1. THE VALUE OF CAP’S Q-PROBES & Q-TRACKS
Peter J. Howanitz MD
Professor, Vice Chair,
Laboratory Director
Dept. Of Pathology
SUNY Downstate
Brooklyn, NY 11203, USA

2. OVERVIEW Discuss History of Q-Probes & Q-Tracks
Demonstrate Results Of Some Studies
Discuss Impact On Pathology
Improve Patient Care
“Skunkworks” For College Of American Pathologists

3. HOW Q-PROBES & Q-TRACKS HAPPENED
1979-Chairman NYSSPATH QC Committee
Workshop For Participants On QC
Made Case For Pre & Post Analytical QC
Chair Of CAP QC Committee 1982
Filled QA Workshop ASCP/CAP Meeting 1986
Began Pilot Planning 6 Quality Indicators 1987
Began Career 1976, and had two mentors, early in my career
One in academics, other in CAP: was one of 2 major CP programs in U.S.
In 1982, only QC and PT

4. TOTAL TESTING PROCESS
Howanitz PJ Laboratory Quality Assurance McGraw Hill 1987 p 2

5. CAP’s Q-PROBES & Q-TRACKS
Q-Probes Launched 1989
Peak Participants Labs
Q-Tracks Launched 1999
Both Programs Continue Today
25th Year Anniversary 2014
CAP began QC committee in 1971, and PT program began in Operated by QPC within CAP. Division of 2 committees in QAS QA and QAS QC in QAS QC operated until 1999.
Lawson et al. Arch Pathol Lab Med. 1997; 121:

6. WHY DEVELOP PROGRAM? Determined Pathology Quality Attributes
Teach Laboratory Community QI
JCAHO (TJC) Requires QI
CLIA’88 Requires QA For All Steps Total Testing Process
CAP Accreditation Requires QI
Q-Tracks Best Drives Improvement
Improve Patient Care
No definition of what quality attributes were for a clinical laboratory.
JCAHO now called TJC
Did workshops with TJC, Participated in CLIA for CAP, and worked with CDCs
No work on importance of Preanalytical and Postanalytical testing
CLIA’88 is a regulation for clinical laboratories.

7. ADVANTAGES OF PROGRAMS
Provide Educational Tools i.e. Publications
Develop Benchmarks
Provide “Off Shelf” Products
Conserve Participant Resources
Partially Fulfill Regulatory Requirements
Help Pathologist With Leadership & Management

8. TYPES OF Q-PROBES STUDIES
All Short Term Subscription Studies
All Steps In Total Testing Process
Extensive List Other Quality Indicators
Safety Practices
Competency Assessment
Good Laboratory Practices
Repeat Studies
Similar To Snapshot
We had discussions about what to do first. Decided to do Q-Probes, and then follow with Q-Tracks. Lots of management issues.
Had data collection from within lab as well as a number of questions which accompanied study.

9. Q-TRACKS Ongoing Studies For Years Limited Number Of Studies
Use Q-Probes Benchmarks
Submit Data Every Quarter
Similar To Movie
18 studies to date. We were unwilling to develop Q-Track until we had experience with the monitor.

10. HOW PROGRAMS WORK Studies Developed By Committee
Field Evaluated Before Made Available
Purchased By Participants
Directions & Materials Participant Data Collection
Data Sent To CAP For Analysis
Benchmarks, Participant Data Returned In Critique
Educational Tools Available
Educational tools include publications, purchase old studies, teleconferences, workshops at National & International Meetings
Used data collection worksheets

11. DATA-COMPLICATIONS OF PHLEBOTOMY
Indicator
Institutions
10th Percentile
50th Percentile
90th Percentile
Median Size Bruise (mm)
4048 Bruises
20.5
11.0
5.0
% Bruised Patients
32.0
16.7
7.1
% Pts Identifying Outstanding Employee
11107 Patients
25.6
46.7
69.8
Median Wait Time (Minutes)
23783 Patients
15.0
6.0
4.0
Early study. Uses percentile ranking with higher percentile means better performance.
Data base is large.
Phlebotomy is one of the Clinical Laboratory functions that directly influences patient care.
Sometimes hard to know what is better performance. Must wait for minutes before phlebotomy
Howanitz et al. Arch Pathol Lab Med 1991: 115:

