IMPROVING YOUR LABORATORY

TESTING PROCESS
A Step-by-Step Guide for Rapid- Cycle Patient Safety and Quality Improvement

c
Agency for Healthcare Research and Quality PATIENT
Advancing Excellence in Health Care www.ahrq.gov SAFETY
IMPROVING
YOUR
This publication is in the public domain and may be used and reprinted
LABORATORY without permission.

These materials were developed by the University of Colorado: Colorado

TESTING ACTION Partnership under contract HHSP2332015000251 from the

Agency for Healthcare Research and Quality. This step-by-step guide is a
revision of the 2013 toolkit, Improving Your Office Testing Process,
developed by Dr. Milton “Mickey” Eder and his team.
PROCESS
A Step-by-Step Guide for Rapid-Cycle The opinions presented in this guide are those of the authors, who are
Patient Safety and Quality Improvement responsible for its content, and do not necessarily reflect the position of the
U.S. Department of Health and Human Services or the Agency for
Healthcare Research and Quality.
 Introduction ..........................................................................................1

The Improvement Process.........................................................................3

ASSESS

CONTENTS
Assess Your Testing Process......................................................................5

Assess Office Readiness..........................................................................9

Assess the Patient Experience..................................................................13

Assess Your Documentation....................................................................17

PLAN

Plan for Improvements............................................................................21

IMPLEMENT

Implement Your Change.........................................................................25

RE-ASSESS
Did We Improve?.................................................................................26

APPENDIX...........................................................................................27

The Patient Handout....................................................................28

Electronic Health Record Evaluation................................................31
Process Maps.............................................................................34
Standard Work...........................................................................36

i
 Purpose

This step-by-step guide can help you increase the reliability of the testing process in
your office. The tools will help you examine how tests are managed in your office,
from the moment tests are ordered until the patient is notified of the test results and the
appropriate follow up is determined.

INTRODUCTION About 40 percent of patient encounters in primary care offices involve some form
of medical test. Studies of primary care offices consistently show that the process
Improving Your Lab Testing Process for managing tests is a significant source of error and patient harm. Maybe you
have had experiences in your office similar to the vignette below.

A routine hemoglobin A1c, along with other tests, was ordered for a 55-year-
old patient. The other tests came back, but the A1c test result (which was 9.7%)
was much delayed and not attended to when it arrived. The clinician did not
notice the previous A1c result when the patient returned six months later. A new
A1c was ordered, and it returned at 10.5%, indicating poor glucose control
that should have been addressed half a year earlier.

Errors in managing tests are more common than most of us realize. You and
your staff can use materials from this guide to take manageable steps to
improve office safety and quality.

Identify the team and a champion for this effort. We understand that the job
titles of those leading a project can vary widely, so we will use the generic title of
“project Leader” throughout this guide. The project leader can be a physician, a
nurse, an administrator, or anyone else who has the skills and the desire to lead the
project.

1
A video is available. The support of your staff is crucial to the success of the
project. The 10-minute video “Testing, Testing, Testing” is available
(http://youtu.be/PaZvalKtC-g) to introduce the lab testing process and quality
improvement to your staff. It can provide a jumping-off point for staff discussion
and action.

The testing process is a system. This guide will help you focus on your
office system rather than on the performance of individual staff members.

Keep your project modest and manageable. Be realistic about what you can
achieve in a busy office environment. Even a small change can take a lot of effort,
but it also can make a big difference.

You donʼt have to use all the tools in the guide. These tools were designed for
specific purposes. Some of the tools can help you identify error-prone aspects of your
lab testing process, and others can help you measure your progress in improving the
process. Choose the tool(s) you think will be most useful to help you achieve
your goals.

You can adapt the tools to fit your pracitce.

Use the same tool to measure your performance before and after
implementing a change. Use the same tool and the same method each time
you collect information (e.g., how charts were selected to audit; how patients were
selected to survey). Consistent data collection will allow an accurate before and
after comparison and enable you to determine if the changes you have made are
producing improvements.

No matter how small, celebrate your successes!

2
THE A Model of the Lab Testing Process

IMPROVEMENT
Figure 1 presents an example of the lab testing process. It shows discrete steps that
should occur in order for the correct test to be performed and the results acted
upon. A mistake might occur during or between any of these steps.

PROCESS IN Think about the testing process in your office. Any of these steps can be a source
of error if the office system allows it. Addressing the system can reduce errors.

YOUR OFFICE
Figure 1. Example of a lab testing process

Test results Test results Patient

Test Test Test results Test results Patient
returned to reviewed by monitored
ordered tracked documented notified of
performed office and clinician through
and filed test results
clinician follow up

3
 Using the Plan-Do-Study-Act (PDSA) Method for
Practice Improvement
Plan-Do-Study-Act (PDSA) is a method for how to conduct quality
improvement in a variety of environments. PDSA is cyclical process to test a
change before adopting it in your practice. It begins with developing a
plan to test a change (Plan), followed by the test (Do). Then you observe
and learn from the results (Study), and decide on any modifications that
should be made to the test (Act).

