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cap.o

QualityManagementTools

Rely on the CAfor condenceso you can focon the patient.

Q-PROBES

In-Depth Quality Assessment Program

Q-TRACKSContinuous Quality Monitoring Program

Q-MONITORS

Customized Quality Monitoring Program

LMIP

Laboratory Management Index Program

CAP LINKSThe Laboratory Integrated Knowledge Source

2012

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Raouf E. Nakhleh, MD, FCAPChair

CAP Quality Practices Committee

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4/282 CollegeofAmericanPathologists 2012Surveys&AnatomicPathologyEducationPrograms


Q-PROBES, Q-TRACKS, andQ-MONITORSofferacomprehensivecollectionoftoolstocomplementyourqualitymanagementprogramneeds.*

SelectQ-PROBES,Q-TRACKS,andQ-MONITORSstudiestosupportyourqualityimprovementinitiatives.

Preanalytic

Analytic

Postanalytic

AnatomicPathology

ClinicalPathology

TurnaroundTime

P

atientSafety

M

icrobiology

TransfusionMedicine

Chem

istry/Hematology

CustomerSatisfaction

Q-PROBES

Hospital Nursing Satisfaction With Clinical LaboratoryServices (QP121)

Turnaround Time for Large or Complicated Specimensin Surgical Pathology (QP122)

Frequency Monitoring of Outpatient Laboratory Testing(QP123)

Timeliness and Accuracy of Reporting

Preliminary Blood Culture Results (QP124)

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 Specimen Collection (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 Blood Bank (QT18)

*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).

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800-323-4040|847-832-7000Option1|cap.org


SelectQ-PROBES,Q-TRACKS,andQ-MONITORSstudiestosupportyourqualityimprovementinitiatives.

Preanalytic

Analy

tic

Postana

lytic

AnatomicPathology

ClinicalPathology

TurnaroundTime

PatientS

afety

Microbio

logy

TransfusionM

edicine

Chemistry/He

matology

CustomerSa

tisfaction

Q-MONITORS

Monitoring of Troponin Metrics for Chest Pain Centers(QM1)

Completeness of Cancer Reporting (QM2)

*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).

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Q-PROBES

4 CollegeofAmericanPathologists 2012Surveys&AnatomicPathologyEducationPrograms

Q-PROBES

AProgramforIn-depthComprehensiveAssessment

Evaluate quality improvements in your laboratoryWith todays focus on reducingmedical errors, laboratories strive to achieve and maintain excellence. Using short-term studies,Q-PROBES provides a one-time comprehensive assessment of key processes in your laboratory.

Structure your data collection and analysis for successUse Q-PROBES to help build andimprove data collection and analysis processes that contribute to quality of care, patient safety,and outcomes.

Establish realistic laboratory benchmarks and performance goalsImplement

Q-PROBES, an external peer-comparison program, to address process-, outcome-, andstructure-oriented quality assurance issues. Establish benchmarks through external databasecomparisons and compare your performance to that of peer organizations to establishlaboratory goals and improve performance.

Q-PROBES activities meet the American Board of Pathology MOC Part IV Practice PerformanceAssessment requirement.

Examine the effectiveness of key processeswith Q-PROBES.

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Q-PROBES

800-323-4040|847-832-7000Option1|cap.org

Hospital Nursing Satisfaction With

Clinical Laboratory Services QP121

Assessment of internal and external customer satisfaction is a key component of the quality improvement program for mostlaboratories and is a requirement for most accrediting organizations. Nursing personnel spend a significant amount of

time interacting with laboratory personnel to initiate testing and follow up on results; therefore, this is an important groupto monitor. This study provides a structured mechanism to obtain constructive feedback from the nursing service to identifyimprovement opportunities.

Objective

This study will determine and characterize the satisfaction of hospital nursing personnel with clinical laboratory services.

Data Collection

Participants will distribute up to 200 satisfaction surveys to nursing personnel (managerial and nonmanagerial) representingall locations within the hospital serviced by the laboratory. Participants have the option to distribute the survey and collect thesurvey responses electronically. Participants will return the results of the first 50 surveys to the CAP for analysis.

