2011 Qmt Catalog

TM

2011 QUALITY MANAGEMENT TOOLS

www.cap.org

Every number is a life.TM

Q-PROBES In-Depth Quality Assessment Program

Q-TRACKS Continuous Quality Monitoring Program

LMIP Laboratory Management Index Program

CAP LINKS The Laboratory Integrated Knowledge Source

Quality Management ToolsThe CAPs comprehensive collection of Quality Management Tools (QMT) strengthens your knowledge of key laboratory processes, identifies quality improvement opportunities, and provides the information you need for effective laboratory management:

Q-PROBES In-Depth Quality Assessment ProgramQ-TRACKS Continuous Quality Monitoring ProgramLMIP Laboratory Management Index ProgramCAP LINKS The Laboratory Integrated Knowledge Source

The CAPs Quality Management Tools help you:Identify quality improvement opportunities and monitor progress over timeEstablish realistic goals for your laboratory using a set of customized external benchmarksDemonstrate the ability to meet accreditation requirements

Integrate QMT into your daily activities to support your quality improvement initiatives!

Available in all Q-PROBES and Q-TRACKS programs

Approved for Maintenance of Certificationby the American Board of Pathology

Quality Management Tools

2011 Quality Management Tools

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Quality ManagementToolsThe CAPs comprehensive collection of Quality Management Tools (QMT) strengthens yourknowledge of key laboratory processes, identifies quality improvement opportunities, andprovides the information you need for effective laboratory management:

Q-PROBES In-Depth Quality Assessment ProgramQ-TRACKS Continuous Quality Monitoring ProgramLMIP Laboratory Management Index ProgramCAP LINKS The Laboratory Integrated Knowledge Source

The CAPs Quality Management Tools help you:Identify quality improvement opportunities and monitor progress over timeEstablish realistic goals for your laboratory using a set of customizedexternal benchmarksDemonstrate the ability to meet accreditation requirements

Integrate QMT into your daily activities to support your quality improvement initiatives!

Quality Management Tools

College of American Pathologists

2 800-323-4040 Option 1 for Customer Contact Center

*The CAP requires accredited laboratories to have a quality management plan that covers all areas of the laboratory and includesbenchmarking key measures of laboratory performance (GEN.13806, 20316). The Joint Commission requires accredited hospitals toregularly collect and analyze performance data (PI.01.01.01, PI.02.01.01). CLIA requires laboratories to monitor, assess, and correctproblems identified in preanalytic, analytic, and postanalytic systems (493.1249, 493.1289, 493.1299).

Q-PROBES and Q-TRACKSoffer a comprehensive collection of tools tocomplement your quality management program needs.*

Q-PROBES

Laboratory Services for EmergencyDepartment (QP111)

Appropriateness of Plasma Transfusions(QP112)

Surgical Pathology Report Defects(QP113)

Clinical Consequences of SpecimenRejection (QP114)

Q-TRACKS

Patient Identification Accuracy (QT1) Blood Culture Contamination (QT2) Laboratory Specimen Acceptability (QT3) In-Date Blood Product Wastage (QT4) Gynecologic Cytology Outcomes:Biopsy Correlation Performance (QT5)

Satisfaction with Outpatient SpecimenCollection (QT7)

Stat Test Turnaround Time Outliers (QT8) Critical Values Reporting (QT10) Turnaround Time of Troponin (QT15) Corrected Results (QT16) Outpatient Order Entry Errors (QT17) Specimen Acceptability in BloodBank (QT18)

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Select Q-PROBES andQ-TRACKS studies tosupport your qualityimprovement initiatives.

Q-PROBES


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Q-PROBES

A Program for In-depth Comprehensive Assessment

Evaluate quality improvements in your lab With todays focus on reducing medicalerrors, laboratories strive to achieve and maintain excellence. Using short-termstudies, Q-PROBES provides a one-time comprehensive assessment of key processesin your laboratory.

Structure your data collection and analysis for success Use Q-PROBES to help buildand improve data collection and analysis processes that contribute to quality ofcare, patient safety, and outcomes.

