Cohort 8: Overdue Results at Westover Hills

Cohort 8: Overdue Results at Westover Hills

Clinical Safety & Effectiveness Cohort # 8 Overdue Results at Westover Hills DATE Educating for Quality Improvement & Patient Safety Team Makeup Stella Koretsky, MD, Medical Director - Westover Hills Jeanette Hernandez, Clinic Manager - Westover Hills Valerie Works-Gomez - Director, HIM - UT Medicine John Cange - Director, EpicCare - UT Medicine Extended Team: Glen Lam, Reporting Analyst - UT Medicine Jarrod Power, EpicCare - UT Medicine Tim Davis, HIM Mgr. - UT Medicine Eli Mendiola, HIM Supv. - UT Medicine Cindy Escalera, MA - Westover Hills Efrain Esqueda, LVN - Westover Hills Roxanne Gonzales, MA - Westover Hills Hope Nora, PhD - CS&E Consultant / Advisor

AIM Statement Reduce Overdue Results at Westover Hills Family Medicine clinic by 80% by September 30th, 2011 Problem Definition Overdue Results (ODR) occur when expected date for an ancillary result is exceeded by: 7 days for a Future order 0 days for a Clinic-performed Normal procedure (A1C, UA) ODR messages are delivered to clinical staffs Epic (EMR) In Baskets. With nearly 1,900 messages to manage, staff is overwhelmed; creating a delay in working messages. ODR negatively impact timeliness of Patient Impact of ODR 1. National Committee for Quality Assurance (NCQA)

Track and Coordinate Care Standard (#5) Practice has documented process for and demonstrates: o Tracks lab tests and flags and follows-up on overdue results. 2. JCAHO The JCAHO requires health care organizations to track and improve the timeliness of reporting and receipt of critical test results by the responsible licensed caregiver. Analysis of Laboratory Critical Value Reporting at a Large Academic Medical Center. Anand S. Dighe, MD, PhD,1 Arjun Rao, MBBS, MBA,2 Amanda B. Coakley, RN, PhD,3and Kent B. Lewandrowski, MD1 Am J Clin Pathol 2006;125:758-764 3. Lit. Review: no relevant ODR, patient safety studies found in moderate scan of the literature (PubMed, NEJM, Google). Project Timeline First Team Meeting & Deliverables 5/18/11 AIM statement 1 Cause/Effect (Fish) diagram Scope Decision: Labs & Imaging

Document Imaging Analysis: 6/1/11 Discuss Lab Issues duplicates, panel tests, Quest: 6/15/11 Re-scope : Labs emphasis AIM statement 2 Data Analysis / Research: 6/15/11 9/15/11 (ongoing) ODR Baseline Data Collection: 1,895 Total ODR at WH Hills: 6/24/11 Interventions 1-X clean ODR message queues: 6/25/11 8/16/11 Intervention Z institutionalize process changes, train providers: 9/1/11 Finalize Control Charts for Presentation: 9/7/11 Deliverables & Project Presentation TODAY! Quantify the Problem: UT Medicine vs. Westover Hills Annual # Orders UT Medicine: 454,984 UT Medicine: 22,528

(projected) Overdue Results (projected) = 4.9% OVERDUE (ALL UT Medicine) Annual # Orders Westover Hills: 14,063 (projected) Overdue Results (6/24/11 snapshot) Westover Hills: 1,895 Categories of Overdue Results - UT Medicine 20,000 94.9%

91.8% 88.5% 99.2% 97.2% 100.0% 90.0% 80.0% 15,000 70.0% # Overdue Results 60.3% 60.0% 50.0% 10,000 40.0%

30.0% 5,000 20.0% 10.0% 0 WH FM 15% of Total Lab ODR Message 0.0% ab L m I g in ag CG E

gy lo o r eu N c ia d ar C i rv e S s ce Categories i M

gy lo o i ob r c O CH E Quantify the Problem: Westover Hills Westover Hills makes a good pilot site for UT Medicine-wide rollout. WH ODR is nearly 3 times the average for all UT Medicine. Also: 6.54% of Normal orders overdue 49.55% of Future orders overdue DISCOVERIES

June to September, 2011 H&H vs. CBC issue BUN vs. Chem confusion Duplicate tests/results: Quest error, provider error Physicians not changing Expected Date default (today) Result Notes column header is not about Results creates confusion Clinic staff not always resulting sameday POC tests/procedures (causes ODR for same-day tests) DISCOVERIES June to September, 2011 H&H vs. CBC issue BUN vs. Chem confusion Duplicate tests/results: Quest error, provider error Physicians not changing Expected Date default (today)

Result Notes column header is not about Results creates confusion Clinic staff not always resulting sameday POC tests/procedures (causes ODR for same-day tests) DISCOVERIES June to September, 2011 H&H vs. CBC issue BUN vs. Chem confusion Duplicate tests/results: Quest error, provider error Physicians not changing Expected Date default (today) Result Notes column header is not about Results creates confusion Clinic staff not always resulting sameday POC tests/procedures (causes ODR for same-day tests) DISCOVERIES June to September, 2011 H&H vs. CBC issue

