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Dear Bharat We received similar non-conformities at recent UKAS inspections. - no documented root cause analysis or evidence of action taken when failing to meet the standard for TaT which we had stated in our Lab Handbook and agreed with users - only monitoring Emergency Dept TaT and annually referred work Our response was to document better (we’d been doing investigation but not documenting it), and to schedule spot audits throughout the year of different panels of tests which have different stated TaTs eg. U+E panel from wards, LFT panel from GPs, TFT panel from all non-urgent location, sample specialist tests. We use 1 months worth of data and perform each audit once in the 2 yearly audit cycle. It’s a bit time consuming but not too bad. I’m sure there are other ways to fulfil the standard but this is what we’ve adopted. Claudia Claudia Tomkins Biochemistry @ Kettering General Sent from my iPhone On 31 May 2019, at 11:54, GRAY, Yusuf (UNIVERSITY HOSPITALS OF DERBY AND BURTON NHS FOUNDATION TRUST) <[log in to unmask]<mailto:[log in to unmask]>> wrote: We monitor monthly using the easiest parameter of 1 hour from receipt in laboratory to authorisation, but not from request in ED to authorisation (which might be a better measure for users). Our standard agreed with ED is 95% within an hour, which was agreed with them before I joined the lab in 2011. We had a similar finding to yours, Bharat, in 2012 that we were not meeting the TAT agreed with users, agreement with users being the crucial part of the non-conformance. The options were to reduce the target to a value we could meet, or to put in place measures to regularly meet he agreed target (which we did and have maintained since then). Be wary of using things you can measure as targets to achieve, rather than aspire to. BW Yusuf Gray Biomedical Scientist Team Manager - POCT | Derbyshire Pathology - Blood Sciences | Royal Derby Hospital T: 01332 788537 Together Everyone Achieves More From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of GERRARD, Adam (BIRMINGHAM WOMEN'S AND CHILDREN'S NHS FOUNDATION TRUST) Sent: 31 May 2019 11:43 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: TAT Sorry, that should have read 4.14.7 From: GERRARD, Adam (BIRMINGHAM WOMEN'S AND CHILDREN'S NHS FOUNDATION TRUST) Sent: 31 May 2019 11:41 To: [log in to unmask]<mailto:[log in to unmask]> Subject: RE: TAT 4.4.17 The laboratory, in consultation with users, shall establish turnaround times for each of its examinations that reflect clinical needs. The laboratory shall periodically evaluate whether or not it is meeting the established turnaround times. BW, Adam From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Brian Shine Sent: 31 May 2019 11:36 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: TAT Yes, it does sound odd. Is it that it’s in your lab specification and you don’t meet it, or that you can’t show your TATs? Best wishes, Brian On 31 May 2019, at 11:22, David James <[log in to unmask]<mailto:[log in to unmask]>> wrote: I'm sorry - what standard is that finding under? Monitoring I can understand, but a finding about not meeting 90% within 1 hour I find hard to understand how that contravenes an ISO stnadrad dj ________________________________ From: Clinical biochemistry discussion list <[log in to unmask]<mailto:[log in to unmask]>> on behalf of Patel Bharat (RWG) West Hertfordshire TR <[log in to unmask]<mailto:[log in to unmask]>> Sent: 31 May 2019 11:11:48 To: [log in to unmask]<mailto:[log in to unmask]> Subject: Re: TAT We have a TAT finding with UKAS - monitoring TAT for all outputs and not meeting 90% TAT within 1hr from ae for several months. Using Path manager on winpath is very tedious and not very user friendly esp with data extraction. How do other labs monitor their TAT for all outputs and your targets and software (method) used for data extractions. Monitoring referred tests?? 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