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ContentsINTRODUCTION TO BP HEALTHCARE GROUP . 4Our Vision . 4Our Mission . 4Our Values . 5Our Goals . 5BP CLINICAL LABORATORY (GLENMARIE) . 6Overview . 6Our Quality Goals . 6Our Core Values . 6Out Tag Line . 6Organization Chart . 7WHAT ARE THE CLINICAL TESTS CONDUCTED IN BP GLENMARIE LAB? . 8Chemical Pathology . 8Immunology . 8Serology. 9Microbiology . 9Blood Banking . 10Haematology. 10Urinalysis & Drugs . 10Cytology & Histopathology . 10QUALITY MANAGEMENT SYSTEM . 11Establishing A Quality Management System . 11Establishing Quality Policy, the mission and goals . 11PROCESS MAP for implementing QMS in the Laboratory . 12Laboratory Quality Management . 13THIS IS HOW COMPLAINTS ARE MANAGED . 14LABORATORY SAFETY . 15Blood Born Diseases . 15Universal Precaution . 16Personal Protective Equipment (PPE). 16Hand Hygiene . 17Decontamination . 21Waste Disposal. 21Safety System . 222 Page 41


INTRODUCTION TO BP HEALTHCARE GROUPEstablished in 1982, BP Healthcare Group (BPHG) has gone through 30 over years ofinnovation and transformation. Today, BP Healthcare Group has over;-70 Laboratories50Diagnostic Centers50 Hearing Aids Centers50 Dispensaries & Pharmacies50 Food and Industrial Testing Centers5 Specialist/ Daycare Centers3 Dental Specialist Clinics1 Eye Specialist ClinicWith this nationwide network (and still expanding), multiple awards and credentials earned,BPHG is a leader in the Malaysia Private Healthcare Industry, serving more than 35 millioncustomers over the last 30 years and the number is growing. We provide comprehensiveprimary health care services in all disciplines to cover the needs of Medical Practitioners,Hospitals and Corporate Clients. With capabilities across the entire spectrum of primaryhealthcare services, BPHG can drive improved health status and lower overall costs tohealthcare, more effectively than anyone else in this industry. BPHG has undergoneaggressive expansion and transformation since its establishment in 1982. The group hasgrown from strength to strength in tandem with the nation's rapid growth.Today, the group is proud to have become one of the country's leading integratedhealthcare providers with core competence and innovative strength in diagnostics,laboratory and medical technologies, complemented by other specialized primaryhealthcare services. The group has remained relentless in its pursuit of healthcare servicesof the highest quality for its customers. To this end the group continues to strive towardsproviding excellence healthcare services through a concerted and committed effort incontinuous improvement; AND investing in state-of-the art medical devices and equipment,competent and dedicated human resource, and information and communicationtechnology (ICT).Our VisionTo be the largest integrated and comprehensive private healthcare provider in the country, with thecore strengths in diagnostics and medical services, and providing healthcare of the highest quality toits customers, to enhance quality of life of MalaysianOur MissionTo achieve the Vision, BP Healthcare Group strives to:4 Page 41

1. Prosper healthy partnerships with public and private healthcare providers, and other relatedagencies to enhance the delivery of integrated and comprehensive healthcare services andbe a leader in health check2. Gain and retain customers’ trust and loyalty through meeting and exceeding theirexpectation3. Invest in human potential to achieve a high competent workforce4. Commit towards innovative technologies to advance the diagnostics and medical services5. Create conducive work environment to enhance safety and productivity of its workforceOur ValuesTo uphold the Vision and Mission, BP Healthcare Group believes in:1. Customer first2. Professionalism3. Teamwork4. Integrity5. Accountability6. Effective communication7. Continuous improvement8. Efficient9. No blame cultureOur GoalsBP Healthcare Group aims to annually:1. Increase market share2. Increase market expansion beyond Malaysia3. Increase productivity4. Increase positive customer feedback5. Increase in number of workforce who are knowledgeable and skillful6. Increase investment in innovative technology5 Page 41

