
GLD-0038 Waste Management
GLD-0039 Chemical Safety
GLD-0040 Electrical Safety
INTRODUCTION
The Laboratory is a major ancillary department of the hospital. The primary function of the
department is to perform laboratory tests for all patients as ordered by the physician and as
required by the patient's population. It provides data to physicians to assist in their diagnosis
and treatment plans.

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
The purpose of this document is to define in clear terms the guidelines, policies, and
procedures that regulate the effective delivery of the laboratory services provided as it is
delivered by the four laboratories of the Compostela Valley Provincial Hospitals of Montevista,
Pantukan, Laak, and Maragusan. It is directed by the Provincial Government of Compostela
Valley headed by the Governor.
VISION: Quality and Affordable Laboratory Services for All.
MISSION: The provision of quality and affordable laboratory services to the community
through sophisticated laboratory equipment as diagnostic tool.
GOALS AND OBJECTIVES

Provide quality services to the community.
Maintain patient satisfaction.
Improve safety precautionary measures in the laboratory.
Develop new knowledge to strengthen and enhance quality and fast procedures.
Services must be uniformly distributed to all constituents.
VALUES
Quality in laboratory practices and procedures.
Work effectively and efficiently with other health care professionals, and have good
co-workers’ relationship.
Use information technology to upgrade technical skills.
Courteous and respectful treatment to all clients.
Adherence to ethical principles and cultural sensitivity.
Understand how laboratory services affect other health care services.
GROUP OF STANDARDS #1: MANAGEMENT RESPONSIBILITY

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0001: Laboratory Management
Rationale: The Compostela Valley Provincial Hospital - Department of Laboratories shall be

managed and supervised by a Pathologist in setting the direction towards providing quality
services and continuous quality improvement, and works hand in hand with the Chief Medical
Technologist of each hospital laboratory in the province who are committed to the
development and implementation of the Quality Management System in the Clinical
Laboratories as set by the Department of Health. This is of prime importance that will help us
operate with updated technologies towards quality delivery of diagnostic services.
Purpose: Implement the Quality Management Standards set by the Department of Health for
clinical laboratory operations.
Scope: Pathologist, Chief Medical Technologist.
Procedure:
PATHOLOGIST
1. The Pathologist sets the direction of the hospital laboratory towards providing quality
services and continuous quality improvement.
1. The Head of the Laboratory is a duly licensed physician, certified by the Philippine
Society of Pathologist - Board of Pathology and renders pathology and clinical
laboratory services. She assumes technical and administrative supervision and
control of the activities in the laboratory.
2. Ensure that a quality management system is in place.
3. The Pathologist will have a regular schedule of supervisory visit in the hospitals to
monitor and make improvements in the strategic direction of the clinical laboratory in
response to the needs of the clients.
4. The Pathologist informs the Chief of Hospital of the laboratory operations.
8

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
5. Conducts monitoring for the full implementation of the Standards in the Quality
Management Systems for Clinical Laboratory operations.
CHIEF MEDICAL TECHNOLOGIST
1. In the absence of the Pathologist the Chief Medical Technologist assumes

responsibility in coordinating and implementation of guidelines and policies in the
day to day activities of the laboratory.
Reference: DOH QMS Manual, CVPH QMS Manual v.2011
Policy GLD-0002: Legal and Regulatory Requirements
Rationale: The Compostela Valley Provincial Hospital - Department of Laboratories shall

comply with the legal and regulatory requirements set forth by the Department of Health and
be updated of the minimum standards and technical requirements for clinical laboratories.
The following documentary requirements shall be complied.
 Administrative Order No. 2007 – 0027

 Revised Rules and Regulations Governing the Licensure and Regulation of
Clinical Laboratories in the Philippines.
Administrative Order No. 2007-0027 states that this apply to all individuals, agencies,
partnerships or corporations that operate clinical laboratories in the Philippines

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
performing examination and analysis of samples of tissues, fluids, secretions,

excretions, or other materials from the human body that would yield relevant
laboratory information, which physicians use for the prevention, diagnosis, and
treatment of diseases, and the management and promotion of personal and public
health.
Purpose: Comply with the legal and regulatory requirements in the renewal of License to
Operate as mandated by law to ensure access to quality and affordable diagnostic services to
clients.
Scope:
Applicant- Individuals or Government Clinical Laboratories who intend to operate a clinical

laboratory
CVPH: Compostela Valley Provincial Hospitals
BHFS: Bureau of Health Facilities and Services
CHD: Center for Health Development
DOH: Department of Health
Procedure:
1. Applicant acquires the prescribed application form from the BHFS, CHD that has
jurisdiction over existing or proposed clinical laboratory.
2. The accomplished form together with the necessary attachments is to be submitted to
the CHD that has jurisdiction over the existing or proposed clinical laboratory.
3. The applicant pays a non-refundable application fee for the License to Operate upon
submission of the accomplished form. All fees, surcharges and discounts follow the
current DOH prescribed schedule and rate of fees.
10

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
4. The CHD conducts inspection in accordance with licensing requirements, as provided

for under this Order and the One-Stop-Shop Licensure System for Hospital.
5. Submit application and renewal of documents three (3) months prior to expiry date but
not later than five days after the expiry date of license
6. Post valid certificates in a discernible area of the laboratory.
Reference: DOH QMS Manual, CVPH QMS Manual v. 2011, DOH AO 2007-0027, DOH AO 2007-
0027A
Policy GLD-0003: Professional Ethics and Conduct
Rationale: All laboratory personnel shall follow professional ethics in the performance of their
task and responsibilities and are committed to fully adhere to the proper conduct and ethics of
the laboratory.
Purpose: To maintain harmonious working relationship to all health workers within the
facility and towards the clients.
Scope: All hospital personnel, patients, watchers
Responsibilities:
CODE OF ETHICS OF MEDICAL TECHNOLOGIST
As I enter the practice of Medical Technology, I shall;
Accept the responsibilities inherent to being a professional.

Uphold the law and shall not participate in illegal works.
11

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Act in a spirit of fairness to all and in a spirit of brotherhood toward other members of the
profession.
Accept employment from more than one employer only when there is no conflict of interest.
Perform my task with full confidence, absolute reliability and accuracy.
Share my knowledge and expertise with my colleagues.
Contribute to the advancement of the professional organization and other allied Health
Organization.
Restrict my praises, criticisms, views and opinions within constructive limits.
Treat any information I acquired in the course of my work as strictly confidential.
Uphold the dignity and respect of my profession and conduct myself with reliability, honesty
and integrity.
Be dedicated to the use of Clinical Laboratory Science to promote life and benefit mankind.
Report any violations of the above principles of professional conduct to the authorized agency
and to the ethics committee of the organization.
To these principles, I hereby subscribe and pledge to conduct myself at all times in a manner
benefiting the dignity of my profession.
Proper Decorum
 No hospital/laboratory staff is allowed to bring alcoholic drinks while on duty.
 No Smoking inside the hospital premises.
 Firearms/explosives are not allowed in the hospital/laboratory premises.
 Exercise utmost courtesy, tact and appropriate conduct.
 Observe respect to superiors, courtesy to equals and consideration to subordinates.
 Possess a spirit of cooperation and mutual assistance among each staff.
 Observe confidentiality in all laboratory results.
12

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
 All laboratory personnel whether on or off duty must refrain from making social visits to
other departments or loiter around the hospital premises except when responding to calls
related to the nature of work or securing their wages from the cashier.
 Complaints from patients and watchers should be referred accordingly to the immediate
supervisor and properly documented in the laboratory's incident logbook.
 Refer to the Pathologist whenever there is doubt or discrepancy in the credibility of the
test results.
 All Medical Technologists and laboratory personnel should follow the Code of Ethics for
Medical Technologist
Endorsement
 Laboratory endorsements are done in every shift before going off duty and be written
in the white board/logbook provided.
 Report 15 minutes before the time.
 Never leave the area without a reliever (during the time when 2-shift a day is available).
Uniform
 Report to duty with the prescribed uniform and proper identification card.
Telephone / Intercom Use

 Telephone / Intercom are necessary for good patient care. It is not to be routinely use
for personal calls unless absolutely necessary.
 Answer the phone promptly.
 Identify yourself by name and department.
 Transfer calls courteously and tactfully.
 Give accurate and relevant answers.
13

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
 Speak in clear, soft tone without shouting.

 Call back rather than putting the call on hold.
Reference: CVPH QMS Manual v. 2011, CVPH SOP, Code of Ethics for Medical Technologists
Policy GLD-0004: Quality and Strategic Planning
Rationale: The Department of Laboratories shall prepare and implement the Quality and
Strategic Plan that will provide adequate laboratory services which is critical to ensure that
communities receive good clinical and diagnostic care. There is an urgent need to develop an
effective laboratory strategic plan to strengthen laboratory system as an integral part of
strengthening the overall healthcare system.
Purpose: This will serve as a guide to further develop and improve the delivery of laboratory
services.
Scope: Pathologist, Chief Medical Technologist, Laboratory staff
Procedure:
1. The Administrative Manual for the Quality Management System in the Clinical Laboratory
is created and patterned according to the Department of Health.
2. Attend trainings and seminars. (Refer to Group of Standards No.2 Resource Management
Policy GLD-0011 on Staff Training and Development)
3. Manage the supply chain of commodities. (Refer to Group of Standards No.2 Resource
Management Policy GLD-0017 on Reagents, Controls, Standards, Glassware and Supplies)
14

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
4. Standardize testing per test (Refer to Technical Manual of Procedures) and equipment
maintenance (Refer to Group of Standards No.2 Policy on Resource Management Policy
GLD-0016 Contingency Plan of Equipment Breakdown).
5. Prepare and formulate the laboratory’s 3-5-year- strategic plan.
6. Submit for approval which will serve as a guide for implementation.
Policy GLD-0005: Budget
Rationale: The provincial government shall provide adequate human and material resources
to ensure that the conduct of quality laboratory services will meet the standard licensing
requirements as well as to cater the diagnostic and healthcare needs of the community.
Purpose: To be guaranteed of adequate manpower, equipment and material supplies needed in

the continuous delivery and quality performance of laboratory services.
Scope: Provincial Government, PEEMO, Chief of Hospital, Administrative Officer, Supply Officer,
Pathologist, Chief Medical Technologist.
Procedure:
1. The Pathologist conducts a series of meetings with the Chief Medical Technologists in
the preparation of the Annual Procurement Plan for the following year based on the
previous year’s consumption and current actual needs of the laboratory.
2. The Chief Medical Technologist prepares the Annual Procurement Plan for the
laboratory of the following year and submits this to the Supply Officer by first week of
15

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
October of the current year for encoding and consolidation to the hospital’s Project
Procurement Plan.
3. Project proposals for acquisition of new machines/devices and reagents for additional
laboratory services is to be coordinated with the Administrative Officer and Chief of
Hospital.
4. The supply officer prepares and consolidates the Project Procurement Plan of the
hospital which is submitted to PEEMO for further verification and confirmation, so that
no item will be missed.
Policy GLD-0006: Management Review
Rationale: This will ensure quality, efficient, and reliable laboratory operations in support of
patient care and will introduce necessary changes for continuing quality improvements.
Purpose: To define specific indicators relevant in making definite plans and modifications in
the current laboratory practices.
Procedure:
1. The Pathologist initiates a quarterly management review with the Chief Medical
Technologist of each hospital.
2. The results of the review are recorded which is to be incorporated into the plan of the
following year.
16

