1 Establishment & Legal
Laboratory Identification Laboratory is clearly identifiable with a name displayed on an outside signboard.
Indicator 001 View details
2 Establishment & Legal
Legal Compliance of Signboard Signboard conforms to prescribed local legal standards.
Indicator 002 View details
3 Establishment & Legal
Advertising Authority Compliance (PDA) Signboard falls within Peshawar Development Authority regulatory framework.
Indicator 003 View details
4 Establishment & Legal
Associated Collection Centers Laboratory operates as a single facility with no associated collection centres; status is documented and compliant.
Indicator 004 View details
5 Establishment & Legal
Signed Memorandum of Understanding (MOU) Signed, valid MOU with Test Zone Diagnostic Centre for specialised test referrals.
Indicator 005 View details
6 Governance & Management
Head of Laboratory Qualifications Head of laboratory holds requisite technical qualifications and experience.
Indicator 006 View details
7 Governance & Management
Laboratory Mission Statement Management has formally laid down the laboratory's mission statement.
Indicator 007 View details
8 Governance & Management
Laboratory Policy and SOPs Detailed laboratory policy and standard operating procedures are documented.
Indicator 008 View details
9 Facility & Safety
Emergency Policy & SOPs Fire and non-fire emergency policy and SOPs are in place, with an annual mock drill.
Indicator 009 View details
Budget and Resource Allocation Management approves a sufficient budget and allocates resources to fulfil the mission.
Indicator 010 View details
Laboratory Organogram Management has established a formal organogram for the laboratory.
Indicator 011 View details
Appointment of Section Heads Shifa Clinical is a routine laboratory; the CEO / Pathologist directly manages appointments.
Indicator 012 View details
Support for Research Activities Research policy is formally documented; laboratory scope is defined as routine diagnostic testing only.
Indicator 013 View details
Awareness of Relevant Laws Management is conversant with all relevant laws and their applicability to the laboratory.
Indicator 014 View details
Regulatory Updates Management regularly updates any amendment in prevailing relevant laws and rules.
Indicator 015 View details
Implementation of Requirements Management ensures implementation of regulatory requirements.
Indicator 016 View details
17 Facility & Safety
Space Allocation & Separation Effective separation between administration and technical laboratory areas.
Indicator 017 View details
18 Facility & Safety
Movement of Technical Staff Measures restrict movement of technical staff between different laboratory sections.
Indicator 018 View details
19 Facility & Safety
Early Detection of Emergencies Plans and provisions exist for early detection of fire and non-fire emergencies.
Indicator 019 View details
20 Facility & Safety
Abatement of Emergencies Provisions exist for abatement of fire and non-fire emergencies.
Indicator 020 View details
21 Facility & Safety
Containment of Fire Emergencies Fire extinguishers, blankets, alarms, exits and training for containment are in place.
Indicator 021 View details
22 Facility & Safety
Displayed Safe Exit Points Safe exit points are clearly marked and displayed for both fire and non-fire emergencies.
Indicator 022 View details
23 Facility & Safety
Annual Mock Drills Mock drills are held at least once a year.
Indicator 023 View details
24 Facility & Safety
Staff Emergency Training Staff are trained for their role in emergencies; each holds a Rescue 1122 certificate.
Indicator 024 View details
25 Human Resources
Job Descriptions Job descriptions for every post are clearly identified and documented.
Indicator 025 View details
26 Human Resources
Eligibility Criteria Eligibility criteria for qualification and experience for each job are available.
Indicator 026 View details
27 Human Resources
Recruitment Recruitment strictly follows the laid-down eligibility criteria.
Indicator 027 View details
28 Human Resources
Orientation Plan An orientation plan book exists for newly inducted employees.
Indicator 028 View details
29 Human Resources
Policy Awareness Each staff member is informed of laboratory-wide and section-specific policies.
Indicator 029 View details
30 Human Resources
Staff Rights & Responsibilities Every staff member is made aware of their rights and responsibilities during orientation.
Indicator 030 View details
31 Human Resources
Patient Rights & Responsibilities All employees are educated on patients' rights and responsibilities.
Indicator 031 View details
32 Human Resources
Performance Appraisal Tools Well-documented performance appraisal tools exist.
Indicator 032 View details
33 Human Resources
Awareness of Appraisal Tools Staff are informed of the appraisal cycle for probation and permanent employees.
Indicator 033 View details
34 Human Resources
Appraisal for Development Appraisals are used as tools for growth and job improvement.
Indicator 034 View details
35 Human Resources
Performance Appraisal Cycle Formal appraisal cadence: 4 months for probationers, December for permanent staff.
Indicator 035 View details
36 Human Resources
Personal Files Personal files are maintained for all full-time and part-time employees.
Indicator 036 View details
37 Human Resources
In-Service Training Plan A structured in-service training plan is in place.
Indicator 037 View details
38 Human Resources
In-Service Training Records Training and education records are documented and stored in each personal file.
Indicator 038 View details
39 Human Resources
Document Verification System Credentials of newly appointed staff are formally verified.