BP CLINICAL LABORATORY (GLENMARIE)OverviewB.P. Clinical Lab Sdn. Bhd. (BP Glenmarie Lab) commenced its business as a provider of medicallaboratory testing services and analyses in 2010. Through our network of laboratories, BP GlenmarieLab currently serves thousands of private medical practitioners, private and public hospitalsthroughout the country and generates millions of test results. BP Glenmarie Lab also serves as apanel laboratory for some corporations and insurance companies.Our strength is our team of highly qualified and competent professional staff comprising a panel ofexperienced pathologists, hundreds of professional medical technical staff and ancillary support. AtBP Glenmarie Lab, we provide an integrated system of high quality, professional and cost efficienthealthcare services throughout our network to serve our customers.Test methodologies, media and laboratory equipment are constantly being evaluated and updatedto keep abreast with the state-of-the-art instrumentation and to improve efficiency of testprocedures with faster turnaround time.BP Glenmarie Clinical Lab is proud to have achieved the 1st in Asia to be awarded Clinical LaboratoryAccreditation by the Joint Commission International (JCI).Our Quality Goals To provide accurate and timely resultsTo communicate effectively with the internal and external customersTo delight our customersOur Core ValuesExcellence - We continuously strive for excellence in our work by being competent, skillful andknowledgeableIntegrity - We are accountable for our actions, honest, ethical and transparent in all we doIntegrity - We adhere to the highest standards of professionalism, ethics, accountable and personalresponsibility, worthy of the trust our clients place in usTeamwork - We value the contributions of all, blending the skills of individual staff members inunsurpassed collaboration and work toward a common goal with a positive attitudeOut Tag Line“The Preferred Laboratory”6 Page 41

Organization Chart7 Page 41

WHAT ARE THE CLINICAL TESTS CONDUCTED IN BPGLENMARIE LAB?Chemical .18.19.Alanine AminotransferaseAlbuminAlkaline PhosphataseAlpha-AmylaseAspartate lCreatine kinaseCreatinineGamma GlutamyltransferaseGlucoseHDL CholesterolLactate DehydrogenasePotassiumTotal nt 3Complement 4C-Reactive ProteinDirect BilirubinHbA1c id FactorUIBCTroponin IApolipoprotein A1Apolipoprotein Anti-TPOHAV IgGHBE-AgHBS-AgHCVHIVRubella IgGAFPCA125CA153CA199CEAHDL CholesterolLactate DehydrogenasePotassiumTotal ProteinSodiumTriglyceridesUric 3Complement 4C-Reactive ProteinDirect BilirubinHbA1c id FactorUIBCTroponin IApolipoprotein A1Apolipoprotein BAnti-HBSAnti-HBEAnti-TGAnti-TPOHAV IgGHBE-AgHBS-AgHCVHIVRubella IgGAFP8 Page steroneProlactinT3T4TestosteroneTHCGTotal PSATSHT-UptakeVitamin B12Unconjugated EstriolDHEA-S TotalANTI0HBC IGMInsulin81. IgGMeasles IgGTotal IgESpecific IgEACTH86.87.88.89.IGFGRHFree PSAVitamin DSerology1. CardiolipinAnti-ds-DNAAnti-Nuclear Factor (ANA/ANF)Anti-Streptolysin O Titer (ASOT)Chlamydia IgGCytomegalovirus IgGCytomegalovirus IgMDengue IgG/IgMEpstein Barr Virus IgA (EBV)Glucose-6-Phosphate Dehydrogenase (G-6PD)Helicobacter Pylori IgG (HP)Herpes Simplex Virus 1 IgGHerpes Simplex Virus 1 IgM14. Simplex Virus 2 IgGHerpes Simplex Virus 2 IgMMonospotSyphilis TPToxoplasma IgGToxoplasma IgMVenereal Disease Research Laboratory(VDRL)Widal Weil Felix (WWF)/Widal Test (WT)Dengue NSI AgUrea Breath Test SwabConjunctival SwabThroat SwabGenital Swab (Cervical & Urethral)Skin SwabOropharyngeal SwabNasopharyngeal SwabSputumAbscess/PusSterile Body FluidTissue Biopsy/SloughUrineStool/Rectal SwabBloodTracheal/Bronchial Washing or AspiratesProcedures on Gram StainProcedures of AFB Stain (Ziehl-NeelsonMethod)Procedures of Aseptic & Pure CultureTechniqueAutoclave Performance CheckProceduresProcedures of Autoclave MaintenanceCatalase Page 41Tube Coagulase TestNovobiocin TestCamp TestOxidase TestTriple Sugar Iron TestAntisera Test for Epec 0157:H7Germ Tube TestBacterial IdentificationEnterotube IIOXI/FERM Tube IIAPI StaphAPI 20 StrepAPI 20 CoryneAPI 20 AAPI 20 EAPI 20 NEAPI 20 NHAntibiotic Susceptibility TestStock CultureFecal Occult BloodStool Examination for Amoeba/Ova/Cyst(A/O/C)Fungal Direct Microscopy

