The Laboratory Quality Assurance Program (LQAP) is responsible for establishing the requirements and standards of medical laboratories in the province of Saskatchewan and to ensure their compliance with the Medical Laboratory Licensing Act and Regulations.
The College of Physicians and Surgeons of Saskatchewan (CPSS) is contracted by the Province of Saskatchewan’s Ministry of Health to operate the LQAP Program.
The purpose of assessing and accrediting laboratories is to evaluate and ensure compliance with established standards, identify areas of excellence and provide recommendations for improvement. Accreditation is defined as the public recognition of quality achievement by a health care organization, as demonstrated through an independent external peer comparison of the organization’s performance against current best practices.
The LQAP consists of two types of committees comprised of medical and technical experts in the relevant disciplines:
1. Program Management Committee (PMC)
2. Discipline-specific Quality Assurance (QA) Commitees for:
- Anatomic Pathology
- Microbiology, and
- Transfusion Medicine.
Role of the PMC
The PMC is the oversight body for operations and decision-making for the program. It is comprised of:
- the chairs of the discipline-specific committees
- representatives from:
- Saskatchewan Association of Combined Laboratory and X-Ray Technologists
- Saskatchewan Medical Association
- Saskatchewan Society of Medical Laboratory Technologists
- Ministry of Health
Role of the QA Committees
The QA Committees develop guidelines for laboratory practice in their specific disciplines, review facilty assessment reports and proficiency testing deficiencies.
Laboratory Accreditation Program Model
The Laboratory Accreditation Program Model is a peer review process with a goal to improve laboratory performance through objective education.
The peer review is conducted by assessment teams:
1. Trained team leaders - conduct opening and summation conferences, assist in report and response review
2. Trained assessors with subject matter expertise – selection based on scope of services
Any facility holding a Medical Laboratory License is subject to
assessment on a 4-year rotation*.
The Assessment Procedure
*Assessment may occur prior
to 4-year rotation if the PMC determines that evidence of compliance was not
a. A pre-assessment notification is sent to the facilities to arrange logistics.
2. Assessment Team Selection
a. Team members are selected based on scope of laboratory services.
3. Information Distribution
a. LQAP provides assessment resources such as previous reports, facility-specific standards, Facility Test Menu, interview templates and more (for assessors)
b. Facilities are required to provide a test menu and staff lists and are also required to complete a Pre-assessment data verification form (PADV) form prior to assessment. (NOTE: Facilities are not required to submit self-assessment documents)
4. Training Session
a. Facilities and assessors are each provided with a training session prior
to the assessment.
a. Team leader conducts an opening meeting.
b. Tour of laboratory.
c. Assessment team members assess their area of expertise by verifying compliance with the intent of the standards. They will review documents and observe practice and interact with staff.
d. Citations are documented on the day of assessment into a report template.
e. Facilities receive a verbal summation of citations at the end of the assessment.
a. All accreditation reports are reviewed by QA and PMC Committees
For more details, consult the Accreditation Program Guide.
b. Responses for non-conformance are due within 30 or 60 days of final report - including evidence of compliance
c. Facilities and assessors receive evaluation surveys after each assessment
d. Facilities are sent an invoice.
e. PMC grants accreditation upon receiving acceptable evidence of compliance.
f. All assessment findings are shared with the Ministry of Health (MoH).
g. MoH receives bi-annual updates of accreditation status.
About the Standards
Standards are secure documents, shared only with a facility's laboratory supervisor and approved designee. Laboratory supervisors further disperse these documents within their organization and manage the security features.
To submit a proposed standards revision, complete the WCDAA Stakeholder Standards Revision Form, ensuring that:
- the specific standards or section are identified
- verifiable references (including link or attachment) are provided
- the request applies to all diagnostic laboratory facilities (not limited to organization specific practice)
- contact information is included
NOTE: The WCDAA standards are copyright College of Physicians and Surgeons of Alberta. College of Physicians & Surgeons of Alberta (CPSA) accredited laboratories and other approved users may download, print or make a copy of this material for their noncommercial personal use. Any other reproduction in whole or in part requires written permission from the CPSA and the material must be credited to the CPSA.
To receive permission to reproduce/reference all or part of the Laboratory Standards, please complete the following form: Standards Copyright Request Form. To help us process your request in the timeliest manner possible, please be sure that the information you provide is both accurate and complete.