Indicator 039 View details
40 Human Resources
Verification of New Credentials Newly acquired qualifications, credentials and training certificates are verified before personnel records are updated.
Indicator 040 View details
41 Procurement & Reagents
Procurement Procedure Documented procurement SOP: specifications → tender → bids → award → delivery.
Indicator 041 View details
42 Procurement & Reagents
Procurement Specifications Standardised minimum specifications, tailored per environment and user.
Indicator 042 View details
43 Procurement & Reagents
Procurement Orders Documented Request/Demand Form template for supplier orders.
Indicator 043 View details
44 Procurement & Reagents
Stock Register Entries Procured items are regularly entered into the stock register.
Indicator 044 View details
45 Procurement & Reagents
Safe Storage & Use of Reagents Reagents stored per hazard class; FIFO applied; temperature/humidity logged.
Indicator 045 View details
46 Procurement & Reagents
Inventory of Reagents Reagent inventory tracks location, quantity and expiration.
Indicator 046 View details
47 Procurement & Reagents
Near-Expiry Alert Expiry calendar tracks items expiring within the next 8 months.
Indicator 047 View details
48 Procurement & Reagents
Labelling of Reagents Reagent labelling follows SOPs — name, concentration, dates, disposal.
Indicator 048 View details
Equipment Log Books Log books for all equipment are available and actively maintained.
Indicator 049 View details
Maintenance & Calibration Records Periodic maintenance and calibration records are filed in equipment log books.
Indicator 050 View details
Log Sheet Displayed on Equipment Relevant log sheets are physically displayed on each piece of equipment.
Indicator 051 View details
Emergency Numbers on Equipment Emergency contact numbers are labelled on all equipment.
Indicator 052 View details
Equipment Inventory Equipment inventory is maintained with make, model and serial numbers.
Indicator 053 View details
54 Records & Reporting
Electronic Patient Records Every patient's data is securely maintained using OneLabz software.
Indicator 054 View details
55 Records & Reporting
Unique Record Identifiers Every laboratory record has a unique identifier (T/R Number or T/R ID).
Indicator 055 View details
56 Records & Reporting
Chronological Patient Record Records provide an up-to-date, chronological account per patient.
Indicator 056 View details
57 Records & Reporting
Authorised Entries Only Only authorised personnel can make entries in laboratory records.
Indicator 057 View details
58 Records & Reporting
Date, Time & Identity Stamped Every entry is date- and time-stamped with the identity of the entrant.
Indicator 058 View details
59 Records & Reporting
Computerised Reporting System A computerised reporting system (OneLabz) is operational.
Indicator 059 View details
60 Records & Reporting
Critical Value Reporting Critical results and notifiable diseases are reported per SOP.
Indicator 060 View details
61 Records & Reporting
Documented Reporting Times Minimum reporting time is documented for every test.
Indicator 061 View details
62 Records & Reporting
Patient-Coded Report Access Reports are accessible to individual patients through a secure code / QR.
Indicator 062 View details
63 Quality Assurance
Quality Assurance SOPs Available Documented QA SOPs cover pre-analytical, analytical and post-analytical stages.
Indicator 063 View details
64 Quality Assurance
Designated QA Focal Person Mr. Afaq Ahmad (Laboratory Technologist) is the designated QA focal person.
Indicator 064 View details
65 Quality Assurance
QA SOPs Communicated to Staff QA SOPs are formally communicated to all laboratory staff.
Indicator 065 View details
66 Quality Assurance
External Quality Assessment EQA participation with nationally and internationally recognised bodies is active.
Indicator 066 View details
67 Quality Assurance
EQA Records Maintenance Records of EQA reports are fully maintained and audited.
Indicator 067 View details
68 Specimen Handling
Safe Specimen Collection Policies and procedures guide safe specimen collection.
Indicator 068 View details
69 Specimen Handling
Specimen Identification & Labelling SOPs guide identification and proper labelling of specimens.
Indicator 069 View details
70 Specimen Handling
Safe Specimen Handling SOPs guide safe handling of specimens.
Indicator 070 View details
71 Specimen Handling
Safe Transportation of Specimens SOPs guide safe transportation of specimens.
Indicator 071 View details
72 Specimen Handling
Specimen Processing SOPs guide the processing of specimens.
Indicator 072 View details
73 Specimen Handling
Safe Disposal of Specimens SOPs guide the safe disposal of specimens.
Indicator 073 View details
74 Quality Assurance
Internal Quality Control (IQC) Internal quality control framework is fully implemented and operational.
Indicator 074 View details
75 Quality Assurance
Process Cycle Records Process cycle records are maintained for all runs.
Indicator 075 View details
76 Quality Assurance
Gap Identification via QA Reports Gaps are identified through QA reports and used to drive improvement.
Indicator 076 View details
77 Quality Assurance
Corrective Actions Corrective actions are implemented upon identification of gaps.
Indicator 077 View details
78 Quality Assurance
Preventing Error Recurrence Measures minimise recurrence of identified errors.
