Critical Test Results: Quality Improvement Plan Proposal

Significance of the problem

JCAHO (2011) explains that failure to communicate critical test results to caregivers could minimize patient safety. This may be manifested through delayed treatment or patient dissatisfaction. In this context, critical test results are those results that may indicate a life-threatening situation. If a health professional fails to convey the results in time, then a patient may face the risk of death. The Joint Commission found that several hospitals nationwide have divergent definitions of critical results, so this makes delivery of results dependant on non-scientific methods. Research communities have not determined thresholds that would make tests ‘critical’. Additionally, laboratory personnel are not certain about the primary caregiver who must receive the results at the end of an examination. Such cases usually develop when more than one medical practitioner is responsible for the case. Pathologists may be confused about the right person to receive the results. Teaching hospitals are highly affected by this problem of communicating critical test results because their residents only stay in the institution for a short time. Laboratory workers may not know who to send the information to when the ordering physician is unreachable.

Baseline data

Dighe et al. (2006) carried out an analysis of laboratory critical value reporting at the Massachusetts General hospital. They carried out their study within a period of 12 months and analyzed about 37,000 incidences of critical results. All tests in hematology, outpatient health center laboratories, and chemistry were analyzed and reported. The data was collected through an examination of the healthcare reporting system. It was then transferred to Microsoft Excel and analyzed. Some of the software they used for collection were Tucson and Misys Healthcare Systems. Additionally, the software they used for data analysis was Microsoft and Redmond.

The authors provided information about the volume, timing, operation and scope of reporting these systems. It was found that critical call back lists diluted the urgency of critical calls. The case of dialysis patients was identified as a typical example. The authors also affirmed that certain hospital settings do not need critical test reporting, such as chemotherapy. However, they found that dealing with outpatients’ critical results was difficult because these individuals had no fixed location inside the hospital premises. It was also found that the professionals who order for information were missing thus leading to poor communication. Additionally, Dighe et al. (2006) also realized that poor coordination between outpatient and laboratories led to critical test miscommunication. Issues of heterogeneity of the patient population in the outpatient population also led to the problem. Different parts of the hospitals, such as the dialysis centers, clinics, physicians’ offices, all has their own reporting procedures. A clear synchronization of procedures was lacking. There were also challenges with on-call coverage of outpatient results that were generated in the evening. All these findings illustrate that a critical test result improvement plan was necessary in the concerned institution. Other hospitals in the region also have the same problem.

Potential strategies

One of the mechanisms for addressing this difficulty is the installation of critical test result communication technology. This involves an electronic system in which physicians or other specialists who order tests confirm that they have received the results. The receiving professionals are also supposed to indicate that they initiated follow up. Perhaps the biggest problem with electronic reporting systems is their potential to overload caregivers with too much information. In an attempt to keep the program relevant, many information systems experts may design the technology in a way that provides too many trivial notifications. As such, caregivers may be unable to differentiate critical results from typical ones. Therefore, electronic systems may document test results well, but this may not translate into actionable results. Effective electronic reporting systems are those ones that track and measure the timeliness of test reporting – hence critical test reporting. Since this occurs as an afterthought, then the success of such a strategy is dependent on too many variables (Bates et al., 1999).

Alternatively, hospitals may choose to establish a shared policy on communication of test results with special emphasis on critical results. If a hospital streamlines its test communication processes, then chances are that the necessary practitioners will receive critical alerts when they arise. The key measure is to have a uniform system that affects all test result conveyors and recipients. The policy would work by establishment of standards for all test results, determination of when the test results ought to be conveyed, and how the notifications ought to take place. This method may encompass a test code and may also involve training of health practitioners concerning the use of the system. One should also measure the effectiveness of the system. The main difference between this approach and the one suggested formerly is that training and monitoring of its effectiveness is not as complicated as the electronic system. Furthermore, monitoring would not take place in order to determine critical test results; it would be done to improve the effectiveness of the system (Hanna et al., 2005).

Recommended interventions

The most effective approach would be the shared test communication policy (cited in the previous paragraph). This would be an effective method because it is proactive rather than reactive. The hospital thinks of all the possible routes that may lead to critical test miscommunication, and then establishes pathways that would prevent the occurrence of such a problem. Furthermore, because the system involves all the test result recipients and conveyors, then it leaves little room for inefficiencies. Primary caregivers, specialists and other parties that order the test will set the standards on critical information. As explained earlier in the ‘significance of the problem’ section, most critical test result miscommunications arise when the concerned parties do not know the threshold for determining critical results or people who need to receive the notification immediately. This strategy solves both problems by laying out the information that should be communicated as well as identifying the stakeholders involved.

Besides identification of the above, the method does not rely solely on technology. Therefore, hospitals that have tight budgets can still use it. This method also includes input from patients and families who are ultimately affected by the results.