Performance Indicators

Overall nursing satisfaction score Percentage of excellent/good ratings

Percentage of below average/poor ratings

New

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

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Q-PROBES


Turnaround Time for Large or Complicated Specimens in

Surgical Pathology QP122

While the College of American Pathologists (CAP) Laboratory Accreditation Program requires monitoring of turnaround time forroutine surgical pathology cases (ANP.12150), there is no such requirement for monitoring of selected large or complicated cases

(CPT codes 88307 and 88309). The Association of Directors of Anatomic and Surgical Pathology (ADASP) recommends thatacceptable turnaround time should be determined on the basis of current literature, keeping in mind that acceptable turnaroundtimes are also defined by the accrediting bodies. Turnaround times are variable depending on case complexity and other factorssuch as the presence of a residency training program. The standards may change over time with the advent of new technologiesand other factors. There is currently limited information in the literature regarding turnaround times for these large or complexspecimens.

Objective

Determine the turnaround time for large or complex cases in surgical pathology.

Data Collection

Participants will review all large or complex surgical pathology cases over a period of 12 weeks or until 50 reports have beenidentified, whichever comes first. For each case, participants will report the CPT code (88307 or 88309), specimen type, organ

system, disease category, type of special handling (if applicable), and the date of surgery, accessioning, and final sign out.Biopsy cases coded as CPT 88307 are excluded from the study.


Primary:o Median turnaround time for cases coded CPT 88307 and 88309

Secondary:o Comparison of turnaround time for different specimen types in various practice settings

New

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

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Q-PROBES

800-323-4040|847-832-7000Option1|cap.org

Frequency Monitoring of Outpatient

Laboratory Testing QP123

Clinical laboratories are commonly asked by institutional administrators to monitor and improve laboratory test utilization. Oneimportant aspect of laboratory utilization includes ensuring that tests are performed at appropriate intervals. This is because

testing patients at inappropriate intervals can have both economic and clinical consequences.This study will examine ordering practices for commonly requested outpatient tests to determine how often these tests areordered excessively. Participating laboratories will have the opportunity to compare their test ordering practices with otherinstitutions and recognized guidelines at a time when they are under pressure to maximize resource utilization.

Objective

Measure how often patients are tested at frequencies that are consistent with recognized guidelines.

Data Collection

Participants will prospectively review 40 outpatient specimens of each type submitted to the laboratory for hemoglobin A1c,total cholesterol, and urine microalbumin. Total cholesterol measurements can be part of a lipid or cholesterol panel, andurine microalbumin will be limited to random or spot urine specimens. The laboratory information system will be queried todetermine if the patient has a previously reported test result for the particular analyte within the past 24 months. Only thosepatients who have had a previous result within the past 24 months will be included. The patients age, the dates of the currentand previous tests, and the current and previously reported test results will be recorded. The study will exclude specimens frominpatients, children under the age of 18, and patients who have received kidney transplants.


Primary:

o Percent of hemoglobin A1c tests performed at appropriate frequency

o Percent of total cholesterol tests performed at appropriate frequency

o Percent of urine microalbumin tests performed at appropriate frequency

Secondary:

o Average intervals between test results for each test examined

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

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Q-PROBES


Timeliness and Accuracy of Reporting Preliminary

Blood Culture Results QP124

The impact on outcome of managing patients with serious bloodstream infections depends, in part, on the timeliness ofreporting preliminary blood culture Gram stain results. It is therefore important to ensure that laboratory practices are optimized

to process positive blood cultures and notify responsible clinicians of results as quickly as possible.

Objective

Measure the timeliness and accuracy of preliminary Gram stain results from positive blood cultures for benchmarking qualityperformance in clinical microbiology laboratories.

Data Collection

Prospectively review up to the first 40 consecutive positive blood cultures in which a Gram stain is performed during a12-week period of time. For each blood culture, participants will record the times when: 1) the positive culture was first detected,2) the Gram stain processing began, 3) the Gram stain was interpreted, and 4) the notification of preliminary results wascompleted. In addition, Gram stain results will be compared to the final culture results and recorded with interpretation ofconcurrence or discrepancy.

