Applying Best Practices

A look into Best practices toward lab cost reduction, compliance and reimbursement, administrative needs and ‘perfect pathology’

Vol. 23 • Issue 5 • Page 16

Quality Management

Quality affects many aspects of laboratory process with tangible benefits. Process improvement maximizes efficiency by reducing redundancy and rework, thus reducing operating costs. It improves patient care by reducing the time to diagnose and treat and reduces misidentification while assuring the most accurate result possible. Increased efficiency improves staff morale and encourages staff interdependence. Continuous Quality Management (CQM) ought to be the priority of every lab.

Cost Reduction

Processes such as CQM, LEAN or Six Sigma can have a dramatic impact on cost reduction. To start, document your current “as is” practice and develop a “to be” best practice, identifying the constraints with related costs. Dashboards quickly can identify actionable details to address bottlenecks and QA issues.

Next, prioritize constraints that address people, process change and technology. Apply automation as cost and safety justified.

Measurable results will include decreased TAT for tissue processing and staining along with an associated increase in production. Direct cost savings typically result in:

  • 15% reduction in re-work
  • 10-20% increase in cases processed per hour per technician
  • 15% reduction in reagents and
  • 7-15% pathologist productivity.

Indirect benefits typically are improved employee satisfaction through workload leveling and continual self-administered feedback.

Lab Cost Reduction
Click to view larger graphic.

Compliance, Reimbursement Accreditation

An “all-hands-on-deck” approach just before inspection is not a good practice. The proactive use of dashboards with defined weighting factors and pre-established key performance indicators (KPIs) are a much more efficient way to manage.

The Centers for Medicare & Medicaid Services (CMS) also has reimbursement quality requirements. The law requires CMS to use a value-based payment modifier. In 2015 with 2013 data, hospitals risk lab reimbursements. Ongoing Professional Practice Evaluation (OPPE) as dictated in CMS regulations and the Joint Commission provide the framework for monitoring that all providers meet or exceed the standard of care. Contract/reference labs must also have performance indicators in the contract that can be measured to prove standard of care is being met.

The best defenses against medical malpractice claims are quantitated evidence of good policies and procedures. Automated QA assures this is done. Best practice dictates that data be derived from the operational confidential peer review process. Not all labs are the same. They have specific CAP checklists, residents or high staff turnover. Different needs for clinical score vs. soft skill blending, different weighting of QA factors with exclusions and different alerts techniques when score goes below KPI(s) also factor into this.

The CMO, performance improvement, risk management and credentialing departments need your data to support administration. Reports should be a byproduct of a job well done with specific weighting and exclusions. They can be granted limited access to vetted reports directly through a role-based interface. Resident program offices respond to ACGME requirements. They must track and report on resident quality. Your system should automatically provide feedback to residents on their slide preparation, gross dissection, diagnosis, etc.

Perfect Pathology

Your goal should be to optimize your ability to provide accurate and timely diagnoses in support of clinical decision making, thus ­maximizing patient safety. This must include monitoring the entire cycle, identifying pre-analytic, analytic and post-analytic variables that contribute to errors. It must leverage quantitative, detailed data that is actionable.

Perfection should be the goal when preparing specimens, verifying ID and performing the diagnosis. Automated peer review and QA process assures errors are caught, documented and acted on. Digital pathology (e.g., slides, gross videos and extramural scanned reports) should be centralized for effective QA.

Both LEAN and Six Sigma approaches are best when you manage-by-exception vs. parsing reports. Dashboards are used to present summary information with supporting drill-downs for details. Thresholds should trigger traffic light indicators changing from green to yellow or red along with task alerts. You should have pre-established intervals for pro forma reports for weekly/monthly meetings, QA meetings, and continually “ratchet” tolerances for CQM.

People and Lab Processes

When QA is automated, people are guided through the processes. With actionable data, details can be used to address issues. Reporting of issues dramatically drops off as quality is incrementally improved (as a result of continuous CQM).

Peer review process should include PAs, lab techs, transcriptionists and secretaries. Individuals like feedback on quality, if it’s quantitative. Leverage individualized dashboards, individual performance as compared to the department average and CAP thresholds or KPIs. Managers see the performance of their subordinates. This process becomes self-policing and often eliminates the necessity for individual one-on-one, stressful interim performance reviews.

Staff management involves certification, authorized equipment, procedures and locations. Reviews must be accomplished on schedule. Deviations must be documented and corrected. Typically this is managed with forms and stored in folders. Now automation exists to ensure compliance and support proactive management of lab staff. Supervisors can be automatically alerted to deviations or when reviews need to be undertaken. Periodic reviews ought to include quantitated data automatically pulled from the QA system, then weighted with proper exclusions. Staff should be able to see their performance compared to the department average, specialty or other KPI.

Process Change

Document “as is” practice vs. “to be,” transforming manual responses derived from forms and reports to proactive, timely alerts when issues arise. Leverage your LIS for automated triggering events to alert specific clinicians or managers of tasks. Alerts and specific guidance are a part of task automation to reduce human efforts and minimize potential for error.

Accommodations need to be made for residents and/or new staff who need focus on specific quality demands. Residents and fellow program offices can respond to ACGME requirements to track and report on their quality and progress. Gauges depict where KPI is out of tolerance. Leverage this information in the LIS (e.g., trigger QA and peer reviews and incorporate exclusions based on CPT). This eliminates redundant data entry and provides alerts when stats are out of spec.

For QA automation to be effective, it must reduce the current effort and support proactive management. Technology to consider may include:

  • QA interface to specific LIS
  • User definable thresholds for triggers and exclusions
  • Flow logic that assigns QA tasks to the proper individual
  • “In box” for task sorting, prioritization and management
  • Menus that adjust to the type of QA being performed
  • Definable KPIs and weighting for the various QA elements
  • Role-based interface, configured for the person and task

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