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Internal Audit Program
Integral to maintaining accreditation, the internal audit program also provides another mechanism for identifying system and procedural improvements.
During the year 45 audits were performed for DTBV, Microbiology, Toxicology, Histology, Molecular Biology, Mortuary, Pathology and Corporate Services to ISO17025, NATA Forensic Science, Medical Testing, Parentage Testing and the code of Good Manufacturing Practice requirements.
Most recommendations pertained to documentation revisions, particularly in light of the implementation of the new document control system.
The three key improvement suggestions from the audits are:
• Documentation reflects practice;
• On-going staff internal training and updating of training files
• Equipment maintenance and schedules.
Continuous Improvement (CIRCA)
CIRCAs are the foundation of the Insti-tute's system for identifying opportunities for system and procedural improvement. During the year 94 individual CIRCA's were raised. Of these, 45% were related to internal services, 2% related to external services, 39% related to safety issues, 2% related to audits and 12% related to customer complaints/feedback.
Improvements arising from some these requests included :
• Changes to internal privacy procedures;
• Streamlined reporting of test results;
• Improvements to mortuary accommodation;
• Improved procedures for family contact;
• Amended procedures for consent for tissue retention;
• Updated IT Helpdesk procedures
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