Mercedes Gutiérrez

Achieving continuous improvement in laboratory organization through performance measurements: a seven-year experience

Abstract Background: Laboratory performance can be measured using a set of model key performance indicators (KPIs). The design and implementation of KPIs are important issues. KPI results from 7 years are reported and their implementation, monitoring, objectives, interventions, result reporting and delivery are analyzed. Methods: The KPIs of the entire laboratory process were obtained using Laboratory Information System (LIS) registers. These were collected automatically using a data warehouse application, spreadsheets and external quality program reports. Customer satisfaction was assessed using surveys. Nine model laboratory KPIs were proposed and measured. Results: The results of some examples of KPIs used in our laboratory are reported. Their corrective measurements or the implementation of objectives led to improvement in the associated KPIs results. Conclusions: Measurement of laboratory performance using KPIs and a data warehouse application that continuously collects registers and calculates KPIs confirmed the reliability of indicators, indicator acceptability and usability for users, and continuous process improvement. Clin Chem Lab Med 2010;48:57–61.

Diagnostic accuracy of icteric index to detect abnormal total bilirubin values

Aims Total bilirubin tests are individually inexpensive but can result in huge costs to healthcare systems worldwide, because they are very commonly requested. The main objective of this study was to evaluate the diagnostic accuracy of the icteric index, a test with zero reagent cost, as a preliminary biomarker to decide when total bilirubin measurement is necessary. Methods We retrospectively reviewed all the requested total bilirubin values and their corresponding icteric index results in a 2-year period (2010–11). Receiver operating characteristic (ROC) curve analysis was used to determine the optimal icteric index cut-off value to discriminate between normal and abnormal bilirubin values (>20.5 μmol/l; >1.2 mg/dl). Results The study included total bilirubin and icteric index results of 100 207 patients. The ROC curve analysis suggested 34.2 μmol/l (2 mg/dl) as the optimal icteric index threshold to identify abnormal bilirubin values. The area under the curve was 0.981. Regardless of the patient population studied (primary care, hospital and different individual hospital departments), sensitivity was greater than 94% and specificity was over 98%. Likelihood ratio values provided strong evidence that total bilirubin is less than 20.5 μmol/l (<1.2 mg/dl) when the icteric index is less than 34.2 μmol/l (<2 mg/dl). Conclusions This study supports the use of the icteric index to identify patients with abnormal total bilirubin values. Considerable economic savings can be achieved if this strategy is applied on a clinical daily basis. Its implementation and report should be discussed and planned by laboratory professionals together with requesting physicians.

Ten years of preanalytical monitoring and control: Synthetic Balanced Score Card Indicator.

Introduction Preanalytical control and monitoring continue to be an important issue for clinical laboratory professionals. The aim of the study was to evaluate a monitoring system of preanalytical errors regarding not suitable samples for analysis, based on different indicators; to compare such indicators in different phlebotomy centres; and finally to evaluate a single synthetic preanalytical indicator that may be included in the balanced scorecard management system (BSC). Materials and methods We collected individual and global preanalytical errors in haematology, coagulation, chemistry, and urine samples analysis. We also analyzed a synthetic indicator that represents the sum of all types of preanalytical errors, expressed in a sigma level. We studied the evolution of those indicators over time and compared indicator results by way of the comparison of proportions and Chi-square. Results There was a decrease in the number of errors along the years (P < 0.001). This pattern was confirmed in primary care patients, inpatients and outpatients. In blood samples, fewer errors occurred in outpatients, followed by inpatients. Conclusion We present a practical and effective methodology to monitor unsuitable sample preanalytical errors. The synthetic indicator results summarize overall preanalytical sample errors, and can be used as part of BSC management system.