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
3. The Chief Medical Technologist disseminates the results of the review to the entire
laboratory staff in their respective stations.
ORGANIZATIONAL STRUCTURE (Please see Annex A - Organizational Charts)
Reference: DOH QMS Manual, CVPH QMS Manual v. 2011
GROUP OF STANDARDS #2: RESOURCE MANAGEMENT
Policy GLD-0007: Human Resource Management
Rationale: The laboratory shall follow a system in the management of human resources in
accordance to the DOH requirements as per DOH DC 2013-0349.
Purpose: This will help in the compliance to the standards set by the DOH licensing to have
adequate manpower for an effective and efficient delivery of laboratory services.
Procedure:
1. In as much as possible, the laboratory follows the Standard Staffing Pattern of the
Department of Health.
a) The laboratory should be operational with an adequate number of qualified,
trained and competent personnel to meet the demands of service in compliance to
the DOH standards.
17

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
2. The Provincial Human Resource Management Development Office is responsible for

personnel recruitment and selection.
a) There is a procedure for hiring and selection of personnel that shall fit the staff to
his/her task and responsibilities.
3. Refer to the Provincial Human Resource Management Development Office for the specific Job
Description and Contracts.
Reference: DOH QMS Manual, CVPH QMS Manual v. 2011, DOH Circular on Standard Staffing
Pattern for Hospitals DOH DC 2013-0349
Policy GLD-0008: Responsibilities
Rationale: This will serve as a guide to the entire laboratory staff of their roles and functions
towards the delivery of quality diagnostic healthcare of the hospital to the community.
Purpose: To perform in accordance to the roles and responsibilities mentioned.
Scope: Pathologist, Chief Medical Technologist, Laboratory Staff
Pathologist/ Head, Laboratory Section

Status: Consultant, Casual
Qualifications: Certified by the Philippine Board of Pathology as a Clinical Pathologist
18

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Duties and responsibilities:

 As head of the laboratory.
 Ensure that a quality management system is in place.
 Conduct a regular schedule of supervisory visits in the hospitals to monitor and make
improvements in the strategic direction of the clinical laboratory in response to the
needs of the clients.
 Inform the Chief of Hospital of the laboratory operations.
 Monitor the full implementation of the Standards in the Quality Management Systems
for Clinical Laboratory operations.
 Ensure orderly and efficient workflow in the laboratory.
 Act as consultant to other physician.
 Address issues and concerns and formulates strategies in the improvement of
clinical laboratory.
Chief Medical Technologist

Status: Permanent
Qualifications: Board certified Medical Technologist by the Professional Regulation
Commission Duties and responsibilities:
 Assume responsibility for coordinating day to day activities of the laboratory.
 Prepare schedule of duties and vacation leave of the staff.
 Monitor monthly and annual reports for submission to the medical record section.
 Prepare and submit annual procurement of supplies to the supply in-charge.
 Attend executive committee meetings as representative of the department.
 Confer with the Pathologist and Chief of Hospital on matters related to the department.
 Represent the laboratory department in the internal and external functions.
 Perform Clinical Chemistry procedures and all other laboratory procedures done by the
Medical Technology Staff.
 Make requisition of laboratory supplies needed.
 Evaluate performance of Medical Technologist I and Laboratory Aide.
19

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
 Perform other related functions assigned by the Chief of Hospital.
Medical Technologist II / Medical Technology I:

Status: Contractual/Casual
Qualifications: Board certified Medical Technologist by the Professional Regulation Commission
 Receive specimen for laboratory examination.
 Extract and collect blood samples from out-patients and in-patients for Chemistry and
Hematology examinations.
 Process blood to derive plasma or serum fractions.
 Perform routine examinations in hematology, Clinical Microscopy and Parasitology.
 Accomplish report forms with results of examinations.
 Record all examinations done during the shift in the logbook.
 Endorse laboratory results to the nurse station.
 In the absence of the Laboratory Aide, wash glassware and other materials used during
the shift.
 Perform other related functions assigned by the supervisor.
Laboratory Aide
Status: Contractual/ Job order
Qualifications: College level
 Maintain the cleanliness and orderliness of the laboratory.
 Endorse laboratory results to the nurse station.
 Wash glassware and other apparatus used during the day.
 Deliver NBS sample for mailing to the post office.
 Make requisition of laboratory supplies needed and withdraw supplies from the
stockroom.
 Record daily statistics of examination done.
20

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
 Receive and process urine for microscopic examination.

 Perform DSSM smears and does AFB staining.
 Collect finger prick and venous blood sample (phlebotomist).
 Perform other tasks assigned by the Medical Technologist.
Reference: CVPH QMS Manual v.2011, PHRMDO Duties and Responsibilities
Policy GLD-0009: Personnel Orientation
Rationale: Newly hired laboratory staff shall undergo a one day orientation related to duties
and responsibilities, relevant hospital and laboratory policies and procedures. Furthermore, a
direct and detailed training for the performance of all duties and tasks is also a prerequisite.
Purpose: To make certain that the provincial government, hospital, and laboratory policies and
procedures will be adhered to and the incoming new laboratory staff is already acquainted with
the hospital and laboratory operations.
Scope: Chief Medical Technologist, New personnel
Procedure:
1. All newly hired employees will have a one day orientation/induction at the office of the
Provincial Human Resource Management Development Office.
2. Upon reporting to duty in their respective place of assignment/hospital, the Chief
Medical Technologist will hold another orientation/induction regarding the
21

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
administrative and specific technical standard procedures, policies and guidelines being
imposed and implemented in the hospital and laboratory.
Reference: CVPH QMS Manual v.2011, PHRMDO SOP
Policy GLD-0010: Work Schedule, Leave of Absence
Rationale: Policies and guidelines are formulated in accordance to the Provincial Human
Resource Management Development Office on the work schedule and filing of leave of absence.
All laboratory staff are to be oriented accordingly of their duty schedule as well as the
procedures in the application for leave of absence.
Purpose: This will serve as a guide for compliance of all laboratory staff.
Scope: All Laboratory personnel
Procedure:
Work Schedule
Work hours/Reporting time:
1. A schedule of duty for all laboratory personnel is made regularly and posted within the
laboratory area. A copy of the schedule will be submitted to the Administrative Office on the
3rd week before the scheduled month for approval.
2. Laboratory personnel must render eight hours in every shift or forty hours a week and
required to go on duty or extend duty hours as needed in the exigency of service.
22

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Staffing Hours:
Pathologist
Tuesdays: CVPH Maragusan, Wednesdays: CVPH Pantukan,
Thursdays: CVPH Montevista Fridays: PEEMO/PHO, Saturdays: CVPH Laak
Chief Medical Technologist/Section Head – 8:00 am to 5:00 pm
Medical Technologist Staff and Laboratory Aide II - 7:00 am to 3:00 pm,
3:00 to 11:00 pm,
11:00 pm to 7:00 am
Leave of absence
Emergency leave is considered as such when it is within the 8 hour notification period provided
it will not be less than two hours.
1. Vacation leave, Sick leave and Other leave privilege - (Refer to PHRMDO)
2. Any unscheduled and emergency leave of absence, it is the responsibility of the
absentee to find a reliever in lieu of his / her absence.
3. The absentee will notify the head of section the name of the reliever, time and date.

23

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0011 Staff Training and Development
Rationale: All staff shall undergo staff development and training program. Training is an
integral part in the efficient delivery of services in the laboratory. It equips employees with
newer sets of skills and makes them more productive.
Purpose: To enhance the skills of each member in the laboratory.
Scope: All laboratory staff
Procedure:
1. Participate in Continuing Programs on Education for staff development and training

initiated by the DOH, PHO and PEEMO, etc.
2. Skilled employees impart their knowledge to new ones.
3. Attend quarterly meetings of Medical Technologists from different hospitals in the
province to be updated on current laboratory activities/ procedures.
4. All training's will be scheduled by the PHRMDO through PEEMO (Provincial Economic
Enterprise Management Office).
5. Keep all proof of training's, certificates, memos and written reports.
Personnel Performance Appraisal and Promotion (Refer to PHRMDO)
Personnel Policies, Disciplines, Resignation and Termination (Refer to HRMDO)
Personnel Records (Refer to PHRMDO)

24

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0012 Staff Meetings
Rationale: Staff meetings shall be held regularly at least once a month. This will serve as an
avenue in disseminating information and instructions and solving problems on all aspects of
laboratory services.
Purpose: To maintain good communication and to resolve problems.
Procedure:
1. Once in every month the Pathologist will hold a conference with all the Chief Medical
Technologists from the four (4) CVPH hospitals. Current issues, new trends and
technologies are tackled for the continuing quality improvement of services. It is then
incorporated into the plan of the laboratory operations.
2. The Chief Medical Technologist will also conduct monthly meeting with all the
laboratory staff.
3. In cases wherein an immediate matter needs attention, the staff concerned is informed
immediately without waiting for the next scheduled meeting.
Policy GLD-0013 Sanctions and Violations

25

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Rationale: Violation of any aspect in the practice of laboratory services shall be grounds for
disciplinary action.
Purpose: To attain highest level of integrity and compliance with the standards of conduct.
Scope: Chief of Hospital, Administrative Officer, Executive Committee, Pathologist, Chief

Medical Technologist, all Laboratory Staff
Procedure:
1. Any violation/offense is documented by making an incident report.
2. Violation/offense is handled by the Chief Medical Technologist and referred to the
Pathologist. The case shall be evaluated fairly and with confidentiality if indicated.
3. All the laboratory issues are confined to the department on a case to case basis so as
not to compromise the credibility of the department.
4. The sanction of the offense is discussed by the Pathologist, Chief Medical
Technologist and the staff involved.
5. Violation/offense that involves other departments is discussed and resolved by the
concerned parties. Any unresolved issue is handled by the Executive
Committee/Grievance Committee.
Sanctions are as follows:
MINOR OFFENSE
First minor offense – Verbal warning
Second minor offense – Written notice
Third minor offense - Report to the COH
MAJOR OFFENSE
First major offense - Verbal Warning and written notice
26

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Second major offense – report to the COH

Third major offense - Reprimand for possible suspension/termination
Reference: CVPH QMS Manual v.2011
Policy GLD-0014 Physical Facilities
Rationale: Laboratory space and facilities shall conform to the standards set forth by the
Purpose: Compliance with the Department of Health Standards for licensing.
Scope: PEEMO, Engineering Department, Pathologist, Chief Medical Technologist
Adequate functional space for all laboratory activities.
 Work area is well ventilated, lighted, clean and safe.

 Size and facility set up should be in conformity with the Department Of Health licensing
requirements.
Facilities for personnel
 Toilet facilities.
 Staff area/rest room for basic catering and washing.
 Storage lockers for personal items.
27

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Facilities for patient
 Clean and comfortable collection area and the privacy of the patient is maintained.
 Patients are not permitted beyond the collection area.
Facilities for storage
 Adequate space for storage of glassware, supplies, records and equipment.

