3/14/2016. About Seattle Children s. The national send-outs problem

Transcription

1 Effective change management: hard decisions and re-organization in a laboratory send-out department Jane Dickerson, PhD, DABCC, Director Chemistry and Reference Lab Services Monica Wellner, Manager Specialty Labs and Send-outs About Seattle Children s Largest tertiary care center in Pacific Northwest (WAMI region), 323 beds 3-fold mission: Clinical Research Teaching Laboratory employs 165 FTE (~180 people) with 16 University of Washington faculty & integrated AP/CP department Test Menu of >700 tests across all pediatric pathology and lab testing domains >1000 test requisitions daily, 150 blood draws/day The national send-outs problem Send-out tests include all clinical lab tests which are sent to other clinical labs Seattle Children s Hospital lab sends to >100 labs; 20% of send-outs are genetic tests Nationally, genetic testing is increasing at a rate of ~15-20% Biggest growth is in proprietary, overbundled tests Motivation to improve lab use is to value of lab tests to patient and society 1

2 Our local send-outs problem Small Team (2.5 FTE)-lack of cross-training/coverage No visual systems showing workload No standard work and documented procedures No front-line leader Workload not level Low employee engagement All add to delays!! Pre-analytic Analytic Post-analytic ordering Tracking Pre-analytic Analytic Resulting Post-analytic 2

3 Change Management 1. (Forced) to Go to Gemba Case study- interventions/tools 2. Used CPI tools to gather data: Root Cause Analysis (Fishbone Diagram) A3 Industrial Engineering Students 3. Used burning platform(s) to create a sense of urgency 4. Create a Vision (Set Goals, Make problems visible) 5. Empower Employees (Right People, Right Tasks) 6. Plan-Do-Check-Act (PDCA) 3

4 The flow of problem solving What is the problem or gap? (What are we trying to improve?) Target Gap What causes are preventing us from meeting our target(s)? What are the root causes? Cause Cause Cause Effect/Problem Current Performance Cause Cause Cause Which actions will address the most important causes? Based on data, what are the causes in order of importance? Goals (Cause) Actions By Who & When Cause #1 Cause #2 Cause #3 Cause #4 Fishbone Tool Ordering Processing -Miscellaneous test orders!! -Specimen labels do not have ref lab name -Spec storage locations not clearly labeled -UM in-box not organized -No visual system -Multiple storage locations -Locations not clearly labeled Specimen packing not in-line withpick-up times Pick up times not optimized- Pending lists not used- Batching groups of tests- Saturday deliveries- Received from multiple sources- Some labs PULL system- Notification varies by lab- No use of pending lists- No schedule- TAT Tracking Resulting Our data showed delays in: 1. Test Ordering 2. Processing and Tracking of Specimens in our Lab 3. Courier Schedules 4. Resulting 4

5 Number of Unique Miscellaneous Tests 3/14/2016 Orders Problem: Miscellaneous test orders Undefined tests cause delays: Manual processes more time consuming Free-text orders require clarification Sample processing requires clarification Easier to make errors at every step > Requiring time to correct/investigate Difficult to track and manage-pending list doesn t display test name Orders Interventions Created standard procedure to reduce MISC tests UM Committee reviews every test ordered >3 times Empowered employee to be owner PDCA (Plan-Do-Check-Act) monthly at UM Meeting Teamed with IS to create a MISC pending list displaying test name Created visual board showing daily MISC test orders to be sent out each day Orders Reduction of miscellaneous tests Months (Sept 2011 to Aug 2012) 5

6 # Unique MISC Tests 3/14/2016 Orders 650 Miscellaneous growth over time Jan Jan Jan Months (Sept 2011 Jul 2015) Tracking MISC pending list 1. Created standard template in MISC comment 2. Created standard work for logging in 3. Built weekly spreadsheet to use as pending Tracking Visual board to measure MISC tests (WIP) Created a board to show Daily WIP (work in progress) 6

