CQI by committee: a multidisciplinary approach.

Developing a continuous quality improvement program in preparation for a JCAHO survey can be a perplexing and sometimes redundant task, especially if you're trying to define and remedy a new problem with old tools. Here's how one laboratory found a fresh approach to CQI by finding out what other hospital departments thought of the laboratory's service.

As laboratorians, we are surrounded and confounded by regulations and requirements that demand our constant attention to the quality of our work and our processes. Even though we monitored turnaround times for Stat tests and morning runs to the point of data overload, we had no way of knowing whether our test results were getting to the right people at the right time. We needed a method to assess whether test results were getting to the people who needed them in a timely way, and a fresh approach to quality assurance and quality improvement.

As luck would have it, I was assigned to a hospital committee - the information management team - whose function was to bring the hospital into compliance with the JCAHO standard for information management. My focus was to meet JCAHO's IM Standard 5, which states: "The transmission of data is timely and accurate." To comply with the standard as it was intended, I needed input from people working in several areas of the hospital who relied on the laboratory's tests for the successful treatment of patients. I needed to develop a multidisciplinary approach to the problem of documenting compliance with the standard.

The scope of this project was overwhelming considering the number of departments in the hospital that generate and receive data - nursing units, billing, medical records, food services, pharmacy, radiology, and, of course, the laboratory. To make the project more manageable, I decided to restrict information gathering from ancillary departments during the first phase to the laboratory, radiology, respiratory therapy, emergency services, medical records, and the patient business office.

The multidisciplinary committee

The first step was to form a subcommittee with representatives from each of the ancillary departments to discuss any problems each department may have experienced with the flow of information in and out of the laboratory. Each participant was asked to bring flowcharts of how each department manages test orders and results.

Defining the perceived problem

With the help of the subcommittee, I was able to identify what needed to be quantified and how to measure it.

At the subcommittee's first meeting, one problem each department identified was an incomplete, illegible, or complete lack of written outpatient orders from the physicians' offices. The group decided to monitor four aspects of incoming physician orders during a three-month data-collection period to verify their perception of problems with efficient flow of information.

We wanted to see if incoming orders were meeting the following four criteria:

1) There is a written or verbal order for the tests requested (as opposed to a patient showing up for a test before the physician alerts the lab)

2) There is a diagnosis with each order

3) The order is legible 

4) The order specifies the dose, test, or procedure to be performed.

Defining the real problem

After the data was collected, the results were analyzed, and it was found that the data did not support the perceived problem. All four criteria were being met 99% of the time.

The next step was to examine the quality and timeliness of the processing and delivery of test results for the people requesting them. Because our hospital has an intermediate-care facility, we have patients who live here who are classified as outpatients. Often they are admitted to an acute care unit, and it is important that their test results follow them as they move from one care site to another.

We designed a second questionnaire to survey the nursing staff to see if test results moved throughout our facility with the patient [ILLUSTRATION FOR FIGURE 1 OMITTED]. The questionnaires were hand delivered to the nurses and physicians, and, to get a good response, we stood and waited for each person to fill out the questionnaire.

Each answer collected from this questionnaire was analyzed by assigning percentages to each response as follows: always = 100%, usually = 75%, sometimes = 50%, rarely = 25%, and never = 0%. The results indicated that test data was following patients and accessible to hospital staff members who needed them only 69% of the time.

Now it was time to reconvene the subcommittee with some representatives from nursing to talk about the problem. The data reflected we had a real problem keeping patient results with patients as they moved throughout the system. As a group, we decided that making results available to nurses as soon as patients were admitted needed to take priority over our other availability goals.

Several recommendations were made to make improvements, which were taken to the information management committee to develop an action plan. We developed a trial procedure for the admissions department to carry out to help flag newly admitted patients who recently had tests done as outpatients so we could get those results to the nursing units. The trial process lasted about three months, after which the nurses and physicians were resurveyed to see if we had improved.

The same questionnaire was used to analyze the data in the same manner. I was pleased to see an improvement in the frequency of availability of test results, overall from 69% to 77%.

The data was plotted on a bar graph to compare the results of the first survey with the results of the second for each of the five questions [ILLUSTRATION FOR FIGURE 2 OMITTED].

We had the good fortune of being able to complete the project shortly before our hospital's inspection for accreditation by JCAHO. Since quality improvement is a key part the inspection, I was asked to give a presentation for the inspectors on this approach to quality improvement. We got some good feedback, and they encouraged us to pursue the multidisciplinary approach to continuous quality improvement. We plan to continue this same format as we focus on information management in other ancillary areas such as food services, pharmacy, and physical therapy. I also am using the process to study the problems associated with pediatric and infant venipunctures and IV starts to decrease the number of unsuccessful venipunctures and coordinate IV starts with obtaining blood for analysis.

There are several advantages of using a multidisciplinary approach to continuous quality improvement. It relieved my tunnel vision of focusing on the laboratory's quality assurance as a means to an end. It emphasized the team concept of healthcare throughout the hospital and showed how all departments are interdependent. It was refreshing to work on a project with people in other areas of the hospital because we all gained a new appreciation for what each of us does and the problems associated with our jobs. I had become very dependent on hard facts and data on previous quality improvement projects and was getting really bogged down with the typical monitoring of things such as turnaround times, the number of corrected reports, and the number of rejected specimens. Collecting data using a survey was new to me, and I appreciated the feedback I gained from the survey because it allowed me to identify problem areas and later, to see improvement.

The survey approach also is customer driven in that the nursing staff and physicians are our customers; we provide them with diagnostic patient information.

I would recommend the multidisciplinary approach to continuous quality improvement to anyone who needs a fresh outlook on the process. Be sure to include as many departments as possible that are involved in, or influenced by, your department's service. Define broadly the service you want to improve or the problem you want to solve, but break it into manageable parts by prioritizing the most important issues. Other aspects of the problem can become future projects. Try using a questionnaire or survey as a data collection method, and think in terms of long-range projects, rather than quick fixes.

Figure 1

Questionnaire on test result movement with patients

We need your help

The Information Management Committee is in the process of improving the processing and delivery of patient results. We need your input to help us identify problem areas. Currently, we are focusing on the service areas of laboratory, radiology, respiratory therapy, and EMS.

Circle the most appropriate response.

1. Results of diagnostic testing follow the patient and are accessible to me.

Always Usually Sometimes Rarely Never

2. If patients are seen in the emergency room, their results follow them with their chart to the third floor or ICU.

Always Usually Sometimes Rarely Never

3. If residents of the second floor are admitted to the third floor or ICU, their previous lab, x-ray, and respiratory therapy results are transferred with them.

Always Usually Sometimes Rarely Never

4. If patients on the third floor are transferred to the second floor as a resident, their lab, x-ray and respiratory therapy results are transferred with them.

Always Usually Sometimes Rarely Never

5. Results of testing done on an outpatient basis prior to a patient's admission are available to me.

Always Usually Sometimes Rarely Never

Thank you for your time. Name:_____ Date:_____