Decreasing turnaround time in getting test results to patients.

Performance Improvement Leadership Develop ProgramUniversity of Missouri – Columbia

2/18/2011

Team Members

• Jacqueline Ruplinger, MD (Blue Team GM)• Cynthia Twenter, LPN (Blue Team GM)• Rosie Powell, PSR (Blue Team GM)

• Anne Fitzsimmons, MD (Sponsor)• Tim Hogan, RRT, PhD (Advisor)• Carol Nierling, MS, RN (Advisor)

Focus Area

• Patients do not get their test results within the 5 day recommendation put forth by University Physicians

• Getting test results to patients is done in a variety of ways and requires a lot of provider and staff time and resources

Aim Statement

Improve the notification process by which patients on blue team receive their test results. We want to decrease the time from the result getting to the provider’s inbox to the patient from >5days to <5days by 90% within 60days of implementation of Healthe and other outlined standardized/streamlined processes.

Relationship to Strategic Goals of the Institution & our Department

UP directive -the patient should receive test results within 5d 1-27-10

FM Departmental Policy - 4-7-10

•Ordering provider will review all results both normal and abnormal•Normal and abnormal results will be communicated to the patient•Approved methods of communication were outlined: clinic visit, PC generated test result letter, lab card with electronic documentation that it was done and sent, phone call-either by provider or nurse*(guidelines as to when a nurse should call outlined)

Project Timeline

08/27/2010 02/18/2011

09/01/2010 10/01/2010 11/01/2010 12/01/2010 01/01/2011 02/01/2011

11/01/2010 - 11/30/2010Collection of pre-intervention data:

· flowchart workflow processes· Time to patient receives results post-visit· Order à Lab in PC à Endorsed à Mail Results

10/01/2010 - 12/23/2010Efforts to get Healthe in GM Blue Team clinic

1. Started enrolling patients

for Healthe

2. standardization

of letters to

patient

02/07/2011 - 02/18/2011Start post-intervention data collection

01/18/2011 - 02/18/2011Initiate Interventions

08/28/2010Start of PILDP

09/17/2010Develop AIM Statement

12/20/2010Finalize AIM Statement

Process Flow Chart for a Provider• Provider steps to

generate a lab letter to a patient

• 21 clicks• 1 min 43 secs

• With Healthe

• 6 clicks• 40 secs

• With Healthe

• 6 clicks• 40 secs

StartStart

Result is in providers inbox

in PC

Result is in providers inbox

in PC

Provider DC on pt name

SC on OK

SC on name & document viewSC on name &

document viewSC on add documentSC on add document

SC on precompleted

SC on precompleted

DC on test results letterDC on test

results letter

SC on show structure

SC on show structure

SC on last 200 results

SC on last 200 results

Click to include labs

Click to include labs

Click on “other” in additonal infoClick on “other” in additonal info

Write note to pt SC on OKSC on OK

SC on macro to include

cholesterol info

SC on macro to include

cholesterol info

SC on sign

Hit “L” to put letter in note

type

Hit “L” to put letter in note

type

SC on request endorser

SC on request endorser

SC in comment & type “send”

SC in comment & type “send”

SC on OKSC on OK

SC to get out of pt chart

SC to get out of pt chart

SC back on results to get

back to rest of results

End

Process Flowchart for a NurseStart

Receive results from Dr to send pap letter to pt

DC to open & read ressult

Open chart to document viewing

SC add +SC on letters DC pt test results

DC on blue teamSC on dateSC on date box okSC salutation

choiceSC opening statement

In cytology clickon the results you

need

SC closing statement

SC sincerely choice

SC on provider insert

Type Dr name SC ok SC sign

Type L in sign line (type box)

SC okSC menu allSC on clinic notesSC updateDC on

communication

Type Dr nameSC on comments

boxType letter doneSC OK

SC forword person again

SC on down arrow for addition

forword

SC on review SC in to box Type my nameSC on comment

boxType please mail SC Ok

SC X box to closechart

In comment box on test results SC

Type letter done and in the mail.

