Policies and guidelines

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The following policies and guidelines apply to all departments within the Division of Laboratory Medicine:

Sample acceptance policy

This policy sets out Manchester University NHS Foundation Trust’s policy for the acceptance process for specimens requiring analysis by Directorate of Laboratory Medicine.

It provides a robust framework to ensure that all specimens are correctly and unambiguously identified.

Download the DLM Specimen Acceptance Policy.

Communication of test results

MFT has produced a Communication of Test Results policy to help to minimise the risk of misdiagnosis or failure/delay in diagnosis and to improve patient outcomes and quality of care, ensuring correct and efficient communication of test results.

It is the responsibility of individual Laboratory Managers within the Directorate of Laboratory Medicine, who provide services for diagnostic testing and/or screening, to develop local procedures relating to those tests and screening in accordance with the Trust ‘Policy for the Management of Clinical Diagnostic Tests or Screening Procedures’ and the guidance in the DLM policy.

Trust policy states:

“…It is the responsibility of the referring healthcare professional to peruse, view, act upon and record the outcomes/results of any diagnostic test and/or screening procedure they have requested. If they are not able to do this during their working hours they must ensure appropriate handover of their responsibilities.”

The Directorate of Laboratory Medicine has developed three flowcharts to help explain to users the communication of test results from the Directorate, showing the attempts made by the Directorate to communicate results, urgent results and the failsafe mechanisms in place.

Underlying these three flowcharts is a Directorate of Laboratory Medicine Policy explaining and detailing these flowcharts: The DLM Communication of Test Results (DLM-QUAL-POL-3).

Confidentiality of patient information

The Division of Laboratory Medicine conforms to the Manchester University Hospitals NHS Foundation Trust Confidentiality Code of Conduct and Information Disclosure Policy ON4-3437.

Manchester University Hospitals NHS Foundation Trust (MFT) collects holds and processes personal data about many individuals including information about its employees, patients, suppliers, clients and stakeholders.
The Trust is committed to handling all information efficiently, securely, effectively and in accordance with relevant legislation in order to deliver the best possible healthcare and services.

The Trust ensures that all staff are aware of their responsibility for patient confidentiality through annual mandatory training. There are several overarching policies on confidentiality and data protection. The Trust has an informatics department which oversees the handling of patients’ records, supports the Information Technology (IT) systems and ensures the security and confidentiality of information.

The Trust information charter can be found on the staff intranet site and the Division of Laboratory Medicine notes that:

• We only ask for information that we need to allow interpretation of results
• We protect the information and ensure only those staff who need to see the information can access it
• We share the information only when we need to for patient care for example sending the information to another laboratory for testing
• We don’t store information for any longer than is absolutely necessary

Sending information to other laboratories

While several hundred laboratory tests are performed within the MFT, for some rare or complex tests patient specimens may be sent to specialist laboratories elsewhere which have the necessary expertise. In some cases there will be only one specialist laboratory in the whole country which performs a particular test, meaning using referral laboratories is essential.

There is a detailed policy in place to govern how we choose these referral laboratories. Referral laboratories are selected for their expertise and their quality standards. We regularly check their accreditation status, which gives us assurance that they have procedures in place for the protection of information.

We also have specialist laboratories within the DLM and we receive specimens from around the country. Therefore our laboratories have procedures in place for the protection of information not just from the patients from our area but all patients from around the country.

When specimens are sent to a referral laboratory we need to send some ‘patient identifiers’ such as name and date of birth. In some tests it is essential to send further information, for example, symptoms or travel information, to allow the referral laboratory to interpret the results for our individual patient. In some tests ethnic origin and family details may need to be shared with the referral laboratory.

Consent to a specimen being taken and analysed is given by the patient presenting at the point of specimen collection. The responsibility for obtaining informed consent for the test(s) resides with the medical staff ordering the test. Informed consent should cover all the tests being undertaken, implications of the results of these tests and the disclosure of clinical and personal details to appropriate health care personnel.