Participants will also complete a questionnaire about laboratory blood culture practices that includes method(s), staffing, andreporting procedures.


Primary:o Overall time interval between the first detection of the positive blood culture and the report of the preliminary

Gram stain result

o Percent agreement between the preliminary Gram stain result and the final culture results

Secondary:o Time interval between the detection of a positive blood culture and the start of Gram stain processing

o Time interval between the start of Gram stain processing and the preliminary Gram stain result

o Time interval between the preliminary Gram stain result and the clinician notification of preliminary results

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

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Q-TRACKS

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Q-TRACKS

AProgramofContinuousQualityMonitoring

Observe performance trends over time to identify and monitor opportunities for quality improvement through quantitative

quality measures. Q-TRACKS offers continuous quality monitoring with longitudinal tracking of performance and keyindicators for clinical and anatomic pathology.

Step 1:Establish realistic benchmarks by comparing yourlaboratory 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 Acceptability

Trend Analysis Report: January-March

Q-TRACKS: QT3 - Laboratory Specimen Acceptability

External Comparison Report: January-March

(most like you)

Q-TRACKS activities meet the American Board of Pathology MOC Part IV Practice PerformanceAssessment requirement.

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Q-TRACKS


Patient Identification Accuracy QT1

In order to report accurate laboratory results and meet The Joint Commission National Patient Safety Goal #1: Improve theaccuracy of patient identification, institutions must properly identify patients. Since most laboratories perform testing awayfrom the patient, patient identification, labeling of specimens, and coordination with test requisitions must be performedaccurately and completely. By continuously monitoring for wristband errors, participants can promptly identify and correctproblems that may interfere with patient care services.

Objective

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

Data Collection

On six predetermined days per month, participants will monitor patient wristband identification for all phlebotomies performed

at their institution. Phlebotomists will tally the total number of wristbands checked, the number of errors found, and the typesof wristband error. This monitor includes all routinely wristbanded patients. (Include emergency department patients only if theemergency department routinely applies wristbands to these patients.)

Performance Indicator Performance Breakdown

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

Blood Culture Contamination QT2

Despite advances in blood culture practices and technology, false-positive blood culture results due to contaminants continue tobe a critical problem. Blood culture contamination rate, the primary indicator of preanalytic performance in microbiology, is

associated with increased length of hospital stay, additional expense, and the administration of unnecessary antibiotics. TheCAP and other accrediting organizations require you to monitor and evaluate key indicators of quality for improvementopportunities. Use this monitor to help meet this requirement.

Objective

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

Data Collection

On a monthly basis, participants will tabulate the total number of blood cultures processed and the total number of contaminatedblood cultures. Blood cultures from neonatal patients are tabulated separately. For the purposes of this study, participants willconsider a blood culture to be contaminated if they find one or more of the following organisms in only one of a series of bloodculture specimens: Coagulase-negative Staphylococcus; Micrococcus;Alpha-hemolytic (viridans) Streptococci; Propionibacteriumacnes; Corynebacterium sp. (diptheroids); orBacillus sp. Participants have the option to monitor institution-specific subgroups.


Neonatal Contamination Rate (%)

Other Contamination Rate (%)

Overall Contamination Rate (%)

Q-TRACKS Clinical Pathology Monitors

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

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Q-TRACKS

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Laboratory Specimen Acceptability QT3

A substantial amount of rework, diagnostic and therapeutic delay, and patient inconvenience can result from specimenrejection. Patient redraws may result from unlabeled, mislabeled, and incompletely labeled specimens; clotted and/orhemolyzed specimens; or insufficient specimen quantity. By continuously monitoring specimen acceptability, collection, andtransport, laboratories can promptly identify and correct problems. Participation in this monitor can help satisfy the CAPs

Checklist requirement GEN.20348, Preanalytic processes are monitored.

