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PRINCE FAISAL BIN KHAT!D CARDIAC CENTER
TITLE: TRAINING ORIENTATION POLICY
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Policy Number
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REVIEW DATE
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PURPOSE:
1.1. The policy identifies and outlines the orientation and re-contracting
activities required when staff are hired, re-contracted or terminated by
the Laboratory department . The requirements identified in the policy also
apply to those individuals scheduled to spend a limited amount of time in the
trainees, volunteers and authorized visitors.
1.2. Toassurethatall staffare
knowledgeable with each procedure they are
expected to perform and practice each procedure according to written
instructions in the department policy and procedure manuals.
2. DEFINITIONS:
2.1.
Personnel Training: The intent oftraining is to provide the individual with the
knowledge and skills necessary to be competent in their assigned duties and
responsibilities.
2.2.
Competency Assessment: Competency Assessment is the means to confirm
that training is effective and that personnel are capable of following
established procedures to accurately perform laboratory testing that
produces quality results.
2.3. Continuing Education: Continuing Education
important for all
laboratory employees to ensure knowledge ofthe latest health care trends,
which in turn, allows for continual interest in day-to-day responsibilities. lt is
a good way for employees to become aware ofthe latest developments in
medical laboratory practices, and can help PFKCC lab provide better patient
(CE) is
care more efficiently.
3.
RESPONSIBILITIES:
3.1. Quality Supervisor
3.1.1 Ensures implementation of training procedure.
3.1.2 Maintains employee training records
3.1.3 Responsible for the evaluation, training and growth of the
technical and quality related skills of employees by
establishing training schedule and rotation for all new
employees and by ensuring personnel receive training and
demonstrate competence.
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PRINCE FAISAL BIN KHATID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POtICY
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3.1.4 Ensures proper supervision oftrainees until training
completed.
3.1.5 Ensures training records are complete.
3.1.6 Monitors employee performance to identify the need for
retraining or additional continuing education
3.1.7 Ensures and records continued competency of employees.
3.1.8 Has relevant knowledge of the technology, methods and
procedures used, purpose of each test, and an understanding
of the significance of deviations found with regard to the
normal use of the items, materials, products, etc. concerned
within their area of responsibility
3.2. Laboratory medical director: Ensures training is conducted and recorded for
quality management system policies and procedures.
3.3. Staff:
3.3.1 Completes required training within specified timeframe
3.3.2 Becomes and stays knowledgeable in procedures and
methods performed, NOTE: Employees are responsible for
self-training, throuBh reading current literature, technical
papers, publishing technical papers
3.3.3 Ensures all FDA mandated training, i.e. annual ethics,
computer security, etc., is completed and certificate
submitted to local training coordinator
3.3.4 Reads and complies with standards, regulations, policies,
procedu res, and work instructions
4.
POLICY:
4.1
Personnel Training: Accurate and reliable test results are achieved when a
test is performed as per manufacturer guidelines. Proper training and
ongoing competency assessment will help to ensure the test is being
performed correctly every time.
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PRINCE FAISAL BIN KHATID CARD]AC CENTER
TITLE: TRAINING ORIENTATION POLICY
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All new employees need orientation and training for lab. Every facility is
regardless of how much laboratory experience an
different,
and
individual has, new employees must be trained in the following areas:
4.1.1 Their assigned duties and responsibilities
4.1.2 Laboratory policies
4.1.3 Laboratory procedure manual(s)
4.1.4 Procedures for all of the tests the individual will be
authorized to perform
4.1.5 Laboratory quality assessment plan
4.1.6 Safety practices
4.1.7 Computer system (LlS), records, and reports
4.2 Current employees need continuous trainint:
4.2.1 When new processes and test procedures are implemented
4.2.2 When current processes and test procedures are changed
4.2.3 Whenever the need for additional training is identified (e.g.,
a failed competency assessment, proficiency testing failure,
identified problem)
The intent of training is to provide the individual with the
knowledge and skills necessary to be competent in their
assigned duties and responsibilities. Additional training may
be necessary to ensure ongoing competency. The training
program should have defined objectives, methods, and
tra ining materials.