 Reagents and supplies are kept according to their use.
 Reagents that need specific storage condition like refrigeration is strictly observed.
 Chemicals/bio-hazard reagents are stored in a well-ventilated room at low
temperature, or as to manufacturer’s storage requirements.
Reference: DOH Licensing Assessment Tool
Policy GLD-0015 Equipment and Instruments
Rationale: The laboratory shall have an adequate number of operational equipment and
instruments required for the provision of services and as required by the licensing of the
Purpose: To ensure optimal operation of all equipment in the laboratory used in any aspect of
patient clinical testing.
Scope: Pathologist, Chief Medical Technologist, All laboratory staff, Bio medical/Maintenance
Engineer
28

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Lists of operational laboratory equipment
Clinical Chemistry Section
 Fully Automated chemistry analyzer

 Semi-automated chemistry analyzer
 Clinical centrifuge
 Reagent refrigerator
 Dry bath
 Automated Electrolyte machine
Hematology Section
 Electric Binocular Microscope

 Electric pipette shaker
 Blood Counter
 Semi-automated hematology analyzer
Clinical Microscopy

 Clinical Centrifuge
Parasitology and bacteriology (DSSM*)
29

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Immuno Serology
 Fully Automated Immunoserology Analyzer
Procedure:
1. Perform technical validation of all equipment and instruments used in the laboratory.
2. Comply with the system on procurement and acquisition of equipment and instruments
used in the laboratory.
3. During installation, check the equipment, calibrate and do performance validation
before it is put into use.
4. Only authorized and trained personnel are allowed to operate, calibrate, and do
periodic maintenance of all laboratory equipment and instruments.
5. Up-to-date instructions on the operation and maintenance of the equipment (including
manufacturer’s manuals) are readily available for the use by the appropriate laboratory
personnel.
6. Defective and non-functional equipment are taken out for service and clearly labeled as
out-of-service until it is being repaired and becomes functional.
Reference: User’s Manual of all available and functional equipment, CVPH QMS Manual v.2011
Policy GLD-0016 Contingency Plan
Rationale: It is important that continuous delivery of laboratory services will always be

sustained. Policies and procedures shall be established to recover hospital/laboratory
operations following a disruption in the delivery of services and are classified accordingly.
30

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Purpose: The Compostela Valley Provincial Hospital Contingency Plan applies to specific
functions, operations, and resources necessary to restore and resume its normal operations in
the laboratory.
The following objectives have been established for this plan to maximize the effectiveness of
contingency operations through an established plan that consists of the following phases:
Phase One: Preparedness

Preparedness refers to the Health Care Facility’s readiness to respond to any emergency. This
includes the specific strategies, plans and actions to respond to the occurrence of any hazard
such as exposure to hazardous substances, whether infectious, chemical and biological spillage
and other toxic substance.
Phase Two: Mitigation and Emergency Response

Mitigation refers to the systematic reduction in the extent of exposure to a risk and/or the
likelihood of its occurrence.
Emergency response refers to the activity carried out by a group of well-trained HCF worker
after activation of the HCF response team. This includes implementation of the emergency
management plan such as the activation of the incident command system relevant to exposure
to hazardous substance, whether infectious, chemical and biological spillage and toxic
substance.
Phase Three: Recovery

The recovery phase can be characterized as a return to normal situation that is similar to the
situation that existed prior to the incident. Recovery phase activities can include the following:
-Preparation of incident/accident report
-Inventory of used items
31

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
-Provision of new supplies to replace the used items

-Psychosocial debriefing of the injured person, as necessary
Scope: all Hospital staff, patients, watchers and other persons associated with it as identified in
this document.
Procedure:
1. Identify the critical activities, resources, and procedures needed to carry out operations
during prolonged interruptions to its normal operations.
2. Assign responsibilities to designated hospital staff, patients, watchers and other persons
associated with it as identified in this document.
3. Ensure coordination in contingency planning among the hospital staff.
Planning Principles
Contingency planning and emergency preparedness is a program of long-term development
activities whose goals are to strengthen the overall capacity and capability of the Healthcare
Facility to manage efficiently all types of emergency and to bring an orderly transition from
relief through recovery and back to sustain development.
The applicability of the plan is predicated on:
1. Funds allotted for emergencies involving hazardous wastes.
2. Number of responsible persons.
3. Information, education and communication
Rationale: Since laboratory results are very essential to aid physicians in the clinical
evaluation and management of diseases of our patients,
*the physical plant shall be regularly inspected and monitored,
32

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
*the laboratory equipment shall have regular preventive maintenance schedule to minimize
breakdown
*spare parts/materials shall also be managed and used appropriately
*inventory of all reagents and supplies are strictly observed for proper monitoring
…to make sure that there will be no disruption in the availability and delivery of laboratory
services.
Purpose: Establish a program on monitoring the physical plant, contingency on equipment

breakdown and preventive maintenance to ensure that all equipment, inventory of all reagents
and supplies, including spare parts/material are well managed and protected from failure or
unavailability.
Scope: Pathologist, Chief Medical Technologist, Laboratory Staff, Bio medical Engineer,
Supplier’s Technical Support
Procedure:
GLD-0016A Disruption of Laboratory Services due to problems in the Physical Facility
1. Do routine inspection and monitoring of physical plant and facilities .

2. Increase level of awareness of staff on maintenance of physical plant and facilities.
3. Document and record the process.
4. Identify problems and issues.
5. Discuss with staff and consult experts/authorized personnel for advice.
6. Resolve and implement action plans.
GLD-0016B Contingency Plan for Equipment Breakdown
7. Improve manpower capability for troubleshooting and maintenance of equipment.
33

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
8. Check, troubleshoot, identify the problem, discuss and consult with experts/authorized
personnel/technical support on how to repair and resolve the breakdown.
9. Inform the Chief Medical Technologist.
10. Refer to service manual of the equipment.
10. Secure replacement of spare parts if needed.
11. Back up machine and reagent should be available.
12. If problem is still unresolved, bring the equipment to the nearest certified service center for
repair.
13. Service call and contact supplier’s technical support or any certified service center as
problems arise.
14. Document details of breakdown including actions taken in the equipment maintenance
logbook.
GLD-0016C Preventive Maintenance
15. Do routine preventive and corrective measures whenever necessary.

16. Keep records.
GLD-0016D Reagents and Supplies

18. Observe proper inventory of all reagents and supplies.
19. Maintain buffer stocks and update Laboratory Supply-in-charge or the Chief Medical
Technologist.
20. When buffer levels have reached critical levels, inform Supply-in-charge/Chief Medical
Technologist for processing of procurement.
Reference: DOH Inspection and Monitoring Assessment Findings, User’s Manual, CVPH QMS
Manual v. 2011, DOH QMS Manual, CVPH Pantukan Contingency Plan
34

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0017 Reagents, Controls, Standards, Glassware and Supplies
Rationale: There shall be a sufficient quantity of reagents, controls, standards, glassware and
supplies.
Purpose: For efficient operation in the laboratory
Scope: Chief Medical Technologist, Supply Officer, Laboratory staff
Procedure:
1.Annual procurement of supplies is made based on the actual consumption and needs of the
laboratory to maintain adequate quantity of reagents and supplies.
2.Make a monthly inventory of all reagents and supplies.
3.Retain 25 – 30% of buffer stocks.
4.Accept and use only unexpired standards/reagents.
5.Requisition of all supplies will be on a monthly basis or as needed.
GROUP OF STANDARDS #3: SERVICE DELIVERY
35

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0018 Customer Needs and Requirements
Rationale: A citizen’s charter shall be posted in a conspicuous place to facilitate direction and
assistance to patients and other clients as required by Anti Red Tape Act.
Purpose: To expedite and systematize the delivery of laboratory services.
Scope: Laboratory staff, hospital staff, patients and watchers
Procedure:
1. Post the following information in the waiting area:

a. Laboratory services with corresponding fees.
b. Waiting time needed to complete the test.
c. Schematic diagram or flowchart from the period of the receipt of laboratory
request to the receipt of results.
d. Update and revise the above information as needed.
2. Distribute copies to the nursing units, emergency room, and outpatient departments,
physician’s offices, collection and billing section.
GENERAL GUIDELINES
PRE-EXAMINATION PHASE
A. REQUEST FORM (In and Out Patient Department)
36

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1. A pre-printed laboratory request form is available for the joint requesting of

urinalysis and fecal analysis and separate forms for hematology, clinical chemistry,
DSSM, and NBS collection.
Details on the request:
1.1 Requests for hematology, clinical chemistry, clinical microscopy,

serology/blood banking contain the following information:
Name of patient: Hospital Case Number:
Age:
Date of birth:
Sex:
Address:
Date of request:
Room/ward:
Impression:
Requesting Physician:
The specific test must be properly ticked on the space provided.
1.2. Request for DSSM contains the following information:

Age:
Date of birth:
Sex:
Date of request:
Room/ward:
Date of collection of the 2 specimen:
Diagnosis:
37

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1.3 Requests for NBS contains the following information:
Baby's last name: Hospital Case Number:

Mother's first name:
Birthday, Time of birth:
Place of delivery:
Name of attending personnel:
Date and time of collection:
Feeding:
Condition of the baby:
Address:
Age of gestation:
Contact numbers:
1.4 Requests for compatibility testing contains the following information:

Age:
Date of birth:
Sex:
Date of request:
Room/ward:
Type of blood component:
Number of units:
Blood type:
Clinical Diagnosis:
Status of Request:
38

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
2. All request forms must be accomplished with essential data and signed by the
Requesting Physician, NOD or OPD clerk.
3. Patients who avail of the lab services with doctors from outside the hospital must
bring with them the request from their doctor and proceed to the cashier’s office and
go directly to the laboratory.
4. In cases of limited availability of laboratory supplies and logistics, all tests to be done
will be in favor of the in-patients and ER patients only.
5. In cases of power supply failure, equipment breakdown and unavailability of
reagents, the Medical Technologist on duty is responsible to inform the Chief Medical
Technologist including the OPD, ER, and wards/nurse stations and all requests will
not be accepted.
6. The Chief Medical Technologist will inform the Pathologist, Administrative Officer,
and Chief of Hospital.
B. REQUEST FROM IN-PATIENT
1. Watchers for in-patient are not allowed to forward requests to the

laboratory for any examination.
2. Any verbal request for an examination by the patient himself during the
collection of blood sample will not be considered. All requests must be
written on the request form by the requesting Physician/NOD.
3. For elective surgery cases, requests for blood chemistry and compatibility
testing shall be forwarded to the laboratory at least a day prior to the
surgical procedures, except for stat cases. The nurse-on-duty should inform
the MOD regarding the status of the patient and the urgency of the result.
4. For patients who are surgical cases and came in for same day admission,
indicate in the request form “for CP Clearance”.
39

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
5. Request for Timed specimen collection / serial collection must be

forwarded at least 2 hours before the collection time and it should bear the
exact time of collection.
6. Requests for in-patients including follow-up, repeat, and stat cases must be
forwarded to the laboratory by the NOD/attendant and must be recorded
in the laboratory’s receiving logbook.
7. All in patients can avail of any laboratory services provided it is requested
by the Physician on duty.
C. TIME WHEN TO FORWARD BLOOD CHEMISTRY REQUESTS:
1. When no Medical Technologist on duty during night shift , requests

will be forwarded immediately upon the arrival of the morning shift
MTOD/ Laboratory Aide.
2. When an afternoon shift is present, requests will be forwarded to the
laboratory before the end of the afternoon shift.
3. It is the responsibility of the 3-11 shift nurse to double check and
forward blood chemistry request or any blood extraction before
11pm.
4. For new admission, the 11-7 shift nurse is responsible to forward the
request before 2am.
5. The nurse-on-duty prepares a separate request for send out
examinations.
D. STAT CASES
1. For stat requests, it is only the ROD/ Requesting Physician who is

allowed to assess as such.
2. STAT requests should have the signature of the Nurse Supervisor on
duty EXCEPT those requested in the emergency room.
40

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
3. No acceptance of stat request for DSSM procedures.

