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Making the grade on the long road to QI.

Throughout the clinical laboratory, quality improvement measures are being tended with increasing care and conscientiousness. Some lab workers resent having to spend precious time and funds on quality improvement activities, which they occasionally consider overdone. True to traditional quality control procedures, laboratorians tend to respond more often to errors than aggressively seek to prevent mistakes--even though with quality assurance, cleanup may be less effective than anticipation. These are among the findings of MLO's recent survey on quality improvement in the clinical laboratory (see "Survey methodology," adjoining page).

[Paragraph] Pervasive. Nine out of 10 respondents (91%) said their labs have a written quality assurance (QA) plan. Not surprisingly, hospital labs were more likely to have written plans than were independent and group practice labs combined (97% vs. 82%, respectively).

Survey data reveal that only two out of three labs accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) comply fully with its 10-step process for monitoring and evaluating QA, which has been outlined in previous MLO articles. [1,2] Quality indicators are reviewed approximately once a month by 46% of the labs responding to MLO's survey. Frequency of QI indicator review will be discussed at greater length later in this article.

Alarmingly, fully one-third (33%) of respondents were unaware that JCAHO will require hospitals to have an institution-wide total quality management/continuous quality improvement (TQM/CQI) plan in place by 1994. This finding is particularly disturbing since virtually all respondents are at the supervisory level or above and about 80% work in hospital labs.

According to 45% of all respondents, the new requirement will force changes in their labs' current programs. According to almost one-third (32%), the requirement will not lead to such changes--suggesting that QI is firmly in place at their institutions already. The facilities of 13% are not accredited by JCAHO. An additional 11% said the requirement did not apply to their labs.

[paragraph] Expensive. Asked to name "the single greatest problem remaining to be solved in your lab regarding QA," respondents speaking for 68 laboratories complained that QA consumes too much time; 21 pointed to the number of people required to do the job; and 34 cited paperwork and documentation. "If paper could cure illness, then this should be the healthiest country in the world," said the veteran lab manager of a small not-fot-profit hospital in Texas. (For definitions of hospital size as used in this article, see "Hospital size," below on this page.)

[paragraph] Reactive. Survey participants were asked to rate commonly used quality indicators by their observed degree of success (Figure 1). The indicators selected as examples on the survey questionnaire were grouped by lab section.

For indicators used throughout the lab, respondents tend to cover QA either via outside agencies or by counting and assessing errors. The most successful indicator, cited by 66% of respondents, was lab performance on proficiency testing (PT) surveys. Lab performance on inspections was the second most successful QA method, at 58%. Incident reports (44%) and error reporting (38%) ranked third and fourth. (Multiple responses were accepted.) The fifth most worthwhile general lab indicator was evaluation of specimen labeling errors, called "very successful" by 36% of respondents. Monitoring patient satisfaction with phlebotomy procedures was considered very successful by 28%.

"The fascination with PT is clearly related to the advent of CLIA '88," says Paul Bachner, M.D., chairman of pathology and laboratory medicine at United Hospital Medical Center in Port Chester, N.Y. Under the provisions of these regulations, he points out, "the penalty for poor performance is significant. In a sense, that attitude has been forced on the lab community by the escalation in lab oversight. When you establish QA systems, you try to look at things you can measure, and error rates are susceptible to computer analysis." Still, some observers feel that taking the proactive stance typified by TQM/CQI is long overdue.

[paragraph] Resentful. QA plas in more than half (53%) of the 91% of respondents' laboratories that have such plans study clinical appropriateness of test orders--a first step toward correcting abuse in that direction. This indicator is lacking, however, in 39% of panelists' written
 Figure I
 Top QA indicators
Indicator Very No QA measure
and lab section successful instituted
G Lab performance
on proficiency
surveys 66% 12%
G Lab performance
on inspections 58% 21
G Incident reports 44 11
G Error reporting 38 11
A Concordance of
frozen secion
diagnoses to final
diagnoses 44 33
M Blood culture
contamination rate 39 30
G Specimen
labeling errors 36 16
H Emergency room
hematology Stat
TAT 35 30
B Wastage of blood
components 34 41
C Emergency room
chemistry Stat TAT 33 28
B Completeness of
transfusion forms 33% 38%
H Comparison of
automated vs.
manual differential 30 49
B Documentation of
sign-out and
starting time of
transfusion 29 46
G Patient
satisfaction with
procedures 28 33
G Patient wristband
problems 27 38
G Physician
response to
critical lab values 26 35
G = general lab; A = anatomic pathology; M = microbiology;
H = hematology; C = chemistry; B = blood bank

QA plans (8% were unsure).