Figure 2. The plan- do-study- act approach to practice improvement

Plan

Act Do
Plan

Act Do Study
Plan

Act Do Study

Study As shown in the figure, you repeat the PDSA cycle for each new change
you want to make. By carefully planning then implementing a change,
while gathering data and reviewing the outcomes, you ensure that you are
creating evidence-informed change.

4
 Purpose
You will find the Assessing Your Testing Process Survey and Scoring Sheet on pages 6 and
7. The survey will help staff and physicians to share their perceptions about problems
in your office system for managing tests. The survey also asks staff and physicians to
consider the potential harm caused by problems with your lab testing system and errors
related to the lab testing process.

ASSESSING When to Use the Tool

This survey is used to collect staff estimates of the frequency of errors and their potential

YOUR TESTING
degree of harm. Use this survey as part of your planning for change. It will help you gather
important data about what steps in the lab testing process are most problematic in your
office.

PROCESS Using the Tool

• Everyone in your office should complete this survey anonymously.
• Ask each person to circle the numbers that best indicate his/her view of the
frequency and severity of errors in your office.

When a large family medicine residency practice

implementation team first saw this guide, they wanted Assessing Risk in Testing
to improve test ordering, because they had previously
identified it as a problem for their practice. However, We know that:
when they administered the “Assessing your Testing • The risk of an event is related to its frequency and the likely severity of harm.
Process” tool to their full practice, the results showed • Balancing these two aspects of risk can be challenging.
that inconsistent communication of results to patients o More common events with less severe harm are easier to overlook, as the risk
was rated as more harmful to patients than were to patients can be underestimated.
problems with the test ordering process. Using the o The risk to patients of an uncommon event that may cause severe harm (a
new data, they shifted the focus of their lab process sentinel event) is often overestimated.
improvement activities to focus on patient • It is important to stay focused on office systems in managing risk.
communication, specifically the process of ensuring all • Note that the Appendix at the end of this guide contains a Patient Handout to help
patients have received their results.
you to ensure you are providing patients with information about what to do after
having a test.

5
Assessing Your Testing Process Survey Date Survey No.

Describe your experience in the testing process:

Test results Test results Patient

Test Test Test results Test results Patient
returned to reviewed by monitored
ordered performed tracked documented notified of
office and clinician through
and filed results
clinician follow up

• Circle the number that you feel most accurately describes the frequency of errors for each step.
• Circle the number that you feel most accurately describes the harm associated with the error.

How often does this happen? What is the usual harm for patients?

Tasks where errors Rarely Occasionally Frequently None Mild Moderate Severe Don’t know/ Total
may occur (Less than once (Once a month) (2 or more times Not applicable
a month) per month)

1. Ordered test not done 1 2 3 1 2 3 4 1

2. Test performed incorrectly 1 2 3 1 2 3 4 1

3. Test results not logged/tracked 1 2 3 1 2 3 4 1

4. Test results not returned to the 1 2 3 1 2 3 4 1

clinician

5. Clinician does not review all 1 2 3 1 2 3 4 1

results

6. Test results not entered in 1 2 3 1 2 3 4 1

patient’s chart

7. Patients not notified of all 1 2 3 1 2 3 4 1

test results

8. Patients with abnormal results 1 2 3 1 2 3 4 1

not monitored through follow up

6
Assessing Your Testing Process Survey Date Survey No.

Scoring Sheet
Scoring the responses:
1. Number each survey.
2. Put each survey over the scoring sheet and line up the tops of the pages.
3. Copy the total scores from each survey into a single column on the scoring sheet.
4. Add all the entries in a row and put that total in the right hand column on the scoring sheet (represents the office total).
5. Refer to the instructions on page 8 to interpret results.

Survey No.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Office
Total

7
 Scoring the Responses
• Scoring can be done either by those completing the survey or by a member of
the leadership team.
• To score each survey, multiply the “frequency” score by the “harm” score to get a
total score for each task.
o If a respondent fails to indicate a frequency or harm score, substitute a
‘Don’t know/Not applicable’ score of 1 for the missing score.
Figure 3. Using the Assessing Your Testing Process Survey o If only ‘Don’t know/Not applicable’ is selected for a task, assign a total
and Scoring Sheet score of 1.
• Write the score in the total column on the far right of the survey.

16
Using the Scoring Sheet
16
• Number each survey.
• Put each survey over the scoring sheet and line up the tops of the pages (see
Figure 3).
• Copy the total scores from each survey into a single column on the scoring sheet.
4
4
4
• Add all the entries in a row and put that total in the right-hand column of the
4
4
4
6
6
scoring sheet to represent the office total.
6
6
6
6
6 5
6
5

Interpreting the Results

• The highest scores for “office total” show areas where staff have identified the
greatest risks in your office.
• Many staff responses of “Don’t know/ Not applicable” for a specific task may
indicate an area for further discussion.
• Share the results and discuss them during a staff meeting.
• Use this information to identify an area that you and your office staff and
physicians will address.
• After identifying a problem, you can use the Planning for Improvements tools
to design a change in your lab testing process.

