Clinical Pathology Quality Dashboard March 2009

Clinical Pathology Quality Dashboard Inpatient Phlebotomy First AM Blood Draws

Clinical Pathology Quality Dashboard Inpatient Phlebotomy First AM Blood Test Results: PT/PTT, CBCP, and Comprehensive Panel

Inpatient Phlebotomy Draws Fiscal Year 2009 Clinical Pathology Quality Dashboard

Turnaround Times

Clinical Pathology Quality Dashboard Molecular Diagnostics Laboratory

Clinical Pathology Quality Dashboard Chemistry In-Lab Turnaround Times

Clinical Pathology Quality Dashboard New Clinical Assays Added in Last Year Yeast identification system: (Vitek II automated) Yeast antimicrobial susceptibility: (Vitek II automated) EBV viral load HIV-1 quantification (COBAS Ampli Prep – COBAS Taqman) (includes extraction, amplification) MRSA surveillance VRE surveillance C.difficile surveillance BCR/ABL1 Kinase Mutation Analysis (Sequencing) Human Erythrocyte Antigen Genotyping (Microarray analysis) IGH/BCL2 Translocation Detection (Real-time PCR) JAK2 V167F Mutation Detection (Allele-specific PCR) KIT D816V Mutation Detection (Allele-specific PCR) KIT Mutation Detection for GIST KIT Mutation Detection of Melanoma NPM1 Mutation Detection (PCR w/ capillary electrophoresis detection) Microsatellite instability analysis PML/RARA t(15;17) Translocation Detection (Real-time PCR) Urovysion – FISH, Bladder Cancer Detection HER2 Amplification – FISH, Breast Cancer UGT1A1 Promoter Genotyping K-Ras Mutation Detection 1,25 Dihydroxy vitamin D Sensitive beta-2 transferrin assay

UMHS Blood Product Utilization Clinical Pathology Quality Dashboard

CAP Proficiency Testing 2 nd Quarter FY 2009 Clinical Pathology 474 = Number of Challenges 99% = Satisfactory Results Anatomic Pathology 2 = Number of Challenges 100% = Satisfactory Results Department Total 476 = Number of Challenges 99% = Satisfactory Results

Clinical Pathology Quality Dashboard CP Financial Measures

Discontinue Cancer Center Hematology Lab (move to Main Lab) – Will Finn, MD, lead Improvement of Critical Value Callback process – Brenda Schroeder, lead Impact of Earlier AM Blood Draw in UH – OMS 490 students and Holly Eliot, leads Improvement of Communication with Patient Care Units – Beverly Smith and Brenda Schroeder, leads Customer Service Initiative – Beverly Smith, lead Lab Formulary Committee – Office of Clinical Affairs, FGP, Pathology Lean Process Improvement Projects – many! Laboratory Safety focus – Brenda Schroeder, lead Improvement of Blood Draw Wait Times - Cancer Center - Taubman 2 - Taubman 3 Creation of Blood Product Utilization Lean Team – Tim Laing, MD, (OCA), lead Clinical Pathology Quality Dashboard Clinical Laboratory Operations Initiatives

Clostridium difficile toxin screening algorithm – 1/09 On-demand unit-specific antibiograms – 2/09 Expedited (rules – based) release of ANCs (absolute neutrophil counts) – 2/09 Integrated hematopathology reports – 2/09 Troponin point-of-care (ED) – 3/09 Clinical Pathology Quality Dashboard Clinical Laboratory Service Enhancements

Kudos Thank you to the Phlebotomy Team! There has been a marked improvement in the average time of completed first AM blood draws in UH. (Please see Dashboard data.) Thank you to Jerry Davis (Hematology Lab), and his colleagues in the Lab and in Pathology Informatics for developing and implementing a new system that has expedited the rapid release of absolute neutrophil counts. (ANCs) Thank you to the Outpatient Phlebotomy team for a greater than 84% (to date) participation rate in the Employee Engagement Survey (open through March 27th). Clinical Pathology Quality Dashboard