Clinical Pathology
Quality Dashboard
October 2014
Clinical Pathology Patient Care Quality
Pathology-Blood Drive
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We have not been able to meet our goal despite numerous endeavors to create incentives
for donors. We’ve also teamed up with Wolverines for Life for donor recruitment and Blood
Battle events.
Typically there are ~ 10 presenting donors per drive that are deferred either due to their
current health status or answers on the donor questionnaire.
We’ve consistently had a large number of no shows that hovers around 25% per drive.
Several investigations with direct communication to donors indicated people either forgot
despite reminders from ARC, or were too busy to come to the appointment.
In response to donor need we have moved the start time starting in August 2014 from 7am
to 6am so more staff could donate before the day shift began or during midnight-day
overlaps.
Blood drives are typically held monthly and can range from 1-2 days. There are numerous
other drives held throughout the University of Michigan campus.
Donors can find upcoming drives by going to wwww.redcrossblood.org and searching
under the Sponsor Code=goblue
Clinical Pathology Patient Care Quality
Blood Bank
Pathology is pursuing a two pronged approach to “specimen quality” in the Emergency
Department (ED).
1. There are and have been ongoing discussions via Nursing Liaisons (Barb Wetula,
RN, and Sheryl Woloskie) to address training for non-Pathology collected
specimens. This focus has been throughout UMHS, with an emphasis on the ED.
2. Pathology and the ED are investigating possible deployment of additional
Pathology personal in the ED POCT lab or utilization of the Soft ID system which
has been shown to decrease patient identification/signature errors at other
institutions.
3. We continue to see a decrease in many of the problems for the 3rd quarter of this
year. Problems that have not decreased have at least been maintained compared
to past quarters. There has been extra effort into refining training as well as
processes. We will continue to monitor this metric for sustainability.
Clinical Pathology Patient Care Quality
Chemistry
Description of Problem: The guaiac
method for detecting blood in the stool as a
detection of colorectal cancer requires the
patient to adhere to several dietary
restrictions as well as to collect three
separate stool samples. Due to this
complexity, we had low compliance
(<20%). Newer methodologies such as
FIT are available that only require a single
sample, no dietary restrictions, and have a
higher sensitivity.
Impact of Problem:
Formerly, the guaiac cards we distributed
had a low rate of return as indicated
above. Use of the newer immunochemical
method has increased the rate of return
almost four-fold due to ease of collection
by the patient.
Reporter of Problem:
Laboratories, physician offices
Description of Solution:
Implement the immunochemical
method for detection of colorectal
cancer. Physicians would order the
test when the kit was handed to the
patient. Pre-stamped envelopes
provided to the patient will be
returned to the laboratory where the
test will be run.
How we know it worked:
We continue to see a positive
outcome relative to patient
compliance with returning the kit for
testing. For the past 6 months we’ve
seen a 1-2% increase each month.
Since November 2013 we have
increased compliance by 40%.
Issues related to the date of order,
release & collection are being
investigated by MiChart &
Chemistry.
Date Solution Implemented:
October 29, 2013
Clinical Pathology Patient Care Quality
Hematology
Description of Problem:
The Hematology lab created specific
parameters related to the complete blood
count (CBC) that reflex to the pathologist
for a review starting in 2005.
Impact of Problem:
Inappropriate requests increase cost due
to the additional pathologist review (pathrev) and impair the turnaround time for
patients that require a pathologist review
since there is no way to prioritize these if
all of the slides are reviewed.
Reporter of Problem:
Hematology Pathologists/Staff
Description of Solution: Alter the
current policy based on medical director
guidance to allow specially trained,
competency assessed technologists to
prescreen path-rev slides. If screens are
determined to be inappropriate for
pathologist review the path-rev
would be canceled.
How we know it worked?
Over 40% of all path-rev orders
requests received each month are
canceled thus improving turnaround
time and decreasing the cost to the
institution and patient. Technologist
decisions are assessed monthly.
Approximately, 10 cases per month
are reviewed rotated between 5
screener technologists. This
equates to each technologist being
assessed twice per year.
Areas for continued
improvement: The Hematology lab
is in the process of reviewing the
criteria set to reflex the path-rev to
determine which criteria require a
pathologist intervention versus
review by qualified technologists.
