The word "progress," by definition, means "forward or onward movement toward a destination." Over the years, LMS (and its predecessor LDM) has provided members of our leadership team various opportunities to see and applaud the work of our clinical and non-clinical staff in improving our healthcare system.
For us to achieve our vision, leaders must have a curiosity about how things are actually working and to create the capability to learn from defects.
Let me highlight the great work of our Department of Pathology and Laboratory Medicine. They already function at high reliability, but nearly perfect is not good enough for them.
Our laboratory is comprised of two specialized areas of testing: the Anatomic Pathology Laboratory and the Clinical Laboratory. Often, specimens are received by Specimen Receiving/Processing that require testing from multiple areas of the Laboratory. These specimens are considered “shared specimens.” An example of a shared specimen might be a cerebral spinal fluid requiring a cell count and differential (Clinical Laboratory - Hematology) and cytology studies (Anatomic Pathology Laboratory - Cytology).
When the Laboratory was considering a project for LMS, one opportunity for improvement was the process of how these specimens are shared between departments. During calendar year 2021, the Laboratory documented 18 instances, out of thousands (a very highly reliable process indeed!), when one or more laboratory sections required additional time locating misplaced specimens. Worse, if the process wasn’t improved, an irreplaceable specimen could be misplaced, resulting in a poor outcome or delay in patient care.
Over the course of 2022, our lab staff implemented several process changes including:
- Creating an over-arching shared specimen procedure to instruct all areas of the Laboratory on exactly how to handle such specimens.
- Improving an outdated specimen routing sheet to include the exact types of specimen containers received and, if applicable, the volume of specimen received.
- Improving the handling of shared specimens in the Clinical Laboratory areas to document exactly who received the specimens and at what time
- Organizing and providing visual cues at refrigerators that store specimens to instruct staff exactly where to place specimens after testing
- Improving handoff systems between the Anatomic Pathology Laboratory and the Clinical Laboratory
The result of these process improvements was a decrease from 18 delays during 2021 to only 3 in 2022. However, the Department of Pathology and Laboratory Medicine continues to scrutinize workflows by employing process confirmations to reach a goal of zero shared specimen delays. By utilizing improved systems, including high level mistake proofing tools such as the routing sheet, organized and clearly labeled storage areas and visual cues, the laboratory has realized an 83% improvement, punctuating the success of the Lean Management System.
How far we have come when our colleagues exhibit the knowledge on the levels of mistake proofing and our understanding of engineering the science of patient safety and eliminating errors and, in turn, improve patient care!
After Jones’ speech, we presented the Spirit of King Award, which recognizes an individual who embodies the spirit and life's work of the late Rev. Dr. Martin Luther King, Jr. and who is dedicated to serving their local community. The winner of this year’s Spirit of King award was one of our volunteers, Pat King. Please join me in congratulating him and all the nominees!
I am grateful to Lisa Walker, our Chief Diversity and Learning Officer, and my colleagues on the Diversity and Inclusion Planning Committee for their hard work on this magnificent event!
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