Table 4.

Summary of Lab Safety Toolkit Use and Outcomes Case Reports

Case Report 1
SpecialtyFamily Medicine (FM)
Practice TypeResidency
LocationThis practice provides a full range of services and serves a mostly urban core population in a medium sized city (population 250,001 to 1,000,000) and includes a large refugee community.
ContextThe practice uses one of the most widely used electronic health records (EHR) systems. This practice has experience with and established processes for doing quality improvement (QI,) including monthly QI meetings. The medical director runs or oversees all of the QI projects. The clinic manager is well trained and experienced in QI. The QI team displays all ongoing QI projects on a whiteboard in a central practice location to keep others in the practice apprised of ongoing QI efforts. They periodically undertake the QI process called Plan Do Study Act (PDSAs) and Kaizen events (rapid improvement events). Residents go through a practice management rotation where they gain exposure to QI. The clinic has good teamwork and communication between the physicians, residents, and the staff. Stable Medical Assistant (MA) staffing is a recent development and it has helped the clinic.
Summary of Toolkit UseWhen the FM residency practice implementation team was first introduced to the toolkit, they had ideas about what they wanted to improve in their laboratory testing process. The implementation team initially thought they would work on test ordering, previously identified as a problem for their clinic through team discussions. However, when they met with the full practice and administered the “Assessing your Testing Process” tool to 15 to 20 clinicians, the results showed that inconsistent communication of results to patients was rated as more harmful to patients than were problems with the test ordering process. This was contrary to their initial opinions about which part of the testing process they anticipated working on at the outset of the project.
OutcomesUsing the assessment data, the implementation team shifted the focus of their lab process improvement activities to focus on patient communication, specifically the process of ensuring all patients have received their results. The developed a “dot phrase” for the EHR to document patient preferences for receiving normal results by letter or another method. Dot phrases are shorthand codes that prepopulate common phrases into documentation for an encounter. For example typing “results” automatically adds the phrase “Patient would like normal results returned via mail.” Some MAs started using the dot phrases. They also developed a dot phrase for clinicians regarding their orders for communicating next steps to the patient pending lab results, so that the patient care staff know what action needs to be taken. The practice is piloting this in the clinic group and will then disseminate more broadly in the clinic. The practice also plans to make results letters in different languages, especially for the Somali refugee patients, but that plan has been harder to implement given the many dialects and the cost of translation services.
Case Report 2
SpecialtyGeneral Internal Medicine (GIM)
Practice TypePart of an integrated health system
LocationThe practice serves a mixed urban and suburban population in small sized city (population 50,000 to 250,000).
ContextThis former private practice joined a local integrated health system about two years prior to this project. It used a widely used EHR system and maintains registries for patients with diabetes and hypertension. The practice is recognized as a Level III patient-centered medical home (PCMH), and is actively involved in multiple advanced primary care practice initiatives. It had a highly engaged practice manager, extensive QI experience, and a history of success with laboratory process improvement projects. The practice holds regular monthly QI team meetings, with representation from all applicable roles in the practice, two patients, plus the head of population health/ambulatory care for the affiliated hospital. There is good teamwork between the MAs and appropriate prompting and insistence on QI from the physicians. Staff engagement indicated a supportive climate and culture for QI. Data systems for monitoring patient experience were in place. The practice reviewed patient feedback quarterly and more frequently when feedback was less positive.
Summary of Toolkit UseThe GIM practice used the Patient Experience Survey in the toolkit to assess their patients' level of understanding and knowledge about the lab tests that were ordered. Although most patients indicated on the survey that they did know why a test was ordered, the care teams observed that, due to the project, more patients were asking questions about what their lab test is or what the results mean.
OutcomesOne MA said about this change from before the project to after the project finished: “It's maybe the realization that we are trying to make sure that they understand what's going on. Now that they know that, it's like, &lquote;Okay, well I can ask them questions. They don't mind if I ask questions.” This led the QI team to reinstitute systematic use of patient education handouts for commonly ordered lab tests and encourage care team members to engage patients in conversations about the reason for their tests and what results they should expect to receive and when. In consultation with the affiliated hospital, the practice created a handout on common blood tests to educate their patients about the test that was ordered and the reason why it was ordered. Thus, use of the revised toolkit helped the practice better engage patients in their care.