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ED Lab Turnaround
Sponsor: Robert Fortney / Ken Hedley
Project Leader: Mark Schumacher
ED
ED Lab
Lab Turnaround
Turnaround –– Rapid
Rapid Improvement
Improvement Workshop
Workshop Project
Project
Overview
• Linkage to BPE/BP/Finance: Deliver care that is timely and convenient
Process Owners: Stephanie Musolf / Erin Omori
ED Lab Turnaround - Define
ED Lab Turnaround – Measure/Analyze
The ED was experiencing extreme lab turnaround delays
Process mapping identified that variability in the front end ordering process was
causing the extreme delays
• Problem Statement: Variability in the current ED lab ordering process creates significant delays in obtaining
results. In May 2009, the median turnaround for general lab orders was 74 minutes and the upper quartile was
111 minutes.
High Level ED Lab Process
ED Lab Order Process
•
• System Capabilities/Deliverables: Redesigned ED lab ordering process capable of achieving stated goals
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• Resources Required: ED leadership and staff, Lab leadership and staff, ED Attendings and Residents, IS staff
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Key Metric(s):
Outcome:
• Median ED Lab Turnaround
• Upper Quartile ED Lab Turnaround
Process:
• # Ordering errors
Nurse
Nurse
• Scope: ED and ED Mezzanine lab ordering, collection, labeling and sending processes through result in
FirstNet. Scope does NOT include in-lab processing.
Yes
Labs drawn
RN
assesses
patient
RN enters
draw/holds
in FirstNet
Draw and
holds?
Labels applied to tubes
Specimens sent to lab
Specimens received in lab
Patient care issues
Patient satisfaction issues
ED throughput delays
Staff frustration in the ED and Lab
Variability created
confusion,
duplication, delays
and blame
RN delivers
specimen to
ED Lab Tech
No
MD
assesses
patient
MD enters
lab orders
in FirstNet
Add on
orders?
ED Lab Tech
reconciles
specimen with
SunQuest Order
Yes
Specimens placed on the line
Lab tests run [NOT IN SCOPE]
RN applies
generic
labels
RN draws
labs
No
Physician
Physician
• Goal/Benefit: Improve median and upper quartile lab turnaround times by 25%.
Orders entered into FirstNet
ED patients were occasionally waiting
more than 6 hours for a critical lab
result
The median turnaround time for
general lab orders was 74 minutes
The upper quartile (75th percentile) for
general lab orders was 111 minutes
Lab turnaround delays created…
EDLab
LabTech
Tech
ED
•
Yes
LabTech
Tech
Lab
Executive Sponsor: Gary Fennessy
Lab Tech
receives
add-on req
Specimen
in Lab?
No
Lab Tech enters
new orders in
SunQuest
ED Lab Tech
prints /applies
SunQuest
labels
Lab Tech applies
new SunQuest
labels
ED Lab Tech
tubes
specimens to
lab
Lab Tech places
specimen with
label on the line
Lab Tech calls
ED to find
missing specimen
Results in FirstNet
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Executive Sponsor: Gary Fennessy
Sponsor: Robert Fortney / Ken Hedley
Clinical Sponsor: Mike Schmidt
Process Owner: Stephanie Musolf / Erin Omori
Improvement Leader: Mark Schumacher
ED Lab Turnaround – Measure/Analyze
ED Lab Turnaround – Improve
The front-end process variability caused two key process errors
The team held a single rapid improvement workshop to design the bulk of the
new ED lab ordering process
•
Two key process errors / delay drivers:
•
– Error #1: An add-on order entered in FirstNet without a
corresponding specimen in the lab
Caused
extreme
delays!
•
The team form formed a set of 8 solution requirements
•
ED Lab Solution Requirements
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Future Process Requirement Criteria
1
One simple, intuitive agreed upon process with minimal variability
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Lab staff supporting the ED are located in CSR rather than the ED
3
All specimens are labeled at the bedside with “line-ready” labels
4
Patients are stuck once
5
Time from order entry to result in FirstNet consistently meets a expectations
6
Process allows for MD or RN to assess patient first
7
Process allows for MDs to order without confirming specimen location
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Process specifies a clear and easy to follow real-time issue resolution process
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Process Changes
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Rapid Improvement Session
– 3.5 hour session
– ED Nursing, ED MDs, Laboratory, IS
– 18 total participants
– Error #2: A stat order entered in FirstNet without a corresponding
specimen sent to the lab
#
ED Lab Turnaround – Improve
– RNs use the rainbow order set
– MDs use the MD rainbow order set
– Repeat tests ordered via the ED Re-draw order set
The designed lab ordering process flow…
– Met 100% of the solution requirements
– Resolved 90% of the issues identified in the session
– Reduced process variability by requiring 67% fewer decision points; 0
decision points by ED physicians and nurses
– Improved process speed by removing 2 steps (10% reduction in steps)
– Saved resources by removing the ED-based Lab Tech role from the
process
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All Lab staff work from Central Specimen Receiving
Issue resolution paging process reduces phones calls and
delays
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ED Lab Turnaround - Results
ED Lab Turnaround – The Team
The process changes reduced overall ED lab turnaround time by 23%
Thank you to everyone that helped make the
ED Lab Turnaround project a success!
ED Lab Turnaround - Results
The process changes addressed the extreme delays caused by Error #2
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RNs enter actual or draw and hold orders for all patients
MDs order all labs via one standard method
All lab draws are labeled and line-ready at the bedside
All clinicians use new lab order sets
Add-on Test Turnaround Time (Order to Result)
140
Time (minutes)
Corresponds to Error #1
Add-on test turnaround times
experienced no meaningful
change
STAT Test Turnaround Time (Order to Result)
120
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100
80
60
40
May-09
Jun-09
Median
STAT Test Turnaround Time (Order to Result)
Time (minutes)
140
120
100
80
60
40
May-09
Jun-09
Jul-09
Median
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Aug-09
Upper Quartile
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Sep-09
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Jul-09
Aug-09
Sep-09
Upper Quartile
Corresponds to Error #2
STAT test turnaround improved
significantly:
– Median decreased 30 minutes
(38%)
– Upper quartile decreased 44
minutes (38%)
Overall lab test
turnaround improved
significantly:
– Median
decreased 17
minutes (23%)
– Upper quartile
decreased 26
minutes (23%)
120
100
80
60
40
May-09
Jun-09
Median
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Susan Eller
Maggie Murphy
Angie Bialkowski-Gunn
Mike Schmidt
Sheri Hudson
Anne Bobb
Ricardo Sumugod
140
Time (minutes)
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Jul-09
Aug-09
Sep-09
Upper Quartile
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Jennifer Bloomquist
Brandon Swinton
Ernestine Lofton
Jacque Punzo
Sue Masarik
Arlene Obias
Peggy Pritchard