| Summary: | In order to achieve accreditation for their services, pathology departments must meet international recognised standards and comply with national guidelines, issued by accrediting bodies such as Clinical Pathology Accreditation (United Kingdom Accreditation Service), the Medicines and Healthcare products Regulatory Agency and the Human Tissue Authority in United Kingdom. Objectives: An evaluation of existing Quality Management System (QMS) and implementation of a quality standard and a centralised electronic document management software (Q-pulse) in a pathology department of a district hospital. Method: A service evaluation utilising an adapted version of the Context, Input, Process, and Product model, (with the addition of the implementation stage). This consisted of context evaluation (an evaluation of the department’s decentralised QMS), input evaluation (an assessment of the various types of electronic document management system (EDMS), implementation (the implementation of a centralised QMS and EDMS), progress evaluation (monitoring, documentation and assessment of the progress of the QMS) and finally impact evaluation (measuring the impact of the newly implemented system). Data collection included quality audits, non-participant observation and qualitative interviews. The implementation strategies involved technical support training and feedbacks. Results: The implementation of a continuous QMS and EDMS within the department, using the adapted CIPP model, increased the involvement of all staff in quality matters. It enabled the department to improve quality control processes, procedures and performance. Staff and quality teams now meet regularly and multidisciplinary workings groups have been put in place to continual improve the quality matters. The level of compliance and awareness to standards and guidelines has increased through education and training of staff in within the QMS, and there is an increase in top level management involvement in quality activities within the department. As a result of this evidence of compliance, the department’s Quality management system, was accorded, an unconditional accreditation, by the accrediting bodies. (Clinical Pathology Accreditation (United Kingdom Accreditation Service), the Medicines and Healthcare products Regulatory Agency). Conclusion: The quality management system is functioning in all the departments. All staff involved in the evaluation processes, judged it to be useful for them and the department. Further research is required to establish the longevity of the implemented products and other modules within Q-Pulse.
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