how to build the quality improvement mindset and sustained ... · 1 how to build the quality...

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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


What gets What gets measured,measured,

Improves!Improves!

Identify Indicators


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.


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


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


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



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

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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.


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


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.

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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


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


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

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5/07

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7/07

11/6

/07

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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

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12/7

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1/1/

08

1/2/

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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

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Sof

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e

Pre-

Test

ing

Spe

cim

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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


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


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

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ded

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est

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ate/

Tim

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ype

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imen

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Num

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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


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


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




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-

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ar-0

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ay-0

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Sep

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Jan-

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ar-05

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ar-06

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Sep-

06N

ov-06

Jan-

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ar-07

May

-07Ju

l-07

Sep-

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ov-07

Date

2.6

UCL

1.4

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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

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Jul-0

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Mar-

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Jul-0

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Sep-

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May-

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Jan-0

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May-0

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Sep-0

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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

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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

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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

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1/1/

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1/16

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Date/Time

Min

utes

Process changed to schedule additional deliveries on nights and weekends


7/22

/07

8/26

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9/8/

07

9/17

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9/30

/07

10/1

5/07

11/1

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11/6

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11/1

3/07

11/1

9/07

11/2

4/07

11/2

6/07

11/2

7/07

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11/3

0/07

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0/07

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1/1/

08

1/2/

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1/2/

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1/3/

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1/4/

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1/6/

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1/7/

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1/8/

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1/11

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1/12

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1/13

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1/14

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1/14

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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

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12/5

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12/5

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/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


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


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


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


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


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.”


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