Quality Cell NABL

Formal recognition of competence of a laboratory by NABL has many advantages:

Assurance of genuine reports
Increased confidence in laboratory Reports issued by the laboratories which emphasise on accuracy and reliable results.
Increased patient satisfaction
Better control of laboratory operations and feedback to laboratories as to whether they have sound Quality Assurance System and are technically competent

The following labs exist At Vardhman Mahavir Medical College and Safdarjung Hospital, Delhi

Apex Regional STD Teaching Training and Research Centre 5TH FLOOR c wing, new OPD Building.**
Microbiology laboratory - Fifth floor VMMC building
Clinical Biochemistry Unit, Third floor Old Emergency Building
Laboratory Medicine, Second floor, Old Emergency Building
Histopathology Laboratory, Fourth Floor, VMMC building
Cytopathology & FNAC Laboratory, VMMC building
Pathology Lab in OBG Department
Pathology lab in Burns Department
Hematology lab, first floor, H Block extension
NEB-Microbiology Laboratory, First floor
NEB-Biochemistry lab, First floor
NEB-Pathology laboratory, First floor
CIO Lab

**Apex Regional STD Teaching Training and Research Centre is an NABL Accredited laboratory since 2014.

The hospital management with the stake holders of various labs is now moving towards NABL Accreditation for all the labs.

VMMC & SJH NABL ACTIVITIES - ONSET AND PROGRESS

The Quality Cell of VMMC & Safdarjung Hospital was established in 2018 for initiating, coordinating, and accomplishing the task of Accreditation of the healthcare institution by NABH and NABL.

There are two divisions of the Quality Cell, viz. NABH division and NABL division.

The NABH division was established to work towards getting the hospital accredited by NABH.

The NABL division was established to work towards getting all the laboratories of SJH, accredited by NABL as per the International standard- ISO-15189:2012.

There are mainly 6 laboratories in VMMC & SJH, with various divisions under them

Department of Clinical Biochemistry
- Main Biochemistry Lab
- NEB Biochemistry
- SSB Biochemistry
Department of Microbiology
- Main Microbiology lab
  - Bacteriology
  - Virology
  - Mycology
  - Parasitology
  - Mycobacteriology
  - Serology
  - Hospital infection control unit
- NEB Microbiology
- SSB Microbiology
Department of Pathology
- Laboratory Medicine
- Histopathology
- Cytopathology
- FNAC lab
- Pathology lab in OBG
- Pathology lab in Burns department
- NEB Pathology
- SSB Pathology
- Blood bank
Department of Haematology
Central Institute of Orthopaedics laboratory (CIO-Lab)
Apex Regional STD Centre & State Reference Laboratory for HIV (STD Centre) - This laboratory has been Accredited by NABL as per ISO-15189:2021 since 2014.

The progress of the NABL division and its activities is given below

Date	Activity	Remarks
2018	Quality Cell was established.	For NABH and NABL activities
24.1.2019	Internal audit of NEB Microbiology laboratory performed.	Non-conformities were raised and given to lab.
31.1.2019	A meeting was held under chairmanship of MS to assess the status of laboratories in initiation of steps towards accreditation.	All 6 laboratories made presentations. Some initial steps were taken by labsOrganogram, mission vision statements, quality policy and objectives, designation of quality managers etc.
18.02.2020	Meeting held in MS office to apprise the MS regarding NABL accreditation plans for all labs.	-
21.2.2019	Internal audit of Biochemistry department.	NCs raised and given to lab.
25.2.2019	Internal audit of Histo/Cyto/FNAC lab	NCs raised and given to lab.
12.3.2019	A one day workshop held in Department of Microbiology for faculty and staff of all laboratories.	An introduction was given to NABL accreditation and ISO15189:2012 standard.
24th – 25th July 2019	Organized a two day workshop for faculty and staff of all laboratories of SJH on ISO15189:2012 standard clauses, Quality Management System and Accreditation process.	Involved lectures and group discussions and interactive sessions. Certificates were given to all attendees.
20th – 23rd July 2020	Four day Training on Internal audit and Quality Management Systems on ISO15189:2012 for 40 faculty and technicians from all 6 laboratories.	Organized by an external agency-MELAP. Three days online sessions and last day on site session. Certificates given to all participants. They are all qualified internal auditors now.
15.09.2020	Purchased 6 copies of the ISO-15189:2012 standard from BIS.	Distributed to all 6 laboratories.
04.08.2020	Meeting held under the chairmanship of MS to review the status of preparedness of laboratories towards NABL Accreditation. Faculty from all labs made presentations on status of their labs in accreditation process.	Targets were set for all laboratories to complete by 31.8.20; 15.9.20 and 30.9.20.
06.08.2020	Provided a signed letter from MS for all the laboratories to establish their legal identity as part of SJH.	This is a requirement for NABL.
21.08.2020	Website content prepared for NABL accreditation activities of the laboratories of the hospital.	-
1st to 16th October 2020	Internal audit of all 6 laboratories conducted by various auditors trained in July 2020.	NCs raised were provided to labs for closure and action.
17.11.2020	A Steering Committee was constituted for spearheading and overseeing the NABL Accreditation activities of the laboratories.	The MS designated as chairman. Dr. Sumathi Muralidhar appointed as Member secretary. In all 20 persons from labs appointed as members.
24.11.2020	Meeting of Steering committee of NABL activities under chairmanship of MS	The common issues and challenges faced by labs discussed.
10th – 15th January 2021	All 6 laboratories followed up on their internal audits and NC closure by conducting the Management Review Meetings in their respective departments.	The minutes of MRM were shared with the Quality Cell.
23.02.2021	A meeting was called by Quality Cell (NABL) under the chairmanship of MS to review the current status of all laboratories and their preparedness to apply for NABL accreditation. Each lab presented its status, problems and issues that were to be sorted.	The Biochemistry laboratory has completed its online application to NABL for accreditation. Haematology and CIO lab are in the final stages of online application. Pathology and Microbiology labs are working on sorting their issues.

"NABL accreditation of Clinical Biochemistry Unit, Department of Biochemistry."

Extensive internal audits have been carried out by a team of experts and the internal audit reports have been handed over to the respective laboratories.