1. Quality Performance Indicators and their values in Patient Safety
Dr. Rana Nabulsi .PhD, MSc ,CPHQ , CSSGB, EFQM
Head of Quality – Pathology & Genetics Department
Dubai Health Authority – Dubai-UAE

2. Objectives Define the Quality Performance Indicators.
List the most common Quality Performance Indicators used in the clinical laboratory.
Discuss how Quality Performance Indicators are related to patient safety.
Illustrate why we need Quality Performance Indicators & Benchmarking in our laboratories.
Discuss the criteria for selecting the best Quality Performance Indicators.

3. What are Quality Performance Indicators?
A set of measureable indicators that a Laboratory uses to monitor the performance of operations in terms of meeting the strategic goals of Healthcare System.

4. Objectives and Goals of Medical Laboratories
Patient Safety
Accuracy and Reliability of results
Stakeholders Satisfaction
Operational Excellence.
Growth and professional development.
Financial results

5. Quality Performance Indicators and Laboratory Objectives
Business Objectives
Quality Performance Indicators
Key Success Factors (KSFs)
Determine.
Tracked by.

6. What gets measured….gets delivered.

7. Remember
“Not everything that counts can be measured; not everything that can be measured counts”. Albert Einstein

8. Reliable Quality Performance Indicators
Play a key role in improving the quality of laboratory services and patient safety.

9. Total Testing Process (TTP)
Safety
Customer
Service
Data
Management
Pre-Analytic
Post-Analytic
Analytic

10. KPIs and Total Testing Process (TTP)
Pre Examination
Examination
Post Examination

11. Quality Performance Indicators for Laboratories
Quality Metric
Quality Performance Indicators for Laboratories
Pre-
Analytic
Post
Anatomic Pathology
Clinical Pathology
Chemistry
Hematology
Micro
biology
Trans
fusion
Patient Safety
Patient satisfaction, specimen collection ●
Patient ID, wristband accuracy
Test Order entry accuracy
Proficiency testing performance
Specimen
Rejections
Specimen ID errors
Blood culture contamination
LABMEDICINE Volume 39 Number 2 February 2008

12. Quality Performance Indicators for Laboratories
Quality Metric
Quality Performance Indicators for Laboratories
Pre-
Analytic
Post
Analyt
Anatomic Pathology
Clinical Pathology
Chemistry
Hematology
Micro
biology
Trans
fusion
Patient Safety
Blood product wastage ●
Completeness of cancer diagnosis
STAT test turnaround time
Corrected results
Critical result reporting
Gynecologic cytology-biopsy correlation
Clinician satisfaction with lab services
LABMEDICINE Volume 39 Number 2 February 2008

13. Why Laboratories need Quality and Safety Indicators?

14. Trigger is Institute of Medicine (IOM) Report,1999

15. Patient Safety
Institute of Medicine (IOM)/NAM claimed that as many as 1 million patients per year suffer
injuries due to medical errors.
The Joint Commission (JC) issued International Patient Safety Guidelines (IPSG).

16. Definition :Patient Safety-IOM/NAM
“Freedom from accidental injury due to medical care, or medical errors.”

17. Quality Performance Indicators
As per Institute of Medicine /NAM, Quality Performance
Indicators shall have the following dimensions :
Patient safety
Timeliness
Effectiveness
Equity
Efficiency
Patient-centered care

18. International Patient Safety Goals
IPSG 1: Identify Patient correctly. IPSG 2: Improve Effective Communication. IPSG 3: Improve safety of high alert medication. IPSG 4: Ensure correct site, procedure and patient surgery. IPSG 5: Reduce the risk of Health Care-Associated Infections. IPSG 6 : Reduce patient falls.

19. Quality Performance Indicators and Patient Safety

20. Quality Performance Indicators Pre Examination
Patient lD errors
Accuracy of Test Order Entry
Blood culture Contamination
Specimen ID &Labeling errors
Rejection of samples
Incidents at Collection

21. Patient ID errors CAP TODAY April 2010 Feature Story Karen Titus
In order to report accurate lab results for the right pt and meet jci of ipsg,we need continously monitoring pt id,wrist band id errors ,so we can identify and correct problems that have –ve impact on pt safety.
CAP TODAY April 2010
Feature Story
Karen Titus

22. Specimen ID errors
Makary MK ET AL,SURGERY 2004.

23. Accuracy of Test Order entry
When lab fails to complete test request accurately, it delays the diagnostic evaluation, extend hospital stay and prolong therapy

24. Rejection of samples Biochemia Medica.Aysenur Atay et al. 2014
Sp rejection will lead to substantial amount of re work or redraw, diagnostic &therapeutic delay &pt inconvenience.
Pt redraws may result from unlabeled,mislabeled,clotted/hemolysed insufficient quantity.
By continously monitoring this kpi,we can promote pat safety
Biochemia Medica.Aysenur Atay et al. 2014

25. Blood Culture Contamination rate.
High rate of BCC is associated with LOS,additional expenses,administration of un necessary antibiotics
Journal of Emergency Nursing.Andrew D& Sausan Bollinger Jan 2013.