Establish realistic laboratory benchmarks and performance goals ImplementQ-PROBES, an external peer-comparison program, to address process-, outcome-,and structure-oriented quality assurance issues. Establish benchmarks throughexternal database comparisons and compare your performance to that of peerorganizations to establish laboratory goals and improve performance.

Examine the effectiveness of key processeswith Q-PROBES.

Q-PROBES offers CE credit to all laboratory staff to help you build a solid foundationof education and knowledge within your organization.

Q-PROBES


Optimal turnaround time (TAT) for testing is a critical element of laboratory service for the Emergency Department(ED). TAT for laboratory testing may impact patient throughput in the ED, which, in turn, can then impact hospital bedcapacity management.

Laboratory TAT for key tests impacts workflow for ED physicians and staff as well as satisfaction of the ED pysicians withlaboratory services. As a result of TAT issues, the laboratory might expend additional resources for point-of-care (POC)testing or satellite laboratories in the ED.

Laboratory TAT for key tests impacts workflow for ED physicians and staff as well as satisfaction of the ED physicianswithlaboratory services. As a result of TAT issues, the laboratory might expend additional resources for point-of-care (POC)testing or satellite laboratories in the ED.

Laboratory Services for Emergency Department QP111

ObjectiveMeasure order-to-report TAT for laboratory tests frequently requested from the ED and measure the satisfaction of EDphysicians with the TAT provided.

Data CollectionFor a four-week period, participants will prospectively review specimens submitted to the laboratory for creatinineand CBC testing and microscopic urinalysis. For each test type, participants will identify three specimens per day,during the day shift, and record the times for test order, specimen collection, laboratory receipt, and result reports.For specimens not collected by the laboratory and for which the order and collection times cannot be determinedelectronically, participants may enlist the aid of ED personnel. POC testing is excluded from this study.

Participants will also send a questionnaire to ED physicians to determine the level of satisfaction with laboratoryservices. Physicians may access and return the questionnaire to the laboratory in an electronic format.

Performance Indicators

Primary:o Order-to-report TATs for creatinine, CBC, and microscopic urinalysis

Secondary:o Satisfaction of ED physicians with clinical laboratory services

New

This is a one-time study conducted in the first quarter.

ObjectiveAssess the conformance of plasma transfusion practice to institutional guidelines and assess the post-transfusioncoagulation testing documentation and extent of coagulation correction achieved.

Data CollectionParticipants will retrospectively review the records from 40 patients receiving plasma transfusion. For each patientsinitial plasma transfusion episode during his or her admission, the clinical indication and recent pretransfusioncoagulation laboratory values will be recorded and evaluated for conformance with the facilitys own guidelines.The study will require the examination of each patients post-transfusion record for documentation ofpost-transfusion coagulation testing and the degree of coagulation correction achieved.


Primary:o Rate of plasma transfusions that met institutional guidelineso Rate of pre- and post-transfusion coagulation testing

Secondary:o Rate of plasma units prepared but not transfusedo Rate of reported transfusion reactions

Q-PROBES


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Blood products are a precious medical therapeutic resource with potential for significant adverse outcome, yet theiruse does not always fall within accepted guidelines. Plasma transfusion is indicated for treatment of coagulopathiesdue to insufficient clotting factors and replacement of single clotting factors for which specific concentrates are notavailable. Hospital Transfusion Services and Transfusion/Blood Utilization Committees must track a variety of qualityindicators in order to meet accreditation guidelines. Appropriateness of plasma transfusion is a clinically relevantindicator, with impact on patient safety as well as inventory and cost.

Appropriateness of Plasma Transfusions QP112New

This is a one-time study conducted in the second quarter.

Q-PROBES



Amended surgical pathology reports convey new information or changes to diagnosis after a final report has beenissued. Report errors may cover a spectrum from the relatively innocuous (eg, the wrong clinicians name is on thereport or the patients age is incorrect) to serious errors that drastically affect patient management (eg, a malignantlesion mistaken for benign). Report errors are often detected through passive means, such as clinician discovery,patient discovery, case review for clinical conferences, or through mandatory case review at a tertiary treatmentcenter. Recent surveillance methods target more active means of detecting errors, such as double review of aselected population of cases (eg, all new malignancies), double review of a set percentage of cases, and review ofwritten reports by ancillary personnel.