8
 Purpose
The Office Readiness Survey will help you assess staff and clinician attitudes about
working together to improve the lab testing process. It will also show how well staff
and clinicians recognize and use office policies and procedures for managing the
testing process.

When to Use the Tool

ASSESSING
Use this survey to assess changes in staff attitudes by comparing responses before
and after implementing a change in your office. You will find the survey at the end of
this section. We recommend that offices with little or no quality improvement

OFFICE
experience start with this survey.

Using the Survey

READINESS • You can administer the survey, rapidly score it, and present and discuss the results
at an office meeting.
• You should have everyone in your office (e.g., clinician, case manager,
receptionist, medical assistant, nurse) complete the survey anonymously.
• Be sure to set a deadline for staff to complete the survey. Give the scorer enough
time to compile the responses and prepare the results, including a summary of
any handwritten comments, for presentation at a staff meeting.

Office Readiness and Patient Safety

We know that:
• Offices and systems vary, so there is no single “best” office system. Effective
systems must function within each office’s environment.
• Offices with a team approach to patient care, good communication among all
staff, mutual trust and support, and a commitment to patient safety are more likely
to discuss mistakes and problems.
• Offices with fewer testing errors and greater patient safety have:
o Written procedures that are readily available to all staff.
o A process for updating and informing staff of changes in office procedures.
o Office systems that focus on and support collaboration among staff rather
than individual performance.

9
Office Readiness Survey Date Survey No.

This tool can be used to assess your office’s readiness for quality and safety improvement.
Circle the number between 1 and 5 that most accurately describes how you feel about your office.

Practice Improvement Strongly Neither Agree Strongly

Disagree Disagree nor Disagree Agree Agree

1. The leadership (e.g.,medical director, office manager, head nurse, or other leader)
at this office demonstrates a commitment to quality and patient safety. 1 2 3 4 5

2. Communication among staff, physicians, and leadership promotes mutual respect and trust. 1 2 3 4 5

3. All staff in this office work as a team. 1 2 3 4 5

4. All staff are asked to provide input on decisions about office processes. 1 2 3 4 5

5. Monthly meetings are held, and quality of care is a regular item on the agenda. 1 2 3 4 5

Comments:

Quality and Safety of the Testing Process

6. This office has written procedures describing how to handle testing and test results. 1 2 3 4 5

7. Everyone in this office has read and follows the testing procedures. 1 2 3 4 5

8. Medical testing errors in this office do not harm patients. 1 2 3 4 5

9. Providers and staff openly discuss causes and effects of errors. 1 2 3 4 5

10. This office has systems to prevent, catch, and/or correct problems in the testing process. 1 2 3 4 5

Comments:

10
Office Readiness Survey Scoring Sheet
Instructions:
1. Number each survey. 6. Count the number of checked boxes in each row, and put the
2. Place each survey over the scoring sheet and line up the tops of the two pages. total in the right hand column.
3. Align the right edge of the survey sheet to the column with the same survey number. 7. Highlight those items where the number of checked boxes is
4. Put a check in each box of the column when the response selected was 1, 2, or 3. more than half the number of completed surveys.
5. Repeat for each completed survey. 8. Refer to the instructions on page 12 of this guide to interpret results.

Total of
Survey No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 checked boxes
Practice Improvement

1.

2.

3.

4.

5.

Total of
Survey No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 checked boxes

Quality and Safety of the Testing Process

6.

7.

8.

9.

10.

11
 Scoring the Responses
Number each completed survey.
1. Place each survey over the scoring sheet provided in this guide (see page
11) and line up the tops of the two pages.
2. Align the right edge of the survey sheet to the scoring sheet column with the
matching survey number.
3. Put a check mark in each box in the column when the survey response is 1,
2, or 3 (see Figure 4).
Figure 4. Using the Office Readiness Survey 4. Repeat for each survey.
and Scoring Sheet 5. Count the number of checked boxes in each row and put the total in the right
hand column.
6. Highlight those items where the number of checked boxes is more than half the
3-28-2013 163-28 -20 13 16

number of completed surveys.

7. Check for handwritten comments; compile comments and look for recurring
issues.

Interpreting the Results

• Highlighted practice improvement items (items 1-5) point to areas where
staff have identified a problem in working together.
• Highlighted quality and safety items (items 6-10) point to areas with a
potential quality or safety problem.
• When responses indicate a problem for either practice improvement or quality
and safety, you should take the time to explore the issues as a group before
undertaking a specific practice improvement project.
• To obtain a more detailed assessment of staff attitudes, consider using
AHRQ’s Medical Office Survey on Patient Safety Culture at
https://www.ahrq.gov/sops/quality-patient-safety/patientsafetyculture/
medical-office/index.html

12
 Purpose
The Patient Experience Assessment on page 14 can help you to assess your
patients' understanding of their tests and how your practice communicates
with patients about their test results.

