WORK FLOW CONCEPT & PROCESS MAPPING

1. WORK FLOW CONCEPT & PROCESS MAPPING

2. Path of Work Flow Sequential process Need of all facilities / Not size dependent Need to provide quality Helps build process Reduces Waste Helps establish the QMS

3. The Path

4. The Path Begins outside - Ends outside Path flow includes Physicians , nurses, clerks , Non lab professional , transporters, couriers Completeness and correctness of their action decided sample quality and TAT and thus accuracy of the test result Lack of completeness – Error , harm to patients , Waste and rework Important to ensure that process and procedure performed by Non Lab staff and fully understood , monitored and meet applicable standards

5. Medical Error Failure of Process Understand the process Document the process – How it happens Control Ideally draw flowcharts

6. Process Flow chart Identify sequence of event Turn inputs to outputs Identifies areas to be documented and instructions are needed Activities that cause problems / inefficiencies can be identified Revise process and procedure to improve performance

7. Blood Sample collection process List out steps in the process Documents that needs to be developed for the same

8. Blood Sample collection Process Order for Collection Received by Laboratory Sample Collection Document Generated Special Collection Precautions needed? No Yes

9. Blood Sample collection Process Special Collection Precautions needed? No Yes Special collection precautions taken Patient is identified

10. Blood Sample collection Process Patient is identified Patient is assessed Laboratory sample receiving process Blood sample(s) collected Sample(s) are immediately labeled

12. The Path

13. Examination ordering Patient Identification Patient Clinical information Authorized requestor Tests/ examination requested Type of sample/ specimen The Lab needs to provide What test are available What can be ordered as STAT Which Lab test need documentation of patient consent How to properly complete Lab request forms Clinical information when relevant Diagnosis Sample source Time of collection

14. Sample collection Patient preparation and pre collection assessment Verify that all preparation requirement are met Evaluate that age specific conditions that may effect the collection approach Fasting 24 hrs urine collections Collection Instructions Verify patients identity Blood collection techniques Instruction for Non blood samples proper labeling Recording the identity of the person who collected the sample Proper disposal of material used in collections Information about collection containers, type and amount of sample, Special timing, preservative and anticoagulants

15. Sample collection Sample transport Instructions for proper and safe packaging Verify that the samples have reached within the time frame appropriate to the nature of the requested tests Within Temperature range specified in instructions Safety requirements are met

16. Sample collection Sample receipt and processing - Primary Sample is your Raw material Instruction for receiving samples into the labs, through courier, through pneumatic tubed , retrieving samples, passing through drawers , windows Evaluating sample labelling Paperwork Completeness and correctness Evaluate condition of samples the source location when sample is unacceptable Communication to source location when the sample is unacceptable Accessioning Samples into the information system ( paper or electronic ) Processing samples ( centrifuge, aliquot , inoculate Expediting the receipt process and handling of samples marked as STAT

17. Sample collection Tracking mechanism to ensure that the samples given are actually received , accounted for and assayed in a timely manner All sample aliquots need to be traceable to the primary sample Process – when samples lack proper identification Process for actions to be taken if there is uncertainty in identification of an irreplaceable or critical sample like CSF or Biopsy The lab should have process for providing feedback on issues related to sample quality to those who collect sample lab or Non Lab Personnel

18. Examination process Perform Verify Interpret Divide them in to clinical disciplines Automated / manual process

19. Examination Method selection Need to Validate examination process, Equipment and computer systems _ process control QSE Examination Performance – How the test is done in the Lab based on package inserts or operator manuals Understood and followed by lab personnel Available at the relevant workstations Also need systems to identify the person completing the work, date of completion , QC program, tolerance limits and corrective action

20. Review of Examination Results Performed by Authorized person Instructions for review of both automated and manual result before data entry or transfer into the computer information system Result verification before the reports are released Instructions needed for follow up of result if they are below or verified limits of the examination method

21. Interpretation The lab needs to document and have available Criteria for evaluating Qualitative examination procedures Comparison of interpreting data ( reference ranges , age specific information , Alert values) Interpretation of morphology For Anatomic Pathology – Process to verify findings for Gross and microscopy to support the diagnosis and correlation with the patient Process for reconciling disparity between frozen sections and final diagnosis between histological and cytological findings