BUN vs. Chem confusion Duplicate tests/results: Quest error, provider error Physicians not changing Expected Date default (today) Result Notes column header is not about Results creates confusion Clinic staff not always resulting sameday POC tests/procedures (causes ODR for same-day tests) Interventions Imaging / HIM Interventions: 6/25/11 1. Establish Productivity Standards for HIM Document Imaging Services Scan TAT of 72 hours or less -- 400 clinical documents /8 hr. day to meet required 2. Improve document delivery: WH Clinics to UT Med HIM via UTM Courier 3. Reduce Provider-to-HIM handoffs so Provider handles

one result via in-basket EpicCare Applications: 7 /15/11 1. Remove Results Notes is not really about Results 2. Increase reliability of ODR data and message delivery by correcting message delivery settings (releasing ~5,000 ODR held in error to clinic pools) Westover Hills Clinical Operations: Total Overdue Results at Westover Hills Family Medicine During & Post-Interventions 2068 WH Staff training and awareness 1868 HIM Productivity Standards Implemented 1668 WH Ops Letters and phone calls to patients 3 attempts, 3-4 weeks # O v

e r d u eR e s u lts 1510 1510 1468 1268 1068 EpicCare corrections, Improved data/reporting 1269 1269

1029 1029 868 24-Jun 30-Jun 7-Jul 12-Jul 19-Jul 26-Jul 2-Aug 9-Aug 17-Aug 23-Aug 30-Aug 6-Sep 13-Sep Post-Intervention to Today WH Cleanup efforts: cancelling orders of non-responsive patients, etc. New Overdue Results by Week 261

221 221 211 160 161 132 132 111 101 61 43 43 41 11

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 01 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 201 2 2/ 9/ 6/ 3/ 0/ 6/ 3/ 0/ 7/ 6/ 3/ 0/ 7/ 3/ 0/ 7/ 4/ 1/ 8/ 5/ 2/ 9/ 5/ 1/ 1/ 1/1 1/2 1/3 2/ 2/1 2/2 2/2 3/ 3/1 3/2 3/2 4/ 4/1 4/1 4/2 5/ 5/ 5/1 5/2 5/2 6/ 1 1 1 1 1 1 1 1 1 01 201 201 201 201 201 201 201 201 2 / / / / / / / / / 26 7/3 /10 /17 /24 /31 8/7 /14 /21 6/ 7 7 7 7 8 8 New ODR Messages 172

159 159 106 106 53 53 132 112 92 72 52 32 6/19/2011 6/26/2011 7/3/2011 7/10/2011

7/17/2011 7/24/2011 7/31/2011 8/7/2011 8/14/2011 8/21/2011 Post-Intervention 2051 # Overdue Results by Week # ODR Messages 152 Total Overdue Results by Week - WH 1851 1651 1451

1620 1620 1328 1328 1036 1036 1251 1051 851 24-Jun 30-Jun 7-Jul 12-Jul 19-Jul

26-Jul June 24 --> post-intervention 2-Aug 9-Aug 17-Aug 23-Aug Return On Investment 4 Providers * 1 extra PT/session * 8 sessions/week = 32 extra PTs/week * $100 (avg rev/visit) * 42 weeks = Gain from Investment = $134,400 ($33,600 per provider, annually) Less Cost of Investment = $40,000 (Team resources @ 400 hrs * $100/hr., incl. benefits) Net

Gain on Investment = $96,000 (4 Providers) ROI = 2.36 Lessons Learned ODR can reduce provider productivity 1 PT / session Prior efforts masked problems: Postponing results only removes message from InBasket, not ODR Report or work queue Continuous effort is required to maintain manageable levels Keep analyzing your data and trying new charting / graphs Identify the data that is really needed sooner, rather than later Get expert help and guidance (fresh eyes), if needed Define and re-define problem(s) clearly, re-examine assumptions

Project Results Project Objectives: 1. 2. 3. Reduced Total Westover Hills ODR messages by 55% (but not 80%) Reduced # of new ODR messages by 63% Achieved Manageable number of ODR messages (~1,000) Operations Improvements: Achieved Positive, Meaningful ROI: 2.36 (to 1) 5. WH FM cleanup process institutionalized 6. Improved Physician understanding of Setting appropriate Expected Dates for Normal vs. Future orders 4. Project Artifacts: 7. Developed / Delivered Improvement Recommendations

Project Results Project Objectives: 1. 2. 3. Reduced Total Westover Hills ODR messages by 55% (but not 80%) Reduced # of new ODR messages by 63% Achieved Manageable number of ODR messages (~1,000) Operations Improvements: Achieved Positive, Meaningful ROI: 2.36 (to 1) 5. WH FM cleanup process institutionalized 6. Improved Physician understanding of Setting appropriate Expected Dates for Normal vs. Future orders 4. Project Artifacts: 7. Developed / Delivered Improvement Recommendations

Project Results Project Objectives: 1. 2. 3. Reduced Total Westover Hills ODR messages by 55% (but not 80%) Reduced # of new ODR messages by 63% Achieved Manageable number of ODR messages (~1,000) Operations Improvements: Achieved Positive, Meaningful ROI: 2.36 (to 1) 5. WH FM cleanup process institutionalized 6. Improved Physician understanding of Setting appropriate Expected Dates for Normal vs. Future orders 4. Project Artifacts: 7. Developed / Delivered Improvement Recommendations

Recommendations UT Medicine Teams: EpicCare: Results Notes column removal HIM: establish QI analysis of Document Imaging WH Clinic: continue ODR monitoring, report reviews Use ODR Message Management Guide Leadership: Continue support of QI efforts (like this CS&E project) Future Cohort(s): Establish Project Team to continue data collection and analysis of ODR reasons for continuous improvement Rollout ODR cleanup process to all UT Medicine clinics ODR Message Management Guide (work in progress) Reason for ODR LAB PANEL / COMPONENT Staff Action If test is included in

comprehensive panel, Cancel order or enter a result referencing the lab panel Contact patient, if patient does not intend to get proc/test done, Cancel the order, notify physician, send letter to patient For non-interfaced results, obtain results, send to HIM for document imaging DRAFT PATIENT-BASED RESEARCH Thank you! Educating for Quality Improvement & Patient Safety

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