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Monthly Quality Monitors


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We just brought on a Lab Quality Manager in our Hospital.     She wants us to report to her some monthly quality monitors that'll look nice in a graph.  

I do a lot of monitors monthly ( CT ratio's, product wastage, etc) but she didn't really think any of those applied to "Quality". 

Can I get any feedback from you guys about some good Quality topics to report monthly.



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We just implemented electronic crossmatches  last quarter so anything with an audit for that would be a great idea.   Do you just check to make sure the patient is eligible ?

We haven't seen an autologous unit here in years.

I check corrected reports as often as possible so that would be a good one too and the FDA reportables. 

Thanks so much!

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What immediately sprang to mind was, to be honest, get a different Lab Quality Manager if she has to ask you (it's her job, for which she gets paid, after all), but another thing is turn around time for non-complex samples - by that, I mean routine samples, with out-liers containing antibodies (particularly antibodies directed against high prevalence antigens or nasty mixtures).

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You may want to drop CT ratio since you implemented electronic crossmatch.     Generally, it usually drops close to 1:1 if you are not setting units up in anticipation of usage.    Your computer system will check to make sure that patient is eligible so that is probably not a good monitor.  I can't think of a thing to monitor for electronic crossmatch.

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Turnaround times for crossmatches...routine, ASAP and STAT.

Turnaround times for emergency release/mass transfusion protocols.

Patient blood management - track patient Hgbs vs transfusion rates, do peer comparisions (look at a specific group of physicians to see if they transfuse at higher Hgbs, look to see if there is an individual whose transfusion rate is higher than his/her peers, etc.)

Specimen labeling - how many rejected, how many missing initials/collection times, how many WBIT (this delays patient care)

Track transfusion rates for specific groups of patients - we monitor OB patients for transfusion if Hgb <8.0

Track ordering problems - duplicate orders, give order for nurses but no prepare order for Blood Bank - education needed for staff/physicians placing orders results in delay of care

Transfusion documentation - check patient flowsheets for missing information (like no 15 min vitals, missing donor #, no signed consent, etc.)

You could spend your whole life on stuff like that, so be selective. Don't just go through the motions with multiple graphs. Choose 1 or 2 things where you can have a positive impact on patient safety or quality of care. Once things are going smoothly with a project, continue monitoring as long as needed and add a new project. Hospital quality will love you for that because its something they can show inspectors from JC, the state, etc. (It can get the lab noticed in a good way!) One of our recent projects came about after receiving complaints about how long it took for us to send blood to the ED for traumas. We started out with what seemed to be a lab problem, but it quickly became obvious that it was much larger. We've now spent almost 3 years working on emergency release processes from order to transfusion, not just working on blood release times by Blood Bank.

Using a multi-disciplinary approach with nursing, we developed job aides, educated, and documented to drop our TATs dramatically and improve the entire process. Nursing staff now has a better grasp of what is expected of them in those kinds of situations and they know what we are going to be doing about providing blood products. Physicians are aware that there is an actual protocol. It makes for pretty graphs for Quality, but most importantly, it greatly benefits patients. As an added bonus, you can develop strong team relationships with staff from other areas. This has the potential to make tackling future problems much easier.

We are not a large facility. It sometimes stretches me pretty thin working on stuff like this, but its worth it over the long haul.

Edited by AMcCord
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