Clinical PathologyQuality Dashboard

January 2013

Clinical Pathology Patient Care Quality

Blood Bank

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

Hematology

Turnaround time for the absolute neutrophil count (ANC) for the Pediatric-Heme-Oncology(PHO) clinic.  The ANC TAT is important for physicians to make real time treatment decisions for oncology patients.  Implementation of the quick release of the ANC prior to slide review in 2011 and the real time tracker application which began in August 2012, have assisted in reducing the TAT in all clinics.

Clinical Pathology Patient Care Quality

Microbiology

Goal≤1 hour

Clinical Pathology Patient Care Quality

Phlebotomy

*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

* Cost/adjusted discharge is the average cost per inpatient & outpatient discharge. Forty outpatient visits~ 1 hospital discharge. Pathology costs include: AP, Autopsy, blood products, specimen procurement, and Pathology Informatics. The Pathology percentage is the cost of an adjusted discharge that is contributed to by Pathology expenses.

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

0.00

4,000.00

8,000.00

12,000.00

16,000.00

20,000.00

24,000.00

FY 2008 FY 2009 FY 2010 FY 2011 FY 2012

Pathology %

Cost

/Adj

uste

d Di

scha

rge

Clinical Laboratory Productivity

UMHS Cost/Adjusted DC Pathology Cost/Adjusted DC Pathology %

Clinical Pathology Q

A Meeting H

ighlight

Clinical Pathology Laboratory Quality Metrics

Laboratory Monitor Description Goal Reporting Frequency

Responsible Person

General Lab Rate of unlabeled/mislabeled specimens

N/A Monthly E. Commiskey

Critical Values Alert Audits >90% critical values notified to caregiver within 20 minutes

Bi-Yearly J. Perrin

Proficiency Testing To participate and in an external performance assessment that determines the accuracy and reliability of analytical results of patient samples

Quarterly B. Schroeder

Capital Equipment Ordering Viewable access to status of all capital equipment by whole department

Monthly C. Shaneyfelt

Lab Procedure Changes Audit Verify changes in lab procedures are documented in procedure manual

Monthly J. Perrin

Vendor Communications Audit Verify communications from vendors, emails, package inserts, etc., have been incorporated into procedures, if necessary

Monthly J. Perrin

MLabs Turnaround Time Monitoring Includes MLabs and UM Outpatient tests expected to be completed within 24 hoursRoutine Tests threshold <10% tests exceed 24 hoursSTAT Tests threshold <10% tests exceed 4 hours

Quarterly D. Fidler

Client Complaint MonitoringIncludes MLabs client complaints

Threshold #complaints <2% total encounters and >=98% complaints resolved within 5 days

Quarterly D. Fidler

Critical Value Notification Includes MLabs critical valuesThreshold >=95% reported immediately to client or physician

Quarterly D. Fidler

M Labs (cont’d) Home Draw Turnaround Time (if applicable)

Includes home draws arranged by MLabs for UM patients provided under JVHL/BCN agreementRoutine Draw threshold <5% draws exceed 24 hoursSTAT Draw threshold <5% draws exceed 4 hours

Quarterly D. Fidler

Patient Wait Times Includes sample of 30 patients drawn in single day once per month at East Ann Arbor draw siteThreshold >95% patients wait <20 minutes and average wait time <15 minutes

Quarterly D. Fidler

Transfusion Medicine TAT Manual and Automated Type and Screens from the ED

Manual 35min Average In Lab to VerifyAutomated 75 minutes In Lab to Verify

Quarterly S. Butch

Blood Product Waste Wasted Red Cells 1.0%

Wasted Platelets 4.0%Wasted Plasma 4.0%

Wasted Cryo7.0%

Quarterly S. Butch

Chemical Pathology TAT 95% of all STAT samples verified within 60 minutes.

