Quality Performance Indicators and their values in Patient Safety

1. Quality Performance Indicators
and their values in Patient Safety
Dr. Rana Nabulsi .PhD, MSc ,CPHQ , CSSGB, EFQM
Head of Quality – Pathology & Genetics Department
Dubai Health Authority – Dubai-UAE

2. Objectives
 Define the Quality Performance Indicators.
 List the most common Quality Performance Indicators
used in the clinical laboratory.
 Discuss how Quality Performance Indicators are related
to patient safety.
 Illustrate why we need Quality Performance Indicators &
Benchmarking in our laboratories.
 Discuss the criteria for selecting the best Quality
Performance Indicators.

3. What are Quality
Performance Indicators?
 A set of measureable indicators that a
Laboratory uses to monitor the performance of
operations in terms of meeting the strategic
goals of Healthcare System.

4. Objectives and Goals of Medical
Laboratories
 Patient Safety
 Accuracy and Reliability of results
 Stakeholders Satisfaction
 Operational Excellence.
 Growth and professional development.
 Financial results

5. Business
Objectives
Key Success
Factors (KSFs)
Quality Performance
Indicators
Tracked by.
Determine.
Quality Performance Indicators
and Laboratory Objectives

6. What gets measured….gets
delivered.

7. Remember
“Not everything that counts can be measured; not
everything that can be measured counts”.
Albert Einstein

8. Reliable Quality Performance
Indicators
Play a key role in improving the quality
of laboratory services and patient
safety.

9. Total Testing Process (TTP)
 Safety
 Customer
Service
 Data
Management

10. KPIs and Total Testing Process (TTP)
 Pre Examination
 Examination
 Post Examination

11. Quality Metric
Quality Performance Indicators for Laboratories
Pre-
Analyti
c
Analyti
c
Post
Analytic
Anatomic
Patholog
y
Clinical
Patholog
y
Chemistry
Hematolog
y
Micro
biolog
y
Trans
fusion
Patien
t
Safety
Patient
satisfaction,
specimen
collection
● ● ● ●
Patient ID,
wristband
accuracy
● ● ● ● ● ● ●
Test Order
entry accuracy
● ● ● ● ● ●
Proficiency
testing
performance
● ● ● ● ● ●
Specimen
Rejections
● ● ●
Specimen ID
errors
● ● ● ● ● ● ● ●
Blood culture
contamination
● ● ●
LABMEDICINE Volume 39 Number 2 February 2008

12. Quality
Metric
Quality Performance Indicators for Laboratories
Pre-
Analytic
Analytic Post
Analy
t
Anatomic
Patholog
y
Clinical
Patholog
y
Chemistry
Hematolog
y
Micro
biolog
y
Trans
fusion
Patient
Safety
Blood
product
wastage
● ● ●
Completene
ss of cancer
diagnosis
● ●
STAT test
turnaround
time
● ● ●
Corrected
results
● ● ● ● ● ●
Critical
result
reporting
● ● ● ● ●
Gynecologic
cytology-
biopsy
correlation
● ●
Clinician
satisfaction
with lab
services
● ● ● ● ● ● ●
LABMEDICINE Volume 39 Number 2 February 2008

13. Why Laboratories need Quality
and Safety Indicators?

14. Trigger is Institute of Medicine
(IOM) Report,1999

15. Patient Safety
 Institute of Medicine (IOM)/NAM claimed that
as many as 1 million patients per year suffer
injuries due to medical errors.
 The Joint Commission (JC) issued International
Patient Safety Guidelines (IPSG).

16. Definition :Patient Safety-IOM/NAM
“Freedom from accidental injury
due to medical care, or medical
errors.”

17. Quality Performance
Indicators
As per Institute of Medicine /NAM, Quality Performance
Indicators shall have the following dimensions :
 Patient safety
 Timeliness
 Effectiveness
 Equity
 Efficiency
 Patient-centered care

18. International Patient Safety
Goals
IPSG 1: Identify Patient correctly.
IPSG 2: Improve Effective Communication.
IPSG 3: Improve safety of high alert medication.
IPSG 4: Ensure correct site, procedure and patient
surgery.
IPSG 5: Reduce the risk of Health Care-Associated
Infections.
IPSG 6 : Reduce patient falls.