It is the priority of the Medical Technologist-on-duty to examine first the
STAT cases before any other routine tests (in and out-patients).
3. Time frame for the endorsement of results to the NOD/ROD by the
Medical Technologist will start after collection or receipt of the
sample.
CBC within 1 hr
Platelet count within 2 hrs
Hematocrit determination within 1hr
Hemoglobin determination within 1hr
BSMP within 2 hrs
CT,BT within 1 hr
Urinalysis within 30 minutes
Fecalysis within 30 minutes
Cross matching within 1hour and 30 minutes/per
bag.
E. REQUEST FROM OUT-PATIENT DEPARTMENT
1. In the event that there is only 1 (one) Medical Technologist on duty, all requests are
catered in the following order before an OPD request be done.
a. All STAT cases (regardless of the test requested).
b. Clinical Chemistry
c. Cross matching
d. DSSM from the previous day
2. Cut off time in accepting requests will be an hour before the scheduled end of shift.
3. Only OPD patients with payment or approval from authorized personnel/social
service will be accepted for examination. Promissory note is not accepted.
41

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
4. For CVPH Personnel and direct dependents, to avail of the discount of laboratory
services, it has to be approved by the authorized personnel. Guidelines for approval
refer to Social Service Manual.
F. COLLECTION
1. In cases wherein the patient, watcher, parent or guardian refused to submit in the
collection of blood specimen, the Medical Technologist on duty will not be held liable if the
patient will not be examined as requested by the Physician. The patient or watcher is then
requested to sign in the request form for the refusal.
2. Consent of the parent/guardian or the watcher must be consulted before any collection be
done to a minor patient. A “No” verbal consent means no collection.
3. Patient who is not on his/her bed during the time of collection with no valid reason will be
considered OOB (out of bed).
a) OOB will be written on the request form including the date and time the laboratory
staff went to the patient.
b) It is not the responsibility of the Medical Technologist on duty to look around or find
the said patient outside the room or ward specified in the request.
c) It is understood that the room/bed number specified in the request form of the patient
written by the NOD will be the basis in locating the patient.
d) The MTOD will return the request to the nurse station.
G. CRITERIA FOR REJECTION OF SAMPLE
Criteria for the Rejection of Sputum specimen:
 Specimen from OPD patient (OUT Patients are referred to RHU’s)

 Incomplete specimen ( less than 2 specimens )
42

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
 Presence of food particles or improperly collected specimen.
Criteria for the Rejection of Urine and Stool specimen:
 Insufficient / inadequate specimen (at least 5ml urine)

 Long – time standing improperly collected specimen
 Contaminated with foreign particles.
 Suspicious specimen-stool wrapped in tissue paper.
Criteria for the Rejection of Blood sample:
 Hemolyzed serum is not accepted for examination

 Insufficient amount of blood needed for specific test
 Contaminated sample
 Not properly labeled.
POST EXAMINATION PHASE
A. REPORTING OF RESULTS
1. All laboratory results shall be official, never relayed verbally and should remain
confidential.
2. The one who performs the examination or procedure must affix signature in the report
form for authenticity of the result.
3. The signature of the Pathologist must be affixed at the lower portion of the report form.
4. Use standard forms in reporting results.
B. RELEASING OF RESULTS
43

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
CRITICAL VALUES.
When in doubt with critical values especially very high/very low test results, deranged
differential count in the CBC, etc. may be first referred and consulted to the Pathologist prior to
release of official result. The Attending Physician should be notified immediately after a
validated CRITICAL VALUE test result.
Out-patients
Blood chemistry - not later than 3:00 pm on the same day of collection.
CBC, Platelet count, Hematocrit determination, urinalysis, fecalysis, blood typing, pregnancy
test, CTBT - within 1-3 hours from time of collection.
In-patients
1. DSSM (AFB) - within 48 hours from the submission of specimen to the lab.
2. Cross matching - not later than 6 hours.
3. Routine examination results will be forwarded to the NOD/Nurse station within the shift the
sample is collected or received.
4. Watchers are not allowed to follow up or get results from the laboratory.
5. When results need to be followed up, it should be done by the ROD/NOD only.
6. A demand for an immediate release of results from a “May Go Home” patient shall not be
allowed unless the patient is for referral to other hospital. Otherwise they have to wait when
the time the result is ready for release.
44

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0019 Issuance of Second Copy
Rationale: This is to eliminate errors in the transcription of results from the logbook to the
duplicates of the result. This will also take out unnecessary tasks to the Medical Technologists,
instead of analyzing the routine and even the stat samples; he/she will have to allocate time to
check on the logbooks instead of doing the more important processing of the tests received
during his/her tour of duty. A second copy of the report form will be released per request by
the ROD/NOD, PHIC Clerk, patient provided the procedures written below have been met.
Purpose: To regulate requisition of second copies.
Procedure:
For In And Out Patients: No second copies shall be issued by the laboratory for the sole
purpose of attaching the results to referral letters of patients to other hospitals. The original
copies released shall be the ones for reproduction by photocopy (c/o relatives) or be written in
the referral letter according to what is feasible to the referring physician.
1. The requesting party pays a second copy fee of 20pesos to the cashier on a per test basis for
out-patients. No fees are collected for the issuance of second copies for admitted patients.
For In-Patients:
Note: The standard protocol in the releasing of laboratory results for admitted patients is that
the laboratory results are being delivered to the wards and duly signed by the receiving nurse-
on-duty/ward staff-on-duty.
1. The person who misplaced the original laboratory result submits an explanation letter to the
laboratory followed by the request for the issuance of a second copy.
45

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
2. The laboratory department conducts an appropriate investigation to identify what really

transpired during the incident.
3. The laboratory staff on duty records the explanation letter submitted.
4. Pathologist reviews the logbook.
5. The laboratory staff gives a verbal warning to the person who submits an explanation letter
to the laboratory. If three explanation letters have been made by one person on different cases,
his/her attention shall be called.
6. The Pathologist/Chief Medical Technologist reports to the Administrative Office when one
person has repeatedly submitted an explanation letter for the fourth time.
For OUT-Patients:
1. Patient/immediate relative requests for the issuance of a second copy.
2. The laboratory staff checks the logbook, informs the requesting party to pay 20 pesos to the
cashier and what time the duplicate is available.
3. The laboratory staff prepares the duplicate of the test result at a time that will not
compromise laboratory operations, and within 24 hours from the time requested.
4. Claimant presents a valid ID and official receipt to the laboratory personnel.
5. Duplicate copies are released only to the patient/immediate relatives, unless a legitimate
reason is presented.
46

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
NOTE: The released second copy of laboratory result bears the mark “SECOND COPY” with
affixed signature of the transcribing laboratory staff to signify authenticity of the result but
does not necessarily mean that it was performed and examined by the undersigned.
Causes of delay or no release of results

 Sudden breakdown of semi-automated and automated equipment/machine
 Power interruption/failure
 Any other inevitable circumstances that need the attention of the Medical
Technologist on duty
 When a doubtful result occurs, however, another specimen will be collected for the
repeat examination without additional payment from the patient.
 If and when during the performance of the tests, an accident happened, like sample
slide broke, test tube cracked or leaked, washed-out specimen, pipette slipped and
other laboratory accidents. A second collection will be done to complete the test.
Approval of the patient must also be considered.
Deference: DOH QMS Manual, CVPH QMS Manual v.2011
Policy GLD-0020 Send Out and Received Samples
Rationale: Laboratory tests which are not available in the institution shall be sent out for
processing. The CVPH Laboratory is responsible for the collection and preparation of the
patient sample to be transported by the relative to the DOH licensed clinical laboratory of their
choice.
Purpose: Provide a systematic process flow for send out samples.
47

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Procedure:
CONDITIONS OF TRANSPORT FOR SEND OUT AND RECEIVED SAMPLES
Clinical chemistry and serology blood sample
1. Transport all blood and blood products only in box/ice chest with ice to maintain the
temperature of the sample. These boxes must have been verified as satisfactory for transport
and storage.
2. Place ice above the sample because cool air moves downwards.
3. Place a barrier in between the specimen and the ice.
For Serum or Plasma sample- separate first the specimen prior to sending out.
New Born Screening Sample
1. Air dry sample card. (do not use any form of heat)
2. Place in an envelope (do not use plastic specimen bag / cellophane).
3. Send the envelope to the Newborn Screening Laboratory.
Note: There is no Memorandum of Agreement between other laboratories in the provision of

their services for send out samples because it is the discretion of the patient to select referral
laboratory, provided it is accredited by the DOH.
Referring Laboratory
Requests from another hospital/clinic will be accepted provided that proper collection as well
as storage of the sample while in transit has been strictly observed and request is completely
48

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
filled up. Should there be doubts in the integrity of the sample received, a remarks may be
written in the signing out of result of such request.
Administrative Procedures (Refer to PART II of this Manual).
A “Manual of Administrative Procedures” has been formulated and contained the following:
1. Administrative Standard Operating Procedures (Quality Procedures)
2. Organizational Structure and Duties and responsibilities
3. Procedures on the acquisition, installation, calibration and validation of equipment
prior to use for patient care.
4. Procedure for preventive maintenance and repair of equipment.
5. Procedures for inventory control of glassware, reagents and supplies.
6. Procedure for Receipt of Specimen and requests.
7. Procedures for Reporting of results of Laboratory Examinations.
8. Procedures for immediate notification of Physicians of Critical Values.
The “Manual of Administrative Procedures” is reviewed / revised at least once a year.
Policy GLD-0021 Clinical Consultative Services
Rationale: The pathologist shall provide consultation on laboratory tests and further discuss
with the medical staff and other representative users of the service on the clinical significance,
the type of sample needed and the interpretation of results. Laboratory services shall be
identified and selected for the satisfaction of the patients and clinicians in accordance with the
applicable standards set forth by the DOH.
49

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Purpose: Help clinicians with the diagnosis for proper management, treatment and prognosis.
Scope: Pathologist, Medical Technologists, Medical Technicians, Laboratory aide, Clinicians,

Nurses/ Nursing aide, Patients,
Procedure:
1. The laboratory performs laboratory procedures as classified in the minimum

licensing requirements of the DOH.
2. The Pathologist / Section Head solicit suggestion and recommendation from the
Clinicians to upgrade laboratory services essential in the analysis and treatment of
diseases based on the technical and clinical developments. This shall be conducted at
least once each calendar year.
3. Pathologist and Section head will deliberate and assess the recommended additional
test.
4. Submits report to the Chief of Hospital for any action deemed necessary.
REPORTING AND RECORDING
1. Use standard forms in reporting results.
2. Maintain logbook in all data recording
Policy GLD-0022 Laboratory Charges
50

