LABORATORY MANAGEMENT

PATHOLOGY AND LABORATORY MEDICINE (PaLM)

London Health Sciences Centre and St. Josephs Health Care London

Page: 1 of 4

TITLE: Information Management Policy

ID: LABM-QMS-INF-A-001

File Name: ainf001.doc

Eff: 04/01/20 Rev: 15/01/26

Authorized: Dr. S. Chakrabarti

CONTROLLED document. Any documents in paper form must be used for reference purposes only. The on-line copy must be considered the current
documentation

TITLE: Information Management Policy

POLICY STATEMENT
The Laboratory collaborates with the Information Management department in order to
report patient results.

PURPOSE
This policy provides direction for the processes and procedures to manage laboratory
information.

RESPONSIBILITY
Chair Chief/Director is responsible for:
Ensuring that appropriate systems and processes are in place to provide health care
providers with accurate and timely information to manage the care of patients.
Maintaining confidentiality of patient results.
Program Head/Laboratory Manager is responsible for:
Ensuring that appropriate systems and processes are in place to provide health care
providers with accurate and timely information to manage the care of patients.
Approving all changes to the computer system that may affect patient care.
Maintaining confidentiality of patient results.
Division Head/Section Head/Coordinator is responsible for:
Liaising with the LIS support technologists to ensure that tests are built appropriately in
order to report; results, interpretation, reference ranges, rules, and limitations.
Approving all auto verification procedures prior to implementation.
Establishing the interpretation of test results as normal, abnormal and critical.
Establishing and monitoring Turn Around Times (TAT).
Ensuring discrepant results are resolved.
Ensuring that incorrect results are amended or corrected.
Maintaining confidentiality of patient results.
LIS Support Technologist is responsible for:
Liaising with Information Management in order to maintain the Lab Information System
(LIS)
Building new and changing existing protocols in the LIS.
Validating/testing new versions of software for the LIS.
Documenting new or changed LIS procedures.
Training users as necessary when new or changed procedures are implemented.
Maintaining confidentiality of patient results.

TITLE: Information Management Policy

ID: LABM-QMS-INF-A-001

Page: 2 of 4
Rev: 15/01/26

CONTROLLED document. Any documents in paper form must be used for reference purposes only. The on-line copy must be considered the current documentation

Laboratory Staff/Affiliate is responsible for:

Following policies, processes and procedures for entering and releasing patient results
in the LIS.
Ensuring that critical results are reported in a timely manner.
Notifying appropriate individual when unexpected results occur or when problems are
suspected or encountered.
Maintaining confidentiality of patient results.
Reporting communicable and reportable diseases to the Medical Officer of Health.

SUPPORTING STATEMENTS
Computer Access & Security
Staff access to computer systems (ie. Cerner, required drives, EPR) is requested and
approved by Coordinator/Manager/Director.
Requests are forwarded to Help Desk (Corporate) for approval & implementation.
Access is based upon job description and granted to requested authorized areas only.
Results Reporting
The laboratory has processes and procedures for reporting all normal, abnormal and
critical results.
Point of Care results included on the patient record are distinguishable from other source
results.
Patient Reports
The Laboratory ensures that released results are legible, properly identified and contain
the appropriate results and interpretive information for the management of the patient.
The identification of the individual releasing results is available.
Operator ID
The Laboratory can trace the identity of the individual who performed the examination
and/or the quality control, as well as the date and time.
Release of Results
The Laboratory has processes and procedures for releasing results, which include who
may release results, and to whom they may be released.
Discrepant Results
The Laboratory has processes and procedures to resolve discrepant results or results
questioned by a clinician.
Corrected Reports
The Laboratory has processes and procedures for correcting issued reports.
Turn Around Times
The Laboratory establishes clinically relevant turn around times for each examination in
consultation with their clients. Procedures are in place to detect excessive delays and
notify users if necessary.

Communicable and Reportable Diseases

TITLE: Information Management Policy

ID: LABM-QMS-INF-A-001

Page: 3 of 4
Rev: 15/01/26

CONTROLLED document. Any documents in paper form must be used for reference purposes only. The on-line copy must be considered the current documentation

The Laboratory complies with legislated requirements for reporting communicable and
reportable diseases.

The following statements are related to computer data entry and reporting.
Data Integrity
The Laboratory periodically checks patient data on computer results/displays with
original input.
Review and Audit
The Laboratory has an audit mechanism in place to periodically check tables,
calculations and quantitative results.
The Laboratory has an audit mechanism to identify all individuals who enter or modify
computer data, files or programs.
Auto verification
The Division Head or Section Head approves all auto verification procedures prior to
implementation.
Change Approval
The Laboratory Director/Manager approves all changes to the computer system that
may affect patient care.
Computer Procedures
The Laboratory ensures that computer processes and procedures are defined and
available to authorized users.
Computer QA
The Laboratory has computer quality assurance methods.
Computer Security
The Laboratory provides adequate protection for all aspects of computer security.
Computer Validation
The Laboratory ensures that computer programs are checked for performance and
validated if changed, prior to implementation.

TITLE: Information Management Policy

ID: LABM-QMS-INF-A-001

Page: 4 of 4
Rev: 15/01/26

CONTROLLED document. Any documents in paper form must be used for reference purposes only. The on-line copy must be considered the current documentation

REFERENCES

NCCLS document HS1-A Vol.22, No.13- A Quality System Model for Health Care;
Approved Guideline
IQMH- Institute for Quality Management in Healthcare Ontario Laboratory
Accreditation Requirements Version 6, December 2013
ISO 15189:2012- Medical Laboratories- Requirements for Quality and Competence

SUPPORTING DOCUMENTS
The following processes support this policy:

LABM-QMS-INF-B-001 Results Reporting Process

LABM-QMS-INF-B-002 Establishing and Monitoring Turn Around Times
Infection Control Manual - Reportable Communicable diseases
GEN 001 Forms and Information Management
GEN 020 Privacy Policy
GEN 022 Confidentiality Policy
INT 008 Electronic Data Storage