how to build the quality improvement mindset and sustained ... · 1 how to build the quality...
TRANSCRIPT
1
How to Build the Quality Improvement Mindset and Sustained Effort into the Laboratory Organization
Bonnie MessingerCPHQ, CMQ/OE (ASQ)
ARUP Laboratories, Inc.
2
“…appreciation of context is often the crux of improvement strategies.”
Carr, Susan. “Evidence and Criteria; “ Patient Safety and Quality Health Care. September/October 2008
Emphasis on Patients
MissionARUP's mission is to continually
improve patient care by building professional relationships through excellence in laboratory testing, service, education, and research.
Making the Best Better
1984
3
Quality Indicators
The JCAHO 10-Step Process1. Assign Responsibility2. Delineate Scope3. Identify Key Aspects of Care/Service4. Identify Indicators5. Set Thresholds6. Monitor7. Identify Improvement Opportunities8. Take Action9. Assess10.Communicate
1989
Responsibility
• Medical Director/Director is responsible for all aspects of the departmental indicator monitoring system
• Manager/Supervisor is responsible for oversight of all division/section quality monitoring activities
• Quality Specialist is responsible for division quality activities: – PT, audits, occurrence reporting,
improvement support, QC, indicator monitoring, instrument validation, SOP’s.
Discovery:Discovery:
Those who own Those who own data collection, data collection, own the own the process.process.
4
Scope
• Anatomic Pathology and Oncology/Genetics • Business Development• Chemistry • Quality & Compliance and Safety• Human Resources and Institute for Learning • R & D and Technology Transfer• Immunology • Strategic Services and Facilities• Infectious Diseases • Support Services • Transfusion Services• IT Systems • University Healthcare Clinical Laboratory and
Services
Discovery:Discovery:
What gets What gets measured,measured,
Improves!Improves!
Identify Indicators
Discovery:Discovery:
The best choices The best choices are measurements are measurements that are easy, but that are easy, but telling, or are telling, or are already being already being measured, but not measured, but not stratified. stratified.
Measuring can be Measuring can be expensive; expensive; indicators that indicators that promise little or no promise little or no improvement improvement return are poorer return are poorer choiceschoices
• Early Warning– Stat testing turn-around time
• Confirmatory– Bench-top cleaning log completion
• Critical Services– First attempt critical result notification success rate
• Critical Processes– Mislabeled specimens by patient care unit
• Latent Error– Number of understaffed shifts
• Human Behavior– Missed test orders by shift
• Compliance– Number of days between competency testing and major
error
5
Quality Systems
Path of work-flow + support + management processes
Functional Silos
Training
Inventory Management
Document Control
Quality
Examples of ARUP Indicators
Structure Measures• Accreditation/ licensure
issues• Audits• Correlation of results/
instruments• Compliance with policy/
procedure• Employee safety issues• Hazardous waste
minimization activities• Instrument/ kit failures• Performance
appraisals• Personnel competency• Proficiency testing
performance
Process Measures• Accuracy/ clarity of
laboratory reports• Appropriateness of
samples and labeling• Appropriateness of
transport conditions• Critical value
notification/ documentation
• Incident reports• Test order accuracy• Provision of adequate
sample/clinical information
• Specimen handling accuracy
• Turn-around time
Outcome Measures• Appropriateness of
requests• Client interaction/
consultation• Clinical correlation• Employee injuries/
safety issues• Patient outcome• Physician/ client
feedback• Lost samples• Corrected reports
6
Set Thresholds
• Use current performance as a baseline and challenge the process.
• Use organizational goals.• Establish criticality (may be 100% is only
acceptable threshold).• Use benchmarking, other organizations,
literature, industry standards (Q-Probes).• Use realistic targets.
Discovery:Discovery:
Standard Standard denominators and denominators and thresholds for key thresholds for key indicators are indicators are critical to critical to spreading spreading improvement improvement successsuccess
Monitor
Internal• Has the potential to
affect product safety, potency and purity, but is caught and corrected before exiting the system.
• Deviation from standard, norm or established process that does not reach the client or patient.
External• Testing not
performed• Result amended• Reporting delayed• Complaint
Discovery:Discovery:
Anything that Anything that touches or has touches or has the potential to the potential to touch the patient, touch the patient, is an improvement is an improvement imperative.imperative.
7
ARUP Quality Cycle
Quality IndicatorMonitoring
QualityAssuranceReporting
SentinelEvent? Trend?