4.3 Quality Test Performance: training must ensure that all testing personnel
are familiar with the following for each test procedure:
4.3.1 The test name and purpose ofthe test
4.3.2 The equipment necessary to perform the test
4.3.3 Specimen collection and handling
4.3.4 Preparation, labeling, use, and storage of reagents, standards,
and controls
4.3.5 Special requirements, safety procedures, etc.
4.3.6 lnstrument maintenance, function checks, and calibration,
when applicable
4.3.7 Step-by-step performance ofthe test procedure
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PRINCE FAISAL BIN KHAIID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POLICY
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4.3.8 Quality control procedures including what constitutes
acceptable results and when to report patients
4.3.9 How to recognize and interpret inconsistent results and test
system problems and perform troubleshooting
4.3.10 Recommended corrective action when controls are
unacceptable
4.3.11 Necessary calculations and derivation of results, when
applicable
4.3.12
4.3.13
4.3.14
4.3.15
Reference ranges and critical values
Result reporting
Quality assessment procedures
important that personnel do not report test results on patient
specimens until training is completed and competency is
verified for each specific test procedure.
4.3.16 A basic protocol for test procedure training could include
having the trainee:
4.3.L6.1
entire package insert and/or test
procedure to become familiar with the items
Read the
listed above
4.3.16.2 Observe the specimen collection, handling, and
processing steps used to obtain the specimen and
get it ready for testing
4.3.16.3 Observe as the trainer performs and documents all
applicable maintenance, startup and function
checks, calibration, and quality control procedures
4.3.16.4 Observe as the trainer tests specimens
4.3.16.5 Observe and discuss the evaluation of quality
control result acceptability and interpretation of
specimen results
4.3.16.6 Perform all quality control procedures
4.3.16.7 Perform the test using previously tested specimens
and compare the results obtained
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PRINCE FAISAT BIN KHATID CARD]AC CENTER
TITtE: TRAINING ORIENTATION POtICY
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4.4 Continuing Education: Continuing Education
P.F.(.C.C
important for all
laboratory employees to
ensure knowledge of the latest
update. lt is a good way for employees to become aware of
(CE) is
the latest developments in medical laboratory practices, and
can help the lab provide better patient care more efficiently.
4.4.1 There are many sources for laboratory continuing
education, including:
4.4.1.1 Conferences, seminars, workshops, and
meetings
4.4.1.2 Presentation and review of case studies
4.4.1.3 Training on instruments or kits by the
manufacturer
4.4.1.4 Annual required training (safety, lnfection)
4.4.1.5 Document all continuing education activities
with the date, topic, source, and
4.5
CE.
Professional Development: Laboratory professionals should look for
opportunities
ongoing professional growth and
for
development including:
4.5.1 Explore any continuing education opportunities that the
organ ization offers
4.5.2 Attend a regional or national meeting or conference
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PRINCE FAISAL BIN KHAIID CARDIAC CENTER
TITtE: TRAINING ORIENTATION POLICY
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Policy Number
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5.
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PROCEDURES:
5.1.
Training Requirements: Before starting any work-related duties, the
employee will be familiar with work related documents. These
documents include procedures, work instructions, applicable
manuals and regulations. Employees undergoing training are
supervised until training is completed and competency
demonstrated.
5.1.1 Training requirements are outlined and documented
on the basis of the position description of duties and
respon sib ilities.
5.1.2 Training is determined by the employee's educational
qualifications, experience, complexity of the test
method, and knowledge of the test method
performed.
5.1.3 The employee will not perform any procedure,
inspection, or method until all applicable training has
been completed and competency demonstrated.
5.1.4 Employees may request training related to their
duties.
5.2
5.1.5 Training and competency records shall be maintained
according to local policy.
5.1.6 The effectiveness of training is evaluated by reviews &
evaluate the employees performance
Training Technique:
5.2.1. The training process for technical procedures such as
laboratory analysis consists of the following steps:
5.2.1.1 Trainee reads the laboratory procedures, work
instructions, or other applicable documents.
5.2.1.2 Trainee observes demonstration ofthe procedure by a
trainer.
5.2.1.3 Trainee performs the procedure under observation by
a
trainer.
5.2.1.4 Trainee successfully completes the procedure
independently.
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PRINCE FAISAL BIN KHALID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POLICY
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The training process for non-technical procedures includes,
but is not limited to:
5.2.2.1
5.2.2.2
5.2.2.3
5.2.2.4
5.2.2.5
5.2.2.6
5.2.2.7
5.2.3
5.3.
Reading laboratory procedures.
lnstructions.
Demonstrations.
Lectures and discussions.
Self-study.
Computer-based training.
Manufacturer's training or demonstration
An employee's performance is verified by measurement
against a defined performance standard. The measures used
to verify an employee's performance are assessment tools.
