The vision and mission of the Department of Pathology are to transform the patient experience. This does not naturally occur on its own. Therefore, a deliberate, concerted effort is needed to bring this vision and mission to life every day. The DQHI strives to explore, experiment, and implement actions to support our departmental vision and mission. Our projects focus on one or more of the five elements of patient-centered care described above.
Patient Asset Management Initiative (PAMI)
A departmental-wide, comprehensive initiative to ensure the Pathology Department can efficiently and accurately manage all patient specimens through the stages of testing (pre-analytic, analytic, and post-analytic) from multiple sources to multiple testing locations.
During strategic meetings in January 2016, leaders from Clinical Pathology, Anatomic Pathology, and Pathology Informatics all expressed interest in beginning a formal approach to improving our management of specimens. Particularly concerning to this group was the number of specimens that go missing or lost and the impact this can have on patients and families. As well, with the pending move of many of the labs to the North Campus Research Complex (NCRC) in 2018, the need for a more formalized tracking of specimens was an operational imperative. Lastly, we are required by the College of American Pathologists (CAP) under standard GEN.40530 to ensure that "for specimens submitted to the laboratory from remote sites, there is a tracking system and record to ensure that all specimens are actually received."
Within the Patient Asset Management Initiative, four sub-projects have been identified:
PathTrack is a comprehensive specimen tracking application developed by Pathology Informatics. It supplements Soft’s workflow tracking and enables us to follow specimens from their creation, through interpretation, and to storage or disposal. This project focused on tracking specimens between University Hospital and our new facility at NCRC, but is now concentrating on implementing PathTrack at other locations within Pathology. For example, the outpatient phlebotomy draw sites, both on medical campus and off-site, will be working to integrate PathTrack into their current workflows. Other opportunities the PAMI Steering Committee envisions include informing staff about the status of processing of specimens, providing visuals of current workloads, and possibly providing specimen tracking information to patients and families in real time through the patient portal.
Phlebotomy Specimen Tracking
Thousands of specimens are collected at our outpatient phlebotomy draw sites (example, Taubman Center and Comprehensive Cancer Center) each day before being routed to our central specimen processing location. Handing off specimens from their collection point to this location is the first step to ensuring they are delivered safely to their destination lab. This is the point where labeling and ordering errors have their biggest impact on specimen routing. As such, ensuring that our specimens are tracked properly at the moment of collection is the critical first step in delivering the right results to our providers. The six on-site draw sites are piloting the use of PathTrack beginning in February of 2019 and full implementation will be completed no later than July 1, 2019.
Similar challenges exist for ensuring specimens collected at our satellite phlebotomy draw stations arrive at our central specimen processing location safely and accurately. These multiple remote locations add additional complexity to a tracking system, which led to the decision to prioritize these remote locations. This group of draw sites will be looking to incorporate the use of PathTrack in the second half of 2019.
Shared Thin Prep Specimens
Shared specimens offer a unique challenge of balancing multiple orders, multiple testing locations, multiple Laboratory Information System modules, and multiple “child” specimens intertwined in a complex network. Shared ThinPrep® specimens from Pap smears model almost all of the challenging processes facing other shared specimens. This project focuses on safely sharing specimens between Cytology and Molecular Microbiology and will serve as a prototype for designing other shared specimen processes as well. This project team is working closely with the PathTrack team to develop a storage solution that enables staff to quickly locate specimens in a systematic approach.
Increasing focus on patient outcomes and cost efficiency mandates new approaches to and better management of diagnostic testing
Inefficient and inappropriate testing has a variety of consequences, including increased cost, further unnecessary testing, patient stress, and suboptimal outcomes
Both over- and underuse of certain tests can lead to less-than-optimal results
A multidisciplinary team from Pathology and clinical partners is tackling this issue based on evidence-based testing guidelines from a variety of sources
The downstream impact of inappropriate testing on overall health care costs and patient outcomes can be extensive. There are many opportunities to address provider ordering patterns for laboratory tests, with the goals of adding value and ensuring efficiency in the delivery of care, as well as improving outcomes. These include inappropriate laboratory ordering that can lead to delays in reaching an accurate diagnosis, increased lengths of stay, and unnecessary invasive testing that can be associated with cost, morbidity, and mortality. Likewise, there may be many opportunities to ensure value-adding tests are ordered when needed. This program aims to leverage a multidisciplinary team with laboratory and clinical expertise to develop and implement interventions to improve test utilization at Michigan Medicine.
Our approach is to develop a standardized method to identify high-impact areas of overuse, misuse, or underuse of laboratory testing. Then, those tests will be prioritized based on the potential clinical impact, value, and feasibility of implementing interventions in ordering practices. Once the program committee has decided to pursue interventions for a particular test, it will identify clinical partners in appropriate departments and/or groups who will take responsibility for implementing these interventions within the population of ordering physicians. Finally, we will monitor changes in ordering patterns to evaluate if the interventions had an impact on ordering behaviors and adapt as necessary.
Resident Quality Improvement Course
In conjunction with the Residency Training Program, the DQHI runs a Quality Improvement course aimed at first and second-year residents. The course guides residents through putting into practice common Lean tools, such as the P-D-C-A cycle, A3 documentation, and Root Cause Analyses. As healthcare moves from a volume-based model to a value-based model, it will be critical for providers to have the skills to identify waste, improve efficiency, and deliver more value to their patients.
The backbone of the course is a group Quality Improvement project that teams of residents work on throughout the semester. Teams of four to five residents select a real problem affecting our labs and work through the process of analyzing the problem, identifying countermeasures, piloting their countermeasures, and measuring the effects. Students learn best by doing, and these projects are an ideal opportunity for residents to practice their QI skills in a real-world setting.