The Manitoba Quality Assurance Program (MANQAP), under the Quality Department of CPSM, establishes standards for –and conducts inspections of– diagnostic and non-hospital medical/surgical facilities for accreditation.  

Inspections are a component of CPSM's extensive quality assurance and improvement initiatives. 

Registration and Approval Required for Physician Office Laboratory Testing  

Physicians in private medical clinics must complete the Physician Office Laboratory Registration Form for each practice location where testing will occur. MANQAP reviews and approves the registration form before the clinic/office can perform and bill Manitoba Health for tests.  

As part of this process, MANQAP may also visit physician offices that offer laboratory testing for inspections. Physician office inspections are chosen by random selection, or if a complaint about an office is received, to ensure offices offering lab testing have sanitary and safe practice environments.  

Inspections of this nature should not be a cause for alarm or pose an additional burden on you. Our goal in attending your office is to help you meet a minimum standard. Our inspection team put together a checklist to help determine how likely your office is to pass an inspection.  

What kind of things will the inspector(s) look at? 

• Is there a dedicated, clean area for performing Physician Office Laboratory testing?

• Are all physician office laboratory supplies and equipment in good working order, clean, and not expired?

• Is there an emergency call button in each patient washroom?

• Are all areas clean and well-maintained? This includes patient waiting room(s), reception, washrooms, exam rooms, offices, staff lunchrooms, testing and equipment processing areas, storage rooms, corridors, etc.  

• Are all chairs, exam beds, surfaces, walls, and floors in good condition and easily cleaned and disinfected? There should be no rips, cracks or chips in surfaces and no chips on the walls.

• Is your staff lunchroom clean and are fridges or freezers located in staff lunchrooms used only for food? Vaccines and other medical or pharmacological supplies cannot be stored in staff lunch areas.   

• Are there documented procedures and policies for reporting Physician Office Laboratory testing results?  

• Are all medical records kept in a secure location when not in use by staff?

• Are there fridges and freezers dedicated to storing vaccines and other medical supplies only?

• Are all supplies, medications, and vaccines stored safely at the correct temperature and are expiry dates recorded and checked regularly? 

• Are the fridge and freezer temperature ranges monitored and documented?

• If you have an autoclave, is it regularly serviced and maintained and located in an area dedicated to its use? Is there an eyewash station located next to the autoclave? Are there MSDS sheets, stain remover, and PPE nearby?

• Are sharps containers properly mounted on a wall and emptied regularly?

• Are emergency lights and fire extinguishers in good working order and checked annually? 

• Are evacuation routes posted and exits clearly marked? 

We look forward to meeting and working with you to ensure physician offices offering laboratory testing have systems in place to maintain, clean, and calibrate medical equipment. 

As a physician, you are responsible for practicing medicine and treating patients in a safe, appropriate, and sanitary environment. We want you to be prepared and succeed should your practice be randomly selected for an inspection.  

If you have any questions, please contact: manqap@cpsm.mb.ca