Root Cause/Failure Modes
Analysis
QualityImprovement/
TeamProject
Implementation
nono
yes yes
INTERNAL
AUDITS
CQI Organization
WEEKLY REVIEW MEETING and DEPARTMENTAL QA MEETINGS
APPROVED RECOMMENDATIONS
Project
Reporting
Discovery:Discovery:
Assigning only Assigning only one tracking one tracking category for each category for each occurrence report occurrence report robs the robs the organization of organization of the incentive to fix the incentive to fix all but the most all but the most obvious unsafe obvious unsafe systemssystems
Source, patient information, client informationRequired billing adjustmentsRequested follow-up
Summary of all discoveries and actions
Event #1Story DatesCategorySub-categoryOutcomeRoot causeSeverity ratingMonitoring departmentInvolved vendorCommunication trail
Event #2Story DatesCategorySub-categoryOutcomeRoot causeSeverity ratingMonitoring departmentInvolved vendorCommunication trail
Event #3Story DatesCategorySub-categoryOutcomeRoot causeSeverity ratingMonitoring departmentInvolved vendorCommunication trail
1990
8
Executive Quality Council
Continuous Improvement Board (CIB)
Improvement / Action
Education / Involvement
Trainer / Facilitators
Quality Improvement Teams
CIB Working Teams
Continuous Quality Improvement Organization
1992
Emphasis on Customers, with focus on patients
MissionThe mission of the Continuous
Improvement Board (CIB) is to act as a facilitator to create an environment of quality teamwork at all levels of ARUP which continuously improves services and products we deliver to customers (both internal and external) and ultimately the patient.
CQI philosophy is CQI philosophy is based on based on leadership, leadership, employee employee feedback and feedback and participation, participation, customer needs customer needs and and expectations, expectations, emphasis on emphasis on patient safety.patient safety.
1994
9
Continuous Improvement Board
• Oversight committee for quality improvement activities Uphold corporate quality philosophy– Train workforce members– Recognize efforts and reward success– Prioritize improvement projects– Form and mentor QIT’s– Support implementation
• Rotating membership ensured broad workforce engagement.
Discovery:Discovery:
An Improvement An Improvement Board should be Board should be composed of 90% composed of 90% committed committed members and 10% members and 10% skeptics. With skeptics. With participation, the participation, the skeptics become skeptics become committed.committed.
CIB Working Teams
Education/Involvement• Recognition• Advertising• Training• Publications
Improvement Action• QIT Request
Approval• Team Formation• Team Tracking
Discovery:Discovery:
Throwing a Throwing a carnival is carnival is unparalleled as an unparalleled as an advertising advertising strategy. strategy.
Games, executive Games, executive participation and participation and popcorn are popcorn are essential.essential.
10
Improve
A process that is failing or inefficient and is….
• Necessary for customer needs• Critical for Operation• Costing money because of poor quality• Causing grief• Continually exceeding thresholds• Very complex• Involving multiple departments
Discovery:Discovery:
Formal Formal improvement improvement teams are teams are resource resource intensive; choose intensive; choose wisely.wisely.
Scaling the team Scaling the team is more important is more important than having broad than having broad representation.representation.
Identify Improvement Opportunities
Discovery:Discovery:
For identifying For identifying improvement improvement opportunities, the opportunities, the Seven Basic Seven Basic Quality Tools are Quality Tools are all you need.all you need.
