November 5, 2010

1. November 5, 2010 UTMB Laboratory Pre-analytical Time Improvement

2. The Team • Alexander Indrikovs • Anthony Okorodudu • Jeffrey Richards • Bert Nash • Theresa Friloux SPONSOR: • Donna Sollenberger CEO, UTMB Health System

3. Aim Statement By September 1, 2010, decrease by one hour the time at which Sample Management completes processing of outpatient samples.

4. Why We Selected This Goal • Outpatient work accounts for 2/3 of all lab tests • Most of these samples arrive in the laboratory between 5 PM and 11 PM • Prolonged outpatient processing delays inpatient testing • Laboratory automation is approved for FY11. For maximum benefit, we must have a continuous flow of specimens into the automated line.

5. Scope of UTMB OUT PATIENT SERVICES: TDCJ Units, Regional Maternal & Child Health Clinics, & UTMB Community Based Clinics

6. Courier Arrival Times

7. Clinical Laboratory Workflow EDTA tubes Sort Sample tubes Receive into lab Aliquot Sort Load centrifuge Unload centrifuge Decap Label aliquot tubes Bottleneck - > 70% of pre-analytic time Walk to analyzers Pre-Analytics 70% of turnaround time Load analyzers Analytics / Post-Analytics 30% of turnaround time Rerun exceptions Locate exceptions Unload analyzers Recap tubes Walk to storage area Store racks Verify at LIS Verify/Manage exceptions Archive tubes Store racks Recap tube Find tube Load on analyzer Verify at LIS Archive tubes Unload analyzer

8. Pre-printed Labels

9. Tube Sorting

10. 22.00

11. Sources of Lab Errors

12. Process Evaluation Process People SOPs inadequate Management Staff in SM not adequately trained Process Equipment People Inadequate training materials SOPs written prior to transition to interfaced testing Orientation not well-organized Multiple order entry processes Staff in SM not adequately trained Multiple order entry processes Most SM Staff not highly educated Different processes for individual clients Clients not knowledgeable about packaging & submission requirements Workstation pending lists inaccurate Errors and delays in pre-analytical processing compromise full benefits of planned laboratory automation system Orders placed for uncollected samples Orders placed more than once Clients not trained about the requirements? Multiple sample packing systems Staffing not adequate or aligned with workload? High turnover Errors and delays in pre-analytical processing compromise full benefits of planned laboratory automation system Different clinics have their own preferences Tecans, frequently fail Inconsistent leadership in SM Staff not knowledgeable on maintenance and repair No team leader on the night shift. Training not ongoing TDCJ samples not bar-coded Suboptimal use of information technology Supervision has not had clear accountability since rebuilding CES lacks parts and expertise maintain Tecans CES not accountable for Tecan performance Suboptimal use of information technology TDCJ samples not bar-coded No one to divide up work on the night shift BC printers not available in units Management Equipment

13. Previous Receiving and In-Lab System Courier Arrives with patient samples Verify Receipts with courier Print Manifest Use Manifest to “In-Lab” Print CERNER Labels Find manifest; Match Samples with labels & Label Tubes Walk to Analytical Area Tecan: Aliquot & Sort Tecan: Decap Tubes

14. Interventions • Installed bar code label printers at 85 Texas Department of Criminal Justice (TDCJ) units • Trained TDCJ staff on use of new labeling process • Piloted new sample accessioning process with one TDCJ route • Implemented new process with all Regional Maternal Clinics

15. X X X Pre-Receipt processing New Receiving and In-Lab System Courier Arrives with patient samples Verify Receipts with courier Print Manifest Use Manifest to “In-Lab” Print CERNER Labels In-Lab Samples, Print Labels And Place on Tubes Modified Streamlined from 9 to 6 steps and modified 3rd step in new system Walk to Analytical Area Tecan: Aliquot & Sort Tecan: Decap Tubes

16. Benefits of Improved Process • Standardize to one process for receiving all interfaced orders • Decrease errors by printing labels and labeling tubes on one patient’s samples at a time • Finish processing Outpatient samples before AM Inpatient samples arrive in the lab • Allow testing areas to monitor pending workload • Eliminate batch processing to provide continuous flow of samples to the labs

17. April – July 2010 Time of Day Last Samples are Ready for Analysis September – October 2010 10.00 Time Out 4.00 0.00

18. Summary

19. One Measure of Success:Turn Around Time (TAT) for Potassium

20. ROI: Financial • Decrease in Sample Management overtime by 46% in September, 2010 or cost reduction by $994; extrapolated to ~ $12,000 per year • Redirected effort of Client Services staff spent on troubleshooting order errors; now used for answering physician and/or provider phone calls • Gains in technical efficiencies/redirection of labor: to be determined • Potential impact of improved TAT on ALOS: to be determined

21. ROI: Patient Safety • Decreased pre-analytical errors with resultant increased reliability of lab results • Improved TAT can result in faster decisions for patient diagnosis and treatment

22. Next Steps • Train all Sample Management staff in new process - completed • Fully implement new process for all outpatient samples - completed • Monitor new process for error rates and turnaround time - ongoing • Implement Automated Track System – submit RFP

23. Thank You! • Sample Management Division at UTMB • CMC Laboratory & Information Service Teams • UTMB Pathology Client Services Team • Regional Maternal & Child Health Clinics Thank you for your time!