Disclosures. Relevant Financial Relationship(s): Nothing to Disclose. Off Label Usage: Nothing to Disclose 6/1/2017. Quality Indicators

Transcription

1 Laurie Griesmann, Quality Specialist May 17, 2017 Disclosures Relevant Financial Relationship(s): Nothing to Disclose Off Label Usage: Nothing to Disclose 1

2 Objectives Define a quality indicator. Recognize why quality indicators are performed. Design and implement key quality indicators. Interpret and act on quality indicator data. Definition of Quality Indicator Measurement of an activity within or across the path of workflow Requires data collection and analysis Phlebotomy Concentrate on Pre-analytical phase Compared to: Benchmarks Standard of Practice Regulatory or Accreditation Requirements Peers Internally derived measures 2

3 Why use? Guarantee that every step of laboratory testing is being done according to standard operating procedures Identify quality concerns Triggers additional investigation Track changes to processes and procedures Improve patient care Provide efficient service & meet expectations of care providers Why use? Create a Quality Culture in the work unit Track individual successes CAP Gen Specimen Collection Feedback Safety for patients and employees Requirement of Regulating Agencies College of American Pathologists (CAP) 3

4 Quality Indicator Process Planning Form Guide used to develop a quality Indicator Selection of an Indicator Rational, Purpose, Stakeholders, Literature references, Indicator Development and Data Collection Operational definitions, data collection plan, sampling, baseline data, target or goal Indicator Analysis and Interpretation Statistics, graphs Data Reporting Plan Receive results, frequency 4

5 CAP Requirement GEN QM Indicators of Quality Phase II The QM program includes monitoring of key indicators of quality in the pre-analytic, analytic and post-analytic phases. No requirement to monitor any specific indicators List of key indicators commonly used to measure laboratory performance Performance should be compared to benchmarks (Q-Tracks, peers) Additional CAP Consideration GEN Customer Satisfaction Phase I The laboratory has measured the satisfaction of healthcare providers or patients with laboratory services within the past two years. Improve Laboratory Services Respond to a patient or physician complaint 5

6 Additional CAP Consideration GEN Requisition Data Entry Phase II Test requisition data elements are entered accurately into the laboratory information or record system. Manual Entries Data elements include: Patient demographic data Name & location of the individual or entity ordering the test Tests Additional CAP Consideration CHM Sweat Rejection Incidence Rate Phase I The incidence of insufficient sweat samples is routinely monitored. Patients 3 months of age and younger = rate of QNS samples should not exceed 10 % Patients > 3 months of age = rate of QNS samples should not exceed 5% 6

7 Patient Identification Accuracy Wristband Errors May lead to misidentification of a patient Percent of patients with: Absent wristbands Wrong wristbands Multiple wristbands Wrong information Missing information Illegible data Customer Satisfaction Percent of patients satisfied with the phlebotomy experience Data Collection Paper vs. Electronic Expectation / Perception The person who collected my blood was: Helpful Courteous Knowledgeable Professional Confident How long did you wait and was your wait reasonable? 7

8 Venipuncture Success Rates Successful Venipuncture is defined as complete collection as requested by provider Track 1 st and 2 nd and unsuccessful attempts Adult vs. Pediatric Workunit monitoring and individual tech monitoring Retraining Redraw Error Rate Percentage of specimens rejected =(total # of Redraws/Total Collections)*100 By Workunit and by Reason 8

9 Redraw Rates Redraws by Techs look for trends Direct observation, Retraining Blood Culture Contamination Rate Percent of Positive Cultures identified as contaminated (false positives) Costly Repeat testing Patients are started on unnecessary antibiotics Increase in patient length of stay 9

10 Needle-stick rate (contaminated) Percent of contaminated needle-sticks. Experience level of Phlebotomist Lack of Training Situation Device Type Straight Needle Butterfly IV Needle ABG Syringe Turn around Time Satisfy providers & patients Delays result in: Complaints Use of Point of Care devices as an alternative Increased ED length of stay Define: Start and Stop points Classification (test, priority, site) 10

11 Test Request Incorrect tests ordered Appropriateness Manual entry error Duplicate tests ordered Goal is to reduce unnecessary testing Discarded Items Goal is to reduce waste Event Management Act on your Data Frequency Daily, Weekly, Monthly, Quarterly Analyze your data Review results Look for trends Continually ask the question: How can we as a workunit improve? Share with Staff Ask for input on ways to improve 11

12 Work Unit Balanced Scorecard Act on your Data Stakeholders Providers Patients Process Improvement Systemic approach to improve processes, systems and infrastructure in order to reduce waste, eliminate inefficiencies and provide the highest quality patient care Quality Improvement methods 12

13 Final Thoughts Provide highest quality sample Equipment Standardization of the collection Standard Operating Procedures Avoid putting what not to do Staff resources Training Continuous Education Competency Assessment Summer in Minnesota 13

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