Gram Stain TAT
400.4
UCL
122.6
CL
0.0
200.0
400.0
600.0
800.0
1000.0
1200.0
7/22
/07
8/26
/07
9/9/
07
9/23
/07
10/1
5/07
10/2
7/07
11/6
/07
11/1
4/07
11/2
1/07
11/2
5/07
11/2
6/07
11/2
8/07
11/3
0/07
11/3
0/07
12/1
/07
12/2
/07
12/3
/07
12/4
/07
12/4
/07
12/5
/07
12/5
/07
12/6
/07
12/7
/07
1/1/
08
1/2/
08
1/2/
08
1/3/
08
1/6/
08
1/7/
08
1/8/
08
1/10
/08
1/11
/08
1/12
/08
1/13
/08
1/14
/08
1/14
/08
Date/Time/Period
Process Change
Growth rate vs. Error Rate
y = 0.0002x + 0.0005R2 = 0.8057
0
0.002
0.004
0.006
0.008
0.01
0.012
0.014
0.016
0.018
0 10 20 30 40 50 60 70 80 90Error rate
Gro
wth
rate
Process
Process
Process
Decision
end
yes
no
Requests for Further Communication
49
30 3023
13 11 9 8 6
29
38.0%
52.4%
63.5%
69.7%75.0%
79.3%83.2%
86.1%
23.6%
0
50
100
150
200
Com
mun
icat
ion
Ord
erP
roce
ssin
g
Clie
nt S
umis
sion
Inte
rfaci
ng
Sof
twar
e
Pre-
Test
ing
Spe
cim
enP
roce
ssin
g
Test
ing
Del
iver
y
Oth
er
Def
ects
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
InLab Time for Gram Stains from the UH
1:00 x x x x x x x x2:00 x x x x x3:00 x x x x x x x4:00 x x5:00 x x6:00 x x x x7:00 x8:00 x x x x9:00 x x x x x
10:00 x x x11:00 x x x x x x x x x12:00 x x x x x x x x x13:00 x x x x x x14:00 x x x x x x x x15:00 x x x x x x x x16:00 x x x x x x x x x x x17:00 x x x x x x x x18:00 x x x x x x x x x19:00 x x x x x x x x x x x x20:00 x x x x21:00 x x x x x x x x22:00 x x x x x x x x23:00 x x x x0:00 x x x x
InLab Time for Gram Stains from the UH
1:00 x x x x x x x x2:00 x x x x x3:00 x x x x x x x4:00 x x5:00 x x6:00 x x x x7:00 x8:00 x x x x9:00 x x x x x
10:00 x x x11:00 x x x x x x x x x12:00 x x x x x x x x x13:00 x x x x x x14:00 x x x x x x x x15:00 x x x x x x x x16:00 x x x x x x x x x x x17:00 x x x x x x x x18:00 x x x x x x x x x19:00 x x x x x x x x x x x x20:00 x x x x21:00 x x x x x x x x22:00 x x x x x x x x23:00 x x x x0:00 x x x x
STL to InLab
0
5
10
15
20
25
30
35
40
-0.90 0.00 0.90 1.80 2.70 3.60 4.50 5.40 6.30 7.20 8.10 9.00 9.90 10.80
Num
ber
LSL 0.00 USL 6.30Mean 2.40Median 2.30Mode 1.38
Cp 1.11Cpk 0.85CpkU 1.37CpkL 0.85Cpm 0.72Pp 0.83Ppk 0.64PpU 1.03PpL 0.64Stdev 1.26Min 0.52Max 9.02Z Bench 4.11ZTarget 0.26% Defects 1.2%PPM 12048.2Expected 19.4Sigma 3.76
Problemstatement
Man Material
Method Machine
TAT
TAT
11
Act
Remedial ActionCorrective ActionPreventive ActionImplementation TeamsDocumentationProject Management
Discovery:Discovery:
The hardest part of The hardest part of improvement is improvement is implementing implementing recommendations. recommendations. Many Many implementations implementations lead directly to lead directly to another another improvement improvement opportunity.opportunity.
Assess
Internal Audits (Examples)• Analytical Measurement• Corrective Actions• Equipment and Process Validation• HIPAA Compliance• Information Technology• Labeling Accuracy• Proficiency Testing• Record Retention and Archiving• Safety• SOP’s and Document Control• Specimen Trackability and Traceability• QC and Preventive Maintenance• Quality Program Effectiveness• Training and Competency
Discovery:Discovery:
Using peers from Using peers from other sections to other sections to conduct internal conduct internal audits spreads audits spreads best practices and best practices and opens lines of opens lines of communicationcommunication
1999
12
1 2 3 4 5 6 7 8 9
Result EntryProcessFailuresTotal PatientsAffected
SignificantEvents
Result EntryTrend
Weekly
CommunicateAgenda• Scheduled client visits and start-ups and
client visit reports• Compliments and successes, shared
practices• Discussion of significant issues from the
previous week• Client focus for selected clients or client
groups• Graphical displays of data trends
– Performance over time for outcomes (misplaced samples, amended reports and significant issues)
– A 10-week moving window for selected processes
