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Value Grand Rounds - June 2017

Value Grand Rounds - June 2017

“Processing CGP (Community Group Practice) External Lab Results” was the topic of the June Value Grand Rounds. Dartmouth-Hitchcock (D-H) Manchester Medical Director and Associate Chief Quality Officer Pam Hofley, MD, presented along with Nikki Crean, BSN, RN, practice manager of D-H’s Maternal Child Health Service Line, the Value Institute’s Dennis McGrath, senior performance improvement consultant, and Danielle Potter, performance improvement associate.

“This standardization project may have been the first of its kind to combine operational leaders and subject matter experts from the southern region working with the Value Institute that wasn’t specifically around coaching Greenbelts,” said McGrath. “This is the foundation and path that hopefully a lot of projects will now follow.”

Situation: There was no reliable way to ensure that providers were reviewing external labs in the CGPs, where patients frequently utilize external lab vendors. Results of lab tests were not consistently and accurately being recorded in eD-H, the D-H electronic record. This left D-H at risk for:

  • Providers missing or overlooking results
  • Delays in care
  • Serious safety events
  • Delayed or missed diagnoses
  • Gaps in care identified through ACO data analysis

Background: Hofley noted that this project was initiated after an apparent cause analysis of a patient’s paperwork showed a delay in care due to the handling of external labs. Additionally, a provider satisfaction survey found that 62 percent of providers in Concord, Manchester and Nashua were either somewhat dissatisfied or completely dissatisfied with the current process for receiving external lab results for their patients.

A process map uncovered the following:

  • Manchester and Nashua’s Health Information Services (HIS) had similar information scanning processes, but the Concord HIS process was different
  • Many departments did not have a standardized process for extracting external lab results
  • Some departments had standard workflows that were department specific
  • There were many opportunities for the provider to never review results
  • HIS was not notifying the provider of results if they were received from the clinic (rather than directly from the external vendor)

Assessment: Crean reported that visits to the clinics in Concord, Manchester, and Nashua revealed that processes were varied within each section. Some clinics had robust processes that were working well, while others had no existing process. Gaps in care were identified due to inconsistent knowledge of how HIS processed external labs, and this resulted in an immediate need to develop a workflow to ensure that providers reviewed external results prior to sending them to HIS.

After conducting a root cause analysis, the following project goals were identified:

  • Reduce risk of patient harm
  • Create a process that would facilitate timely provider review of every result
  • Make it easier to view external lab results in eD-H
  • Ensure that accurate order status was reflected in eD-H
  • Allow departments to effectively track expired orders
  • Improve efficiency for departments using myD-H notifications for these external results

Recommendations:  A centralized scanning model was developed that bypassed the departments and sent lab results directly to Concord HIS, which then disseminates the results to providers via eD-H. This allows all of the extracted data to flow into myD-H. Current staff and management were trained in the new process—after all the labs are received via eFax, the lab values are abstracted and attached to the original order, and the lab vendor is identified and documented in the abstraction process.

The pilot showed the following results:

  • Orders linked to the component results
  • Scanned documents attached to the order for review
  • All component values visible to patients via myD-H
  • Results that are workable, similar to internal result processing
  • Providers have the ability to include external results in component trending
  • Results will update Health Maintenance and help ACO metrics
  • In basket notification to providers are clear and scans are easily accessible
  • Expired results folder more accurately reflects missing labs and gaps in care

At the end of the presentation, the following team members were thanked for their contributions to the project:

Value Institute: Alison Mumford, LSSBB, CPHQ, Danielle Potter, MS, LSSBB, and Dennis McGrath, MS, LSSBB

Sponsor: Pamela Hofley, MD
Regional: Nikki Crean, BSN, RN, and Cheryl Rowe
Nashua:Heather Tuden, PA, Alison Jean, Cathy Steinberg, Carrie Hogan, RN
Concord: Lisa Atkinson, MD, Tina Dandurand
Manchester: Tim Burdick, MD, Brenda Allen, Ashley Melo, RMA