Clinical PathologyQuality Dashboard

May 2013

Clinical Pathology Patient Care Quality

Blood Bank

April 2013 ED Specimen Errors

Clinical Pathology Patient Care Quality

Chemistry

Goal: Inpatient/Outpatient STATs=60 minutes; Internal project to reach 45 minutes. Routines=120 minutes.

Clinical Pathology Patient Care Quality

Microbiology

Goal≤1 hour

Clinical Pathology Patient Care QualityPhlebotomy

*Data compiled using PT/PTT, WBC, Gluc data, which are components of high volume testing. Draws begin at 4am. Mott draws begin at 6am.

Clinical Pathology Efficiency

Clinical Pathology Financials

CP Process Improvement Monthly Highlight

Description of Problem: CP specimens are collected in the operating rooms and placed in a bin for pick-up. The fourth floor phlebotomist is paged to retrieve and delivery the specimens to Specimen Processing. The phlebotomist may be delayed in retrieving these samples due to their primary responsibilities. Additionally, at times there are issues with this communication and specimens can be left for a lengthy period of time leading to issues with specimen integrity.

Impact of Problem: Delays in testing and reporting of patient samples. Compromised specimen integrity due to delay in transport.

Reporter of Problem: Microbiology and associated RMPRO reports.

Description of Solution: Utilize existing Pathology resource from Anatomic Pathology with responsibilities in the OR for sample retrieval. This should reduce confusion with only having one contact for all Pathology samples. Phlebotomists do not have to leave the floor during patient rounds to collect samples. This is only applicable for routine sample collections. STAT collections will continue to follow the same workflow of having the OR staff hand deliver specimens directly to Specimen Processing. All Blood Bank samples from the OR will be treated as STAT.How we know it worked: Post-Pilot data indicated ~45 % reduction TAT (log book to order in Pathnet) for CP Main OR samples. Additionally, a 34% reduction in the number of hand delivered samples allows the OR staff to focus their time on OR specific duties. This also eliminated the phlebotomy interaction that distracted these staff from their primary responsibilities of inpatient blood draws.

Date Solution Implemented: April 15, 2013

Lab Avg Time (min)

BB -74.2%Micro -54.3%Heme -55.7%Chem 6.1%Cyto -43.2%Total -44.6%

Average time in minutes is calculated from check into OR log book to order

entry time in lab.

Table 1: Reduction in TAT (log book to order in Pathnet) due to pilot changes.

Clinical Laboratory News, Notes, and Kudos------------------------------------------------------------------------------------• Labs that are working on process improvement projects that

would like to display data can contact Kristina Martin (martkris@umich.edu) for future dashboards.

Kudos

*Dr. Duane Newton and the Microbiology laboratory for implementation of the MALDI-TOF instrumentation to assist clinicians with determination of identification of bacteria so they can begin appropriate treatment for the patient. Dr. Newton along with the team of pharmacists and clinicians involved in the impact of implementing this technology will be presenting at the Executive Directors Forum.