– Client trends
Amended Reports
Report Delivery ProcessPost- Analytical Sample Management Process
Data Entry/Result Verification
Pre-Testing Process
Order Processing
Specimen Processing
Test Procedure Performance
Data-Analysis/Interpretation
Computer-Assisted Data Entry Process
Exception Resolution Process
Monthly
Communicate
Monthly data is reviewed in Section Monthly QA Meetings
13
Quarterly
CommunicateTotal # of Temporariliy Misplaced Specimens
by Location Found Track Exception Handling
Specimen Processing ASM Storage
Technical Section In Transit
Unknown/Not Documented Vendor Laboratory
Staging Area
Month BMonth A
Lost Specimens per Million Billed Units
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33
Week
Lost
/1 M
illio
n B
U
Specimen Processing Errors
20.3%
39.7%
53.3%
63.0%
72.2%
80.5%
88.8%94.7%
Sam
ple
Mis
labe
led
by N
ame
Clin
ical
Info
rmat
ion
Not
For
war
ded
to th
eTe
stin
g Se
ctio
n
Sam
ple
Mis
labe
led
by T
est
Req
uire
d Sa
mpl
eTe
mpe
ratu
re N
otM
aint
aine
d
Sam
ple
Mis
labe
led
by D
ate/
Tim
e
Sam
ple
Mis
labe
led
by T
ype
Spec
imen
Not
pH
'dD
urin
g Pr
oces
sing
Sam
ple
Mis
labe
led
by O
rder
Num
ber
Inco
mpl
ete
Spec
imen
Han
d-of
f
Type
Def
ect C
ount
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Annually
Communicate
Improve Care
Measure Quality
Measure Outcome
Most Effective 452 428 298 Somewhat Effective 249 267 189 Not Effective 68 67 71 Not Applicable 16 21 222
Indicator Effectiveness Counts
Number of indicators where monitoring was…
14
Communicate with Customers
Discovery:Discovery:
Transparency Transparency promotes promotes collaboration and collaboration and sharing.sharing.
Pairing the ARUP Pairing the ARUP QA report with the QA report with the client Exception client Exception report provides a report provides a clearer picture of clearer picture of quality than one quality than one or the other alone or the other alone would provide.would provide.
Emphasis on Relationships
Through excellence in laboratory testing, service, education and research, ARUP’s mission is to continually improve patient care and support the mission of the University of Utah
ARUP's vision is to be the reference laboratory of choice for community health care systems, as the most responsive source of quality information and knowledge
15
Act
• 7 Basic Quality Tools• 7 Management Quality Tools• Automation• Process Simulation• Error-proofing/Innovation• Lean• Six Sigma• Agile
Discovery:Discovery:
No single quality No single quality model or method model or method will suffice over will suffice over time to address time to address the quality needs the quality needs of a growing of a growing organization.organization.
Automation
ARUP’s automation initiative develops, implements and integrates systems, instruments and applications.
• Expert Specimen Processing • Image Management • Automated Core Laboratory testing platform• Track delivery• Automated Specimen Management • Automated Endocrinology testing platform• Shipment Tracking• Thawing and Mixing Work Cell
16
Total Quality Management
Employee Break Room ImprovementImplemented immediately• Ice machine• A promise of continued improvement tied to financial
successImplemented in 1 year• Larger vending machines with better selections• Modular tables and chairs to save spaceImplemented in 5 years• Area for personal telephone calls• Private area for nursing mothers• Separate meeting rooms• RecyclingImplemented in 10 years• Improved ambience• Cafeteria with subsidized meal options
Prim Con Labeling Error Not Caught
in Processing
Erroneous Container ID Not Caught in Prep
Prep ID error not caught in testing
Testing ID Error Not Caught at Result Entry
Patient treated inappropriately
Primary Container ID Error Not
Caught at Labeling
Primary container re-ID’dCollect labelOrder labelTrack label
