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 |