26. Total Testing Process (TTP)
Data
Management
Safety
Customer
Service
Pre-Analytic
Post-Analytic
Analytic

27. Quality Performance Indicators -Examination
Staff Competency
Transfusion errors
MRSA incident rate
Correlation Cytology/Biopsy
EQAP Failure

28. Transfusion Errors
Transfusion Error Surveillance system TESS Report,Lab safety. 2013

29. Rate of MRSA Incidence
Monitoring rate of MRSA incidence BY MICRO AND Infection control to monitor Hospital acquired infection rate and accordingly we can identify the reasons, take corrective actions, adopt best practice and consequently improve patient outcome.

30. Correlation Cytology /Histology
Monitoring the correlation ,the lab can identify and address the potential problems requiring improvement, ensuring better pat results.
Acta ortop.bras.vol.22no.3 Sao Paulo 2014.

31. Competency of Staff https://viewics.com/solutions/anatomic-pathology/
We need to monitor our staff for competency in different areas to ensure they are releasing accurate lab results and identify their weakness areas and help them to improve by continouing training.

32. % Proficiency Testing failure
Monitoring our failure in PT will help us to identify our errors in testing pt samples and
Help us to do improve to release accurate lab testing.
CDC-1996 Clinical laboratory performance on PT samples-USA. March 08,1996

33. Total Testing Process (TTP)
Pre-Analytic
Safety
Customer
Service
Data Lab
Management
Post-Analytic
Analytic

34. Quality Performance Indicator -Post Examination
STAT test Turn around time
Critical Result Reporting
Revised/Corrected Reports

35. STAT Turn Around Time

36. STAT Turn Around Time (example Troponin)
Pts presenting at ED with chest pain must be evaluated quicly.so reducing TAT in troponin testing will lead to decreased LOS &more rapid initiation of anti ischemic treatment. Consequently pt safety is improved
Chris Christopher, Lab Quality Confab,2010

37. % of Critical Results reported in 45 minutes
Regulations agencies &accreditaionbodies from CMS,CAP,JCI mandate labs to notify clinicians,healthcare givers of critical values as immediate pt diagnosis and treatment,consequently pt safety will be improved.

38. Proportion of Revised /Amended reports
Accuracy of lab results is critical for the effectiveness of pat care for accurate diagnosis &treatment.
Any erroneous test result can delay or alter pt dx n treatment.
-timely detection of erroneous test results and timely correction is vey crucial for pat safety.

39. Link Targets of Quality Indicators with Six Sigma Model

40. Quality Indicators and Six Sigma
Sample Size
Variance
Percent Variance (Variance/Sample Size x 100)
Parts per Million
Six Sigma Quality
1,000,000
3.4
Pre Analytic
Missing information on requests
Tissue samples
2,691 43
1.5979
15,979
Cytology, Papanicolaou smears
6,932
695
100,259
Correction of errors on ordered tests
197,195
616
0.3123
3,123
Patients without identification bands
26,400
139
0.5265
5,265
Specimen redraws
503
1.9053
19,053
Collection of TDM peak/trough specimens at improper time
280 58
107,140
Sample label errors
138
0.5227
5227
Number, source, and nature of unacceptable specimens
332,223 35
0.0105
105
Analytic
Laboratory testing error
192,665
140
0.0726
726
Interpretation misjudgments in microbiology
34,734
256
0.7370
7370
Post Analytic
Laboratory reporting errors
389,860
208
0.0533
533

41. Quality Indicators and Six Sigma
Defects per Million Operations (DPMO)
Percent Error
Efficiency 1
690,000 69
0.31 2
308,000
30.8
0.69 3
66,800
0.67
0.993
3.5
22,750
0.23
0.998 4
6,210
0.06
0.9994
4.5
1,350
0.01
0.9999 5
233
0.002 6
3.4

42. Other Quality Performance Indicators
Timeliness of responding to clinical advice .
Operating Room Blood Delivery Turn Around Time.
Completeness of Cancer Reporting.
% of cases of Molecular Testing in Anatomic Pathology that adhere to established Clinical guidelines.

43. Why Use Quality Indicators?
Performance effectiveness.
Patient Safety
Easier decision making.
Measure of laboratory processes and outcomes.
Monitor changes.
Detect potential problems.

44. Criteria for Selection of Quality Indicators
Cover Pre-examination, examination & post- examination.
Operational units ( Hematology, Microbiology, POCT, AP).
Patient Safety.
Financial, Human Resources.
Customer needs.
Accreditation requirements (e.g. JCI,ISO, CAP, CPA, etc..)
Regulatory requirements.