Surgical Pathology Report Defects QP113

ObjectiveExamine the rate of report defects and the reasons for those defects, determine the means by which report defectsare discovered, and determine the effect of report defects on patient care.

Data CollectionParticipants will conduct two data collections. The first will prospectively identify all forms of amended reports over aperiod of 12 weeks, or until 50 amended reports have been reviewed, whichever comes first. For each case,participants will determine the type of error present and how the error was discovered. The second data collectionwill retrospectively identify amended reports that specifically involve diagnostic changes over a period of 12 monthsor to a maximum of 10 amended reports, whichever comes first. For each case, participants will determine how theerror was discovered and the degree of diagnostic change.

Performance Indicator Rate of surgical pathology report defects

Performance Breakdown

Breakdown of surgical pathology report defect reasons:o Misinterpretationo Misidentificationo Specimen defectso Defects related to the report itself

New

This is a one-time study conducted in the third quarter.

Q-PROBES


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Specimen rejection may have significant consequences for patients and their clinical management. Patients whosespecimens are rejected are frequently subjected to repeat specimen collection, resulting in inconvenience, thediscomfort of repeat phlebotomy or other collection procedures, and/or the potential need for blood transfusion dueto excessive iatrogenic blood loss. Specimen rejection and the need for specimen correction or recollection alsoultimately lead to a delay in specimen analysis and the availability of test results.

Clinical Consequences of Specimen Rejection QP114

ObjectiveQuantify the effect of laboratory specimen rejection on the delay in test result availability and determine the effecton test result availability by: a) the reason for specimen rejection, b) the detection method for mislabeledspecimens, and c) the laboratorys policy regarding resolution of improperly labeled specimens.

Data CollectionDetermine the number of blood and urine specimens received by the chemistry and hematology laboratorysections to identify 80 rejected specimens or until you have reviewed specimens for six weeks, whichever comes first.For each rejected specimen, record the following times: laboratory receipt, time specimen deemed unacceptable,request time of specimen recollection, and time of recollected specimen receipt. Rejected specimens will becategorized as improperly labeled or inappropriate or inadequate specimen.

This study excludes blood and urine specimens submitted for highly specialized testing, including flow cytometric,molecular DNA or RNA, and/or cytogenetic analysis, as well as specimens for point-of-care testing.


Primary:o Median specimen processing delay for all rejected chemistry and hematology blood specimens, regardless of

the reason for rejection

Secondary:o Percentage of rejected chemistry and hematology blood specimenso Percentage of corrected or redrawn chemistry and hematology blood specimens received

Performance Breakdown

Breakdown of rejection reason for the two groups:o Improperly labeled specimeno Inappropriate or inadequate specimen

New

This is a one-time study conducted in the fourth quarter.

Q-TRACKS



Q-TRACKS

A Program of Continuous Quality MonitoringObserve performance trends over time to identify and monitor opportunities for quality improvement throughquantitative quality measures. Q-TRACKS offers continuous quality monitoring with longitudinal tracking ofperformance and key indicators for clinical and anatomic pathology.

Step 1:Establish realistic benchmarks by comparingyour laboratory to others like yours.

Step 2:Identify improvement opportunities.

Step 3:Monitor improvement over time toensure accurate diagnosis, patientsafety, and quality patient care.

Q-TRACKS: QT3 - Laboratory Specimen AcceptabilityTrend Analysis Report: January-March

Q-TRACKS: QT3 - Laboratory Specimen AcceptabilityExternal Comparison Report: January-March

(most like you)

Q-TRACKS offers CE credit for all laboratory staff each quarter to help you build a solidfoundation of education and knowledge within your organization.

Q-TRACKS


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ObjectiveDetermine the rate of blood culture contamination using standardized criteria for classifying contaminants.

Data CollectionOn a monthly basis, participants will tabulate the total number of blood cultures processed and the total number ofcontaminated blood cultures. Blood cultures from neonatal patients are tabulated separately. For the purposes ofthis study, participants will consider a blood culture to be contaminated if they find one or more of the followingorganisms in only one of a series of blood culture specimens: Coagulase-negative Staphylococcus; Micrococcus;Alpha-hemolytic (viridans) Streptococci; Propionibacterium acnes; Corynebacterium sp. (diptheroids); or Bacillus sp.Participants have the option to monitor institution-specific subgroups.