Secondary containerReprinted IDHandwritten IDRemove and re-place IDPooled specimen
Processing and/or Testing Container ID type change
Name NumberSymbolPosition
Deliberative reasoning
Deliberative reasoning
Intuitive thinkingDeliberative reasoning
Intuitive thinking
Intuitive thinking
Erroneous Identification at
Collection
Erroneous/No Identification on
Primary Container
Erroneous/No Label Attached to Primary Container
Erroneous/No ID on Container Sent
to Lab
Erroneous/No ID Sent for Testing
Result Matched to Incorrect Patient
Registration
No ID on Collection Container
ID Confirmation Step Fails
Wrong Label Affixed to Correctly
Labeled Primary Container
Intuitive thinking
Intuitive thinking
Primary container labeledTransport container labeled
Col
lect
ion
Prim
ary
Con
tain
er L
abel
ing
Pro
cess
ing
Prep
arat
ion
Test
ing
Res
ult E
ntry
Rep
ortin
g
Wrong Label at Aliqouting
Wrong ID Attached to Prep
Container
Testing Container ID’d
Incorrectly
Worng ID Used To
Enter Result
UH Mislabel ratio for 2007: 1/1600 September UH mislabels in QARS: 21Client mislabels in QARS (because they weren’t caught by SP: 184
Denominator: Number of ARUP Draws…..Sept: 20638
Denominator: Number of …..Sept: 20638
Denominator: Number of ARUP Draws…..Sept: 20638
Denominator: Number of ARUP Draws…..Sept: 20638
Denominator: Number of ARUP Draws…..Sept: 20638
Secondary containerReprinted IDHandwritten IDRemove and re-place IDPooled specimen
Patient ID Not
Confirmed by Caregiver
ID Error Not Caught by Client, Physician
a/o Patient
Result Reported is for the Wrong
Patient
No Label Affixed to Primary
Container
Aliquot Not Labeled
ID Error Not Caught by Lab Personnel
Incorrect/No ID Presented to
Processor
Erroneous ID on Client Container
Erroneous/No Subsequent Label on Prim Container
Prep Container Not
Labeled
Testing Container Not ID’d
Result Reported is for the Wrong
Patient
Results reported are for the wrong
patient
Trea
tmen
tFault Tree Analysis
Identification Error Risk• Assess event risk• Assess cumulative risk
17
Causal Tree
Response to a highly complex event • The time sequence of the events was not linear. • The communication requirements were complex.• Each player was choosing downstream actions based
on incomplete upstream information
IT Communication
Failure Modes and Effects Analysis
• Revised the standard search checklist for all departments to include all possible locations for samples to “disappear” at each step in the sample delivery and storage process.
• New checklist approved and adopted October 2005.
Misplaced Samples
2.6
UCL
1.4
CL
0.2LCL
Jul-0
1S
ep-0
1N
ov-01
Jan
-02M
ar-02
May
-02
Jul-02
Sep
-02N
ov-02
Jan
-03M
ar-03
May
-03Jul
-03
Sep
-03N
ov-03
Jan-
04M
ar-0
4M
ay-0
4Ju
l-04
Sep
-04No
v-04
Jan-
05M
ar-05
May
-05Ju
l-05
Sep
-05N
ov-05
Jan-
06M
ar-06
May
-06Ju
l-06
Sep-
06N
ov-06
Jan-
07M
ar-07
May
-07Ju
l-07
Sep-
07N
ov-07
Date
2.6
UCL
1.4
CL
0.2LCL
Jul-0
1Se
p-01
Nov-
01Ja
n-02
Mar-0
2M
ay-02
Jul-02
Sep-0
2
Nov-
02Ja
n-03
Mar-0
3Ma
y-03
Jul-0
3Se
p-03
Nov-0
3Ja
n-04
Mar-
04Ma
y-04
Jul-0
4
Sep-
04No
v-04
Jan-0
5Ma
r-05
May-0
5Ju
l-05
Sep-
05No
v-05
Jan-0
6M
ar-06
May-
06Ju
l-06
Sep-0
6No
v-06
Jan-0
7Ma
r-07
May-0
7Ju
l-07
Sep-0
7No
v-07
Date
New checklist in place
18
LeanSpecial Chemistry Work Area Redesign
• 31% reduction in distance traveled per test
• Gained 100 sq-ft bench space
• Reduced overall lab size by 10%
• Gained 17% lab bench top
• Increased workstations to add 3-5 FTE
• Created space for a larger capacity piece of equipment
Process Simulation
Process simulation VSM showed that travel time and non-standard work processes lengthened processing time.
• Redesigned the work area to improve efficiency and minimize travel time.
• Standardized steps to a best practice model.• Changed to an alternate platform, eliminating labor intensive and
lengthy sample preparation steps.• Improved sensitivity with the new platform.
