Report accurate, timely laboratory results to clinical staff

Transcription

1 PERFORMANCE PLAN PHD Matthew Bolssen x5616 Program Purpose Report accurate, timely laboratory results to clinical staff Program Information Operated in two sites: Fenwick and Sequoia. In the fall 2015, laboratory services were consolidated at Sequoia. In preparation for the move, laboratory facilities at Fenwick were closed for several months, tests usually conducted in-house were sent to outside laboratories. Provides testing and support for 15 clinics/programs: o 87% of tests done in-house; tests diagnose parasites, anemia, pregnancy, o urinary tract and sexually transmitted infections 13% of tests sent to external labs; decision based on cost effectiveness; examples of tests include diagnoses of liver and kidney function Sends specimens from outbreaks/specimens for rabies testing to external labs Decontaminates medical waste from clinics Sterilizes medical instruments used in clinics Serves as sentinel lab for early detection of biological agents for CDC Operates within regulations of Clinical Improvement Amendments (CLIA); Department of Environmental Quality (DEQ) Waste Management Regulations; and Occupational Safety and Health Administration (OSHA) Maintains comprehensive internal quality assurance program including realtime review of tests requiring interpretation by staff (58% of all tests) Partners: Division of Consolidated Services; Corporation of America; Animal Welfare League of Arlington PM1: How much did we do? Staff Total of 6.0 FTEs: o 1.0 FTE Bureau Chief o 1.0 FTE Technologist II o 2.0 FTEs Technologist I o 2.0 FTEs Assistant Contracted pathologist serves as laboratory director Customers and Service FY 2015 FY 2016 FY 2017 Number of unduplicated clients served by Lab * 3,871 3,813 3,556 Number of tests conducted by ACPHD Lab 29,479 25,671 27,182 Number of blood draws by ACPHD Lab 7,568 7,855 7,433 Number of tests conducted by external labs 4,537 6,190 4,670 Number of instrument sterilization cycles Pounds of regulated medical waste decontaminated 2,031 1,764 1,975 *Number of clients does not include WIC clients; data not in an accessible database Decrease in the number of clients served is reflective of a corresponding decrease in the number of Maternity, Family Planning, and STI clients. Main laboratory closed from July October, 2015, due to move to Sequoia. Tests typically conducted in-house were sent to DCLS and LabCorp during this timeframe. Medical waste could not be processed internally during this lab closure. increase in sterilization cycles is due to a smaller autoclave used during the lab move. Instruments were packaged in smaller packages, thus more cycles. Page 1

2 PERFORMANCE PLAN PM2: How well did we do it? 2.1 Clinical staff satisfaction surveys 2.2 Client satisfaction surveys 2.3 Compliance with regulations PM3: Is anyone better off? 3.1 Availability of time sensitive test results during clinics 3.2 Proficiency test results Page 2

3 PERFORMANCE PLAN Measure 2.1 Clinical staff satisfaction surveys Clinical Staff Satisfaction Survey 2% 2% 2% 2% 2% 2% 2% 2% 2% 2% Goal = 95% Green 2% 25% 33% 33% 33% 31% 33% 27% 35% 35% 35% 37% 37% 73% 67% 63% 63% 67% 67% 63% 63% 71% 65% 61% 61% 50/51 54/54 52/54 proj 50/51 54/54 53/54 proj 50/51 54/54 53/54 proj Staff are Helpful Staff are Responsive Overall Satisfaction Strongly Agree Agree Disagree Strongly Disagree : 96% of respondents agreed/strongly agreed lab staff were helpful; 98% of respondents agreed/strongly agreed lab staff were responsive; 98% agreed/strongly agreed they were satisfied with lab services Survey conducted annually, electronically distributed to Clinic Aides, Public Health Nurses, Nutritionists, and Clinicians in Community Health Services, Community Health Protection and Occupational Health bureaus. Response rate was Goals were met in all surveyed areas, with overall satisfaction of 98%. The program continues to train new clinical staff about laboratory processes to develop staff understanding of laboratory services, which may contribute to high satisfaction. The high response rate is due to response tracking and ensuring all staff respond to the mandatory survey. These changes were implemented in : anticipate agree/strongly agree responses to remain above the goal of 95% for all three statements Page 3

4 Percent of Clients PERFORMANCE PLAN Measure 2.2 Client satisfaction surveys Client Satisfaction Survey 0.2% 1% 1% 0.3% 0.5% 1. 13% 11% 11% 21% Goal = 95% 13% 9% 9% 78% 87% 88% 88% 79% 87% 91% 91% 401/ / /199 (proj) 384/ / /185 (proj) Staff was Professional Overall Satisfaction Strongly Agree Agree Disagree Strongly Disagree : 99% of clients agreed/strongly agreed that the laboratory staff was professional and were satisfied with lab service Questions addressing client satisfaction with laboratory services are part of semiannual satisfaction surveys done in the PHD clinics which use lab services at Sequoia Plaza. These include WIC, Maternity, Family Planning, Teen, and STI Clinics. In, WIC clients were not included in the survey because WIC administered a state-required survey instead of the local survey. services provided at Sequoia Plaza are primarily blood draws; testing is limited. Response rate for the clinic clients satisfaction surveys was 84%. Client satisfaction exceeded goal of 95% in both areas. Comments received were overwhelmingly positive and there were no suggestions for improvement. : anticipate agree/strongly agree responses to remain above the goal of 95% for both statements Page 4

