Version: 2019 December

Domain: LAB File ready to submit? 0

Name of Lead Data Collector: 0

Phone Number: 0
Email Address: 0
Data for the month of: December 1
Year: 2019 1
Facilty Code: 0
Facility Name: 0
All data entered? 0

Attention: Prior to submitting this data file, it must undergo a review with the
data collector, with the Change Agent or Domain Leader, and with the PIU Agent
Note that the Change Agent, PIU Agent and Data Collector cannot be the same person.

Data Review Prior to Submission

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Reviewed by Change Agent or Domain Leader? 0
Name of Change Agent or Domain Leader: 0
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yes
no

Maternity
Pediatric
General

2018
2019

January
February
March
April
May
June
July
August
September
October
November
December

H1 - King Salman Riyadh

H2 - Al Iman Riyadh
H3 - MCH Al Yamamah Riyadh
H4 - Mohammed Bin Abdulaziz Riyadh
H5 - Abdulrahman Alafaisal Riyadh
H6 - King Khalid Al Kharj
H7 - MCH Al Kharj
H8 - King Fahad Specialist Buraydah
H9 - Buraydah Central Hospital
H10 - MCH Buraydah
H11 - King Saud Oneiza
H12 - Dammam Medical Complex
H13 - MCH Dammam
H14 - Jubail General
H15 - Qatif Central Hospital
H16 - King Fahad Hofuf
H17 - MCH Hofuf
H18 - King Khalid Hafar Al Batin
H19 - MCH Hafar Al Batin
H20 - MCH Abha
H21 - Asir Central
H22 - MCH Khamis Mushyt
H23 - Khamis Mushyt General
H24 - Prince Mushari Bin Saud Beljurashi
H25 - King Fahad Baha
H26 - King Abdullah Central Bisha
H27 - King Fahad Central Jizan
H28 - Sabia General Jizan
H29 - Prince Mohammed Bin Nasser Jizan
H30 - Heraa Hospital Mecca
H31 - King Faisal Mecca
H32 - MCH Mecca
H33 - Al Noor Specialist Mecca
H34 - King Abdulaziz Mecca
H35 - MCH Medina
H36 - Ohod Medina
H37 - King Fahad Medina
H38 - Yanbu General
H39 - King Abdulaziz Specialist Taif
H40 - King Faisal Medical Complex Taif
H41 - Pediatric Hospital Taif
H42 - Al Amal Psych Hospital Riyadh
H43 - Psych Hospital Buraydah
H44 - Al Amal Psych Hospital Dammam
H45 - Psych Hospital Tabuk
H46 - Psych Hospital Jizan
H47 - Psych Hospital Medina
H48 - Psych Hospital Taif
H49 - Psych Hospital Jeddah
H50 - Al Amal Psych Hospital Jeddah
H51 - MCH Azizia Jeddah
H52 - King Abdulaziz Jeddah
H53 - King Fahad Jeddah
H54 - Al Thagher Jeddah
H55 - MCH Mousadiya Jeddah
H56 - King Abdullah Jeddah
H57 - East Jeddah Hospital
H58 - Al Qunfudhah General
H59 - King Khalid Tabuk
H60 - King Fahad Specialist Tabuk
H61 - Prince Muteb Al Jouf
H62 - MCH Al Jouf
H63 - King Abdulaziz Specialist Al Jouf
H64 - Al Qurayyat General
H65 - Arar Central Hospital
H66 - MCH Arar
H67 - Rafha Hospital
H68 - King Khaled Hail
H69 - MCH Hail
H70 - Hail General Hospital
H71 - King Khaled Najran
H72 - MCH Najran
My file is NOT ready to submit
Sending KPI 1: Lab Lab
Department Stat Or Routine Lab Test Type TAT Volume
ED Stat Hematology 0
ED Stat Chemistry 0
ED Routine Hematology 0
ED Routine Chemistry 0
Inpatient Stat Hematology 0
Inpatient Stat Chemistry 0
Inpatient Routine Hematology 0
Inpatient Routine Chemistry 0
Facility Cod Facility Name
AA-GEN-1 King Fahad Central Hospital In Hafouf
AA-GEN-2 Prince Saud Bin Jalloway Hospital
AA-GEN-3 Al-Jabr ENT and Eye Hospital
AA-MCH-1 Maternity & Children Hospital in Hassa
AS-GEN-1 Asir Central Hospital
AS-GEN-10 Uhod Rafidah General Hospital
AS-GEN-2 Mahayel General Hospital
AS-GEN-3 Khamis Mushayt General Hospital
AS-GEN-4 Sarat Ubaida General Hospital
AS-GEN-5 Dhahran Al-JaNoab General Hospital
AS-GEN-6 Al-Namas General Hospital
AS-GEN-7 Bllsamar General Hospital
AS-GEN-8 Al-Majardah General Hospital
AS-GEN-9 Rejal Almaa General Hospital
AS-MCH-1 Khamis Mushayt Maternity Hospital
AS-MCH-2 Maternity & Children's Hospital in Abha
BA-GEN-1 Prince Meshari Bin Saud General Hospital
BA-GEN-2 King Fahad Hospital in Al-Bahah
BH-GEN-1 King Abdullah Hospital in Beshah
C1-GEN-1 King Salman Bin Abdulaziz Hospital
C1-GEN-2 Al Iman General Hospital
C1-GEN-3 Al Imam Abdul Rahman Al Faisal Hospital
C1-MDC-1 General Hospital King Saud Medical City
C2-GEN-1 Prince Mohammed bin Abdul Aziz Hospital
C2-MCH-1 Al Yamamah Hospital
C2-MDC-1 King Fahad Medical City