Resource implications

This strategy will involve all the hospital personnel who order, handle and are affected by test results. First, ordering physicians or primary care providers will be involved. Alternative medical professionals like senior medical residents, or medical emergency personnel; they must also be included. Secondly, the process will involve pathologists and laboratory personnel. These are all individuals who administer the test and carry out follow ups. Residential nurses should also be involved if they carry out end point corrections. Ambulatory services must also be covered. Hospital administrators as well as IT personnel will be part of the system.

Implementation of the policy will take a period of one year as several steps are involved. There will be a number of supplies that will contribute towards the realization of this goal. Hospitals will need pagers, intranet facilities, calling centers, information system databases with call schedule lists, and tracking systems. Financing will be necessary for training and payment of the professionals who instate all the parts of the systems (Hanna et al., 2005).

Implementation process

The first step is identification of the parties that will receive results. The people in charge of this step will be a team of pathologists (3), hospital administrators (3) as well as physician representatives (3). The step will last for 1 month starting from 30^th July 2012 to 30^th August 2012. Only the end-point clinicians ought to be identified since intermediaries would only complicate the process. The highest ranking hospital administrator will give approval to move to the next phase.

The second step is determination of a substitute recipient when the ordering clinician is unavailable. The latter-team will also carry out the second step, which will also last for one month. It will commence on 1^st September and end on 30^th September. The same hospital administrator will give approval to proceed to the third phase. This should work by linking patients to providers at any time of admission.

After the latter step, hospitals need to identify the nature of test results that meet the ‘critical’ threshold. 3 physician representatives and 3 pathologists will carry out this step. The head pathologist will approve completion of the phase. Identification will start on 1^st October 2012 and end on 30^th October 2012. The institution will need to classify all its tests into three major categories: high priority, mid-level and low priority tests. They should give suitable names to all the categories.

The fourth step is identification of the time frames that all test results should be conveyed. Critical results could necessitate immediate notification while mid-level test results could be conveyed within hours. Low level results may be communicated in a matter of days. Three pathologists will be responsible for this and the most experienced pathologist will provide approval for the next phase. It will start on 1^st November 2012 and end on 30^th November 2012.

The next step is identification of the notification process. The above-mentioned pathologist will carry out and approve termination of the phase. Notification procedure identification will start on 30^th November and end on 30^th December. The notification system should start by first calling the ordering physicians within a set time, such as within the first 15 minutes. If no response is found, then the call center should determine the second care provider. This person should be notified in the next 30 minutes of obtaining the results. A follow up of the call center should be done as fast as possible. It should be noted that pathologists will know which results are critical from the delta values determined by the information system instated.

After identification of the notification procedure, all stakeholders ought to be taught about the communication procedures. On-the-job practice of the process should start. This will commence on 1^st January 2013 and end on 30^th June 2013. The team of pathologists, physician representatives and hospital administrators that started phase one will be responsible for this aspect. The head hospital administrator will approve completion of training. All physicians, primary caregivers and pathologists will receive training.

The last step of the strategy should be instatement of reliability in the test result system. Here, pathologists must obtain pager numbers of ordering physicians. They should also have tracking systems that ensure critical test results are well communicated. Ambulatory services particularly benefit from these tracking systems as they are always mobile (Singh & Vij, 2010). The phase will coincide with communication and training procedures, so it will also start on 1^st January and end on 30^th June 2013. Pathologists will be in charge of this phase and the most experienced pathologist will determine the completion of the process. Physicians, IT experts and physicians will also participate in the process.

Outcome evaluation

Two major parameters will be analyzed and they include: response times for critical tests, as well as call systems workability. The response times will be analyzed by collecting data on call schedules, response times and number of times inaction was recorded. These results will be collected on a biweekly basis (2 times a month) from 30^th June 2013. 2 hospital administrators will analyze response times for critical tests. If declining figures are noted, then corrective actions ought to be instated. Success will be indicated when response times reduce drastically.

Call systems workability will be monitored by hospital administrators as well. This process will involve detection of the number of times call systems failed to contact a caregiver. It will also start on 30^th June 2013 and will be assessed every fortnight. The intervention will be a success if no failures are reported or when one call breakdown occurs biweekly.

References

Bates, D., Pappius, E., Kuperman, G. (1999). Using information systems to measure and improve quality. International Journal of Medical Information, 53, 115-124.

Dighe, A., Rao, A., Coakley, A. & Lewandrowski, K. (2006). Analysis of laboratory critical value reporting at a large academic medical center. American Journal of Clinical Pathology, 125, 758-764.

Hanna, S., Griswold, P., Leape, L. & Bates, D. (2005). Communicating critical test results: safe practice recommendations. Joint Commission Journal on Quality and Patient Safety, 31(2), 70-80.

Joint Commission of Accreditation of Healthcare Organizations JCAHO (2011). Up to the minute: Ensuring timely reporting of critical test results..The Joint Commission Perspective on Patient Safety, 11(12), 1-4.

Singh, H., & Vij, M. (2010). Eight recommendations for policies for communicating abnormal test results. Joint Commission Journal on Quality and Patient Safety, 36, 226-232.