CAHIIM Standard Assessed:
Subdomain VI.C. Work Design and Process Improvement
Subdomain VI.I. Project Management
Introduction: College Community Hospital (CCH) is a 200-bed facility offering adult medical, surgical, orthopedic, and psychiatric care. The hospital provides a full range of diagnostic and therapeutic services, including CT and MRI scanning and an eight-bed intensive care unit. The 200 beds are distributed over six inpatient floors:
One year ago, faced with decreased patient and staff satisfaction and rising costs, the management of CCH adopted a Total Quality Management strategy. They formed a Quality Council and chartered several performance improvement projects. Over a nine month period, projects were successfully completed in Dietary, Nursing, Psychiatry, Materials Management, Pharmacy, Health Information, and Outpatient Surgery, they are now ready to begin the second round of projects.
One major source of dissatisfaction for physician and nursing staff has been slow turnaround time (TAT) for laboratory tests. The lab performs about 3000 blood tests per week, the most common being CBC (complete blood count), serum electrolytes (sodium, potassium, chloride and CO2), BUN, a kidney function test, and blood sugar.
Given the high level of complaints about slow lab test turnaround time, the Assistant Administrator asked the Quality Council to initiate a Performance Improvement project team to tackle the problem of improving the number of tests completed within the hospital standard. The Quality Council agreed, chartered a team, and asked the Assistant Administrator to act as Team Leader.
The Assistant Administrator was familiar with Total Quality Management concepts and recruited a team, including the Transport Supervisor, who had recently attended a class in PI Methods and Tools. When all the recruiting was done, the team members were:
Problems with scheduling the team meetings made in impossible to include a representative from the lab night shift.
Now, it’s time for the first team meeting. Use your imagination and “pretend” you are Cathy Filer and you are attending this meeting! Notice the personalities and behavior of each of the different team players.
Lotta: First, I want to thank you all for volunteering for this team. I think we have…..
Sam: (interrupting) I wouldn’t exactly say we all volunteered. In fact, I’d say I was drafted.
Lotta: Well, I suppose some of you were picked. I asked the managers for people who really know what goes on in this process. So, you’re the experts. And I asked Cathy Filer to join us because she may be able to help us to use the EHR system more effectively to help with this improvement opportunity.
Cathy: I hope I can help!
Lotta: Let me describe the problem. We’re getting too many complaints about long turnaround times for lab tests – I mean from the time the physicians decide blood work is needed until the time the results are available to them. Harry helped me pull some data together that will give us a picture of how big the problem is. Everyone take a look at your handout.
Harry: This bar chart shows the percent of tests that got done within the standard for the past year. The average is about 84%.
Beth: What are the standards, anyway? No one ever told me there were standards. I thought everything was stat, stat, stat! I know I spend a lot of time calling down to see when results are going to be available.
Sam: Maybe that’s because we’re not making the standards all that often, whatever they are.
Tom: Let me explain these standards. When the doc’s fill out the request, they indicate whether it is STAT, Urgent or Routine. There are different turnaround time standards for each priority. STATs are 2 hours, Urgents are 6 hours and it’s 24 hours for Routines. The times are from when the test is ordered to when the results are available to the doc.
Steve: Well, whatever the standard is, I know the problem isn’t the time we take to actually do the test. We’ve been measuring our turnaround time within the lab for more than a year now.
Harry: Steve’s right. We did have some problems in the lab a couple of years ago. We had some pretty ancient equipment. But, we were able to replace most of that last year.
Cathy: Well, that is great to know. Since we already know that the turnaround time for actually doing the test, and I am assuming we can show data to back that up, then the team can focus our time on other parts of the process.
Sam: I don’t know why we need a team to solve this one. It’s pretty obvious to me that you guys may be able to do the tests quickly, but you leave specimens sitting in your receiving window for long times. You probably measure your own turnaround time from when you take the specimen from the box, not when it gets there.
Steve: That’s not true. If you want to blame somebody, just last week, I noticed that the messenger service left results in our out box for more than an hour before picking them up.
Harry. That’s right. I think there are just a few “bad apples” around here, including in the lab. I’m looking into that now. I’ll find them……I have my ways.
Beth: (to Tom) Tom, we’re not supposed to be going right to what we thing the solutions are, are we? Or finding ways to blame other people?
Tom: (with a sigh) Beth’s right. What we have to do is see if we can find out what’s wrong with this process. We have to get out of the habit of thinking it’s always someone doing something wrong. So, the first thing we have to do is to make a flow chart showing how this process works. Then, we’ll think about what could be causing the problem of long turnaround times. We’ll have to test our theories and collect data and make sure we find the root cause. Until we do all that, we won’t have much of a chance of solving the problem for good.