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Rationale: Current laboratory charges shall be computed according to the actual cost per test
and submitted to the provincial government for legislation and approval of tariff rates of the
laboratory services and shall be reviewed and updated regularly.
Purpose: Implement proper collection of laboratory charges based on the approved tariff.
Scope: Cashier, Laboratory and Nursing staff, Patients and watchers
Procedure:
1. The Medical technologist on duty examines all in-patients’ specimen with or without prior
payment. It is the prerogative of the patient to pay upon discharge.
2. Patient/Watcher pays OPD laboratory requests before going to the department for
examination including new, repeat and stat cases.
Note: A “no payment request” for an OPD patient will only be accepted if it has the notation of
the Social Worker and ROD as indigent or charity patient. (Refer to the OPD Nurse on duty for
instructions on how to socialize laboratory fees)
3. For paid requests, patients who refused to submit for sample collection, may process refund
at the cashier immediately, provided the original official receipt is presented.
Reference:DOH QMS Manual, CVPH QMS Manual v.2011
Policy GLD-0023 Point of Care Testing
Rationale: Point of Care testing is defined as a medical diagnostic testing performed outside
the clinical laboratory in close proximity to where the patient is receiving care. POCT is
51

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
typically performed by non-laboratory personnel and the results are used for clinical decision
making.
Purpose: Ensure that quality is maintained in using point of care testing kits even outside the
laboratory.
Scope: Licensed Medical Technologist, Laboratory Technicians, Laboratory Aide, Nurses
General Guidelines:
Collection, Reporting and Recording
1.Handling, collection and storage of point of care testing kits shall conform to the
manufacturer’s manual of operations.
2. Proper orientation on specimen collection, handling and storage should be based on the
policies and guidelines.
3. Collection of specimen can be done bedside and requires at least two nurses’ to ensure the
validity of the result.
4. All testing personnel should either put their initials or their legible signature on the result
form (and beside the result on the request form.)
5. All patient testing results must be reported to the physician and should be attached in the
patient’s chart.
6. All results must be endorsed to the laboratory for documentation with the names of the two
nurses who performed the test.
7.Reference range or normal value must be in the result form.
8. In case of abnormal results (above/below normal), the test should be repeated twice.
9. In case of limited availability of strips, all tests to be done will be in favor of the in- patients
and ER patients only.
10.If supply is unavailable all requests will not be accepted.
Procedure:
1. Collect patient’s sample at bedside.
52

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
2. Record all patient test results in the result form and encode in the corresponding logbooks.
3.Affix signature or initials of operator in the result form.
3. Inform attending physician of the result.
4. Attach result in the patient’s chart.
5. Indicate reference range or normal values in the result form .
6. Repeat testing for abnormal samples, if consistent with the previous result, release.
Supervision of Operators of POCT

The POCT Coordinator shall be responsible for the supervision of POCT device/instrument and
conducts the following:
1.Review quality control daily/weekly/monthly.
2.Check the competency of operators monthly.
3. Ensure that all operators are properly trained.
4. Proper orientation in performing/releasing of results and updated guidelines of the POCT.
Quality Control
1.Run at least once a day.
2.Results are recorded in quality control chart which will be reviewed by the Coordinator daily
or monthly.
3.Quality checks are done and trends are analyzed.
4.When the control results are outside of range, the results are referred to the department of
Pathology for resolution.
Reference: DOH Licensing Team Findings, Glucometer User’s Manual
GLD-0024 Turn Around Time
Rationale: There shall be a regular monitoring of performance indicators such as Turn Around
Time. Turn Around Time starts from the receipt of patient’s laboratory request and ends upon
53

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
the release of its result. On-time processing and release of laboratory services is essential in the
proper management of patients which is a key performance indicator of laboratory service.
Purpose: To comply laboratory test processing within the established turn around time of each
laboratory request performed to help clinicians in the efficient and effective management of
patients.
Scope: All Laboratory Staff
Procedure:
1. Record the time of each laboratory request received in the logbooks provided.
2. The sample and request is forwarded to its respective sections for processing.
3. The test result is forwarded to the laboratory releasing clerk for recording.
4. The Laboratory staff forwards the results to the respective stations (for in patients and ER
only, OPD results will be released in the laboratory).
5. Document the time released and signed by the receiving party (ward/nurse/patient) in the
releasing logbook.
Technical Procedures - Refer to Technical Manual of Procedures
A Manual of Technical Procedures is a document of all laboratory tests performed in the facility
to assure proper observance and compliance on the technicalities that will provide reliable and
accurate results.
54

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1. The laboratory procedures are documented in a “Manual of Technical Procedures” available

in each section of the laboratory.
2. This is placed in a visible and accessible area of that particular section in the laboratory.
GROUP OF STANDARDS #4: MONITORING PERFORMANCE
Policy GLD-0025 Quality Assurance System
Rationale: A quality control program is a set of procedures done in the laboratory for an
assurance of the reliability and conformity of the test results to standards.
Purpose: Ensure compliance to continuing quality improvement activities through active

participation in the Quality Assurance Program of the institution, both internal and external
quality assurance system
Procedure:
1. Determine the functional condition of automated and manual equipment.

2. Check the quality of the reagent, laboratory procedures, practices and
working area.
3. Check proficiency of the laboratory personnel.
4. Establish confidence on the part of the personnel when she reports results.
5. Identify errors and do prompt correction.
Advantage: Results received by the referring physician reflect the accuracy as to the true
55

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
value of the determination.
Policy GLD-0026 Internal Quality Control Program
Rationale: Internal Quality Control involves the in-house procedure for continuous monitoring
of operations and systematic day to day checking of the test results that will help the medical
technologist in deciding whether the test results performed for the day are reliable enough to
be released.
Purpose: To verify that for every batch of examinations, the intended quality of results is
achieved.
Scope: Pathologist, Chief Medical Technologist, All laboratory staff
Procedure:
1. Run appropriate control samples with every batch of examination.

2. Always review the results, and it should be within the reference range given.
3. When control results are within the reference range, record and release test results.
4. Make a quality control graph or Levy Jennings graph.
5. When control results are out of the reference range -
a. check the expiration, appearance, turbidity and the date of reconstitution of the
reagent.
b. Review procedures done.
c. Repeat examination of the sample collected, appearance, volume and color.
56

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
d. Check the performance of the machine and other equipment and glassware
being used.
e. Never release any result until values are within the reference range.
6. Eliminate the cause of the error.
7. Repeat the examination on the batch.
8. When the results of control samples of the repeat examination are within
control reference range, release the results.
Policy GLD-0027 External Quality Control Program
Rationale: The laboratory shall participate in External Quality Assessment Surveys. The
external quality control involves reference from other laboratories and participation in
National inter-laboratory sample and data exchange program.
Purpose: Through participation in the NEQAS activities, acceptable errors are discovered so
that corrective actions can be taken.
Scope: Pathologist, Chief Medical Technologist, Section Head/Rotating Medical Technologists
Procedure:
1. The laboratory applies and participates in the External Quality Assessment Surveys (EQAS)
conducted by the National Reference Laboratories (NRL) or the Philippine Council for Quality
Assurance in Clinical Laboratories (PCQACL).
Hematology
Blood Chemistry
Direct Smear for Sputum Microscopy (AFB)
57

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Parasitology
2. Perform appropriate tests on EQAS samples received.
3. The laboratory submits the results from EQAS samples to the organization running the EQAS.
4. Upon receipt of results of EQAS report, the evaluation of the performance of the laboratory is
reviewed.
5. Feedback is reported in an evaluation sheet and corrective actions are taken.
6. Participation in the NEQAS provides valuable data and information which:
 allow comparison of performance and results among different test sites
 provide early warning for systematic problems associated with kits or operations
 provide objective evidence of testing quality
 indicate areas that need improvement
 identify training needs.
EQA helps to assure customers, such as physicians, patients, and health authorities, that
the laboratory produce reliable results.
Provincial Level:
DSSM: All smears examined in the laboratory will be sent to the Provincial Health Office and
validated by the PHO Med. Tech. as to the correctness of the procedure done.
MALARIA: On-site evaluation is being done by the Provincial Malaria Coordinator. A set of
unknown slides are given to the Medical Technologist for examination at a given time. It will be
checked immediately and evaluated as to the correctness of the examination.
Regional Level:
A set of 20 slides are given to the Medical Technologist for examination. It will be evaluated by
a representative from the Regional Health Office as to its accuracy of the examination.
58

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Reference: DOH QMS Manual, CVPH QMS Manual v.2011, National Reference Laboratories for
EQAS in Hematology, Chemistry, Parasitology and Microbiology
Policy GLD-0028 Factors Affecting Quality of Technical Procedures Performed
Rationale: There are a lot of factors in the laboratory processes that affect the quality of
results. It is therefore clinically significant to be able to identify these, when we encounter
doubtful results.
Purpose: Identify possible sources of error in the laboratory procedures that affect the quality
of laboratory results. These will serve as basis in the formulation of corrective and preventive
measures.
Procedure:
REAGENT
1. Do not use expired reagent for it might alter laboratory results.

2. Properly label all containers as to content and inspect routinely for any signs of
deterioration.
3. Maintain the integrity of the label.
4. Avoid erasable markings, abbreviations, formula and codes in labeling containers.
5. Indicate date in the containers upon receipt and upon first opening.
6. Discard reagents that have changed in color or appearance.
7. Date chemicals when purchased and discard after predetermined maximum period of
storage.
59

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
EQUIPMENT
1. Daily monitor and record the temperature of the refrigerator used to store sample, standard
and reagents.
2. Ensure that the refrigerator is functioning properly.
3. Do appropriate corrective action if the temperature is not within acceptable limits.
4. Calibrate machine using a known control sample and standard in clinical chemistry.
5. Maintain a quality control chart to determine whether the automated equipment is properly
operating.
6. Connect all laboratory equipment to an auto voltage regulator to maintain the right electrical
supply needed and prevent errors in the results.
7. Calibrate all laboratory equipment and maintain functional conditions.
METHODS AND PROCEDURES
Use Standard Operating Procedures for routine technical and general activity to ensure that no
significant deviation from the procedures will occur. (Manual of Standards on Quality
Management Systems in the Clinical Laboratory, SOP Manual, Technical Procedures Manual)
COLLECTION AND STORAGE OF SPECIMEN
Strictly observe proper handling, collection and storage of specimen must in accordance to the
standard operating procedures. (Manual of Standards on Quality Management Systems in the
Clinical Laboratory, Technical Procedures Manual)
LABORATORY PERSONNEL
1. Properly trained technologists and technicians perform the tasks.

60

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
2. Avoid frequent personnel turn-over.

3. Maintain proportionate rate of workers to workloads.
4. Comply with the standard staffing pattern of the Department of Health.
REPORTING AND RECORDING
1. Double check test results before releasing reports.