Two Minutes of Monthly Monitoring Can Ensure Quality Laboratory Service Every Day of the Year

Objective: The aim of this study was to show how opportunities for improving laboratory performance can be identified by monitoring indicators. The testing process was also monitored using indicators to evaluate the impact of improvement measures on laboratory service and customer satisfaction. Methods: The process, which began with the delivery of samples to the laboratory and ended with a laboratory report, was evaluated over an 80-month study. The laboratory process was monitored before and after improvement measures were introduced using a series of indicators as transport, timely verified blood glucose requests, workload, and customer satisfaction indicators. Three improvement measures were implemented: redesign of the courier route, incorporation of automated sample distribution technology, and hiring another courier. Results: All of the improvement measures implemented led to a favorable evolution of the evaluated indicator. Conclusions: The use of simple strategies improved the efficacy of this laboratory’s testing process and customer satisfaction. * PCCs : primary care centers TAT : turnaround time LIS : laboratory information system OLAP : online analytical processing ANOVA : variance analysis

Three years of preanalytical errors: Quality specifications and improvement through implementation of statistical process control

Abstract Background: The objectives of this research were to show the most frequent preanalytical sample errors from two distinct patient populations and blood-drawing personnel, to calculate preanalytical quality specifications, and to demonstrate an improvement strategy for patients whose samples have been drawn in the primary health care center by means of a monthly preanalytical quality control report based on statistical process control (SPC). Material and methods: We collected preanalytical errors from the tests requested for hematology, coagulation, chemistry, and urine samples in both populations. To monitor an improvement strategy, we designed a set of indicators. The indicator results for 35 months were entered into the statistical software application, where they were statistically analyzed. The preanalytical quality specifications were calculated using the SPC control charts. The intervention consisted of the sending of a monthly preanalytical quality report to a pilot Decentralized Phlebotomy Center (DPC) and setting up a direct communication channel between the laboratory and the DPC. Results: Fewer errors were observed when the sample drawing was carried out by the laboratory personnel, showing distinct preanalytical quality specifications. Improvements were seen in the DPC after four months of the improvement strategy. Conclusions: We show a practical and effective methodology for the identification, monitoring, and reduction of preanalytical errors using the technology employed in daily total testing laboratory process.

Should we customise critical value procedure according to patient origin and laboratory turnaround time

Introduction Our routine laboratory critical value notification procedure is based on a short list of six fundamental critical values. The report system for our Stat laboratory is not based on this ‘short list’; instead, critical values are always reported according to the patient clinical context and the previous laboratory results. The aim of our work is to show how a critical value notification procedure based on a rigid list of values and thresholds can result in completely different results depending on whether the tests are requested in a stat or a routine manner. Material and methods We reviewed the number of critical value notifications based on the short list for the routine laboratory. For the stat laboratory, we studied the number of real notifications based on the pathologist validation of the individualised situation of the patient and calculated the number of notifications that would have been reported if the routine short list would have been used instead. Results The number of critical values that would have been reported if using the routine short list in stat laboratory was high when compared with the number of critical values that were really reported. Conclusions Using a rigid list of laboratory values to notify critical values resulted in completely different results depending on whether the tests were requested in stat or routine. Reporting only really unexpected values through an individual custom-made reporting procedure may avoid the wasting of time and resources and raising false alarms among referring physicians and patients.

Customising turnaround time indicators to requesting clinician: a 10-year study through balanced scorecard indicators

Aim The purpose of this study is, first to present a 10-year monitoring of postanalytical turnaround time (TAT) adapted to different clinicians and patient situations, second to evaluate and analyse the indicators results during that period of time, and finally to show a synthetic appropriate indicator to be included in the balanced scorecard management system. Methods TAT indicator for routine samples was devised as the percentage of certain key tests that were verified before a specific time on the phlebotomy day. A weighted mean synthetic indicator was also designed. They were calculated for inpatients at 15:00 and 12:00 and for primary care patients only at 15:00. The troponin TAT of emergency department patients, calculated as the difference between the troponin verification and registration time, was selected as the stat laboratory TAT indicator. Results The routine and stat TAT improved along the 10-year study period. The synthetic indicator showed the same trend. Conclusions The implementation of systematic and continuous monitoring over years, promoted a continuous improvement in TAT which will probably benefit patient outcome and safety.