Blood Banking12ABO GroupingCoomb’s Direct34Coomb’s IndirectDU Test5678Sickle CellReticulocytesMicrofilariaESRHb Electrophoresis6789Urine FEMESeminal HPEGrossingDecalcificationTissue processingParaffin block & sectioningHaematoxylin and Eosin stainSlide preparationHaematology1234Full Blood countPBF slide preparation, examination andmanualDifferential countMalarial parasiteUrinalysis & ine Pregnancy testCytology & Histopathology1. smearSputum CytologyBronchial brushingBronchial washing and body fluidFNACPap stainLeishman stainSlide preparation10 P a g e 4 1

QUALITY MANAGEMENT SYSTEMEssential to all aspects of health care are laboratoryresults that are accurate, reliable, and timelyEstablishing A Quality Management SystemEstablishing Quality Policy, the mission and goalsImplementing of quality management MONITORR11 P a g e 4 1

PROCESS MAP for implementing QMS in the LaboratoryORGANISATION &MANAGEMENTRESPONSIBILITY4.1Organization and management responsibility4.15 Management review4.4 Service agreementPLANACTQUALITY MANAGEMENT SYSTEM4.2 Quality management system4.3 Document control4.13 Control of recordsRESOURCE MANAGEMENT5.1 Personnel5.2 Accommodation and environmental conditions5.3 Laboratory equipment, reagents and consumables4.6 External Services and supplies5.10 Laboratory information systemEVALUATION AND CONTINUALIMPROVEMENT4.8 Resolutions of complaints4.9 Identification and control of non-conformities4.10 Corrective action4.11 Preventive action4.12 Continual improvement4.14 Evaluation and AMINATION PROCESSPre –analytical process4.5 Examination by referral laboratories4.7 Advisory services5.4 Pre-examination processesAnalytical process5.5 Examination processes5.6 Ensuring quality of examination resultsAnalytical process5.7 Post-examination processes5.8 Reporting of results5.9 Release of resultsReportPROCESSPlease refer to the LABORATORY QUALITY MANUAL for more detail information12 P a g e 4 1USERSatisfaction/DissatisfactionOUT PUT

Laboratory Quality Management– Takes into account contribution ofmedical laboratory service to patientcare– Not only testing, also advisory,interpretative and educational servicesWORK IN A Accommodation andEnvironmental Conditions Enough space must be available, forquality work, safety, etc. Staff andpatient facilities – ALL sites Attention to: power, light, ventilation,water, waste, noise, etc.Personnel Organizational plan Job description – qualification and duties Personnel need to be trained in qualityassurance and quality management Management must authorize personnel toperform particular tasks- Sampling- Examination (analysis)- Operation of equipment, use thecomputer system and access patient data Optimize the comfort of the occupants,and to minimize occupational healthrisks Patients, staff and visitors must beprotected from recognized hazards Need to monitor, control, recordenvironmental conditionsPre-Examination ProceduresREQUEST FORMS:Unique ID of patientSample details, Tests required, Relevantclinical information, date and time ofcollectionPrimary collection manual (Pathologyhandbook)Criteria for rejection/acceptance ofprimary samplesProcedures needed for handling urgentsamplesUSE: Laboratory Equipment The laboratory shall be furnished withall the equipment it needs Capable of achieving performancerequired Establish maintenance program Uniquely labeled Records Operated by authorized personnel. If defective, clearly labeled and takenout of serviceMUCH MORE! READ MS ISO 15189:2014 and JCI Standards13 P a g e 4 1

THIS IS HOW COMPLAINTS ARE rbal/written) the complaintwithin 48 hoursInvestigateInform SeniorManagementthrough emailimmediatelyIf potentially medico-legalInform LegalOfficersIf it is just amiscommunication betweenstaff and the complainantIf the complaint is veryserious and furtherinvestigation is neededPrepare the sequence of events and identifythe root cause of the problemTake corrective /preventivesactionGive feedback andassurance to thecomplainantResolvedNot ResolvedComplaintclosedConduct FurtherInvestigateDocumentation14 P a g e 4 1Arrange meeting with Patient/Doctor/Management

LABORATORY SAFETYThe laboratory should be kept NEAT,CLEAN & FREE of materials that are notpertinent to the workBlood Born DiseasesHow do MLTs get infected with bloodborne pathogens?Blood Borne Pathogens Pathogens are infectious microorganisms inhuman blood & other body fluids that cancause disease in humans Blood & body fluids pose the greatest threatto health in a laboratory The most common examples are humanimmunodeficiency virus (HIV), Hepatitis B &Hepatitis C Most recent is the Ebola Viral Disease (EVD) We do NOT know which blood is contaminated with whatpathogens. Therefore, the standard medical practice regardsall blood & body fluid as potentially infectious Transmission in the laboratory can occur through:– a break in the skin (e.g. a cut, a needle-prick injury or injury fromsharp object, cracked skin, etc.)– contact with a mucous membrane found in your eye, nose or mouth Open cuts & broken skins must be covered with a suitableprotection & seek medical advice if necessary15 P a g e 4 1