2. Write legibly when reporting results.
3. Use standard forms.
4. Maintain logbook in all data recording.
GROUP OF STANDARDS No.5: QUALITY IMPROVEMENT ACTIVITIES
Policy GLD-0029 Continuing Quality Improvement
Rationale: The clinical laboratory shall establish a system for managing continuing quality
improvement activities. The over-all objective of Continuing Quality Improvement System is to
design, implement and maintain Quality Assurance in the Laboratory.
61

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Purpose: Improvement on the quality of laboratory test results and practices.
Scope: Pathologist, Medical Technologists, Medical Technicians, Laboratory aide
Procedure:
1. Document plan for quality improvement which includes policies and procedures for
identifying problems or poor delivery of service.
2. Plan for quality improvement in identifying problems, problem solving and primary
preventive measures are discussed during the monthly meetings of the Chief Medical
Technologist with the Pathologist.
3. Identify problems / indicators (personnel, equipment, physical set up, supplies and
procedures) of poor delivery of service.
4. Keep records of complaints and negative customer feedback.
5. Report to the Chief of Hospital the records of complaints and negative comments such
as the patient satisfaction survey forms answered by the patients.
6. Resolve any complaint during the Executive Committee Meeting.
7. Monitor indicators of laboratory performance.
8. Develop and implement a system for continuing quality improvement.
9. Designate a Quality Improvement Committee or Team to perform Quality Improvement
studies (problem-solving).
A. Delegate a designated staff to attend appropriate training in Quality
Improvement methodology.
B. The QI team undertake QI studies to continually improve the quality of
laboratory services.
C. The QI team submit its recommendations for the improvement of services to
Management.
D. The Management implements the approved recommendations of the QI team for
the improvement of services.
E. The QI team monitor the implementation of the approved recommendations
through appropriate indicators.
62

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
F. The QI team record and analyze the monitoring data on indicators and submits
recommendations on successful corrective measures.
G. The clinical laboratory management review and take the necessary action for the
institutionalization of successful corrective measures.
GROUP OF STANDARDS No.6: INFORMATION MANAGEMENT
Policy GLD-0030 Information Systems
Rationale: The laboratory shall develop, establish and implement a system of information
dissemination and communication to ensure customer satisfaction to clients.
Purpose: Promote customer satisfaction through proper communication and information

dissemination of the service capabilities and workflow of the laboratory activities.
Scope: All laboratory staff, patients, watchers
Procedure:
1. Observe courtesy to all patients.

2. Post a list of services available, flowchart of activities, and turn-around time in a visible area
of the hospital and laboratory premises.
3. Distribute Patient Satisfaction Survey form to the patients.
4. Do regular review of the patient satisfaction survey forms.
63

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
5. Take appropriate actions from the salient data provided in the survey.
Policy GLD-0031 External and Internal Communication
Rationale: The laboratory shall establish, implement and monitor a system on external and
internal communication.
Purpose: To ensure appropriate and effective external and internal communication.
Scope: Pathologist, Chief Medical Technologist, All Laboratory staff
Procedure:
1. External Communication
- For any concern that needs attention from another section within the agency, inform
the department head.
- The Section/Department Head calls the attention of the involved party for a discussion.
- The Department/Section Head together with the involved parties discuss and resolve the
issue.
- Refer to the Administrative Office/Chief of Hospital for further assistance if needed, to settle
the
issue.
2. Internal Communication
- Report to the Chief Medical Technologist for matters that need attention in relation to
laboratory operations.
- Chief Medical Technologist conducts investigation and settle the issue.
- Refer to the Pathologist for further assistance if needed, to address the issue.
64

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Policy GLD-0032 Document and Record Control
Rationale: There shall be a system for the management and control of laboratory forms, as
well as policies and procedures of all laboratory documents and records shall also be in place.
Purpose: To have a systematic approach in the management of all laboratory documents and
record control.
Scope: Pathologist, Chief Medical Technologist, Document Control Custodian, All laboratory
staff
Procedure:
Laboratory Forms
1. Formulate, prepare draft and submit for approval of new laboratory forms:
a. Present a proposed draft of the laboratory form to the entire laboratory staff.
b. Get the consensus of the department as to comments and suggestions of the
proposal.
c. Present the proposed laboratory form in a meeting with the Chief Medical
Technologists and the Pathologist.
d. Finalize the proposed laboratory form for approval.
e. The Head of the laboratory recommends to the COH the new laboratory form.
f. Submit the new laboratory form to the COH for final approval and circulation.
2. Review, revise, and delete obsolete forms.
a. Conduct review, revision and deletion of laboratory forms as warranted.
65

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
b. Discuss in the regular monthly meeting of the Chief Medical Technologists with
the Pathologist regarding the proposed changes in the laboratory forms.
Document and Record Control
1. Appoint a document control custodian who is responsible for the implementation of the
procedures for documents and forms.
2. The Chief Medical Technologist initiates the conduct of annual review and revision of all
policies and procedures.
a. A copy of the 3-part Laboratory Manual is available and placed in a prominent
and secure area in the laboratory.
Part I: Manual of Standards on Quality Management Systems in the Clinical
Laboratory
Part II: Administrative Procedures (Standard Operating Procedures)
Part III: Technical Procedures
b. Every newly hired laboratory staff is required to read and orient
herself/himself of this 3-part Laboratory Manual, and obliged to follow what is
in the manual.
3. Retention, storage and security of documents, forms and records.
c. Filled up laboratory request forms are kept for two years.
d. Logbooks are retained for 10 years.
e. Unclaimed patient result forms are kept for 1 month.
f. All documents and forms are organized and placed securely in the storage area
of the laboratory
Policy GLD-0032 Laboratory Information System
66

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Rationale: The laboratory shall establish a Laboratory Information System and become fully
operational in 2017. This is a computer program that process, store and manage data from all
stages of laboratory processes and tests. This will transmit information obtained from patients
as it interconnects with the Hospital Information System so that all other hospital processes
relevant to the laboratory will be accessed.
Purpose: Facilitate faster workflow process and tracking with the interconnection of patients
data and laboratory process in the computerized system.
Scope: All laboratory staff, Patients, Watchers
Procedure:
1. Request for Laboratory Examination (Refer to Part II Administrative Manual - Standard

Operating Procedure)
2. Delivery of Reports of Laboratory Examinations (Refer to Part II Administrative Manual

– Standard Operating Procedure)
3. Workload Report and other Statistical Reports
a. Make a daily census of laboratory tests.

b. Consolidate the reports monthly.
c. Submit to the Medical Records.
67

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
GROUP OF STANDARDS #7: ENVIRONMENTAL MANAGEMENT AND BIOSAFETY
Policy GLD-0034 Housekeeping and Working Conditions
Rationale: The clinical laboratory shall formulate a system of good housekeeping and safe
working conditions to ensure that the environment, as well as the patients, staff, and visitors
are free of any biohazard risks.
Purpose: To shield healthcare workers, patients, watchers and the environment from the
potential biohazards of hospital/laboratory risks.
Procedure:
Housekeeping
1. Keep workplace clean and tidy with the use of disinfectant available in the facility.
2. Clean up spills, broken equipment, floods and general clutter promptly. This especially
applies to the area around any electrical equipment.
3. Sweep and mop frequently and as needed.
4. For spills on the floor, flood the area with disinfectant, mop up solution, then clean with
detergent and water.
5. Disinfect working table every after work.
6. For soiled items, disinfect before disposal.
Working Condition
68

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1. The Chief Medical Technologist conducts regular review of procedures for safe work
practices of staff.
2. Determine the potential hazards and appropriate safety precautions before beginning any
new operation or procedure.
3. Laboratory staff wears appropriate personal protective clothing and equipment when
dealing with potentially infectious and hazardous material.
4. Be alert to unsafe conditions and actions such as the equipment being used and procedures
to be done.
5. Call attention to any unsafe conditions and actions so that corrections can be made as soon as
possible.
Policy GLD-0035 Preventive Safety Measures
Rationale: Know the safety rules and procedures within the laboratory for these will serve as
the best precautionary measure to safe working conditions.
Purpose: To avoid biohazard risks and infections related to laboratory operations.
Scope: All Laboratory Staff, Patients
Procedure:
1. Always use gloves when handling lancets and needles that are exposed to blood and other
body fluids.
2. Advice patient not to pull his/her hand during the collection of blood to prevent accident
pricks and sticks.
69

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
3. Do not put back the cap of the lancet or needle.

4. Do not bend or break the lancet and needle by hand.
5. Learn the right way to handle and throw away lancets, needles and other sharp objects.
6. Do not overfill sharp containers.
7. Never re-sheath lancets and needles.
8. Be aware of the main risk posed by lancet pricks and needle sticks injuries to workers.
Blood-borne viruses concerned are Hepatitis B, Hepatitis C, Human immunodeficiency virus,
Syphilis (VDRL)
Policy GLD-0035 Aseptic Technique
Rationale: Aseptic technique is employed to maximize and maintain the absence of pathogenic
organisms so as to protect the worker from diseases and prevent the possible spread of
infection.
Purpose: Strict compliance to aseptic techniques prevents contamination, transmission and

spread of infectious diseases from pathogens in the laboratory set up.
Scope: All Laboratory staff
Procedure:
1. Use smearing or fume hoods when performing DSSM.

2. Use Personal Protective Equipment like face mask and gloves.
70

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
3. Change and discard used gloves if contaminated or damaged and after completion of
specimen processing.
4. Minimize formation of droplets, spatters, splashes and spills.
5. Avoid contaminating the outside of any sample container.
6. Wash hands frequently before and after performing laboratory tests.
7. Observe proper hand washing.
a. Wet hands and apply soap.
b. Palm to palm, fingers interface.
c. Right palm, over left, left over right.
d. Back fingers to opposing fingers interlocked.
e. Rotational rubbing of right thumb clasp in left palm and vice versa.
f. Rotational rubbing backwards and forwards with top of fingers and thumb of
right hand in left.
g. Take note that no dirt is left under the fingernails, then rinse with water.
h. Wipe hand with clean towel to dry.
Reference; DOH QMS Manual, CVPH QMS Manual v.2011
Policy GLD-0037 Orderliness and Labeling
Rationale: The laboratory shall sort, arrange, label and store all laboratory materials and
documents utilized in the various sections, according to category, manufacturer’s storage
requirements, order, frequency of use, etc. In order to establish a well-organized system of
storage and retrieval of materials and records
Purpose: This is to facilitate easy and fast retrieval of materials and documents in the
laboratory.
71

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1. Store all materials used such as documents, records, patients' sample, glassware, reagents
and supplies according to category, manufacturer’s storage requirements, order and frequency
of use, etc.
2. Label reagents with the date it is opened or reconstituted.
3. Label sample with name of the patient and date of collection to facilitate fast identification
storage.
4. Handling of patient samples at all stages within the laboratory including phlebotomy,
labeling, sample transport, subsampling, analytical procedures and disposal shall be made
available at all workstations and given to all staff. (Refer to Group of Standards No.3 Service
Delivery General Guidelines)
5. Place warning signs, labels and devices on various hazards are placed appropriately on
conspicuous areas.
Policy GLD-0038 Waste Management
Rationale: The laboratory shall develop, establish and implement a system for proper waste
management. The hazardous materials and waste management plan are the mechanism for
interaction and supervision for regulating pathological, reactive and infectious wastes.
Purpose: Avoid risk of infections due to improper handling of laboratory waste.
Scope: All laboratory personnel
Procedure:
72

