decreasing turnaround time in getting test results to patients. performance improvement leadership...
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Decreasing turnaround time in getting test results to patients.
Performance Improvement Leadership Develop ProgramUniversity of Missouri – Columbia
2/18/2011
Team Members
• Jacqueline Ruplinger, MD (Blue Team GM)• Cynthia Twenter, LPN (Blue Team GM)• Rosie Powell, PSR (Blue Team GM)
• Anne Fitzsimmons, MD (Sponsor)• Tim Hogan, RRT, PhD (Advisor)• Carol Nierling, MS, RN (Advisor)
Focus Area
• Patients do not get their test results within the 5 day recommendation put forth by University Physicians
• Getting test results to patients is done in a variety of ways and requires a lot of provider and staff time and resources
Aim Statement
Improve the notification process by which patients on blue team receive their test results. We want to decrease the time from the result getting to the provider’s inbox to the patient from >5days to <5days by 90% within 60days of implementation of Healthe and other outlined standardized/streamlined processes.
Relationship to Strategic Goals of the Institution & our Department
UP directive -the patient should receive test results within 5d 1-27-10
FM Departmental Policy - 4-7-10
•Ordering provider will review all results both normal and abnormal•Normal and abnormal results will be communicated to the patient•Approved methods of communication were outlined: clinic visit, PC generated test result letter, lab card with electronic documentation that it was done and sent, phone call-either by provider or nurse*(guidelines as to when a nurse should call outlined)
Project Timeline
08/27/2010 02/18/2011
09/01/2010 10/01/2010 11/01/2010 12/01/2010 01/01/2011 02/01/2011
11/01/2010 - 11/30/2010Collection of pre-intervention data:
· flowchart workflow processes· Time to patient receives results post-visit· Order à Lab in PC à Endorsed à Mail Results
10/01/2010 - 12/23/2010Efforts to get Healthe in GM Blue Team clinic
1. Started enrolling patients
for Healthe
2. standardization
of letters to
patient
02/07/2011 - 02/18/2011Start post-intervention data collection
01/18/2011 - 02/18/2011Initiate Interventions
08/28/2010Start of PILDP
09/17/2010Develop AIM Statement
12/20/2010Finalize AIM Statement
Process Flow Chart for a Provider• Provider steps to
generate a lab letter to a patient
• 21 clicks• 1 min 43 secs
• With Healthe
• 6 clicks• 40 secs
• With Healthe
• 6 clicks• 40 secs
StartStart
Result is in providers inbox
in PC
Result is in providers inbox
in PC
Provider DC on pt name
SC on OK
SC on name & document viewSC on name &
document viewSC on add documentSC on add document
SC on precompleted
SC on precompleted
DC on test results letterDC on test
results letter
SC on show structure
SC on show structure
SC on last 200 results
SC on last 200 results
Click to include labs
Click to include labs
Click on “other” in additonal infoClick on “other” in additonal info
Write note to pt SC on OKSC on OK
SC on macro to include
cholesterol info
SC on macro to include
cholesterol info
SC on sign
Hit “L” to put letter in note
type
Hit “L” to put letter in note
type
SC on request endorser
SC on request endorser
SC in comment & type “send”
SC in comment & type “send”
SC on OKSC on OK
SC to get out of pt chart
SC to get out of pt chart
SC back on results to get
back to rest of results
End
Process Flowchart for a NurseStart
Receive results from Dr to send pap letter to pt
DC to open & read ressult
Open chart to document viewing
SC add +SC on letters DC pt test results
DC on blue teamSC on dateSC on date box okSC salutation
choiceSC opening statement
In cytology clickon the results you
need
SC closing statement
SC sincerely choice
SC on provider insert
Type Dr name SC ok SC sign
Type L in sign line (type box)
SC okSC menu allSC on clinic notesSC updateDC on
communication
Type Dr nameSC on comments
boxType letter doneSC OK
SC forword person again
SC on down arrow for addition
forword
SC on review SC in to box Type my nameSC on comment
boxType please mail SC Ok
SC X box to closechart
In comment box on test results SC
Type letter done and in the mail.
