IG-09 Who Does What — LAB-QM-008

Hospital Directorexecutive authority

›

Pathologistclinical & technical oversight

›

Chief Medical Technologist/ Laboratory Quality Manager

›

Medical Technologiststechnical work

›

Laboratory Aidessupport work

The Hospital Director and the Pathologist are separate roles with distinct authorities — neither replaces the other (§5.1). The full organizational chart is F-QM-008-A-V0; this page is a responsibility summary, not the chart.

Role	Authority & key responsibilities
Hospital Director	Executive leadership, direction and resources for the laboratory; ultimate institutional accountability. Grants final approval for all laboratory policies, SOPs and forms before implementation.
Pathologist	Clinical and technical oversight of operations and examination quality. Reviews and concurs on all technical and quality policies, SOPs and forms before approval. Signs relevant SOPs within 2 months of appointment to the role.
Chief Medical Technologist / LQM	Day-to-day leadership of the laboratory's technical, clinical and administrative operation. Maintains and posts the org chart (F-QM-008-A-V0); documents delegation and leave coverage (F-QM-008-B-V0); escalates matters beyond laboratory authority to the Pathologist and Hospital Director.
Medical Technologists	Perform technical and quality duties within their verified competence. Report quality concerns, risks and nonconformities through established channels. Accept formally delegated duties only within the limits of the delegation.
Laboratory Aides	Non-technical support duties only; report observed problems to a Medical Technologist or the CMT/LQM. NEVER perform, verify, interpret or release laboratory examinations — and never collect patient specimens.

Role

Authority & key responsibilities

Hospital Director

Executive leadership, direction and resources for the laboratory; ultimate institutional accountability. Grants final approval for all laboratory policies, SOPs and forms before implementation.

Pathologist

Clinical and technical oversight of operations and examination quality. Reviews and concurs on all technical and quality policies, SOPs and forms before approval. Signs relevant SOPs within 2 months of appointment to the role.

Chief Medical Technologist / LQM

Day-to-day leadership of the laboratory's technical, clinical and administrative operation. Maintains and posts the org chart (F-QM-008-A-V0); documents delegation and leave coverage (F-QM-008-B-V0); escalates matters beyond laboratory authority to the Pathologist and Hospital Director.

Medical Technologists

Perform technical and quality duties within their verified competence. Report quality concerns, risks and nonconformities through established channels. Accept formally delegated duties only within the limits of the delegation.

Laboratory Aides

Non-technical support duties only; report observed problems to a Medical Technologist or the CMT/LQM. NEVER perform, verify, interpret or release laboratory examinations — and never collect patient specimens.

Delegation & leave cover (§5.4)

Delegation is in writing on F-QM-008-B-V0, to qualified, competent staff only — e.g. QC review, method verification, PT monitoring, equipment oversight, occurrence review, LIS administration.
The person who delegates keeps ultimate accountability.
Leave needing delegation is not processed without a completed F-QM-008-B-V0 naming who assumes the duties.

Notify DOH in writing (§5.2.2)

Inform HFSRB / CHD-RLED of any change in: ownership · location · Head of Laboratory (Pathologist) · laboratory personnel.
CMT/LQM prepares the notification; the Hospital Director signs and submits it. File the copy and proof of receipt with the LTO.

Posted where clients can see (§5.2)

Current organizational chart (F-QM-008-A-V0) — names, photos, designations.
Current, valid DOH License to Operate (LTO).