19. Quality Performance Indicators
and Patient Safety

20. Quality Performance Indicators
Pre Examination
Specimen ID &Labeling errors
Blood culture Contamination
Patient lD errors Accuracy of Test Order Entry
Rejection of samples Incidents at Collection

21. Patient ID errors

22. Specimen ID errors
Makary MK ET AL,SURGERY 2004.

23. Accuracy of Test Order entry
Performance Indicators Rate (%)
Accurate Test orders 94,972 99.97%
Test(s) Missing 25 0.03
Wrong Test 7 0.01
Total of test order errors: 32 0.04%

24. Rejection of samples
Biochemia Medica.Aysenur Atay et al. 2014

25. Blood Culture
Contamination rate
Journal of Emergency Nursing.Andrew D& Sausan Bollinger Jan 2013.
.

26. Total Testing Process (TTP)
 Data
Management
 Safety
 Customer
Service

27. Quality Performance Indicators
-Examination
Transfusion errors
Staff Competency
EQAP Failure
Correlation Cytology/Biopsy
MRSA incident rate

28. Transfusion Errors
Transfusion Error Surveillance system TESS Report,Lab safety. 2013

29. Rate of MRSA Incidence
https://www.nuh.com.sg/about-us/clinical-outcomes/mrsa-in-nuh.html

30. Correlation Cytology /Histology
Acta ortop.bras.vol.22no.3 Sao Paulo 2014.

31. Competency of Staff
https://viewics.com/solutions/anatomic-pathology/

32. % Proficiency Testing
failure
CDC-1996 Clinical laboratory performance on PT samples-USA. March
08,1996

33. Total Testing Process (TTP)
•Safety
•Customer
Service
•Data Lab
Management

34. Quality Performance Indicator
-Post Examination
Critical Result Reporting
STAT test Turn around time
Revised/Corrected Reports

35. STAT Turn Around Time

36. STAT Turn Around Time
(example Troponin)
Chris Christopher, Lab Quality Confab,2010

37. % of Critical Results
reported in 45 minutes

38. Proportion of Revised
/Amended reports

39. Link Targets of Quality
Indicators with Six Sigma Model

40. Quality Indicators and Six Sigma
Quality Indicator Sample Size Variance
Percent
Variance
(Variance/Samp
le Size x 100)
Parts per
Million
Six Sigma Quality 1,000,000 3.4 0.00034 3.4
Pre Analytic
Missing information on requests
Tissue samples 2,691 43 1.5979 15,979
Cytology, Papanicolaou smears 6,932 695 10.0259 100,259
Correction of errors on ordered tests 197,195 616 0.3123 3,123
Patients without identification bands 26,400 139 0.5265 5,265
Specimen redraws 26,400 503 1.9053 19,053
Collection of TDM peak/trough specimens at improper time 280 58 20.7140 107,140
Sample label errors 26,400 138 0.5227 5227
Number, source, and nature of unacceptable specimens 332,223 35 0.0105 105
Analytic
Laboratory testing error 192,665 140 0.0726 726
Interpretation misjudgments in microbiology 34,734 256 0.7370 7370
Post Analytic
Laboratory reporting errors 389,860 208 0.0533 533

41. Quality Indicators and Six Sigma
Sigma Defects per
Million Operations
(DPMO)
Percent
Error
Efficiency
1 690,000 69 0.31
2 308,000 30.8 0.69
3 66,800 0.67 0.993
3.5 22,750 0.23 0.998
4 6,210 0.06 0.9994
4.5 1,350 0.01 0.9999
5 233 0.002 0.99997
6 3.4 0.00003 0.999996
41

42. Other Quality Performance
Indicators
 Timeliness of responding to clinical advice .
 Operating Room Blood Delivery Turn Around Time.
 Completeness of Cancer Reporting.
 % of cases of Molecular Testing in Anatomic Pathology that
adhere to established Clinical guidelines.

43. Why Use Quality Indicators?
 Performance effectiveness.
 Patient Safety
 Easier decision making.
 Measure of laboratory processes and
outcomes.
 Monitor changes.
 Detect potential problems.

44. Criteria for Selection of Quality
Indicators
 Cover Pre-examination, examination & post- examination.
 Operational units ( Hematology, Microbiology, POCT, AP).
 Patient Safety.
 Financial, Human Resources.
 Customer needs.
 Accreditation requirements (e.g. JCI,ISO, CAP, CPA, etc..)
 Regulatory requirements.

45. Criteria for Quality Indicators
selection
 Validity :Does the KPI measure what it is supposed to
measure?
 Reliability: Does the KPI provide a consistent measure?
 Acceptability: Are the KPIs acceptable?
 Feasibility :Is it possible to collect the required data and is it
worth the resources?
 Explicit evidence base :Is the KPI supported by scientific
evidence?