5 PERFORMANCE PLAN Measure 2.3 Compliance with regulations Number of Deficiencies Noted on Regulatory Inspections (projected) CLIA 0 N/A 3 N/A DEQ CLIA: Clinical Improvement Amendments DEQ: Department of Environmental Quality There were no alleged violations, areas of concern or deficiencies in the DEQ inspection The CLIA inspection in July 2016 found three deficiencies CLIA conducts inspections every two years at both laboratory locations to determine compliance with CLIA regulations. Inspections review data for the prior two years. The next CLIA inspection will be in FY DEQ conducts annual inspections to determine compliance with Virginia Regulated Medical Waste Management Regulations The laboratory demonstrates compliance by consistently meeting DEQ regulations. The CLIA deficiencies were: storing reagents at colder temperatures, improper documentation, and not performing quality control tests on reagents, media, or culture tubes prior to testing on patient samples. As of October 2016, all CLIA deficiencies from the July inspection have been corrected and policies have been updated to prevent future violations. In, there was 5 turn over in laboratory staff. The number of new staff, combined with the move to the new facilities at Sequoia, may have contributed to the results of the CLIA inspection. audits indicate that the quality assurance and quality control measures implemented to correct the CLIA violations are effective. Audits included review of all technical procedures, quality assurance on all testing, and appropriate documentation of quality control material. All laboratory quality assurance is reviewed twice per month, once by the Technologist II and once by the Bureau Chief. The quality assurance reviews are performed separately and any problems or issues are addressed immediately. Quality assurance processes were reviewed with the Assistant Division Chief. : anticipate continued compliance with the CLIA and DEQ regulations. Conduct monthly audits on all Quality Assurance and Quality Control processes for all laboratory testing areas, including those involving CLIA deficiencies. through monthly quality assurance/ quality control audits. Page 5

6 Percent of Responses PERFORMANCE PLAN Measure 3.1 Timeliness of test results during clinics Percent of Wet Preparation Specimens Turned Around in 15 Minutes or Less 2% 98% 401/ /370 Goal = Yes No 321/322 proj Clinical Staff Satisfaction with Timeliness 22% 78% 2% 2% 2% 28% Goal = 95% Green 2% 2% 33% 33% 7 63% 63% 51/51 53/54 52/54 (Proj) Results are Provided in a Timely Manner Strongly Agree Agree Disagree Strongly Disagree These tests are being completed in 15 minutes of the time Each quarter, the month with the highest volume of wet prep specimens is used for the sample measure. Lab slips are date/time stamped upon receipt of specimen and again when testing is complete. Lab slips manually reviewed and minutes taken to complete test are tallied in groups of 15 or >15 Survey of Clinical Staff (Clinic Aides, Public Health Nurses, Nutritionists, and Clinicians) found 96% agreed/strongly agreed laboratory results were received in a timely manner Page 6

7 PERFORMANCE PLAN Turnaround time of 15 minutes does not compromise specimen integrity. Staff trained on the importance of time stamping all laboratory requisition slips. Tests with missing time stamp information are assumed to be outside of 15-minute timeframe. In, the one test that was outside of the timeframe was missing the time stamp. Clinic staff is satisfied with the timeliness of laboratory results. Turnaround times for laboratory tests vary and depend on which type of test is performed. with continued training of staff about time stamping. : anticipate meeting the goal of completing this test in 15 minutes of the time and anticipate agree/strongly agree responses for clinical staff satisfaction with timeliness of laboratory results to remain above the goal of 95% Page 7

8 PERFORMANCE PLAN Measure 3.2 Proficiency test results Accuracy of Proficiency Testing Minimum Mininmum Average Average Score Score Required = Goal = 95% for all areas except Parasitology (9) 94% 94% 98% 94% 98% 93% Bacteriology Hematology Mycology Syphilis Serology Parasitology (Proj) All scores are well above minimum required score of Five unknown specimens for each lab specialty are sent 3 times per year from a CLIA-approved Proficiency Testing (PT) program. Specimens are tested inhouse and results submitted to PT program for scoring. shows average score for PT events in each specialty Minimum average testing event score of is required to demonstrate successful participation and satisfactory performance per CLIA regulations Chlamydia/Gonorrhea PT results for FY17 = 96% (not included in the graph) PT programs evaluate testing performance and improve accuracy of patient results. All PT scores of less than prompt an internal process review for the purpose of continuous quality improvement. The goal for PT results was met for Hematology, Mycology, Syphilis Serology, and Parasitology. The score of 94% for bacteriology was 1% less than our goal and well above the minimum average testing score of required by CLIA regulations. We reviewed the bacteriology results to see if a pattern could be identified, but none was found. Mycology is considered medium complexity test CLIA. The remaining areas are considered high complexity tests. Parasitology PT scores have greater fluctuation as specimens from these testing events are graded on one component. Other specialty PT scores are graded on several components. : anticipate proficiency test scores will be about the same Page 8