When to Use the Tool

Use this tool to measure patient experience at baseline and again after changes
have been implemented, especially if you are not already asking patients about
their experience with lab tests.

PATIENT
Using the Survey
You can administer this survey to assess patient understanding at one of two points in

EXPERIENCE
the testing process.

1. After a patient has a test ordered or performed, but before the results are back.

ASSESSMENT
2. After a patient has been notified of their test results. An optional question
designed for offices where patient follow up is a problem can be used.

Follow these steps to use the survey:

• Prepare a list of patients to survey. You can identify patients who had a test
ordered or those who were notified of test results in several ways, depending on
how your office functions. For example, you can look at a lab log, review charts
or the electronic health record at the end of a day, or ask staff or physicians to
A General Internal Medicine (GIM) practice’s use of the keep a list for a day or two.
Patient Experience Survey in this guide helped them • We recommend you collect at least 15-20 surveys to look for patterns in
explore their patients’ level of understanding about the responses.
lab tests that were ordered. While most patients • You should survey patients within 1-2 days of their visit or notification of results.
indicated on the survey that they did know why a test • Use a survey form for each patient. If a patient has had multiple tests, select the
was ordered, the care teams observed that patients answer you think best represents the patient’s understanding.
started asking more questions after completing the
survey. This led the QI team to re-institute systematic use
of patient education handouts for commonly ordered Patient Engagement and Patient Safety
lab tests. The QI team also encourages care team We know that:
members to engage patients in conversations about the
• Patients often do not know what test has been ordered or why it has been
reason for their tests, what results they should expect to
ordered.
receive, and when.
• Patients may not know when to expect test results.
• Patients often assume or may be told that “no news is good news” and so may
not take the initiative to get their results.
• Patients encounter challenges in following up on abnormal results and may
require additional support.
13
Patient Experience Assessment Date Survey No.

Instructions: Ask patients to complete.

1.Do you know what medical tests were ordered for you at your last office visit? Yes q No q

2. Do you know why the test (or tests) was ordered? If yes, what was the reason?” Yes q No q
q Routine check-up or screening q check current condition q identify the cause of symptoms q don’t know q other

3. Do you know when to expect your test results? Yes q No q

4. Do you know what to do if you don’t hear from us when your test results are due? Yes q No q

5. Did you tell us how you would like to be contacted with your test results? If yes, how?” Yes q No q
q office visit q phone call q card/letter q electronic patient portal q email to __________________________

6. Did you receive your test results? If the answer is “no,” the survey is complete. Yes q No q

7. Were you given clear instructions, advice, or information about following up on your test result? Yes q No q

14
Encuesta sobre la experiencia Fecha Encuesta No.

de pacientes
Instrucciones: Pida al paciente que complete.

1. ¿ Sabe usted qué exámenes médicos le ordenaron cuando visitó la clínica la última vez? Si q No q

2. ¿Sabe usted por qué le ordenaron los exámenes médicos? Si respondió que sí, ¿cuál fue la razón? Si q No q
q examen de rutina o de detección q examinar por una condición actual q encontrar la causa de síntomas q no sé q otro

3. ¿Sabe usted cuándo estarán listos los resultados de sus exámenes Si q No q

4 ¿Sabe lo que debe hacer si no le llamamos con los resultados de sus exámenes en la fecha en que deben estar listos? Si q No q

5. ¿Nos informó cómo prefiere que nos comuniquemos con usted para darle los resultados de sus exámenes? Si respondió que sí, Si q No q
¿cómo?
q visita a la clínica q por teléfono q una carta q portal electrónico para pacientes q correo electrónico a_________________________________

6. ¿Recibió usted el resultado de sus exámenes? Si la respuesta es “no”, termine la encuesta. Si q No q

7. ¿Le dieron instrucciones, consejos e información clara acerca de cómo dar seguimiento con los resultados de sus exámenes? Si q No q

15
 Scoring the Responses
• Add up the responses for each question.
• Identify the questions with the highest proportion of ‘no’ responses.
• Optional Question: Compare responses to information in the patient record to
determine the accuracy of communication with the patient.

Interpreting the Results

Any “no” responses to a question indicate:
• An area where errors may occur.
• An area to improve your patients’ knowledge about their tests.

Sample another group of patients after you implement a change to assess whether your
change improved their understanding of the role they play in the testing process.

16
 Purpose
The Chart Review Tool on page 20 can help you assess how well your office
enters information about tests and test results in the patient’s medical record.
Good documentation makes information readily available.

When to Use the Tool

ASSESS YOUR Use this tool to collect data to track different tasks throughout the testing process,
including how well abnormal results are managed.

DOCUMENTATION Using the Tool

You should be selective in how you use this tool. The way you use the Chart
Audit Tool will depend on the information you need to collect for your project.
This tool will help you collect data on:
o Documentation.
o The time it takes to move through tasks in the testing process.
o Reporting normal and abnormal results to patients.