Performance Indicators Neonatal Contamination Rate (%) Other Contamination Rate (%) Overall Contamination Rate (%)

ObjectiveAssess the incidence of wristband errors within individual institutions, compare performance between participatinginstitutions, and identify improvement opportunities.

Data CollectionOn six predetermined days per month, participants will monitor patient wristband identification for all phlebotomiesperformed at their institution. Phlebotomists will tally the total number of wristbands checked, the number of errorsfound, and the types of wristband error. This monitor includes all routinely wristbanded patients. (Include emergencydepartment patients only if the emergency department routinely applies wristbands to these patients.)

Performance Indicator Performance Breakdown Wristband Error Rate (%) Breakdown of Wristband Error Types (%)

Q-TRACKS Clinical Pathology Monitors

In order to report accurate laboratory results and meet The Joint Commission National Patient Safety Goal #1:Improve the accuracy of patient identification, institutions must properly identify patients. Since most laboratoriesperform testing away from the patient, patient identification, labeling of specimens, and coordination with testrequisitions must be performed accurately and completely. By continuously monitoring for wristband errors,participants can promptly identify and correct problems that may interfere with patient care services.

Patient Identification Accuracy QT1

Despite advances in blood culture practices and technology, false-positive blood culture results due to contaminantscontinue to be a critical problem. Blood culture contamination rate, the primary indicator of preanalyticperformance in microbiology is associated with increased length of hospital stay, additional expense, and theadministration of unnecessary antibiotics. The CAP and other accrediting organizations require you to monitor andevaluate key indicators of quality for improvement opportunities. Use this monitor to help you meet this requirement.

Blood Culture Contamination QT2

Look for your input forms approximately three weeks prior to the quarter.

Q-TRACKS



A substantial amount of rework, diagnostic and therapeutic delay, and patient inconvenience can result fromspecimen rejection. Patient redraws may result from unlabeled, mislabeled, and incompletely labeled specimens;clotted and/or hemolyzed specimens; or insufficient specimen quantity. By continuously monitoring specimenacceptability, collection, and transport, laboratories can promptly identify and correct problems. Participation in thismonitor can help satisfy the CAPs Checklist question GEN.20348, Are preanalytic processes monitored?

ObjectiveIdentify and characterize unacceptable blood specimens that are submitted to the chemistry and hematologysections of the clinical laboratory for testing.

Data CollectionThis monitor includes all blood specimens submitted for testing to the chemistry and hematology departments of theclinical laboratory. On a weekly basis, participants will record the total number of specimens received, the numberof rejected specimens, and the primary reason each specimen was rejected.

Performance Indicator Performance Breakdown Specimen Rejection Rate (%) Breakdown of Reasons for Rejection (%)

Laboratory Specimen Acceptability QT3

Blood for transfusion is a precious resource. At a minimum, wastage of blood that is not out-of-date represents afinancial loss to the health care system. More ominously, systemic wastage of blood may reflect an environment ofcare that is out of control and could pose risks to patient safety.

In-Date Blood Product Wastage QT4

ObjectiveCompare the rates of blood product wastage (ie, units discarded in-date) in participating hospitals and track ratesof improvement over time.

Data CollectionOn a monthly basis, participants will use blood bank records to obtain information on the total number of unitstransfused for each type of blood component. Participants will track the number and type of blood units that arewasted in-date and the circumstances of wastage. Include the following types of blood components: whole blood(allogeneic); red blood cells (allogeneic); frozen plasma; platelet concentrates; single-donor platelets; andcryoprecipitate.

Performance Indicators Performance Breakdown Overall Blood Wastage Rate (%) Breakdown of Circumstances of Wastage (%) Wastage Rates by Blood Component Type (%)


Q-TRACKS


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Specimen collection is one of the few areas of laboratory medicine that involves direct outpatient contact. As aresult, patient satisfaction with this service is a vital indicator of quality laboratory performance. Accrediting agenciessuch as The Joint Commission and CAP (GEN.20368) require measurement of patient satisfaction with laboratoryservices. Use this monitor to help you meet this requirement.

