Decreasing the Number of Patients
Sent to the Outpatient Diagnostic Centers
with No Lab Orders
Presenters:
Charisse Acosta, CT (ASCP), SSGB, CQIA
and
Joan Woods, MLT, SSGB
Office of Quality Improvement, Pathology and Laboratory Medicine
1
Office of Quality Improvement,
Pathology and Laboratory Medicine
OUR MISSION:
To support the Division of Pathology and
Laboratory Medicine in consistently exceeding
accreditation, safety, and regulatory
compliance requirements and in driving
sustainable improvement through the use of
systematic quality methodologies.
Office of Quality Improvement,
Pathology and Laboratory Medicine
OUR GROUP:
Team of 4 Quality Technologists – MLT, MT, CT, Lean
Training, SSGG, Over 50 years combined laboratory
experience
Project Director – Industrial Engineer, SSBB, MBA
PROJECTS:
• Lab Layout Design
• Workflow Improvement
• Turnaround Time Reduction
• Material Management
• Waste Reduction
Background
2010 PI Project:
Reduce Patient wait Time in the Outpatient
Diagnostic Centers
- Converted to a pull process
- Moved patient sign-in
away from front desk
Background
Results:
Goals:
Decrease patient wait time
Decrease congestion and confusion at front desk
Increase patient satisfaction
Increase on time arrival to downstream appointments
Background
2011 Phlebotomist 5S Project:
Standardized workstations
Organized
Fully stocked
Labeled
Background
2011 Diagnostic Center PSC Workflow Project:
- Clarified patient sign-in form
- Issues identified and categorized
- Intradepartmental issues improved
- Outside Issues prioritized
The Team
CS&E Team Members: Charisse Acosta, Joan Woods, Vijaya Bapat, Starnisha
Anderson-Moore, Yvette Bobb and Lisa Thomas
Facilitator: Ron Phipps, PLM QI Project Director
Champion: Bob Del Guidice, CAD, General Services
Sponsor: Dr. Elizabeth Wagar, Chair, Laboratory Medicine
Contributing Partners
Diagnostic Centers:
Ashley Williams (Clark Clinic), Luz Hurtado (Mays Clinic)
Lymphoma Clinic:
RaShaundra Jacobs, Cynthia Jenkins
Anesthesia Assessment:
Rosemary McCullar
Holli Williams
GI Clinic:
Jessica Campbell
Veronica Smith
GYN Center:
Russell Content
Breast Center:
Stephanie Staten
GU Center:
Hamid Refai
DEFINE PHASE
5/17/11 - 5/27/11
5/28/11 - 6/17/11
6/18/11 - 7/1/11
7/2/11 - 8/14/11
8/15/11 - 8/31/11
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
5/16/2011 - 6/17/2011
Baseline Data Collection
6/1/2011
5/16/11
7/1/2011
8/1/2011
8/31/11
Aim Statement
The purpose of this project was to decrease
the amount of patients arriving at Clark and
Mays Diagnostic Centers for blood
collection with no orders for labs by 50%
before Aug 31, 2011.
Strategic Alignment
Patient Care
Strategy 1.2 - We will increase the quality, safety and
value of our clinical care.
Strategy 1.5 - We will enhance productivity, access and
efficiency by strengthening our infrastructure and support
systems.
Resources
Strategy 7.1 - We will continuously improve our
administrative infrastructure to support the efforts of our
people in achieving our mission through health
information technology and quality improvement
education and research.
