National Reference Laboratory Quality Assurance Dashboard. Quality Improvement Metrics Q2 2017

Transcription

1 National Reference Laboratory Quality Assurance Dashboard Quality Improvement Metrics Q2 July

2 INTRODUCTION National Reference Laboratory (NRL), part of Mubadala's network of world-class healthcare providers, created in partnership with and managed by Laboratory Corporation of America (LabCorp), recognizes that a successful clinical laboratory network requires supportive management with clear direction and goals guided by patient and client-focused laboratory policies and sustained regulatory oversight. To guarantee efficient, up-to-date operations and collective benefits across all laboratories, the Quality Assurance (QA) department together with the Technical Operations team are collaborating to review all of the current test procedures in every NRL facility to ensure standardization and the sharing of best practices. Goals were set at designated timeframes to complete a three stage review with the technical, scientific and Quality Assurance team s involvement in order to finalize the procedures for staff distribution. The first phase of the project began in January and concluded in June of. This initial phase comprised the review of 231 procedures within the following scope: routine chemistry, hematology, coagulation and urinalysis, blood bank and point of care testing. More complex and esoteric testing will be assessed during the second half of the year as phase two of the project commences. This technical procedure standardization project across NRL s network provides the following benefits: - facilitates streamlined management of the network through standardized procedure templates which allow quality review of test menu, reference ranges, adherence to manufacturer s guidelines, and the validation of operational practices to ensure compliance with regulatory requirements - improves the process of bi-annual documents review of multiple procedures from the various sites - maximizes the quality of monitoring practices through an effective, controlled document management system An overview of the project status is provided below which compares the target goal with the actual progress: Technical SOP Project Plan - Phase 1 Jan to March April May June Total Goal: Total Number of SOPs to be Reviewed Actual: Total Number of Reviewed SOPs National Reference Laboratory, QA Dashboard Q2 Page 2 of 5

3 Procedure Project Plan - Phase 1 Progress Q1 Apr-17 May-17 Jun-17 Goal: Total Number of SOPs to be Reviewed Actual: Total Number of Reviewed SOP STRATEGIC QUALITY METRIC 1. New Test Integration Test menu expansion to achieve enhanced patient, quality care and business growth is an area that must be monitored for appropriate management. Patient and client impact and the cost to integrate new tests and sustain the current test menu are key considerations in this endeavor. NRL collects all relevant data before an assay is added to the test compendium to ensure quality of care and operational processes. During Q2, the following tests were integrated into NRL s test menu and are now offered to all clients. Order Code Order Code Name CPT Code T- and B-Lymphocyte and Natural Killer Cell Profile HIV-1/2 Ab Confirmation and Differentiation, Serum 86355, 86357, 86359, Human Immunodeficiency Virus-1 Qualitative RNA, Plasma National Reference Laboratory, QA Dashboard Q2 Page 3 of 5

4 KEY PERFORMANCE INDICATORS 1. Technical Support / Speed of Answering Calls Technical Support responsiveness is key for all other indicators. The timely support provided to clients ensures that the answers to their questions will facilitate more accurate specimen submission and/or process completion. Therefore, tracking and improving processes relative to call abandon rates is an indicator of customer satisfaction. The average time it takes to answer a telephone call is measured in wait time which is the average time, in seconds, that a caller waits/holds in queue for a Technical Support Representative. Target: 12 seconds Average wait time was just above the target at 13 seconds for the first time during the month of April due to staff on scheduled and emergency leaves. May and June showed a return to the target and the response time is once again meeting the appropriate response time. Seconds Client Average Wait Time - Target < 12 sec. Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec 2. Quality Concerns/Non-Conformities Monitoring The investigation, review and monitoring of nonconformities is an important component of NRL s Quality Management System (QMS). Utilizing the Corrective Action Preventive Action (CAPA) module in NRL s electronic, document control management system, the QA department is able to identify, track and control nonconformities which are referred to as Quality Concerns. There are two types of Quality Concerns: Internal and External. Internal concerns are identified by staff within the organization. External concerns are raised by clients and customers for necessary follow- National Reference Laboratory, QA Dashboard Q2 Page 4 of 5

5 up and resolution. Identifying the root cause of non-conformities is essential for continuous quality improvement. Monthly Quality Concern Meetings are held with representatives from all departments including management, finance/insurance, business development, technical operations and information technology. The meetings focus on data review and analysis for associated improvement. Their mission is to: - enhance NRL s level of service provided to clients - detect potential errors internally and identify educational opportunities - identify the root cause of non-conformities and formulate corrective and preventive action plans - monitor quality concern data and key performance indicators Target: < 0.2% of total monthly test volumes The rate of internal and external quality concerns raised and addressed during Q2 are well below the 0.2% threshold. 0.07% 0.06% 0.05% 0.04% 0.03% 0.02% 0.01% 0.00% Rate of Quality Concerns - Target < 0.2% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Summary: Overall, National Reference Laboratory has had a successful second quarter in by maintaining acceptable Key Performance Indicator targets. Additionally, effectively implementing and monitoring the standardization of technical procedures across the network as per the planned schedule was positively accomplished. National Reference Laboratory, QA Dashboard Q2 Page 5 of 5