Kingdom of Saudi Arabia

‫المملكة العربية السعودية‬

Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 1 of 14

‫ااا‬

1- MISSION

Alamal& psychiatric Hospital laboratory mission is to make a positive impact in health care through
excellence in the practice of laboratory testing by providing a specialized and high quality Services
for Mental and addicted from both outpatient and inpatient departments all over Jazan region and to
ensure their satisfaction through the highest standards.

2 - VISION

We hope to provide the optimum level of delivering laboratory services and become one of the referral
laboratories with distinguished staff according to National Quality Standard.

3- VALUES

We, the laboratory staff of Al amal& Psychiatric laboratory, believe in the following values:

 Superiority
 Respect
 Passion
 Team work
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 2 of 14

4. POLICY:

4.1 It is the policy of Al Amal& Psychiatric Hospital laboratory that scope of services as
provided by this policy be known and applicable to all department concern as well as from
MOH healthcare organizations and other healthcare centers.
4.2 The laboratory services are in compliance with applicable national standards.
4.3 Basic laboratory services (e.g., hematology and biochemistry) are available twenty four
hours a day, seven days a week. :

4.3.1 Biochemistry
4.3.2 Hematology

5.LOCATION:
The laboratory is located in ground floor in the center of the hospital building .
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 3 of 14

6.WORKING HOURS:
divided to three shifts in day

Shift Days Section Staff

Sunday to Thursday All section All staff
Morning
07:00am To 15:00 Chemistry Two staff
Friday and Saturday
pm Hematology

Evening Chemistry
All days Two staff
15:00 To 23:00 Hematology
Night All days Chemistry Two staff
23:00 To 07:00 Hematology

7. LAB SERVICES

These are carried by departments of the Al amal& Psychiatric Hospital laboratory:

7.1 Reception & collection unit

7.1.1 Receive the patient
7.1.2 Arrange patient for phlebotomy

7.1.3 Patient identification

7.1.4 Patient preparation
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 4 of 14

7.1.5 Blood collection

7.1.6 Sample labeling
7.1.7 Transfer the samples to units

7.2 Hematology unit

7.2.1 CBC
7.2.2 ESR
7.2.3 Sickling test
7.2.4 Stain
7.2.5 coagulation PT, APTT , INR

7.3 BIOCHEMISTRY

7.3.1 Glucose
7.3.2 Renal profile: Urea, Creatinine , UA

7.3.3 Liver Function Tests (LFT): AST , ALT , ALP ,T. Bilirubin, D. Bilirubin, T. Protein,
Albumin, GGT, FE.

7.3.4 Electrolytes :Sodium, Potassium and Chloride tests.

7.3.5 Cardiac Profile: CK, LD, CK-MB, LDH

7.3.6 MG , CA, FE , IBCT , LAC,

7.3.7 AMYLASE , LIPASE, CHOL,

7.4 PARASITOLOGY

7.4.1 Urine Analysis, Stool Analysis and Urine Pregnancy Test.

 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 5 of 14

7.5 SEROLOGY UNITS

7.5.1 CRP and RF

7.5.2 ASO Titer
7.5.3 Hepatitis B and C Viruses(HBsAg, HBcAb, Anti-HBs and HCV Ab.)
7.5.4 HIV 1&2
7.6 Toxicology UNITS

7.6.1 Amphetamines
7.6.2 Cannabinoids
7.6.3 Cocaine
7.6.4 Barbiturates
7.6.5 Benzodiazepine
7.6.6 Opiates
7.6.7 Methyl Alcohol

8. P.O.C.T( POINT OF CARE TEASTING)

8.1 Glucometer

9 - Lab. services are introduced to the following populations :

9.1 The laboratory services are in compliance with applicable national standards .
9.2 Patients of the Al amal& Psychiatric Hospital from both outpatient and inpatient departments
(males and females of different age groups )
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 6 of 14

10. LAB CUSTOMER:

10.1External Customers:
10.1.1 Patient via appropriate channel
10.1.2 visitors
10.1.3 families,
10.1.4 Comprehensive rehabilitation Center
10.1.5 prisoners

10.2 Internal Customers:

10.2.1 All medical department.
10.2.2 Medical and non-medical maintenance department.
10.2.3 Medical records department.
10.2.4 OPD Clinics.
10.2.5 Hospital Staff Via Staff Clinic
10.2.6 Contractors
10.2.7 Supplier

10.1a :There is written agreement or verbal understanding between the department and
other clinical departments and/or external customers, explaining the expectations of each
party.

10.1b : The department head has a mechanism for identifying and handling customers’ needs
and feedbacks (e.g., responding to complaints, satisfaction surveys)
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 7 of 14

11 .Staff (Positions and Tittles ) Who provides /performs the care/service

Number
Position title Qualifications & requirements
of staff
Laboratory Master degree in Medical Technology or Bachelor's degree in Medical
1
manager Technology + above 5 years experience
Physician Bachelor's degree in medicine and surgery (MBBCH) degree 1
Medical Master or Bachelor's degree in Medical Technology or Bachelor's degree
5
technologist in Medical Technology
Laboratory
diploma degree in laboratory science 11
technician
Safety officer Bachelor's degree + 3 years experience safety and (OSHA) certificate 1
Bachelor's degree in Medical Technology or Bachelor's degree with 2
Quality officer 1
years experience in quality management
Total number of employees 20

11. STAFF MOTIVATION

11.1 : Motived staff lab. Administration will select one staff monthly as employee in the month

11.2 : the name of the employee will be kept on main board in administration area .
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 8 of 14

12 STAFFING PLAN:

STAFFING PLAN

DEPARTMENT POSITION REQUIRED AVAILABLE DEFICIENT QUALIFICATION/

TITLE NUMBER NUMBER NUMBER TRAINING/ EXPERIENCE

Clinical 2 1 1 Bachelor's degree in medicine and

surgery (MBBCH) degree
pathologist
Three (3) years experience in related
field.