45. Criteria for Quality Indicators selection
Validity :Does the KPI measure what it is supposed to measure?
Reliability: Does the KPI provide a consistent measure?
Acceptability: Are the KPIs acceptable?
Feasibility :Is it possible to collect the required data and is it worth the resources?
Explicit evidence base :Is the KPI supported by scientific evidence?

46. How to develop Quality Indicators?
Definition
Name, purpose, scope, authority, domain.
Method of data collection and Analysis.
-Numerator , Denominator, frequency, calculations.
Targets
-International bench mark.
-organizational performance goal
-Evidence base.

47. Q-Track -CAP

48. Quality Performance Indicators are not enough

49. Benchmarking is needed

50. "Improving ourselves by learning from others."
Benchmarking Simply
"Improving ourselves by learning from others."

51. Benchmarking
Is the practice of being humble enough to admit that some organizations are better than you at something and wise enough to try and learn from them their best practice.
American Productivity and Quality Center-1988

52. Benchmarking is Making Best Practices Your Daily Practice.

53. Why Benchmarking ? Better Awareness of Our Laboratory
What we are doing
How we are doing it
How well we are doing it
Better Awareness of the Best laboratories
What they are doing
How they are doing it
How well they are doing it

54. Benchmarking and World Class Performance
Benchmark Purpose and Quality Maturity I
Learning from success VI
National leadership II
Borrowing ideas
III
Best-in-firm IV
Beating industry standards V
Best-in-class
Quality Maturity
World-class Leadership

55. Levels Of Benchmarking
Internal benchmarking - Within one’s organization.
Competitive benchmarking - Analysis the performance and practices of best in class laboratories.
Non-competitive benchmarking -Is learning something about a process a laboratory wants to improve by benchmarking.
World class benchmarking - Ambitious and looking towards recognized leader.

56. Why laboratories need Quality Indicators & Benchmarking
Quality Improvement and Patient safety.
Satisfying Accreditation Requirements.
Satisfying Payer Requirements.
Positioning the Laboratory in a Competitive Marketplace.
Enforce accountability.
Staff Motivation.

57. Satisfying Accreditation Requirements
CLLIA (The Clinical Laboratory Improvement Amendment ).
The Joint Commission .
Collage of American Pathology (CAP).
ISO standards for medical laboratories.
labmedicine.com February Volume 39 Number

58. Benchmarking in Laboratories
Continuous measuring for Quality Performance Indicators and comparing your laboratory processes against those of another laboratories
Discover Gaps between one’s own processes and those of Leading laboratories.
Incorporate leading laboratory’s Best practice Into your own strategy

59. Example: Proficiency Testing & Benchmarking
Benchmarking accuracy over time is associated with improved performance for Laboratories.

60. Continuous and Breakthrough Improvement

61. Sources of Quality Performance Indicators for Laboratories
Agency for Healthcare Research and Quality (AHRQ )
National Guideline Clearinghouse (NGC) Web sites.
College of American Pathologists (CAP) Web sites .
NCQA (National Committee for Quality Assurance ) Accreditation.
Centers for Disease Control and Prevention (CDC).
PubMed database using various terms
Shahram & Snyder. Am J Clin Pathol 2009;131:

63. Take Home Messages
Medical Laboratories need to report the Right test result to the Right patient at the Right time in the Right form. In addition, it should be the Right test choice with the Right interpretation and with the Right advice.

64. Take Home Messages
Reliable Quality Performance Indicators play a key role in improving the quality of laboratory services and patient Safety.

65. Give Benchmarking a Chance -
Take Home Messages
Give Benchmarking a Chance -
It’s Worth It.

66. References:
Quality indicators in laboratory medicine: A fundamental tool for quality and patient safety.Mario Plebani a, Laura Sciacovelli a,Mariela Marinova a, Jessica Marcuccitti a, Maria Laura Chiozza b
Harmonization of laboratory testing — Current achievements and future strategies Jillian R Tate a,⁎, Roger Johnson b, Julian Barthc, Mauro Panteghini.
Quality indicators to detect pre-analytical errors in laboratory testing M. Plebani a,⁎, L. Sciacovelli a, A. Aita a, A. Padoana, M.L. Chiozza b.

67. References: College of American Pathologists.www.cap.org.
Reducing Errors in the Practices of Pathology and Laboratory Medicine. David A. Novis, MD, 1,2 and George Konstantakos,Mario Plebani . Clin Chem LabMed 2012.
Benchmarking Laboratory Quality.Paul Valenstein, MD, Frank Schneider, MD2.
10-Clinical & Laboratory Standards Institute (CLSI)- GP35
Shahram Shahangian & Susan Snyder, Am J Clinc Pathol 2009; 131: 418 – 431.

68. Thank you