Quarterly S. Stern

TAT 95% of all ROUTINE samples verified within 120 minutes

Quarterly S. Stern

Molecular Diagnostics 95th Percentile TAT (Outlier) Investigation for all tests

<5% total outliers aggregate; <10% outliers for each individual test

Monthly J. Sanks

Hematology TAT for ANC in Cancer Center Clinics-OS orders

TAT for ANC in C&W clinics-OS orders

>80% verified in <60 minutes >80% verified in <60 minutes

Quarterly N. Renner

Coagulation TAT – PTT (inpatients) >80% completed in <60 minutes Monthly N. RennerFlow Cytometry Run time of MLabs cases >80 % completed in 4 hours Monthly N. RennerCytogenetics Lab Blood, bone marrow, tumor,

amniocentesis, chorionic villi and tissue samples monitor: *TAT - routine and STAT *inadequate specimens

> 90% within CAP guidelines for: Routine TAT: 14 days for amniocentesis and chorionic villus sampling; 21 days for bone marrow/ blood for malignancy; 28 days for constitutional peripheral blood; 6 weeks for tissuesSTAT TAT: 3 day preliminary and 7 day final report for bone marrow/blood for malignancy and constitutional peripheral blood Inadequate Cultures:Number of inadequate cultures are monitored for adverse trends and corrective action is documented

Quarterly B. Cox

Microbiology Blood culture contamination rate <3%, National Standard Monthly D. NewtonCSF Gram Stain Turn Around Time 95% verified within 60 minutes Monthly D. Newton

Specimen Processing Call Back/Fax Back Compliance Rate

Goal to be established Monthly B. Grayson

Order Entry Accuracy Review Goal to be established Monthly B. GraysonMLabs Order Entry Accuracy Review

Goal to be established Monthly B. Grayson

Inpatient Phlebotomy Inpatient Customer Survey   Quarterly B. Noyack

Adult Outpatient Customer Survey   Quarterly S. CampbellPediatric Outpatient Customer Survey

  Quarterly S. Campbell

Pathology Informatics Number of times we are > 10 messages behind in the outbound hub-CDR queue

Goal(s) to be established by Pathology Informatics

Monthly K. Davis/B. Hubbard

Histocompatibility TAT – new kidney patient evaluationsCompleteness, relevance and usefulness of information received on requisitionsMonitor HLA reports and antibody screening between reporting systemsPre-analytic monitors of problems received in laboratoryDocumentation of problems and complaints

  Monthly C. Schall     

Michigan Medical Genetics Laboratories

Biochemistry: 1. TAT – Plasma amino

acids, Urine organic acids2. Review of all reports for

accuracy3. Monitor number and

reasons for tests canceled

1. 95% of results released in 7 days

2. 97% of reports require no corrections

3. Less than 5% of tests canceled for handling or storage issues (grouped). Less than 5% of tests canceled due to hemolysis, insufficient quantity or incorrect tube type.

Monthly D. Weigel

Molecular:1. TAT – CMA2. TAT – PWSMP3. TAT – PTEN

 1. 80% reported out in 28

days2. 95% reported out in 14

days3. 95% reported out in 28

days

Monthly T. Ackley

Michigan Center for Translational Pathology

TAT – PCA3, CTC PCA3 – 6 daysCTC – 3 days

Monthly J. Siddiqui

Adult Blood Gas Number of results verified after 8 hours

Less than 20 per month Monthly H. Fredenburg

Pediatric Blood Gas Errors in documenting critical values

Less than 6 per month and no single tech greater than 3 per month

Monthly M. Britt 

Burn Lab Resource        Burkholderia cepacia Research Lab

Number of corrected reports issued due to laboratory clerical and non-clerical errors

Less than 1% of isolates require corrected reports

Bi-Yearly B. Foster

Mi-Oncoseq        

This information along with the corresponding laboratory’s tracking of metrics can be found on the w:drive under QA_DATA-Clinical Pathology.

W:\QA_DATA\Clinical Pathology\Quality Improvement Plan 12-13.docx

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.

KudosApheresis Unit for rendering excellent patient care. Below are patient comments from a recent Patient Satisfaction Survey. The nurses are really nice, respectful and caring. Sandy has learned

how to do my port a certain way and has taught other nurses and that helps my procedure go good. Thank You.

Staff is excellent-everyone is so friendly. I feel safe and secure in that any problem that might happen would be handled by the staff.

Services are great. As long as there are plenty of Lorna Doones we are happy.

Extremely competent and caring staff. All are experts in their procedures and are extremely knowledgable. They all take a deep interest in their patients’ well being. This is truly an example of the “Michigan Difference.”

You ROCK!!!

Histocompatibility LaboratoryOn February 5th the Histocompatibility Laboratory passed the ASHI (American Society for Histocompatibility and Immunogenetics) inspection with a PERFECT score. Thank you to all of the hard work it takes daily to maintain a safe and compliant laboratory!