Indicator 078 View details
Biosafety SOPs Available Biosafety manual and SOPs are available and reviewed every 6 months.
Indicator 079 View details
Biosafety SOPs Communicated Biosafety SOPs are communicated to laboratory employees.
Indicator 080 View details
Designated Biosafety Technician Mr. Afaq Ahmad (Laboratory Technologist) is designated for biosafety activities.
Indicator 081 View details
Biosafety Monitoring Reports Regular biosafety monitoring reports are generated.
Indicator 082 View details
Biosafety Consumables & Equipment Appropriate consumables, equipment and facilities ensure biosafety.
Indicator 083 View details
Staff Vaccination Handling / disposal staff receive Hepatitis B vaccination (evidence on file).
Indicator 084 View details
Annual Medical Check-Up Annual staff medical check-up is documented in personal files.
Indicator 085 View details
86 Patient Facilities
Ventilated Waiting Areas Well-ventilated patient waiting areas are provided.
Indicator 086 View details
87 Facility & Safety
Restricted Working Area Patients are not allowed inside the laboratory working area.
Indicator 087 View details
Incident Reporting All incident reports — including near-misses — are documented within 48 hours.
Indicator 088 View details
Disinfectants & Spill Kits Required disinfectants and spill kits are available in the laboratory.
Indicator 089 View details
Sample Storage Area Access Sample storage area is restricted and access is controlled.
Indicator 090 View details
91 Waste Management
Sample Transportation Records Sample transportation is properly recorded via the Test Zone portal.
Indicator 091 View details
92 Waste Management
Waste Management SOPs Written laboratory waste management SOPs are available with outsourced disposal contract.
Indicator 092 View details
93 Waste Management
Waste SOPs Communicated Waste management SOPs are communicated to all laboratory employees.
Indicator 093 View details
94 Waste Management
Waste Handling Consumables & Equipment Appropriate consumables and equipment for waste management are stocked.
Indicator 094 View details
95 Waste Management
Waste Disposal Contracts Contracts with waste disposal service organisations are available.
Indicator 095 View details
96 Waste Management
Waste Transportation Records Waste transported from collection to final disposal is recorded.
Indicator 096 View details
97 Patient Facilities
Client Feedback Mechanism Client feedback and complaint pathways are displayed and accessible.
Indicator 097 View details
98 Patient Facilities
Basic Facilities Basic facilities are accessible in the laboratory.
Indicator 098 View details
99 Patient Facilities
Clean Washrooms Clean toilets/washrooms with bolts, preferably separate for male and female.
Indicator 099 View details
100 Patient Facilities
Facilities for Disabled Patients Facilitated toilets for disabled patients are available.
Indicator 100 View details
101 Patient Facilities
Phlebotomy for Disabled Patients Phlebotomy services are adapted for disabled patients.
Indicator 101 View details
102 Patient Facilities
Directional Signage Directional arrows guide patients to important areas.
Indicator 102 View details
103 Services & Emergency
Laboratory Services & Tariff Policy Full tariff and reporting times published for routine and outsourced tests.
Indicator 103 View details
104 Services & Emergency
Biannual Performance Monitoring System to monitor and measure laboratory performance biannually against mission.
Indicator 104 View details
105 Services & Emergency
Kit Consumption Audit Procured kits and their consumption are compared with tests performed during audit.
Indicator 105 View details
106 Services & Emergency
Emergency Handling of Patients Documented protocols for anaphylaxis, cardiac arrest, seizure, stroke, asthma, diabetes, MI, syncope and hyperventilation.
Indicator 106 View details
107 Services & Emergency
Emergency Contact Numbers Verified directory of emergency contacts is maintained.
Indicator 107 View details
Sentinel Event Definition Sentinel events are defined per international standards.
Indicator 108 View details
Sentinel Event Analysis Root cause analysis and action plans are prepared within 45 calendar days.
Indicator 109 View details
110 Services & Emergency
Home-Based Sample Collection — Availability Home-based sample collection service is available.
Indicator 110 View details
111 Services & Emergency
Home-Based Sample Collection — Records Records of home-based sample collections are properly maintained.
Indicator 111 View details
Scope of Informed Consent Mandatory written consent for invasive procedures, teaching, research and specific tests.
Indicator 112 View details
Consent for Incapacitated / Urgent Care Defined process for urgent care, next-of-kin hierarchy and unaccompanied patients.
Indicator 113 View details
114 Services & Emergency
Tariff List Displayed to Patients Full routine and outsourced tariff list with reporting times is available to patients.
Indicator 114 View details
Additional Reports Policy Additional reports generated from the same sample are provided at no extra cost.
Indicator 115 View details
Complaint Registration Patient complaints are accepted and properly registered.
Indicator 116 View details
Remedial Actions on Complaints Proper actions and remedial measures are taken in response to complaints.
Indicator 117 View details
Confidentiality of Patient Records Confidentiality of patient records is strictly maintained.
Indicator 118 View details 