05 August 2017

Department Memorandum No. 2009-0086


February 3, 2009


DEPARTMENT MEMORANDUM
No. 2009 – 0086


IMPLEMENTATION OF EXTERNAL QUALITY ASSESSMENT PROGRAM AS A REGULATORY REQUIREMENT FOR LICENSING OF CLINICAL LABORATORIES


Pursuant to Administrative Order No. 2007 – 0027 entitled “Revised Rules and Regulation Governing the Licensure and Regulation of Clinical Laboratories in the Philippines,” a clinical laboratory is required to have a Quality Assurance Program (QAP). The QAP shall include an Internal and External Quality Control Program. The Internal QAP covers inputs, processes and outputs as well as practice of continuous Quality Improvement Program covering all aspects of laboratory performance. On the other hand, for External Quality Assessment Program (EQAP), a clinical laboratory is required to participate in the National External Quality Assessment Scheme (NEQAS) administered by the designated National Reference Laboratories (NRLs) or in other local or international EQAP recognized by the Department of Health. The NEQAS shall be conducted to ensure that laboratory procedures are done in accordance with standards and laboratory results are accurate and within the standard range for quality health care.

As provided in Department Order No. 393–E series 2000, five institutions were designated as the National Reference laboratories namely:

1. Research Institute for Tropical Medicine


National Reference Laboratory for Dengue, Influenza, Tuberculosis and other Mycobacteria, Malaria and other parasites, Bacterial enteric diseases, measles and other viral exanthems, Mycology, Enteroviruses, Antimicrobial resistance and Emerging Diseases; NRL for confirmatory testing of blood donors and blood units.


2. San Lazaro Hospital


National Reference Laboratory for HIV/AIDS, Hepatitis and Sexually Transmitted Diseases


3. East Avenue Medical Center


National Reference Laboratory or Environmental and Occupational Health; Toxicology and Micronutrient Assay.


4. National Kidney and Transplant Institute


National Reference Laboratory for Hematology including immunohematology (consistent with previously issued D.O. 301–I series 1999)


5. Lung Center of the Philippines


National Reference Laboratory for Anatomic Pathology and Biochemistry


The following guidelines shall be enforced as requirement for renewal of license to operate (LTO) of clinical laboratories nationwide:

1. Certificate of Participation/Registration for NEQAS shall be a requirement for the renewal of license to operate of clinical laboratories in the following areas:

a. Hematology – Primary, Secondary and Tertiary Clinical Laboratories in National Capital Region (NCR).

b. Clinical Chemistry – Tertiary Clinical Laboratories in the National Capital Region (NCR) and Center for Health Development IV–A CALABARZON

c. HIV/AIDS, Hepatitis B & C Proficiency Testing – All HIV Accredited Testing Laboratories and Secondary and Tertiary Clinical Laboratories performing Hepatitis B and C tests.

d. Drug and Water Proficiency Testing – all Water and Drug Testing Laboratories.

2. A Certificate of Participation shall be issued by the NRLs to the participating clinical laboratory every time NEQAS is conducted. For the initial implementation of NEQAS, only one (1) certificate is required for the renewal of license to operate.

3. NEQAS /Proficiency Testing for Drug and Water Testing Laboratories require participation and a satisfactory rating on the survey. For Microbiology, TB and Parasitology, participation in the three components is required and a certificate of participation in Antimicrobial Resistance Surveillance Program (ARSP) is recognized as NEQAS for Microbiology component only and participation in the TB and Parasitology component is still required.

4. The schedule of fees per participation is as follows:

a.      Hematology                                  xxx
b.      Clinical Chemistry                       xxx              
c.       HIV/AIDS, Hepa B & C             xxx
d.      Drug Proficiency Testing             xxx
e.      Water Proficiency Testing            xxx
f.        Microbiology                              xxx 

For strict compliance.



FRANCISCO T. DUQUE III, MD, MSc
Secretary of Health 



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