Satisfaction with Outpatient Specimen Collection QT7

ObjectiveAssess patient satisfaction with outpatient phlebotomy services by measuring patients assessment of waiting time,discomfort level, courteous treatment, and overall satisfaction.

Data CollectionOn a monthly basis, participants will distribute copies of a questionnaire to a minimum of 25 outpatients (maximumof 99 outpatients), using predetermined data collection criteria. This monitor includes any outpatient undergoingvenipuncture. This monitor excludes patients seen in the emergency department, ambulatory surgery area, urgentcare facility, chest pain center, 23-hour short-stay facility, employee health department, outpatient health screeningfair/promotion, dialysis center, nursing home, or extended care facility.

Performance Indicators Overall Patient Satisfaction Score Patients More Than Satisfied (%)

The stat test turnaround time (TAT) outlier rate, expressed as a percentage of tests missing target reporting times, is ameasure of outcomes that evaluates how well the laboratory meets patient and clinician needs. This monitor helpsmeet CAP Checklist question GEN.20316, Does the QM program include monitoring key indicators of quality?

Stat Test Turnaround Time Outliers QT8

ObjectiveMonitor the frequency with which stat test TAT intervals exceed institutional stat test TAT expectations.

Data CollectionBefore beginning data collection, participants will establish a specimen receipt-to-report deadline for emergencydepartment (ED) stat potassium tests. On six predetermined days per month, participants will monitor the TAT of up to10 randomly selected ED stat potassium tests on each of three eight-hour shifts (up to 180 tests per month) and trackthe number of ED stat potassium determinations reported later than the established reporting deadline. This monitorincludes stat potassium tests ordered as part of a panel and excludes stat potassium levels that are requested onbody fluids other than blood, as part of timed or protocol studies, or after the specimen arrives in the laboratory.

Performance Indicator Performance Breakdowns Stat Test TAT Outlier Rate (%) Breakdown of Outliers by Shift (%)

Breakdown of Outliers by Day of Week (%)


Q-TRACKS



Laboratories commonly refer to critical values as results requiring immediate notification to the physician or caregiverfor necessary patient evaluation or treatment. Recent regulations from agencies and accreditors such as CMS, TheJoint Commission, and the CAP (GEN.20316, 20365, 41320) mandate that laboratories develop and implement analert system for critical values. Use this monitor to document compliance with your laboratorys alert plan.

Critical Values Reporting QT10

ObjectiveEvaluate the documentation of successful critical values reporting of general chemistry, hematology, andcoagulation analytes for both inpatients and outpatients according to the laboratorys policy.

Data CollectionOn a monthly basis, participants will evaluate 120 inpatient and 120 outpatient critical values. Data collection willinclude general chemistry, hematology, and coagulation analytes on the critical values list. Retrospectively,participants will record the total number of critical values monitored and the number with documentation ofsuccessful notification. This monitor will exclude critical values for microbiology, cardiac markers, drugs of abuse,therapeutic drug levels, urinalysis, blood gases, point-of-care tests, tests performed at reference laboratories, andcritical values on discharged patients.

Performance Indicators Total Critical Values Reporting Rate (%) Inpatient Critical Values Reporting Rate (%) Outpatient Critical Values Reporting Rate (%)

The swiftness with which physicians establish diagnoses of acute myocardial infarction (AMI) in patients presenting tothe emergency department (ED) with chest pain may determine the type and predict the outcomes of therapythose patients will receive. Included in the total time consumed in establishing diagnoses of AMI are the componentintervals required to measure biochemical markers of myocardial injury. One of the most critical biochemical markersis troponin. Help meet CAP Checklist question GEN.20316 with this monitor.

Turnaround Time of Troponin QT15

ObjectiveDetermine the median order-to-report turnaround time (TAT) of troponin (I or T) and the percent of troponin resultsreported by each institutions established deadline.

Data CollectionParticipants will record TATs (in minutes) for three randomly selected troponin specimens obtained from patients seenin EDs on each of three traditional shifts (total of nine measurements) on six predetermined days per month. They willmeasure TATs from the time the tests are ordered to the time that results are made available to ED personnel.

