HOW LABS ARE ENGAGING ALL HOSPITAL DEPARTMENTS … · how labs are engaging all hospital departments to improve specimen handling: combine lean and informatics tools to improve patient

HOW LABS ARE ENGAGING ALL HOSPITAL DEPARTMENTS TO IMPROVE SPECIMEN HANDLING:

COMBINE LEAN AND INFORMATICS TOOLS TO IMPROVE PATIENT CARE IN MEASURABLE WAYS

JoAnne Scalise, MS-Patient Safety Leadership, RN

November 3, 2015

2© 2015 Sunquest Information Systems, Inc. | Confidential and Proprietary

IS THIS YOUR TYPICAL DAY IN SPECIMEN MANAGEMENT?


TODAY LET’S TALK ABOUT

• The pre-pre-analytical phase of the Total Testing Process (TTP) and potential for error – and why the Lab Leader must take on the challenge to zero error

• How do we effectively assess and address enduser needs to streamline workflow and consistently achieve positive patient identification (PPID) and accurate specimen labeling – what have our colleagues done and how have they succeeded

• Evaluating current TTP practice for at least one opportunity for improvement and how you can work effectively with the interdepartmental team of lab and nursing to decrease errors of mislabeling, nonlabeling and lack of PPID.

• BONUS! Financial metrics the lab leader will want to consider as you improve the interdepartmental specimen management process


Errors throughout the pre-analytic phase of the specimen management process phase – which have been determined as high as 68% in some studies by Plebani (2010) – are preventable.

Because there are more than two brains in the “Brain to Brain” loop!

WHY IS THIS DISCUSSION NECESSARY?

Brain

To Brain

To Brain


Patient identification errors – which might occur as frequently as 1-2% in some studies (Lippi et all, 2008) – are preventable.



Brain

To Brain

To Brain


An increasing number of laboratories worldwide are adopting risk management strategies such as FMEA, FRACAS, LEAN and Six Sigma since these techniques allow the identification of the most critical steps in the total testing process, and to reduce the patient-related risk of error (Plebani, Lippi 2011)



Brain

To Brain

To Brain


WE HAVE TO ASK THE DIFFICULT QUESTIONS –WITH THE EASY ANSWERS

So what IS an acceptable rate of error?– In healthcare?

– In the total testing process?

– How about in YOUR care?– Your family’s?


We’re human…so probably not

What we have to focus on isPREVENTABLE HARM

ARE ZERO ERRORS POSSIBLE IN HEALTHCARE?

99% GOOD (2.8 Sigma)

• Unsafe drinking water for almost 15 min qd

• 5000 incorrect surgeries qwk

• 200,000 incorrect prescriptions annually

• No electricity for almost 7 hours per month

• Two short or long plane landings qd

99.99966% GOOD (6 Sigma)

• Unsafe drinking water for 1 min q7mo

• 1.7 incorrect surgeries qwk

• 68 incorrect prescriptions annually

• No electricity for 1 hour every 34 years

• One short or longlanding q5yrs

99% - GOOD ENOUGH?

IS ANY NUMBER – REMOVED FROM THE PERSON – GOOD ENOUGH?

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HOW DO WE GET TO ZERO ERRORS?


Sometimes these two questions have the same

answers

How can we reduce or eliminate errors?

How can we reduce steps?

AT ITS CORE, LEAN HAS TWO DRIVERS


THE LAB IS KEY TO DIAGNOSTIC SUCCESS


Pre-analytic and pre-pre-analytic phases of the TTP can differ

ONE PRE- OR TWO?

The pre‐analytic phase involves sample collection, patient identification, sample transportation, and

sample preparation. (Plebani, 2012)


1 in 18 sample identification errors leads directly to an adverse event (Valenstein, Raab, & Walsh, 2006)

The WBIT (Wrong Blood in Tube) rate has been reported as 1:1986 specimens (Stubbs, Bundy, & Van Buskirk, 2012)

The average cost of a misidentified specimen was $712, (Kahn, 2005) This is $878.54 in 2015 dollars.

The bulk of errors occur in the pre (pre) analytic phase: 46-68%

THE PHASES PRIOR TO ANALYSIS ARE RIPE WITH OPPORTUNITIES FOR IMPROVEMENT

patient identification

sample collection

sample transportation

and sample preparation.


• presence of an identifiable modifiable cause

• reasonable adaptation to a process will prevent future recurrence

• adherence to guidelines

The top three definitions (Nabhan 2012):

“Preventing harm in healthcare is paramount to improving patient safety which translates

into quality of care”

WHEN ARE ERRORS PREVENTABLE?