Meconium Sample Preparation Process
Cent ri fuge 3000
rpm 1Sonicat eUl tra Cent ri fuge 14000 rpm
0 deg CB ui ld Workli st
Sor t
Al iquotand wei gh
A dd Met hanol and cap
H o m o ge n iz e
Prepare B lanks Wai t for Bl anks
Blank
Ali quot
AddMethal oni c
HCL
Pr eDry Stor age
Load Dryer s Add M et hanol and cap
S hake
Wai t f or All S amples to
D ryAliquot
and cap
Prepare Micr otubes wit h Buf fer
Label i nst rument
t ubes
Tube w/Label
Instr ument Al iquot
Cent ri fuge 3000 rpm
LoadCent ri fuge
1
Sampl e
PreRun S tor age
M orni ng Run
Start Run
Wait for Next Load -Cent ri fuge
U nload Cent ri fuge
1
Wai ti ng for R un
B uil dWor kli st
Wai t for Next Load -Ul tr aCentr if
uge
Load Ult ra Centr if uge
U nloadU ltr a
Cent ri fuge
Met han ol& C ap
Pr ep fo rDr ye r
C VE2
C VE1
Unl oadDr yers
Post Dry St orage
Needs Mor e Dr y Tim e
N eeds Mor e Dr y Ti me
Met ha nol& Ca p
Wait for Next Load -S oni cator
LoadS oni cator
UnloadSonicator
A
A
Wait f or Next Load -C entr ifuge
2
Load C ent r ifuge
2
U nload Cent ri fuge
2
Mi cr of ugeAl iq uot
Microf uge 1400 rpm 0 deg C A nal yze
Wai t for N ext Load -Mi crof uge
LoadMi crof uge
U nloadMicr ofuge
I nst rume ntAl iq uot
Wait f or Next Load -Analyzer
LoadAnalyzer
UnloadAnal yzer
B
B
M icrot ube w/B uffer
Evening Run
Pass
19
Six Sigma
Time from Collect to In Lab
7/22
/07
8/26
/07
9/8/
07
9/17
/07
9/30
/07
10/1
5/07
11/1
/07
11/6
/07
11/1
3/07
11/1
9/07
11/2
4/07
11/2
6/07
11/2
7/07
11/2
8/07
11/3
0/07
11/3
0/07
12/1
/07
12/2
/07
12/3
/07
12/3
/07
12/4
/07
12/4
/07
12/5
/07
12/5
/07
12/6
/07
12/6
/07
12/8
/07
1/1/
08
1/2/
08
1/2/
08
1/3/
08
1/4/
08
1/6/
08
1/7/
08
1/8/
08
1/10
/08
1/11
/08
1/12
/08
1/13
/08
1/14
/08
1/14
/08
1/16
/08
Date/Time
Min
utes
Process changed to schedule additional deliveries on nights and weekends
Time from Collect to In Lab
7/22
/07
8/26
/07
9/8/
07
9/17
/07
9/30
/07
10/1
5/07
11/1
/07
11/6
/07
11/1
3/07
11/1
9/07
11/2
4/07
11/2
6/07
11/2
7/07
11/2
8/07
11/3
0/07
11/3
0/07
12/1
/07
12/2
/07
12/3
/07
12/3
/07
12/4
/07
12/4
/07
12/5
/07
12/5
/07
12/6
/07
12/6
/07
12/8
/07
1/1/
08
1/2/
08
1/2/
08
1/3/
08
1/4/
08
1/6/
08
1/7/
08
1/8/
08
1/10
/08
1/11
/08
1/12
/08
1/13
/08
1/14
/08
1/14
/08
1/16
/08
Date/Time
Min
utes
Process changed to schedule additional deliveries on nights and weekends
Minutes
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time from Collect to In Lab by Day of the Week
Minutes
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time from Collect to In Lab by Day of the Week
Time From Collect to In Lab
7/22
/07
8/25
/07
8/31
/07
9/9/
07
9/22
/07
10/4
/07
10/1
5/07
10/2
7/07
11/4
/07
11/1
1/07
11/1
5/07
11/2
0/07
11/2
4/07
11/2
5/07
11/2
6/07
11/2
7/07
11/2
9/07
11/3
0/07
11/3
0/07
11/3
0/07
12/1
/07
12/2
/07
12/3
/07
12/3
/07
12/4
/07
12/4
/07
12/5
/07
12/5
/07
12/5
/07
12/6
/07
12/6
/07
12/7
/07
Date
Min
utes
Average
Weekend Deliveries
Time From Collect to In Lab
7/22
/07
8/25
/07
8/31
/07
9/9/
07
9/22
/07
10/4
/07
10/1
5/07
10/2
7/07
11/4
/07
11/1
1/07
11/1
5/07
11/2
0/07
11/2
4/07
11/2
5/07
11/2
6/07
11/2
7/07
11/2
9/07
11/3
0/07
11/3
0/07
11/3
0/07
12/1
/07
12/2
/07
12/3
/07
12/3
/07
12/4
/07
12/4
/07
12/5
/07
12/5
/07
12/5
/07
12/6
/07
12/6
/07
12/7
/07
Date
Min
utes
Average
Weekend Deliveries
Time from Collect to In Lab by Step
37.2%
68.4%
85.3%
94.9%
STL to In Lab Order to STL Collect to Order Collect to Stamp Stamp to Order
Step
Min
utes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Time from Collect to In Lab by Step
37.2%
68.4%
85.3%
94.9%
STL to In Lab Order to STL Collect to Order Collect to Stamp Stamp to Order
Step
Min
utes