Only about half of respondents (51%) said the medica staffs of their institutions were involved in determining clinical appropriateness as a quality assurance measure. A substantial 38% specifically said they were not involved, and 12% were unsure.

Nearly half (48%) of the laboratorians responding to the survey said their institutions lacked a formal procedure by which the medical staff reviewed the appropriateness of their own use of laboratory services. Such a procedure does exist in 34% of respondents' labs, while 18% didn't know.

"JCAHO requires medical staff involvement in setting guidelines for determining the clinical appropriateness of tests, yet 38% of the survey respondents said that isn't happening," points out Lucia M. Berte, M.A., MT(ASCP), director of laboratory quality assurance at Elmhurst (Ill.) Memorial Hospital. "This is quite an admission that people really aren't paying attention" to an important requirement that could help solve a common complaint, she adds. A fuller discussion of appropriateness of test orders will be found in the second part of this report, which follows in this issue.

* CLIA's coming. Where written QA plans are in place, two out of five (42%) of respondents' labs overall (45% of hospital labs, 31% of independent and group practice labs) had implemented them by 1987. QA plans were instituted in 16% of labs that now have such plans in 1988; 21% in 1989; 14% in 1990; and 8% in 1991. Possibly in anticipation of the implementation of CLIA '88 regs, independent and group practice labs were far more likely than hospital labs to have first implemented a written plan in 1991 (28% vs. 4%, respectively).

* Written plans. Where written QA plans are in effect, most such plans (89%) describe lab services, while 8% do not and 4% of panelists in this group were unsure.

Just over half (56%) of panelists whose labs have written QA plans said their plans describe the population served by the facility. This is not so for 34%; 11% were uncertain. Quality plans instituted by hospital laboratories (60%) were far more likely to describe their populations than were independent and group practice labs (39% collectively). Written QA plans describe the populations served in 60% of JCAHO-accredited facilities and in 43% of non-JCAHO-accredited labs.

* JCAHO 10-step process. One-fourth (25%) of labs accredited by JCAHO comply in part with that organization's 10-step process; 2% do not; and 6% of respondents were unsure. Among non-JCAHO-accredited labs, 21% fully comply; 30% comply in part; 36% do not follow the recommendations; and respondents from 13% were unsure. Not surprisingly, hospital labs were more likely to practice full compliance (66%) than were independent and group practice labs (14%).

* Who's responsible? In 34% of respondents' labs, the principal job function for at least one FTE is to monitor quality. In fact, QA represents a new career opportunity for laboratories, said more than half (54%) of panelists.

Figure II lists the titles of those who wrote their labs' QA plans and who now coordinate and evaluate QI. Lab managers largely contributed to writing

the plans (61%) and also have the most responsibility for coordinating (58%) and evaluating (58%) QA efforts.

Beneath the level of lab manager, some interesting splits occur between those who wrote the plan and those who carry it out. Lab supervisors had responsibility for writing the plans in 30% of cases but coordinate the plans in 43% of cases. Pathologists were responsible for writing QA plans in 28% of cases but evaluate them afterward in 54% of cases. Only 8% of QA plans were written by technologists, who nonetheless coordinate QA in 18% of cases overall (somewhat more so in independent and group practice labs, labs in small hospitals, and labs in the South and West) and evaluate it in 17% (somewhat more in independent, Midwestern, Western, and non-JCAHO-accredited labs). MTs coordinate written QA plans in 27% of facilities that are not accredited by JCAHO and have such plans.

* Coordinating quality. Facility-wide QA coordinator is a job title in 81% of respondents' institutions, but not in 17%, while 2% of panelists were unsure. Of all respondents, 83% reported that their institutions had facility-wide QA committees or work groups; 15% said they did not, and 2% were unsure.

* Sharing information. Almost all laboratorians (93%) employed


by facilities that have facility-wide QA committees or work groups reported that quality information derived in the lab is routinely shared with the others. Quality data obtained in the laboratory is not routinely shared in 4% of such institutions, and 3% of respondents were unsure.

