Quality Officer:

1. Make a table with an overview of all the examinations performed in the laboratory.
2. Determine the total TAT for each examination.
3. Determine for each examination, using the flow charts developed in phase 2, per process step the maximum allowed time needed to perform that step. If you see that a step is now taking a long time and should be possible in a shorter amount of time, introduce this change (only make organizational changes, do not change the examination procedure itself). For example: if you see that the Result Report is drafted in the afternoon while the results are already available in the morning, the TAT of the step "Making the Result Report" can be decreased by assigning the person making the report to start earlier.
4. Set for each examination the maximum allowed turnaround time. Determine this in discussion with the clients.
5. When the quality manual is developed later in phase 3, include the table with maximum allowed TATs in this manual (see activity for drafting the quality manual to know in which chapter the table must be included).
6. If not yet included: adapt the SOP on Reporting and Archiving of Results developed in phase 2 to include the procedure that the requester is immediately informed in case the TAT for an examination is exceeded and this delay can compromise patient care.
7. Explain in a weekly staff meeting that this procedure is new and included in the SOP on Reporting and Archiving of Results, and that everybody from now on needs to adhere to this procedure.