Universal Precaution All laboratories must practice Universal Precaution with a set of strategiesdeveloped to prevent transmission of blood borne pathogens MLTs are strongly encouraged to undergo Hepatitis B Screening & if necessary to getthe Hepatitis B immunization. Your record on the immunization shall be maintained MLTs will be provided with personal protective equipment to protect them from theabove exposurePersonal Protective Equipment (PPE)16 P a g e 4 1

Hand Hygiene17 P a g e 4 1

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Hand CareImportant to look after the skin & fingernails by keeping them moisturized at work & at homeDamaged skin leads to loss of a smooth skin surface & increases the risk of skin colonization with resistantmicro organismsContinuing to work with damaged, cracked or weeping skin may expose the healthcare worker to increasedinfection risk & which could also lead to dermatitis19 P a g e 4 1

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DecontaminationWaste Disposal21 P a g e 4 1

Safety System22 P a g e 4 1

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Chemical Safety25 P a g e 4 1

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FIRE SAFETY1st FloorGlenmarie Laboratory Work Room (EMERGENCY EXIT PATH)29 P a g e 4 1


EMERGENCY RESPONSE PLANSTANDARD OPERATING PROCEDURESBP HEALTHCARE GROUP SAFETY POLICYBP Healthcare Group is committed to provide a safe and healthy work environment through effectiveadministration, education and trainingThe Management will:Ensure all employees work in a manner which follows accepted rules and proceduresProvide a safe and healthy environment for its staff, patients and visitorsDevelop the infrastructure to ensure a safe and healthy working environmentEnsure all equipment, plants and tools are safe and properly maintainedProvide suitable resources, information, training and supervision on aspect of safetyConduct regular reviews on health and safety systemsThe management, directors, supervisors and workers are required to make every effort to ensure thatBP Healthcare Group meets all legislature requirements and maintains the highest safety standardsINTRODUCTIONThe overall purpose of an Emergency Response Plan (ERP) is to provide safe and proper operationsof BP Healthcare during evacuation plan (emergency events). ERPs are a means to provide astandardized response and recovery protocol to prevent, minimize, and mitigate injury and damageresulting from emergencies or disasters of man-made or natural origin.Whilst fire is the principal reason for the implementation of an evacuation plan, other instances suchas gas leak, bomb scare, chemical spillage etc, may well necessitate evacuation of the premises.It is of vital importance that all members of BP Healthcare are familiar with the procedure. In theevent that any part of this procedure is unclear, please contact the Safety Committee members.31 P a g e 4 1

EMERGENCY RESPONSE PLANIn the event of an emergency, or upon notification of fire, fire alarm or upon orders of an authorityhaving jurisdiction, buildings or structures, Fire Marshall shall be immediately evacuated oroccupants shall be relocated in accordance with established plans.Should an emergency occur and there is no notification, either by alarm or by someone in authority,an individual who feels the need to evacuate should relocate themselves in accordance withprocedures contained in the emergency plan for the building or structure in which they inhabit. Thisdoes not mean that individuals should go home. They should assemble in the designated emergencyarea and wait for further instruction from designated emergency personnel.Each employee has a responsibility when an emergency occurs to evaluate, notify and implement theemergency response plan. Evaluation involves an immediate assessment of the circumstances todetermine the nature of the emergency. Immediately notify appropriate emergency and companypersonnel, including the Floor Warden(s), Fire Marshals or Safety Officer.Then prepare to implement the department emergency plan, as well as follow all instructions ofpolice, fire, medical, EH&S, or other authorized emergency personnel.PROCEDURES IN CASE OF FIRE1. You discover a fire:1.1. Help people in immediate danger1.2. Warn others by shouting “Fire, Fire, Fire”, raise the alarm if not yet already sounding andtelephone 999.1.3. Decide if you can put the fire out, if you are not sure, do not attempt to.1.4. Don’t attempt to use a fire extinguisher if you have never been instructed on how to use one.1.5. If you can put out the fire then do so, if not proceed to evacuate the building.1.6. Inform the Security Department of the fire location and details2. You hear the fire alarm ringing; you must prepare to evacuate the building:2.1. Switch off all computers, printers and electrical appliances.2.2. Close all windows and doors.2.3. Gather your personal belongings in preparation to immediately evacuate the building.2.4. Organize/help other people in the room.2.5. Evacuate the building and proceed to the assembly area:2.6. Move at a quick walk, do not run2.7. DO NOT PANIC3. If you have to move through a closed door that you cannot see through:3.1. Feel the door to see if it is hot;3.2. Look for smoke coming under the door;3.3. Open the door slowly and look around it to see if there is a fire behind it;3.4. If there is no fire on the other side, proceed through and close the door behind you;3.5. Walk down the fire escape staircase to the ground floor.32 P a g e 4 1