Objective

Identify and characterize unacceptable blood specimens that are submitted to the chemistry and hematology sections ofthe clinical laboratory for testing.

Data Collection

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

Performance Indicator Performance Breakdown

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

In-Date Blood Product Wastage QT4

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

Objective

Compare the rates of blood product wastage (ie, units discarded in-date) in participating hospitals and track rates of

improvement over time.

Data Collection

On a monthly basis, participants will use blood bank records to obtain information on the total number of units transfusedfor each type of blood component. Participants will track the number and type of blood units that are wasted in-date and thecircumstances of wastage. Include the following types of blood components: red blood cells (allogeneic), frozen plasma,platelet concentrates, single donor platelets, and cryoprecipitate.

Performance Indicators Performance Breakdown

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


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Q-TRACKS


Satisfaction With Outpatient Specimen Collection QT7

Specimen collection is one of the few areas of laboratory medicine that involves direct outpatient contact. As a result, patientsatisfaction with this service is a vital indicator of quality laboratory performance. Accrediting agencies such as The JointCommission and CAP (GEN.20368) require measurement of patient satisfaction with laboratory services. Use this monitor tohelp meet this requirement.

Objective

Assess patient satisfaction with outpatient phlebotomy services by measuring patients assessment of waiting time, discomfortlevel, courteous treatment, and overall satisfaction.

Data Collection

On a monthly basis, participants will distribute copies of a questionnaire to a minimum of 25 outpatients (maximum of 99outpatients), using predetermined data collection criteria. This monitor includes any outpatient undergoing venipuncture. Thismonitor excludes patients seen in the emergency department, ambulatory surgery area, urgent care facility, chest pain center,23-hour short-stay facility, employee health department, outpatient health screening fair/promotion, dialysis center, nursinghome, or extended care facility.


Overall Patient Satisfaction Score

Patients More Than Satisfied (%)

Stat Test Turnaround Time Outliers QT8

The stat test turnaround time (TAT) outlier rate, expressed as a percentage of tests missing target reporting times, is a measureof outcomes that evaluates how well the laboratory meets patient and clinician needs. This monitor helps meet CAP Checklistrequirement GEN.20316, The QM program includes monitoring key indicators of quality.

Objective

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

Data Collection

Before beginning data collection, participants will establish a specimen receipt-to-report deadline for emergency department(ED) stat potassium tests. On six predetermined days per month, participants will monitor the TAT of up to 10 randomlyselected ED stat potassium tests on each of three, eight-hour shifts (up to 180 tests per month) and track the number of ED statpotassium determinations reported later than the established reporting deadline. This monitor includes stat potassium testsordered as part of a panel and excludes stat potassium levels that are requested on body fluids other than blood, as part oftimed 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 (%)


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Q-TRACKS

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Critical Values Reporting QT10

Laboratories commonly refer to critical values as results requiring immediate notification to the physician or caregiver fornecessary patient evaluation or treatment. Recent regulations from agencies and accreditors such as the CMS, The JointCommission, and the CAP (GEN.20316, 20365, 41320) mandate that laboratories develop and implement an alert systemfor critical values. Use this monitor to document compliance with your laboratorys alert plan.

Objective

Evaluate the documentation of successful critical values reporting of general chemistry, hematology, and coagulation analytesfor both inpatients and outpatients according to the laboratorys policy.

Data Collection

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


Total Critical Values Reporting Rate (%)

Inpatient Critical Values Reporting Rate (%)

Outpatient Critical Values Reporting Rate (%)

Turnaround Time of Troponin QT15

The swiftness with which physicians establish diagnoses of acute myocardial infarction (AMI) in patients presenting to theemergency department (ED) with chest pain may determine the type and predict the outcome of therapy those patients willreceive. Included in the total time consumed in establishing diagnoses of AMI are the component intervals required to measurebiochemical markers of myocardial injury. One of the most critical biochemical markers is troponin. Help meet CAP Checklistrequirement GEN.20316 with this monitor.

