Quality essentials

Summary of findings

Planned intervention to address identified gaps

Document and record

· SOPS not signed by relevant personnel.

· General Laboratory Register and Work sheet not updated

· Mentored HOD and relevant Lab staff to review and sign SOPs and update outstanding documents

Organization and personnel

· Organizational chart describing hierarchical relationships of staff not available.

· Personnel folders do not containing relevant certificates and training records of staff such as license, Job description ,training and competency etc.

· Supported HOD to design an organogram and each staff encouraged to populate folders with relevant documents

Internal and/ external quality control

· L-J Charts for IQC runs not plotted

· EQC and IQC records not reviewed by designated officers Records of poor EQC/IQC performance not adequately documented in CAPA

· Laboratory internal audit not done

· Not registered for at least one EQC Scheme

· Conducted on-site coaching and mentoring on IQC and EQC documentation.

· Provided CAPA form to capture incidence and occurrence

· Conducted step-down training on the principle of internal auditing and provided the necessary tools

· Registered site for at least CD4+ EQC scheme

Inventory control system

· Tally card not updated

· Ambient temperature and refrigerator not properly monitored

· Broken thermometer

· Verified and updated tally cards to account for reagents/consumables

· Provided tools to monitor and record temperature and updated missing information

· Provided new thermometer

Equipment

· Operator’s equipment maintenance charts not up to date and not reviewed by supervisor

· Faulty equipment due to rat infestation

· Equipment not covered when not in use

· Faulty air conditioner

· Strengthened capacity to document daily maintenance activity and provide tools

· Faulty equipment and air conditioner were repaired or replaced

· Fumigation was done and regular schedule established

· Sample referral was institutionalized and strengthened and local biomedical engineers were trained to carry out minor repairs

Signage/bench top references

· Laboratory signs and bench top reference for equipment not pasted

· Provided the necessary lab signs, job aids and advocate with hospital management to review the policy of no wall posters

Facility and safety

· Waste not properly segregated and disposed.

· Expired fire extinguisher, expired eye wash

· Contact information of PEP focal person not available

· First-Aid box not available

· Hanging of electrical wire

· Provided training on biological waste management involving facilities cleaners

· Provided sharp containers, colour-coded bins and liners

· Refilled expired fire extinguishers and provided First Aid Box/Eye wash

· Ensured focal person for PEP identified with contact information accessible to all staff

· Reviewed and updated safety policy

· Hanging electrical wires were repaired