Assessment tools:
5.3.1 Administration of a Written Evaluation: Written evaluations can
be used in areas where verification of a participant's knowledge
is desired. Knowledge of theory or principles, problem-solving
ability, logical sequence used, and independent or group
decision making may be established.
5.3.2 Observation of Procedure, Process, or Outcome: Observation by
a trainer of an employee performing or demonstrating a
procedure.
5.3.3 Response to OralQueries Related to a Step or Procedure:
Answers provided by the employee to questions asked by
trainer.
5.3.4 Testing Blind QC Samples: Employees are unaware when blind
test samples are assigned. They appear identical to other
samples, are in routinely used containers, and are from a
similar source. The intent is to provide simulated samples to
measure realistic analytic conditions. This tool assesses all
phases of laboratory performance.
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PRINCE FAISAL BIN KHALID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POLICY
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Policy Number
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EFFECTIVE DATE
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REVIEW DATE
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5.3.5 Testing of Known Samples: Participants know and often plan for
known testing events, such as external proficiency surveys and
commercially prepared quality control samples. Samples for
quality assurance or quality control purposes are identified
immediately upon receipt in the laboratory. lt is considered a
waste of time and resources to conduct more careful handling
and analysis on these samples or perform duplicate testing.
This tool assesses the analytical phase only.
5.3.6 Testing Previously Analyzed Samples: Duplicate or replicate
testing provides accessible internal comparisons and
contributes to the validation of the analytic phase. These
sources may be previously tested samples, samples of known
constituents, and already reported proficiency testing samples.
This tool assesses the analytical phase only.
5.4. Authorization of Personnel:
5.4.1 Laboratory management authorizes personnel to perform
specific laboratory Training in each section.
5.4.2 When personnel are authorized to be trainee, the training
records must indicate which parts of the method the employee
has received training.
5.5. Training
Records
5.5.1 Training and competency records are maintained
5.5.2 Training records should include a description ofthe training, the
trainee name, the trainer, dates of training, and indication of
successful completion. Training records are archived for exiting
employees. Examples of training records:
5.5.2.1 Completed training checklist prepared internally for
procedure.
5.5.2.2 Completed blind quality control (QC) samples,
proficiency surveys, acceptable preparation and
analysis of QC samples.
5.5.2.3 Completed written evaluations.
5.5.2.4 Signed acknowledgment of reading assigned
procedural documents.
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PRINCE FAISAL BIN KHATID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POtICY
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5.5.2.5 Attendance sign-in sheets for in-house training.
5.5.2.6 A certificate from manufacturer's training courses.
5.6 Orientation Plan: Covers all the areas mentioned below:
5.6.1. The Section Head and Supervisor of the
5.6.2.
5.6.3.
applicable
laboratory section are responsible for ensuring that all
new staff, trainees, locums, volunteers have been
appropriately oriented and complete the necessary
checklist items.
All new staff must go through the orientation process
and complete the New Employee Checklist Hospital
Checklist and the applicable section specific orientation
and training checklists.
Departments & Location: The section supervisor shall
provide orientation to new staff about the laboratory
departments/section, with respect to their location,
heads, supervisors and technical staff. He/she also
provide information about the other related
departments like Biomedical and general maintenance
5.6.4.
with their contact information.
Policy & Procedure: All new employees read the
appropriate departmental policies, the section
supervisor and head of the department will provide all
the related information either the hard copies or
electronic copies of these policies or procedure to the
staff and staff should sign that they have read and
understood them, they should be informed about the
5.6.6.
Laboratory Mission, Vision and Values.
Safety:(Refer to lab. Safety policy and Lab. (safety
manual)
5.6.7.
Employee should inform about their roles &
responsibility in different adverse event.
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PRINCE FAISAL BlN KHATID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POI-lCY
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5.6.7.1 tn case of fire:
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When there is a fire in
your immediate work
area.
5.6.7.t.L Fire's point of origin.
5.6.7
.1.2 Where location of pull stations, fire
doors, fire extinguishers,
evacuation routes, and
procedures.
How
to
use
fire
extinguisher.
5.6.7.1.3 How to Use and functioning of fire
alarm systems
5.6.7.1.4 Fire exit plan
5.6.7.1.5 RACE & PASS
5.6.7.1.6 Disaster plan and their codes- Yellow
, Red etc.
5.6.7.1.7 Electrical Safety
5.6.8. Flammable, Chemical and Corrosives Liquids: Supervisor
and safety officer provide information about the
following points:
5.6.8.1 Storage -Store only in approved safety
cans or storage cabinets. Be sure they
are labeled.