Clinical Pathology Patient Care Quality
Hematology
Description of Problem:
Historically, MD requests have been
processed as ordered. During the past
year, there has been an upward trend in
the number of Pathology Review
requests from providers. Investigation
into why this is occurring and whether
the requests are appropriate and could
be triaged in other ways is in progress.
Impact of Problem:
If requests are inappropriate this results
in the unneeded cost of Pathologist
review and delays turnaround time for
patients that should require a pathologist
to review their slide.
Reporter of Problem:
Hematology Pathologists/Staff
Description of Solution: Alter the
current policy and allow technologists to
prescreen MD request slides similarly to
the Path-rev process used for CBCs.
This is done after after an initial
audit by a pathologist review of
cases deemed not to require MD
Path Review assures patient safety.
If screens are determined to be
inappropriate the MD Path Review
would be canceled by the
technologist.
How we know it worked?
TBD-Plans for implementation are
ongoing. Late 2014 is the
anticipated target date for
implementation.
Areas for continued
improvement: Hematology will be
investigating reasons why orders
are received in error to providers
(e.g. standing orders, errant orders,
or improper understanding of the
order code).
Clinical Pathology Patient Care Quality
Microbiology
URCC=urine
culture
UA=urinalysis
UC=UA with
reflex URCC if
UA=positive
Root Cause
Follow-up
Ordering cultures on
asymptomatic
patients
Training for care
providers on proper
test utilization
Collecting
specimens from
urine catheter bag
not the catheter line
Training
implemented for
nursing
Delays in transport
cause bacterial
growth=false
positives
Use BD urine
vacutainers for
collections to
increase storage
time at room temp
Triage screening
test UC (UA with
reflex URCC) not
available for
inpatients
Made UC triage
available for
inpatients
Urine cultures being
“over worked”
Modify protocols for
urine specimens to
be consistent with
guidelines
Description of Problem: Rates of catheter
associated urinary tract infections (CAUTI) are
a metric benchmark for patient quality of care.
The inpatient population is particularly prone to
high rates of infection. The CCMU (6D) is a
focus of attention due to their patient
population and propensity for positive urine
cultures. The NHSN (National Healthcare
Safety Network) benchmark is 2.9 infections
per 1000 catheter days. In 2013 the CCMU
rate was 5.5. While investigating the CCMU, it
was discovered that the rate was falsely
elevated due to a large number of false
positive cultures (>80 % non-pathogen yeast
with 20% of these indicating a negative
urinalysis).
Areas for continued improvement:
1.
Impact of Problem:
Clinically irrelevant positive urine cultures can
lead to additional testing and antibiotics, both
of which may be unnecessary. Inefficient use
of resources to process these specimens is
also a concern.
Reporter of Problem: CCMU, Microbiology
leadership & Infection Control
Description of Solution:
Several countermeasures are being
implemented or addressed.
2.
3.
Data pertaining to the use of the UC
and UA/URCC orders indicates that
re-education regarding use of the
test codes is warranted. This is being
facilitated by Infection Control.
Continue to revise Microbiology
protocol for culture work-up
The CCMU CAUTI rate has dropped
to 4.5 since countermeasures have
been implemented, however rates
need to meet the NHSN benchmark
of 2.9.
Clinical Pathology Patient Care Quality
Point of Care
*Note Aug 2013 data decreased
due to POC coordinator absence
and RMPRO reports not entered
during this time frame.
*
Description of Problem:
Once MiChart was implemented, a change
occurred in how the patient was identified. In
order to correlate billing information relative to
the specific patient stay, the CSN number on
the patient’s wristband is used rather than the
MRN. The patient’s wristband was changed so
that the glucometer CSN number is now a 1D
barcode versus the MRN which is a 2D
barcode. Since making this change, numerous
errors have occurred where the MRN was
manually entered by mistake into the RAALS
laboratory middleware. The RAALS
middleware requires the current CSN to
function properly.
Impact of Problem: The errors cause a delay
in results being reported to the patient record.
Additionally, the corrective action is for the POC
Coordinator to match the misidentified patient
results and then manually report them to the
correct CSN. This opens the opportunity for
human transcription errors along with inefficient
use of the coordinator’s time to work on other
tasks.
Reporter of Problem: POC Coordinator &
Nursing Leadership
Description of Root Causes Identified:
•
Nursing is not able to access the barcode
and has to manually enter CSN. Manual
entry may be incorrect or the MRN
(traditionally used for other tasks when
identifying patients) may be used.
