1. Clinical Pathology Quality Dashboard
August 2013

2. Clinical Pathology Patient Care Quality Blood Bank Specimens
The total number of errors for the month of July is higher than the average, but not markedly. The number of hemolyzed specimens has returned to the usual amount after a month of less than expected.
Pathology is pursuing a two pronged approach to “specimen quality” in the ED.
There is and has been ongoing discussions via Nursing Liaisons (Barb Wetula, RN, and Sheryl Woloskie) to addressing training for non-Pathology collected specimens. This focus has been on all of UMHS, with an emphasis on the ED.
Marty Lawler (Pathology) is investigating possible deployment if additional Pathology personal in the ED POCT lab. These individuals would take over labeling and related issues.

3. Clinical Pathology Patient Care Quality Chemistry
Parameters of observed data point changed from monitoring of “order to verify” to “received to verify” starting in June Due to variations of how specimens are ordered in the Emergency Department order to verify data has absurd data that is not indicative of any errors in process within the ED laboratory.

4. Clinical Pathology Patient Care Quality Hematology
CBC & CBCD Turnaround Times (Received In Lab- Verified): Spot Comparison of Cerner in May 2013 vs. Soft in June 2013.
Turnaround times for CBC and CBC with differential: Cerner versus Soft were compared.
The data represent TAT from the time specimens were received in lab to times of verification.  TAT’s were predictably shorter due the deployment of “Auto-Receipt” (specimens are auto-logged into Received status by the instrumentation) concurrent with the deployment of Soft on June 1, 2013
TAT (in lab) after Soft deployment was shorter, but variation was greater. Performance will be reanalyzed after additional stabilization of Soft.

5. Clinical Pathology Patient Care Quality Microbiology
TAT Goal ≤ 1 hour
During the transition to the Soft LIS (Go-live; June 2, 2013) an increase in TAT was observed. This was attributed to downtime for the upgrade along with staff learning how to navigate effectively in the new system. July data indicates that operations have stabilized and TAT is back to normal levels.

6. Clinical Pathology Efficiency
*Cost/adjusted discharge is the average cost per inpatient & outpatient discharge (Forty outpatient visits~ 1 hospital discharge). Pathology costs exclude: 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.

7. Clinical Pathology Financials
There was an increase in overtime hours worked during the run up to Soft go live (June 2, 2013). As the system stabilizes it is anticipated that staffing should return to normal levels.

9. Were Clerks and Receptionists helpful?
Outpatient Phlebotomy Patient Satisfaction Survey 2012
Were Clerks and Receptionists helpful?
Did Clerks and Receptionists treat you with courtesy?
Did the person drawing your blood treat you with courtesy and respect?
Did the person drawing your blood have success the first-try?
Blood Draw Stations
YES
YES SOMEWHAT NO
Briarwood Center for Women, Children and Young Adults 29 28 1 27 2 23 6
Briarwood Family Medicine
138
137
Briarwood Medical Group
103 18
105 16
109 13
Brighton Health Center 60 61
Cancer Center
827 3
837 21
841 19
828
Canton Health Center 97 98
101
Patients are queried annually via the Joint Venture Hospital Laboratories (JVHL) survey at all outpatient clinic blood draws stations. The phlebotomy areas have been a key focus area for Pathology relative to Service Excellence over the past several years.

12. 2013 Quality Week Applicants
Clinical Laboratory News, Notes, and Kudos
Labs that are working on process improvement projects that would like to display data can contact Kristina Martin for future dashboards.
Kudos
Sue Stern &Dr. Don Giacherio for implementing the EGFR calculation in Soft to meet the needs of nephrology physicians.
2013 Quality Week Applicants
Lab
Poster
Blood Bank
Implementation of Massive Transfusion Protocol-copartner with Transfusion Committee
Chemistry
PTHI platform and workflow change
Hematology
Better laboratory testing to optimize argatroban usage
New LIS helps to eliminate manual scanning
Screening technologists eliminate unnecessary pathologist reviews
HLA
Freezer reorganization
Paper Reduction
Quality Management
Micro
Blood Cultures and MALDI
Respiratory Virus
Implementation of Pre-Prostate Biopsy Screens
Carbapenem Resistance Collaborative- copartner with MDCH and IC
Pathology
Clinical Pathology specimens collected in the OR
Phlebotomy
Outpatient-Improving Accuracy and Frist Time Quality of Cancer Center Lab Draws-copartner with Cancer Center Nursing
C&W-Reducing Anxiety and Increasing Comfort for Blood draws in the Outpatient Area: Support staff training related to comfort strategies and coping skills-copartner with C & W Child Life Nursing
POCT
Improving Performance by Meeting Learning Needs of ACS Clinical Staff-copartner with Ambulatory Care