While the doctor-patient relationship has always been considered the center of medical care, this relationship does not exist in a vacuum. Today, it is supported by interrelated systems of individuals, procedures, technologies, regulations, and organizational structures associated with the care provided Laboratories are an integral part of this larger construct, and the improvement in patient safety achieved is shared by all systems involved[i].
Through effective organizational teamwork where competent individuals work together (through all phases of the testing process) to ensure that the most accurate test results are provided in a timely manner to the requesting physician, patient safety is maximized.
The POL Testing Process[ii]
Most errors that occur in the testing process occur in the pre and post-analytical phases of testing. When the testing process is further defined into distinct activity steps commonly experienced in a physician office setting, (see below) the location of potential errors is also identified:
Ordering: A physician makes a decision to obtain a test and communicates that decision to the appropriate personnel
Implementation: The order is transmitted to those performing the test and/or obtaining the specimen(s); the patient is prepared for the test and/or the specimen(s) are obtained.
Tracking: The test order is monitored internally (within the primary care practice) until the results are returned.
Return of results: The results are sent back to the office (and to the physician) from testing facilities or locations.
Response: The physician makes a decision as to the meaning of the results and creates an action plan.
Documentation: Physician and/or staff note in the medical record that the result has been reviewed; that the physician has responded to the result; and that the patient has been notified.
Notification: The patient is informed of his/her test result and the physician’s recommendations for action.
Follow up: The process whereby abnormal results and/or results requiring action are monitored until such action is taken or the patient refuses the action.
In a field as complex as medicine, there are multiple potential sources of ambiguity (e.g., patients with similar names) and small mistakes (e.g., incorrect filing of a test result) that can cascade into consequences disproportionate to their sources (e.g., allowing a critical condition to go untreated). Testing represents a common arena for these types of errors. According to data from the National Ambulatory Medical Care Survey, the average family physician sees approximately 100 outpatients per week and orders diagnostic tests on 39% of them.
A Culture of Safety and Teamwork
An organization has a “culture of safety” when it understands the need for an organizational approach to address these risks, and is willing to commit the necessary resources.. These organizations take advantage of new opportunities (e.g., information technology) to improve quality. Safety and adaptability are not static properties of an organization but reflect a dynamic struggle to create safety.
Quality care is dependent upon effective teamwork, where competent individuals work together (through all phases of the testing process) to ensure that the most accurate test results are provided in a timely manner to the requesting physician. Teamwork can be categorized as internal, i.e., within the laboratory; and external or ancillary, as relating to other departments or systems within the greater organization.
Improved quality patient care and enhanced patient safety requires an understanding of how the testing process involves interaction with organizational systems beyond the laboratory. It can be described as a multi-phase process, wherein multiple people, tasks, technologies, and environmental and organizational factors interact to determine the outcome.
Teamwork is a two-way process, where open communication between laboratory professionals and those in other departments meet regularly to discuss issues of mutual concern. When carried out with mutual respect, careful planning, open and honest assessments of common needs and issues to be addressed, the result is enhanced quality of patient care.
Support Institutional Teamwork[iii]
- Encourage communication between management and staff, and between the laboratory and the rest of the office. Be open to new ideas, feedback and suggestions.
- Reporting of issues, problems, events and errors is encouraged and supported
- Learning culture: issues, problems, events and errors are handled as learning opportunities, with corrective actions for the lab team; not used to denigrate employees.
- Ensure that all new employees are mentored into the team culture of the medical practice, as well as properly trained and vetted for competency
- Recognize achievement. Celebrate successes due to combined efforts of staff; thank people for doing a job well; publicly recognize hard work; praise staff commitment during difficult times.
- Help all employees succeed. Provide employees with the resources and support to do their work, and as they show signs of readiness, be willing to entrust them with new tasks and greater responsibility.
Support Process Improvements[iv]:
- Implement a formal test-tracking system. A tracking system assures that all tests ordered are returned, ideally to the physician but at least to the practice. Such a system requires that all physicians in a practice agree to standardize how they order tests and how returned results will be handled. Although a formal tracking system can be incorporated within an EHR, this is not a requirement for having a working system A system needs to be simple, have some built-in redundancies (to account for human error in entering data), and be accessible and accountable to multiple people
- Make a policy of notifying every patient of every result. “No news is good news” should be a policy relegated to history. Practices should decide on a standardized system for notifying patients of both normal and abnormal results.
- Empower patients to serve as safety double-checks. Patients should be educated as to what tests are being ordered, their purpose, and when (and how) results will be relayed. If patients do not receive their results within a specified time, they should not assume that means “everything is OK.” Rather, they should be instructed to contact the office for the results.
- Only file signed reports, letters, dictations, and results. Whereas many offices have a policy that nothing enters a chart (electronic or paper) without being signed first, too often, unsigned or inappropriately signed reports get filed. The response to the report (normal, abnormal) also needs to be noted by the physician, and empowering all who find such a breach to take steps to fix it can help ensure the system succeeds.
Ensure office staff are adequately trained and competent
One area of special importance is ensuring the proper training and competency of all non-laboratory staff that are involved in the pre-analytic and post-analytic phases of testing. It is easy to think of front office personnel, including those who may also perform phlebotomy, or order lab supplies, as “other than” laboratory people; however, they play significant roles in the operation and success of the lab. This is especially true for the pre-analytic phase of patient testing, as office staff are often involved in getting important patient information, ensuring that specimens are sent to the requested reference labs, and performing data entry on the office computer system. This multi-tasking may also extend to post-analytic activities such as receiving specimens collected off-site as well as the receiving and filing of reference lab reports. This includes front office personnel, including receptionists, medical assistants, secretaries, phlebotomists, couriers, and even the office manager, are properly trained for anything they do that affects any aspect of the laboratory operation. This training should be documented. This need extends beyond training to competency assessment. One possibility is to consider incorporation of competency assessments of laboratory-related activity into staff evaluations. It is also important to remember that this is often the staff that interacts directly with patients providing pre-test preparation information.
Ensure Participation in Multi-disciplinary Committees
Laboratory management also should ensure that there is appropriate representation on all institutional committees handling issues of mutual concern. These committees could include:
- Medical Executive
- Pharmacy and Theraputics
- Transfusion Services
- Infection Control
- Safety and Employee Health
- Waste Management
There are many more ways in which teamwork for the mutual goal of improving patient safety can be achieved, but the key here is to see the laboratory as part of the entire institutional team, not as a separate insular department striving for quality care on its own.