This is especially true of pediatric wristbands
which are smaller. Nurse educators have
refocused training on this aspect.
Investigation into modifying the patient
wristband to allow more barcodes to be visible
is ongoing by MiChart.
•
CSN mismatch-Examples of patients
presenting at the ER or IPLV (Inpatient
Like Venues) and then admitted on a
different day (thus different CSN) still
have their “old” wristband on which is no
longer valid. Wristband printing-future
visit day used to print wristband.
Practice change by nursing to replace
patient wrist band every time patient
comes or returns to the floor (e.g. go to
OR or procedure area and come back).
•
Identified reasons why nurses are
manually entering MRNs and
implementing countermeasures to
address delays in downloading patient
names & results to the patient’s record.
•
Modification of the wristband to limit the
frequency of manually entered CSNs.
•
POC coordinators are working with
Alere and the interface with the
glucometers to identify reasons why
patient information does not download to
the meter for positive patient ID.
BW2
Canton
Chelsea
DOM
DFW
FMC
EAA
Livonia
Northville
Saline
WAA
Ypsi
Needs attention
Progressing
Excellent
Not Completed Yet
N/A
BWO
BMG
Brighton
Health Center Safety Audits
Clinical Pathology Quality and Performance
Safety audits were performed by the Pathology Safety Liaisons between March and
September 2014. Each Safety Liaison will work with the section supervisor &
Compliance Manager to rectify the “needs attention” areas.
Chose another topic to audit
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Chose another topic to audit
replacing ergonomics
Chose another topic to audit
replacing ergonomics
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Phlebotomy
Specimen Processing
Needs attention
Progressing
Excellent
Not Completed Yet
N/A
Laboratory Safety Audits
Clinical Pathology Quality and Performance
Safety audits were performed by the Pathology Safety Liaisons between March and
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CP QA Meeting Highlight
Michigan Molecular Genetics Laboratory (MMGL)
Description of Problem: Late December 2013 MMGL
contracted with Blue Cross Blue Shield to perform in-state
BRCA1 & BRCA2 genetic testing. Mutations of two genes
are linked to the risk a woman has of developing breast or
ovarian cancer. Men carrying these mutations are at
increased risk for breast cancer and for prostate cancer.
The methodology used by MMGL at that time could not
handle the anticipated increase in workload due to the
low number of specimens batched and long analytic time.
Impact of Problem: The current methodology would not
sustain the anticipated increase in volume. This could
result in an increased turnaround time (TAT) that would
be unacceptable to patients.
Description of Solution: Modify methodology to
accommodate the increase in testing volume.
How we know it worked: Entire process is less costly
and the TAT decreased. In addition, the TAT for other
assays also improved due to increased capacity of the
Biomek FX that was purchased to help facilitate the
improvement process.
Date Solution Implemented: January 2014
CP QA Meeting Highlight (cont.)
Michigan Molecular Genetics Laboratory (MMGL)
Clinical Pathology Quality and Performance
Proficiency Testing Performance
2013
The Clinical laboratories are required to test unknown specimens to
generate results that are submitted to the College of American Pathologists
(CAP). CAP then reviews the results for accuracy. These results are
considered pass or fail based on specific cutoffs established by CAP. There
may be instances where typographical errors occur which also results in a
failure. Frequent failure can result in a laboratory not being able to test the
analyte at their facility. The Clinical Laboratories continue to illustrate
superb performance relative testing these unknown samples. In the 1 st &
3rd quarter of 2014 we observed a minor decline. In both instances this
was due to one laboratory failing to turn in results by the required deadline,
thus resulting in a failure. This laboratory is refining their procedure for
handling submission of CAP results to avoid this in future challenges.
Clinical Pathology-Current Projects
**This is a highlight of projects ongoing in the CP labs. This list is not meant to be all inclusive
of every activity occurring in the department.
Project
Brief Description
Owner
Customer Service/Call
Center
Address multiple issues related to
providing an appropriate level of
customer service for UMHS care
providers.
Dr. Newton
ER Specimen Issues
In coordination with the Emergency
Department reduce the number of
RMPRO specimen errors (e.g.
hemolysis, mislabels etc.)
