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F-QM-003-A-V0 — Quality Indicator Register, CQI Schedule, and Performance Improvement Log

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

Parent document: LAB-QM-003 — Continual Improvement, Quality Indicators, and Performance Improvement Program Policy (parent is encoded in the form number)

Rendered in-browser from the project's Word file F-QM-003-A-V0-quality-indicator-register-and-performance-improvement-log.docx (policies-docx / forms-docx — the file Junry reviews). Formatting is faithful, not pixel-perfect; the DOCX is the official copy.

Document #	F-QM-003-A-V0	Parent Document	LAB-QM-003 — Continual Improvement and Performance Improvement Program Policy

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Part 1 — Quality Indicator Specifications Table (Planning Elements per LAB-QM-003)

Register of approved quality indicators, their specifications, monthly monitoring metrics, and targets:

Indicator ID	Quality Indicator Title	Phase (Pre / Exam / Post)	Quality Objective Relates To	Numerator & Denominator Definition	Calculation Method / Unit	Data Source	Target / Threshold Limit	Monitoring Frequency	Process Owner
QI-PRE-01	Specimen Rejection Rate	Pre-Analytical	Reduce pre-analytical specimen collection errors	N: Total rejected specimens; D: Total accessions received	(N / D) x 100 (%)	F-QM-PRE-003-A-V0	Target < 1.0%	Monthly	Medical Technologist (Receiving)
QI-PRE-02	Request Form / Labeling Completeness	Pre-Analytical	Ensure 100% positive patient and test identification	N: Incorrectly labeled or identified requests; D: Total requests	(N / D) x 100 (%)	F-QM-PRE-003-A-V0	Target < 0.5%	Monthly	Medical Technologist (Phlebotomy)
QI-ANA-01	PT / EQAP Acceptable Performance Rate	Examination	Maintain technical competency and analytical accuracy	N: Satisfactory PT results; D: Total PT challenges evaluated	(N / D) x 100 (%)	F-QM-ANA-004-A-V0	Target 100% (Min 80%)	Per Survey Event / Annual	Chief Medical Technologist
QI-ANA-02	Internal QC Failure / Out-of-Control Rate	Examination	Ensure analytical precision and run stability	N: QC runs exceeding 1-3s or 2-2s limits; D: Total QC runs	(N / D) x 100 (%)	Sectional QC Logs	Target < 2.0%	Monthly	Medical Technologists (Bench)
QI-ANA-03	Equipment Downtime	Examination	Monitor equipment availability and out-of-service time	Total equipment out-of-service time recorded for the month	Hours per month (trending)	Equipment downtime log / LIS	Trending — target to be set	Monthly	Medical Technologists (Bench)
QI-POST-01	Routine Test Turnaround Time (TAT)	Post-Analytical	Timely delivery of outpatient and inpatient results	N: Routine tests meeting stated TAT; D: Total routine tests	(N / D) x 100 (%)	Lab-LIS / Daily Worksheets	Target >= 95%	Monthly	Chief Medical Technologist
QI-POST-02	STAT Test TAT Compliance	Post-Analytical	Immediate release of emergency diagnostic tests	N: STAT tests released within 60 min; D: Total STAT tests	(N / D) x 100 (%)	F-QM-POST-003-A-V0	Target >= 98%	Monthly	Chief Medical Technologist
QI-POST-03	Critical Values Notification Compliance	Post-Analytical	Urgent physician phone notification within 15 min	N: Critical values called within 15 min; D: Total critical values	(N / D) x 100 (%)	F-QM-POST-002-A-V0	Target 100%	Monthly	Medical Technologists (Testing)
QI-POST-04	Corrected / Amended Report Rate	Post-Analytical	Ensure clinical report accuracy and integrity	N: Corrected / amended reports; D: Total reports issued	(N / D) x 100 (%)	F-QM-POST-001-A-V0	Target < 0.2%	Monthly	Chief Medical Technologist
QI-GEN-01	Customer & Patient Satisfaction Rate	General QMS	Continual service and customer satisfaction	N: Positive satisfaction ratings; D: Total survey responses	(N / D) x 100 (%)	F-QM-004-A-V0	Target >= 90%	Quarterly / Annual	Chief Medical Technologist
QI-GEN-02	Monthly Test Volume & Workload	General QMS	Track workload for staffing and capacity planning	Total tests performed in the month	Count	Lab-LIS	Trending only — no target	Monthly	Chief Medical Technologist

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Part 2 — Monthly Performance Tracking and Improvement Actions Log

Monitoring Period (Month/Year)	Indicator ID	Actual Result / Rate	Target Met? (Y/N)	Analysis / Variance Explanation	Corrective / Performance Improvement Action	Responsible Person	Target Completion Date	Follow-up Status
								[ ] Open [ ] Closed
								[ ] Open [ ] Closed
								[ ] Open [ ] Closed
								[ ] Open [ ] Closed
								[ ] Open [ ] Closed
								[ ] Open [ ] Closed

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Part 3 — Annual CQI Study Matrix & Priority Schedule

Planned clinical and operational CQI studies scheduled across quarters per LAB-QM-003 Section 5.4:

Study No.	CQI Study Title / Problem Statement	Priority / Rationale	Lead Investigator	Methodology / Data Source	Target Sample Size / Scope	Scheduled Quarter	Target Completion	Progress Status	Outcome / Project Charter Ref
CQI-2026-01	Reduction of Pre-analytical Hemolysis in ER Blood Draws	Elevated hemolysis rate observed in emergency specimens	Medical Technologist Rep	Hemolysis tracking log	All ER blood specimens over 60 days	Q1–Q2	June 30	Ongoing	Charter # CQI-C-01
CQI-2026-02	Optimization of CBC Turnaround Time during Outpatient Rush	Outpatient release delay between 09:00–11:00 peak hours	CMT / LQM	LIS timestamp audit	200 consecutive outpatient CBC requests	Q3	September 30	Planned	Charter # CQI-C-02
CQI-2026-03	Patient Adherence to Clean-Catch Midstream Urine Instructions	Contaminated urinalysis specimens from outpatient clinic	Nursing Rep	Patient interview & repeat sample audit	100 consecutive routine urinalysis patients	Q4	December 15	Planned	Charter # CQI-C-03

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Part 4 — Annual Review & Concurrence Sign-Off

Role	Name	Signature	Date
Maintained by: Chief Medical Technologist / Laboratory Quality Manager	Junry, RMT
Reviewed & Approved by: Pathologist / CQI Chair