september 2009 dashboard

Clinical PathologyQuality Dashboard

September 2009

Clinical Pathology Quality Dashboard

Inpatient Phlebotomy First AM Blood Draws University Hospital

0%

20%

40%

60%

80%

100%

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

2008 2009

8am

9am

10am

Drawn by

Mott Hospital

0%

20%

40%

60%

80%

100%


2008 2009

8am

9am

10am

Drawn by


Inpatient Phlebotomy First AM Blood Test Results:

PT/PTT, CBCP, and Comprehensive Panel

University Hospital

0%

20%

40%

60%

80%

100%


2008 2009

0

100

200

300

400

Avg

Daily V

olu

me

8am

9am

10am

Results by

Mott Hospital

0%

20%

40%

60%

80%

100%


2008 2009

0

2

4

6

8

10

12

Av

g D

ail

y V

olu

me

8am

9am

10am

Results by

Inpatient Phlebotomy Draws


19,773

26,062

19,75920,459

19,598 19,795

21,992 21,71420,986

21,651 22,07322,675

0

5,000

10,000

15,000

20,000

25,000

30,000

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

2008 2009


Turnaround Times

CSF Gram StainVolume and Turnaround Time

0

20

40

60

80

100

120

140

160


2008 2009

Mo

nth

ly V

olu

me

> 1 hour

30 min-1 hour

<30 minutes

TAT

Emergency Department Cardiac MarkerVolume and Turnaround Time

0

200

400

600

800

1000

1200

1400


2008 2009

Mo

nth

ly V

olu

me

> 2 hours

1-2 hours

<1 hour

TAT

Point of Care service began


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

October 2008 - August 2009

0:00

0:14

0:28

0:43

0:57

1:12

Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09

Tu

rnaro

un

d T

ime i

n M

inu

tes


Molecular Diagnostics Laboratory

Specimens Received and Turnaround TimeJanuary 2002 - August 2009

0

200

400

600

800

1000

1200

1400

January2002

July 2002 January2003







July 2009

Month/Year

Spe

cim

ens

Rec

eive

d pe

r M

onth

0

1

2

3

4

5

6

7

8

9

10

TAT

(day

s)# Specimens TAT Linear (# Specimens) Linear (TAT)


Chemistry In-Lab Turnaround Times

Sample Turn-Around Time

0

5

10

15

20

25

30

35

Aug 07 - Aug 09

Per

cent

age

Routine >60 min >45 Inpt STAT >45 Outpt STAT

UMHS Blood Product Utilization


Crossmatch/Transfusion Ratio

1.3

1.4

1.5

1.6

1.7

1.8

1.9

Sep Oct Nov Dec J an Feb Mar Apr May J un J ul Aug

2008 2009

Threshold

Wasted RBC

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%


2008 2009

Threshold

Wasted Platelets

0%

1%

2%

3%

4%

5%


2008 2009

Threshold

Wasted Plasma

0%

1%

2%

3%

4%

5%

6%


2008 2009

Threshold

Wasted Cryoprecipitate

0%

5%

10%

15%

20%

25%

30%


2008 2009

Threshold

Blood Product Utilization

0

1000

2000

3000

4000

5000

6000

7000

8000


2008 2009

0

1000

2000

3000

4000

5000

6000

7000

8000

Pa

tie

nt

Po

pu

lati

on

Random Platelets

Allo RBC Units

Plasma Units

Cryo Units

Partial Units

SD Platelets

AdjustedDischargesUnits Used


CAP Proficiency Testing

4th Quarter FY 2009

Clinical Pathology 91 = Number of Challenges 92% = Satisfactory Results

Anatomic Pathology 0 = Number of Challenges N/A = Satisfactory Results

Department Total 91 = Number of Challenges 92% = Satisfactory Results

Clinical Pathology Scores

92

1009999.597

1009998

0

100

200

300

400

500

600

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

Nu

mb

er o

f C

hal

len

ges

50

60

70

80

90

100

Per

cen

t S

atis

fact

ory

FY2008 FY2009


CP Financial Measures

Monthly Amount Paid to Southeastern Michigan American Red Cross

1,000,000

1,050,000

1,100,000

1,150,000

1,200,000

1,250,000

1,300,000

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

2008 2009

Do

llars

Clinical Path Expense per Test*

$4

$5

$6

$7

$8

$9

$10

* excludes Blood Bank and Phlebotomy

Clinical Path Tests per FTE and Total Tests By Month

1,000

1,200

1,400

1,600

1,800

2,000

Tes

t p

er F

TE

275,000

300,000

325,000

350,000

375,000

400,000

425,000

To

tal

Tes

ts

Tests per FTE Total Tests

• Lean Process Improvements – Many!

• Board access H1N1 influenza testing program


Clinical Laboratory Operations Initiatives

• Design and implementation of new requisition for complex, multiple-site, multiple-times Interventional Radiology blood samples – by Chemistry

• Outstanding improvements in ED turnaround times for troponins, CBCs, basic panels, and urine analysis - by Chemistry


Clinical Laboratory Service Enhancements

• Congratulations and Thank You to the entire Blood Bank/Transfusion Medicine group for a very successful rigorous FDA on-site inspection with “no observations”.

• Kudos to the Microbiology Laboratory (especially Marc Deroo and Jeana Vandorp) for “above and beyond” support of Pediatrics Critical Care Medicine patient in early September.

• Kudos to Duane Newton, Ph.D. (Director, Microbiology Laboratory) for his tireless and expert support of UMHS preparation for H1N1 influenza.

• Kudos to Steven Mandell, M.D. for his leadership in helping to develop a “Better Specimen Box”. Dr. Mandell organized a team of 25 people – including nurses, managers, phlebotomists, pathologists, housekeepers, and others – to create what is now officially called a “unit-based specimen drop box”.


Kudos

september 2009 dashboard

Health & Medicine