SC ok End SC update

DC on letterSC on letter you

just didSC for word SC down arrow for

additional for wordSC sign SC in the to box

• Nurse sends “nl” pap letter for provider

• 43 clicks• 4 min

Standardizing “nl” papletters saves steps

Process Flow Chart for a PSR

DC pt’s name in powerchart

Start

SC Programs button

SC MS Office

SC Word to open

SC Powerchart

SC and drag to copy letter

RT Click for submenu in Microsoft Word

SC Paste button on submenu to paste letter

SC by address and drag to copy

SC on mailing button in title bar

SC envelopes on menu bar

SC envelopes on Menu Bar

SC Add to document button in the envelopes and labels

dialogue box

SC Office button on title bar

SC Office button

SC Print button

SC Okay button

SC X in print dialogue box

SC X on title bar to close letter and envelope

SC No to save document

RT Click in powerchart

SC on modify to type addendum

Type printed and mailed letter under addendum

SC on sign button

SC X to close pt’s chart

End

• Process for mailing a letter

• 25 clicks• 4-5 min

Utilizing see-through envelopes saves steps and eliminates errors

Fishbone Diagram

Decrease the time it takes for pts to get

their test results

Holidays &Weekends

Patient

Staff

Providers

Lab

Communication

Delays results

Letter on FridaysAuto delay

Variation in Staffing

inconsistency in provider Work pattern

Proxy (inbox)

Time involvement

Multi steps

Interruptions

Letters arelow on priority list

Differences in providers(No standerdization)

Phone calls Triage

Med refills

Specimen not labeled

Inadequate specimen

Missed lab order

Results go towrong provider

Lost specimen

Long turn around time

Send off labs

Not scanned into power cahrt

Phone

Email

Mail

Length of time to getout of system and deliverd

Letter

Not sent

Wrong pt

Does not Have PC

Wrong address

No workingphone

No working phone

Not clear aboutexpectations

DNKA

Lab

F/U appt

TimeConstraints

Not getting Results

Abnormal resultsNeed more work

Process is timeconsuming

Not educated in EMR shortcuts

Inconsistency amongproviders in how

they get results out

PSR Letter Nurse calls

Provider calls F/U appts

Nurse calls

Doc callsMail pickup 1x/d

Stakeholders

• Patients• Providers-residents and attending physicians• Staff-phone nurses, PSRs & floor nurses• Care coordinator-Joan Asbee• Lab/radiology• Cerner staff

Baseline data

Baseline Data cont.

• One providers experience to endorse and make lab letters on 14 patients-37min to do 14 letters-238 clicks

(Note this does not include the time it takes for the nurse or PSR to process the letter and mail the letter, this would add an additional 63 min)

Interventions Considered

• Electronic Approach-Healthe• Phone approach-standardize times when

providers would ask the nurse to call patients*• Standardization of workflow processes-letters,

envelopes• Request input from patients how they would

like to hear about their test results*already outlined by our department April 2010

Measurements

• Time it took for patients to get test results • Time it takes to process letters to patients• Time for the letter to get through the mail• Patients perception pre and post intervention

Outcomes to Date

Patient FeedbackN=36

Workflow Change

Anticipated ROI/ Benefits Realized

• Using the electronic approach to communicate test results to pts-541 physician hrs/yr in time saved-867 staff hours/yr saved-$5,200 saved in postage

• Workflow processes streamlined• Secondary benefits of Healthe• Eliminated wrong letter to wrong ptAll increases pt, staff and provider satisfactionAll increases pt, staff and provider satisfaction

Lessons Learned

• It took much longer to get Healthe going • Pts did not register as quickly as we anticipated• When the “create” button lights up in “results to

endorse” that does not mean the pt has registered• FU after an intervention is very important• Improvement work takes people with different

backgrounds and skill sets• There are a lot of tools available and IT’s FUN!

Future Steps

• Continue the momentum in enrolling pts • Focus on the FU surveys before rolling out to the

rest of Green Meadows• Share our findings/experiences at team mtgs• Present our findings at a Colwill seminar• Cont. to look at all the test result processes• Integrate PDSA in our daily routine-meet monthly

Summary

• By implementation of an electronic way of communicating results to patients greatly reduced turnaround time and did not take more provider or staff time

• Standardizing how results get to patients and creating form letters & utilizing see-through envelopes also decreased waiting times

Summary

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Questions?