Performance Indicators Median Troponin Order-to-Report TAT (minutes) Troponin TAT Compliance Rate (%)



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The CAP developed this Q-TRACKS monitor in recognition of the importance of timely detection and correction oferroneous laboratory results. Accuracy in laboratory results is critical to the effectiveness of a physicians plan of carefor a patient. An erroneous result can delay or alter patient treatment; therefore, detection of erroneous results shouldbe a priority in every laboratory and should be monitored as a key quality indicator. Help measure your compliancewith CLIA 493.1299, Postanalytic Systems Quality Assessment, with this monitor.

Corrected Results QT16

ObjectiveMonitor the number of corrected test results within individual institutions and compare performance with that of allinstitutions and those institutions similar to yours.

Data CollectionOn a monthly basis, participants will monitor the number of corrected test results and the total number of billable testsfor that month. Include test results for all patients in all care settings with the following exclusions: anatomic pathologytests, narrative physician-interpreted tests (ie, bone marrow biopsies and peripheral smear reports), and point-of-caretests.

Performance Indicator Test Result Correction Rate (per 10,000 billable tests)

Order accuracy bears an obvious relationship to the quality of laboratory testing. When the laboratory fails tocomplete a requested test, it delays the diagnostic evaluation, potentially extending a patients hospital stay andprolonging therapy. When the laboratory completes a test that was not requested, the cost of care increases,patients may be subjected to unnecessary phlebotomy, and laboratory efficiency declines.

Outpatient Order Entry Errors QT17

ObjectiveMeasure the incidence of incorrectly interpreted and entered outpatient physician test orders into the laboratorycomputer, compare performance across institutions, and track performance over time.

Data CollectionOn six preselected weekdays per month, participants will compare eight outpatient requisitions or order sheets tothe orders entered into the laboratorys information system to determine if any order entry errors occurred. Orderentry error categories include requesting physician errors; incorrect, missing, and extra test errors; test priority errors;and nonroutine routing request errors. This monitor excludes tests performed in transfusion medicine/blood bank oranatomic pathology. This monitor also excludes tests from the following patient care settings: inpatient, ED,ambulatory surgery, urgent care, chest pain center, 23-hour short stay facility, employee health department,outpatient screening fair/promotion, and dialysis center.

Performance Indicators Performance Breakdown Outpatient Order Entry Error Rate (%) Breakdown of Error Types (%) Order Entry Error Rates by Type (%)

Q-TRACKS


Q-TRACKS



Appropriate collection and labeling of patient specimens are essential for accurate specimen analysis and reportingof test results. Mislabeling of blood bank specimens can result in catastrophic outcomes when patients receiveincompatible red blood cells. Accrediting agencies, such as AABB and the CAP (TRM.30550, 30575), requiremonitoring of key specimen quality issues and demonstration of a system for continual process improvement.This Q-TRACKS monitor will allow you to compare your performance to your peers.

Specimen Acceptability in Blood Bank QT18

ObjectiveIdentify and characterize incorrectly collected and labeled blood specimens submitted to the blood bank for testing.

Data CollectionOn a weekly basis, participants will record the total number of specimens submitted to the blood bank and thenumber of rejected specimens. Participants will also report the primary reason for specimen rejection based on thefollowing categories:

Participants will provide weekly numbers of ABO/Rh typing results discrepant from the historical record.

Performance Indicators Performance Breakdown Specimen Rejection Rate (%) Breakdown of Rejection Reasons (%) ABO/Rh Discrepancy Rate (%)

Wrong collection container Unlabeled specimen Incompletely labeled

specimen Mislabeled specimen

Requisition does not match specimen Specimen hemolyzed Specimen clotted Insufficient specimen volume Duplicate specimen

Specimen with any suitabilityconcerns later reported bycaregivers

Other reason for rejection(ie, broken specimen)


Q-TRACKS


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ObjectiveQuantify the correlation between the findings of cervicovaginal cytology and corresponding histologic material.