• You need to identify the problem you want to investigate and adapt the audit
tool to suit your needs.
• Staff may choose to focus on a particular type of test or the performance of a
particular laboratory.
• The number of charts you audit will depend on:
o How easy it is to identify patients with tests and/or critical abnormal results.
o How much time your staff can devote to identifying charts, auditing charts, and
compiling and interpreting results.
• A minimum of 10 audits is recommended for both before and after testing; 20
audits will provide a more reliable measurement.
• You will complete the appropriate sections of the audit form for each patient’s
medical record.
• It is important to record the patient’s name/ID number and the type of test, as this
information may be needed if you discover a patient safety problem.
• You may find it useful to know the type of test performed, particularly if your
office uses different labs.

17
For projects about documentation of tests:
Check the “yes” and “no” options to indicate whether information is recorded in the
patient record. If you are uncertain, the accepted practice is to check the “no”
option.

Place (overlap) the completed audits so the “no” responses are visible on multiple
pages (see Figure 5).
Many “no” responses to the same question point to an area where tasks are
incomplete, and errors are more likely to occur.
Design a change to reduce error in your office system by using a Planning for
Improvements tool. After implementing the change, use the Chart Audit
Tool again to determine if your office system has improved.

Figure 5. Aligning data sheets for review

18
For projects concerned with time intervals within the testing process:
• Fill in the appropriate dates as recorded in the medical record.
• Be consistent in how you count the number of days. Decide whether or not to
include weekends in the total number of days.
• For each review form:
o Calculate the number of days between the date of test order and the date the
result was recorded in the chart.
o Calculate the number of days between the date the result was recorded in the
chart and the date the patient was notified.
• Compile the intervals from all forms and calculate the averages.
• Identify any specific results within an interval that are greater than the average.
• Discuss these results with your staff, and determine if they are acceptable or
whether the variation reflects a problem with the office system.
• Design a change to reduce error in your office system by using the Planning
for Improvements Tool. After implementing the change, use the Chart Review
Tool again to determine if your office system has improved.
• Results from different tests may arrive on different days, so you may want to focus
on a specific test.

Chart Review and Patient Safety

We know that:
• Chart reviews are widely used to provide information about office systems.
• Chart reviews rely on documentation, which may not accurately reflect actual
care or practice.
• Electronic health records automate many processes but do not eliminate all errors.
• A failure to monitor automated processes may introduce patient safety risks.

19
Chart Review for Baseline and Follow Up Date of Review

Instructions: Use one form for each test.

Enter all available information about a specific test from each medical record.

Patient Name & ID Type of Test

q blood test q non-blood test q imaging (CT, MRI, x-ray, etc) q mammogram q other______

1. Is there an order for this test in the patient’s chart? Date ordered __________ yes q q no

2. Is the test result in the chart? Date result recorded __________ yes q q no

Is the signature dated? yes q q no

3. Is there evidence in the chart of the response to the test result (e.g., normal, further testing, etc)? yes q q no

4. Is there documentation in the chart that the patient was notified of the test result? Date patient notified __________ yes q q no

5. Is there documentation that the patient was notified of the follow-up plan? yes q q no

6. Is there documentation that the patient acted on the follow-up plan? yes q q no

For abnormal results on the following test(s):

q Pap smear q mammogram q INR q other _____________

1. Was the patient notified of the abnormal result within the timeframe specified by your office policy? Date patient notified __________ yes q q no

2. Did the patient receive follow-up care within the timeframe specified by your office policy? yes q q no

20
 Purpose
The Process Mapping tool will help you and your staff to document your
"current state" for your lab testing process.

When to Use the Tool

Use the Process Mapping tool to document your current office system for
managing lab test ordering, tracking, and follow-up on results and referrals.

Using the Tool

PLANNING FOR • Meet with critical staff relevant to the laboratory testing
process and your quality improvement team (if applicable).

IMPROVEMENTS • Follow the steps on the left side of page 22 to create a "current
state" process map.

PROCESS MAPPING
• Brainstorm solutions.

• Map the "ideal state" for laboratory testing process within your
practice. That is, if it's working well, what should or shouldn't be
happening.

Tips For Creating Maps

• Don't worry about getting everything exactly right the first time through.

• Each box should contain an ACTOR (who does this) and an ACTION (what
they do).
• Avoid putting more than one action in a box; it might be easier to break it into
more than one step.
• While mapping, if ideas come up for fixes or there are questions that can't be
answered, have the note taker keep track of these on a separate sheet of paper
so you can come back to them later without slowing down the mapping
process.

