Decreasing the Number of Patients

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Decreasing the Number of Patients Sent to the
Outpatient Diagnostic Centers with No Lab Orders
Presenters Charisse Acosta, CT (ASCP), SSGB,
CQIA and Joan Woods, MLT, SSGB Office of Quality
Improvement, Pathology and Laboratory Medicine
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Office of Quality Improvement,Pathology and
Laboratory Medicine

• OUR MISSION
• To support the Division of Pathology and
  Laboratory Medicine in consistently exceeding
  accreditation, safety, and regulatory compliance
  requirements and in driving sustainable
  improvement through the use of systematic quality
  methodologies.

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Office of Quality Improvement,Pathology and
Laboratory Medicine

• OUR GROUP
• Team of 4 Quality Technologists MLT, MT, CT,
  Lean Training, SSGG, Over 50 years combined
  laboratory experience
• Project Director Industrial Engineer, SSBB,
  MBA
• PROJECTS
• Lab Layout Design
• Workflow Improvement
• Turnaround Time Reduction
• Material Management
• Waste Reduction

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Background

• 2010 PI Project
• Reduce Patient wait Time in the Outpatient
  Diagnostic Centers
• - Converted to a pull process
• - Moved patient sign-in
• away from front desk

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Background

• Results
• Goals
• Decrease patient wait time
• Decrease congestion and confusion at front desk
• Increase patient satisfaction
• Increase on time arrival to downstream
  appointments

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Background
2011 Phlebotomist 5S Project Standardized
workstations Organized Fully stocked Labeled
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Background
2011 Diagnostic Center PSC Workflow Project -
Clarified patient sign-in form - Issues
identified and categorized - Intradepartmental
issues improved - Outside Issues prioritized
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The Team
CSE Team Members Charisse Acosta, Joan Woods,
Vijaya Bapat, Starnisha Anderson-Moore, Yvette
Bobb and Lisa Thomas

• Facilitator Ron Phipps, PLM QI Project Director
• Champion Bob Del Guidice, CAD, General Services
• Sponsor Dr. Elizabeth Wagar, Chair, Laboratory
  Medicine

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Contributing Partners

• Diagnostic Centers
• Ashley Williams (Clark Clinic), Luz Hurtado
  (Mays Clinic)
• Lymphoma Clinic
• RaShaundra Jacobs, Cynthia Jenkins
• Anesthesia Assessment
• Rosemary McCullar
• Holli Williams
• GI Clinic
• Jessica Campbell
• Veronica Smith
• GYN Center
• Russell Content
• Breast Center
• Stephanie Staten
• GU Center
• Hamid Refai

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DEFINE PHASE
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Aim Statement
The purpose of this project was to decrease the
amount of patients arriving at Clark and Mays
Diagnostic Centers for blood collection with no
orders for labs by 50 before Aug 31, 2011.
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Strategic Alignment

• Patient Care
• Strategy 1.2 - We will increase the quality,
  safety and value of our clinical care.
• Strategy 1.5 - We will enhance productivity,
  access and efficiency by strengthening our
  infrastructure and support systems.
• Resources
• Strategy 7.1 - We will continuously improve our
  administrative infrastructure to support the
  efforts of our people in achieving our mission
  through health information technology and quality
  improvement education and research. 

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MEASURE PHASE
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Data Collection Methods

• Clark and Mays Diagnostic Center PSCs log each
  patient with no orders on a log sheet
• Date
• MRN
• Clinic
• Time patient presented
• Time problem corrected in system
• Additional comments

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Baseline Metrics

• Baseline data collected
• May 3, 2011 June 17, 2011
• Metrics Analyzed
• Daily total errors
• Counts by Clinic
• Time to correct
• Special connectors

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Baseline Measures

• Average errors per day 11
• Average time to correct 23 minutes
• Weekly Waste
• 21 hours of additional patient wait time
• 26.5 hours PSC rework