Senior Medical 3 0 3 Master degree in Medical Technology .

Specialist non Med
Five years experience in related field .

Laboratory 25 7 15 Bachelor Graduate in

Medical Specialist laboratory field.
non Med
Laboratory At least one year experience.
Department 0 12 0
Laboratory Diploma in any related course.
Technician
At least one year experience.

Laboratory 6 0 6 Diploma in any related course.

Phlebotomist
At least one year experience.

Secretary 2 0 0 Diploma in any related course.

At least one year experience.

 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 9 of 14

13. PATIENT POPULATION

Total population
13.1.1 We provide the laboratory services to all the population of Jazan region

13.2 Age & Gender :

13.2.1 Average population number 1.800.000

13.2.2 Including all genders and ages
13.2.3 Average investigations done per year: around 60.000. tests
13.2.4 Average number of patients per year 40.000

14. TRAINING POLICIES AND REQUIREMENT (CONTINUOUS MEDICAL

EDUCATION) :
14.1 Orientation program for the new employee about the different department in the lab

14.2 Training program on any new procedure or piece of equipment that arrive to the lab.

14.3 Training about safety and quality control in every department.

 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 10 of 14

15. THE COMMUNICATION METHODS WITH OTHER DEPARTMENTS, DIVISIONS

AND SERVICES.
15.1 Direct personal communication, telephone service, mobiles, beeper, Fax, letters, written
reports – e-mail

Telephone No:

Administration: 2258

Main Lab: 2255

Reception: 2268

Toxicology: 2256

File Room: 2257

16. DEPARTMENTAL MEETINGS AND COMMITTEES

16.1 Quality and patient safety committee

16.2 Training committee

16.3 Safety and Infection control committee

16.4 Meeting not less than 10 meeting in year of the Head of departments and lab. Director with
the lab.
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 11 of 14

17. THE SPECIAL EQUIPMENT AND OR PROCESSES USED IN THE PROVISION OF

THE SERVICE :

S.No. Machine Section Use

1 Ruby cell-dyn Hematology CBC
2 Vitros 350 Chemistry All chemistry tests
3 Architect C4000( abbott ) Toxicology All chemistry tests
4 Evolus Virology Hbsag, Hbsagab marker, HCV, HIV
5 Microsope Para Urine & stool analysis
6 Stago Hematology Coagulation
7 XP- sysmex Hematology CBC

18 .OUT SOURCE ( SEND OUT )

S.No TEST SECTION SEND TO

.
1 TORCH , DNA ,RNA ,C3 ,C4 , ANCA, Serology King Fahad Central Hospital
IHA , H.pylori , RIBA ,
2 Hormones Sample Hormones King Fahad Central Hospital
3 Hb- Electrophersis, G6PD Hematology King Fahad Central Hospital
4 All cultures Microbiology Prince Mohamed Bin Nasser
Hospital
5 Therapeutic drug ( see attachment ) Chemistry Toxicology center through
TAT Requirement OTARR
6 Confirmatory Drug of Abuse Toxicology Toxicology center through
OTARR

When laboratory services are provided through a contract, the hospital provides oversight and
management of the contract through the process described
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 12 of 14

Referral to outsource policy (DPP-LAB-001-08 )

19. New tests introduced within last 3 years:

Process for requesting new test products or service:

19.1 With the need of a new test by the doctors of the hospital or by the laboratory workers for
expanding the type of services for covering the patient health care.

19.2 For generating a new test we need a clear justification from the requesting physician
including the clinical impact on the patient management and statistics about expected number of the
requested tests per month & year

19.3 We take in consideration the balance between the clinical values, cost effectiveness and
work load.

19.4 We search for the availability of the test in the MOH tender and acquire the code number

19.5 Based on the previous mentioned information’s we will decide to implement the test inside
our lab or to send it to a reference lab outside

19.6 Then the approval of these requested tests through the lab executive committee will be take
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 13 of 14

20 .FORMS & ATTACHMENTS

Organizational chart

21. MATERIALS & EQUIPMENTS:

Laboratory service guide Manual

22. REFERENCES:
KFSH & RC, IPP LAB –OM 0101J, Scope of Providing Care
 Kingdom of Saudi Arabia
‫المملكة العربية السعودية‬
Ministry of Health ‫وزارة الصـحـة‬
Directorate of Health Affairs Jazan ‫المديرية العامة للشئون الصحية بجازان‬
Al amal& Psychiatric hospital in Jazan ‫مستشفى األمل و الصحة النفسية بجازان‬
‫قسم المختبر‬
Laboratory Department

DEPARTMENTAL POLICY PROCEDURE

DPP POLICY NUMBER: DPP-LAB-001-01 APPLIES TO: LAB STAFF

VERSION:1 TITLE: SCOPE OF LABORATORY SERVICES

APPROVAL DATE: October, 15, 2018 EFFECTIVE DATE: October, 30,

2018

DUE FOR REVIEW: September, 15, 2020 NUMBER OF PAGES: Page 14 of 14

23. APPROVAL:

NAME POSITION SIGNATURE DATE

Prepared by: Department Quality 15/10/2018

Mr.Bandar Shaiban
Coordinator
Reviewed by: Mr.Aqeel Aqeel Department HOD 15/10/2018

P &P Committee 15/10/2018

Dr.Mohammad Hamza
Concurred Chairman

Dr. Ibrahim Shaeri Quality Director 15/10/2018

Dr.Mohammad Alhamzy Medical Director 15/10/2018

Approved
Dr. Ibrahim Arishi Hospital Director 15/10/2018