21
Step by Step:

1. Write down the name of the process Lab Testing Process—ordering through notification
1
at the top.
2. Ask the team, “What happens first in 3 4
the process?” and write it down on the Provider Provider types order 7

PROVIDERS
decides to directly into EHR
far left, in that role’s “swim lane.” 5
order lab
2
3. Draw a box around it. test(s)
Provider writes order on EHR
4. Ask the team what usually happens 6 billing sheet; hands to MA transmits
next in the process; write it down order to
below or to the right of first box; draw laboratory
MA types order into
MAs
a box around it.
EHR
5. Draw an arrow linking the two boxes.
LABORATORY

6. Ask the team if there are alternative Lab reconciles

ways to achieve the next step in the specimen with
process. order

7. Keep going, asking the team, “What

happens next?”

8. Review the map and revise.

 Purpose
The Action Planning tool will help you and your staff to develop a
plan to make your lab testing process safer.

When to Use the Tool

Use the Action Planning tool to document the changes you will make.

PLANNING FOR Using the Tool

IMPROVEMENTS Develop an action plan and include the following elements:

• List all who will be involved in performing and managing the change, including

ACTION PLANNING staff and leaders.

• Be absolutely certain that the people who will be involved in the change help
to develop the action plan, or they may not be fully invested, understand
what is happening, or believe that the change is doable or meaningful!
• Decide if this should be "standard work" (see Appendix).

Preparing to Implement a Change

• Select another tool from this guide to measure the changes you plan to
implement.
• Collect baseline data and, using that information, specify a goal for reducing
errors.
• Implement the office system changes you have identified.
• Use the same tool to collect data after you make a change so you can assess
any differences your change has made.

2233
Action Planning Tool
Who will make the change in the practice? What will be changed?
 Nurse?  Task?
 Assistant?  Hand-off?
 Physician?  Combination?
 Administrator?  Flow or pathway?

______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________

How will the change be made?

Define the specifics of what will take place:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

When will it be made? Where in the practice will the

 Pick a specific start date and time change be made?
 Pick a specific end date (when we can determine  Describe the details of the physical
if the change was successful) location where the change will take
Make the timeline visible to all in the practice to maintain
place
focus!

______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
______________________________________ ____________________________________________
24
 Get ready to make the planned improvement
Now that you know what you want to change to improve your lab testing
process, it's time to try it!

Before you start...

IMPLEMENT • Remind everyone about the planned change.

• Hold a meeting to discuss the implementation details. Be

YOUR sure key people are included.

• Agree on a start date and end date.

CHANGE • Plan to meet regularly to ask for feedback about how the change
is going and see if you need to make small changes to the plan.
• Plan to meet at the end of the implementation period to get ready to
reassess your testing process, office readiness, patient experience, or
documentation.
• Prepare and communicate standard work.

Helpful Hints for Leaders

• Express a sense of importance or ugency that you want to fix this

problem.
• Develop and communicate a vision of how the change may help.

• Empower the team to act.

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 Did We Improve? Reassessing Your Process
After you have implemented the new process, use the same assessment tool (or
tools) to gather data to measure what changed.

Interpreting the Results

At a staff meeting, encourage your staff to discuss the implementation. Present the data
from before and after you implemented the change.

REASSESS
• If your performance improved and you reached your goal:
o Make the change permanent and write the change(s) into your office
procedures and policy.

YOUR
• If you improved but expected to do better:
o Decide on how to further modify the testing process. Revise the Action
Planning Tool.

TESTING
• If your error rates did not change or got worse:
o Review the changes that were planned.
o If planned changes did not occur, consider whether the changes are practical.

PROCESS
u If practical: Consider trying again; collect additional data.
u If impractical: Revise the Action Planning Improvements Tool.
o If planned changes did occur:
u Continue and collect additional data.
u Or: Develop a new change to test and measure.

Remember, it often takes a few tries to create real,

measurable improvement!

26
 APPENDIX

The materials in the appendix include:

• The Patient Handout: This handout can help to engage patients in the testing
process by providing them with information about what to do after having a test.

• Electronic Health Record Evaluation: This tool can identify how your electronic health
record (EHR) can support you and your office staff in monitoring the safety of your testing
process.

• Process Maps: These exerpts of process maps are from a primary care practice that
used this step-by-step guide. The first shows the "current state" of the practice, followed
by the "ideal state" map they developed to guide their practice changes.

• Standard Work (Blank and Completed Example): This form shows how a practice can
document standard work. It is followed by a completed example of the form.

27
 Purpose
The Patient Handout on the next two pages can help you to engage patients in the
lab testing process by providing them with information about what to do after
having a test.

When to Use the Tool

First, use the Patient Engagement Survey to determine how well patients understand
their medical tests, their test results, and the need for follow up. Then give patients
the completed handout. You may also choose to use some of the points from this

THE
patient handout as part of an after-visit summary you already provide to your
patients.

PATIENT Using the Handout

HANDOUT
This handout has two parts. It is to be filled out by staff and given to patients at one of
two points in the testing process.

Point 1. Complete the handout after an office visit during which a test is ordered. Give
the handout to the patient to remind them of their role in making sure they get their test
result.