7 Problem: courier schedule Log-in times Package times Pick-up times UW (1) 10:20 HSV Run Time Overnight 15:00 ARUP 15:20 Quest 16:30 UW (2) 17:00 Mayo 20:00 Sendouts Start Shift Time 8:00 UW (1) Mayo 10:00 Overnight 14:15 Quest ARUP 15:00 UW (2) Mayo 15:45 Sendouts End Shift Time 17:00 Log-in 8:30 Log-in 12:00 Log-in 15:30 Interventions: burning platform tool Newborn baby admitted with fever and rule out sepsis, including HSV Testing for HSV PCR in blood and CSF was ordered Results expected following day by care team, but were not received until 2 days later This delay prolonged patient discharge by > 12 hours. Patient received at least 2 additional doses of Acyclovir, a potentially nephrotoxic drug, while awaiting test results. Building effective burning platforms Bring providers to your lab to share their perspective Bring patients to your lab to share their experience Encourage staff to observe clinical processes 7

8 Number of specimen 3/14/2016 Intervention: students Partner with the University of Washington- Industrial Systems Engineering (ISE) College students are harmless -staff don t feel like they are being monitored Champions of change HSV Specimen Draw Times: May - July :00-5:00 15:00-24: May June July 0 Time of Day May June July Number of specimen (per month) Number of specimen between (per day/per month) Total UW HSV specimen (per month) Percent of total specimen drawn between (per month) 61.3% 53.9% 57.6% Solution UW (1) 7:15 UW (2) 14:00 FedEx 15:00 ARUP 15:30 Quest 16:30 Mayo 20:00 UW (3) 22:00 6:15 Lab Assistants package Send-outs team Moved this work from Sendouts (Referral Technologist) to Lab Assistants 8

9 Improvement in send-outs delivery Goal Month Result % Goal Result Goal Status Goal 90% of UW specimens sent out same day Dec Not Meeting Goal Jan Meeting Goal Feb Meeting Goal Meeting Goal Goal Month Result % Goal Result Goal Status Goal 90% of Quest and ARUP specimens sent out same day Dec Not Meeting Goal Jan Meeting Goal Feb Meeting Goal Meeting Goal Resulting Results are back Check for duplicate entries Scanned Manually enter Resulting Problem: result entry delays Reference Lab Results not entered in a timely manner No reliable method to check for overdue results 9

10 Resulting A3 Tool "5 Why's" Resulting Intervention: A3 Reduce Reporting Delays Problem Statement: Results from send-out testing are sometimes not received or entered in timely fashion, causing delay for patients. Background / Current Condition: The Lab s Send-outs department sends samples to reference labs, Results come from multiple reference labs and arrive in multiple forms, such as fax, web portals, and snail mail. No expectations for result entry (No SOP/No Schedule) Resulting A3: Reduce reporting delays Ideal State: Results entered when they arrive in lab Project Steps (Action Plan): Standard result delivery method for Reference Labs Create a FAXsys (outlook) and stop using shared fax machine Expanded the team (cross-training) Improved SOP for result entry Set expectations on resulting TAT (within 24 hrs) 10

11 Current Status: Non routine Procedures: Distractions: Safety Concerns: Abnormal Conditions: Communications Daily Task Staff Status Daily WAR Report Check Results to HIM Verifying Scanned results Retrieve Results: Gene Connect Mailbox SCCA Mayo manual Faxsys Tania Kylene Kylene/Emilie Patient watcher Board: Check Dispatched Pending Linda Patient Watcher Board: Check Result Pending List (2-3 times per week ideal) UM sending cases ing providers Update UM database Linda David David David Fed Ex David Sustaining is hard Measure Metrics Monitor Management and Monica Valuable metrics and how to measure Volume of miscellaneous entered test orders Volume of results/orders left un-entered after 8 hrs # or % of samples that miss pick-up (or run) time % results not retrieved or acted on by care team Laboratory test volume by analyte Utilization management impact (e.g. % orders modified) Measures of sample quality (e.g. mislabels, QNS, etc) Corrected result rate 11

12 Sustaining with daily huddles Daily huddles with send-outs team at 9:30 Monday: QUALITY: Error Corrected Reports Tuesday: COST: Overtime and Improvement Ideas Wednesday: DELIVERY: Arup/Quest/UW TAT Thursday: SAFETY: Safety Friday: ENGAGEMENT: Share recognition/impact Planning Reporting up Lab Wide Daily Huddle Each lab section reports their status. Acknowledgements Seattle Children s Send-out Team Michael Astion, MD PhD David Stanley Tania Zapata-Garcia Jessie Conta, GC Darci Sternen, GC Shannon Stasi, GC Rhona Jack, PhD Processing and Lab Client Services Lisa Wick Angela Vetch Jack Messner Emilie Fruland Kylene Marquiss Whitney Tingle Marnae LaMarsh Lab IS Paul Hirawai 12