Standards › Standard 33 › Policies
Policy · LBT-POL-002 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 33.5
At a glance
- The laboratory takes part in an external scheme for each test where one exists.
- Each unsatisfactory result is investigated and corrected (LBT-REG-004).
- Results are reviewed at a set interval by the laboratory lead.
- Tests with no scheme are listed with the reason.
- Stop and get help straight away if: a test with an available scheme is run with no participation and no reason recorded.
1. Purpose
To check the laboratory’s results against other laboratories through external quality assessment (33.5).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
A laboratory that does not compare its results with others may have a problem it cannot see. External quality assessment shows how its results compare with peers.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Laboratory director | Enrols the laboratory in the schemes | Medical director |
| Senior scientist | Investigates and reports each result | Laboratory director |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Enrol.
- Enrol in an external scheme for each test where one exists.
Key point: Enrolled.
Step 2. Submit and review.
- Submit each round and review the result on receipt (LBT-REG-004).
Key point: Reviewed.
Step 3. Investigate.
- Investigate each unsatisfactory result and record the correction.
Key point: Investigated.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Tests with scheme participation | 100% | Annual | Laboratory director | Escalate to the medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| LBT-REG-004 | External quality assessment results register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on ISO 15189:2022 Medical laboratories: requirements for quality and competence, ISO 9001:2015 for supplier control, and the Global Patient Safety Action Plan 2021–2030 for critical results. |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)