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Conducting QI studies that effect change.

The only way to achieve true quality improvement is to fine-tune the organization as a whole.

QUALITY IMPROVEMENT may be variously defined as a system that balances risks and benefits, a methodology that improves patient care, or a way to monitor the workings of an organization to promote the excellence of patient care. In my view, the most sensible definition and the one that is easiest to work with relates to service: internal efforts to meet or exceed customers' requirements and expectations.|1~ To do this we must know who our customers are (fairly easy) and understand their needs (more difficult).

For clinical laboratories, external customers include a broad range: patients, patients' families and friends, hospital nurses, ward clerks, physicians, third-party payers, suppliers of reagents and equipment, and the media--which can be relied upon to subject our errors to public scrutiny. Internal customers are the employees of the lab. Satisfying the needs of internal and external customers to the best of our ability enhances patient care.

In this article I will focus on the external customers of the laboratory. How can we determine what they need? One good method is to ask them.

Take a positive approach. Asking "What problems are you having with the laboratory?" invites satisfied clients to look for shortcomings. Open-ended questions are better, such as "How are we doing?" You might pose the question in person or through a survey.

For internal customers located in the hospital, practice serendipitous QI. Simply wander around the floors and make yourself available for comments and conversation. Doing this regularly is a good way to learn how your laboratory is perceived by members of other departments. Meanwhile, your openness serves as excellent public relations.

Talk to customers, keeping track of your activities and documenting any problems you discover. You will then be able to focus monitoring, data collection, and problem solving to help resolve issues that clients bring up. To a certain extent, we are what we are perceived to be.

We can't necessarily supply everything a customer wants. Negotiation must often come into play. In talking with emergency room physicians at Tucson Medical Center (TMC), a large not-for-profit hospital, I learned that some of the turnaround times they wanted were shorter than the times needed to perform the tests by our present methods. Explaining this to them defused their irritation.

* Serendipitous QI. Involve the lab's pathologists|2~ and executive director in conducting informal inquiries. At TMC, pathologists are assigned to specific hospital departments. Following this practice for the last few years has improved the relationship between laboratorians and nurses while facilitating the resolution of problems.

One problem uncovered by serendipitous QI related to infant heelsticks. The nursing staff reported excessive trauma to the infants' heels. Working together, several individuals at different levels in the laboratory and nursing departments improved the situation. First, the laboratory agreed to provide additional training for the phlebotomists. Second, we enforced an existing protocol that required a more-experienced phlebotomist to be on hand when the less-experienced one was having difficulty obtaining blood. Total quality improvement programs that involve colleagues at many levels provide an ideal way to promote QI. The surveys described in this article are multidisciplinary audits that are led by the laboratory and carried out with the cooperation of other departments.

Written surveys help define the customer's needs. Keep in mind, however, that a QI survey is a tacit promise of improvement. If you aren't willing to resolve problems revealed by the survey, don't distribute questionnaires.

* QI by Q&A. Such surveys should be short--no longer than two pages--and specific. When possible, quantitate the answers.

Figure 1 is based on a survey designed by the pathologists and management at TMC. It is easily adaptable to other situations.

Our questionnaire was sent to our most active clinicians--high-volume admitting physicians who use the hospital laboratory. Anonymity was not our goal; as in all our surveys, each bore the name of the recipient so that we could provide feedback on problems of particular interest to each person. Printing respondents' names on surveys permits redistribution of the questionnaire to those who fail to respond to the first mailing.

We have begun to respond to some of the problems uncovered by the survey. For example, because several physicians complained that digoxin results were never available until late in the day, we started to provide them earlier. We are currently planning a similar survey of the nursing staff.

At our institution, every patient is handed a general survey by a hospital volunteer. Only a few questions pertain to the laboratory. We are now working on a focused survey of a smaller number of patients.

* Independent labs. QI surveys can be instructive at independent labs as well. Figure 2 is based on a survey created by a commercial lab with which I am associated. The basic questionnaire is changed as needed to focus on specific problems and distributed annually to all clients.

Respondents who rate services as poor or below average receive follow-up calls from laboratory management. Section supervisors address any problems identified in their own areas. Recently we handled two communication problems discovered in the pathology service.

The area that draws the largest number of complaints tends to be billing. The head of accounts replies personally to all such difficulties. After analyzing the response to the 1991 survey, we decided to add a quality control check before bills are mailed.

The questionnaire is fairly specific in its treatment of individual performance. The results enable us to assess the track records of the laboratorians who interact most with external customers.

Supervisors and administrators review responses as a team and discuss them with a eye to the system as a whole. We might discuss, for example, whether billing errors are the result of a problem in that department or of data input errors from the original processing.

* No Band-Aids. Problem solving in clinical laboratories is too often done in a stopgap manner. Long-term solutions and prevention are our goals.

If your QI studies uncover a problem, break it down and examine potential factors individually. Could part of the difficulty reside outside the lab? If turnaround time is excessive, the fault is usually assumed to lie in the laboratory. Yet that isn't necessarily the case. Examine the turnaround chain.

There are eight steps in laboratory TAT analysis: physician gives order; order is sent to lab; specimen is collected; specimen is processed; results are analyzed; results are recorded; results are sent to physician; physician responds.

Obtain data on each step. One of the hardest areas to analyze is the lag between the time the physician writes the order on the form and the time of its arrival in the laboratory. When a TAT complaint is investigated prospectively, ask the physician to write the time the test is requested on the order form and (later) the time he or she received the results on that document. Examining a relatively small number of forms should reveal a pattern. Even a study of 20 consecutive test requests may provide an overview that gives the laboratory more credibility.

A study of TAT in conjunction with our emergency department showed that considerable delay was occurring before the laboratory received physicians' written test orders. Result reports later languished in the emergency room before physicians were able to review them.

* Redesigning flow. The executive director of the laboratory and I went to the emergency room and spent time observing. I also sent our chemistry supervisor and the pathologist in charge of chemistry to observe and to discuss the issue with ER doctors. In pooling our observations, we learned that some of the delay occurred after specimen processing and before chemistry tests were done. We found this unacceptable and (for other reasons as well) are currently redesigning the flow of tests in the laboratory. Our lab was strengthened by this attention to clients' needs. Clients know we are concerned with quality and that we will work to resolve problems as they arise.

* Assuring quality. To meet your clients' expectations, you must understand their requirements. QI studies, whether done informally or by questionnaire, can help identify problems. The laboratory should then study attendant procedures and adjust them as needed to prevent recurrence.


1. Bozzo P. Implementing Quality Assurance. Chicago: ASCP Press; 1991: xv.

2. Platt MS, Igel HJ, Novack RW. Getting pathologists onto the floors: A proposed proactive quality assurance function for pathologists. Lab Med. August 1991; 22: 540-542.

The author, medical director of Tucson Medical Center Hospital and Tucson Medical Center Health Enterprises, Inc. (TMCHE), Laboratory, is also an associate at the University of Arizona Health Science Center, Tucson.
COPYRIGHT 1992 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1992 Gale, Cengage Learning. All rights reserved.

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Title Annotation:quality improvement in medical laboratories
Author:Bozzo, Paul D.
Publication:Medical Laboratory Observer
Date:Oct 1, 1992
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