22. Post examination Process Primary Reports alert , critical values Process to confirm patient identification before giving verbal reports Ensure the results were heard correctly Final report to include details of preliminary report issue

23. Final report - Product Culmination of the combined process across the workflow Represents the Laboratory to all its customers Format content , and standardized terminology should be used Process so the final report is legible relevant interpretable and without transcription errors Report Turnaround time Are you able to track it Do you have a process to inform the requester when the reports are delayed

24. The Final Report – Product Corrected reports Mechanism for correcting reports and maintain both original and revised Sample Management Sample storage Sample retention Sample Indexing - need process for sending out samples, slides tissues blocks smears

25. Application of examination results to patient care The Workflow is not complete until examination results are applied to patient care The lab needs to provide health care professional the opportunity to consult the lab Ask any question about the results and interpretation Discuss results in the light of the patients condition Obtain information on follow up investigation

26. Techniques to collect workflow data • process mapping • sample & test mapping • tube analysis • workstation analysis • staff interviews • task process mapping • An is a fundamental prerequisite to any performance optimization strategy.

27. Data - Important in any workflow analysis • . • Laboratory data are rather easy to produce from automated analyzers and information systems, • Data must be complete, valid, or in the format required. • If data is incorrect it will lead to wrong downstream decisions that can have a negative impact on operations.

28. Sample and test Mapping • Analyse distribution of sample and tests over time - daily tests, test s batched • Goal • Identify overall workload • Asses if resources are appropriately matched to needs • Whether turnaround time and Quality indicators can be improved • Density of Test per sample • Arrive at bottle necks alter workflow to achieve better outcome Delays are less the result of instrument issues per se, and are more the result of workflow patterns that are not matched to instrument capabilities.

29. Tube Analysis “Tube labor” Sorting and centrifuging aliquoting racking unracking loading, and unloading samples on analyzers; retrieving tubes for add-on tests performing manual dilutions or reruns (depending on instrument storing tubes. On an average of 10 seconds per tube, it will take a laboratory 3.3 hours to sort 1200 tubes per day Sample mapping provides information about how many containers are received within a specified interval Tube analysis helps to analyze how many additional “tube-related” tasks have to be done

30. Workstation Analysis A typical laboratory is divided into stations for allocating work and scheduling staff The goal of workstation analysis is regardless of how a laboratory is organized, it is important to understand where, when, and how the work is performed. A key component of any workstation is equipment. Understand how each analyzer is used, associated costs, potential opportunities to improve performance. The operating characteristics of each instrument should be detailed as part of this process.

31. Test Menu analysis • Are the tests performed appropriate for the facility, given the volume and frequency of test analysis? • Sometimes the best way to improve turnaround time and lower the cost of a test is not to perform it. • Processing Mode and Load Balancing • Can affect both the cost and the timeliness of testing. Batched or run continuously • Batch processing is often less expensive than continuous processing • Continuous processing is facilitated by load balancing, a technique of spreading testing over a longer period to better match instrumentation throughput. For example, outpatient work, which does not require a rapid turnaround time, can be sequenced into the workflow during off hours

32. Interviews • Data collection is not complete without interviewing staff. • provides an opportunity for staff to participate in analyzing workflow and improving performance. • Identifies issues that would not be readily apparent from data collection alone • Particularly valuable in understanding what occurs outside the laboratory. • Test ordering patterns or habits can have a significant impact on a laboratory’s ability to meet clinician needs. • Visits to patient care units and discussions with nursing unit staff can identify pre-processing improvements that cost little to implement but save considerable money downstream.

33. Task process mapping • No workflow study is complete without mapping of the tasks or processes involved in performing a test • Detail every specimen-handling step, each decision point, and redundant activities. • Applied to any segment of a laboratory’s workflow, whether technical or clerical. • On ongoing activity • Should be done whenever a workstation, test, new technology is added or any significant change to a laboratory process. • When implementing change, it is important to avoid unnecessary or additional steps that are inadvertently added in the name of “efficiency”; • task mapping helps identify these steps. • Mapping also helps compare processes before and after change

34. Optimizing performance refers to the process by which workflow (including laboratory design) and technology are integrated to yield an operation that best meets clinical needs financial goals of the organization: high quality at low cost. In practice, there are times when workflow changes improve service levels and reduce cost

35. Work Flow metric Examples

36. Strategies to optimize performance