C3-GEN-1 Buraydah Central Hospital
C3-GEN-2 King Saud Hospital in Oniazah
C3-GEN-3 Al-Rass General Hospital
C3-GEN-4 Al-Bikeriah General Hospital
C3-GEN-5 Al-Mothneb General Hospital
C3-GEN-6 Al-Badaa General Hospital
C3-GEN-7 King Fahd Specialist Hospital in Buraydah
C3-MCH-1 Maternity and Children Hospital in Qassim
E1-GEN-1 Dammam Medical Complex
E1-GEN-2 Al Qatif Central Hospital
E1-GEN-3 Al-Jubail General Hospital
E1-GEN-4 Al Khafji General Hospital
E1-MCH-1 Maternity and Children Hospital in Dammam
E1-MDC-1 King Fahad Specialist Hospital in Dammam (KFSH-D)
HA-GEN-1 King Khaled Hospital in Hail
HA-GEN-2 Hail General Hospital
HA-GEN-3 King Salman Specialized hospital
HA-MCH-1 Maternity and Children Hospital in Hail
HB-GEN-1 King Khaled Hospital in Hafer Al-Baten
HB-GEN-2 Hafer Al Batin Central hospital
HB-MCH-1 Maternity and Children Hospital in Hafer Al Batin
JD-GEN-1 King Fahad Hospital
JD-GEN-2 King Abdullah Medical Complex (Northern Jeddah)
JD-GEN-3 Rabigh General Hospital
JD-GEN-4 East Jeddah Hospital
JD-GEN-5 Al-Thagher General Hospital
JD-GEN-6 King Abdul Aziz Hospital and Oncology Center
JD-GEN-7 Adhom General Hospital
JD-MCH-1 Children and Maternity Hospital in Msaeidiah
JD-MCH-2 Children and Maternity Hospital in Aziziyah
JF-GEN-1 Prince Moteb bin Abdulaziz Hospital
JF-GEN-2 Tabarjal General Hospital
JF-GEN-3 Domat Al-Jandal General Hospital
JF-GEN-4 King Abdulaziz Specialist Hospital
JF-MCH-1 Maternity & Children Hospital in Skaka
JZ-GEN-1 Prince Mohammed bin Nasser Hospital
JZ-GEN-2 Sametah General Hospital
JZ-GEN-3 Sabya General Hospital
JZ-GEN-4 Abu Arish General Hospital
JZ-GEN-5 Besh General hospital
JZ-GEN-6 King Fahd Central Hospital in Jazan
JZ-GEN-7 Jazan General Hospital
MD-GEN-1 King Fahad Hospital
MD-GEN-2 Yanbu General Hospital
MD-GEN-3 Uhod General Hospital
MD-GEN-4 Prince Abdul Mohsen Hospital Al-Ola
MD-GEN-5 Al-Anssar General Hospital
MD-GEN-6 Khayber General Hospital
MD-MCH-1 Maternity and Children Hospital in Madinah
NB-GEN-1 Arar Central Hospital
NB-GEN-2 Tarif General Hospital
NB-GEN-3 Prince Abdulaziz Bin Mosaad Bin Jalloway Hospital
NB-GEN-4 Rafha General Hospital
NB-MCH-1 Maternity & Children Hospital in Araar
NJ-GEN-1 King Khaled Hospital
NJ-GEN-2 Najran General Hospital
NJ-GEN-3 Sharorah General Hospital
NJ-MCH-1 Maternity and Children Hospital in Najran
QN-GEN-1 Al-Qunfudah General Hospital
QN-GEN-2 South Qunfudah Hospital
QR-GEN-1 Al-Qrayat General Hospital
RH-GEN-1 King Khalid Hospital Kharj
RH-GEN-10 Dawadmi Hospital
RH-GEN-11 Shaqraa Hospital
RH-GEN-12 Afif Hospital
RH-GEN-13 Hemaymlah Hospital
RH-GEN-2 King Khalid Hospital Magmah
RH-GEN-3 Zulfi Hospital
RH-GEN-5 Goeyah Hospital
RH-GEN-5 Goeyah Hospital
RH-GEN-6 Wadi Adwaser Hospital
RH-GEN-7 Aflaj Hospital
RH-GEN-9 Hotat Tamem Hospital
RH-MCH-1 Children and Delivery Hospital Kharj
TB-GEN-1 King Khalid Hospital
TB-GEN-2 Alwagh
TB-GEN-3 Temaa General Hospital
TB-GEN-4 Hagh General Hospital
TB-GEN-5 Omlog General Hospital
TB-GEN-6 Dubaa General Hospital
TB-GEN-7 King Fahad Specialized Hospital
TB-MCH-1 Children & Delivery Hospital
TF-GEN-1 King Faisal Hospital in Taif
TF-GEN-2 King Abdulaziz Specialist Hospital
TF-MCH-1 Maternity Hospital in Taif
TF-PED-1 Children's Hospital in Taif
W1-GEN-1 King Abdulaziz Hospital
W1-GEN-2 King Faisal Hospital in Makkah
W1-GEN-3 Hera General Hospital
W1-GEN-4 Al-Noor Specialist Hospital
W1-MCH-1 Maternity & Children's Hospital in Makkah
W1-MDC-1 King Abdullah Medical City
Month # Days
April 30
August 31
December 31
February 28
January 31
July 31
June 30
March 31
May 31
November 30
October 31
September 30
 Request
Request # or Time of Sample Section
Date Time of Order
Patient # (DD-MMM-YYYY) Stat or Routine? Enter if STAT Extraction (Chemistry or
Mandatory Enter if ROUTINE Hematology only)
X X X X X X
Stat Chemistry
Routine Hematology
 Arrival in Lab enter if > 0 KPI 1
Patient Type Calendar Days Calendar
Days later for Time Result sent Time from
(ED / later arrived in Time of Arrival in Lab result sent back to requestor Start to Lab Sample TAT
Inpatient) Lab
back
X X X X X X X
ED
Inpatient
 Lab TAT Lab Volume

