Quality & Patient Safety Indicators

DSM is committed to quality and patient safety across at all sites across Manitoba, and to ensuring Manitobans have the information they need about quality assurance and patient safety in the provincial lab system. We aim to provide useful and relevant information that will foster a better understanding of the processes behind your care with DSM.

External Proficiency Testing

External Proficiency Testing (EPT) is a fundamental piece of the quality process for DSM’s laboratory operations. This essential patient safety assurance mechanism helps to ensure that DSM’s analytical systems are performing appropriately compared with expected results and peer labs. DSM subscribes to numerous EPT programs from various laboratory organizations in Canada, the US and the UK, which assess performance on thousands of tests across all laboratory disciplines several times per year. 

Each EPT program sends out samples that are carefully prepared to duplicate actual human samples. Each sample is tested as if it were an actual patient sample and the results are sent to the EPT program. The correct results are unknown to DSM at the time of testing. The EPT program compares the results to peer groups and to the ‘true’ value for each result and sends a report back to DSM. Non-conforming (NC) results are those that do not meet the standards set by the EPT program, but are not necessarily clinically significant ‘errors’. All non-conforming results are analyzed in detail by DSM to determine what caused them and what could prevent them in future.

All provincial EPT data flows through a central data analysis process and as such is a very valuable tool to monitor performance. EPT data is reviewed on an ongoing basis by DSM’s Lab Managers and Supervisors, DSM Laboratory Discipline Teams, DSM Senior Management, the DSM Patient Safety Committee and our health care partners at the Manitoba Quality Assurance Program (MANQAP).

DSM continues its excellent EPT performance in fiscal 2011/2012:

Summary of EPT Results in the second quarter of fiscal 2011/2012

EPT Conformance Rates over Time

Turn Around Times

Turn around time (TAT) is a measure of how quickly results are reported back to the clinician who ordered the test. The most common way of reporting TAT is the interval from the time when the specimen is received by the lab to the time when the result is reported to the clinician. DSM strives to provide test results to requesting physicians within the timeframe appropriate for each test.  Since DSM’s test menu includes thousands of different tests, with varied complexities and clinical requirements, the target TAT for each test or group of tests must be set appropriately.

DSM is focused on reducing TAT through a variety of initiatives including process improvement/lean design and alternative models of service. Click here for more information on DSM initiatives in these areas.

ER Tests

Emergency and stat tests are always performed on a priority basis, ensuring timely results in all urgent situations.  Below is an example of TAT for common lab results reported to the Emergency Rooms (ER) at Winnipeg community and teaching hospitals during fiscal 2011/2012:

Community Hospitals - percentage reported within 60 minutes
Fiscal 2011/2012

Teaching Hospitals - percentage reported within 60 minutes
Fiscal 2011/2012

* Complete Blood Count

Pathology Tests

As in all disciplines, critical and urgent pathology tests are given priority. DSM strives to complete 95% of pathology tests within a three-week timeframe, with our ultimate goal of meeting the timelines required by our accreditors. All urgent cases and routine cases can have results reported within days while more complicated tests can take longer, depending on complexity.  DSM makes every effort to appropriately manage pathology workload to ensure timely results for all cases, while also focusing on ensuring the quality and accuracy of results. Below is a table with most recent surgical pathology reporting data.

Mean Surgical Pathology TAT reported in Working Days +/- 1 SD (Standard Deviation) for fiscal 2011/2012

*Westman Laboratory Pathology TAT is represented as a Median value; SD values are not currently calculated.