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Pathology User Guide Bedford Hospital Trust Page 6 of 98 Workforce GSTS Pathology will maintain a high quality flexible workforce that are committed, engaged, trained and supported to provide the highest level of service to our users in accordance with relevant good professional guidance. Through recruitment, induction and training, staff will be made familiar with this policy and relevant content and procedures of the management system. Each staff member holds a personal responsibility for the quality of the work that they perform. Competency assessment and appraisal is used to ensure ongoing capability and identify individual personal development. Managers and supervisors provide effective leadership and create a culture and working environment that allows operational performance and change management to be achieved by staff that are empowered to make suggestions and take decisions. Assessment and Monitoring Key performance and quality indicators are used to enhance operational performance and remove variation from laboratory processes. Internal Quality Control (IQC) and assurance with External Quality Assurance (EAQ) is used as part of the overall assurance mechanism along with clinical and internal audit to monitor adequacy of operating procedures and effectiveness of the quality system. Quality tools such as Root Cause Analysis (RCA) are used to ensure effective corrective actions are implemented. We recognise the confidentiality of information we hold on patients, donors and clients and allow accreditation and regulatory bodies appropriate access to the knowledge systems maintained to provide third party assurance to GSTS Pathology and our stakeholders. GSTS is registered with the Care Quality Commission (CQC) as an independent healthcare provider at all locations on which it operates for the provision of diagnostic and screening services and blood and transplant services. File Name: BED-USER-14 GSTS Pathology User Guide Version 4.2 Authorised: A. Strong