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1. All laboratory personnel will attend seminars, training's and workshops on waste
management.
2. General waste do not pose special handling or hazard to humans and the environment.
a. Provide waste receptacles for easy and proper segregation.
b. Black color-coded cellophane or container for non-infectious dry waste (such as
paper, boxes, bottles, plastics, packaging materials, styrofoam, candy wrapper)
c. General wastes are taken by the municipal garbage truck to the LGU landfill.
3. In the identification and segregation of waste containers, mark or label waste

containers according to segregation if color coding is not available.
4. Treat all laboratory waste as a biologic hazard before they are thrown in the trash.
5. Identify materials that need special handling so that prescribed sanitary procedures are
done to minimize the risk of unsafe and improper disposal.
a. Microscope Slides: Soak used slides of Urinalysis and Fecalysis in a container
with liquid disinfectant (1:10 dilution Chlorox) before disposal.
b. Lancets, needles and capillary tubes: Collect all used lancets, needles and
capillary tubes in a puncture proof disposal containers with lid/ caps. Each
container must contain liquid disinfectant (1:10 dilution Chlorox).
c. Applicator sticks: Soak applicator sticks used in smearing stool and sputum
specimen in a container with disinfectant (1:10 dilution Chlorox) before
disposal.
6. Infectious Sample/Pathological wastes: Place all other infectious/pathological laboratory

wastes in a separate bin. Bins will be collected by the utility worker everyday and disposed
in waste disposal vault located at the rear part of the hospital.
73

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
7. The laboratory implements a procedure for the safe handling of hazardous liquids and
chemicals used in the laboratory.
a) Treat and dispose liquid waste in accordance with the Environmental Compliance of
the Department of Environment and Natural Resources.
b) Observe maximum attention and care in the completion of any laboratory procedure
when a certain corrosive, combustible or flammable chemical is being used.
c) Safeguard worker from any accidental spillage.
Reference: DOH QMS Manual, CVPH QMS Manual v.2011, PCO Notes
Policy GLD-0038 Chemical Safety and Storage
Rationale: Chemicals are considered biohazard and extremely dangerous when not handled
and stored properly. Property of each chemical shall be known to the user and stored according
to the manufacturer’s standard handling procedures. These can also be stored in a well-
ventilated room at low temperature.
Purpose: Knowledge on the chemical property of each material helps prevent chemical-related
accidents, explosions and fire.
Scope: All Laboratory Staff, Supplier of Reagents/Chemicals
Procedure:
1. The supplier of reagents/chemicals in the laboratory must provide a copy of the MSDS
(Material Safety Data Sheet) of all the reagents/chemicals used in the laboratory.
74

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
2. Each laboratory staff must be familiar with the individual property of all the
reagents/chemicals used in the laboratory as provided by the supplier.
General Guidelines For Flammable & Combustible Liquids
 Do not store in conventional refrigerators.

 Never place near an open fire.
 Store in lower places to prevent accidental spillage
 Label all containers properly.
 Store only minimum amounts of flammable liquids in the laboratory.
Chemical Safety and Material Safety Data Sheets

1. Conducting chemical inventories helps laboratory staff keep track of chemicals and
prevents unnecessary chemical purchases. Personnel must inventory all chemicals
found in the laboratory and specify the maximum amount normally found at this
location. Inventories must be reviewed and updated annually and updated
whenever there are significant changes in your chemical inventory.
While conducting your inventory, examine containers for deterioration and
integrity. Chemicals that are expired, in bad shape or no longer needed must be
managed as hazardous chemical waste and must be disposed of accordingly.
All employees must have the right to ready access of MSDSs for the chemicals they
are working with.
2. Material Safety Data Sheets (MSDS)
MSDSs are documents that describe the physical and health hazards of chemicals.
75

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Laboratory staff must have a ready access to MSDSs for all chemicals used in the
laboratory. All personnel using the chemicals or working around the chemicals
must be able to demonstrate that they can retrieve the MSDSs for a chemical within
a short period (such as within five minutes). Paper copies for MSDSs must be
maintained for the hazardous chemicals most likely to spill and/or cause injury to
someone. Having an MSDSs immediately available when someone has been exposed
to a hazardous chemical helps emergency personnel decide how to respond and
treat that person.
A. Chemical Procurement
Most chemical products can be purchased without restriction from the manufacturer.
The following rules and guidelines apply to some chemicals.
1. Hazardous Chemicals
Order only the amount of chemicals needed. Do not stockpile chemicals. Chemicals
that are expired and/or appear to be no longer useful are considered hazardous
waste.
If possible, hazardous chemicals should be received directly by the laboratory.
When the package is opened, it should be verified that the proper chemical was
sent, that the container is intact, and that the label is legible. The date of receipt
should be written on the container’s label.
B. Chemical Storage
1. Segregate Incompatibles
To avoid dangerous interactions among incompatible chemicals, chemicals should
be physically segregated by checking the MSDSs.
76

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Chemical Use Category Segregation Table

Acids Segregate acids from active metals such as sodium, potassium,
magnesium, etc.
Segregate oxidizing acids from organic acids such as glacial acetic acid
and from flammable and combustible materials, such as cardboard
boxes.
Segregate acids from chemicals which could generate toxic or
flammable gases upon contact, such as sodium cyanide, iron sulfide,
calcium carbide, etc.
Segregate acids from bases.
Bases Segregate bases from acids, metals, explosives, organic peroxides and
easily ignitable materials.
Flammables Store in approved safety cans or cabinets. Segregate from oxidizing
acids and oxidizers. Keep away from any source of ignition: heat,
sparks, or open flames.
Oxidizers Store in a cool dry place. Keep away from combustible and flammable
materials. Keep away from reducing agents such as zinc, alkali metals,
and formic acid.
Cyanides Segregate from acids and oxidizers.
Water Reactive Store in a cool dry place away from any water source. Have a Class D
Chemicals fire extinguisher available in case of fire.
Light Sensitive Store in amber bottles in a cool, dry, dark place.
77

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Chemicals
Peroxidizable Store in airtight containers in a dark and cool place. Most Peroxidizable
Chemicals compounds are flammable and should be stored in a flammable liquid
storage cabinet or room. Label containers with receiving, and opening
dates. Periodically test for the presence of peroxides. Discard before
exceeding expiration date.
Toxic Chemicals Store according to the nature of the chemical, using appropriate
security where necessary.
Nitrated Nitrated compounds can be considered explosive; special care and
Compounds handling may be required.
2. General Chemical Storage Guidelines

Follow good storage practices no matter wherever the chemicals are stored (i.e.
cabinets, refrigerators, or shelves).
a. Good Storage Practices
1) Cabinets – Whenever practical, chemicals should be stored in approved
cabinets.
2) Shelves – All shelves should be securely anchored to walls and fitted with 2-
inch lipped edges or enclosed in cabinets with latched doors.
3) Heavy Objects – Heavy objects should be stored on lower shelves.
4) Corrosives – Corrosives should be stored only below eye level.
78

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
5) Secondary Containment – When practical, chemicals in the same hazard

class should be stored in secondary containment tubs that are chemically
resistant and unbreakable.
6) Chemical Waste – Store chemical wastes following the same guidelines as
above. Original container labels must be obliterated and the containers must
be labeled with a completed hazardous waste label. Secondary containment
is required if chemical waste is stored near a floor drain or other drain to
sanitary sewer. Avoid mixing incompatible waste materials. Serious
laboratory accidents, such as death can occur if incompatible waste
materials are mixed.
b. Incorrect Storage Practices
1) Acids – Do not store inorganic acids with flammable solvents. Contact of a
concentrated oxidizing acid with a flammable solvent may result in a fire or an
explosion.
2) Heat/Direct Sunlight – Exposure of chemicals to heat or direct sunlight should
be avoided. Even if the chemical is stable, plastic containers have degraded
from sunlight.
3) Storage on Floors, on Bench Tops or in Fume Hoods – Chemicals should not be
stored on the floor or clutter bench tops. Storing chemicals in a fume hood will
compromise the effectiveness of the hood.
4) Storage Height – Do not store heavy containers on the floor or above waist
level. Do not store corrosives above eye level. Do not store items closer than
18 inches from the ceiling if the area has fire sprinklers.
3. Chemical Storage Quantity Limits
79

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
a. There must be a quantity limit for each hazardous material. This can be aided by
maintaining an accurate chemical inventory.
Example of Hazardous Material Quantity Limits
Material Quantity Limits
Flammable Liquids 10 gallons
Liquid Corrosives 10 gallons
Toxics 6 gallons
Chemistry Reagents Not more than 2 kits
Other liquid analytical reagents 3 gallons
C. Chemical Labeling
1. Original Container
The label on an original container must be legible, be written in English and include
the chemical name, the hazard warnings and the manufacturer’s name and address.
If a container label becomes illegible during use, you must affix an extra copy of the
original container label or a completed generic label.
Chemicals that form peroxides or other hazardous products when exposed to air
must be labeled with the date the container was first opened.
2. Transfer to Secondary Container
Chemicals are often transferred from the original container to another container.
The secondary container must be labeled with the chemical name (which should be
80

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
the same name as on the MSDS) and hazard warnings. The label should also include
the initials of the person who made the transfer and the date of the transfer.
3. Labeling Instructions
A container that is too small for labels; installed into a process but routinely
opened; or would become unusable for its intended purpose if labeled must still be
identified unless the container will not be used beyond the end of the day. Use any
labeling method that enables employees and visitors from other agencies such as
the fire department to identify the chemicals and their hazards. Examples include a
sign identifying the materials and their hazards and color or numeric codes or
location of the chemicals and hazards.
Handwritten Label
The container’s contents must be identified and the chemical’s hazards must be
described. Also, the name and date associated with the container to help with
chemical management.
Example:
ACETONE
Flammable
Skin, eye, and respiratory tract
irritant
CNS depressant
February 10, 2010
81

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
4. Labeling Wastes
Waste containers must be labeled following guidelines for hazardous chemical
waste. If reusing a container to hold waste, the container must be compatible and
appropriate for the waste. Completely deface all old labels.
D. Transporting Chemicals
Avoid transporting chemical containers which may have contamination on the outside
(i.e., avoid the need to wear gloves or other PPE while transporting chemicals). If gloves
must be worn, either be escorted by another person to open and close doors or remove
the glove from one hand and use it to open doors while holding the chemical in the
other hand.
1. Transporting between Floors and Buildings
Do not transport chemicals in your own personal vehicle.
a. Moving a Single Chemical
1) The person doing the moving must be trained in the hazards of the chemical
and know what to do in the event of a spill of that chemical.
2) Chemical bottles should be labeled, securely capped and placed in a bottle
carrier.
3) Chemical containers that are glass and do not have closing caps or handles
should be placed in bottle carriers or larger containers and surrounded by
vermiculite or other absorbent material.
b. Moving Multiple Chemicals
82

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
1) The person doing the moving must be trained in the hazards of the
chemicals and what to do in the event of a spill of those chemicals. The
person must also have a spill kit that can handle the spill of those chemicals.
2) Chemicals should be segregated and packaged by hazard class in a larger
container.
3) Containers used to transport multiple chemicals should be lined with an
absorbent material such as vermiculite or other absorbent material to
cushion the load and absorb and contain any spills.
4) Carts used to move chemicals should be stable under the load and have
wheels large enough to negotiate uneven surfaces without tipping or
stopping suddenly.
E. Special Chemical Hazards
Personnel need to take special precautions with chemicals that are reactive, explosive,
highly toxic, or experimental.
1. Reactive Chemicals
A chemical is reactive if it has the capability to undergo violent chemical change,
such as explosions or production of toxic fumes, in certain situations. Purchase and
use these chemicals in small quantities or find a suitable alternative. Take extreme
care when handling and storing these compounds.
a. Compounds That Generate Toxic Gases
Some compounds that contain sulfide or that have a cyanide (-CN) functional
group can generate toxic gases in sufficient quantities to present a danger to
83