Data CollectionOn a monthly basis, participants will record information on true-positive, false-positive, and false-negativecytology-biopsy correlations. The false-negative correlations will be classified into four error categories: screeningerrors, interpretive errors, screening and interpretive errors, and adequacy determination errors. Participants will alsorecord the biopsy diagnoses for Pap tests with an interpretation of atypical squamous cells (ASC-US and ASC-H) oratypical glandular cells (AGC). This monitor includes patients for whom a cervical biopsy specimen is submitted tothe laboratory and for whom a satisfactory or satisfactory but limited Pap test has been submitted within threemonths previous to the biopsy or at the time of the biopsy.

Performance Indicators Predictive Value of Positive Cytology (%) Sensitivity (%) Screening/Interpretation Sensitivity (%) Sampling Sensitivity (%) Percent Positive for ASC-US Interpretations Percent Positive for ASC-H Interpretations Percent Positive for AGC Interpretations

The correlation of cervicovaginal cytology (Pap test) findings with cervical biopsy results comprises a significant partof the cytopathology laboratorys quality assurance program. By monitoring this correlation, the laboratory canidentify potential problems that require improvement, thereby ensuring better patient results.

Gynecologic Cytology Outcomes: Biopsy Correlation Performance QT5

Q-TRACKS Anatomic Pathology Monitor


LMIP



LMIP

Laboratory Management Index ProgramManage your laboratory more effectively with LMIP The Laboratory ManagementIndex Program (LMIP), an effective fiscal management tool, offers a valuable peercomparison of your laboratorys performance. LMIP can help you with the annualbudget process, contract negotiations, and daily operations management.

With more than 10 years of experience and the largest laboratory participantdatabase, LMIP is the best management resource for health care professionalscharged with decision-making responsibilities. Using management ratios asperformance indicators, LMIP extends beyond traditional analysis of productivityand staffing to focus on the most important factors affecting laboratoryperformance:

Productivity How effectively are you using your laboratory personnel? Utilization How do your test-ordering patterns compare to those of your

peers? Cost-effectiveness How efficiently are you using your supplies, equipment,

and labor?

With LMIPs statistically valid method of peer grouping (fingerprint clustering), youreceive the most meaningful comparisons. These comparisons allow you, yourcolleagues, and your administration to make informed and realistic decisions aboutstaffing, budgets, and other performance targets.

Achieving quality test results involves more than just ensuring properly conductedtests. Understanding financial factors that drive laboratory processes enhances yourconfidence in the management decisions you make. Ultimately, these decisions willguide your organization to deliver superior patient care.

LMIP


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The input items you will collect include:

Blood Expense Outpatient Visits

Consumable Expense Referred SBTs

Equipment Depreciation Expense Referred SBT Expense

Equipment Maintenance and Repair Expense Testing Labor Expense

Hospital Inpatient Days Testing Paid Hours

Hospital Inpatient Discharges Total Labor Expense

Inpatient SBTs Total Laboratory Paid Hours

Nonpatient SBTs Total Laboratory Worked Hours

On-Site SBTs Total SBTs

Outpatient SBTs

LMIP uses the Standardized Billable Test (SBT) as the primary unit of measure. The SBT standardizes test counts andeliminates billing, accounting, and interpretation variations to ensure valid comparisons.

LMIP provides a report of your laboratorys overall operation. Quarterly reports summarize relevant managementratios that provide analysis of the productivity of personnel, laboratory policies and procedures, salary and otherexpenses, physician test utilization, and organizational benefits.

Laboratory Management Index Program LMB

CAP LINKS



CAP LINKS

The Integrated Knowledge SourceConsolidate proficiency testing, accreditation, and quality improvementdata for your entire organization into concise and actionable reports.

The CAP designed CAP LINKS for multihospital systems, academic medical centerswith numerous testing locations, and national commercial reference laboratories.CAP LINKS provides a high-level overview useful in identifying improvementopportunities and demonstrating good QI performance. You can access CAP LINKSdata directly from the CAP laboratory improvement database. Therefore, the CAPdoes not require additional data submission. Use CAP LINKS for all of your CAPlaboratory improvement programs, including:

Surveys & Anatomic Pathology Education Programs and EXCEL

Laboratory Accreditation Program Q-TRACKS Program LMIP Laboratory Management Index Program

The enchanced CAP LINKS provides you the ability to do the following: Download data and manipulate reports to accommodate your specific

institutions needs Use email to forward one or all reports to appropriate individuals for viewing Designate viewing options to select individuals directly via the CAP website Receive CAP LINKS reports more promptly via the Webthe CAP will continueto forward your printed reports via regular mail

Respond to exceptions in a more timely manner

The report package allows you to quickly see good performance and identify sitesthat may require special attention, both at the laboratory level and at the system orcorporate level.