SC ok End SC update
DC on letterSC on letter you
just didSC for word SC down arrow for
additional for wordSC sign SC in the to box
• Nurse sends “nl” pap letter for provider
• 43 clicks• 4 min
Standardizing “nl” papletters saves steps
Process Flow Chart for a PSR
DC pt’s name in powerchart
Start
SC Programs button
SC MS Office
SC Word to open
SC Powerchart
SC and drag to copy letter
RT Click for submenu in Microsoft Word
SC Paste button on submenu to paste letter
SC by address and drag to copy
SC on mailing button in title bar
SC envelopes on menu bar
SC envelopes on Menu Bar
SC Add to document button in the envelopes and labels
dialogue box
SC Office button on title bar
SC Office button
SC Print button
SC Okay button
SC X in print dialogue box
SC X on title bar to close letter and envelope
SC No to save document
RT Click in powerchart
SC on modify to type addendum
Type printed and mailed letter under addendum
SC on sign button
SC X to close pt’s chart
End
• Process for mailing a letter
• 25 clicks• 4-5 min
Utilizing see-through envelopes saves steps and eliminates errors
Fishbone Diagram
Decrease the time it takes for pts to get
their test results
Holidays &Weekends
Patient
Staff
Providers
Lab
Communication
Delays results
Letter on FridaysAuto delay
Variation in Staffing
inconsistency in provider Work pattern
Proxy (inbox)
Time involvement
Multi steps
Interruptions
Letters arelow on priority list
Differences in providers(No standerdization)
Phone calls Triage
Med refills
Specimen not labeled
Inadequate specimen
Missed lab order
Results go towrong provider
Lost specimen
Long turn around time
Send off labs
Not scanned into power cahrt
Phone
Length of time to getout of system and deliverd
Letter
Not sent
Wrong pt
Does not Have PC
Wrong address
No workingphone
No working phone
Not clear aboutexpectations
DNKA
Lab
F/U appt
TimeConstraints
Not getting Results
Abnormal resultsNeed more work
Process is timeconsuming
Not educated in EMR shortcuts
Inconsistency amongproviders in how
they get results out
PSR Letter Nurse calls
Provider calls F/U appts
Nurse calls
Doc callsMail pickup 1x/d
Stakeholders
• Patients• Providers-residents and attending physicians• Staff-phone nurses, PSRs & floor nurses• Care coordinator-Joan Asbee• Lab/radiology• Cerner staff
Baseline data
Baseline Data cont.
• One providers experience to endorse and make lab letters on 14 patients-37min to do 14 letters-238 clicks
(Note this does not include the time it takes for the nurse or PSR to process the letter and mail the letter, this would add an additional 63 min)
Interventions Considered
• Electronic Approach-Healthe• Phone approach-standardize times when
providers would ask the nurse to call patients*• Standardization of workflow processes-letters,
envelopes• Request input from patients how they would
like to hear about their test results*already outlined by our department April 2010
Measurements
• Time it took for patients to get test results • Time it takes to process letters to patients• Time for the letter to get through the mail• Patients perception pre and post intervention
Outcomes to Date
Patient FeedbackN=36
Workflow Change
Anticipated ROI/ Benefits Realized
• Using the electronic approach to communicate test results to pts-541 physician hrs/yr in time saved-867 staff hours/yr saved-$5,200 saved in postage
• Workflow processes streamlined• Secondary benefits of Healthe• Eliminated wrong letter to wrong ptAll increases pt, staff and provider satisfactionAll increases pt, staff and provider satisfaction
Lessons Learned
• It took much longer to get Healthe going • Pts did not register as quickly as we anticipated• When the “create” button lights up in “results to
endorse” that does not mean the pt has registered• FU after an intervention is very important• Improvement work takes people with different
backgrounds and skill sets• There are a lot of tools available and IT’s FUN!
Future Steps
• Continue the momentum in enrolling pts • Focus on the FU surveys before rolling out to the
rest of Green Meadows• Share our findings/experiences at team mtgs• Present our findings at a Colwill seminar• Cont. to look at all the test result processes• Integrate PDSA in our daily routine-meet monthly
Summary
• By implementation of an electronic way of communicating results to patients greatly reduced turnaround time and did not take more provider or staff time
• Standardizing how results get to patients and creating form letters & utilizing see-through envelopes also decreased waiting times
Summary
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Questions?