Driving Clinical Excellence in Microbiology with Consolidation, Real-Time Dashboards and Physician Concierge Services

Transcription

1 Driving Clinical Excellence in Microbiology with Consolidation, Real-Time Dashboards and Physician Concierge Services Executive War College May 1, 2013 David Vinson med fusion, Lewisville, TX

2 Introduction to med fusion 2

3 About med fusion Full-service reference lab formed by four leading healthcare providers: Baylor Healthcare System (BHCS) Dallas US Oncology (now McKesson) (USON) Texas Oncology (TxO) Pathologists Biomedical Laboratories (PBM) 3

4 About med fusion, cont. Located in Lewisville, TX (approximately 7 miles North of DFW airport) Began operations in May 2010 Focused on improving the overall episode of care costs by providing high-quality, patient-centric diagnostic testing As part of the formation, laboratory testing and other services were consolidated from BHCS including: Molecular Diagnostics Special Coagulation Immunology Microbiology 4

5 Microbiology Consolidation 5

6 Why Consolidate? Advantages of Consolidation: Quality: Accumulate specialists in a single location Standardized processes 24/7 coverage for faster TAT Economies of Scale: Aggregation of volume Lower unit costs Ability to acquire newer technologies sooner Staffing: Increased staff productivity Fewer MTs needed More rewarding (staff sees lots of variety) 6

7 Consolidation Overview Consolidation of microbiology labs from 8 hospitals: Two medical center/transplant hospitals Six community medical centers This was a difficult change for some, primarily the ID physicians Various metrics measured following the transition in a very reactive manner: Challenge: No published guidelines for metrics and/or goals could be located to benchmark our microbiology services against 7

8 Our First Attempt at Service Improvement Serial Kaizen events targeted at end-to-end processes for Bacteriology services Included events specifically directed at: Specimen receiving and processing Cultures: Blood Urine Wound Respiratory Cross-functional teams led by technologists in the section: Included Lab Assistants, IT staff, purchasing and warehouse staff, couriers, facilities, etc. Continuous monitoring and sharing of metrics with staff, leadership and BHCS: Led to the creation of our Microbiology Dashboard 8

9 Our Micro Dashboard 9

10 Dashboard Overview Dashboard devised to track key aspects of preanalytical, analytical and post-analytical processes: Joint BHCS/med fusion sub-committee defined relevant goals and dashboard constituents Real-time weekly updates and meetings to discuss results with lab staff Daily huddles with Senior Leadership and Lab Management Strengthened med fusion/bhcs partnership: True quality/process improvements involve every aspect of test ordering to result delivery 10

11 Dashboard Overview, cont. Dashboard highlights: 50 med fusion and BHCS metrics measured and trended: 10 pre-analytic measures, including: Collect to receive TATs Culture contamination rates Specimen quality 30 analytic measures, including: TAT Gram stain/culture discordances Corrected reports 10 post-analytic measures, including: Client Service metrics Posted weekly in the lab and discussed at staff meetings Monthly Board-level review of metrics and trends with med fusion and BHCS leadership 11