Las perspectivas financiera y de aprendizaje y crecimiento del cuadro de mando integral en las instituciones públicas: aplicación en el laboratorio clínico

El cuadro de mando integral traduce la visión de una orgaización en un conjunto de objetivos y medidas cuantificables, mplementando la estrategia con ayuda de la métrica. Mide cuaro perspectivas: cliente, proceso interno, aprendizaje/crecimiento financiera1,2; la última está claramente influida por las primeas y la penúltima otorga al profesional el valor de motor de la rganización. Es un instrumento clave en la gestión integral de un aboratorio clínico. El objetivo del estudio es mostrar cómo cuantificar la mejora n la utilización de Intranet y la gestión del material sanitario de n laboratorio clínico, enmarcándolo en las perspectivas de aprenizaje/crecimiento y financiera del cuadro de mando integral. El laboratorio del Hospital Universitario de San Juan (Alicante) tiende a 233.075 habitantes y dispone de Intranet como instruento de comunicación interna, pues informa acerca del sistema e calidad3 y presenta indicadores mensuales del cuadro de mando ntegral, para así conseguir la mejora continua, los objetivos estraégicos y la visión. Se mide su utilización mediante el número de isitas a la Intranet y las incidencias de averías graves de autoanaizadores registradas en ella (que se comparan con las incidencias eales del servicio técnico). Por otro lado, se mide la gestión del aterial sanitario a través del número de incidencias leves de stock e reactivo (se toma la última caja de reactivo disponible en el almaén) registradas en Intranet, y graves (falta del reactivo buscado), n 2009 y 2010. El indicador de rendimiento de material sanitario (razón número e pruebas informadas/compradas) en la Unidad de Bioquímica utomatizada (651.866 y 659.089 pruebas en 2009 y 2010, resectivamente) se calculó tras establecer medidas correctoras externalización, cambio de tecnología, procesamiento semanal, isminución de controles o calibraciones). Las fuentes de regisro procedían del Sistema de Información del Laboratorio y uministros. Los resultados muestran que el número de visitas a la Intranet umentó, y el resto de los indicadores mejoraron (tabla 1). La consecución de objetivos de aprendizaje/crecimiento es ifícilmente cuantificable, pero el indicador relacionado con la utiización de la Intranet puede ser útil. La Intranet es un sistema vivo, onde debe anotarse diariamente cualquier incidencia relacionada on averías y stock de reactivos que, aunque se trata de indicadoes de soporte, están claramente relacionados con la perspectiva nanciera. Mejoró la utilización de la Intranet, y también el stock, ues el aumento de incidencias leves es positivo ya que refleja poco tock inmovilizado, y el aumento de incidencias graves es negativo orque estas incidencias impiden trabajar.

Stat laboratory timeliness management according to clinician needs.

Stat laboratories are under pressure to supply information as quickly as possible for the diagnosis and treatment of disease. In this context, laboratory turnaround time (TAT) is considered an indicator of stat laboratory efficiency (1). However, over 80% of laboratories receive complaints about TAT (2). Assessment of customer satisfaction is an important component of any quality assurance program (3). In the stat laboratory, objective information on clinician satisfaction, perceptions and TAT needs can offer stat laboratories guidance on how to improve performance in meeting TAT according to each setting (4). The stat laboratory is an independent laboratory located in the central University Hospital Laboratory in a health district of Alicante, Spain. The laboratory serves a population of 234,403 and processes requests for in-patients and emergency department (ED) patients. In 2009, stat laboratory workload was 620,511 tests (22.83% of the total workload). The stat laboratory is staffed by 10 technicians who process, verify, and report every hematology, coagulation, blood gas, urinalysis and chemistry test. Technicians are organized into three shifts (3, 2 and 1 technician in the morning, afternoon and night shift, respectively). An ED physician satisfaction survey was conducted in November 2007 to assess satisfaction with overall laboratory service in relation to three specific issues: reliability of test results, staff accessibility and TAT. Evaluations were rated on a scale of 1–5 as follows: 1. poor; 2. below average; 3. average; 4. good; and 5. excellent. Physicians were also

Retrospective Study of Critical Values: Agreement and Improvement

Background: Accreditation agencies now require clinical laboratories to list critical limits, formulate notification procedures, document critical results, and notify clinicians. The objective of this study has been to perform a retrospective review of our critical value notification procedure and improve it by reaching a consensus with our clinicians. Methods: The main outcome measures were the number of critical values (CVs) reported in our laboratory and the number and rate of CVs if we had applied the universal critical limit list used by the majority and the supercritical limit list. Results: Fifty-four CVs were reported with 660 theoretical CVs and 120 supercritical CVs. The list CV and notification procedure was improved according to expert opinion. Conclusion: Every laboratory should have at its disposal a procedure to notify critical results. A consensus should be reached with clinicians to establish a specific list of critical limits according to the type of patient and the timeliness of laboratory tests.