MEASURE PHASE
5/17/11 - 5/27/11
5/28/11 - 6/17/11
6/18/11 - 7/1/11
7/2/11 - 8/14/11
8/15/11 - 8/31/11
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
5/16/2011 - 6/17/2011
Baseline Data Collection
6/1/2011
5/16/11
7/1/2011
8/1/2011
8/31/11
Data Collection Methods
• Clark and Mays Diagnostic Center PSC’s
log each patient with no orders on a log
sheet
– Date
– MRN
– Clinic
– Time patient presented
– Time problem corrected in system
– Additional comments
Baseline Metrics
• Baseline data collected:
May 3, 2011 – June 17, 2011
• Metrics Analyzed:
– Daily total errors
– Counts by Clinic
– Time to correct
– Special connectors
Baseline Measures
• Average errors per day: 11
• Average time to correct: 23 minutes
• Weekly Waste:
– 21 hours of additional patient wait time
– 26.5 hours PSC rework
Clark Clinic Baseline
Average: 10.6 patients per day
Clark Clinic Value Stream Map
Current State-Value Stream Map
Patients with No Orders in CARE
Patient arrives
in Outpatient
Diagnostic
Clinic for
Blood
Collection
TIME BREAKDOWNS
Additional Patient Wait time : 23 minutes
Diagnostic Center PSC Rework Time: 9 minutes
Clinic Personnel Rework time: 20 minutes
Total Employee Rework Time: 29 minutes per patient
Patient fills
out sign in
sheet and
gives to DC
PSC
Patient gets
blood drawn
Patient
arrives
Patient called
for blood draw
Patient Scheduling
CARE
PHONE
DC PSC
receives
patient sign
in slip
5 secs
DC PSC
looks in
CARE for
appointment
and orders
to arrive
patient
No orders in
CARE
1 min
DC PSC
calls clinic
main line
2 mins
Receptionist
looks up
patient for dr
and ordering
PSC
information
Call
transferred to
ordering
PSC
DC PSC
gives patient
MRN to
ordering PSC
and notifies of
no order
Ordering PSC
finds CSR
and puts
order in
system
2 mins
3 mins
1 min
14 mins
23 mins
ADDITIONAL PATIENT WAIT
TIME DUE TO ERROR
DC PSC
checks for
orders in
system and
completes
patient arrival
3 mins
DC PSC
prints
patient
labels
I
Phlebotom
ist calls
patient for
blood draw
14
mins
Addressed
in previous
project
ANALYZE PHASE
5/17/11 - 5/27/11
5/28/11 - 6/17/11
6/18/11 - 7/1/11
7/2/11 - 8/14/11
8/15/11 - 8/31/11
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
5/16/2011 - 6/17/2011
Baseline Data Collection
6/1/2011
5/16/11
7/1/2011
8/1/2011
8/31/11
Pareto Chart
Clark Baseline (5/31/2011 – 6/17/2011
67% of issues arise
from 3 clinics
Stratifying the Data
Anesthesia
Assessment Center
Anesthesia Assesment Center
Same Day Appointments
Assumptions:
• Patients are sent directly to the lab
directly following Anesthesia
appointment
•Ordering is still in process when
patient arrives at the lab
•Clinic Service Requisition (CSR)
has not been given to PSC for
entering before patient leaves clinic
Percent of total
100%
83%
80%
60%
40%
20%
16%
0%
Not same day
Same day
Type of appointment
- But how do we know for sure?
Stratifying the Data
Q: How long does it take to correct Anesthesia problems?
•Average overall time to
correct: 23 mins
•Average time to correct
Anesthesia problems: 11
mins
Clark Clinic - Errors vs >15 Completion Time
Baseline (5/3/2011 - 6/17/2011)
60
50
40
30
20
10
0
53
a
si
e
h
st
e
An
50
41
25
18 15
10 13 7
11
G
I
om
h
p
m
y
L
a
C
TR
C
BM
T
In
na
r
te
11
lM
•Clinic Proximity to Lab
total errors
6
10
5
85
8
3
74
7
2
ed
e
e
c
a
is
in
ci
in
D
m
r
p
a
o
c
S
oc
or
rc
fe
d
d
h
a
n
T
I
S
an
En
n
i
a
Br
>15 min comp
Conclusion: Time to enter an order > Time for patient to arrive in DC
Stratifying the Data
Lymphoma
•
60% of 24 hr urine errors
come from the Lymphoma
Center
Ordering:
• 24 hr urine not included in
panel workup code
• Same day patients must
have separate appointment
for next day to return with
urine specimen
Cause and Effect Diagram
Diagnostic Center Patients with No Labs Ordered
DOCUMENTATION
COMMUNICATION
PERSONNEL
Filled out by MD or MLP
May get over
looked or lost
DC PSC’s don’t
have correct # to call
PSC holds CSR and
enters closer to
appointment date
Patient must wait in DC until
orders are completed
CSR
Clinic Service
Requisition
X
Clinics unavailable
before 8:00 am
X
Different versions used
CSR not filled
out adequately
Ordering confusion
No documentation
for records
Clinics don’t
answer the phone
Once placed in “to be scanned
box” PSC cannot retrieve
Dr fails to give CSR to
PSC before seeing next pt
CSR’s can get misplaced
May get lost or over looked
and never entered
Each PSC has own system
of ordering, tracking, filing
No Standard Process
Between Clinics
Correct lab codes not used
