Implementing Rapid Real-time Process “Defect” Collection to Optimize Anatomic Pathology Workflow: A two pronged approach Based on End-User Work Setting

Michael Riben, MD1,Leslie Nesbitt,1Shibu Ninan3,Mark J. Routbort, MD, PhD2

Departments of (1) Pathology and (2) Hematopathology, and the (3) Section of clinical Laboratory Informatics, Division of Pathology and

Laboratory Medicine, University of Texas MD Anderson Cancer Center Houston, TX

Context - Background

Our workflow optimization project leverages manufacturing based quality improvement methods, such as Lean and Six Sigma, which strive for zero “defects” as a measure of quality.

We have implemented a change management infrastructure that utilizes data collection and analysis to aid decision making

Context: Background

In order to analyze the type and kind of defects occurring in our workflows, we strove to implement a “defect reporting system” that would fit into the entire staff’s workflow for real time collection, whether they worked at a workstation that included a computer, or not.

Definition of Defect: a flaw, an imperfection, or a deficiency in specimen

processing that requires us to delay or stop our work or return work to the sender. We interpreted this definition to apply to all aspects of case

workflow Types of waste included process flaws associated with

overproduction, time waiting, transportation, processing, stock on hand, movement, defective products, dictation problems, etc…

Measures of Process Defects and Waste in Surgical Pathology as a basis for Quality Improvement InitiativesRichard J. Zarbo, MD, DMD and Rita D'Angelo, MS, ASQE, SSBBAm J Clin Pathol 2007;128:423-429.

Criteria for a optimal Defect Reporting System:

Easy to use Real-time data capture Equal access to all Standardized Menu-drive Defect capture closest to

discovery

Visual presentation and public exposure

Blameless participation Compliance with

participation Reusability.

Measures of Process Defects and Waste in Surgical Pathology as a basis for Quality Improvement Initiatives, Richard J. Zarbo, MD, DMD and Rita D'Angelo, MS, ASQE, SSBB Am J Clin Pathol 2007;128:423-429.

The Visual Data Displays

❚Image 1 Visual data display poster showing data entries by❚pathologists that captured detail on misidentifications arisingin the surgical pathology process.

Measures of Process Defects and Waste in Surgical Pathology as a basis for Quality Improvement InitiativesRichard J. Zarbo, MD, DMD and Rita D'Angelo, MS, ASQE, SSBBAm J Clin Pathol 2007;128:423-429.

What walls?

What Walls?

Technology:

We utilized paper-based customized Post-it® (3M) notes with a 4 quadrant design, and developed a custom data entry form in PathStation, our VB.Net/SQL based workflow integration software application. (previously described)

Design A coded defect classification and location/process list was developed and

distributed to all employees. The data collection event lasted for 12 working days. For non-computer based workstations, defects were captured in real-time using

the custom designed Post-it notes using the coded choices Completed Post-it® notes were posted in each lab at designated “ wall” locations. We did not have space for Visual Data Displays, described by D’angelo et al due to

space constraints. Notes were collected every other day for data entry into the electronic module.

Running totals were reported back to each area on an ongoing basis For computer based settings, an integrated “defect” collection module

automatically set user context, case context, date/time, user location, and utilized an identical defect classification. A running total was always visible in the module. All entered defects were visible and sortable on a display tab. Ultimately, all defects were recorded into the electronic module to facilitate visibility to

the widest possible audience and allow for data analysis.

Process for Non-computer based workstations

The “analog” process

Distributed Defect Codes and Locations

Custom Post-it®

Analog Visual Displays

Providing Feedback Sample of

Posters placed in all areas with running totals

PathStation Defect Reporting Module

The Electronic Process

PathStation access

Added button to the main tab of Pathstation

Electronic Defect Reporting Module

Electronic – Case/Patient Context Set.

the Submit – View Process Defects form will open with the <CaseNumber> field auto populated.

Indicating where the defect occurred

To indicate the location where the defect or process has occurred click on the dropdown arrow to the left of the <Defect/Process Location> field and select a location. Location codes are grouped by major areas. Note this is not the location documented. We automatically set this by where PC device name and known location for all PC’s,

Selecting a Defect code

Defect codes are grouped by asset or process.

Selecting a Defect code

Defect codes are grouped by asset or process.

Adding comments

Submitting a defect

Viewing the defects

Running total of defects and details

The defects are listed in a table view with sortable columns.

Results

A total of 1291 defects were detected over a 12 consecutive reporting work days 917 unique cases

“Nesbitt” Classification

Group Defects

Communication 76

Hardware 11

Identification 349

Procedural 430

Software 4

Technical 315

Tracking 71

“Nesbitt” Classification

76

11

349

430

4

315

71

0

50

100

150

200

250

300

350

400

450

Communication

Hardware

Identification

Procedural

Software

Technical

Tracking

Defects by Case Type

33

1

53

413

70

89

370

7

136

378

17

0

50

100

150

200

250

300

350

400

1

Bone MarrowBone Marrow ReferralDeep FNAEndo FNAGynNon-GynOutside ConsultationOutside ReferralSup FNASurgical BiopsySurgical CaseUS FNA

Defect Occurrence

4

77

321

133

264

52

20

300

119

0

0

50

100

150

200

250

300

350

Defect Occurrence

Autopsy

Cyto

External

Faculty

Fellows

HemPath

Other

Path

Support Services

Warehouse

Where Defects Reported

12978

5

94

261

724

0

100

200

300

400

500

600

700

800

Reporting Location

Cyto

Faculty

Fellows

HemPath

Path

Support Services

Conclusions

The ability to document “defects” in real-time enhances reporting opportunities and increases compliance with data gathering events, critical to designing improvements that optimize efficiency and quality.

We demonstrate the ability to document the defect identified in less than 5 seconds in settings with, and without, a computer workstation.

Next Steps

Implement Workflow changes Re-collect defects Compare defect capture before and after

workflow optimization