clinical pathology quality dashboard

Clinical PathologyQuality Dashboard

May 2010

Clinical Pathology Quality Dashboard

Inpatient Phlebotomy First AM Blood Draws

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May0%

20%

40%

60%

80%

100%

University Hospital

8am 9am

10am

2009 2010

Drawn by


20%

40%

60%

80%

100%

Mott Hospital

8am

9am

10am

2009 2010

Drawn by


Inpatient Phlebotomy First AM Blood Test Results:

PT/PTT, CBCP, and Comprehensive Panel


20%

40%

60%

80%

100%

0

100

200

300

University Hospital

8am

9am

2009 2010

Avg

Dai

ly V

olu

me

Results by


20%

40%

60%

80%

100%

0

1

2

3

4

5

6

7

8

Mott Hospital

8am

9am

10am

2009 2010

Avg

Dai

ly V

olu

meResults by

Inpatient Phlebotomy Draws


May June July Aug Sep Oct Nov Dec Jan Feb Mar Apr May0

5,000

10,000

15,000

20,000

25,000

30,000

20,98621,651 22,073

22,675

20,208

22,942

21,65020,940

22,907

20,934

23,27422,544 22,848

2009 2010


Turnaround Times

May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May

0

20

40

60

80

100

120

140

CSF Gram StainVolume and Turnaround Time

> 1 hour

30 min-1 hour

<30 minutes

2009 2010

Mo

nth

ly V

olu

me TAT


0

200

400

600

800

1000

1200

1400

Emergency Department Cardiac MarkerVolume and Turnaround Time

> 2 hours

1-2 hours

<1 hour

2009 2010

Mo

nth

ly V

olu

me TAT


Specimen Processing Turnaround TimeAverage Daily Turnaround Time + 1 standard deviation

for Inpatient Specimens going to Chemistry

September 2006 - July 2007

0:00

0:14

0:28

0:43

0:57

1:12

Sep-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07

Tu

rnaro

un

d T

ime i

n M

inu

tes

May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-100:00

0:14

0:28

0:43

0:57

1:12

May 2009- May 2010

Tu

rna

rou

nd

Tim

e in

Min

ute

s


Molecular Diagnostics Laboratory

April 2

008

May

2008

June

2008

July

2008

Augus

t 200

8

Septem

ber 2

008

Octobe

r 200

8

Novem

ber 2

008

Decem

ber 2

008

Janu

ary 2

009

Febru

ary 2

009

Mar

ch 20

09

April 2

009

May

2009

June

2009

July

2009

Augus

t 200

9

Septem

ber 2

009

Octobe

r 200

9

Novem

ber 2

009

Decem

ber 2

009

Janu

ary 2

010

Febru

ary 2

010

Mar

ch 20

10

April 2

010

May

2010

0

200

400

600

800

1000

1200

1400

0

1

2

3

4

5

6

Molecular Diagnostics LaboratorySpecimens Received and TAT

April 2008 - May 2010

Series1 Linear (Series1)

Month/Year

# o

f S

pec

imen

s re

ceiv

ed

TA

T (

day

s)


Chemistry In-Lab Turnaround Times

0

5

10

15

20

25

30

Per

cen

tag

e

Oct 07 - Mar 2010

Sample Turn-Around Time

Routine > 60 min stat > 45 min inpt stat > 45 min outp stat

UMHS Blood Product Utilization



1.3

1.4

1.5

1.6

1.7

1.8

1.9

Crossmatch/Transfusion Ratio

2009 2010

Threshold


0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

Wasted RBC

2009 2010

Threshold


0%

1%

2%

3%

4%

5%

Wasted Platelets

2009 2010

Threshold


0%

1%

2%

3%

4%

5%

6%

Wasted Plasma

2009 2010

Threshold


0%

5%

10%

15%

20%

25%

Wasted Cryoprecipitate

2009 2010

Threshold


0

1000

2000

3000

4000

5000

6000

7000

8000

0

1000

2000

3000

4000

5000

6000

7000

8000Blood Product Utilization

Series1

Random Platelets

Allo RBC Units

Plasma Units

Cryo Units

Partial Units

SD Platelets

2009 2010

Pat

ien

t P

op

ula

tio

n

AdjustedDischargesUnits Used


CAP Proficiency Testing

3rd Quarter FY 2010

Clinical Pathology 53 = Number of Challenges 100% = Satisfactory ResultsAnatomic Pathology 0 = Number of Challenges N/A = Satisfactory ResultsDepartment Total 53 = Number of Challenges 100% = Satisfactory Results

9799.5 99 100

92

9998

100

50

60

70

80

90

100

0

100

200

300

400

500

600

4th Qtr 1st Qtr 2nd Qtr 3rd Qtr 4th Qtr 1st Qtr 2nd Qtr 3rd Qtr

Per

cen

t S

atis

fact

ory

Nu

mb

er o

f C

hal

len

ges

Clinical Pathology Scores

FY2008 FY2009 FY2010


CP Financial Measures

*excludes Blood Bank and Phlebotomy

3853

4

3862

6

3871

8

3880

8

3889

9

3899

1

3908

3

3917

3

3926

4

3935

6

3944

8

3953

9

3963

0

3972

2

3981

4

3990

4

3999

5

4008

7

4017

9

4026

9$4

$5

$6

$7

$8

$9

$10

$11

Clinical Path Expense per Test*

3853

4

3859

6

3865

7

3871

8

3877

7

3883

8

3889

9

3896

1

3902

2

3908

3

3914

2

3920

3

3926

4

3932

6

3938

7

3944

8

3950

8

3956

9

3963

0

3969

2

3975

3

3981

4

3987

3

3993

4

3999

5

4005

7

4011

8

4017

9

4023

8

4029

9

1,000

1,200

1,400

1,600

1,800

2,000

275,000

300,000

325,000

350,000

375,000

400,000

425,000

Clinical Path Tests per FTE and Total Tests By Month

Tests per FTE Linear (Tests per FTE)Total Tests

Te

st

pe

r F

TE

To

tal T

es

ts

May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar Apr May1,000,000.00

1,050,000.00

1,100,000.00

1,150,000.00

1,200,000.00

1,250,000.00

1,300,000.00

1,350,000.00

1,400,000.00

1,450,000.00

0

2000

4000

6000

8000

10000

12000

Blood Costs vs. Total Blood Products Used

Units

Cost

2009 2010

Do

llars

(m

illio

ns)

pai

d t

o S

E

Mic

h A

mer

ican

Red

Cro

ss

Blo

od

Pro

du

ct U

nit

s (t

-h

ou

san

ds)

• The Safety Committee, led by Brenda Schroeder, has started a robust Safety Inservice curriculum. This activity promises to dramatically raise our “safety quotient”.

• Congratulations and thank you to all for successful completion of our biannual CAP self-inspection (May, 2010.)


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clinical pathology quality dashboard

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