Steve: Boy, that sure sounds like a lot of work.
Lotta: That’s why we’re here. We’ll learn a lot and have some fun, too. But, we’d better keep an eye on the ground rules we put together. That will keep us focused on the problems, rather than on blaming others.
Tom: OK, let’s get to the first step – flowcharting this beast. You folks tell me the steps in the process and I’ll write them on these poster size Post-Its and stick them on the wall. Then when we think we have all the steps we’ll move the Post-its around and put them in the right order.
Lotta: Sounds good. So, where does this process begin? What’s the starting point of our flow chart?
Beth: Well, here’s the doc, making his rounds or checking a patient. He decides that some kind of test is needed and writes the request….sometimes the nurse writes the order and has the Doc co-sign it…..and whether it’s STAT, Urgent or Routine is written right on the order.
Cathy: How does he write the request? On a paper request sheet? Are we using the Order Entry option in the EHR?
Beth: No, they write it on a request slip.
Cathy: That is good to note.
Steve: You know, I think the doc’s overdo it on the Urgents. I bet that plenty of the Urgents could really be Routines. Maybe they’re in a big hurry to get out of here, so they make it an Urgent.
Harry: Well, 24 hours is a long time to wait for a Routine. Maybe the doc is making rounds in the afternoon and would like to have test results back for the next morning.
Beth: Sure, that happens. But, that’s not really unreasonable is it? Maybe the standards should be tighter.
Harry: For pity sakes, we’re not meeting the standards we have now. I think the standards are set by the Patient Care Committee. They’re all docs and you know they’ll just want to tighten them up if we bring this to their attention.
Beth: Maybe so….but, I think we should look at the standards. I wonder what that standards are at River Valley Medical Center.
Tom: Hold on, hold on. We’re supposed to be flowcharting now. These are good thoughts, so let’s write them down in our idea log and make sure they get included with our minutes so we don’t forget them. Let’s get on with this process.
Lotta: Well, the requests go to you, Beth, don’t they?
Beth: Right. I stamp them with the patient’s name and medical record number. Then I put them in the floor out box for lab pickup.
Steve. The Routines go into the box, but you call us on the STATs and Urgents.
Beth: That’s right.
Sam: Then the lab notifies me and I go up, pick up the request and do the draw. That’s assuming the patient is there.
Lotta: What do you mean “assuming the patient is there?”
Sam. Just that. Sometimes I go up and there’s an empty bed. Maybe I was given the wrong room numbers, or maybe the patient is visiting Radiology or PT, or whatever. There’s nothing like having a STAT order and you can’t find the patient.
Lotta: So, what do you do then?
Beth: Usually, he comes over and harasses me – like I’m not busy enough already.
Tom: OK, let’s put that on our chart as a problem. If it happens fairly often, it could be part of the turnaround time problem. But, let’s say the patient is there. You do the draw, right?
Sam: Right. Then I take the specimen down to the lab and put it in the in box. (Under his breath)…..Where it grows old.
Steve: OK Sam, I heard that.
Tom (intervening) Everyone did. Let’s keep one eye on the ground rules until we get used to working as a team.
Harry. The lab people are always checking the in box and, when there’s a specimen, we take it, set up the equipment and do the test.
Steve: We put the results on the form and put it in the out box. The messenger picks up the results when they come by on their rounds, and takes them back to the floor.
Beth: When I get them , I put them with the chart and flag it. Usually, if it’s a STAT, I make sure the doc knows the results are there.
Cathy: OK, that sounds like the whole process, except when do the results get put into the patient EHR?
Beth: We don’t. The results get sent down at discharge with the rest of the paper chart and I think they get scanned. I’ve seen scanned result slips before.
Cathy: OK, another thing for me to think about.
Lotta: OK, let’s get to work flowcharting this process.
You will create a Team Charter for this case scenario. Use the information in your Lesson to guide you through the process of creating the charter and use the information and people in this project packet to complete the charter. Your charter must include:
Your problem statement should be customer-focused, performance-related, and stated in measurable terms. It should not imply a solution or a cause! Here is an example:
“The current process for delivery, maintenance, storage, and purchase of pump controllers is fragmented and inefficient. The result is wasted staff time, lack of available functioning equipment, inappropriate use of space and frustration on the part of the customers.”
Your Goal Statement should also be stated in measurable terms. The statement should show a clear target for improvement. For example:
“Pump controllers will be available in proper working order within 10 minutes of request from the floor 95% of the time, beginning in November 1992.
This goal statement offers 3 points of measurement for success. 1.) There is a minute goal, 2.) There is a goal for how often, and 3.) There is a timeline for reaching the goal.