Among facilities that oversee QI interdepartmentally, the person responsible for quality in the lab is a member of the facility-wide group in two out of three cases (67%) overall (in 70% of midsize or large hospital labs and in 58% of small hospitals). Unfortunately, in 29% of facilities that have an interdepartmental QI group, the laboratory QA
 Figure III
 How QA deficiencies
 are corrected
Continued monitoring 93%
Counseling of staff 84
Continuing education 79
Written communication
within lab 78
Communication with users 72
Redesign of system 60
Educational programs 59
Insufficient action taken 6
Other 2
 Total exceeds 100% due to multiple

coordinator does not belong to it; 4% of panelists were unsure.

Only one-third (33%) of laboratorians responding to the survey said they were "very satisfied" with the way their QA plans and information are shared with all levels of lab employees; 53% were "somewhat satisfied." Outright dissatisfaction was expressed by 14%. Clearly there is room for (quality) improvement in communication, a sadly overlooked aspect of teamwork throughout the business world, laboratories included.

* Quality indicators. In nearly half (46%) of respondents' labs, findings derived through QA indicators are reviewed 12 times a year. Findings are reviewed quarterly in 31% of labs and biannually in 5%. The proportion is the same--4%--for frequencies of once, six times, and 13 times a year.

For reasons of space, the listing of commonly used indicators by frequency of use in Figure I does not break down the data according to type of institution, bed size (in hospital labs), region of the country, and CAP/JCAHO accreditation status. These factors were considered in the statistics themselves, however. The complete data gathered by MLO reveal some interesting variations in indicators used in the following laboratory sections:

[paragraph] General lab. Monitors for error reporting and lab performance on inspections were deemed "very successful" at 44% of large hospitals and by one-third (33%) of respondents from small and midsize hospitals.

[paragraph] Hematology. Labs in small hospitals were less likely than those in midsize and large facilities combined to have instituted emergency room Stat TAT as an indicator (11% vs. 20%, respectively).

[paragraph] Microbiology. Only 15% of midsize and large hospital labs and 28% of small hospital labs fail to used blood culture contamination rate as a monitor. The same indicator was considered "very successful" by respondents in 51% of Western labs, the largest geographic component. Only 36% of labs in the rest of the country, on average, liked it that much.

[paragraph] Anatomic pathology. Labs at small hospitals were less likely than those in larger facilities to use the following indicators: specimens received without proper history (47% vs. 67%); adequacy of cytology specimens (44% vs. 76%); compliance of surgical pathology and autopsy report data with "standard formats" (45% vs. 72%); concordance of frozen section diagnoses to final diagnoses (67% vs. 87%); fine-needle aspiration cytology correlation to histologic diagnoses (43% vs. 69%); and specimen identification and labeling errors (53% vs. 70%).

* Ask the customer. While most quality indicators look inward at laboratory procedures, some turn outward to customer service. Just over half (54%) of respondents said their labs conduct user satisfaction surveys, while 41% did not and 5% were unsure.

User satisfaction surveys are conducted in 64% of labs in small and midsize hospitals and in 50% of large-hospital labs.

Of the laboratories that conduct user satisfaction surveys, 80% ask patients; 46% ask the medical staff; 37% ask physicians' offices; 27% ask nurses; and 9% include other groups. Small-hospital labs are considerably more likely than those in larger facilities to ask patients for their opinions (95% vs. 78%). Among laboratories in large hospitals, 60% involve the medical staff in user satisfaction surveys and 38% tap nurses. The figures for midsize and small hospitals are 44% for physicians and 22% for nurses, respectively.

Is there any point in asking the ultimate client to assess laboratory quality? "It's fine to ask patients what they think of the lab's performance," says Luci Berte, "but patients are not the immediate users of the laboratory product, which is information used by doctors and nurses." A fuller discussion of communication between labs and their constituencies appears in the second part of this survey report.

* Problem solving. Problem identification forms are used for QA purposes in 61% of panelists' labs. Such
 Figure IV
 Extent of chief pathologist's participation in lab QA
Consults with medical staff departments
on lab appropriateness issues 53%
Attends laboratory QA meetings 48
Is involved with institution's
medical staff QA committee 44
Suggests new indicators 42
Participates in selecting monitors 39
Reviews patient charts 30
Teaches CE 13
Not at all involved 11
Teaches QA-related CE programs
to medical staff 9
Unsure 7
 Total exceeds 100% due to multiple responses.

forms do not exist, however, in one-third (33%) of labs; 6% of respondents were unsure. Most respondents (83%) said their labs have a standard method for following up incident reports, while 14% did not and 2% were unsure.

