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F-QM-001-A-V0 — Laboratory Strategic & Quality Master Plan

Type: Form · Version: V0 · Status: DRAFT — UNAPPROVED · Served read-only from the bundled QMS copies. The Drive master is untouched.

Parent document: LAB-QM-001 — Quality Management Manual (parent is encoded in the form number)

Rendered in-browser from the project's Word file F-QM-001-A-V0-laboratory-strategic-and-quality-master-plan.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.

Document #	F-QM-001-A-V0	Parent Document	LAB-QM-001 — Quality Management Manual

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Part 1 — Official Mission, Vision, and Core Values Statement

1.1 Mission

To provide accurate, timely, and reliable diagnostic laboratory services through advanced technology, quality management, and professional expertise, supporting effective clinical decision-making and optimal patient care.

1.2 Vision

To be a premier center of clinical laboratory excellence, recognized for innovation, high standards of quality assurance, and exceptional patient-centered care.

1.3 Core Values

Integrity: Uncompromising commitment to honesty, ethical reporting, and confidentiality.
Accuracy & Quality: Excellence and rigor in every pre-analytical, analytical, and post-analytical procedure.
Compassion & Patient Focus: Respectful, patient-centered service delivery to the community of Tarangnan.
Continuous Improvement: Proactive learning, error detection, and compliance with national and international standards.

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Part 2 — Three-Year Strategic Priorities & Multi-Year Roadmap

Planning Horizon: 2026 – 2028 | Reviewed Annually by Hospital Director, Pathologist, and Chief Medical Technologist

Strategic Pillar	Strategic Goal / Initiative	3-Year Target	Year 1 Milestone	Year 2 Milestone	Year 3 Milestone	Lead Responsible	Required Investment / Resources
1. Service Excellence & Scope	Modernize primary testing services and streamline send-out referral paths	100% adherence to standard test menu and 0 specimen lost in transit	Establish formal SPH MOA; audit transport boxes	Upgrade urine chemistry reading system	Evaluate expanded POC menu	CMT / LQM	Equipment budget, MOA approval
2. Quality & Accreditation	Full DOH A.O. 2021-0037 compliance and alignment with ISO 15189:2022	100% compliance on annual DOH regulatory inspection	Complete QMS policy/SOP baseline and form digitization	Implement full internal audit cycle	Pursue national recognition / DOH CQI award	Pathologist & CMT	Training, audit tools
3. Workforce Development	Sustained competency and continuous professional education for technical staff	100% compliant CPD units and annual competency clearance	Complete annual competency assessments for all MTs	Formalize biosafety and chemical safety certification	Establish bench rotation & leadership succession	CMT / LQM	CPD registration support
4. Technology & Infrastructure	Transition to integrated digital records and resilient equipment maintenance	Fully verified Lab-LIS workflows and 99% equipment uptime	Digitize all quality logs into Excel/LIS backups	Procure backup UPS for clinical chemistry/CBC	Explore interfaced analyzer connectivity	Hospital Admin & CMT	IT hardware, SAN PHARMA SLA

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Part 3 — Annual Action Plan & Operational Milestones

Operational Work Plan for Current Calendar Year | Monitored Monthly during Laboratory Staff Meetings

Task No.	Planned Activity / Operational Project	Specific Output / Deliverable	Responsible Lead	Target Start	Target Completion	Budget / Resource Needs	Monitoring Frequency
AP-01	Annual Review and Update of QMS Policies and SOPs	Revised manual & controlled document logs	CMT / LQM	Jan 15	Feb 28	Office supplies	Monthly
AP-02	Semi-Annual Internal Quality Audit Cycle 1 & 2	Completed Audit Reports & CAPA Plans	Lead Auditor / CMT	Mar 01	Oct 31	Audit checklists	Semi-Annual
AP-03	Annual Staff Competency Assessment & Performance Reviews	Competency records for all MTs and LAs	CMT / LQM	Apr 01	May 31	Evaluation rubrics	Annual
AP-04	Equipment Calibration and Preventive Maintenance Cycle	Calibration certificates & PM service tags	CMT / MTs	Ongoing	Nov 30	Contracted vendor	Quarterly
AP-05	Management Review Meeting Preparation & Execution	Documented MR Minutes & Action Items	CMT & Pathologist	Nov 15	Dec 15	Conference room	Annual

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Part 4 — Laboratory Quality Plan & Annual Quality Objectives Matrix

One-Year Measurable Quality Objectives and Performance Indicators per LAB-QM-001 Section 5.5

Objective No.	Quality Objective / Target Area	Key Performance Indicator / Metric	Baseline Performance	Annual Target	Action Steps / Strategies	Responsible Owner	Resources Required	Target Timeline
QO-01	Pre-examination Specimen Quality	Specimen Rejection Rate	< 2.0%	< 1.0%	Nurse orientation; phlebotomy re-training	CMT / LQM	Training supplies	Q1–Q4
QO-02	Analytical Reliability & Proficiency	EQA / PT Survey Performance	100% participation	100% acceptable	Daily QC monitoring; immediate CAPA on shift	Medical Technologists	Control reagents	Q1–Q4
QO-03	Timeliness & Turnaround Time	Routine CBC & Urinalysis TAT	90% within 45 min	>= 95% within 45 min	Workflow optimization; batching minimization	Medical Technologists	LIS tracking	Q1–Q4
QO-04	Critical Value Communication	Critical Value Timely Notification	95% within 15 min	100% within 15 min	Direct phone escalation log verification	Medical Technologists	Dedicated landline	Q1–Q4
QO-05	Client & Patient Satisfaction	Overall Customer Satisfaction	88%	>= 92%	Customer service reinforcement; quarterly surveys	Complaints Officer	Survey forms	Q1–Q4

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Part 5 — Annual Endorsement & Administrative Authorization

Role	Name	Signature	Date
Prepared by: Chief Medical Technologist / Laboratory Quality Manager	Junry, RMT
Reviewed by: Pathologist / Head of Laboratory
Approved by: Hospital Director

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