SOPs for the Yorkshire General Histopathology EQA Scheme

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STANDARD OPERATING PROCEDURES Standard Operating Procedure 39: Audit of the Quality Management System (CPA Standards: A4, H1, H3, H5) The Quality Manager is responsible for undertaking the annual audit of the quality management system. The purpose of the audit is to: a) determine compliance of the quality management system with CPA requirements b) determine the effectiveness of the implemented quality management system for the purposes of meeting specified quality objectives c) ensure that corrective actions agreed upon as a result of the previous audit have been completed effectively The audit of the quality management system will be undertaken as follows: a) Review of the quality management system b) Review of previous non-compliances, reasons/ contributing factors and actions taken c) Conduct document review d) Conduct on-site audit activities e) Completion of Quality Management System spreadsheet referencing the findings of the review of each document/standard f) Raise critical non compliances to Scheme Organiser with immediate effect g) Prepare, approve and distribute the audit report h) Monitor the work undertaken to address non-compliance The report on the audit of the Quality Management System will be provided on an annual basis to the Scheme Organising Committee. 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 44 of 47 Author: Leeds Office MW Authorised By:
STANDARD OPERATING PROCEDURES Standard Operating Procedure 40: Quality Improvement (CPA Standards: A2, H1, H5) All members of the EQA team are required to ensure a process of continual quality improvement through the undertaking of internal quality assurance. The Quality Manager will develop a plan for undertaking the audits indicated in SOPs 36 and 39 with the support of the Scheme Organising Committee. The audit plan will include details of the audits to be undertaken and relevant timescales. On completion of each audit the Quality Manager will provide a summary and action plan of the findings including non-conformities identified, reasons/ contributing factors for the non-conformity, action required, responsible individual and timescales. The Quality Manager will also identify areas where noncompliance may occur if preventative action is not taken. These will be provided to the members of the EQA Scheme Organising Committee for approval. The Quality Manager will monitor the progress of the action plan and provide feedback to the EQA Scheme Organising Committee. All outcomes of the quality improvement programme will be summarised to the staff members for educational purposes as part of the EQA team meetings. 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 45 of 47 Author: Leeds Office MW Authorised By:
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SOPs for the Yorkshire General Histopathology EQA Scheme

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