The Case of the Belated Lab Tests
The Case of the Belated Lab Tests
Performance Improvement Opportunity – Part 2
Part 1: Create a flowchart of the process that was discussed in the first meeting (see packet 1) to illustrate the workflow that is currently being used. This will help the team decide where there may be problems in the current workflow.
Packet 1:
Lotta: First, I want to thank you all for volunteering for this team. I think we have…..
Sam: (interrupting) I wouldn’t exactly say we all volunteered. In fact, I’d say I was drafted.
Lotta: Well, I suppose some of you were picked. I asked the managers for people who really know what goes on in this process. So, you’re the experts. And I asked Cathy Filer to join us because she may be able to help us to use the EHR system more effectively to help with this improvement opportunity.
Cathy: I hope I can help!
Lotta: Let me describe the problem. We’re getting too many complaints about long turnaround times for lab tests – I mean from the time the physicians decide blood work is needed until the time the results are available to them. Harry helped me pull some data together that will give us a picture of how big the problem is. Everyone take a look at your handout.
Harry: This bar chart shows the percent of tests that got done within the standard for the past year. The average is about 84%.
Beth: What are the standards, anyway? No one ever told me there were standards. I thought everything was stat, stat, stat! I know I spend a lot of time calling down to see when results are going to be available.
Sam: Maybe that’s because we’re not making the standards all that often, whatever they are.
Tom: Let me explain these standards. When the doc’s fill out the request, they indicate whether it is STAT, Urgent or Routine. There are different turnaround time standards for each priority. STATs are 2 hours, Urgents are 6 hours and it’s 24 hours for Routines. The times are from when the test is ordered to when the results are available to the doc.
Steve: Well, whatever the standard is, I know the problem isn’t the time we take to actually do the test. We’ve been measuring our turnaround time within the lab for more than a year now.
Harry: Steve’s right. We did have some problems in the lab a couple of years ago. We had some pretty ancient equipment. But, we were able to replace most of that last year.
Cathy: Well, that is great to know. Since we already know that the turnaround time for actually doing the test, and I am assuming we can show data to back that up, then the team can focus our time on other parts of the process.
Sam: I don’t know why we need a team to solve this one. It’s pretty obvious to me that you guys may be able to do the tests quickly, but you leave specimens sitting in your receiving window for long times. You probably measure your own turnaround time from when you take the specimen from the box, not when it gets there.
Steve: That’s not true. If you want to blame somebody, just last week, I noticed that the messenger service left results in our out box for more than an hour before picking them up.
Harry. That’s right. I think there are just a few “bad apples” around here, including in the lab. I’m looking into that now. I’ll find them……I have my ways.
Beth: (to Tom) Tom, we’re not supposed to be going right to what we thing the solutions are, are we? Or finding ways to blame other people?
Tom: (with a sigh) Beth’s right. What we have to do is see if we can find out what’s wrong with this process. We have to get out of the habit of thinking it’s always someone doing something wrong. So, the first thing we have to do is to make a flow chart showing how this process works. Then, we’ll think about what could be causing the problem of long turnaround times. We’ll have to test our theories and collect data and make sure we find the root cause. Until we do all that, we won’t have much of a chance of solving the problem for good.
Steve: Boy, that sure sounds like a lot of work.
Lotta: That’s why we’re here. We’ll learn a lot and have some fun, too. But, we’d better keep an eye on the ground rules we put together. That will keep us focused on the problems, rather than on blaming others.
Tom: OK, let’s get to the first step – flowcharting this beast. You folks tell me the steps in the process and I’ll write them on these poster size Post-Its and stick them on the wall. Then when we think we have all the steps we’ll move the Post-its around and put them in the right order.
Lotta: Sounds good. So, where does this process begin? What’s the starting point of our flow chart?
Beth: Well, here’s the doc, making his rounds or checking a patient. He decides that some kind of test is needed and writes the request….sometimes the nurse writes the order and has the Doc co-sign it…..and whether it’s STAT, Urgent or Routine is written right on the order.