Interruptions
during Process
Loss of concentration
when entering orders
CSR
X
Different versions used
PF9 Master Browse list not
utilized by ordering PSC’s
Send pt to lab w/o giving CSR to PSC
CSR not given to PSC to enter
Patients Sent to
Diagnostic Center
with no labs
ordered
in CARE
System
or Confusing
VAR LAB
code entered
24 hr urine on
Today Pt
not entered
separately
PSC holds CSR for later input
so pt notification is sent closer
to appt time
Process not Followed
ENVIRONMENT
PSC does not
create order
Illegible handwriting
No Standard tracking
Process between PSC’s
Lack of communication
CSR not sent to
PSC for ordering
Did not receive CSR
CSR Interpretation
X
MD, MLP, or Nurse
PSC doesn’t know
where to find
correct lab code
Verbal orders
Scanned Version of
CSR in Clinic Station
Proximity of
Doctors/MLPS
to PSC’s
Inadequate training
Clinic unaware
That no orders
were placed
CS version not available immediately
CSR not filled out
PSC uses
wrong mnemonic
CARE System
X
Allows appointment to be
made with no orders placed
Daily report
CSR Interpretation of missing labs
underutilized
Illegible handwriting
METHODS/PROCESSES
Proper mnemonic not looked up
Lab Bulletin of Information
Lab Code not in Lab Bulletin
MATERIALS/EQUIPMENT/
SYSTEMS
Major Issues Identified
• Underutilized daily CARE reports
• Clinics are unaware that no orders were
placed
• 24 hr urines not ordered separately
• Patients bring in 24 hr urines that were not
ordered
• DC PSC’s don’t have correct clinic numbers
• Patients are sent to lab before clinic PSC
receives Clinic Service Requisition (CSR)
IMPROVE PHASE
5/17/11 - 5/27/11
5/28/11 - 6/17/11
6/18/11 - 7/1/11
7/2/11 - 8/14/11
8/15/11 - 8/31/11
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
5/16/2011 - 6/17/2011
Baseline Data Collection
6/1/2011
5/16/11
7/1/2011
8/1/2011
8/31/11
Diagnostic Center
Implemented Improvements
• Updated clinic contact lists
– Physician/PSC Team lists
– Direct Clinic PSC lines
• PSC Training on Phone Directory usage
• CARE Missing Labs Report
– Allows correction before patient arrives
Clark Clinic
Implemented Improvements
Anesthesia Assessment Center
• Lab Check Out Desk
Patients orders completed
before leaving clinic
Lymphoma/Myeloma
• Retrain PSC’s on 24 hr urine ordering procedures
• Utilize missing labs CARE report
• New terminology for patient schedules
Confusing Patient Schedule Wording
for Lymphoma Patients
Blood and Urine
Blood collection only
Very Similar Wording
New Schedule Wording
BLOOD/24 HR URINE COLLECTION
or
BLOOD ONLY
or
24 HR URINE COLLECTION ONLY
Patient has clear understanding of the
appointment’s testing expectations
RESULTS
RESULTS –
Overall
ClarkClinic
Clinic
OverallImprovement
Improvement Clark
73%Overall Improvement
Lymphoma Clinic Improvements
89% Improvement
Anesthesia Assessment Center
Improvements
92% Improvement
Benefits
Soft Savings:
• Avoided Rework
- 20 hours per week of employee time
- $16,545 per year
• Wait Time
- Avoided 836 hours of additional
patient wait time per year
Additional Benefits
• Improved utilization of resources
- Increased productivity
- More on time arrivals to downstream appointments
• Improved patient satisfaction
- shorter, less stressful day for patients
- trust in system
• Improved Institution image
- smooth, coordinated efforts between departments
- professional, competent atmosphere
The right testing at the right time
CONTROL PHASE
5/17/11 - 5/27/11
5/28/11 - 6/17/11
6/18/11 - 7/1/11
7/2/11 - 8/14/11
8/15/11 - 8/31/11
DEFINE
MEASURE
ANALYZE
IMPROVE
CONTROL
5/16/2011 - 6/17/2011
Baseline Data Collection
6/1/2011
5/16/11
7/1/2011
8/1/2011
8/31/11
In Progress/Next Steps
Current:
• Continued data collection
• Continued work with additional clinics to find
improvements
• Currently piloting online CSR’s
Future:
• Incorporate business needs of the lab in the
requirements for new patient scheduling system
upgrade
• Corrections to CSR’s
• Expand use of order sets, online CSR’s, and CARE
system reports
Our Keys to Success
• Always back up your story with data
• Great resources are the people that do the
work or are effected by the work
• Persistence is key
• Buy in is crucial
• Don’t be afraid to ask
• Change is rewarding!
“Every system is perfectly designed to get
exactly the results it gets.”
- Anonymous
In other words, if you don’t like the results…
Change The System!
Thank you!
Any Questions?
Charisse Acosta
Joan Woods
bcacosta@mdanderson.org
jtwoods@mdanderson.org