Interviewer: Brian Jackson, MD, MS
This interview is based on Chacon’s previous experience as a quality consultant at University of Utah Healthcare from 2013–2015.
Q. In 2013, you joined a new department at the University of Utah hospital focused on quality. What was that all about?
A. The university medical group had recently created a new internal consulting group. It included a hospitalist who had been promoted to chief medical quality officer (CMQO), an experienced patient safety consultant, several people with long experience in the hospital’s quality and compliance department, and then a few relative newcomers, including me.
Q. For you and the other consultants, who were newer to healthcare, was your lack of clinical experience a barrier?
A. No, it was actually more of a plus. For example, a couple of the clinical people in our consulting group had spent many years in patient care, compliance, and risk. They knew the system, but they also knew how slowly things changed. As a result, they had low expectations—they had been broken down by the system. Those of us coming from outside of healthcare were able to see things through fresh eyes. But more importantly, we weren’t burnt out, so we brought enthusiasm and hope to our roles, and that was critical to our effectiveness. Having said that, my clinical exposure in both the emergency department (ED) and cardiology was really valuable to me, because it helped me appreciate just how frustrated doctors, nurses, and patients are with the health systems they’re forced to work within.
Q. Was the quality consulting team received positively by the clinical departments?
A. Yes and no. Senior leadership knew the value we could bring to the organization, but everyone below that level was not used to change nor seeing us as an extra resource. They saw us as suits, not clinical people; they were certain we were there for cost control. They also thought we would interrupt their workflow and be punitive.
Q. How did you overcome clinical departments' resistance?
A. First I had to convince people I was there for the patients. I wasn’t there for the benefit of administration and not primarily for the clinical departments either. It was also important for them to see that we cared enough to quickly learn about the clinical processes and how things worked in their area.
Q. Could you describe an example of a challenge involving lab services and how you approached it?
A. One day the hospital chief medical officer and CMQO said to me, in effect, two clinical units are angry at the lab: go see what you can do to fix it. First I met with the unit leadership and asked them to solicit the top five lab complaints from their staff. I then took those complaints to the lab leadership, couriers, and lab information technology (IT) liaison so they could investigate and prepare answers. I also asked lab staff to give me their top five unit complaints. I took these complaints to the hospital unit leadership. Next I invited the lab representatives to the regularly scheduled early morning clinical staff meetings, and we went down the lists of complaints. We set up a monitoring process and made sure that both sides, the labs and the hospital unit, participated in developing solutions.
Q. What were the main complaints?
A. One big category was electronic medical record (EMR) issues (Epic). The clinical staff blamed the lab for all the problems in Epic. The lab staff were frustrated by this because they didn’t have direct control over the issues. But at the same time it was helpful for the lab to see the IT issues from the clinical side, and not just their own perspective. It helped them more effectively problem-solve with the hospital IT staff. Another perennial big complaint was turnaround time (TAT).
Q. What was the nature of the TAT issues?
A. In many cases, anecdotes about individual outlier events would get passed from person to person and would lead to a global perception of slow TAT. It seems to me that people often want to latch on to one-off situations, but when you ask for details, the responses are vague. And people share these perceptions with others and the stories spread—a little bit like a bad restaurant review that can poison other people's perceptions. I took the approach of letting the data we collected and the process analysis lead to the answers.
Q. Were you successful in improving interdepartmental relationships?
A. The perceptions of bad TAT were very disconnected from the data, and the providers didn’t know anything about the factors that contribute to TAT, such as instrumentation, volume, or problematic samples. So transparency was key to improving these relationships. I asked the lab to provide the range of TATs for different areas such as the ED, and I shared these with the departments. This helped the providers to calibrate their expectations, and to identify when there was a problem that needed to be investigated and when there wasn’t.
Q. Transparency sounds like a valuable principle here.
A. Definitely. One thing that really struck me when I started that job was the complete lack of communication and understanding across departmental silos, including between clinical groups and the lab. The lab was at least willing to come to the table and collaborate, but some of the hospital administrative and clinical groups had jaded attitudes: “Everything’s broken, nothing’s going to get fixed” and “We’ve tried that before and it gets nowhere.” The lab was a scapegoat for all issues related to testing, most of which our analysis showed were not the lab’s fault.
Q. So what did you do?
A. I started with the data. We had a large collection of patient safety incident reports filed by clinical staff. Reading through these, I saw a lot of frustration, but many of the reports were vague and didn’t shed light on what the real problems were. Still, I knew the units filing the most incident reports would be the place to start. My second step was to ask department leaders how many of their staff knew anything about what takes place inside the lab and its processes. I also posed the reverse question to the lab staff: How many knew anything about clinical operations? In both cases, the answer was not many. I set up tours for clinical leadership to see the labs and the specimen flow, which was really enlightening for them. One provider told me afterwards that they had assumed the entire first floor was dedicated to the lab, and they were surprised to see just how little space we actually had there. And the lab staff were amazed at the pace that nurses were working and the number of tasks they juggled at once.
Q. It makes sense that tours could enhance general understanding and empathy. What about resolving specific issues?
A. One of the most important steps was having lab staff attend clinical staff meetings and formally discuss issues on a regular basis. It enabled them to respond immediately to most concerns, rather than saying that they would come back next month with an answer. I also learned that it is essential to have hospital IT in the room at the same time, as some of the issues were EMR-related; not the lab.
Q. Any other good examples of patient safety issues that you worked on?
A. We had a lot of concerns from higher medical leadership about lost tissue specimens from a particular patient care unit. We performed a root cause analysis and discovered that although there were formal procedures for specimen handoffs, which had been approved by the section chief, no one was following them. When we interviewed staff, most had no idea that the procedures existed. We discovered through the interviews that there were gaps at each step along the way, and that it was uncertain who was responsible for each step; staff would arbitrarily take care of things at their convenience. All of these steps were upstream from where lab employees got involved. We also investigated the specimen flow in the histology lab, and found it was a well-oiled machine. We did identify several steps in the lab’s process that could be tightened up, but they were minor.
Q. So how were your findings received?
A. I believe the hospital administration and clinical leadership were surprised by the findings, because they were convinced that most of the problems had been on the lab side. If we had reported that the issues were a 50:50 split between clinical unit and lab, they would have been OK with it. But it was really 80:20, with most problems on the clinical side. Still, we were able to implement standardized handoff procedures and we found that the problems were reduced.
Q. What are the biggest misconceptions that you observed in doctors and nurses about the laboratory?
A. The biggest surprise for nurses is discovering that the lab staff care about patients as much as they do. Doctors need to understand lab processes and the time it takes to return results with top accuracy. Doctors and nurses at times have the mindset that the lab is their personal laboratory—they have no idea how many samples are being received and processed in an hour or a day. The common misunderstanding for both groups was blaming the lab for issues that turned out to be EMR-related.
Q. What do lab professionals misunderstand about clinical environments?
A. Lab professionals rarely have the opportunity to see the clinical areas, units, or surgery rooms. Often they do not fully understand the complicated ordering systems in the clinical environment and the amount of tasks that clinicians are trying to balance at one time.
Brian Jackson, MD, MS, is vice president and chief medical informatics officer for ARUP Laboratories, and associate professor of pathology (clinical) at the University of Utah in Salt Lake City. +Email: [email protected]
CLN's Patient Safety Focus is sponsored by ARUP Laboratories