UTMB Laboratory Pre-analytical Time Improvement November 5, 2010

The Team Alexander Indrikovs Anthony Okorodudu Jeffrey Richards Bert Nash Theresa Friloux SPONSOR: Donna Sollenberger CEO, UTMB Health System

Aim Statement By September 1, 2010, decrease by one hour the time at which Sample Management completes processing of outpatient samples.

Why We Selected This Goal Outpatient work accounts for 2/3 of all lab tests Most of these samples arrive in the laboratory between 5 PM and 11 PM Prolonged outpatient processing delays inpatient testing Laboratory automation is approved for FY11. For maximum benefit, we must have a continuous flow of specimens into the automated line.

Scope of UTMB OUT PATIENT SERVICES: TDCJ Units, Regional Maternal & Child Health Clinics, & UTMB Community Based Clinics

Courier Arrival Times 6

Clinical Laboratory Workflow EDTA tubes Receive into lab Sort Sample tubes Bottleneck - > 70% of pre-analytic time Load centrifuge Unload centrifuge Decap Label aliquot tubes Aliquot Sort Walk to analyzers Pre-Analytics 70% of turnaround time Load analyzers Analytics / Post-Analytics 30% of turnaround time Store racks Archive tubes Recap tubes Walk to storage area Unload analyzers Verify/ Manage exceptions Rerun exceptions Locate exceptions Verify at LIS To summarize, with Abbott you will have the flexibility to implement some or all of our solutions which will help streamline your process. This diagram depicts a typical laboratory process. By implementing a pre-analytic automation such as ACCELERATOR APS you will be able to automate the most labor intensive processes in the lab. Informatics can address many of the post-analytic steps such as archiving and results validation. Implementation of a track will eliminate the sneaker net and tube storage and retrieval will automate add-on and repeat testing. Furthermore, APS gives you the flexibility to any or all of these components at any time ensuring that your system will grow and change as you do. Find tube Load on analyzer Verify at LIS Unload analyzer Recap tube Archive tubes Store racks

Pre-printed Labels

Tube Sorting

22.00 10

Sources of Lab Errors

Process Evaluation People Process Equipment Management SOPs inadequate Staff in SM not adequately trained Inadequate training materials SOPs written prior to transition to interfaced testing Staff in SM not adequately trained Orientation not well-organized Multiple order entry processes Multiple order entry processes Most SM Staff not highly educated Different processes for individual clients Clients not knowledgeable about packaging & submission requirements Workstation pending lists inaccurate Errors and delays in pre-analytical processing compromise full benefits of planned laboratory automation system Orders placed for uncollected samples Orders placed more than once Clients not trained about the requirements? Multiple sample packing systems Staffing not adequate or aligned with workload? Errors and delays in pre-analytical processing compromise full benefits of planned laboratory automation system High turnover Different clinics have their own preferences Tecans, frequently fail Inconsistent leadership in SM Staff not knowledgeable on maintenance and repair No team leader on the night shift. Training not ongoing TDCJ samples not bar-coded Suboptimal use of information technology Supervision has not had clear accountability since rebuilding CES lacks parts and expertise maintain Tecans CES not accountable for Tecan performance Suboptimal use of information technology Equipment TDCJ samples not bar-coded Management No one to divide up work on the night shift BC printers not available in units Management Equipment 12

Previous Receiving and In-Lab System Courier Arrives with patient samples Verify Receipts with courier Print Manifest Use Manifest to “In-Lab” Print CERNER Labels Find manifest; Match Samples with labels & Label Tubes Walk to Analytical Area Tecan: Aliquot & Sort Tecan: Decap Tubes

Interventions Installed bar code label printers at 85 Texas Department of Criminal Justice (TDCJ) units Trained TDCJ staff on use of new labeling process Piloted new sample accessioning process with one TDCJ route Implemented new process with all Regional Maternal Clinics

New Receiving and In-Lab System Courier Arrives with patient samples Verify Receipts with courier Print Manifest Use Manifest to “In-Lab” Print CERNER Labels X Pre-Receipt processing In-Lab Samples, Print Labels And Place on Tubes Modified Streamlined from 9 to 6 steps and modified 3rd step in new system Walk to Analytical Area Tecan: Aliquot & Sort Tecan: Decap Tubes

Benefits of Improved Process Standardize to one process for receiving all interfaced orders Decrease errors by printing labels and labeling tubes on one patient’s samples at a time Finish processing Outpatient samples before AM Inpatient samples arrive in the lab Allow testing areas to monitor pending workload Eliminate batch processing to provide continuous flow of samples to the labs

Time of Day Last Samples are Ready for Analysis April – July 2010 September – October 2010 10.00 Time Out 4.00 0.00

Summary Measure April –July 2010 Sept 15-Oct 29 Mean Time out 04:22 1:05 Standard Deviation 02:37 0:29

One Measure of Success: Turn Around Time (TAT) for Potassium May 18, 2010 Oct 26, 2010 Average TAT (hrs) 4.8 2.2 SD (hrs) 6 2.5 % Completed within 4 Hrs of in-Lab 68 90

ROI: Financial Decrease in Sample Management overtime by 46% in September, 2010 or cost reduction by $994; extrapolated to ~ $12,000 per year Redirected effort of Client Services staff spent on troubleshooting order errors; now used for answering physician and/or provider phone calls Gains in technical efficiencies/redirection of labor: to be determined Potential impact of improved TAT on ALOS: to be determined

ROI: Patient Safety Decreased pre-analytical errors with resultant increased reliability of lab results Improved TAT can result in faster decisions for patient diagnosis and treatment

Next Steps Train all Sample Management staff in new process - completed Fully implement new process for all outpatient samples - completed Monitor new process for error rates and turnaround time - ongoing Implement Automated Track System – submit RFP

Thank You! Thank you for your time! Sample Management Division at UTMB CMC Laboratory & Information Service Teams UTMB Pathology Client Services Team Regional Maternal & Child Health Clinics Thank you for your time!