12 Dashboard Overview, cont. Microbiology Dashboard V4.2 Pre-Analytical Metric Target Target Units Responsible 7/1/2012 7/8/2012 7/15/2012 7/22/2012 7/29/2012 8/5/2012 8/12/2012 8/19/2012 8/26/2012 9/2/2012 9/9/2012 9/16/2012 9/23/2012 9/30/2012 (per month) 10% % BHCS 5.1% Urine Culture Contamination 2.9% 2 Blood Culture Contamination (per month) 2% % BHCS 2.8% 2.2% 2.3% 3 Blood Culture Blood Volume, 8-10mL fill Pre-analytical 80% % BHCS No Data Measures No Data 60.0% 4 Wrong Orders, source 0 # BHCS No Data No Data No Data No Data No Data Wrong containers 0 # BHCS No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data 6 Unacceptable sputum samples received at MDF 5% % BHCS 50.0% 51.2% 42.6% 37.5% 34.2% 35.3% 48.5% 41.9% 46.9% 37.5% 34.4% 47.2% 50.8% 38.9% TAT - Collect to SPR at hospital laboratory within 2 hours, all 7 95% % BHCS No Data No Data 97.3% specimens 8 TAT - Hospitals' SPR to received at MDF, all specimens 2 hours MDF 2:02 1:58 2:00 2:00 1:54 1:47 1:44 1:48 1:40 1:39 1:38 1:49 1:44 2:02 9 Leaking, damaged container, in transport 0 # MDF No Data TAT - Blood Culture (BC) receipt at MDF to load in BAC-T Alert 30 minutes MDF No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data Analytical Metric Target Target Units Responsible 7/1/2012 7/8/2012 7/15/2012 7/22/2012 7/29/2012 8/5/2012 8/12/2012 8/19/2012 8/26/2012 9/2/2012 9/9/2012 9/16/2012 9/23/2012 9/30/ TAT - Gram Stain (except blood, sterile BF and STATs) 4 hours MDF TAT - Gram Stain (sterile body fluid and STATs) 1 hour MDF TAT - BC - Removed from Bac-T Alert to Gram Stain report 1 hour MDF TAT - BC - Received at MDF to GS report TBD TBD MDF No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data 15 TAT - BC - Received at MDF to 1st sensitivity TBD TBD MDF No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data 16 TAT - BC - Received at MDF to negative report 120 hours MDF No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data 17 TAT - No Growth Urine Cultures, non-invasive 27 hours MDF TAT - No Growth Urine Cultures, invasive 48 hours MDF TAT - Positive Urine Cultures 40 hours MDF TAT - No Growth Wounds Cultures 76 hours MDF TAT - Positive Wounds Cultures 60 hours MDF TAT -Wound time to 1st sensitivity 42 hours MDF TAT - No Growth Body Fluids Cultures 76 hours MDF TAT - Positive Body Fluids Cultures Analytical TBD hours MDF Measures TAT - Body Fluids time to 1st sensitivity TBD hours MDF TAT - Normal Respiratory Cultures (Exclude CF) 48 hours MDF TAT - Positive Respiratory Cultures (Exclude CF) 60 hours MDF TAT - Respiratory culture time to 1st sensitivity 52 hours MDF TAT - No Growth Tissue Cultures 76 hours MDF No Data TAT - Positive Tissue Cultures 60 hours MDF TAT - Tissue culture time to 1st sensitivity 42 hours MDF TAT - MRSA cultures 28 hours MDF TAT - C. diff screen 10 hours MDF TAT - AFB smears 24 hours MDF Absolute number of Corrected Reports N/A # MDF % Corrected reports (NOTE: 100% review of all corrected reports by Scientific Director and Management Team occurs daily) 0.034% % MDF 0.10% 0.08% 0.11% 37 Absolute number of Clarified Reports N/A # MDF % Clarified reports 0.034% % MDF 0.13% 0.04% 0.03% 39 Discrepant Gram stains - CMC read (per month) 1.0% % BHCS 0.0% 0.7% 0.6% 40 Discrepant Gram stains - MDF read (per month) 1.0% % MDF 2.7% 1.7% 0.9% NOTE: All TAT statistics are measured from time of receipt at med fusion to time of report Post- Analytical Metric Target Target Units Responsible 7/1/2012 7/8/2012 7/15/2012 7/22/2012 7/29/2012 8/5/2012 8/12/2012 8/19/2012 8/26/2012 9/2/2012 9/9/2012 9/16/2012 9/23/2012 9/30/2012 within % % MDF 99.29% % % 99.59% % 98.65% % % 99.65% 99.82% % 99.45% 99.40% 99.69% 41 Notification of Critical results min NOTE: General Client 42 Notification of Alert results within 1 hour 100% % MDF % % % % % % % % % % % % % % Services stats 43 Notification of Corrected reports within 15 min 100% % MDF % % % % % 97.44% % % % % % % % % Post-analytical Measures Client Services Metric Target Target Units Responsible 7/1/2012 7/8/2012 7/15/2012 7/22/2012 7/29/2012 8/5/2012 8/12/2012 8/19/2012 8/26/2012 9/2/2012 9/9/2012 9/16/2012 9/23/2012 9/30/ Total calls N/A N/A MDF NOTE: Micro Hotline 45 Calls answered in < 20 seconds 95% % MDF 98.58% 96.71% 97.95% 98.11% 97.59% 97.40% 95.16% 95.56% 96.20% 96.00% 92.63% 97.63% 95.64% 95.75% stats 46 First call resolution 95% % MDF 99.54% 99.79% 99.74% 97.68% 98.57% 97.86% 98.64% 97.83% 97.86% 98.00% 97.36% 98.56% 98.43% 98.12% 47 Abandoned calls 2% % MDF 1.58% 0.68% 0.70% 1.84% 1.07% 0.82% 2.12% 1.52% 2.17% 1.34% 0.28% 0.76% 0.51% 0.50% 48 Calls Escalated to Tech/Manager/Scientific Leadership 30% % MDF No Data No Data 34.49% 15.22% 5.54% 14.84% 13.00% 8.38% 7.32% 6.99% 8.81% 10.61% 10.28% 9.31% 49 Average length of calls 2 minutes MDF th Percentile length of calls 5 minutes MDF No Data No Data No Data No Data No Data

