1. Implementing Rapid Real-time Process “Defect” Collection to Optimize Anatomic Pathology Workflow: A two pronged approach Based on End-User Work Setting Michael Riben, MD 1, Leslie Nesbitt, 1 Shibu Ninan 3,Mark J. Routbort, MD, PhD 2 Departments of (1) Pathology and (2) Hematopathology, and the (3) Section of clinical Laboratory Informatics, Division of Pathology and Laboratory Medicine, University of Texas MD Anderson Cancer Center Houston, TX

2. Context - Background Our workflow optimization project leverages manufacturing based quality improvement methods, such as Lean and Six Sigma, which strive for zero “defects” as a measure of quality. We have implemented a change management infrastructure that utilizes data collection and analysis to aid decision making

3. Context: Background In order to analyze the type and kind of defects occurring in our workflows, we strove to implement a “defect reporting system” that would fit into the entire staff’s workflow for real time collection, whether they worked at a workstation that included a computer, or not.

4. Definition of Defect: a flaw, an imperfection, or a deficiency in specimen processing that requires us to delay or stop our work or return work to the sender. We interpreted this definition to apply to all aspects of case workflow Types of waste included process flaws associated with overproduction, time waiting, transportation, processing, stock on hand, movement, defective products, dictation problems, etc… Measures of Process Defects and Waste in Surgical Pathology as a basis for Quality Improvement Initiatives Richard J. Zarbo, MD, DMD and Rita D'Angelo, MS, ASQE, SSBB Am J Clin Pathol 2007;128:423-429.

5. Criteria for a optimal Defect Reporting System: Easy to use Real-time data capture Equal access to all Standardized Menu-drive Defect capture closest to discovery Visual presentation and public exposure Blameless participation Compliance with participation Reusability. Measures of Process Defects and Waste in Surgical Pathology as a basis for Quality Improvement Initiatives, Richard J. Zarbo, MD, DMD and Rita D'Angelo, MS, ASQE, SSBB Am J Clin Pathol 2007;128:423-429.

6. The Visual Data Displays ❚ Image 1 ❚ Visual data display poster showing data entries by pathologists that captured detail on misidentifications arising in the surgical pathology process. Measures of Process Defects and Waste in Surgical Pathology as a basis for Quality Improvement Initiatives Richard J. Zarbo, MD, DMD and Rita D'Angelo, MS, ASQE, SSBB Am J Clin Pathol 2007;128:423-429.

7. What walls?

8. What Walls?

9. Technology: We utilized paper-based customized Post-it® (3M) notes with a 4 quadrant design, and developed a custom data entry form in PathStation, our VB.Net/SQL based workflow integration software application. (previously described)

10. Design A coded defect classification and location/process list was developed and distributed to all employees. The data collection event lasted for 12 working days. For non-computer based workstations, defects were captured in real-time using the custom designed Post-it notes using the coded choices Completed Post-it® notes were posted in each lab at designated “ wall” locations. We did not have space for Visual Data Displays, described by D’angelo et al due to space constraints. Notes were collected every other day for data entry into the electronic module. Running totals were reported back to each area on an ongoing basis For computer based settings, an integrated “defect” collection module automatically set user context, case context, date/time, user location, and utilized an identical defect classification. A running total was always visible in the module. All entered defects were visible and sortable on a display tab. Ultimately, all defects were recorded into the electronic module to facilitate visibility to the widest possible audience and allow for data analysis.

11. Process for Non-computer based workstations The “analog” process

12. Distributed Defect codes

13. Distributed Defect Codes and Locations

14. Custom Post-it®

16. Analog Visual Displays

17. Providing Feedback Sample of Posters placed in all areas with running totals

18. PathStation Defect Reporting Module The Electronic Process

19. PathStation access Added button to the main tab of Pathstation

20. Electronic Defect Reporting Module

21. Electronic – Case/Patient Context Set. the Submit – View Process Defects form will open with the field auto populated.

22. Indicating where the defect occurred To indicate the location where the defect or process has occurred click on the dropdown arrow to the left of the field and select a location. Location codes are grouped by major areas. Note this is not the location documented. We automatically set this by where PC device name and known location for all PC’s,

23. Selecting a Defect code Defect codes are grouped by asset or process.

24. Selecting a Defect code Defect codes are grouped by asset or process.

25. Adding comments

26. Submitting a defect

27. Viewing the defects

28. Running total of defects and details The defects are listed in a table view with sortable columns.

29. Results A total of 1291 defects were detected over a 12 consecutive reporting work days 917 unique cases

30. “Nesbitt” Classification GroupDefects Communication76 Hardware11 Identification349 Procedural430 Software4 Technical315 Tracking71

31. “Nesbitt” Classification

32. Defects by Case Type

33. Defect Occurrence

34. Where Defects Reported

35. Conclusions The ability to document “defects” in real-time enhances reporting opportunities and increases compliance with data gathering events, critical to designing improvements that optimize efficiency and quality. We demonstrate the ability to document the defect identified in less than 5 seconds in settings with, and without, a computer workstation.

36. Next Steps Implement Workflow changes Re-collect defects Compare defect capture before and after workflow optimization