3.6. If the smoke is too thick, get under the smoke by crawling. You should be able to see whereyou are going;3.7. Move to the assembly areas quick as possible;3.8. Report to your Marshal that you/your group is there and if you know of anyone trapped inthe building;3.9. Remain in the assembly area until you are informed that you may leave or move by eitherthe Marshal or a member of the Safety Committee.4. You notice someone on the verge of panic:4.1. Give them a task or responsibility;4.2. The person will still require constant monitoring;4.3. Do not hit them;4.4. Take hold of one of their hands and guide them out of the building to the assembly area.4.5. If they do not cooperate or start to grab hold of things, leave them where they are;4.6. Evacuate yourself and inform your marshal, the Safety Officer, one of the securitypersonnel, or the police or Fire and Rescue Services immediately.5. If you are trapped in a room:5.1. Exit through a window if you are on the ground floor;5.2. If you are not on the ground floor or cannot exit through a window:5.3. Close the door;5.4. Go to the window;5.5. If there is smoke in the room open the window a little so you can breathe fresh air. If not,do not open the window. This can assist in the spread of fire into your area from lowerfloors;5.6. Attract people's attention to your plight. This can be achieved by writing on a paper andsticking it to the window or calling out the window. If you open the window remember toclose it again as this can be an entry point for fire. Do not open the window up fully;5.7. If the room is filling with smoke, stay close to the ground. The air is cooler and oxygen ismore plentiful in this region;5.8. Wait for the Fire and Rescue Service to rescue you.6. Do not procrastinate: REMEMBER6.1. Fires spread rapidly;6.2. Fires produce thick black smoke that is difficult to see through and causes suffocation;6.3. The freshest air will always be near the floor;6.4. Move quickly. Do not run;6.5. Be decisive;6.6. Think for 10 to 30 seconds;6.7. Make a decision and follow that decision.33 P a g e 4 1

MOBILITY IMPAIRED PEOPLEIf you encounter a person with some form of physical disability that restricts their mobility, you maybe required to assist them from the building. If you are unable to remove them from the buildingmany stairwells have respite areas for mobility impaired persons. They can be left here, where theyare shielded from the fire, and retrieved by emergency personnel on arrival. It is important to informthe emergency personnel of their location so that they can be retrieved as soon as possible. Leavethe person's mobility aids behind; they can always be claimed on insurance.USE OF FIRE EXTINGUISHERSUse extinguishers on small fires ONLY if safe to do so – use the P-A-S-S method Pull the pin in the handleAim at the BASE of the fireSqueeze the nozzle, while employing aSweeping (Sway) motion, from side to sideHANDLING THE NEWS MEDIAStaff members should not discuss emergency situations with the news media. All enquiries should beforwarded to the Chairman of OSH. This is to ensure that the media is furnished with accurateinformation and additional copycat incidents or crank calls are not precipitated by irresponsiblestatements from uniformed sources.34 P a g e 4 1

MyCPD New RegistrationSteps:To access the myCPD system, the user should follow the steps below:Type into the address bar of your browser and pressthe Enter key. The MYCPD portal screen displays. See Figure 1.1.Figure 1.1: MOH PortalClick on the New Registration link under Login navigation bar. The link will open CPDRegistration page as displayed in Figure 1.2.35 P a g e 4 1

Figure 1.2: myCPD Registration pageTo proceed with the new registration, click on the “CPD Registration - User” icon and thesystem will open the Registration Form as in Figure 1.3 and Figure 1.4.Figure 1.3: CPD Reg

Apr 10, 2015 · (BP Glenmarie Lab) commenced its business as a provider of medical laboratory testing services and analyses in 2010. Through our network of laboratories, BP Glenmarie . 7 Seminal Analysis 8 Benzodiazepines 9 Ecstasy Cytology & Histopathology 1. Pap smear 2. Sputum Cytology 3. Bronchia