Objective

Determine the median order-to-report turnaround time (TAT) of troponin (I or T) and the percent of troponin results reported byeach institutions established deadline.

Data Collection

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


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


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Q-TRACKS


Corrected Results QT16

The CAP developed this Q-TRACKS monitor in recognition of the importance of timely detection and correction of erroneouslaboratory results. Accuracy in laboratory results is critical to the effectiveness of a physicians plan of care for a patient. Anerroneous result can delay or alter patient treatment; therefore, detection of erroneous results should be a priority in everylaboratory and should be monitored as a key quality indicator. Help measure your compliance with CLIA 493.1299,

Postanalytic Systems Quality Assessment, with this monitor.

Objective

Monitor the number of corrected test results within individual institutions and compare performance with that of all institutionsand those institutions similar to yours.

Data Collection

On a monthly basis, participants will monitor the number of corrected test results and the total number of billable tests for thatmonth. Include test results for all patients in all care settings with the following exclusions: anatomic pathology tests, narrativephysician-interpreted tests (eg, bone marrow biopsies and peripheral smear reports), and point-of-care tests.

Performance Indicator

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

Outpatient Order Entry Errors QT17

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

Objective

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

Data Collection

On six preselected weekdays per month, participants will compare eight outpatient requisitions or order sheets to the ordersentered into the laboratorys information system to determine if any order entry errors occurred. Order entry error categoriesinclude requesting physician errors; incorrect, missing, and extra test errors; test priority errors; and nonroutine routing requesterrors. This monitor excludes tests performed in transfusion medicine/blood bank or anatomic pathology. This monitor alsoexcludes 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.


Outpatient Order Entry Error Rate (%) Breakdown of Error Types (%)

Order Entry Error Rates by Type (%)


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Q-TRACKS

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Specimen Acceptability in Blood Bank QT18

Appropriate collection and labeling of patient specimens are essential for accurate specimen analysis and reporting of testresults. Mislabeling of blood bank specimens can result in catastrophic outcomes when patients receive incompatible red bloodcells. Accrediting agencies, such as AABB and the CAP (TRM.30550, 30575), require monitoring of key specimen qualityissues and demonstration of a system for continual process improvement. This Q-TRACKS monitor will help you to meet these

requirements and will allow you to compare your performance to your peers.

Objective

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

Data Collection

On a weekly basis, participants will record the total number of specimens submitted to the blood bank, the number ofrejected specimens, and the primary reason for specimen rejection.

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


Specimen Rejection Rate (%) Breakdown of Rejection Reasons (%)

ABO/Rh Discrepancy Rate (%)

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Q-TRACKS


Gynecologic Cytology Outcomes: Biopsy Correlation Performance QT5

The correlation of cervicovaginal cytology (Pap test) findings with cervical biopsy results comprises a significant part of thecytopathology laboratorys quality assurance program. By monitoring this correlation, the laboratory can identify potentialproblems that require improvement, thereby ensuring better patient results.

Objective

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

Data Collection

On a monthly basis, participants will record information on true-positive, false-positive, and false-negative cytology-biopsycorrelations. The false-negative correlations will be classified into four error categories: screening errors, interpretive errors,screening and interpretive errors, and adequacy determination errors. Participants will also record the biopsy diagnoses forPap tests with an interpretation of atypical squamous cells (ASC-US and ASC-H) or atypical glandular cells (AGC). This monitor

includes patients for whom a cervical biopsy specimen is submitted to the laboratory and for whom a satisfactory or satisfactorybut limited Pap test has been submitted within three months previous to the biopsy or at the time of the biopsy.


