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Keeping on top of quality assurance.

Keeping on top of quality assurance

Quality assurance is becoming more aggressive in seeking to eliminate service deficiencies. That's due to increased emphasis by the Joint Commission on Accreditation of Hospitals on documentation of efforts to monitor and correct problems.

This emphasis in the JCAH manual prompted our 650-bed hospital to form an ancillary services quality assurance committee. Members include representatives from physical medicine, respiratory function, radiology, nuclear medicine, home care, ambulatory services, and social services, as well as two pathologists and myself from the laboratory.

At the beginning of the year, the laboratory representatives on the committee present lab-related hospital problems from the past 12 months that are important enough to monitor. Members of our staff collect the data, and then we contact other departments in an attempt to solve each problem. After taking remedial steps, we conduct another study to see if we succeeded.

At the same time, the laboratory pursues longstanding quality assurance activities designed to maintain trouble-free operations. These we call continuous QA programs, as opposed to the new programs generated by the ancillary services QA committee. We will describe both thrusts in this article, starting with continuous programs:

Before implementing any new test, we collect 50 to 100 normal patient values. We then calculate the mean and standard deviation and set the normal or target range. Parallel analyses are also performed, either by us or by a reference laboratory, and where feasible, we check patient charts to see whether test results correlate with the medical information.

To insure rapid reporting of critical values, our staff follows a three-part protocol. Technologists first telephone the result to either a physician or a nurse on the unit; then they fill out two critical-value forms. One copy goes to the attending physician and becomes part of the patient's chart. The other goes to the clinical pathologist, so that he or she can follow up to make certain the medical situation is taken care of immediately. A table of critical values is posted in each laboratory work area.

The laboratory-nursing committee meets eight times a year to try to solve mutual problems and improve the quality of patient care. One example: Preoperative Stat test work from intensive care and open-heart units used to drift into the laboratory all night long. That left no time to clean and recalibrate instruments between shifts. Delivering the many scattered specimens also put a strain on the hospital's messenger service, and sometimes the floors phoned for results before specimens had even arrived in the lab.

Alerted to these problems, the laboratory-nursing committee recommended that preoperative test work go to the laboratory between 5 and 5:30 a.m., a schedule that is now followed. After this work is batched, the incoming day shift cleans and recalibrates instruments for the next big batch between 8 and 8:30 a.m.

We compile workload statistics daily--not only CAP values but also the volume of tests requested by each unit. As a check against excessive ordering and to insure a proper level of staffing, we look for changes in test demand over a period of time compared with the same period a year earlier.

Electrolyte test volume on the night shift, for example, recently spurted by almost 20 per cent. Following up, we discovered no pattern of abuse. The increased test ordering was due to a rise in surgery and acuity of illness. Under DRGs, which were introduced to our state last year, many patients go home sooner. Those who remain in the hospital are more seriously ill and require more laboratory work.

Statistics often get results where comments and complaints can't. One study proved what we had been saying all along--that having a technologist on duty Saturday and Sunday, for CK-MB and digoxin assays primarily, would greatly improve utilization of the emergency room, the coronary care unit, and the laboratory. The added staffing, 14 hours per weekend, was approved.

Our monthly newsletter, "Laboratory Update,' is an important part of quality assurance efforts. This one-page bulletin outlines new procedures and concepts in laboratory medicine. It is closely read by physicians and nurses as well as the laboratory staff; after each issue, some physicians will phone the laboratory seeking additional information.

As noted earlier, new QA programs reflect the JCAH manual's increased emphasis on monitoring and documentation:

We check turnaround time on work received from the emergency room to guard against slippage --the average usually is 30 to 40 minutes, thanks to a pneumatic tube system for delivery of specimens and results. During a random one-week period each month, turnaround time is checked in four areas: chemistry, hematology, coagulation, and urinalysis. Delays uncovered in one such study led to acquisition of a urine screening instrument.

One week a month, we record all repeat complete blood counts that are ordered within each 24-hour period. The average is low, but if one particular unit shows an increase, the laboratory administrator alerts the patient care coordinator and the house staff on the unit.

The legibility of addressograph plates was a problem that affected virtually every department in the hospital. Since we are not computerized yet, all records are filed by hand, alphabetically. If a patient's name is unreadable, laboratory results may be misfiled, requiring duplicate testing or time and phone calls to track down the lost information. Working with the admitting and nursing departments, we resolved one big problem by redesigning the printer head to make the letters M, N, H, and W distinctive. Overall addressograph plate legibility improved when we started using new embossers.

Temporary addressograph plates are issued to pregnant women when they are preadmitted, replacing handwritten forms. With legible patient information, any laboratory work done in the labor and delivery suite is much less likely to go astray. Plates are also issued for the baby after delivery, to make sure that cord blood serologies and any emergency blood work are returned to the proper chart.

One survey found that at times 30 to 40 per cent of the patients in some wards were missing their name bracelets. The laboratory administrator discussed the problem with the head of nursing, and the nurses' aides now check the bracelets as part of a.m. and p.m. care. A recent survey documented a marked improvement--95 per cent of the patients are wearing name bracelets.

We have launched two new quality assurance projects this year. The first keeps track of the frequency and validity of Stat test requests. The second involves meetings with house staff physicians to explain procedures and help control overutilization of laboratory services. Not that physicians aren't already practicing more efficient utilization. For example, they have taken to ordering an eight-test chemistry profile when the case warrants it, instead of a more extensive profile.

We have also changed the way we administer projects. Each supervisor is in charge of one quality assurance project that affects his or her section.

Through quality assurance, supervisors and technologists have become aware of avenues available to solve problems and at the same time improve patient care. They are willing to take the extra time to participate in QA studies because they know positive action will follow.
COPYRIGHT 1987 Nelson Publishing
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Copyright 1987 Gale, Cengage Learning. All rights reserved.

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Title Annotation:one hospital's methods
Author:Schachter, Yvette
Publication:Medical Laboratory Observer
Date:May 1, 1987
Previous Article:How to use the positive reinforcing meeting.
Next Article:How we customized our lab for DRGs.

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