% not within
Stat Routine Stat Routine target

Hematology #DIV/0! #DIV/0! 0 0 #DIV/0!

ED
Chemistry #DIV/0! #DIV/0! 0 0 #DIV/0!
Hematology #DIV/0! #DIV/0! 0 0
Inpatient #DIV/0!
Chemistry #DIV/0! #DIV/0! 0 0
Overall #DIV/0! #DIV/0! 0 0
 Extraction to Lab Lab Volume % not
(optional) KPI 1: Lab TAT (# tests) within
target
Stat Routine Stat Routine Stat Routine
Hematology
ED
Chemistry
Hematology
Inpt
Chemistry
 Instructions:
Complete this slide if your Lab data is collected
% of tests exceeding 30 mins through an IT system.
% of tests exceeding 45 mins By submitting data from IT reporting, you agree
that you may be audited on the submitted KPIs
% of inpatient tests exceeding 4 and if this happens, you have the supporting
hours documentation and raw data.
r Lab data is collected
T reporting, you agree
on the submitted KPIs
ave the supporting
ata.
 KPI

General Inclusions &

Exclusions

Sample Size

1. Lab TAT
 Definition
Included tests: Chemistry and Hematology tests
Excluded tests: Histopathology, microbiology, serology. Any tests in Chemistry or Hematology not
mentioned on the inclusion list
Exclude Hormonal and Immune assays
Included patients: ED patients, CC patients, and Inpatients
Excluded patients: OPD patients

100% if using IT system, 650 per month if manually collected

Sample Turnaround Time

For STAT cases:
Start point: Time of order
For Routine cases:
Starting point: Time of sample extraction

Ending point: Time result sent back to requesting department

Calculation = [Ending point] – [Starting point]
Grouped by ED, CC and Inpatient, by Stat and Routine, by Chemistry and Hematology.
 Included Hematology Tests

* CBC/ Differential/ hematocrit/ Hemoglobin.

* PTT/PT-INR.
* Fibrinogen.
* Supply of blood and blood components.
 Included Chemistry Tests

• ALT, ALP, AST

• Albumin
• Aldolase
• Total Protein
• Osmolality
• G6PD
• IgA, IgG
• HDL
• Triglycerides
• Cholesterol
• Fe (Iron)
• Iron Binding Capacity
• BUN (Blood Urea Nitrogen)
• Bilirubin
• Cardiac Markers: Troponin/CKMB/CPK
• Creatinine
• CRP (C-reactive protein)
• Glucose
• Ammonia
• Amylase
• Lipase
• Calcium
• Magnesium
• Phosphorus
• Electrolytes: Chloride/Sodium/Potassium
• CSF (Cerebrospinal Fluid)
• Beta HCG
• Available TDM (Therapeutic Drug Monitoring): E.g.
Tacrolimus/Cyclosporine/Theophylline/Phenytoin/Valproic acid
etc…