Cathy: How does he write the request? On a paper request sheet? Are we using the Order Entry option in the EHR?
Beth: No, they write it on a request slip.
Cathy: That is good to note.
Steve: You know, I think the doc’s overdo it on the Urgents. I bet that plenty of the Urgents could really be Routines. Maybe they’re in a big hurry to get out of here, so they make it an Urgent.
Harry: Well, 24 hours is a long time to wait for a Routine. Maybe the doc is making rounds in the afternoon and would like to have test results back for the next morning.
Beth: Sure, that happens. But, that’s not really unreasonable is it? Maybe the standards should be tighter.
Harry: For pity sakes, we’re not meeting the standards we have now. I think the standards are set by the Patient Care Committee. They’re all docs and you know they’ll just want to tighten them up if we bring this to their attention.
Beth: Maybe so….but, I think we should look at the standards. I wonder what that standards are at River Valley Medical Center.
Tom: Hold on, hold on. We’re supposed to be flowcharting now. These are good thoughts, so let’s write them down in our idea log and make sure they get included with our minutes so we don’t forget them. Let’s get on with this process.
Lotta: Well, the requests go to you, Beth, don’t they?
Beth: Right. I stamp them with the patient’s name and medical record number. Then I put them in the floor out box for lab pickup.
Steve. The Routines go into the box, but you call us on the STATs and Urgents.
Beth: That’s right.
Sam: Then the lab notifies me and I go up, pick up the request and do the draw. That’s assuming the patient is there.
Lotta: What do you mean “assuming the patient is there?”
Sam. Just that. Sometimes I go up and there’s an empty bed. Maybe I was given the wrong room numbers, or maybe the patient is visiting Radiology or PT, or whatever. There’s nothing like having a STAT order and you can’t find the patient.
Lotta: So, what do you do then?
Beth: Usually, he comes over and harasses me – like I’m not busy enough already.
Tom: OK, let’s put that on our chart as a problem. If it happens fairly often, it could be part of the turnaround time problem. But, let’s say the patient is there. You do the draw, right?
Sam: Right. Then I take the specimen down to the lab and put it in the in box. (Under his breath)…..Where it grows old.
Steve: OK Sam, I heard that.
Tom (intervening) Everyone did. Let’s keep one eye on the ground rules until we get used to working as a team.
Harry. The lab people are always checking the in box and, when there’s a specimen, we take it, set up the equipment and do the test.
Steve: We put the results on the form and put it in the out box. The messenger picks up the results when they come by on their rounds, and takes them back to the floor.
Beth: When I get them , I put them with the chart and flag it. Usually, if it’s a STAT, I make sure the doc knows the results are there.
Cathy: OK, that sounds like the whole process, except when do the results get put into the patient EHR?
Beth: We don’t. The results get sent down at discharge with the rest of the paper chart and I think they get scanned. I’ve seen scanned result slips before.
Cathy: OK, another thing for me to think about.
Lotta: OK, let’s get to work flowcharting this process.
Part 2: The following information was extracted from the floor secretary logs from the past week.
A total of 3622 tests were done and 589 were over the standards for turnaround time
The breakdown by urgency is as follows:
Of 459 STATs, 77 were over standard
Of 1042 Urgents, 334 were over standard
Of 2121 Routines, 178 were over standard
You want to bring a graph of this data for the next team meeting.
NOTE: Your Excel table might look something like this in order to make a graph that will be valuable.
URGENT
ROUTINE
STAT
TOTAL
Number > Standard
334
178
77
589
% of Total > Standard
57%
30%
13%
100%
Cumulative % of Total
57%
87%
100%
TASKS:
Create a graph, using Excel, depicting the data above. Analyze this data once your graph is made. What conclusions can be drawn? Write a short summary of what the graph is telling you.
Decide! Does the team have enough data? Brainstorm a list of the data you would like to have. Where would you get that data? Submit a shortlist of your brainstorm ideas and explain what you would discuss with the team regarding gathering more
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