46. How to develop Quality
Indicators?
 Definition
Name, purpose, scope, authority, domain.
 Method of data collection and Analysis.
-Numerator , Denominator, frequency, calculations.
 Targets
-International bench mark.
-organizational performance goal
-Evidence base.

47. Q-Track -CAP

48. Quality Performance
Indicators are not enough

49. Benchmarking is needed

50. Benchmarking Simply
• "Improving ourselves by
learning from others."

51. Benchmarking
• Is the practice of being humble enough to admit that
some organizations are better than you at something and
wise enough to try and learn from them their best
practice.
American Productivity and Quality Center-1988

52. Benchmarking
• Benchmarking is
Making Best Practices Your
Daily Practice.

53. Why Benchmarking ?
Better Awareness of Our Laboratory
What we are doing
How we are doing it
How well we are doing it
Better Awareness of the Best laboratories
What they are doing
How they are doing it
How well they are doing it

54. Benchmarking and World
Class Performance
Benchmark Purpose and Quality Maturity
I
Learning
from
success
VI
National
leadership
II
Borrowing
ideas
III
Best-in-
firm
IV
Beating
industry
standards
V
Best-in-
class
Quality
Maturity

55. Levels Of Benchmarking
 Internal benchmarking - Within one’s organization.
 Competitive benchmarking - Analysis the performance
and practices of best in class laboratories.
 Non-competitive benchmarking -Is learning something
about a process a laboratory wants to improve by
benchmarking.
 World class benchmarking - Ambitious and looking
towards recognized leader.

56. Why laboratories need Quality Indicators &
Benchmarking
 Quality Improvement and Patient safety.
 Satisfying Accreditation Requirements.
 Satisfying Payer Requirements.
 Positioning the Laboratory in a Competitive
Marketplace.
 Enforce accountability.
 Staff Motivation.

57. Satisfying Accreditation
Requirements
 CLLIA (The Clinical Laboratory Improvement
Amendment ).
 The Joint Commission .
 Collage of American Pathology (CAP).
 ISO 15189 standards for medical laboratories.
labmedicine.com February 2008 Volume 39 Number

58. Benchmarking in Laboratories

59. Example: Proficiency Testing &
Benchmarking
Benchmarking accuracy over time is
associated with improved performance
for Laboratories.

60. Continuous and Breakthrough
Improvement

61. Sources of Quality Performance
Indicators for Laboratories
 Agency for Healthcare Research and Quality (AHRQ )
 National Guideline Clearinghouse (NGC) Web sites.
 College of American Pathologists (CAP) Web sites .
 NCQA (National Committee for Quality Assurance )
Accreditation.
 Centers for Disease Control and Prevention (CDC).
 PubMed database using various terms
Shahram & Snyder. Am J Clin Pathol 2009;131:418 - 431

63. Take Home Messages
Medical Laboratories need to report the Right
test result to the Right patient at the Right
time in the Right form. In addition, it should
be the Right test choice with the Right
interpretation and with the Right advice.

64. Take Home Messages
Reliable Quality Performance Indicators play
a key role in improving the quality of
laboratory services and patient Safety.

65. Take Home Messages
Give Benchmarking a Chance -
It’s Worth It.

66. References:
 Quality indicators in laboratory medicine: A fundamental tool
for quality and patient safety.Mario Plebani a, Laura
Sciacovelli a,Mariela Marinova a, Jessica Marcuccitti a,
Maria Laura Chiozza b 2014.
 Harmonization of laboratory testing — Current
achievements and future strategies. 2013.Jillian R Tate a,⁎,
Roger Johnson b, Julian Barthc, Mauro Panteghini.
 Quality indicators to detect pre-analytical errors in laboratory
testing. 2014 .M. Plebani a,⁎, L. Sciacovelli a, A. Aita a, A.
Padoana, M.L. Chiozza b.

67. References:
 College of American Pathologists.www.cap.org.
 Reducing Errors in the Practices of Pathology and
Laboratory Medicine. David A. Novis, MD, 1,2 and
George Konstantakos,Mario Plebani . Clin Chem
LabMed 2012.
 Benchmarking Laboratory Quality.Paul Valenstein,
MD, Frank Schneider, MD2.
 10-Clinical & Laboratory Standards Institute (CLSI)-
GP35
 Shahram Shahangian & Susan Snyder, Am J Clinc
Pathol 2009; 131: 418 – 431.

68. Thank you