Clinical PathologyQuality Dashboard

March 2013

Clinical Pathology Patient Care QualityBlood Bank

Clinical Pathology Patient Care QualityChemistry

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

00.5

11.5

22.5

33.5

44.5

55.5

66.5

77.5

8

July

Aug

Sep

Oct

No

v

De

c

Jan

Perc

en

tag

e

Fiscal YR 2012 - 2013 Chemistry TAT report

Routines >60 min Stat >45 min Outpatient >45 min Inpatient

Clinical Pathology Patient Care QualityHematology

Clinical Pathology Patient Care QualityMicrobiology

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

* 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 Financials

J uly 11 Aug 11 Sept 11 Oct 11 Nov 11 Dec 11 J an 12 Feb 12 Mar 12 April 12 May 12

J une 12

J uly 12

Aug 12 Sept 12 Oct 12 Nov 12 Dec 12 J an 13

Department ID

317520 301 349 224 77 142 324 296 62 106 116 184 405 304 208 248 89 464 89 383

317521 8 85 125 76 53 104 164 243 253 137 159 38 121 70 84

317530 295 209 265 328 173 503 287 177 135 68 194 255 245 129 289 219 431 124 330

317542 239 237 136 83 108 406 151 249 220 182 197 422 267 234 160 388 257 96 83

317544 1,032 1,027 1,094 736 943 1,349 1,210 945 947 858 1,223 1,402 1,014 1,331 1,201 1,199 1,395 1,154 1,242

317546 1,378 987 1,574 1,053 1,071 1,545 1,094 735 782 1,022 879 1,281 903 1,249 1,447 1,103 1,845 852 1,220

317548 231 106 185 266 151 124 265 184 151 110 69 306 204 257

317549 150 494 298 108 85 31 22 89 175 184 151 213 210 162 222

317560 338 232 363 249 180 461 315 114 104 186 90 389 251 144 317 120 301 65 418

317607 12 -1 10 -8 10 23 22 16 14 22 -14 18 15 29 16 8 22 13 3

317608 382 427 331 295 346 379 295 312 283 277 429 339 257 245 282 236 267 303 254

317609 37 50 62 99 153 227 70 77 110 56 97 127 97 67 49 2 25 15 32

317610 159 97 148 93 148 156 204 156 40 25 34 91 167 122 228 104 115 34 160

317613 2 0 1 0 13 -8 0 15 -4 8 -1 2 1 0 0 0 1 0 1

317615 47 12 33 42 24 16 15 16 76 -9 44 24 29 78 -12 35 37 27 38

317632 23 10 17 96 23 108 64 43 39 21 25 76 49 36 61 37 69 20 52

317720 57 16 18 24 0 60 77 -1 0 25 -9 68 59 2 45 0 48 0 90

317760 32 21 55 31 10 21 7 7 105 16 19 47 2 12 9 13 40 8 14

4,332 3,673 4,329 3,199 3,502 6,381 4,635 3,290 3,361 3,157 3,700 5,541 4,271 4,357 4,759 3,871 5,955 3,235 4,883

Department ID Description

UMH Chemical Pathology

CW Path Peds ED

UMH Microbiol Pathology

UMH Path O/P Phlebotomy

UMH Path Central Distrib

UMH Path I/P Phlebotomy

UMH Flow Cytometry Lab

UMH Cytogenetics Lab

UMH Molecular Diagnostics

CW Path O/P Phlebotomy

CW Path I/P Phlebotomy

UMH Path Hemo/Coag Unit Uh

Total Overtime Hours

UMH Pathology Blood Bank

UMH Blood Bank Bone Marrow

UMH Transfusion/Apheresis

UMH Virology Lab

UMH Special Chemistry

UMH Histocompatibility

Clinical Pathology QA Meeting Highlights

In June 2012, we expanded and corrected our reporting process to be more specific to whether an RN or RT was notified of critical values. A department meeting was held to discuss changes and how best to improve the error rate. In the meantime, individual techs were counseled if their documentation error rate was excessive. Since that practice was started, correction rates have steadily declined to a point almost equal to May 2012.The response from the techs has been positive, they appreciate the monthly updates on their progress.

Pediatric Blood Gas Lab-Addressing Documentation Errors

The Mlabs Call Center has a goal of answering 90% of calls within 30 seconds or less. In the past year several issues including additional work processes related to a particular client as well as staffing have affected this metric. These two factors have been eliminated, however the metric has not returned to it’s normal status. Analysis as to the root cause of this are being investigated. It has been observed that the length of individual calls has increased most likely due to the increased number of molecular clients with more complex questions. Continued efforts to improve continue by analyzing several potential contributing factors. Email and interfacing with clients have been used in an attempt to reduce the call traffic and respond within the desired time frame.

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. Lina Shao (Cytogenetics) has implemented an assay platform for array-based Comparative Genomic Hybridization (array CGH) studies. The Clinical Cytogenetics Lab will offer this analyses for oncology cases.

• Christine Shaneyfelt has developed a fully functional and robust system for tracking capital equipment requests and acquisitions.

• Beth Lawless-(Specimen Procurement-Sendout Lab) has provided consistent and high quality data in support of the UMHS Laboratory Formulary Committee.