Results Handling Change Package 2017/2018 Results Handling Overall 100% 80% 60% 40% 20% 0% 01/07/2016 01/08/2016 01/09/2016 01/10/2016 01/11/2016 01/12/2016 01/01/2017 01/02/2017 01/03/2017 01/04/2017 01/05/2017 01/06/2017
Aim: 100% of all lab results will be actioned within seven days What types of laboratory test results should I focus on? To start with, the Safety in Practice initiative is focusing on the following blood tests only (but you can vary this to suit your practice needs): Full Blood Count (FBC) egfr Liver Function Tests (LFT) Thyroid Function Test (TFT). How many patients? We recommend that you undertake routine audits of 10 patients every month, which is not too much of an onerous activity. Which patients? On the day of the data collection each month, run the query (available to download from http://www.safetyinpractice.co.nz) and randomly pick 10 patients who had one or more of the blood tests listed above undertaken at least three weeks previously. Why do this? Hopefully you ll quickly see the potential of the care bundle approach in helping you to pinpoint areas of strength and potential weakness so you can take steps to improve the system focus in the appropriate areas (e.g. ensuring reliable communication of all test results to patients). The data you collect is entered into a spreadsheet, where it is automatically graphed for you as a run chart allowing to you to see at a glance how compliant your system is with the bundle measures. This will give you a much better idea of how safe and reliable your practice systems are for results handling. You can monitor your progress and focus on improving those areas identified by the audit as being a potential problem. Your ultimate aim is in maintaining 100% compliance. How do the Results Handling Care Bundle measures work? The Results Handling Care Bundle measurements are questions that are answered on a Yes, No or N/A basis. For example, if you answer Yes or N/A to ALL questions for EVERY patient in the data collection cycle, then you will have 100% Bundle compliance (10 out of 10). However, if you were to answer NO to one of the questions for a single patient but answered YES for all other questions for all remaining patients, then you will have achieved 90% compliance (9 out of 10). Therefore, we are interested in what is called an All or Nothing approach, i.e. whether ALL ordered tests for EVERY patient match to a positive answer for ALL five questions.
To illustrate further, if one patient had an egfr, FBC and Glucose done, but only the egfr and Glucose were viewed by a practice clinician within two working days of being received, then answer NO for question one of the bundle. Results Handling Audit Questions The following questions are used for monthly auditing in practices for the results handling bundle: Was a definitive decision recorded by a clinician on EACH test result within seven calendar days of being received? Have the decisions for EACH test result been actioned by the practice including appropriate recalls and tracking of the actions? (if no actions are required record at N/A) Was the patient informed as instructed? (If no instruction record at N/A) Overall compliance.
Theory of Improvement
Process for Results Handling Bundle 1. Identify patients for whom one or more of FBC/eGFR/LFT/TFT has been ordered in the previous three months 2. A query has been developed for MedTech and My Practice PMSs to assist with this, which is available online at http://www.safetyinpractice.co.nz 3. From the identified list, randomly select a sample of 10 patients 4. Print and complete the Results Handling Audit Paper Form (included in the Results Handling audit spreadsheet and online at http://www.safetyinpractice.co.nz 5. Transfer the data collected to the Results Handling audit spreadsheet 6. Please make sure the date is entered beside each individual record. The data will automatically be collated and displayed on the run charts that can be printed as needed 7. Save the spreadsheet 8. Email the completed spreadsheet by or on the 10 th of each month (i.e. June data is due on 10 July, July data is due on 10 August). The spreadsheet is to be emailed to roxanne.leech@middlemore.co.nz Practice Name Review Month Patient Was a definitive decision recorded by a clinician on EACH test result within 7 calendar days of being received? Have the decisions for EACH test result been actioned by the practice including appropriate recalls and tracking of the actions? (if no actions are required record at N/A) Note: This sheet is not for entering data on your computer, it is only for printing and completing by hand. Once you have done this, enter your data on the appropriate data collection form. Please circle response as appropriate Was the patient informed as instructed? (If no instruction record at N/A) 1 Y N Y N N/A Y N N/A 2 Y N Y N N/A Y N N/A 3 Y N Y N N/A Y N N/A 4 Y N Y N N/A Y N N/A 5 Y N Y N N/A Y N N/A 6 Y N Y N N/A Y N N/A 7 Y N Y N N/A Y N N/A 8 Y N Y N N/A Y N N/A 9 Y N Y N N/A Y N N/A 10 Y N Y N N/A Y N N/A Comments
Alternative Way Tested by One Practice Nominate a staff member (nominee,) likely admin/reception staff, to run the initial part of the bundle progressively over seven days. Ensure nominee has access to and familiarity with the PMS sections/icons to complete the bundle audit. Select a random number generator the nominee can use (Google this, multiple choices) or simply select a list of numbers and use these each time, e.g. first 10 prime numbers; every third number starting from four. (For ease, I would recommend either of these two choices rather than random number generator). Identify a clinical staff member to complete the bundle (clinician). 1. Initially run through one trial audit of ten patients to assess the amount of time taken and effectiveness of the process then discuss as either the full practice team or the core Safety in Practice team in regard to: Size of audit e.g. stay with ten per month vs expanded numbers based on practice size One audit per practice vs one audit per GP. Consideration may relate to level of FTE e.g. audit all GPs over 0.4 as separate audits and those equal or under as a group Remember this is not necessary as the bundle is for an audit of 10 per month but may give more valuable data to both the practice and individual GPs but will be at a cost of time. 2. Nominee decides which day to select to start the bundle not advising other staff 3. Nominee starts prior to GPs on the day of the audit 4. Nominee opens provider inbox and selects all providers. After the initial audit and discussions above this may need to be for each individual GP or selected groups depending on practice decisions. Use the filter button (looks like a rainbow) to select lab test only for the provider inbox 5. Using random number generator, select the highest number for each providers inbox and generate the list of ten numbers or use the preselected numbers to select the audited results. 6. Nominee records the NHI for the selected audit group and looks at results and checks that they are assigned to a specific GP from the practice.
