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Clinical Pathology Quality Dashboard October 2012
Clinical PathologyQuality Dashboard
October 2012
Clinical Pathology Quality and Performance
Blood Bank
*Blood product waste refers to outdated and improperly handled units within the blood bank, by clerks, nursing, medical staff, the pneumatic tube system losses and expired units.
Clinical Pathology Quality and Performance
Chemistry
Goal: Inpatient/Outpatient STATs=60 minutes; Internal project to reach 45 minutes. Routines=120 minutes.
Clinical Pathology Quality and Performance
Microbiology
Goal≤1 hour
Clinical Pathology Quality and Performance
Molecular Diagnostics
Clinical Pathology Quality and Performance
Phlebotomy
*Data compiled using PT/PTT, WBC, Gluc data, which are components of high volume testing. Draws begin at 4am. Mott draws begin at 6am.
Clinical Pathology Quality and Performance
Phlebotomy
Clinical Pathology Quality and Performance
Proficiency Testing Performance
* CAP=College of American Pathologists
Month/Year: August Surveyor: DT 92% 92%
INPATIENT POINT OF CARE Overall ComplianceQUALITY MANAGEMENT 92%
Pathology-Nursing Dated Reagents Use Prior to Exp. Date
Each month Pathology staff conducts a survey in the inpatient units, and records the following information for POC Glucose reagents :
Inspections are focused on the following items.
1. Are opened glucose reagents marked with an open and/or expiration date?
Reagents are marked with an “opened date” if expiration is not affected by opening bottle/container. If reagent is affected by opening container (example: good for 14 days after opening) it is marked with “expiration date”.
2. Reagents in use are prior to expiration date.
Compliance is calculated as a percentage of all inpatient units within UMHS.
Clinical Pathology Quality and Performance
Inpatient Point of Care Testing
Clinical Pathology Financials
Clinical Pathology Financials
Clinical Pathology SafetySafety Walk Audits
Compliance Topic & Survey Date
CommentsMost Recent Survey
Laboratory
Adult Blood Gas
Anatomic PathologyAutopsy
Blood BankChemistry
Microbiology-Virology
CytopathologySpecimen ProcessingPhlebotomy ServicesHematology
MMGL
Peds PulBlood GasPeds Biochem
8/7 Current UCI not immediately available
8/7 Surge Suppresor in Use
8/7 Storage bins above 18" f ire safety line Dirty bins stored against lab coats
8/7 Open bottle of hz chemical located in hood. Hz w aste overflow ing on floor.l
CommentsMost Recent Survey
Compliance & Survey Date
CommentsMost Recent Survey
LaboratoryHistocompatibilityImmunologyMolecular Dx
CytogeneticsMCTPMLABS
Need's Attention
Progressing
Excellent
Not Evaluated
9/4 Chemical waste stored in hood. No CAP poster
Safety Walkthrough Last Revision Date bls
9/4 Chemical storage in hood. No accumulation start date on medical waste.
9/4 Drench hose eyewash - Yusef will obtain specs for proper eyewash.
9/4 missig CAP poster
Clinical Pathology QA Meeting Highlight
Blood Bank has implemented quarterly gemba walks with input from front line staff. Examples of outcomes are listed below.
Clinical Laboratory Service Enhancements------------------------------------------------------------------------------------• Labs that are working on process improvement projects
that would like to display data can contact Kristina Martin ([email protected]) for future dashboards.
Kudos
Special thanks goes out to Bill Hubbard and Kathy Davis for beginning the work of consolidation of the various electronic ordering system nomenclatures for laboratory tests at UMHS.
Thank you to the CAP Inspection team who recently visited the University of North Carolina Medical Center• Dr. Lawrence Jennings (Guest Inspector)• Usha Kota• Kristina Martin• Dr. Duane Newton• Christine Rigney• Dr. Diane Roulston• Brenda Schroeder• Brian Smola• Sue Stern• Eric Vasbinder• Dr. Jeff Warren
