Clinical Pathology Quality Dashboard

1. Clinical Pathology Quality Dashboard March 2009

2. Clinical Pathology Quality Dashboard Inpatient Phlebotomy First AM Blood Draws

3. Clinical Pathology Quality Dashboard Inpatient Phlebotomy First AM Blood Test Results: PT/PTT, CBCP, and Comprehensive Panel

4. Clinical Pathology Quality Dashboard Inpatient Phlebotomy Draws Fiscal Year 2009

5. Clinical Pathology Quality Dashboard Turnaround Times

6. Clinical Pathology Quality Dashboard Molecular Diagnostics Laboratory

7. Clinical Pathology Quality Dashboard Chemistry In-Lab Turnaround Times

8. Clinical Pathology Quality Dashboard New Clinical Assays Added in Last Year Yeast identification system: (Vitek II automated) Yeast antimicrobial susceptibility: (Vitek II automated) EBV viral load HIV-1 quantification (COBAS Ampli Prep – COBAS Taqman) (includes extraction, amplification) MRSA surveillance VRE surveillance C.difficile surveillance BCR/ABL1 Kinase Mutation Analysis (Sequencing) Human Erythrocyte Antigen Genotyping (Microarray analysis) IGH/BCL2 Translocation Detection (Real-time PCR) JAK2 V167F Mutation Detection (Allele-specific PCR) KIT D816V Mutation Detection (Allele-specific PCR) KIT Mutation Detection for GIST KIT Mutation Detection of Melanoma NPM1 Mutation Detection (PCR w/ capillary electrophoresis detection) Microsatellite instability analysis PML/RARA t(15;17) Translocation Detection (Real-time PCR) Urovysion – FISH, Bladder Cancer Detection HER2 Amplification – FISH, Breast Cancer UGT1A1 Promoter Genotyping K-Ras Mutation Detection 1,25 Dihydroxy vitamin D Sensitive beta-2 transferrin assay

9. Clinical Pathology Quality Dashboard UMHS Blood Product Utilization

10. Clinical Pathology Quality Dashboard CAP Proficiency Testing 2nd Quarter FY 2009 Clinical Pathology 474 = Number of Challenges 99% = Satisfactory Results Anatomic Pathology 2 = Number of Challenges 100% = Satisfactory Results Department Total 476 = Number of Challenges 99% = Satisfactory Results

11. Clinical Pathology Quality Dashboard CP Financial Measures

12. Clinical Pathology Quality Dashboard Clinical Laboratory Operations Initiatives • Discontinue Cancer Center Hematology Lab (move to Main Lab) – Will Finn, MD, lead • Improvement of Critical Value Callback process – Brenda Schroeder, lead • Impact of Earlier AM Blood Draw in UH – OMS 490 students and Holly Eliot, leads • Improvement of Communication with Patient Care Units – Beverly Smith and Brenda Schroeder, leads • Customer Service Initiative – Beverly Smith, lead • Lab Formulary Committee – Office of Clinical Affairs, FGP, Pathology • Lean Process Improvement Projects – many! • Laboratory Safety focus – Brenda Schroeder, lead • Improvement of Blood Draw Wait Times • - Cancer Center • - Taubman 2 • - Taubman 3 • Creation of Blood Product Utilization Lean Team • – Tim Laing, MD, (OCA), lead

13. Clinical Pathology Quality Dashboard Clinical Laboratory Service Enhancements • Clostridiumdifficile toxin screening algorithm – 1/09 • On-demand unit-specific antibiograms – 2/09 • Expedited (rules – based) release of ANCs (absolute neutrophil counts) – 2/09 • Integrated hematopathology reports – 2/09 • Troponin point-of-care (ED) – 3/09

14. Clinical Pathology Quality Dashboard • Kudos • Thank you to the Phlebotomy Team! There has been a marked improvement in the average time of completed first AM blood draws in UH. (Please see Dashboard data.) • Thank you to Jerry Davis (Hematology Lab), and his colleagues in the Lab and in Pathology Informatics for developing and implementing a new system that has expedited the rapid release of absolute neutrophil counts. (ANCs) • Thank you to the Outpatient Phlebotomy team for a greater than 84% (to date) participation rate in the Employee Engagement Survey (open through March 27th).