7. Day 2, the nominee reviews the practice/specific-provider inbox and reviews if results are still present or have been filed. If not filed, is there any evidence the GP has interacted with these? E.g. record in notes or use audit tab heading within the inbox to see if the GP has accessed the result (question one) 8. Day 7, the nominee gives the NHI list to the clinician 9. The clinician reviews the inbox and notes of the patient and answers questions two, three and four of the bundle 10. The nominee and the clinician meet briefly to advise if question five is yes. This completes questions one to five of the bundle. In regard to question 6 and 7 of the bundle, the easiest way to do this would be to set all lab requests to be tracked starting the first of the month, and at the end of the month review any tracking tasks not signed off. For those patients who have not had the tracking task completed, review the notes and see if the requested task has not been done. Discuss the uncompleted list at a practice meeting. What does this mean to the practice; how do we manage this in the future?
Change Ideas Tested Update practice policy on results handling policy expectation that all results will be annotated not just signed Consideration of how this will fit with patient portal Using standardised comments against lab results Doctors to send a text (or post letter) for all results that are normal or stable Result forwarded to nurse to follow-up with patient if result is not normal/stable. Comments section used to advise nurses on action desired Surveyed patients as we saw them on their knowledge of our current process Getting the GP team to understand how their action/notes on a result can help the nursing team relay the GP plan to the patient in a timely fashion Ensure patient preferred contact information is loaded into PMS Update information on results process for patient education Communication with clients at each visit, how result should be communicated doctor, nurse and reception asked methods of communication and documented in notes in the to-do task Poster made and placed in waiting room advising clients to check for results if it has not been communicated to them within seven days of doing tests All staff took responsibility in keeping updated contact details Allocating other doctors to monitor inbox of absent or locum doctors this system worked well and all results were dealt with in appropriate timely manner Lead clinician audited inboxes/results daily of any locum doctors, especially weekend staff Individual feedback to doctors to not include both interpretation and action required Enforce inbox standards sent to doctors top 10 inbox messages sent to nurses that waste their time Education of doctors in barriers to dealing with results in a timely manner. Benefits/Positives It has been motivating to see the staff buy-in in general on providing a more streamlined results handling process within the practice Further implementation of PMS direct patient communication (via email and text) has ensured that we are able to see a trail of actions taken with each result within the PMS system Medical staff now check inboxes prior to leaving for the day and during the day as appropriate Some doctors are able to access their inbox from home to check their results Alerts and recalls are being set when repeat tests are necessary Patients are being informed of results earlier than before Tangible benefits evident from first cycle was a strong re-enforcement for continuing improvement Strong drivers to doctors continuing to consistently annotate and try to improve Awareness that what they were doing had a significant impact on both the nurses workload and on the ease of them doing undertaking their work Made several big changes in the first cycle (annotations and clear shorter timeframes ) with subsequent cycles mostly re-enforcing and encouraging to apply changes diligently as opposed to several cycles of smaller stepwise improvement
Significant increase in awareness of how the comments they make on the results impacts both the ease of nurses doing their role, and on the reassurance of the patient s experience previously viewed these more as comments they were making for their own recording Less interruptions to do with interpreting someone s results Realising that we aren t that bad, understanding that there are still improvements to be made Has got clinic interested in the portal Starting a conversation with staff and patients Thinking about how to go about larger scale change, e.g. now blood taking. Issues/Negatives GPs are finding that it takes longer to annotate results Keep developing new keywords for results perhaps too many Sluggish uptake from some GPs to utilise standard result notes and participate We realise there is much more to be done and probably we are not that great at actually measuring things. Standardised Comments Fields Clinic One "normal" "stable, repeat: " "abnormal: " "followed by specialist" These are standardised across the practice for all GPs to be using. We have only specified them for use on blood tests at this stage however some have been using them for other results (e.g. MSU/swabs etc), which is fine too. Clinic Two The following is a list of our current results annotation options. The numbered ones at the top of the list are the preferred options that are being used by GPs.
