Quality Management

Shared Health’s Quality Management System for diagnostic services is thorough and full of checks and balances to help ensure that the results we report to doctors and health care providers are accurate and timely.

Patients and their families also have a role to play in quality; safety comes from asking questions and accessing information related to your health care journey. That’s why we have committed to helping Manitobans understand the processes at work behind their diagnostic care; the information that follows on this page provides a high level picture of different aspects of the quality systems in place.

Know your lab and imaging

Bring your Manitoba Health Card to your appointment or one other piece of identification that has your picture.

You are required to show appropriate identification before your sample will be taken. Your Manitoba Personal Health Identification Number (PHIN) Card is your primary health identification. Alternate identification card examples include:

  • RCMP
  • Military
  • First Nation Inuit and Aboriginal Health (10-digit number)
  • Health card from another province

To protect patient safety, Shared Health’s diagnostic centres have the right to refuse service when patients do not present adequate and appropriate identification; photo identification may be requested.

Follow the instructions given to you by your doctor carefully – for instance, if your physician indicated you cannot eat for 12 hours, you must follow this or we cannot complete your lab tests.

For more specific information and answers to common questions about your lab and imaging, please see Preparing for Lab Tests or Imaging Procedures.

Quality Management System

Below is a snapshot of the key components of Shared Health’s Quality Management System:

Organization and Strategy
Shared Health is committed to creating a culture that places utmost value on quality and patient safety and continuously works to ensure these values permeate through all of our operations.

Accreditation
Two main third party accreditation agencies, the Manitoba Quality Assurance Program (MANQAP) and College of American Pathologists (CAP), evaluate our diagnostic services to ensure quality and safety is continuously at the forefront of all operations. CAP is one of the highest ranked accreditation agencies for medical laboratories in the world and we’re proud that our largest medical laboratory sites at Health Sciences Centre and St Boniface General Hospital) and other pathology laboratories are CAP accredited. The remainder of our laboratories and diagnostic imaging facilities across Manitoba that require accreditation are accredited by MANQAP, which is run by the College of Physicians and Surgeons of Manitoba.

Visit Shared Health’s Accreditation webpage to learn more and to see the Accreditation Certificates for Shared Health diagnostic services sites.

External Proficiency Testing
External Proficiency Testing (EPT) is an important activity in the quality management system at Shared Health. This testing helps to ensure that the systems Shared Health uses when analyzing patient samples are performing well when compared with expected results and results from similar labs.

Shared Health takes part in the EPT programs from various laboratory organizations in Canada, the United States, and the United Kingdom. These programs assess performance on thousands of tests across all laboratory disciplines several times per year.

How these programs work:

  • A program sends out samples that have been carefully prepared to duplicate actual human samples.
  • Shared Health’s diagnostic services receives the sample and tests it in the same way an actual patient sample would be tested, except that the results are sent back to the program rather than a health care provider. The correct results are unknown to Shared Health at the time of testing.
  • The EPT program then compares our results to peer groups and to the ‘true’ value for each result and sends a report back to Shared Health.
  • Any results that do not meet the standards set by the program are called non-conforming (NC) results. But not all non-conforming results are real ‘errors’ with clinical significance. Shared Health reviews and analyzes the reports in detail to determine what caused our results to deviate from the standard and to determine what other steps need to take place to prevent a similar non-conformance in the future.

Shared Health’s EPT data for laboratories across the province are handled through a central point so that the process is a valuable tool to monitor quality and performance across the organization and not just in a single laboratory. EPT data is reviewed on an ongoing basis by Shared Health’s diagnostic services, lab managers and supervisors, laboratory discipline Teams, senior management, the Patient Safety Committee and our health care partners at the Manitoba Quality Assurance Program (MANQAP).

Internal Audits
Shared Health routinely conducts its own audits of diagnostics sites to ensure compliance with standards. Since the goal is to be “accreditation ready” at all times, the audits may be scheduled or unannounced. Audits may be completed by: Shared Health’s quality services discipline teams and associated scientific personnel occupational health and safety Operational peers.

Equipment Installation, Validation, and Maintenance
Shared Health has established systems to work with vendors to install equipment and ensure that all equipment is operating at optimum levels. Discipline teams who are responsible for equipment selection regularly monitor equipment and validate results to ensure that equipment is properly calibrated and maintained. There is a Standard Operating Procedure for each piece of equipment and system used in Shared Health’s laboratories and imaging facilities.

Occurrence Management & Critical Incidents
The purpose of occurrence management is to record and analyze information when situations affecting quality occur so that Shared Health can look for trends, determine root problems and identify system-wide solutions. Occurrences can be relatively minor incidents that are immediately corrected to significant issues that have impacted patient safety and well-being. When patients are harmed or nearly harmed, the incident is called a Critical Incident.

Learn more about occurrence management and critical incidents.

Process Control & Improvement
Diagnostics involves several medical/scientific disciplines. Each of these disciplines defines all the processes for its particular operations through detailed policies. These are used by staff to ensure consistency in performance. This level of process control enables us to detect potential errors as well as prevent errors altogether. Even with these controls in place, there is need for continuous improvement. Sources of information used to improve our Quality Systems include each of the components being described here, as well as other sources such as literature reviews, turn-around time audits, and patient and physician feedback. Shared Health diagnostic services analyzes all the feedback and information and looks for ways to enhance or improve the Quality Management System.

Document Control
Diagnostics involves several medical/scientific disciplines. Each of these disciplines defines all the processes for its particular operations through detailed policies. These are used by staff to ensure consistency in performance. This level of process control enables us to detect potential errors as well as prevent errors altogether. Even with these controls in place, there is need for continuous improvement. Sources of information used to improve our Quality Systems include each of the components being described here, as well as other sources such as literature reviews, turn-around time audits, and patient and physician feedback. Shared Health diagnostic services analyzes all the feedback and information and looks for ways to enhance or improve the Quality Management System.

Human Resources
Shared Health’s Human Resources department has clear processes for recruitment, orientation, and training and performance evaluation to help ensure that highly qualified people are in the right positions and to monitor the competency and performance of staff. From medical and scientific staff to technologists to transcriptionists – this program ensures that people have the right qualifications to do their jobs, as well as the ongoing training, support and evaluation needed for them to meet Shared Health’s expectations of quality.

Procurement & Vendor Relationships
Critical supplies and services must be identified through vendors. Shared Health’s procurement department helps establish quality criteria for vendors and manages relationships with vendors.

Client Services
Shared Health’s client services department advocates on behalf of the patients we serve and accepts feedback from patients, their families and their physicians. The department works to resolve complaints and to improve quality with respect to the service being provided.

Partnerships & Safety
Another important measure of quality is derived from our health care partners. Shared Health works closely with all of our health care partners and the Health Authorities in Manitoba, in order to create opportunities to understand the needs and challenges of our front line health care partners.

Top