Point 2. Complete the handout after the patient has received his/her test result.
• Confirm that the patient received the test result.
o If he/she did not receive the result:
u Arrange for the patient to get the result.
u Note the error and examine your office system to determine why he/she
did not receive the result.
• If he/she has received the result, complete Part 2 of the handout to remind the
patient of his/her role in following up on the test result.

Patient Education and Medical Tests

We know that:
• Many patients will not follow up to obtain their test results without notification or
encouragement from the office.
• Patients have better outcomes when they know the reasons for their tests, take
some responsibility for making sure they get their test results, and understand what
the results mean.
• The teach-back method in which a patient repeats what they have been told has
been shown to enhance patient understanding.
28
What to Expect After Your Lab Test Patient Name

Instructions: Complete the appropriate section of this form and give it to the patient.

Reason for Medical Test(s)

q check-up q manage my health q understand the cause of my symptoms

1. After having a test:

I will hear from the office with my results by ___________________________________________________________________________________________

(date)

If I don’t hear back, I should call _____________________________ and ask for _____________________________________________________________
(phone number) (office contact person)

2. After getting a test result:

When I got my result(s), I was told (please check all that apply):
q Do nothing
q The result was normal
q Continue my same medication or treatment
q Change my medication or treatment
q Return to the office for more tests ________________________________________________________________________________________________
(date and time)
q See a specialist or go to another facility___________________________________________________________________________________________
(name/address/phone)
____________________________________________________________________________________________

If I have questions and the situation is not an emergency, I should call:______________________________________________________________________

(office contact person and phone number)

29
Formulario para el Paciente Nombre del paciente

Instrucciones: Complete la sección apropriada de esta formulario y entréguelo al paciente.

Razón del examen médico

q examen de rutina q control de mi salud q entender la causa de mis síntomas

1. Después de hacerme el exámen médico:

La clínica me va a contactar con el resultado el ________________________________________________________________________________________

(fecha)

Si no me contactan, debo llamar al ____________________ y preguntar por ________________________________________________________________

(teléfono) (persona de contacto en la clínica)

2. Después de recibir el resultado de un examen:

Cuando recibí mi resultado me dijeron (marque todas las respuestas que aplican):

q No hacer nada
q El resultado fue normal
q Continuar el mismo medicamento o tratamiento
q Cambiar mi medicamento o tratamiento
q Regresar a la clínica para más exámenes médicos ___________________________________________________________________________________
(fecha y hora)
q Ver a un especialista o ir a otra clínica ____________________________________________________________________________________________
(nombre/dirección/teléfono)

Si tengo preguntas y la situación no es una emergencia, debo llamar a: _______________________ _____________________________________

(teléfono) (persona de contacto en la clínica)

30
 Purpose
The Electronic Health Record Evaluation Tool can help you identify how your
electronic health record (EHR) can support you and your office staff in monitoring the
safety of your lab testing process.

When to Use the Tool

Use the Electronic Health Record Evaluation Tool to evaluate the capabilities of your

ELECTRONIC
current EHR or to evaluate potential systems when shopping for a new EHR.

Using the Tool

HEALTH RECORD • Identify the individuals who prepare or use reports and ask them to complete the
tool.

EVALUATION
• A “No” answer to any shaded question indicates either:
o Your EHR cannot provide data on this aspect of patient safety and the testing
process.
o Or, staff are not aware of the EHR’s capacity to provide these data.
• A “Yes” answer to a shaded question followed by “No” answers to the
subsidiary questions indicates that the EHR can provide limited support in that
area.

Using EHR Reports for Quality Improvement

• Identify the report(s) that will provide the most helpful information for your project.
• Be sure to consider staff resources needed to generate and review a report.
• Generate the report(s) before a change has been implemented and then a few
weeks after the change.
• Note that a reduction in the proportion of problematic results will indicate that the
testing process was improved.

Using EHR Reports to Monitor Your Office System

You should generate the same report regularly to monitor performance and identify any
positive or negative trends.

31
EHRs and Patient Safety
We know that:
• Introducing EHRs into primary care offices can make locating patient records
much easier.
• Offices may not document staff responsibilities for using EHR reports to monitor
the testing process.
• Offices often struggle with a new system that may not address their specific
needs and processes.
• EHRs automatically complete some tasks in the testing process. However, offices
with EHRs that automatically document steps in the testing process do not
eliminate all errors.
• Most EHRs do not automatically document these tasks:
o Interpretation of test results by providers.
o Notification of patients about their results.
o Follow up on abnormal tests.

32
Electronic Health Record (EHR) Evaluation Tool
For these questions, a “test” is defined as any type of laboratory or imaging test.

Which reports are you able to obtain from your EHR?