EVEN “NEVER EVENTS” ARE NOT ALWAYS PREVENTABLE*

Can ZERO errors be achieved?

YESbecause errors within the closed loop

of specimen collection and transfusion management

are NOT inevitable

*Hospital Patient Safety Leaders AHRQ:Never Events.

http://psnet.ahrq.gov/primer.aspx?primerID=3 webcite

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SELECTING PROJECTS FOR CHANGE THAT CAN BE

SUSTAINEDSometimes the projects pick YOU


HOW DO WE CHOOSE WHAT TO IMPROVE?

Time wasted on label and list management

Four (of many) barriers to safe and effective lab care ‐identifiable and modifiable

Potential fragmentation of the TTP

Mislabeled specimens

Non‐lab ready labels

Lack of PPID can result in the most serious errors and should be prioritized – because it is PREVENTABLE


Use the evidence – commit to evidence based practice throughout process and departments Self‐select change champions Bring the right people from all departments to the table Commit the resources: people, time, other needs Understand the current process with handoffs to develop the new Dive in with Healthcare Failure Mode Events Analysis Commit to Communicate, Educate, and stay Accountable

PURPOSE:

• Improve patient safety• Ensure specimen integrity • Improve efficiency in label management• Physical aspect of label management: batching, creating lists, etc..• Label placement

• Improve TAT from collection to resulted

How one 18 bed Cardiothoracic ICU prepared for and sustained change

WHAT’S NEEDED TO CHANGE PRACTICE?


TEAM: included front line and staff members from: • CTICU + Phlebotomy + Patient Safety + Lab + Quality + Pathology + Risk Management + Information Services + Nursing Administration + Intensivists + Blood Bank



HFMEA and planning – approximately 6 monthsPROCESS:

– Evaluated and developed every aspect of current and future state– Designed education and education frequency and documentation– Determined critical metrics to demonstrate goal achievement– Implementation– Evaluation– Continuous improvement


SOME OUTCOMES:

• Collect to Receipt Time = 36% decrease•Mislabels: ZERO•Workarounds: NONE

PURPOSE:

• Improve patient safety• Ensure specimen integrity • Improve efficiency in label management• Physical aspect of label management: batching, creating lists, etc.• Label placement

• Improve TAT from collection to resulted




Pre‐ Process Improvement Labeling Errors

Mislabeling and/or Omissions in time/date/collector identification

• Specimens are removed from the bag, label must be reviewed for time, date and collector identification

• If all 3 elements are there, information is hand keyed into LIS for accuracy when results post to the EHR

• If all 3 elements are NOT there, a recollect of the specimen must be requested.

LABELING ERRORS FORCE THE NEED FOR RE-COLLECTION OF SPECIMENS CAUSING POTENTIAL DELAYS IN CARE

UPMC Shadyside

23

Post‐ Process Improvement Labeling Errors

DOES NOT OCCUR

• Specimens are collected utilizing bedside technology with auto‐generated collector identification, date and timestamp

• All specimens taken out of bags and placed directly on robotic line for analysis.

IF A LABEL IS ON THE TUBE, IS OUR JOB HERE DONE?

Even if you have fixed these:

• Mislabeling• Nonlabeling• Illegible• GHEM • QNS • Wrong Spec Type • Contaminated • Clotted Specimen • Spec. Leaking • Blood Product Issue • Spec. Transport • Wrong Requisition • No Requisition • Bar Code ‐ No Read Other

Try humor to educate

UPMC

25

COLLECTING DATA AND CRITICAL METRICS

Can help you identify the people and process that need your help


SPECIMEN QUALITY PARAMETERS THAT ORIGINATE IN THE PREANALYTIC PHASEMetrics to evaluate – proper collection

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June JulyClotted 45 54 79 58 86 78 51 66 88 58 60 95 78 77 38 66 60 61 56Hemolyzed 39 51 49 40 46 56 38 28 41 28 31 21 41 29 38 41 41 38 33QNS 36 27 44 36 36 36 28 32 41 41 33 28 30 22 31 49 38 40 35Contaminated 26 33 24 24 18 30 29 23 26 19 24 23 40 31 37 33 34 30 42

0

10

20

30

40

50

60

70

80

90

100

Num

ber o

f Spe

cimen

sTotal Clotted, Hemolyzed, QNS,

Contaminated


SPECIMEN QUALITY PARAMETERS THAT ORIGINATE IN THE PREANALYTIC PHASEMetrics to evaluate – labeling issues

Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June JulyUnlabeled 34 30 26 22 54 40 34 34 34 32 42 28 51 40 38 34 37 43 46Mismatch 6 11 9 10 5 7 8 6 9 9 12 13 7 7 8 8 10 9 11Mislabeled 1 13 15 10 13 8 8 8 6 3 9 8 9 8 6 6 10 3 13Incomplete 43 39 28 30 46 22 34 30 27 38 25 34 40 43 52 50 36 39 27

0

10

20

30

40

50

60

Num

ber o

f Spe

cimen

s

Unlabeled, Mislabeled, Incomplete, Mismatch

TODAY LET’S ANSWER THE QUESTION

Without authority but total responsibility, how can the POC lab leader effectively communicate, manage conflict, and develop positive relationships with nursing for bottom-line lab quality, safety, and financial outcomes – and consistently perform at a 5 sigma level?


• “What we do when no one’s looking”

• Each person is responsible and accountable for their behavior and contributions

• Tone is set by leaders

Culture

PREVENTING HARM THROUGH PEOPLE AND PROCESS

• Policies•Workflow• Consistency

Process

Every healthcare organization must address both

Communication bridges culture and process

30

ONE WORD

Nursing


WHAT DO THOSE NURSES DO ANYWAY?



WHAT WE’RE REALLY THINKING

Lab: Nurses + Labels = Mislabeled specimens

Nurses: – Relabeling– TAT– Accessioning – Receive time

Obviously these have nothing to do with nursing

and everything to do with the lab


LESSONS LEARNED IN NURSING

How to work AROUND the workaround?• Know the process AND the best argument

• Identify the most influential USERS –invite them to participate

• Be ready to revisit the issue (over and over again)

• Be credible, flexible, and committed to safety:for organization, patients, and staff

35

TECHNOLOGY FIXES EVERYTHING!

36

TECHNOLOGY FIXES EVERYTHING?

But we’re the ones who think

TECHNOLOGY IS ONLY THE BEGINNING

Northeast Hospital SystemWhere they were:• 300 labeling errors per month

Changes Made:2010 - new patient-focused care model• Step one - Lean and Six Sigma (-50%)• Step two - Training and socialization• Step three - Technology

When symptoms occur, how do we know how to fix them – if we don’t know the etiology?

LESSONS LEARNED:

Technology sustains the necessary process that is determined for future state – PEOPLE must be engaged and know WHY the improvement matters

Nursing leadership is vital to adoption and success

Lab and Nursing are partners in decreasing errors and improving safety throughout the total testing process

The importance of asking the right questions


WHY FOCUS ON WORKFLOW?

Workflow are how we accomplish goals, and consist of

Tasks – ordered chronologically into processes

the set of people or resources

needed for those tasks

The interactions between them

Probability of Performing Perfectly

Probability of Success for Each Step in the Process

Number of Steps 0.95 0.99 0.999 0.999999

1 0.95 0.99 0.999 0.9999

25 0.28 0.78 0.98 0.998

50 0.08 0.61 0.95 0.995

100 0.006 0.37 0.90 0.990

COMPLEX CARE REQUIRES COMPLEX WORKFLOWS, RIGHT?

• Engage stakeholders• Sketch out how your process

works today• Look at point to point process flow

– Draw to receipt– Receipt to analysis– Where else in the TTP?

• Walk the flow and obtain real data• Focus on issues and metrics• This will give you the foundation

for the future state

START BY MAPPING YOUR CURRENT STATE

Nebraska Medical Center

Tucson Medical Center

UPMC


FUTURE STATE MAPPING

•Metrics • Flow•Efficiencies• Labor•Cost•Other resources

What are the goals?

•Bottleneck•Unknowns•Redundancies

Where are the issues? • Involve stakeholders in

change process• Education• Implementation roadmap

Future state ideals


WORKFLOW SPECIFIC ACTION STEPS:

Determine who is affected

Engage endusers and stakeholders

Dedicate enough time

Communicate to all involved

Whiteboard current state v. future state

Institute future state workflow


ISSUE: Significant increase in nonlabeled specimens – “out of nowhere”INVESTIGATIONAL FRAMEWORK: 1. Workflow observation and assessment2. Team interviews3. Lab observation

When new challenges occur, how do we know the cause?

AND THEY ALL LIVED HAPPILY EVER AFTER?