12. BEDSIDE GLUCOSE ENABLERS INCREASED ACCURACY
VARIABLE
MEDIAN ACCURACY
P VALUE
Lab Personnel vs RN Responsible For Testing
67 vs 49
.0007
Lab Personnel Perform Testing
65 vs 53
.01
Nursing Personnel Not Performing Testing
63 vs 57
.04
Lab Personnel Performs Training
64 vs 50
.02
Lecture Used In Training Program
63 vs 45
Repeat Training/Performance Review Operators
63 vs 41
.0002
Regular Clinical Lab Result Correlations
63 vs 50
Regularly Compare Proficiency Results
62 vs 50
Participate In Bedside Glucose Proficiency Testing
.03
Laboratorian vs RN Collected This Study Results
67 vs 51
Offers opportunity to study variables used to improve. Here 10 enablers studied on their effect to improve performance in 605 institutions with statisticians defining significance. Statiticians provided for each study, attended committee meetings, and help design studies.
Some are expected (Lab Personnel vs RN Responsible for testing)
Jones et al. Arch Pathol Lab Med 1993;177:

13. SELECTED BENCHMARKS STEP Sample Size Median Benchmark Order Right Test
15,011 Tests
23.0%
Anti-HBC Test, No AST, ALT
Patient Prepared
18,679 Toxic Levels
24.4%
Digoxin Collected > 6 Hrs Dosing
Accurate Orders
224,431 Measurements
1.8%
Test Ordered, Not Received Lab
Patient Identified
451,436 Pts
6.5%
Patients Wristband Incorrect
Specimen Collection
29,700 Pts
6.0 min
Timely Of Collection
Specimens Rejected
35,325 Specimens
0.38%
CBCs Rejected
Results Evaluated
5837 Results
85.0%
% Abnormal Results Documented
QI Resources
9860 Indicators
40 h/Mo
Time To Complete QI
An example of benchmarks that were developed. They need to updated from time to time: Many studies in literature about single laboratories improvement-

14. COMPTENCY ASSESSMENT
Howanitz et al Arch Pathol Lab Med:2000;124:

15. TROPONIN TURNAROUND TIMES
159 Hospitals, 1352 ED Physicians, 7020 troponin values
One of most common studies, CSF , ED x 4, Routine test, outpatient testingUA, OR blood delivery, Early morning rounds collection, blood component preparation, 2 Q-Tracks Outliers and troponin, 6 AP studies.
Q-Tracks study resulted in collaboration with Chest physicians.
Novis, DA. Arch Pathol Lab Med 2004:128:

16. ED TURNAROUND RESULTS
TAT of potassium and hemoglobin results from ED patients in 2 studies

17. CLINICAL LABORATORY ERROR RATES
These are 12 of the studies we have conducted over time using Q-Probes.
Looks at errors throughout the total testing process.
Remember that there are many steps in this process of trying to get the results to a patient and the liklihood of not having an error is rare.
Most errors in preanalytical and postanalytical areas. One of most difficult issues is ordering the correct test.
Howanitz PJ Arch Pathol Lab Med 2005;129:

18. 27 TURNAROUND TIME STUDIES
CSF Analytes
ED-(4)
Routine Test
Stat Test Outliers*
Routine Outpatient Tests (2)
Biochem Markers AMI*
Reporting Positive Blood Cultures
Morning Rounds Test Results Available*
Blood Component Preperation
OR Blood Delivery
Urinalysis
27 studies, 10 AP, 14 CP Q-Probes and 3 Q-Tracks
Have looked at all the disciplines of the clinical laboratory, heme, chem, TM, and MB.
*Also Q-Tracks Studies

19. Q-TRACKS WRISTBAND ERROR RATES CONTINUOUS IMPROVEMENT
Data from the first Q-Tracks study that was published. In US, wristbands are used to identify patients. When we published this, some from Europe commented that it was improper to use wristbands and that patients should not have numbers/ID. We argued it was a patient safety issue.
Note that beginning new year with new participants adds a potential issue and rate in this case stays same.
Howanitz et al. Arch Pathol Lab Med 2002: 126:

20. Q-TRACKS WRISTBAND ERROR RATES CONTINUOUS IMPROVEMENT
Have Wristband errors continue to decrease overall over 4 years. We have studied some of these and found that rates continue to decrease even after 10 years!