1. A report that identifies all tests ordered during a specific time period? yes q q no
If yes:
Are you able to organize the report by test type? yes q q no

2. A report that identifies all outstanding test orders? yes q q no

If yes:
Are you able to organize the report by test type? yes q q no
Are you able to organize the report by lab/imaging center? yes q q no
Does your EHR automatically notify you if test results are not returned within a predetermined timeframe? yes q q no

3. A report that identifies the time it takes for results to be returned to your practice? yes q q no
If yes:
Are you able to organize the report by test type? yes q q no
Are you able to organize the report by lab/imaging center? yes q q no

4. A report that indicates how long it takes to review results after they are available in the EHR? yes q q no

5. A report that identifies those patients who did not receive their results? yes q q no

6. A report that identifies all abnormal results for a specific time period? yes q q no
If yes:
Are you able to determine how long it took to notify the patient after the result was received by the office? yes q q no
Are you able to determine whether the patient has followed up appropriately? yes q q no

33
Current State Process Map

34
Ideal State Process Map

35
Standard Work
STEP WHO ACTION DETAILS WHY

36
Standard Work
Lab result communication process

STEP WHO ACTION DETAILS WHY

Reduce errors in delayed notification of
Review non-critical lab results within 24 Critical lab results called by lab immediately to
1 Provider lab results. Improve patient care and
hours. triage RN (day) or senior resident (night).
satisfaction.
Recommendations: If result is abnormal and
requires medical explanation, then provider
Different results require different levels of
Determine how lab results should be should call patients. Other options include
urgency and medical understanding to
2 Provider communicated to patient, based on letters, portal, follow-up visits, etc. Factors to
address patient concerns and ensure
clinical judgment. consider include abnormality/complexity of
timely follow-up.
the result, patient health literacy, patient
language literacy, etc.
If decision involves action needed by
All MAs are attached to the overall pool.
MA (e.g. send result letter or call Do not send to individual MA because
3 Provider patient for uncomplicated result he/she may not be in clinic at the time,
Routed messages should be clear in action
communication) then route result note to and this could result in delays.
items needed.
MA pool.
MA calling patients in their languages
Medical If MA speak a language other than English, permits the patients to ask medical
Routinely review pool for lab results that
4 Assistant some MA pay particular attention for results questions. The patients have an
require communication to patients.
(MA) that require communication in that language. opportunity to confirm understanding of
the message.
If MA needs to call patients in a
language that the MA does not speak, Refer to nursing notes for name of interpreter
5 MA
then interpreter or language line to be used in the visit and language spoken. Attempts should be made to
used. communicate the results in a language
Determine how lab results should be that a patient understands/prefers.
6 MA communicated to patient, based on 2-3 failed phone attempts should be made first.
clinical judgment.
Document in result note that patient was
7 MA Route back to ordering provider. Closed-loop communication.
notified of results and by what method.

37
Project Team

Revised Guide Donald E. Nease, Jr., MD

John M. Westfall, MD Department of Family Medicine
Department of Family Medicine University of Colorado School of Medicine
University of Colorado School of Medicine
Elizabeth W. Staton, MSTC
Douglas H. Fernald, MA Department of Family Medicine
Department of Family Medicine University of Colorado School of Medicine
University of Colorado School of Medicine

Peter Ferrarone, MA, MSW First Version

Division of Health Care Policy & Research Milton “Mickey” Eder, PhD Director of Research &
University of Colorado Anschutz Medical Campus Evaluation Access Community Health Network
Chicago, IL
R. Mark Gritz, PhD
Associate Director of Business Development Sandy G. Smith, PhD
Division of Health Care Policy & Research University of Chicago
University of Colorado Anschutz Medical Campus Access Community Health Network

Jodi Summers Holtrop, PhD, MCHES James Cappleman, MSW

Department of Family Medicine Access Community Health Network
University of Colorado School of Medicine
John Hickner, MD, MSc
Chair, Department of Family Medicine
Bethany M. Kwan, PhD, MSPH Cleveland Clinic
Department of Family Medicine
University of Colorado School of Medicine Nancy Elder, MD
Associate Professor, Department of Family Medicine
Natalia Loskutova, MD, PhD University of Cincinnati
American Academy of Family Physicians National
Research Network Gurdev Singh, MScEng, PhD Director, University of
Buffalo Patient Safety Research Center
SUNY University at Buffalo

38
Consultants

Revised Guide First Version

John Hickner, MD Bruce Bagley, MD
Chair, Department of Family Medicine American Academy of Family Physicians
University of Illinois-Chicago
Terry McGeeney, MD
Nancy Elder, MD TransforMED
Research Director, University of Cincinnati
James Meisel, MD, FACP
Ranjit Singh, MB BChir, MBA Boston University
Vice Chair for Research, Director, Primary
Care Research Institute, SUNY-Buffalo John Orzano, MD, MPH
Concord Hospital
Milton “Mickey” Eder, PhD
Eric Poon, MD, MPH
Assistant Professor, Department of Family
Brigham and Women’s Hospital
Medicine and Community Health
Harvard Medical School
University of Minnesota

Glen Seils, BE
GSeils Consulting

Leif Solberg, MD
HealthPartners Research Foundation

39
U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality
540 Gaither Road
Rockville, MD 20850

29
AHRQ Publication No. 18-0005-1-EF
December 2017