13 Result Examples 13

14 Positive Urine Culture TAT: Improvement MDF - June to April 2013 Median 26.7 hours MDF - April 2012 Median 37.9 hours Pre MDF Mean 52.8 hours 14

15 Negative Urine Culture TAT: Improvement MDF - June to April 2013 Median 25.2 hours MDF - April 2012 Median 38.2 hours Pre MDF Mean 50.4 hours 15

16 Positive Wound Culture TAT: Improvement MDF - June to April 2013 Median 49.5 hours MDF - April 2012 Median 57.6 hours Pre MDF Mean hours 16

17 Negative Wound Culture TAT: Improvement Pre MDF* Mean hours MDF - June to April 2013 Median 67.9 hours MDF - April 2012 Median 67.2 hours Physician-requested extended incubations * 48 versus 72 hour minimum incubation times 17

18 Reduction in Urine Contamination Rate for BHCS CMC urine contamination rates as high as 30%, overall rate around 18%, exceeding national average 1 med fusion partners supported BHCS in identifying problem, providing rates, and targeting opportunity Rates varied due to non-standard processes for collection and transport; med fusion collaborated to set best process 20.0% 18.0% 16.0% 14.0% 12.0% 10.0% Current Rate (April 2013) 8.0% = 2.5% 6.0% 4.0% Established standardized processes for collection, preservation and transport Worked with reference lab and agreed upon a common definition for contaminated urines Established monitoring as part of pre-analytical dashboard measures 2.0% 0.0% BHCS Urine Contamination Rate Jan - Aug Arch Pathol Lab Med Vol 132, June 2008

19 Service Enhancement Summary Much has been accomplished thus far, but are committed to continuing our efforts to improve the quality of these initiatives in an effort to improve patient care Service enhancements were not enough to convince ID physicians of improved patient care from what they were before because something had been taken from them Needed to do more, but wanted direct input from ID physicians 19

20 Transition to Concierge Services 20

21 Concierge Services Our First Attempts ID Liaison: First attempt at personalizing ID services Former Manager in largest hospital consolidated Primary role: Engage Lab Directors in hospitals: Great success in this regard Expanded role to Strategic Account Manager with focus beyond microbiology services Problem: Indirect contact with ID Physicians 21

22 Concierge Services Our First Attempts, cont. Physician Daily Reports: Push of pending culture status each morning: Limitations: Data from our LIS ID docs are often consultants not ordering physician Some success with physicians, but not widely embraced Led to the creation of additional customization of reports with specific purposes 22

23 Custom Reports Custom Report Development: Infection Control Report: Provided daily to Pharmacists and Infection Control Officers Reports organisms with certain resistant susceptibility profiles (e.g., VRE and MRSA) by location in each hospital Positive Blood Culture Report: Provided daily to ID Physicians and Lab Directors Reports all positive blood cultures by location in each hospital NOTE: Will soon include contaminated blood cultures, which are currently provided monthly BHCS system-wide rate is currently 2.0% 23