21. VARABILES Q-TRACKS STUDY
Q-Tracks program is able to monitor one variable that is important. Here for wristband errors, missing wristband was the largest source of errors. Conflicting wristbands include patients that have had their own wristband on
Aggregate percentage of types of wristband errors (N=45197) for 2 years. Arch Pathol Lab Med. 2002:126:

22. PHYSICIANS’ 8 MOST IMPORTANT CLINICAL LABORATORY SERVICE ASPECTS
Chose most important laboratory service characteristic. Other choices accounted for less than 1% of other characteristics. Also different for nurses.

23. COMMITTEES’ 8 MOST IMPORTANT QUALITY INDICATORS
DISCIPLINE
TESTING PROCESS
Customer Satisfaction
Entire Laboratory
Entire Process
Test Turnaround Times
Each Discipline
Blood Utilization
Transfusion Medicine
Preanalytical
Patient Identification
Blood Culture Contamination
Microbiology
Specimen Rejection
Proficiency Testing
Analytical
Critical Value Reporting
Post Analytical
8 include all major steps in total testing process, and each of the major clinical hospital laboratories.
Howanitz PJ. Arch Pathol Lab Med 2005; 129:

24. Q-PROBES DEMOGRAPHICS
AP NUMBER
CP NUMBER
Q-PROBES STUDIES 52
115
AUTHORS & COAUTHORS 33 50
ARCHIVES PUBLICATIONS 49 75
OTHER PEER REVIEWED PUBLICATIONS 18 21
NON-ARCHIVES CITATIONS
ARCHIVES CITATIONS
1355
1609
PARTICIPANTS
15,406
42,663
COUNTRIES 24
CAP TODAY ARTICLES 17 55

25. PROGRAM ACHIEVEMENTS 17TH CAP CONFERENCE -300 PARTICIPANTS
Arch Pathol Lab Med 1990:114:
Invited To Discuss Juran Institute International Meeting
Identified 1 or 6 Outstanding Medicine Programs By Healthcare Forum
Healthcare Forum J 1993: 36:37-52
Personal Awards, Careers
CDC Finalists Best Manuscript 3 Times
CAP conference open to public in 1990-Only CAP conference that was profitable. First CAP conference open to the public
Juran Institute Conference in Atlanta by Invitation participants interested in Quality Improvement -1991
Healthcare forum

26. PROGRAM ACHIEVEMENTS Competency Assessment Program POCT
Influence On CAP Accreditation Program
Approved For Maintenance Of Certification
Cytology Conference
CDC Grant
Specialty CAP Pathologist Certificate Program
Evalumetrics
Assessment of best practices for standardized QA activities-7 manuscripts published
Awards from CAP, CDC, AACC
Two committee members had individual grants for PI
Committee members defined as experts, asked for interviews for magazines, newspapers, etc –may not be a good thing-testified in court cases.

27. 41,000 enrollees. Idea sent to CAP leadership, began for POCT personnel and has grown.

28. THE JOINT COMMISSION REQUIREMENTS
Organization Monitors Healthcare Quality
Medical Staff Requirements
Performance Data On All Physicians
Ongoing i.e. Not At 2 Year Reappointment Process
Department Specific Requirements
Chair Of Department Responsible
Med Staff Executive Committee Responsible
Credentials Committee Responsible
Earlier we talked about CLIA’88 and regulatory requirements. Also regulations from CAP, and from a group assuring quality in healthcare. When we stated Q-Probes, I participated in a number of jointly sponsored workshops between CAP and TJ.

29. EVALUMETRICS CAP Released 2013 2 Years In Development
Software Designed In House
Ongoing Professional Practice Evaluation
Focused Professional Practice Evaluation
Competency Program For Pathologists
Over 60 Metrics On Introduction

30. EVALUMETRICS CP METRICS
Metric Title
Practice Area
Description
Laboratory Management TAT
Core
Timeliness Document Approval
PT Peer Review
Quality PT Review
Transfusion RX Report Review
Transfusion Medicine
Written Report Review
Bone Marrow Aspiration
Hematology
Properly Performing Procedure
Protein Electrophoresis Peer Review
Chemical Pathology
Interpretation Concordance
On Call Reliability
General Pathology
Available, Respond Promptly

31. CONCLUSIONS Discussed History of Q-Probes & Q-Tracks
Demonstrated Results Of Some Studies
Discussed Impact On Pathology
Improved Patient Care
“Skunkworks” For College Of American Pathologists-Innovation New Programs
Questions