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

Q-TRACKS Anatomic Pathology Monitors


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Q-MONITORS

800-323-4040|847-832-7000Option1|cap.org

Q-MONITORS Customized Quality Monitoring Program

Monitoring of Troponin Metrics for Chest Pain Centers QM1

Patients presenting to the emergency department (ED) with chest pain must be evaluated quickly. Rapid serum troponinmeasurement is an important part of ED practice that can provide decisive information for patient management. Reducingdelays in troponin testing has been reported to result in shorter length of stay in the ED and more rapid initiation of anti-ischemic treatment. Chest pain centers should therefore have effective procedures for ensuring optimal turnaround time (TAT) fortroponin and a process for ongoing monitoring to ensure that performance meets expectations. Participants will monitor two toeight metrics required by the Society of Chest Pain Centers (Cycle IV: Key Element 4.4.0.0) and monitor the CMS requirement(Measure OP-16) for troponin turnaround time of 60 minutes or less when measured from patient arrival to result availability.

Objective

Help meet the CMS and Society of Chest Pain Centers (SCPC) quality performance requirements for monitoring ED troponinTAT and meeting timeliness goals.

Data collectionSelect a sample of patients in whom troponin is measured and record time points for certain actions in the testing process.These times include patient arrival, test order, specimen collection, laboratory receipt, and result availability. Participants willselect which metrics to monitor, with the option to monitor all metrics.

Participants will also complete a questionnaire about clinical and laboratory practices related to troponin testing.

SCPC Metrics

Main Laboratory Troponin Testing

at least one of the following:

Patient arrival to result availability

Specimen collection to result availability

Test order to result availability

and at least one of the following:

Patient arrival to test order

Test order to specimen collection

Specimen collection to laboratory receipt

Laboratory receipt to result availability

Point-of-Care Troponin Testing

Specimen collection to result availability (required)

Patient arrival to result availability (optional)

Performance indicators

Median TAT for troponin testing intervals (monthly)

Test order to result availability compliance rate (if applicable) Specimen collection to result availability compliance rate (if applicable)

Reports

Participants will receive benchmarking, as compared to all institutions, for specimen collection toresult availability turnaround time.

A report will be provided on a quarterly basis for compliance with Chest Pain Centerkey element 4.4.0.0; ED Baseline Troponin Turn-Around-Time Metrics.

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Q-MONITORS


Completeness of Cancer Reporting QM2

In 2004, the American College of Surgeons Commission on Cancer introduced Standard 4.6 for accredited Cancer Centerspertaining to pathology reports. The Commission required that at least 90% of cancer resection reports contain all of therequired data elements defined by the CAP Cancer Protocols. The CAP Laboratory Accreditation Program contains a similarrequirement (ANP.12350).

The Joint Commission standards for medical staff MS.4.15 and MS.4.40 stipulate that medical staff members undergoOngoing Professional Practice Evaluation (OPPE) more often than every year, and completeness of cancer reporting has beensuggested as one measure suitable for OPPE. Finally, the CMS pay-for-performance standards for pathologists providedincentives for the inclusion of specific elements in colon, breast, and prostate cancer reports (H.R. 6111).

This ongoing quality performance measure can be used to assess whether departments are in compliance with standardsrelated to cancer reporting. The data may also be subcategorized by individual pathologist for use in ongoing professionalpractice evaluations.

Objective

Determine the adequacy of cancer reporting.

Data Collection

To achieve the Commission on Cancer Center designation, the lesser of 75 cases or 10% of cancer reports must be reviewedeach quarter for adequacy. For other laboratories, a minimum of 30 cases per quarter is required for evaluation. Institutionsmay optionally collect data for individual pathologists to be used for ongoing professional practice evaluations. Reports willbe evaluated for the presence of all CAP-required data elements, as specified in the CAP Cancer Checklists, and the use ofsynoptic format.


Primary:o Percent of reports that include all CAP-required data elements

o Percent of reports using a synoptic format

Secondary: (optional)o

Percent of reports that include all CAP-required elements, stratified by individual pathologist code

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LMIP

LMIP

LaboratoryManagementIndexProgram

Manage your laboratory more effectively with LMIPThe Laboratory Management IndexProgram (LMIP), an effective fiscal management tool, offers a valuable peer comparison of yourlaboratorys performance. LMIP can help you with the annual budget process, contractnegotiations, and daily operations management.

