Clinical PathologyQuality Dashboard
March 2009
Clinical Pathology Quality Dashboard
Inpatient Phlebotomy First AM Blood Draws
University Hospital
0%
20%
40%
60%
80%
100%
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
2008 2009
8am
9am
10am
Drawn by
Mott Hospital
0%
20%
40%
60%
80%
100%
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
2008 2009
8am
9am
10am
Drawn by
Clinical Pathology Quality Dashboard
Inpatient Phlebotomy First AM Blood Test Results:
PT/PTT, CBCP, and Comprehensive Panel University Hospital
0%
20%
40%
60%
80%
100%
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
2008 2009
0
100
200
300
400
Av
g D
ail
y V
olu
me
8am
9am
10am
Results by
Mott Hospital
0%
20%
40%
60%
80%
100%
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
2008 2009
0
2
4
6
8
10
12
Avg
Daily V
olu
me
8am
9am
10am
Results by
Inpatient Phlebotomy DrawsFiscal Year 2009
Clinical Pathology Quality Dashboard
21,182
23,348
19,773
26,062
19,75920,459
19,598 19,795
0
5,000
10,000
15,000
20,000
25,000
30,000
July Aug Sept Oct Nov Dec Jan Feb
2008 2009
Clinical Pathology Quality Dashboard
Turnaround Times
CSF Gram StainVolume and Turnaround Time
0
20
40
60
80
100
120
140
160
Mar April May June July Aug Sept Oct Nov Dec Jan Feb2008 2009
Mo
nth
ly V
olu
me
> 1 hour
30 min-1 hour
<30 minutes
TAT
Emergency Department Cardiac MarkerVolume and Turnaround Time
0
200
400
600
800
1000
1200
1400
Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb2008 2009
Mo
nth
ly V
olu
me
> 2 hours
1-2 hours
<1 hour
TAT
Clinical Pathology Quality Dashboard
Molecular Diagnostics Laboratory
Specimens Received and Turnaround TimeJanuary 2002 - December 2008
0
200
400
600
800
1000
1200
1400
January2002
July 2002 January2003
July 2003 January2004
July 2004 January2005
July 2005 January2006
July 2006 January2007
July 2007 January2008
July 2008
Month/Year
# of
Spe
cim
ens
rece
ived
0
1
2
3
4
5
6
7
8
9
10
TAT
(day
s)
# Specimens TAT Linear (# Specimens) Linear (TAT)
Clinical Pathology Quality Dashboard
Chemistry In-Lab Turnaround Times
Last 12 months
0
2
4
6
8
10
12
14
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
2008-2009
Per
cen
tag
e
Routines 60 min Total stat
45 min In patient 45 min Outpatient
Clinical Pathology Quality Dashboard
New Clinical Assays Added in Last Year
Yeast identification system: (Vitek II automated)Yeast antimicrobial susceptibility: (Vitek II automated)EBV viral loadHIV-1 quantification (COBAS Ampli Prep – COBAS Taqman)
(includes extraction, amplification)MRSA surveillanceVRE surveillanceC.difficile surveillanceBCR/ABL1 Kinase Mutation Analysis (Sequencing)Human Erythrocyte Antigen Genotyping (Microarray analysis)IGH/BCL2 Translocation Detection (Real-time PCR)JAK2 V167F Mutation Detection (Allele-specific PCR)KIT D816V Mutation Detection (Allele-specific PCR)KIT Mutation Detection for GISTKIT Mutation Detection of MelanomaNPM1 Mutation Detection (PCR w/ capillary electrophoresis
detection)Microsatellite instability analysisPML/RARA t(15;17) Translocation Detection (Real-time PCR)Urovysion – FISH, Bladder Cancer DetectionHER2 Amplification – FISH, Breast CancerUGT1A1 Promoter GenotypingK-Ras Mutation Detection 1,25 Dihydroxy vitamin DSensitive beta-2 transferrin assay
UMHS Blood Product Utilization
Clinical Pathology Quality Dashboard
Wasted Plasma
0%
1%
2%
3%
4%
5%
6%
Mar Apr May J une J uly Aug Sep Oct Nov Dec J an Feb
2008 2009