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
human health when combined with other compounds, such as hydrochloric

acid.
Toxic Gas Generators
Copper (II) cyanide Mercury (II) Sodium
cyanide cyanoborohydride
1,4 Dicyanobutane
Methyl sulfide Sodium dicyanoaurate (I)
Diethyl cyanophosphonate
Octyl cyanide Sodium sulfide
Fumaryl chloride
Potassium cyanide Toluene diisocyanate
Heptyl cyanide
Sodium cyanide
b. Oxidizers
Oxidizers are chemicals that initiate or promote combustion of other materials.
Oxidizing agents include halogenated inorganics, nitrates, chromates,
persulfates and peroxides.
Oxidizers
Ammonium dichromate Lithium perchlorate Potassium chlorate
Ammonium nitrate Nitric acid Potassium
permanganate
Chlorine (liquid or gas) Nitric oxide
Sodium nitrate
Chromic acid Oxygen (liquid or
gas) Strontium nitrate
Guanidine nitrate
84

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Perchloric acid Sulfuric acid
c. Chemicals That May Polymerize

Polymerization is a chemical reaction in which small molecules combine to form
larger molecules. Polymerization can be hazardous when the reaction releases
large amounts of energy or drastically increases the volume of the chemical.
Chemicals that May Polymerize
Acrylic acid Isopropenyl acetate Vinyl bromide
Acrylonitrile Styrene 2-Vinylpyridine
1,3-Butadiene
d. Water Reactive Chemicals

Water reactive chemicals react violently with water to release a gas that is
either flammable or presents a health hazard. Alkali metals, many
organimetallic compounds, and some hydrides react with water to produce heat
and flammable hydrogen gas.
Water Reactive Chemicals

Alpha-toluenesulfonyl Oxalyl chloride Sodium metal
85

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
fluoride
Antimony trichloride Phophorus Tert- Butyllithium
pentachloride
Calcium hydride Titanium (IV) chloride
Phosphorus
Hydrobromic acid Trimethylchlorosilane
pentasulfide
Lithium aluminum
Phosphoryl chloride
hydride
Potassium metal
2. Potentially Explosive Chemicals

An explosive chemical, when subjected to heat, impact, friction, electric or chemical
charges, can produce a sudden, quick release of pressure, gas, and heat. When
detonated in an uncontrolled or unexpected circumstance, explosives can result in
serious bodily harm or extensive property damage. Shock sensitive explosives are
known to detonate even when bumped or handled normally. Common potentially
explosive chemicals are:
a. Nitrated Compounds
Nitrated organics and inorganics constitute the largest class of compounds that
are explosive when dehydrated.
Purchase nitrated compounds in small quantities. Do not break the seal on the
cap until the chemical is needed.
When you purchase a nitrated compound, weigh the container and note the
weight on the bottle. Prior to subsequent use, weigh the container again. If the
86

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
container weighs less, add an appropriate solvent to replace the weight lost.
After the reagent is opened and an aliquot is taken, again note the weight of the
container. Visually inspect the container for problems prior to each use and
wipe down the bottleneck, cap, and threads with a wet cloth before resealing.
Nitrated Compounds
Diphenyl hydrazine 3-Nitrotoluene Trinitrophenol (Picric
acid)
Nitrocellulose Trinitrobenzene
Trinitrotoluene
Picric acid is a nitrated compound usually purchased as a solid wet with 10%
water. Extreme heat, blasting cap, or electric charge can detonate picric acid. It
becomes highly unstable if allowed to dehydrate. When wet, picric acid is an
orange colored, compact crystalline solid with the consistency of lumpy sand.
When dry, picric acid is a crystalline solid with visible air pockets below the
surface.
Picric acid will readily form explosive metal picrates. These metal picrates are
extremely shock sensitive and will detonate with the slightest movement or
vibration. Do not allow picric acid to contact metal that is readily oxidized or be
stored in a container with a metal cap. Lead, iron and copper metals are
particularly dangerous, due to metallic picrate formation.
b. Organic Peroxide-Forming Solvents
87

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Organic peroxide-forming solvents become shock sensitive when allowed to

oxidize and form appreciable quantities of explosive peroxides. Most of these
solvents are also flammable. Most peroxide forming solvents are colorless,
mobile liquids. Oxidation can occur when the solvent is exposed to atmospheric
oxygen. This reaction is catalyzed by light as well as by temperature and
pressure changes.
Organic Peroxide Forming Solvents
Severe Hazard High Hazard Moderate Hazard
3 months 6 months 12 months
Once exposed to oxygen, Once exposed to Once exposed to

rapidly oxidizes forming oxygen, oxidizes at a oxygen, slowly oxidizes
explosive peroxides. moderate rate forming forming explosive
explosive peroxides. peroxides.
Diisopropyl ether Acetaldehyde Ethylene glycol ethers
Divinylacetylene Cumene Ethyl vinyl ketone
Potassium amide Cyclohexene Oleyl alcohol
Potassium metal Cyclopentene Tetrabutylammonium

fluoride
Sodium amide Diethyl ether
Thorium nitate
Vinylidene dichloride Di-n-propyl ether
88

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
(1,1-Dichloroethylene) p-Dioxane hydrate
Furan
Methyl isobutyl
ketone
Tetrahydrofuran
Vinyl ethers
c. Azides
Organic and inorganic azides, R-N3, can explode when heated or exposed to
ground glass joints. Some azides are shock sensitive. Metal azides are relatively
insensitive to shock, but may explode when heated. Sink disposal of azides can
be extremely hazardous because they can form metal azides that are shock
sensitive, like iron azide. Azides present a hazard around ground glass joints
because they can be shock sensitive.
d. Fulminates
Fulminates are compounds that contain a carbon-nitrogen-oxygen group. Metal

fulminates such as mercury, silver, gold are highly explosive. Explosions are
typically initiated by heat.
F. Incident/Accident Reports
89

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
Laboratory supervisor should keep copies of all incident/accident reports filed

pertaining to the laboratory or involving laboratory staff especially in incident/accident
during handling hazardous chemicals.
Reference: DOH QMS Manual, CVPH QMS Manual v.2011, Google Search
Policy GLD-0040 Electrical Safety
Rationale: The laboratory staff shall establish and follow electrical safety information system
to address the hazards and consequences of fires.
Purpose: To save lives and property.
Procedure:
1. Install and maintain appropriate electrical system.

2. Attend training's on the use of portable fire extinguishers and other fire-fighting
equipment.
3. Place fire extinguishers in a strategic location.
4. Do regular inspection and proper maintenance of fire extinguishers.
5. Post fire warning signs, instructions and escape routes in a conspicuous place in each
room/hallway.
90

Pathologist

Chief of Hospital
Policy
HOSPITAL
Date
Approval
Date
Page
Supersedes
Date of Next
Review
6. Participate in hospital fire drills.
Electrical Operated Equipment
1. Do not interfere with marker tags or labels on electrical equipment.

2. If an equipment or associated wiring is suspected to be in a dangerous condition, switch
off the equipment (where safe to do so), unplug and inform any competent person
immediately.
3. For non-functional equipment that needs repair, place a notice on the equipment
stating, "Faulty - Do Not Use".
4. Electrical portable outlet devices are to be used only if they have overload protection.
[AVR]
5. Home-made electrical portable outlet devices are not to be used in the laboratory.
6. Do not attempt to operate any device and equipment before reading the operation
manual.
7. Read the appropriate safety manuals for all laboratory equipment and logistics.
8. Ask experience colleague or supplier to demonstrate procedures.
9. Any question about the operation of laboratory equipment, consult the supplier.
10. Equipment not familiar with should not be used, as damage may occur to the equipment
and/or other individuals.
Determine that all laboratory equipment:
 Have adequate controls and safeguards

 Is installed in a safe location with adequate ventilation, if required
 Is being used only for its designated purpose.
 Is not used in flammable or combustible atmospheres.
91

Pathologist

Chief of Hospital

CVPH QMS Manual 2016

Uploaded by

Copyright:

Available Formats

CVPH QMS Manual 2016

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CVPH QMS Manual 2016

Uploaded by

Copyright:

Available Formats

Policy

COMPOSTELA VALLEY PROVINCIAL Number

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Verified by: Ferdinand Anthony C. Soberano, MD, FPSMS

POLICY NUMBER PAGE NUMBER

Group of Standards No. 1 Management Responsibility

GLD-0001 Laboratory Management

GLD-0002 Legal & Regulatory Requirements

GLD-0003 Professional Ethics and Conduct

GLD-0004 Quality & Strategic Planning

GLD-0006 Management Review

Group of Standards No. 2 Resource Management

GLD-0007 Human Resource Management

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Verified by: Ferdinand Anthony C. Soberano, MD, FPSMS

GLD-0009 Personnel Orientation

GLD-0010 Work Schedule, Leave of Absence

GLD-0011 Staff Training & Development

GLD-0012 Staff Meetings

GLD-0013 Sanctions & Violations

GLD-0014 Physical Facilities

GLD-0015 Equipment & Instruments

GLD-0016 Contingency Plan

GLD-0016A Disruption of Laboratory Services due to Problems in the Physical

GLD-0016B Contingency Plan for Equipment Breakdown

GLD-0016C Preventive Maintenance

GLD-0016D Reagents & Supplies

GLD-0017 Reagents, Controls, Standards, Glassware, and Supplies

Group of Standards No. 3 Service Delivery

GLD-0018 Customer Needs & Requirement

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Verified by: Ferdinand Anthony C. Soberano, MD, FPSMS

Pre Examination Phase

A. Request Form (In and Out Patient)

B. Request from In Patient

C. Time when to forward Blood Chemistry request

E. Request from Out Patient

G. Criteria for Rejection of Sample

B. Releasing of Result Out Patient and In Patient

GLD-0019 Issuance of Second Copy

GLD-0020 Send Out & Received Sample

GLD-0021 Clinical Consultative Services

GLD-0022 Laboratory Charges

Reviewed by: Nerilyn B. Kunnang, RMT, MD, FPSP, FPSMS

Verified by: Ferdinand Anthony C. Soberano, MD, FPSMS

GLD-0023 Point of Care Testing

GLD-0024 Turn Around Time

Group of Standards No. 4 Monitoring Performance

GLD-0025 Quality Assurance System

GLD-0026 Internal Quality Control Program

GLD-0027 External Quality Control Program

GLD-0028 Factors affecting Quality of Laboratory Results

Group of Standards No. 5 Quality Improvement Activities

GLD-0029 Continuing Quality Improvement

Group of Standards No. 6 Information Management

GLD-0030 Information System

GLD-0031 External and Internal Communication

GLD-0032 Document and Record Control

GLD-0033 Laboratory Information System

Group of Standards No. 7 Environmental Management and Biosafety