Diagnostic Laboratory
4-Year Accreditation Assessment
Assessor Checklist – Hematology
Facility Name
Guidance:

Includes Surgical Pathology, Ancillary Studies, Autopsy Pathology, Electron Microscopy, Cytopathology and
Telepathology
 All Standards designated with a Patient / Staff Safety Risk must be directly assessed where ever possible
 This tool is provided to assist assessors/provide practical direction in the performance of assessment activities and is to
be used in conjunction with the Standard document tool
 Determine the scope and nature of potential citations:
 is there a P/P/ or P?
 Is the P/P/ or P in compliance with the standards?
 is the P/P/ or P being followed as written?
 Is there evidence of training/competency assessment for the activity?
 is there acceptable documentation of the activity?
 Is the required review of the activity performed and documented?
Assessment Task Review
Quality Practices
Adequate space /
environment /
housekeeping
Equipment/Reagents
Guidance
Conduct a review of Hematology quality practices including:
 sampling of records of initial and on-going training/ competency assessment of
staff
 sampling of Quality Control records/corrective action/follow-up
 sampling of Quality Indicator monitoring and follow-up
 EQA participation and performance – previous 2 years
 Management/supervisory review of EQA performance/follow-up – previous 2 years
For Hematology services and functions including:
 Specimen receipt/ preparation
 slide preparation
 staining
 technical functions
 storage
 clerical/administrative functions
Conduct a review of a sampling of:
 new reagent/shipment validation records
 reagent records (e.g. appropriate lot#, package insert review)
 equipment records (identification, validation, calibration, maintenance, service etc.)
 manual hematology equipment such as counting chambers for adequacy (no
scratches etc.)
Assessor Checklists – Diagnostic Laboratory
© Copyright 2013 College of Physicians and Surgeons of Alberta
1
√
CPSA: March 2013
Assessment Task Review
Safety
Guidance
Conduct a safety audit of the Hematology laboratory facility including:
 overall physical facility (e.g. tripping hazards, adequate emergency lighting etc.)
 ergonomic assessment
 appropriate evacuation routes and security
 placement and certification of fire extinguishers
 good housekeeping practices
 use of appropriate Personal Protective Equipment (PPE) in compliance with facility
policy
 ready access to safety equipment such as eyewashes, emergency showers, spill kits,
first aid equipment
 containment of hazardous materials (chemicals etc.)
√
Biohazard containment:
 Conduct an audit of biohazard containment activities:
appropriate sharps containers
Biological Safety Cabinets (BSC) including annual certification and
routine monitoring documentation
aerosol containment (use of shields etc.)
Path of Workflow
Slides/ images
Diagnostic reports
Waste disposal:
 Conduct an audit of waste disposal practices in the Hematology laboratory sections.
Follow the path of workflow for multiple/different sample types and examinations to
assess all facets of the pre-examination, examination and post-examination processes.
Request the facility to pull a sampling of blood film slides/images for an audit of:
 Unique identification
 Overall smear quality (staining, cell distribution, lack of stain precipitate etc.)
 Special stains where applicable
Request a sampling of hematology patient reports across multiple examinations and
include a case with referred out testing and an amended report.
Assessor Checklists – Diagnostic Laboratory
© Copyright 2013 College of Physicians and Surgeons of Alberta
2
CPSA: March 2013