Threshold
Crossmatch/Transfusion Ratio
1.3
1.4
1.5
1.6
1.7
1.8
1.9
Mar Apr May J une J uly Aug Sep Oct Nov Dec J an Feb
2008 2009
Threshold
Wasted RBC
0.0%
0.5%
1.0%
1.5%
2.0%
2.5%
3.0%
Mar Apr May J une J uly Aug Sep Oct Nov Dec J an Feb
2008 2009
Threshold
Wasted Platelets
0%
2%
4%
6%
8%
10%
Mar Apr May J une J uly Aug Sep Oct Nov Dec J an Feb
2008 2009
Threshold
Wasted Cryoprecipitate
0%
5%
10%
15%
20%
25%
Mar Apr May J une J uly Aug Sep Oct Nov Dec J an Feb
2008 2009
Threshold
Blood Product Utilization
0
1000
2000
3000
4000
5000
6000
7000
8000
Mar Apr May June July Aug Sep Oct Nov Dec Jan Feb
2008 2009
0
1000
2000
3000
4000
5000
6000
7000
8000
Pa
tie
nt
Po
pu
lati
on
Random Platelets
Allo RBC Units
Plasma Units
Cryo Units
Partial Units
SD Platelets
AdjustedDischarges
Units Used
Clinical Pathology Quality Dashboard
CAP Proficiency Testing
2nd Quarter FY 2009
Clinical Pathology Scores
0
100
200
300
400
500
600
1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr
Nu
mb
er o
f C
hal
len
ges
50
60
70
80
90
100
Per
cen
t S
atis
fact
ory
FY2008 FY2009
Clinical Pathology474 = Number of Challenges
99% = Satisfactory Results
Anatomic Pathology2 = Number of Challenges
100% = Satisfactory Results
Department Total476 = Number of Challenges
99% = Satisfactory Results
Clinical Pathology Quality Dashboard
CP Financial Measures
*excludes Blood Bank and Phlebotomy
Clinical Path Expense per Test*
$4
$5
$6
$7
$8
$9
$10
Total Expense per Test
Clinical Path Tests per FTE and Total TestsBy Month
1,000
1,100
1,200
1,300
1,400
1,500
1,600
1,700
1,800
1,900
2,000
Tes
t p
er F
TE
275,000
300,000
325,000
350,000
375,000
400,000
425,000
To
tal T
ests
Tests per FTE Total Tests
•Discontinue Cancer Center Hematology Lab (move to Main Lab) – Will Finn, MD, lead
•Improvement of Critical Value Callback process – Brenda Schroeder, lead
•Impact of Earlier AM Blood Draw in UH – OMS 490 students and Holly Eliot, leads
•Improvement of Communication with Patient Care Units – Beverly Smith and Brenda Schroeder, leads
•Customer Service Initiative – Beverly Smith, lead
•Lab Formulary Committee – Office of Clinical Affairs, FGP, Pathology
•Lean Process Improvement Projects – many!
•Laboratory Safety focus – Brenda Schroeder, lead
•Improvement of Blood Draw Wait Times- Cancer Center- Taubman 2- Taubman 3
•Creation of Blood Product Utilization Lean Team – Tim Laing, MD, (OCA), lead
Clinical Pathology Quality Dashboard
Clinical Laboratory Operations Initiatives
•Clostridium difficile toxin screening algorithm – 1/09
•On-demand unit-specific antibiograms – 2/09
•Expedited (rules – based) release of ANCs (absolute neutrophil counts) – 2/09
•Integrated hematopathology reports – 2/09
•Troponin point-of-care (ED) – 3/09
Clinical Pathology Quality Dashboard
Clinical Laboratory Service Enhancements
Kudos
•Thank you to the Phlebotomy Team! There has been a marked improvement in the average time of completed first AM blood draws in UH. (Please see Dashboard data.)
•Thank you to Jerry Davis (Hematology Lab), and his colleagues in the Lab and in Pathology Informatics for developing and implementing a new system that has expedited the rapid release of absolute neutrophil counts. (ANCs)
•Thank you to the Outpatient Phlebotomy team for a greater than 84% (to date) participation rate in the Employee Engagement Survey (open through March 27th).
Clinical Pathology Quality Dashboard