With more than 10 years of experience and the largest laboratory participant database, LMIP isthe best management resource for health care professionals charged with decision-makingresponsibilities. Using management ratios as performance indicators, LMIP extends beyondtraditional analysis of productivity and staffing to focus on the most important factors affectinglaboratory performance:

ProductivityHow effectively are you using your laboratory personnel? UtilizationHow do your test-ordering patterns compare to those of your peers?

Cost-effectivenessHow efficiently are you using your supplies, equipment, and labor?

With LMIPs statistically valid method of peer grouping (fingerprint clustering), you receive the mostmeaningful comparisons. These comparisons allow you, your colleagues, and your administrationto make informed and realistic decisions about staffing, budgets, and other performance targets.

Achieving quality test results involves more than just ensuring properly conducted tests.Understanding financial factors that drive laboratory processes enhances your confidence in themanagement decisions you make. Ultimately, these decisions will guide your organization todeliver superior patient care.

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LMIP

Laboratory Management Index Program LMB

LMIP provides a report of your laboratorys overall operation. Quarterly reports summarize relevant management ratios thatprovide analysis of the productivity of personnel, laboratory policies and procedures, salary and other expenses, physician testutilization, and organizational benefits.

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

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CAPLINKS

CAP LINKS

TheIntegratedKnowledgeSource

Consolidate proficiency testing, accreditation, and quality improvement

data for your entire organization into concise and actionable reports.

The CAP designed CAP LINKS for multihospital systems, academic medical centers with numeroustesting locations, and national commercial reference laboratories. CAP LINKS provides a high-leveloverview useful in identifying improvement opportunities and demonstrating good QI performance.

You can access CAP LINKS data directly from the CAP laboratory improvement database.Therefore, the CAP does not require additional data submission. Use CAP LINKS for your CAPlaboratory improvement programs, including:

Surveys and Anatomic Pathology Education Programs and EXCEL

Laboratory Accreditation Program

LMIPLaboratory 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 promptly via the Webthe CAP will continue to forwardyour 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 sites that may requirespecial attention, both at the laboratory level and at the system or corporate level.

The CAP generates reports on a quarterly basis and distributes them via the Internet and by mail toan individual whom you designate as your systems primary contact. Annually, your primary

contact will receive an overview of the systems full-year performance for proficiency testing. Thoseindividuals with granted viewing privileges may view these secure online reports.

7/30/2019 2012 Qmt Catalog


CAPLINKS

Accreditation reports recap inspection findings for each laboratory.

Quarterly reports summarize PTsystemwide average results bydiscipline to allow for interlaboratorycomparisons.

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800-323-4040|847-832-7000Option1|cap.org

QualityManagementToolsPricingOverview

Quality Managmnt Tool Picing Ovviw

2012 Q-PrObes

Modul/Packag Poduct Cod Pic

Individual QP Studies QP121, QP122, QP123, QP124 $395 each

All Four QP Studies PRO $1,424

2012 Q-TrACKs

Modul/Packag Poduct Cod Pic

Individual Clinical Pathology (CP) MonitorsQT1, QT2, QT3, QT4, QT7, QT8,QT10, QT15, QT16, QT17, QT18

$940 each

Individual Anatomic Pathology (AP) Monitors QT5 $940 each

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

Clinical Pathology Module Includes all 11 CP Monitors QTC $9,380

2012 Q-MONITOrs

Modul Poduct Cod Pic

Individual QM Studies QM1, QM2 $780 each

2012 Laoatoy Managmnt Indx Pogam

Modul Poduct Cod Pic

LMIP LMB $820

2012 CAP LINKs

Comination Pogam Option Poduct Cod suvy/eXCeL LAP Pic

Option 1 IMR1 z z $2,800

Option 2 IMR2 z z $2,000

Option 3 IMR3 z $2,200Individual Pogam Option

Surveys/EXCEL IMRPT z $1,500

Laboratory Accreditation Program IMRLP z $800

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Help your laboratory meet CAP Laboratory Accreditation

Program requirements and CLIA-mandated competency

assessment regulations. New for 2012, access Safety &

Compliance courses specic to the clinical laboratory.