The CAP generates reports on a quarterly basis and distributes them by mail and viathe Internet to an individual whom you designate as your systems primary contact.Annually, your primary contact will receive an overview of the systems full-yearperformance for proficiency testing. Those individuals with granted viewing privilegesmay view these secure online reports.

CAP LINKS


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Accreditation reports recap inspection findings for each laboratory.

Quarterly reports summarize PTsystemwide average results bydiscipline to allow forinterlaboratory comparisons.

Inspection Performance Overview by LaboratoryLaboratory Accreditation Program

Northwest Hospital System

Note: Includes inspection deficiency information used in the most recent accreditation decision

College of American Pathologists325 Waukegan Road, Northfield, Illinois 60093-2750800-323-4040 l www.cap.org

23451-01 05/25/2001 Laboratory 1 Cambridge, MA

23455-01 05/25/2001Laboratory 2

Johnston, RI

23478-01 08/16/2001 Laboratory 3 Pittsburg, PA

Combination Program Options Product Codes Surveys/EXCEL LAP Q-TRACKS LMIP Price

Option 1 IMR1 $2,800Option 2 IMR2 $2,000

Option 3 IMR3 $2,200

Option 4 IMR4 $1,500

Individual Program Options

Surveys/EXCEL IMRPT $1,500Laboratory AccreditationProgram IMRLP

$800

Q-TRACKS IMRQT $500

LMIP IMRLM $500

Module Product Code Price

LMIP LMB $820

Modules/Package Product Codes Price

Individual Clinical Pathology (CP) Monitors QT1, QT2, QT3, QT4, QT7, QT8,QT10, QT15, QT16, QT17, QT18 $940 each

Individual Anatomic Pathology (AP) Monitor QT5 $940 each

Combined CP/AP Module Includes all 12 QTMonitors QTP $9,700

Clinical Pathology Module Includes all 11 CPMonitors QTC $9,380

Patient Safety Module Includes QT1, QT2, QT10,QT15, QT16, QT17 QTS $4,988

Quality Management Tools Pricing Overview

2011 Q-TRACKS

2011 Laboratory Management Index Program



Quality Management Tools Pricing Overview

2011 CAP LINKS

Modules/Package Product Codes Price

Individual QP Studies QP111, QP112, QP113, QP114 $395 each

All Four QP Studies PRO $1,424

2011 Q-Probes

Tools to Help You Manage Your Workload

n Alerts you that your proficiency testing (PT) products have shipped n Allows you to track your shipment through a linkn Results in less worries

n Provides access to your time-critical evaluation of Linearity Reports within two business days of data submission through e-LAB SolutionsTM

n Saves valuable time, getting you results up to 10 days soonern Minimizes PT failure with prepopulated electronic forms and drop-down menusn Eliminates clerical errors due to scanning or faxingn Manages your workload with timely email reminders for data submission and result reporting

n Provides ongoing information about all divisions of the College of American Pathologists (CAP)n Offers periodic updates available for review on the CAP website by selecting the Accreditation and Laboratory Improvement tab

n Provides regulatory and other important information relative to CAP products and services n Contains time-sensitive information for laboratories

SM

Accreditation Offers the gold standard for laboratory accreditation

Proficiency Testing Ensures precision and confidence for your laboratory

CAP 15189SM Recognizes a sustainable Quality Management System

Education Serves as a leading resource for information and education in the laboratory

Efficiency/Quality Tools Allows more time for patient care

Advocacy Represents the interests of pathologists in the government and regulatory arenas and in the private sector

Membership Provides valuable benefits and leadership for all laboratory professionals

SNOMED Terminology Solutions (STS) Offers consultation and education services to transform health information

Programs and Resources

17.2M/710/40996-2

TM

325 Waukegan RoadNorthfield, IL 60093-2750

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2011 Qmt Catalog

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