Purpose 

Our goal is to provide the highest quality Laboratory Services to our patients at SIH hospitals 24 hours a day, seven days a week, 365 days per year.

Key Strategic Focuses

  1. To perform all services so that outcomes meet of exceed established goals for patient satisfaction as determined by Press Ganey scores.
  2. To work to create an efficient work environment, contain costs and provide the highest quality results for our patients. This is accomplished by participation in Lean projects, monitoring of monthly budget statements, negotiation of reagent/equipment pricing and enrollment in proficiency surveys for all analytes tested. 
  3. To maintain CAP Accreditation and establish ongoing QA monitors for each individual area within the laboratories. 

Types and Ages of the Patients Given Care

  A. Laboratory personnel collect and analyze specimens from inpatients, outpatients and emergency room patients. In addition, specimens are sent in to the SIH Laboratories for analysis by other health care providers within the surrounding communities. The ages of the patients served are as follows.

  1. Neonate <1 month
  2. Infant  1 month - 1 year
  3. Pediatric  1 year-13 years
  4. Adolescent  14 -18 years
  5. Adult  19 - 64 years
  6. Geriatric  >65 years

Scope of Current and Planned Services/Practices

   A. SIH Laboratories employs Medical Technologists and Medical Laboratory Technicians to perform analytical and diagnostic procedures in the areas of Hematology, Urinalysis, Coagulation, Blood Band, Immunology, Microbiology, Molecular Diagnostics, Chemistry, Histology, Cytology, and Point of Care. Phlebotomists are employed to obtain patient blood specimens. The Pathology department employs Histotechnicians for the processing of tissue and fluid specimens. A pathologist serves as the Laboratory Medical Director.
  B. The laboratory shall only examine specimens at the written request of a licensed physician and physician assistants, dentist, podiatrist, chiropractors, business Medical Review Officer, insurance carriers via the company physician, or authorized law enforcement agency. The physician or other authorized person shall submit a written request with the patient, electronically or faxed prior to  lab work being performed. 
  C. The laboratory maintains an online compendium which is available to all inpatient and outpatient care areas. Additional information such as testing methods, including performance specifications will be made available upon request.
  D. Changes to laboratory testing methodology and changes to normal ranges that could impact patient care will be communicated to the providers we serve. 

Availability of Staff

  A. SIH Laboratories are staffed 24 hours per day, seven days per week, 365 days per year with testing personnel and phlebotomists. The Laboratory Manager is available on-site or by phone at any time.
  B. Laboratory staffing may adjust depending on anticipated workload and involvement in lab projects.
  C. All positions are staffed with personnel that have completed initial and annual competency for the job being performed.

Methods Used to Assess and Meet Patients Needs and Services

  A. The Laboratory participates in patient satisfaction surveys (Press Ganey). Periodic huddles and staff meetings are used to share the results and comments from these surveys and to discuss areas for improvement, as well as operational issues. 
  B. The Laboratory will continually look to bring in new testing and upgrade existing testing platforms to better serve our patient population.

Recognized Standards/Guidelines of Service

  A. College of American Pathologists
  B. Illinois Department of Public Health (Clinical Improvement Act CLIA)
  C. Health Care Financing Administration (HCFA)
  D. The Joint Commission (TJC)
  E. Food and Drug Administration (FDA)
  F. The Laboratory is inspected and accredited on a bi-annual basis by the College of American Pathologists (CAP)
  G. American Association of Blood Banks.

Department Performance Improvement Plan

  A. The SIH Laboratory Quality Assurance and Performance Improvement Program is designed to objectively and systematically monitor and evaluate the quality and appropriateness of patient care as provided by the Laboratory. The Laboratory will continually pursue opportunities to improve patient care, and resolve problems as they arise.
  B. Quality indicators are established for all sections within the Laboratory. Each indicator is measurable and serves as a monitor of specimen collection processes, testing processes and result outcomes.
  C. Monitoring may include any or all of the following:

  1. Turn Around Times for Emergency Room and Morning Run
  2. Error reports
  3. Critical value reporting
  4. Blood Utilization
  5. Test Utilization
  6. Monthly budget and expense
  7. Employee competency
  8. Specimen collection, handling and transportation
  9. Patient satisfaction
  10. Blood culture contamination rate

  D. Lab will participate in Lean Daily Management with metrics related to safety, quality, productivity, delivery and cost with daily report to administration. Metrics will be chosen based on opportunity  for improvement and alignment with the SIH Strategic Plan (X Matrix).