Competency Assessment Program includes: Competency assessment courses with customized training

and CE credit

Reassessment courses

A library of educational training courses (Pro Courses) with

CE credit Instrument-specic observation checklists for competency

and training

Course-building and modifying tools

Management tracking and reporting

Individual transcripts

Safety & Compliance courses for the laboratoryAll seven courses are included in the package and are appropriate

for annual laboratory compliance training and for clinical laboratory

science students prior to clinical rotations. Safety & Compliance

courses are available throughout the subscription period and areupdated when necessary to reect changes in regulations or best

practices.

OSHA Bloodborne Pathogens

OSHA Chemical Hygiene

OSHA Electrical Safety

OSHA Fire Safety

OSHA Formaldehyde

Tuberculosis Awareness

Medical Errors and Patient Safety

Note: You must purchase the Safety & Compliance course package in conjunctionwith the Competency Assessment Program subscriptionit is not available for purchase

separately. The Safety & Compliance courses listed above do not offer CE credit.

See complete information at cap.org/competency.

Competency AssessmentProgram now offersSafety & Compliance courses

NEW

Scan this mobile bar code with your smart phone to learn more about the program.

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For Proficiency TestingReduceclericalerrorswithpre-populatedformswithdrop-downinstrument,reagent,andmethodselections

CorrectclericalerrorsduetoscanningorfaxingpriortoevaluationandavoidunnecessaryPTfailures

ReceiveemailnotificationsiftheCAPhasnotreceivedyourdata

Receiveyourevaluationupto10dayssooneronline

Accessproficiencytestingimagesonline

Reviewyourlaboratorysperformanceforuptosixmailings

CheckoutMyPTShippingCalendar,yourcustomizedshippingcalendar

AccessthePT Troulshootng Gud nd PT excpton invstgton Chcklst tools

For Laboratory Accreditation ProgramElectronicallysubmitanapplication/reapplicationtotheaccreditationprogram

Updateactivitymenuswhenchangesaremadetoensurethatthemostcurrentandaccurateinformationis

communicatedtotheCAP,CMS,andinspectors

Maintaindemographicinformationonpersonnel,licensure,changeindirectorshiporlocation,etcthroughout

theaccreditationcycle

DownloadMasterandCustomChecklistsyourself-inspection,inspection,orCAPcurrent/fullsetchecklists

AccesstheLaboratoryDataReport,acomprehensivereportshowingdemographicinformationaboutyour

laboratory,testmenu,andpersonnel

Viewdeficiencyreportsfromyourcurrentandpreviousinspections

Createreports,includingtheLaboratoryActivityMenuwithProficiencyTestingOptions,toaidinaccurate

proficiencytestingenrollmentandoptions

For Competency Assessment ProgramAdministerthecompetencyandtrainingprogramforyourentirelaboratory

Enrolllearnerswhocanquicklyaccessassignmentsthroughe-LabSolutions

Finduserguidesandmoreinformationaboutcourses

To create an account or to log in, go to cap.org.

Log in to e-LAB Solutions todiscover these benefits:

e-LAB Solutions Laboratory

Information at Your Fingertips

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Accreditation for LaboratoriesOffersthegoldstandardforlaboratoryaccreditation

Prociency TestingEnsuresprecisionandcondenceforyourlaboratory

CAP 15189SMRecognizesasustainableQualityManagementSystem

Accreditation for BiorepositoriesProvideslaboratorieswiththemeanstoestablishbestpractices,maintainstandardization,andensurecondenceinbiospecimenquality

Quality Management ToolsAllowsmoretimetofocusonthepatient

EducationServesasaleadingresourceforinformation

andeducationinthelaboratory

AdvocacyRepresentstheinterestsofpathologistsinthegovernmentandregulatoryarenasandintheprivatesector

MembershipProvidesvaluablebenetsandleadershipforalllaboratoryprofessionals

SNOMED Terminology Solutions (STS)Offersconsultationandeducationservices

totransformhealthinformation

ProgramsandResources

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2012 Qmt Catalog

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