Clinic Three Quick key Press spacebar after letters Suggested comments for INBOX results.a acceptable no action required.ar acceptable repeat in (insert time frame for recall or message).disc non-urgent - can discuss at next visit 3/12 visit.ex ordered and being followed up by external provider.inr INR result been actioned.life please discuss with patient appropriate lifestyle advice.me note - change in medications.n normal.nad no abnormality detected.nar no action required
.ni.ot.sf.si.st.stn no infection?otahuhu patient - forward on and send back sample forwarded to other lab for testing similar to previous - no current action required stable continue to monitor (add in timeframe and by whom) stable no current action required.tci patient to make appt to come in and discuss non urgent (2 weeks).tciu patient to come in to see doctor URGENTLY (identify timeframe required).tr transferred - send back and to new practice.un unmatched - send back Clinic Four.n = normal.a = acceptable.aa= acceptable repeat in....tci= to come in.sp= test arranged by specialist.ix= further investigations arranged Clinic Five Current comment options are normal, abnormal no action required, add comment improved from before or gone worse, abnormal, and add comments, i.e. plan of action.
Results Comments The following is a list of comments that clinicians might usefully communicate to staff and patients what their results mean and action that needs to be taken by both the practice and patient. Non-actionable comments Results are normal Normal see task Results slightly out with normal range but acceptable and no further action is needed Tell Patient Acceptable Noted EGFR low no action needs to be taken Patient has been told Tell patient when they phone in Document seen no action required Review already organised GP has spoken to patient Nurse has already spoken to patient No significant infection found Antibiotic already given Actionable comments Add/Change medication Contact patient and tell them Kidney function slightly abnormal repeat in 1 week phone patient Make an appointment for bloods Make an appointment for fasting bloods Make URGENT in person appointment with Make URGENT telephone appointment with Make NON URGENT appointment with Make NON URGENT telephone appointment with: A particular doctor Any doctor Make in person appointment with PRACTICE NURSE Make telephone appt with PRACTICE NURSE No action today workflow to usual GP to advise Other results normal forward to practice nurses for cholesterol/blood sugar comment Repeat test(s) Prescription required Prescription issued DNS to do test action to arrange with them Please print result and post to patient with attached comment if any Send benign letter to patient confirming that lesion removed at minor surgery was benign and does not need any further action.
Results Handling Systems Practice Self-Assessment Questions These questions might usefully guide a practice meeting about how to make your results handling systems safer. Systems issues Does our practice have a results handling system outlined in a protocol? How does our practice ensure the results are reviewed and acted on in a timely manner? How does our practice handle results when a clinician is absent from the practice (e.g. on leave or due to illness) and/or when a locum orders a test? How does our practice action emergency test results communicated by the laboratory? How does our practice track tests that are ordered and results received so that missing results are identified and chased up? How does our practice monitor the reliability of its result handling system? How does our practice ensure laboratory results are reviewed and commented on by the appropriate clinician? What is the system in our practice to ensure laboratory results are seen by the clinician who ordered them? Do we have standards for reviewing abnormal and/or normal results within clinically appropriate timescales agreed within the practice? What is our practice system for dealing with multiple test results not yet returned to the practice? (i.e. this is to avoid a situation where a number of tests have been carried out and the patient is told that the result is normal, when other test results are still to be returned). Training issues How are our staff, including locums, trained in the results handling system? Communication issues Has our practice agreed on the nature of wording used to communicate test results? (e.g. no action or normal comments are often not of assistance to administrative staff in communicating effectively and safely with the patient) How do we review these phrases to ensure they are appropriate? Patient s health literacy issues How does our practice inform our patients about the different steps involved in how, when and how to access their test results? How well informed do we feel our patients are about the process? How does our practice record that it has notified patients of their results and actions required? How does our practice identify patients who do not make appointments for tests or who do not attend for a related appointment?