document control dap quality conference may 12, 2008 debbie penn
TRANSCRIPT
Why Document?
Documenting policies, processes, and procedures communicates how to do a quality job to all workers.
Patient Safety -def
“The prevention and mitigation of unsafe acts within the health-care system. Strategies for improving patient safety include: Creating a culture that supports the identification
and reporting of unsafe acts; Effective measurement of patient injuries and
other relevant outcome indicators; and Tools for developing or adapting structures and
processes to reduce reliance on individual vigilance.”
Definition: Canadian Council on Health Services Accreditation (CCHSA) 2003
Why Document Control?
Controlling documents ensures that workers access and use only the most current versions of documents.
ISO 151894.3 Document Control
4.3.1 The laboratory shall define, document and maintain procedures to control all documents and information that form its quality documentation. A copy of each of the controlled documents shall be archived for later reference and the laboratory director shall define the retention period.
4.3.2 Procedures shall be adopted to ensure thata) All documents issued to laboratory personnel as part of the quality management system are reviewed and
approved by authorized personnel prior to issueb) A list, also referred to as a document control log, identifying the current valid revisions and their distribution is
maintainedc) Only current authorized versions of appropriate documents are available for active use at relevant locationsd) Documents are periodically reviewed, revised when necessary, and approved by authorized personnel,e) Invalid or obsolete documents are promptly removed from all points of use, or otherwise assured against
inadvertent use,f) Retained or archived superseded documents are appropriately identified to prevent their inadvertent use,g) If the laboratory’s documentation control system allows for the amendment of documents by hand pending the
re-issue of documents, the procedures and authorities for such amendments are defined, while amendments are clearly marked, initialed and dated, and a revised document is formally re-issued as soon as practicable, and
h) Procedures are established to describe how changes to documents maintained in computerized systems are to be made and controlled
4.3.3 All documents relevant to the quality management system shall be uniquely identified, to includea) Title,b) Edition or current revision date, or revision number, or all these, c) Number of pages (where applicable),d) Authority for issue, and e) Source identification.
Lab Standards: DAPX2.0 Procedures and processes are documented, current, accurate, and
controlled. x2.1 The laboratory uses documentation to ensure consistency of analysisx2.2 Documentation contains all the relevant material necessary to perform the
procedurex2.3 The laboratory defines and maintains procedures to control documents:
Documents are reviewed and approved by the medical leader or designate prior to issue There is evidence of document review at regular intervals by the medical leader and
technical staff All documents are uniquely identified Invalid or obsolete documents are promptly removed from all points of use Copies of master documents are archived Archival time for master documents is defined by the medical leader Version identification ensures that the latest approved version is in use Only current authorized versions of documents are available for active use A master index of all laboratory documents identifying current version and distribution is in
place Procedures are established to control document changes in computerized systems There are processes to address the amendments of documents by hand
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview(Renewal)
Release &Distribute
OK?
DraftDocument
No
Yes
Document Audit
•Title
•Document Identifier
•Responsible Person/Position
•Authorizer(s)
•Distribution locations
Document Lifecycle
Master Index
CHM1082SOP
Document Lifecycle
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview(Renewal)
Release &Distribute
OK?
DraftDocument
No
Yes
Document Audit
Review
•Does the process or procedure described work?
Approval
•Who has the authority to place this document into operation?
Document Lifecycle
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview(Renewal)
Release & Distribute
OK?
DraftDocument
No
Yes
Document Audit
Master Index:•Title•Document Identifier •Responsible Person/Position•Authorizer(s)•Distribution locations
•Version Number
•Effective Date
•Next Scheduled Review Date
Document Lifecycle
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview(Renewal)
Release & Distribute
OK?
DraftDocument
No
Yes
Document Audit
Audit
Controlled (working copies) of documents need to be easily identified, and in the location they are required for work as identified by the Master Index
Document Control Rules for Organization
Document Lifecycle
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview
(Renewal)
Release &Distribute
OK?
New/ModifiedDocument
No
Yes
Document Audit
Master Index:•Title•Document Identifier •Responsible Person/Position•Authorizer(s)•Distribution locations•Version Number•Effective Date•Next Scheduled Review Date -updated
Document Lifecycle
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview(Renewal)
Release &Distribute
OK?
New/ModifiedDocument
No
Yes
Document Audit
Review frequency
Document Lifecycle
.
Review & Approval
DCRDocument
ChangeRequest
ScheduledReview(Renewal)
Release &Distribute
OK?
New/ModifiedDocument
No
Yes
Document Audit
Who?
What?
Why?
CLSI GP2-A5 Laboratory Documents: Development & Control
Appendix R: Sample Document Change Request Form
Document Lifecycle
.
Review & Approval
DCR(Document
ChangeRequest)
ScheduledReview(Renewal)
Release &Distribute
OK?
New/ModifiedDocument
No
Yes
Document Audit
1. Document Creation & Approval Process
2. Document Distribution Process
3. Document Audit Process
4. Scheduled Document Review Process
6. Document Archive/Destruction Process
5. Document Change Process
3 ways to get this done…
Manually Paper based
Semi-Manually Common network to
store/make available documents electronically
Document Control Application
Where do I start?
1. Create an Identification Number and versioning convention for your documents
…and document it…
What do I do next?
2. Create a Master Index Database or spreadsheet Divide/delegate by process or department if it is
too large to manage in a consolidated fashion Identify responsibility for the Master Index
…and document it…
What do I do next?
3. Gather your documents Apply the document identifier Determine where all copies of the document are in
use
4. Create a master document file Place the master into that file with all of the
appropriate authorization and scheduled review signatures
Apply the “Control” mechanism to controlled working copies of the master document
Then What?
5. Complete the Master Index Transfer the document attributes to the
Master Index
•Title•Document Identifier •Responsible Person/Position•Authorizer(s)
•Distribution locations•Version Number•Effective Date•Next Scheduled Review Date
That takes care of documents you already have, now what?
6. Create your document processes Document Creation, Review & Approval Document Versioning, Distribution & Audit Document Change Document Archive
…and document them
Create instructions:
7. Write relevant document control procedures including: How to write a procedure (templates, etc.) Assign an identification number Register the document on the Master Index Identify “Controlled” documents
And finally…
CLSI GP2-A5 Laboratory Documents: Development & Control
Appendix S: Ten Rules for Document Control
CLSI GP2-A5 Laboratory Documents: Development & Control
Appendix S: Ten Rules for Document Control
8. Develop roles & responsibilities for document users
Write on/make changes to controlled documents?
White out?
Create additional copies beyond those distributed?
Document Control Dos & Don’ts
DO… Read Reference Vigilant “Control” DCR
DO NOT… Write White out Photocopy Print/retain Release
•Berte,L., Nevalainen,D., Quality Systems for the Laboratory, American Society of Clinical Pathologists, Chicago, USA, 2000
•Clinical and Laboratory Standards Institute (CLSI), GP2-A5 Laboratory Documents: Development and Control; Approved Guideline-Fifth Edition, CLSI document GP2-A5, Pennsylvania USA, 2006
•Canadian Standards Association (CSA), The ISO 15189:2003 Essentials, Mississauga, Ontario, Canada, 2004
•Clinical and Laboratory Standards Institute (CLSI), HS1-A2 A Quality Management System Model for Health Care; Approved Guideline-Second Edition, CLSI document GP2-A5, Pennsylvania USA, 2004
References:
Thank youDebbie Penn