24 Custom Reports, cont. Newborn Blood Culture Report: Developed to meet the recommendation that newborns with negative blood cultures at 48 hours can be released Provided for each newborn blood culture at 48 hours of incubation (± 1 hour) Challenges: Reports too specialized and not driving client satisfaction or standardization amongst ID physicians Limited to information we had in our LIS Needed to relate directly to what is in client HIS 24

25 Current Concierge Services In partnership with BHCS, we identified two ID Physician Champions to develop these services: Represented two ID practices that served 4 community medical centers in the system Started with the concept of the daily physician report and modified using my patient list from HIS Created custom reports that met the needs of the entire practice (not at the level of individual physicians), which helps with: Lab workflow Standardization 25

26 Current Concierge Services, cont. Movement from general reports to those specified by a physician group: Directly linked to patient data from HIS Sorted by location, culture type and/or results Clinically interesting organisms identified Morning and evening reports issued: Culture plates pulled and reviewed, real-time comments added to these reports Assigned small groups of techs to work with ID practices, so that they get to know who they are working with (both physicians and techs) Now serving 4 ID practices in the system 26

27 Concierge Physician Report Example HOSP patient test specimen collect date coll time accn rec'd Report 1st / 2nd shift tech IRV Last, First Body Fluid Culture Body Fluid RIGHT KIDNEY FLUID 4/1/ M /01/2013(1924) IRV Last, First Urine Culture Urine 4/2/ T /03/2013(0054) GRAPE Last, First Tissue Culture Tissue Breast, Right 4/2/ T /03/2013(0211) GRAPE Last, First Tissue Culture Tissue Breast, Left 4/2/ T /03/2013(0222) GRAPE Last, First Wound Culture Wound Breast, Right 4/2/ T /03/2013(0211) GRAPE Last, First Wound Culture Wound Breast, Left 4/2/ T /03/2013(0220) IRV Last, First Urine Culture Urine 4/2/ T /03/2013(0054) Rare Gram negative rods Identification and susceptibility to follow,,,,, at 0830 susceptibility will be ready sometime after 5 pm today.,,,,, 2nd shift will update this afternoon since culture setup after midnight today.,,,,, 2nd shift will update this afternoon since culture setup after midnight today.,,,,, 2nd shift will update this afternoon since culture setup after midnight today.,,,,, 2nd shift will update this afternoon since culture setup after midnight today.,,,,, 2nd shift will update this afternoon since culture setup after midnight today.,,,,, 2nd shift will update this afternoon since culture setup after midnight today. Deepika / Pilar 2nd shift - Christina 2nd shift - Pilar 2nd shift - Pilar 2nd shift - Felicia 2nd shift - Felicia 2nd shift - Christina Rare Gram negative rods, Identification and susceptibility to follow, Susceptibility will be ready sometime after 5 pm today. 27

28 Summary 28

29 Lessons Learned Microbiology Consolidation: Difficult at best for any organization Engage ID physicians early and frequently Develop value added services to replace what they feel will be lost Beware of tribal knowledge Dashboard Metrics: Helps appropriately focus attention and resources Increases the engagement of: Lab staff and leadership Lab and its clients Fosters a mindset of continuous quality and process improvement: Positive impact on organizational culture 29

30 Lessons Learned, cont. Concierge Services: Dedicated Liaison between lab and clients helps Engage physicians early and listen to their needs: Remove emotional ties; focus on patient care needs Try to address the needs of a group practice, instead of each physician independently Helps drive standardization amongst that group Requires a strong IT focus for scalability: Must deliver information at client (HIS) level Labor intensive (even with IT support) Use push strategy Under-promise and over-deliver! 30

31 The Future Like the dashboard, a lot of progress has been made, but we re not done yet! Working to automate the process further: Requires interoperability of med fusion and BHCS IT systems Other IT/technology tools? Continue to refine reporting to: Meet the changing needs of the ID physician practices Harmonize reporting capabilities with newer technologies: Molecular testing Mass spectrometry Etc. 31

32 Thank you! 32