qualified patients. The laboratory tracks trends in physician orders, patient returns, and positive/ negative results—reporting this information on a

version of policies and procedures are available for staff at all laboratory sites. Users access policies and procedures electronically at the bench by desk-top computers and iPads. There is elec- tronic access to the current version of policies and procedures for all lab- oratory departments. Each Ambula- tory Lab has a corresponding site in MediaLab where staff can access site- specific policies and procedures. Staff members receive mail noti- fication when a new document or major revisions are appli- cable to their jobs and auto- matically notifies supervisors if employees haven’t signed-off on time.

There’s also a process in MediaLab for periodic staff reviews of policies and procedures with documentation. And most impor- tantly, it eliminated paper copies of procedure manuals! Today, the two fixed laboratories and Ambulatory Draw Sites are paperless.

Microbiology Technologists performing digital plate reading

weekly basis. Receiving timely information allows physicians to provide early detection and treatment. The Outreach Manager and Microbiology Man- ager are members on the Infection Control and Antibiotic Stewardship committees at each of the nursing homes serviced by Lancaster General Health Laboratory to offer expert guidance. One of the tools that has come about through this partnership is an antibiogram based on the patient population. Lancaster General Health’s partnership with a new Behavioral Health Hospital which opened in 2018 allowed them to provide mobile labora- tory and diagnosis services to a group of formerly underserved patient population in the community. LGH has implemented a huddle process across the organization. Each department has daily huddles and huddle boards that are used to evaluate work processes to generate ideas for improvement.

Education and training Mandatory annual continuing education programs are required for all laboratory staff. In addition, every employee is required to complete additional elective continuing education programs of their choosing. The content of the elective programs is reviewed with their immediate supervisor for approval. The department manager is responsible to prepare a yearly listing of educational activi- ties available to employees, the Medical Director is responsible for approving the listing. Recently the entire laboratory implemented an electronic document control system. All laboratory departments transitioned from a paper system to electronic systems in MediaLab.

The Electronic Document Control System for lab- wide policies and procedures ensures the current


Strategic outlook Last summer, LGH joined their

Penn Medicine colleagues in adopting the following

Penn Medicine Experience Standards: t Be compassionate: I serve with my head and heart. t Be Present: I show up and remain engaged. t Be Empowered: I drive results with intention. t Be Collaborative: I partner with unwavering support. t Be Accountable: I commit to every single moment.

LGH also continued deployment of the Lean Management System to align with the following

senior level goals: t Development of Huddle Board Quality Metrics. t Gemba (a Japanese term meaning “the actual

place”) Walks to identify and eliminate waste. t Engage staff regarding problem solving in their area. t Use of Process Standard Work. t Corrective Actions through Plan-Do-Check-Act cycles.

Lab inspections

In 2018 the LGH lab implemented MediaLab Electronic Accreditation System, InspectionProof. The software allows for inspection documentation in one system. Documentation for checklist items are completed by entering text responses, upload- ing supporting files, and linking to policies and procedures. Compliance to CAP requirement is measured by the system. Additionally, the laboratory has an internal audit team comprised of staff technologists. All members participate in ISO 15189 educational courses on internal auditing. The audit team developed the program’s policies, procedures, and training process. The first audit cycle started in 2014 after the CAP on-site inspection. A trained lab auditor audits each lab department once a year. The internal audit team helps each department to stay inspection ready.

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