Performance improvement (PI) metrics are a great way to assess the overall quality of your laboratory program. They allow you to track vital data related to CMS outcome measures, which can directly impact the financial well being of your organization. However, labs should be careful when choosing which metrics to monitor, and should routinely evaluate if the metrics they’re using are still meaningful to them.
Even a small laboratory will generate a ton of data throughout the year. The key questions to ask yourself are: 1) What do I want to know? 2) What will I do about it once I have the answer?
There may be different sets of metrics that laboratories will have to monitor and report, depending upon who the target audience of the final data analysis will be. Metrics and reports can be generated for your patients/customers, internal laboratory staff, management, and senior leadership. You may also be called upon to share your metrics with regulatory agencies as well to prove the effectiveness of your quality assurance program.
Ensure your reports are relevant and meaningful to the audience they are being shared with. Customer/Patient centered metrics can include items such as satisfaction survey results, average waiting time for outpatient blood drawing locations, and average cost/revenue per test. Internal laboratory staff metrics can include turnaround time reports for STAT tests, compliance with critical call notifications to providers, and percent completion for required monthly maintenance tasks. Higher level metrics that can be reported to management and administration may include performance on proficiency testing surveys, regulatory inspection results, and percent of corrected reports that were issued.
If goals have been met and sustained consistently, consider raising the bar and challenging yourself even further. Each metric should have 3 goals: 1) Minimum Threshold (must be achieved each review period), 2) Annual Goal (desired overall goal to account for monthly fluctuations in the data), 3) Stretch Goal (motivational tool, achievable but not guaranteed a high rate of success). Increase your minimum threshold limits to be closer to your stretch goals, and see what your particular organization can realistically meet and sustain. Be careful to not set unrealistic expectations, as this can lower morale and result in misleading interpretations of the data. Work with your clinicians and regulatory agencies to determine appropriate, and realistic goals, and utilize national benchmark standards when available.
Metrics that were added to address and monitor a specific known issue or problem should be evaluated for necessity once the issue is corrected. Consider reducing the monitoring of these items from monthly down to quarterly, semi-annually, or annually until you have confidence that it no longer requires monitoring.
When issues are identified, a root cause investigation should be performed with the intent of identifying the true cause of the problem – not to point blame to a particular person. The depth and intensity of your investigation will depend upon the specific metric which failed to meet its goal.
Properly identify the problem. To learn from our mistakes, we must first properly identify them. What may seem like an obvious root cause, may not be the real reason for an issue. For example, turnaround time metrics – if you did not complete STAT troponin tests in <45 minutes, simply purchase a new instrument that is faster. Well, it’s not quite that simple.
Break it down further into pre-analytic, analytic, and post-analytic times. Is the bulk of your 45 minute window taken up in the pre-analytic phase? Are samples being held in a central receiving area for 20 minutes and batched before being brought to the chemistry department? Are you testing serum (which needs to first clot before being spun) or plasma (which can be spun down immediately)? Is there a delay in verifying/releasing results into your LIS where autoverification would improve this process?
Before attributing instrument downtime as a cause, confirm that the outliers were in fact during the time period when the instrument was down. There’s a higher chance you have a pattern of poor TAT performance around change of shifts or meal breaks, than during a 6hr downtime on a single day in the month. Also look at how you are analyzing your metrics to ensure they are accurate. Are you including add-on tests based on their original received time, or based on when the troponin was added to the original order?
Develop a corrective action/preventive action plan. Based on what you identified to be the true root cause(s) that contributed to poor PI metrics, develop a plan for addressing these weaknesses. Identify who specifically will be responsible for performing each step in the action plan, and who will be held accountable for ensuring it was performed.
Implement the plan(s). Document the date the corrections were fully implemented, along with any delays or obstacles encountered.
Collect and analyze more data. Depending on the severity of the failed metric, you may want to begin analyzing the effectiveness of your improvement plan immediately. If there was a spike in the number of employee safety incidents reported last month due to ongoing construction in a department, the work conditions should be monitored daily/weekly for improvements.
Conversely, looking at data too soon may not paint an accurate picture of the true effectiveness of your corrective actions. Some corrective action plans may require several steps or phases for full implementation. For example, a process change will require an update to your procedure manual, retraining of all staff, and then rolling out the new process. This may take several days-weeks before 100% implemented and improvements can be detected.
Monitor the results. Check for sustainability of your corrections – staff may be on their best behavior the first week after being spoken to, but can return to old habits after that. They may not fully understand that although one process is easier for them, it is adversely affecting the overall performance of the entire lab team.
If you are consistently struggling to meet your metrics, consider looking for ways to implement lean process changes. Upgrading to a STAT spin centrifuge may save you 5 minutes on the pre-analytical side; but you may still have room for improvement. Do you consistently receive 20 samples at a time, meanwhile your centrifuge will only hold 8 tubes? Do you receive tubes of different sizes (adult vs pediatric), and is your centrifuge capable of quickly and easily interchanging inserts to accommodate both types?
Ultimately, be sure to engage your frontline staff and listen to their opinions on what is working, and what could be improved upon. They are the ones doing the tasks day in/day out, and are your subject experts on where some of the shortfalls may lie. Even if the answer is simply not having enough staff available, having detailed analytical metrics can help management justify the cost of adding additional team members, and also pinpoint the exact days and times where the help is needed most.
Kyle Nevins, MS, MLS(ASCP)CM is one of ASCP’s 2018 Top 5 in the 40 Under Forty recognition program. She has worked in the medical laboratory profession for over 18 years, and is currently employed at Northwell Health Laboratories on Long Island, NY. In her current position as a Laboratory Supervisor for the Northwell Consulting Team, she transitions between performing laboratory audits across the entire Northwell Health System, consulting for at-risk laboratories outside of Northwell Health, bringing laboratories up to regulatory standards and acting as supervisor and mentor in labs with management gaps.
-Kyle Nevins, MS, MLS(ASCP)CM is one of ASCP’s 2018 Top 5 in the 40 Under Forty recognition program. She has worked in the medical laboratory profession for over 18 years. In her current position, she transitions between performing laboratory audits across the entire Northwell Health System on Long Island, NY, consulting for at-risk laboratories outside of Northwell Health, bringing laboratories up to regulatory standards, and acting as supervisor and mentor in labs with management gaps.