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The facility medical director must be a registrant of the ºÚÁÏÉç, whose scope of practice confers experience in management of the diagnostic services being employed.

Organizations seeking to become accredited for PCR or serology services will be required to have a medical director or consultant who holds appropriate credentials with at least one of the following bodies:

• Canadian ºÚÁÏÉç of Microbiologists
• Royal ºÚÁÏÉç of Physicians and Surgeons of Canada, microbiology specialty
• American Board of Medical Microbiology

The facility medical director (e.g. registrant of the ºÚÁÏÉç) must sign one accreditation agreement per facility.

If you are seeking point-of-care or microbiology DAP accreditation, please submit evidence to the standards listed on the spreadsheet.

As part of the pre-assessment activity, review the spreadsheet and submit the required evidence for POC/MIC accreditation. The spreadsheet contains standards that will provide assurance of your facility's state of readiness for assessment.

Prepare the evidence by labelling the file with:

• criteria descriptors (e.g. ERS4.2.1 or ERS4.2.1-ERS4.2.6)
• highlighting the evidence

On the spreadsheet, complete the following columns:

• File name of evidence (e.g. ERS4.2.1 – Maintenance Record)
• Location of the evidence within the file (e.g. page 2)

Submit the evidence and spreadsheet to dap@cpsbc.ca.

Upon receipt, the DAP will review the evidence according to the standards and then an on-site assessment will be scheduled.

The DAP will try to review evidence as soon as possible.

We aim to review the evidence within a week of submission, although it can take longer depending on assessor availability. If further evidence is required a DAP staff will be in contact.

It is important for a facility to validate the instrument they receive before performing patient testing.

Upon receiving equipment, facilities need to verify that the device is functioning as intended to ensure delivery of high-quality, safe patient care. This is completed through a validation study. You can perform validation by asking other labs for samples or contacting a commercial proficiency testing (PT) provider. 

Proficiency testing (PT) is an evaluation of participant performance against pre-established criteria by means of interlaboratory comparison.

A PT program is a quality assessment tool that provides a retrospective measure of technical quality. To be most effective, PT must be used in conjunction with the laboratory’s internal quality control program and be a part of the quality management system.

The objectives of the PT program for the DAP are to:

• provide objective evidence of laboratory competence through continual monitoring
• identify trends in acceptable PT results and flag unacceptable PT results requiring investigation
• monitor the outcomes of investigations and subsequent corrective actions
• provide laboratories the opportunity to identify issues related to systemic error, imprecision, or human error; potentially unrecognized issues if PT is not fully incorporated into the quality management system
• consider laboratory PT performance during the assessment and accreditation process using a combination of data collected through the PT monitoring process and evidence provided during onsite assessment

Learn more about proficiency testing and how to manage it