Almost two out of three respondents (64%) reported that their labs keep logs on the status of problems identified. Fully 29% keep no such log; 7% were unsure. As usual, there was a discrepancy between hospital sizes. Large-hospital labs were more likely than those in smaller facilities to keep continuous logs on running problems (74% vs. 60%). Among laboratorians whose labs keep such logs, nearly all (92%) said their logs were reviewed periodically to assess whether the problem was solved; 4% said the log was not reviewed; and 4% were ensure.

MLO's data indicate that many laboratorians responding to the survey of quality practices rely on outside observers or error and incident reports to detect problems, yet 29% don't bother to keep a log on the status of problem solving. Respondents tend to react to problems by studying the issue (Figure Ill). Asked "What actions, if any, are taken to correct problems identified in the QA process?," 39% of laboratorians checked "continued monitoring."

Labs in the West faced with problems were more likely to counsel staff (94%) and redesign the system (72%) than were labs in all other regions of the country (averages of 81% and 57% for those two activities, respectively). Hospital labs were more likely than independent and group practice labs to react to problems with continued monitoring (95% vs. 90%), continuing education (81% vs. 73%), written communication within the lab (81% vs. 67%), and educational programs (61% vs. 47%).

* Sharing the burden. Two out of three respondents (66%) reported their labs employ no FTE whose principal function is QA. Quality is monitored by one FTE in 28%, by two FTEs in 3%, and by three FTEs in 1%. Just over 2% of labs have four or more such workers.

When asked to measure the involvement of the lab's chief pathologist in QA activities (Figure IV), more than half of respondents (53%) checked off "consults with medical staff departments on appropriateness issues." Chief pathologists at midsize and large hospital labs were more likely than those at small hospitals to consult the medical staff regarding appropriateness (62% vs. 52%, respectively), attend lab QA meetings (57% vs. 40%), and help select monitors (47% vs. 30%).

Chief pathologists were more likely to review patients' charts as part of QA at small and midsize hospital labs than large facilities (40% vs. 28%, respectively). Chief pathologists in the West were more likely than those in other regions to consult on appropriateness (63% vs. an average of 51% in other regions) and to become involved with the medical staff's QA committee (57% v. 41%).

* TQM/CQI. Half (50%) of the laboratorians responding to the survey said that their institutions have organization-wide TQM/CQI programs; 38% do not, and 13% were unsure. Those more likely to have a program included all hospital labs (58%), large-hospital labs (65%), and those accredited by CAP (56%) and JCAHO (56%).

About one-third (30%) of respondents employed by institutions with TQM/CQI programs felt the new proactive approach was more useful than QA in solving problems. One-fifth (21%) said it was not, and a plurality (49%) were unsure.

Among respondents whose labs lack a TQM/CQI program, almost half (46%) reported plans to begin one within the next two years. No written plan is on the agenda for 19% of labs; 36% of panelists were unsure. Among hospital labs that are not accredited by JCAHO, panelists working in 62% say they will begin TQM/CQI in the next two years. Only 27% of nonaccredited labs expect to do so.

* What works. Survey respondents were asked to rank the extent to which the emphasis on quality has benefited the lab and laboratorians (Figure V). No group seemed particularly optimistic about having heightened the retention of medical technologysits through QA. In part two of this survey, laboratorians offer additional view on the effects of QI in the laboratory of the present and future.

[1] Baer, D.M.; Belsey, R.E.; and Schaefer, B. How to earn perfect scores from your JCAHO surveyor. MLO 23(12): 37-40, December 1991.

[2] Berte, L.M. Growing into laboratory quality assurance. MLO 22(2): 24-29, February 1990.
COPYRIGHT 1992 Nelson Publishing
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Copyright 1992 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Readers' Strategies for Quality Improvement, part 1; quality improvements; includes related article on the methodology of the survey
Author:Jahn, Mike
Publication:Medical Laboratory Observer
Article Type:Cover Story
Date:Mar 1, 1992
Previous Article:HCFA, IRS, FBI intensify fraud and abuse investigations.
Next Article:How straight is the road to QI?

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