Clinical Pathology Quality Dashboard March 2009. Clinical Pathology Quality Dashboard Inpatient...

Clinical PathologyQuality Dashboard

March 2009

Clinical Pathology Quality Dashboard

Inpatient Phlebotomy First AM Blood Draws

University Hospital

0%

20%

40%

60%

80%

100%

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2008 2009

8am

9am

10am

Drawn by

Mott Hospital

0%

20%

40%

60%

80%

100%


2008 2009

8am

9am

10am

Drawn by


Inpatient Phlebotomy First AM Blood Test Results:

PT/PTT, CBCP, and Comprehensive Panel University Hospital

0%

20%

40%

60%

80%

100%


2008 2009

0

100

200

300

400

Av

g D

ail

y V

olu

me

8am

9am

10am

Results by

Mott Hospital

0%

20%

40%

60%

80%

100%


2008 2009

0

2

4

6

8

10

12

Avg

Daily V

olu

me

8am

9am

10am

Results by

Inpatient Phlebotomy DrawsFiscal Year 2009


21,182

23,348

19,773

26,062

19,75920,459

19,598 19,795

0

5,000

10,000

15,000

20,000

25,000

30,000

July Aug Sept Oct Nov Dec Jan Feb

2008 2009


Turnaround Times

CSF Gram StainVolume and Turnaround Time

0

20

40

60

80

100

120

140

160

Mar April May June July Aug Sept Oct Nov Dec Jan Feb2008 2009

Mo

nth

ly V

olu

me

> 1 hour

30 min-1 hour

<30 minutes

TAT

Emergency Department Cardiac MarkerVolume and Turnaround Time

0

200

400

600

800

1000

1200

1400

Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb2008 2009

Mo

nth

ly V

olu

me

> 2 hours

1-2 hours

<1 hour

TAT


Molecular Diagnostics Laboratory

Specimens Received and Turnaround TimeJanuary 2002 - December 2008

0

200

400

600

800

1000

1200

1400

January2002

July 2002 January2003






July 2008

Month/Year

# of

Spe

cim

ens

rece

ived

0

1

2

3

4

5

6

7

8

9

10

TAT

(day

s)

# Specimens TAT Linear (# Specimens) Linear (TAT)


Chemistry In-Lab Turnaround Times

Last 12 months

0

2

4

6

8

10

12

14

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb

2008-2009

Per

cen

tag

e

Routines 60 min Total stat

45 min In patient 45 min Outpatient


New Clinical Assays Added in Last Year

Yeast identification system: (Vitek II automated)Yeast antimicrobial susceptibility: (Vitek II automated)EBV viral loadHIV-1 quantification (COBAS Ampli Prep – COBAS Taqman)

(includes extraction, amplification)MRSA surveillanceVRE surveillanceC.difficile surveillanceBCR/ABL1 Kinase Mutation Analysis (Sequencing)Human Erythrocyte Antigen Genotyping (Microarray analysis)IGH/BCL2 Translocation Detection (Real-time PCR)JAK2 V167F Mutation Detection (Allele-specific PCR)KIT D816V Mutation Detection (Allele-specific PCR)KIT Mutation Detection for GISTKIT Mutation Detection of MelanomaNPM1 Mutation Detection (PCR w/ capillary electrophoresis

detection)Microsatellite instability analysisPML/RARA t(15;17) Translocation Detection (Real-time PCR)Urovysion – FISH, Bladder Cancer DetectionHER2 Amplification – FISH, Breast CancerUGT1A1 Promoter GenotypingK-Ras Mutation Detection 1,25 Dihydroxy vitamin DSensitive beta-2 transferrin assay

UMHS Blood Product Utilization


Wasted Plasma

0%

1%

2%

3%

4%

5%

6%

Mar Apr May J une J uly Aug Sep Oct Nov Dec J an Feb

2008 2009

Threshold

Crossmatch/Transfusion Ratio

1.3

1.4

1.5

1.6

1.7

1.8

1.9


2008 2009

Threshold

Wasted RBC

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%


2008 2009

Threshold

Wasted Platelets

0%

2%

4%

6%

8%

10%


2008 2009

Threshold

Wasted Cryoprecipitate

0%

5%

10%

15%

20%

25%


2008 2009

Threshold

Blood Product Utilization

0

1000

2000

3000

4000

5000

6000

7000

8000

Mar Apr May June July Aug Sep Oct Nov Dec Jan Feb

2008 2009

0

1000

2000

3000

4000

5000

6000

7000

8000

Pa

tie

nt

Po

pu

lati

on

Random Platelets

Allo RBC Units

Plasma Units

Cryo Units

Partial Units

SD Platelets

AdjustedDischarges

Units Used


CAP Proficiency Testing

2nd Quarter FY 2009

Clinical Pathology Scores

0

100

200

300

400

500

600

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr

Nu

mb

er o

f C

hal

len

ges

50

60

70

80

90

100

Per

cen

t S

atis

fact

ory

FY2008 FY2009

Clinical Pathology474 = Number of Challenges

99% = Satisfactory Results

Anatomic Pathology2 = Number of Challenges


Department Total476 = Number of Challenges



CP Financial Measures

*excludes Blood Bank and Phlebotomy

Clinical Path Expense per Test*

$4

$5

$6

$7

$8

$9

$10

Total Expense per Test

Clinical Path Tests per FTE and Total TestsBy Month

1,000

1,100

1,200

1,300

1,400

1,500

1,600

1,700

1,800

1,900

2,000

Tes

t p

er F

TE

275,000

300,000

325,000

350,000

375,000

400,000

425,000

To

tal T

ests

Tests per FTE Total Tests

•Discontinue Cancer Center Hematology Lab (move to Main Lab) – Will Finn, MD, lead

•Improvement of Critical Value Callback process – Brenda Schroeder, lead

•Impact of Earlier AM Blood Draw in UH – OMS 490 students and Holly Eliot, leads

•Improvement of Communication with Patient Care Units – Beverly Smith and Brenda Schroeder, leads

•Customer Service Initiative – Beverly Smith, lead

•Lab Formulary Committee – Office of Clinical Affairs, FGP, Pathology

•Lean Process Improvement Projects – many!

•Laboratory Safety focus – Brenda Schroeder, lead

•Improvement of Blood Draw Wait Times- Cancer Center- Taubman 2- Taubman 3

•Creation of Blood Product Utilization Lean Team – Tim Laing, MD, (OCA), lead


Clinical Laboratory Operations Initiatives

•Clostridium difficile toxin screening algorithm – 1/09

•On-demand unit-specific antibiograms – 2/09

•Expedited (rules – based) release of ANCs (absolute neutrophil counts) – 2/09

•Integrated hematopathology reports – 2/09

•Troponin point-of-care (ED) – 3/09


Clinical Laboratory Service Enhancements

Kudos

•Thank you to the Phlebotomy Team! There has been a marked improvement in the average time of completed first AM blood draws in UH. (Please see Dashboard data.)

•Thank you to Jerry Davis (Hematology Lab), and his colleagues in the Lab and in Pathology Informatics for developing and implementing a new system that has expedited the rapid release of absolute neutrophil counts. (ANCs)

•Thank you to the Outpatient Phlebotomy team for a greater than 84% (to date) participation rate in the Employee Engagement Survey (open through March 27th).


Clinical Pathology Quality Dashboard March 2009. Clinical Pathology Quality Dashboard Inpatient...

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