SOPs for the Yorkshire General Histopathology EQA Scheme

More documents

Recommendations

Info

STANDARD OPERATING PROCEDURES Standard Operating Procedure 36: Scheme Audit and Monitoring Exercises (CPA Standards: A2, H1, H3, H4, H5) The Scheme Secretary will ensure that the scheme participates in any audits requested by the Scheme Organising committee. These currently include: 1. Database validation exercise: the Scheme Secretary checks 10% of the entered results for errors. Details of this are retained for future reference. 2. Participant Satisfaction Questionnaires: the Quality Manager circulates a satisfaction questionnaire every year to ascertain any issues the participants may have. This questionnaire is sent to all participants. 3. Audit of Attendance at Participants Meetings: the Scheme Secretary records attendance on the regional spreadsheet which highlights those who have not attended the three most recent meetings. 4. Audit of the Quality management System: the Quality Manager is responsible for regularly auditing the Quality Management System in line with the recommendations of SOP 39. The results of this audit are recorded on the relevant Audit of QMS spreadsheet. This audit is performed yearly by the Quality Manager. Filename: yorkshire histo eqa sops v8 Version No: 8.0 Date Created: 01/08/2013 Last Revised On: 01/08/2013 Review Date: 08/14 Page 40 of 47 Author: Leeds Office MW Authorised By:
STANDARD OPERATING PROCEDURES Standard Operating Procedure 37: Confidentiality and Data Safety (CPA Standards: A9, D2, F3, F4, G1) The IT Manager is responsible for ensuring that the network is secure and the EQA drives are only accessible by the required EQA staff. They will ensure that incremental back-ups of the network take place, and will complete regular investigations of the audit log. All of the audit logs are archived for future reference. Access to the EQA drives will only be granted following completion of a network authorisation form, which must be authorised by the Quality Manager and current Scheme Secretary. All members of the Quality Assurance Reference Centre have completed training in Information Governance. Throughout the running of the scheme all correspondence and documentation is based on participant code numbers; the corresponding participant names are only known by the Scheme Secretary. On occasions the Scheme Secretary may have a member of the Quality Assurance Reference Centre or other sources requesting details of a participant’s code or results. The Secretary must not divulge this information, if the person continues with their enquiry the Scheme Secretary will refer them to the Scheme Organiser. The Scheme Secretary will be required to divulge the links between the code and name in the following circumstances: In writing to a participant who requests a reminder of his/her code number, this cannot be done by telephone. In writing to the Chairman of the Histopathology / Cytopathology National Advisory Panel of the Joint Working Group on Quality Assurance, in order to investigate appropriately a case of persistent substandard performance. When persistent substandard performance is identified the Scheme Organiser is not told the identity of the participant. Any correspondence between the Scheme Organiser and the participant only contains the participant code and should be placed in a sealed envelope with only the code visible for the Scheme Secretary to put in an appropriately labelled envelope. Filename: yorkshire histo eqa sops v8 Version No: 8.0 Date Created: 01/08/2013 Last Revised On: 01/08/2013 Review Date: 08/14 Page 41 of 47 Author: Leeds Office MW Authorised By:
Page 1 and 2: Yorkshire General Histopathology Ex
Page 3 and 4: STANDARD OPERATING PROCEDURES Stand
Page 25 and 26: STANDARD OPERATING PROCEDURES Any f
Page 39: STANDARD OPERATING PROCEDURES Stand
Page 43 and 44: STANDARD OPERATING PROCEDURES Docum
Page 47: STANDARD OPERATING PROCEDURES Stand

SOPs for the Yorkshire General Histopathology EQA Scheme

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?