Quality Manual - Quality Manual Right Patient, Right Test, Right Result, Right Time, Right Support - Changes from last version

Sep 2, 2026

Quality Manual for Scarborough, Hull, York Pathology Service (York & Scarborough Hospitals; formally Laboratory Medicine) defining governance, quality policy, and supporting information for laboratory services. The manual records recent controlled changes from the previous version, including updates to reference naming, organisational charts, document control, and specific section additions and replacements across pages. It structures requirements across general information, references, definitions, and management and technical obligations for consistent service delivery and quality assurance.

LanguageEnglish

CategoryForms

FormatDOCX

Pages82

Reading Time29 min

AccessFree to download

General Information

Purpose

Scarborough, Hull, York Pathology Service (SHYPS)

Laboratory Service Scope

Quality Policy

Information on SHYPS Services

References

Definitions & Abbreviations

Management Requirements

Organisation and Management Responsibility

Quality Management System (QMS)

Document control

Service Agreements

Examination by Referral Laboratories

External Services and supplies

Advisory Services

Resolution of complaints

Identification and Control of Nonconformities

Corrective Action

Preventive Action

Continual Improvement

Control of Records

Evaluation and audits

Management Review

Technical Requirements

Quality Manual Scarborough, Hull, York Pathology Service York & Scarborough Hospitals (Formally known as Laboratory Medicine) ‘Right Patient, Right Test, Right Result, Right Time, Right Support’ Changes from last version of this document General updates including CR6847: Trust S&N now DIS CR6934: LM-INF-UKAS LAB1 has been replaced by LM-INF-GEN 6 CR6935: Reference to the name Laboratory Medicine amended throughout the document. Laboratory Manager renamed Head Biomedical Scientist in the organisational charts. CR6936: Section 4.1.1.2 removal of the organisation Monitor, added a link to the compliance certificate. CR7481: Added BT-SOP-CONT PLAN to section 5.10.3 CR7613: Page 10 POCT services also provided on BH site CR7614: Added reference to PC-INF INDUCTION & PC-INF-TRAINMAN 5.1.4 CR7616: Section 5.6.3.1 added reference PC-SOP-EQA CR7617: Section 5.6.4: added reference to PC-SOP-ADV CR7618: Added PC-SOP-CONT PLAN to section 5.10.3 Page. 24: LM-POL-REFERRAL has been replaced by SHY-POL-REFERRAL Page. 58: Transfusion Quality Assurance Policy (BT-POL-QA) has now been included in section 5.6.2 Page 68: Update for new Care Group Structure Page 69: Update of Clinical Leadership organisational chart Page. 71: Update to the SHYPS senior management organisation chart Page. 76: Creation of the blood science specimen reception organisation chart Page. 78: Addition of the Network Chief BMS to the Microbiology organisation chart Table of Contents TOC \o "1-3" \h \z \u HYPERLINK \l "_Toc149832401" 1. General Information PAGEREF _Toc149832401 \h 7 HYPERLINK \l "_Toc149832402" 1.1 Purpose PAGEREF _Toc149832402 \h 7 HYPERLINK \l "_Toc149832403" 1.2 Scarborough, Hull, York Pathology Service (SHYPS) PAGEREF _Toc149832403 \h 8 HYPERLINK \l "_Toc149832404" 1.2 Laboratory Service Scope PAGEREF _Toc149832404 \h 9 HYPERLINK \l "_Toc149832405" 1.2.1 Blood Sciences PAGEREF _Toc149832405 \h 9 HYPERLINK \l "_Toc149832406" 1.2.2 Cellular Pathology and Microbiology/Virology PAGEREF _Toc149832406 \h 10 HYPERLINK \l "_Toc149832407" 1.2.3 Central Service PAGEREF _Toc149832407 \h 10 HYPERLINK \l "_Toc149832408" 1.3 Quality Policy PAGEREF _Toc149832408 \h 11 HYPERLINK \l "_Toc149832409" 1.4 Information on SHYPS Services PAGEREF _Toc149832409 \h 11 HYPERLINK \l "_Toc149832410" 2. References PAGEREF _Toc149832410 \h 11 HYPERLINK \l "_Toc149832411" 3. Definitions & Abbreviations PAGEREF _Toc149832411 \h 12 HYPERLINK \l "_Toc149832412" 4.0 Management Requirements PAGEREF _Toc149832412 \h 14 HYPERLINK \l "_Toc149832413" 4.1 Organisation and Management Responsibility PAGEREF _Toc149832413 \h 14 HYPERLINK \l "_Toc149832414" 4.1.1 Organisation PAGEREF _Toc149832414 \h 14 HYPERLINK \l "_Toc149832415" 4.1.2. Management Responsibility PAGEREF _Toc149832415 \h 16 HYPERLINK \l "_Toc149832416" 4.2 Quality Management System (QMS) PAGEREF _Toc149832416 \h 19 HYPERLINK \l "_Toc149832417" 4.2.1. General requirements PAGEREF _Toc149832417 \h 19 HYPERLINK \l "_Toc149832418" 4.2.2. Documentation requirements PAGEREF _Toc149832418 \h 20 HYPERLINK \l "_Toc149832419" 4.3 Document control PAGEREF _Toc149832419 \h 21 HYPERLINK \l "_Toc149832420" 4.4 Service Agreements PAGEREF _Toc149832420 \h 22 HYPERLINK \l "_Toc149832421" 4.4.1 Establishment of Service Agreements PAGEREF _Toc149832421 \h 22 HYPERLINK \l "_Toc149832422" 4.5 Examination by Referral Laboratories PAGEREF _Toc149832422 \h 24 HYPERLINK \l "_Toc149832423" 4.5.1 Selecting and Evaluating Referral Laboratories and Consultants PAGEREF _Toc149832423 \h 24 HYPERLINK \l "_Toc149832424" 4.5.2 Provision of Examination Results PAGEREF _Toc149832424 \h 25 HYPERLINK \l "_Toc149832425" 4.6 External Services and supplies PAGEREF _Toc149832425 \h 25 HYPERLINK \l "_Toc149832426" 4.7 Advisory Services PAGEREF _Toc149832426 \h 25 H

FAQs

What is the purpose of the Quality Manual for SHYPS?

It sets out the general information, quality policy, and requirements governing Scarborough, Hull, York Pathology Service laboratory activities and service consistency.

What types of updates are included from the last document version?

The manual lists controlled changes such as updated references, renamed roles in organisational charts, section revisions, added links, and replacements of referenced policies or documents.

How are management requirements structured in the manual?

They are organized under organisation and management responsibility, the quality management system (QMS), document control, service agreements, external/referral activities, nonconformities and actions, continual improvement, record control, audits, and management review.

Sep 2, 2026

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