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Elapsed Time by Step (September 2007 to January 2008)
-16.5
183.5
383.5
583.5
783.5
983.5
1183.5
1383.5
1583.5
Collect to Order Order to STL STL to In Lab Collect to In Lab
Step
Min
utes
Elapsed Time by Step (September 2007 to January 2008)
-16.5
183.5
383.5
583.5
783.5
983.5
1183.5
1383.5
1583.5
Collect to Order Order to STL STL to In Lab Collect to In Lab
Step
Min
utes
Collect to Stamp10%
Stamp to Order5%
Collect to Order17%
Order to STL31%
STL to In Lab37%
Collect to Stamp10%
Stamp to Order5%
Collect to Order17%
Order to STL31%
STL to In Lab37%
Distribution of Total Time from Collect to In Lab
0
5
10
15
20
25
30
35
40
45
Minutes
Distribution of Total Time from Collect to In Lab
0
5
10
15
20
25
30
35
40
45
Minutes
Correlation Between Collection Time and In Lab Time
y = 129.79x + 500.24R2 = 0.0274
12:00:00 AM 4:48:00 AM 9:36:00 AM 2:24:00 PM 7:12:00 PM 12:00:00 AM 4:48:00 AM
Time
Min
utes
Correlation Between Collection Time and In Lab Time
y = 129.79x + 500.24R2 = 0.0274
12:00:00 AM 4:48:00 AM 9:36:00 AM 2:24:00 PM 7:12:00 PM 12:00:00 AM 4:48:00 AM
Time
Min
utes
Time from Collect to In Lab
7/22/0
7
8/22/0
7
8/27/0
79/8
/079/9
/07
9/22/0
7
9/30/0
7
10/15
/07
10/23
/07
11/1/
07
11/4/
07
11/10
/07
11/13
/07
11/16
/07
11/21
/07
11/24
/07
11/25
/07
11/26
/07
11/27
/07
11/28
/07
11/29
/07
11/30
/07
11/30
/07
11/30
/07
12/1/
07
12/1/
07
12/2/
07
12/3/
07
12/3/
07
12/4/
07
12/4/
07
12/4/
07
12/4/
07
12/5/
07
12/5/
07
12/5/
07
12/6/
07
12/6/
07
12/7/
07
12/8/
07
Date/Time
Min
utes
Time from Collect to In Lab
7/22/0
7
8/22/0
7
8/27/0
79/8
/079/9
/07
9/22/0
7
9/30/0
7
10/15
/07
10/23
/07
11/1/
07
11/4/
07
11/10
/07
11/13
/07
11/16
/07
11/21
/07
11/24
/07
11/25
/07
11/26
/07
11/27
/07
11/28
/07
11/29
/07
11/30
/07
11/30
/07
11/30
/07
12/1/
07
12/1/
07
12/2/
07
12/3/
07
12/3/
07
12/4/
07
12/4/
07
12/4/
07
12/4/
07
12/5/
07
12/5/
07
12/5/
07
12/6/
07
12/6/
07
12/7/
07
12/8/
07
Date/Time
Min
utes
Gram Stain Turn-around Time Study
One-page Project Manager•• ScopeScope•• Business ModelBusiness Model•• Objectives, Objectives,
Mission, GoalsMission, Goals•• BudgetBudget•• Policies, Policies,
Processes and Processes and ProceduresProcedures
•• Forms and Forms and TemplatesTemplates
•• Evaluation and Evaluation and Monitoring Monitoring CriteriaCriteria
•• AuditsAudits•• Risk Risk
AssessmentsAssessments•• Staff and Staff and
ResourcesResources
Department Set-up Process
20
Agile Software Development
System 2000™ Phase IIIPhase I: Replace Phase I: Replace DOSDOS--based product based product (complete)(complete)Phase II: Phase II: Accessioning in the Accessioning in the field (complete)field (complete)Phase III: PrePhase III: Pre--accessioning in the accessioning in the field for interface field for interface clientsclients
Three sprints Three sprints completedcompleted
Phase IV: WebPhase IV: Web--based System 2000 based System 2000
e-Solutions
Laboratory test selection support tool:• lab tests categorized into disease-
related topics• clinical background information, test
ordering suggestions, and concise diagnostic advice
• direct links to relevant references • algorithms to support clinical decision-
making • available in both Web and PDA
formats
ARUP Consult™
21
Quality Plan
Quality Systems• Organization• Staff & Resources• Equipment & Supplies• Purchasing & Inventory• Contract Management• Product Development• Process Control• Documents & Records• Information Management• Occurrence Management• Assessments & Compliance• Process Improvement• Service and Satisfaction• Facilities and Safety
Discovery:Discovery:
Most organizations Most organizations operate from an operate from an internalized Quality internalized Quality Plan. That was the Plan. That was the case with ARUP. case with ARUP. Putting the Plan in Putting the Plan in writing wasnwriting wasn’’t so t so daunting as we daunting as we imagined.imagined.
2004
ARUP’s Five Pillars• To Provide Excellent Patient Care by
Supporting Clients• To Create a Good Working Environment• To Do the Right Thing• To Improve Continuously• To Act Responsibly
Emphasis on the Relationship Between Customers and Employees
2005
22
Emphasis on Context
Basic principlesSimple rules; cultural normsExecutives as role models
Holistic qualityEmbracing who we arePlanning for who we will be
Collegial relationshipsPatients, practitioners, suppliers and the community as
partnersOrganizational learning
Mistakes as opportunitiesWorkforce open to growth
Empowered TeamsCharacterized by accountabilityDriven by front line champions
“Management systems that conform to a rigid and complex “quality” blueprint in the hope of rubber-stamping success will fail.
The successful strategy is one that creates a unique culture of quality that has the ingenuity and intelligence to continually evolve.”
23
Evolution
Needs of the organization evolved beyond those provided by the early organizational structure.
• Continuity• Agility• Responsiveness• Ready and dedicated resources• Feasibility analyses• Tracking• Implementation• Communication
Discovery:Discovery:
Quality is a Quality is a systems property systems property in that it is:in that it is:
•• EvolutionaryEvolutionary
•• AdaptableAdaptable
•• EmbeddedEmbedded
•• Emergent and Emergent and
•• Inherently Inherently orderedordered
2009
Executive Operations
Council on Improvement and Integration
Project Management
Office
Qualityand
Compliance
Institutefor
Learning
HumanResources
EngineeringInformation Technology
Technical
Council on Improvement and Integration
Representation from…
2009
24
2009
Improvement Activity Target
Wedges are Wedges are strategic strategic prioritiespriorities
Rings are stages in Rings are stages in the improvement the improvement processprocess
Tags are activitiesTags are activities•• Name and ID Name and ID
NumberNumber•• DescriptionDescription•• Contact informationContact information•• ColorColor--coded prioritycoded priority•• BeneficiaryBeneficiary
2009
25
Communication – the 10th Step
With employeesWith the end user—patients, clients,
caregivers, payorsWith vendors and suppliersWith peers
About successesAbout challengesAbout discoveries
Even about heartbreaks
Discovery:Discovery:
Communication is Communication is the thread that the thread that ties all the ties all the players together; players together; it ties quality to it ties quality to culture and culture and primes the primes the organization for organization for successsuccess
And finally, back to context….
“Usually improvement cannot be accomplished or sustained without giving the messy business of social interactions, communication, power and organizational context its due.”
Discovery:Discovery:
Any improvement Any improvement strategy, no strategy, no matter how matter how brilliant, has little brilliant, has little chance of chance of success if it success if it operates outside operates outside the context of the context of our belief about our belief about ourselves and ourselves and our work.our work.
““Priority is a Priority is a function of function of context.context.””
--Stephen R. CoveyStephen R. Covey Carr, Susan. “Evidence and Criteria; “ Patient Safety and Quality Health Care. September/October 2008