45

ALWAYS ANALYZE FOR FINANCIAL IMPACT

:How a call for help in compliance and

workflow optimization turned into over $2,000,000 in savings

ONE LAST EXAMPLE


Questions we needed to answer:• How is specimen management

technology (SMT) used throughout the hospital?

– How do nurses use it in the ED?– Nursing use in the rest of the

hospital?– How do phlebotomists use

technology?– When SMT is used, is it used safely

and effectively?

• What are the barriers to using SMT 100% of the time?

• What could be done to achieve the goal of 100% safe and effective SMT usage?

HOW DO WE MANAGE WHEN THE INITIAL PROCESS TO IMPROVE –DOESN’T?

Collaborative evaluation and planningCurrent state

RRCA

When the team doesn’t act as a team, and the patients and organization suffer


LET’S DO THE MATH – IN ONE WEEK:

• 12880 specimens – ED usually responsible for 50%

• Paper requisitions: – ED 239 = 0.037

• Aggregate extended LOS approximately 47.74 hours• Internal capacitance loss of 8.18 patients• Average revenue approximately $2500 per ED patient treated

• Average weekly loss of revenue approximately $20,000• Based upon this run rate, annual revenue loss of approximately $1.04 million

OPPORTUNITIES

TOOLS

Hardware IT/IS

PEOPLE

Practice opportunities Leadership Staffing Education Perceptions

CASCADING IMPACTS OF CURRENT PROCESSES

Universal use of technology vs. Manual method with requisitions

• 446 requisition occurrences in low occurrence week• Represents approximately 24,000 requisitions annually• 24,000 patients exposed to risk of misidentification during specimen collection

• 24,000 nurse exposures to risk of making an unintentional error is specimen collection process

• Greater than 24,000 specimens requiring relabeling in lab• Average of 60 seconds of lab time per specimen relabeled• Represents greater than 400 laboratory hours annually


SILENT COSTS OF MISLABELED SPECIMENS

90‐94/month mislabeled specimens

at $878.54 cost/mislabeled specimen* =

Insidious loss of $79068‐82583/month or

$948,823‐990,993/year

$712 in original 2005 study adjusted for inflation using CPI (saving.org)


BENEFITS OF RECOMMENDATION IMPLEMENTATION

There is always a financial cost of errors, change, and resistance to change

$ 2,110,908/yearLost ED revenue $1.04 million

Average costs of mislabeled specimens: $969,908Clinical RN time lost from log in/printer issues: $120,000

Lab time relabeling specimens: $8,000

52

FILLING THE QUALITY GAP

Laying the foundation for taking meaningful action

Quality and workflow thought leaders provide theory, structure, and actionable process

Healthcare organizations operationalize quality methods in

system plan – through a Just Culture of Safety

The Lab leader CAN bridge the quality gap

Lab leaders can bridge the gap between 1 and 5 Sigma with an interdisciplinary

team through communication, accountability and

transparency

Lab leaders have unique PS opportunity AND responsibility since they are

responsible for quality throughout all phases of the specimen management

continuum

The Potential Quality Gap in the Pre‐Pre Analytic Landscape Can Be Easily Filled Through Lab Leadership


ONE LAST RESOURCE – AND IT’S WITHIN YOU


HOW MAY I BE OF SERVICE ON YOUR JOURNEY TO ZERO ERRORS?

JoAnne Scalise MS-Patient Safety Leadership, RN Manager, Clinical Nurse [email protected]


REFERENCES AND RESOURCES

• Hawkins R. Managing the Pre- and Post-analytical Phases of the Total Testing Process. Ann Lab Med 201; 32: 5-16.

• Lippi G, Blanckaert N, Bonini P, et al. Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics. Clin Chem Lab Med. 2008; 47(2):143–153.

• Plebani M. The detection and prevention of errors in laboratory medicine. Ann Clin Biochem 2010; 47: 101-10.

• Plebani M, Lippi G. Closing the brain-to-brain loop in laboratory testing. Clin Chem Lab Med 2011; 49: 1131-3.

• Wilkerson, ML; Henricks, WH; Castellani, WJ; et al. Management of Laboratory Data and Information Exchange in the Electronic Health Record. Arch Pathol Lab Med. 2015;139:319–327; doi: 10.5858/arpa.2013-0712-SO)

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HOW LABS ARE ENGAGING ALL HOSPITAL DEPARTMENTS … · how labs are engaging all hospital departments to improve specimen handling: combine lean and informatics tools to improve patient