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Clark Clinic Baseline
Average 10.6 patients per day
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Clark Clinic Value Stream Map
Patient arrives
Patient called for blood draw
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ANALYZE PHASE
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Pareto Chart Clark Baseline (5/31/2011
6/17/2011
67 of issues arise from 3 clinics
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Stratifying the Data
Anesthesia Assessment Center

• Assumptions
• Patients are sent directly to the lab directly
  following Anesthesia appointment
• Ordering is still in process when patient arrives
  at the lab
• Clinic Service Requisition (CSR) has not been
  given to PSC for entering before patient leaves
  clinic

- But how do we know for sure?
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Stratifying the Data
Q How long does it take to correct Anesthesia
problems?

• Average overall time to correct 23 mins
• Average time to correct Anesthesia problems 11
  mins
• Clinic Proximity to Lab

Conclusion Time to enter an order gt Time for
patient to arrive in DC
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Stratifying the Data

• Lymphoma
• 60 of 24 hr urine errors come from the Lymphoma
  Center
• Ordering
• 24 hr urine not included in panel workup code
• Same day patients must have separate appointment
  for next day to return with urine specimen

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(No Transcript)
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Major Issues Identified

• Underutilized daily CARE reports
• Clinics are unaware that no orders were placed
• 24 hr urines not ordered separately
• Patients bring in 24 hr urines that were not
  ordered
• DC PSCs dont have correct clinic numbers
• Patients are sent to lab before clinic PSC
  receives Clinic Service Requisition (CSR)

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IMPROVE PHASE
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Diagnostic Center Implemented Improvements

• Updated clinic contact lists
• Physician/PSC Team lists
• Direct Clinic PSC lines
• PSC Training on Phone Directory usage
• CARE Missing Labs Report
• Allows correction before patient arrives

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Clark Clinic Implemented Improvements

• Anesthesia Assessment Center
• Lab Check Out Desk
• Patients orders completed
• before leaving clinic
• Lymphoma/Myeloma
• Retrain PSCs on 24 hr urine ordering procedures
• Utilize missing labs CARE report
• New terminology for patient schedules

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Confusing Patient Schedule Wording for Lymphoma
Patients
Blood collection only
Blood and Urine
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New Schedule Wording
BLOOD/24 HR URINE COLLECTION or BLOOD ONLY or 24
HR URINE COLLECTION ONLY
Patient has clear understanding of the
appointments testing expectations
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RESULTS
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RESULTS Overall Improvement Clark Clinic
Overall Improvement Clark Clinic
73Overall Improvement
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Lymphoma Clinic Improvements
89 Improvement
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Anesthesia Assessment Center Improvements
92 Improvement
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Benefits

• Soft Savings
• Avoided Rework
• - 20 hours per week of employee time
• - 16,545 per year
• Wait Time
• - Avoided 836 hours of additional patient
  wait time per year

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Additional Benefits

• Improved utilization of resources
• - Increased productivity
• - More on time arrivals to downstream
  appointments
• Improved patient satisfaction
• shorter, less stressful day for patients
• trust in system
• Improved Institution image
• smooth, coordinated efforts between departments
• professional, competent atmosphere
• The right testing at the right time

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CONTROL PHASE
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In Progress/Next Steps

• Current
• Continued data collection
• Continued work with additional clinics to find
  improvements
• Currently piloting online CSRs
• Future
• Incorporate business needs of the lab in the
  requirements for new patient scheduling system
  upgrade
• Corrections to CSRs
• Expand use of order sets, online CSRs, and CARE
  system reports

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Our Keys to Success

• Always back up your story with data
• Great resources are the people that do the work
  or are effected by the work
• Persistence is key
• Buy in is crucial
• Dont be afraid to ask
• Change is rewarding!

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• Every system is perfectly designed to get
  exactly the results it gets.
• - Anonymous

In other words, if you dont like the results
Change The System!
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Thank you!Any Questions?
Joan Woods jtwoods_at_mdanderson.org
Charisse Acosta bcacosta_at_mdanderson.org