5.6.8.2 How to clean different type of spills
5.6.8.3 Clean up spills right away.
5.6.9. Other Situations:
5.6.9.1 lnformation about hazardous materials including
material safety datasheet (MSDS).
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PRINCE FAISAT BIN KHALID CARD]AC CENTER
TITLE: TRAINING ORIENTATION POtICY
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5.6.9.2 lnformation on lnfection Control and Sharp
disposal. How to report adverse event including.
5.6.9.2.7 When to complete an Occurrence
Variance Report
-
OVR.
5.6.9.2.2 Where to route the Occurrence
variance Report
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OVR.
5.6.9.2.3 General lnformation about the Lab
Quality Management Program
5.6.10
Orientation:
All staff required to use the Laboratory lnformation
System (LlS) must be granted the appropriate access
and receive training in the appropriate LIS applications.
LIS
The LIS Manager/LlS coordinator are responsible to
provide unique access and the training about the
LIS
and LIS orientation form should be filled and copy will
kept in the employee file. Both the staff member and
the Laboratory LIS Coordinator must sign the access
form. The staff member will be instructed in the train
domain using a generic password.
5.6.11 Personal:
The section supervisor provides information about the
laboratory team, Administrative, technical, Operational
with their designation and contact information. He / She
also inform about the organizational chart and chain of
command.
5.6.12 Work process:
Provide basic information about the laboratory working
and ground rules in the laboratory. Keeping in mind the
main phases of work flow (Pre analytical, Analytical and
the post analytical).
General lnformation on Communication devices:
Telephone System.
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PRINCE FAISAL BIN KHATID CARDIAC CENTER
TITLE: TRAINING ORIENTATION POLICY
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Number of Pages
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5.6. 13.Staff
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Evaluation Process:
The following steps shall be followed:
5.6.13.1 All new employees receive an assessment of
the knowledge, skills and attitude required of
the employee to function successfully in
his/her position.
5.6.13.2 All new employees receive education on the
proper use of equipment including
troubleshooting and reporting malfunctions.
5.6.13.3 All new employees receive more clarification
as needed on all topics provided in the general
orientation and this is signed by the employee
and immediate supervisor.
5.6.13.4 Orientation for new employees is located in
the employee's personnel file.
5.6. 14.
Re-contracting
5.6.14.1 At time of employee re-contractin8. the
activities and requirements outlined on the
Employee Reconstructing Checklist must be
complete.
5.6.14.2 The re-contracting package should be
completed, signed by the Laboratory Director
and submitted to hospital committee of at
least 3 months prior to the end of contract
date.
5.6.14.3 Updated BLS (Basic Life Support) and
participating in Continuing education Programs
in the laboratory are needed
5.6.L4.4 Completing Competency assessment.
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5.6.15 Accountability:
5.6.15.1 The section supervisor must ensure
that the staff member has successfully
completed the training.
5.6.15.2 The staff member must complete the
Confidentiality Agreement.
5.6.15.3 Arrange for additional training
employee has not successfully
if the
completed the training.
5.6.15.4 Visitors, volunteers and trainees who are
expected to spend more than one working
day in the laboratory must undergo an
abbreviated orientation process. The
Section Head and Supervisor ofthe
section visited are responsible for
ensuring visitors, volunteers and trainees
have been appropriately oriented
completely.
6.
REFERENCES:
6.1. Clinical and Laboratory Standards lnstitute (CLSI), Training and
6.2.Competence Assessment, Approved Guideline-Third Edition
6.3.CLSl Document GP-21-A3 (ISBN 1-56238-691-3)
7. ATTACHMENTS:
7.1 Orientation check list form (PFKCC/LAB/FO15
7c,
lit
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TITLE: TRAINING ORIENTATION POtICY
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APPROVAT:
Prepared By
Na me
Title
Hanadi AL-Yenbawi
Laboratory Quality
Signature
Date
Coordinator
Mr. lbrahim ALWadie
Laboratory Director
Dr. Eisa Assiri
QIPS Director
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-(,--raf?o
l-t-u"r"
Reviewed By
Dr. Amer Hassan
Medical Director (for
Assiri
Medical PP's)
Mr. Ali Al Qarnie
Nursing Director (for
b/e/?oh
lt1lllotu
Nursing PP's)
Approved By
Dr. Adel Maswary
Center Director
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