S. Butch/K. Martin/T. Morrow
Pathology Handbook
Maintain and update the Pathology
handbook to be a robust resource
for our customers.
K. Davis/K. Martin
NCRC Planning
Begin work to plan for the future
state of the non-STAT Clinical Labs
move to NCRC
PRR Committee
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
2014 CP Symposium Planning Committee for
planning 2 days of enriching CE
opportunities
Kelly Anderson
Suzanne Butch
Kristina Martin
Carol Young
Linda Brish
Suzanne Clark
Dr. Newton
Denise Brown
Eric Jedynak
Pam Warwashana
Pathology
Quality
Month
Posters
1.
Lab
Molecular Diagnostics
Project Title
Molecular Diagnostics
Laboratory Process
Improvement:
Organizing and Tracking
Patient Tissue Section
Samples
Argatroban
Monitoring: Anti-IIa Vs
aPTT
Team Members
Michelle Russell,
Catherine Dixon, Nanci
Lefebvre, and Jennifer
Bergendahl
2.
Hematology
3.
Hematology
Auto Receipt of
Specimens on a Robotic
4.
Hematology
PNH: Developing a High
Tech Test to Improve
Patient Care
5.
Pathology
Physician InboxEnsuring Results are
Routed to the Correct
Provider
6.
Histology
Explants in Pathology
Lisa Taulbee, Histology
Lab Manager
Meagan Weighman,
Senior Histotechnologist
Nancy Fritzemeier,
Pathology Office
Manager
Christine Rigney,
Assistant Administrator,
AP Operations
John Perrin, QC
Bill Lalonde, Tissue
Specimen Coordinator
Debbie Woodard, Lab
Assistant
7.
Consult Accessioning
Pathology Transfer
Christine Rigney,
Sara Gay MT(ASCP),
Steven W. Pipe, MD,
Ngoc Vu, Pharm D,
Cesar Alaniz, PharmD
Gerald (Jerry) Davis,
MT(ASCP) MPH, Usha
Kota, MT(ASCP), Mary
Jane Liu MT(ASCP),
Megan Lim, MD PhD,
heme staff, SCC
Laura (Laurie) Gable,
MT(ASCP), Usha Kota,
MT(ASCP), Lloyd M.
Stoolman, MD, Flow
Cytometry lab staff
Brian Kurtz, Elizabeth
Renner (AntiCoagulation Service),
Sam Coffey, Cybill
Rowerdink, Adam
Schneider (MCIT),
Kathy Davis, Chris
Gaunt, Bill Hubbard,
Kristina Martin, Harry
Neusius (Pathology)
Pathology
Quality
Month
Posters
7.
Lab
Consult Accessioning
Project Title
Pathology Transfer
Case Material Returns
Team Members
Christine Rigney,
Assistant Administrator,
AP Operations
Nancy Fritzemeier,
Office Manager
Shirley Andrews, Lead
Pathology Admin
Consult Accessioning
Team: Sheri Welton,
Alex Short, Lorraine
Bourassa, Therese
Nickerson, Tammi Toth
8.
Chemistry
Decreasing ED Stroke
Prothrombin Turnaround
Times
9.
Immunology
Implementation of a
New Ordering System in
the Immunology Lab
Ch-Ch- Changes!
Moving to a 10 hour
shift to reduce overtime
Quick & Easy Chemistry
Test Results
Sample Manager Switch
leads to TAT
Satisfaction
Catheter Associated
Urinary Tract Infections
(CAUTI), not the “yeast”
of our concerns
John Alfsen, Don
Giacherio, David Harro,
Chemistry ED
Laboratory Technicians
Donna Bush
10. Immunology
11. Chemistry
12. Microbiology
13. Histocompatibility
HLA Lab Software
System Saves Money,
Improves Efficiency &
reduces TAT
Chris Offord
Eric VasBinder,
Therese Horning and
Ruth Miller
Noel Baldwin, RN
Jennifer Dammeyer,
RN, MSN
Sam Miller, RN
Duane Newton, Ph.D.,
D(ABMM)
Laraine Washer, MD
Amanda Valyko, MPH,
CIC
Lena Kleyman Thomas
Franks
Saburo Shelton Thomas
Peterson
Debra Schauss Mia
Kost
Jagadish Chaparala
Judy Knakiewicz
Gregory Simmons Judy
Wysocki
Yusuf Peak Caitlin
Parsons