Vrcfs Jci Presentation Samples

8/22/2019 Vrcfs Jci Presentation Samples

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QUALITY

@

LIFELINE HOSPITAL

Our Journey to Improvement


2/20

Senior Management Committee

Quality Council

Medical Executive

Commitee

Quality Management

Department

Clinical PI teams

Patient/ Customer

Nursing AffairsAdminstration

Medical Staff

Committees

Medical Staff

Departments

Nursing Affairs

Committees

Administration PITeams

Quality Improvement program

Information Flow Structure

Board of

Governance


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Priority Setting Criteria (Rationale)

High Risk

Problem Prone

High Volume

High Cost

Internal and External Customer satisfaction


4/20

A 9 Step Process to Quality

Improvement

Find

Organize

Clarify

Uncover

Start


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A Success Story

ISSUE:-

Rejected samples in laboratory


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Rationale

20% of blood transfusion errors due to pre-transfusion testing (NBS Clinical Audit & EffectivenessDepartment)

Lab provides 70-80% of data used by physicians

to make diagnoses (High Risk) Majority of the errors occur at pre-analytical stage

Improperly labelled samples - can lead to exchange ofpatient reports

Breach in sample integrity - will result in inaccuratereport

Inadequate patient information in requests - willprevent accurate result correlation

Repeat extraction of sample - inconvenient to patients


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Definitions

Definition for sample rejection:-

Any sample sent to lifeline laboratory not fulfilling the

criteria for acceptance will be rejected. The same

ensures that appropriate and relevant reports can be

sent to the correct destination. When unacceptable

samples are received, laboratory personnel will notify

the ordering provider of the rejection


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Opportunity for Improvement

Samples Rejected (May'08-July'08)

74

64

81

2.772.312.64

0

10

20

30

40

50

60

70

80

90

%of samples rejected 2.64 2.31 2.77

Number of samples rejected 74 64 81

May-08 Jun-08 Jul-08

Desired

Result


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Organize the Team

HOD Laboratory

Quality manager

Quality In charge laboratory Technicians


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Clarify the processFLOWCHART FOR THE LABORATORY SERVICES

OUT PATIENTS

Patients with

requisition form

Sample

Collection

Dispatch of

Samples

Receiving of

Samples

Processing of

sample

Results are fed

into the

computer

Verification of

reports

If abnormal result

Requisition slipgiven to patient

Billing

If referred patient

requisition slip

filled at sample

collection reception

NO

IN PATIENTSEMERGENCY

Order for

investigation

Generate order

for investigation

Sample

Collection

Sample

Collection

Dispatch of

Samples

Receiving of

Samples

YESYES

Consult with

the

consultant

Dispatch the

reports

Outsidelaboratory

samples


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Uncover the Root Causes

Reject samples

MACHINE

METHOD

MAN

MATERIAL

Improperly filled tubes

Incorrect container

Improperly stored and transported samples

Clotted samples in anticoagulant tubes

Leaking specimens

Specimen receivedwithout request

Improperly

labeled

samples

Insufficient volume

Hemolysed sample

Missed samples

Incorrect

sampling time

Incomplete request


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Uncover the Root Causes

Average Sample Rejections and Reasons(May-Aug'08)

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Average 26.46 25.42 7.96 7.85 6.14 5.49 5.05 3.40 3.07 3.11 3.25 2.80

Incomplete

request

Improperly

stored and

transported

Incorrect

container

Improperly

labeled

samples

Insufficient

volume

Improperly

filled tubes

Hemolysed

sample

Incorrect

sampling

time

Leaking

specimens

Specimen

received

without

Clotted

samples in

anticoagula

Missed

samples

60% of Rejections are due to

first two reasons


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Root causes

Incomplete requests

Most of the improperly stored & transported

samples from outside laboratories

Samples for urgent requests represented most ofthe improperly labeled & filled tubes

Hemolysed, lipemic and clotted samples are from

within & outside of hospital

Majority of the inadequate samples from pediatricpatients


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Start PDCA


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PLAN

To train staff of outside laboratories whosespecimens constitute majority of poorly preservedsamples

To remind doctors to send fully filled request

forms To educate the nurses & technicians in selecting

extraction tubes and mixing of samples in

anti-coagulant containers

Stressing the importance of sending samples inappropriate transport containers.

Calling for help from anesthetists in patients withdifficult veins


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DO

Implement ALL PLAN activities


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CHECK

Causes for Rejection (Comparision)

0.00

5.00

10.00

15.00

20.00

25.00

Average(May'08-Aug,08) 19.33 18.67 5.67 5.67 4.67 4.00 3.67 2.33 2.33 2.33 2.33 2.00

Average(Sep'08-Dec'08) 10.25 9.25 1.5 3.5 2.75 1.25 0.25 1 1.25 0.5 0.5 0.25

Incomplete

request

Improperly

stored and

transporte

Incorrect

container

Improperly

labeled

samples

Insufficient

volume

Improperly

filled tubes

Hemolyse

d sample

Leaking

specimens

Specimen

received

without

Clotted

samples in

anticoagul

Incorrect

sampling

time

Missed

samples


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CHECK

Reject Samples (Mar'08-Dec'08)

4

24

44

64

% of samples rejected 2.64 2.31 2.77 2.26 1.11 1.22 0.62 0.71

Number of sam les re ected 74 64 81 71 32 45 25 27

May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08

Desired

Result


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ACT

To continuously strive for Zero rejections

Share the success story with other departments

and hospitals


20/20

Quality Improvement

@Lifeline Hospital

24 x 7 x 365

Thank You

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