Initiatives

Getting Started

Improving the reliability of your organizations ability to communicate critical test results requires addressing the core issues of information transfer, teamwork, and communication. Success requires a cooperative effort, with caregivers sharing responsibilities across disciplines and units. You will be required to change how people and systems work, and will meet with resistance as a result. The case studies of successful hospital programs to improve the communication process highlight four fundamental ingredients for success:

1. Clearly-identified leadership support
2. A cross-disciplinary cooperative implementation team with strong leadership representation from each key stakeholder groups: physicians, nursing, and representatives from diagnostic test centers (laboratory, cardiology, and radiology)
3. Highly-visible use of data, both to motivate caregivers and to show whether individual changes are leading to improvement
4. Start small, stay focused

The following links provide some tips on getting started developed over the course of the Massachusetts Coalition for the Prevention of Medical Errors’ two-year Communicating Critical Test Results Collaborative

Leadership Commitment
Form a Team
Collect Baseline Data
Develop Mission and Aim Statements
Choose Where to Start
Begin Testing
Planning Your Communicating Critical Test Results Improvement Project

Leadership Commitment

Leadership engagement is essential for a successful implementation effort to improve performance on communicating critical test results. Hospital teams participating in the Communicating Critical Test Results Collaborative have had identified the following tasks for leadership to support the implementation teams:

1. Provide very clear directions on organizational goals and expectations from the highest level of your organization (CEO/President/COO):
   Be committed, set the standard – make it clear that this is how we will practice:
   All diagnostic test results on patients cared for in our institution will be communicated to the responsible physician and acknowledged in a time frame appropriate to the degree of clinical urgency associated with those results.
2. Appoint an executive sponsor for the implementation team; the executive sponsor can stand in for leadership in addressing some of the issues below and provide an active voice supporting the team
3. Sufficiently resource the effort: allocate sufficient time for team members to work on testing, relieve them of some of their other responsibilities during the testing phase, and clearly assign resources for the ongoing data collection effort
4. Review the team’s monthly data and timeline regularly
   Be sure this initiative is part of the ongoing quality and safety reporting to leadership
   Build into strategic plan in way that reporting-out at Board-level happens naturally
   Ask about the project on executive walk rounds
5. Remove barriers where possible
   Develop support from all (IT, medical records, staff education, etc)
   Eliminate need for forms committee approvals during testing
6. Role of incentives???
   Should be part of management’s core mission
   Find ways to reward both management and staff

Form a Team

Identify a multidisciplinary team to direct your Communicating Critical Test Results effort using the form at the end of this document. Team Roster Form

Key voices that need to be on the team include:

• Executive sponsor
• Clinical leadership for all key stakeholder groups:
  physicians, nurses, all diagnostic testing centers (laboratory, cardiology, radiology)
• Front-line caregivers: nursing all shifts
• Patient Safety Officer and/or reps from QI/RM
• Key services related to the project (Communication center, IT)
• Special successes from engaging hospitalists, residents, staff education, ambulatory practices.

Collect Baseline Data

Begin a risk assessment of your current processes, collecting baseline data and developing high-level flow charts of existing workflow. It can also be helpful to review any root cause analyses of recent communication errors (poor handoff of diagnostic test information) that resulted in missed or delayed treatment, and develop a mini-FMEA identifying what can go wrong when communicating critical test results/interpretations.

Instructions for collecting baseline data and an accompanying Excel spreadsheet can be found in the Measures section:
Data Collection Tool
Protocol for Data Collection

Develop Mission and Aim Statements

Frame a mission statement to sharply focus your organizations purpose for this project. Include all stakeholder groups in framing the mission statement with the following elements:

• the project’s goal of improving patient safety (to keep your group focused)
• what you want to promise to patients in your care
• your expectations for fixing the problem of missed or delayed treatment from ineffective communication handoffs.

The mission statement should be coupled with both long and short term aim statements.
Aim statements should include quantified goals (success rates for reliable communication) and time frames for achieving those goals.

• identified populations (lab, cardiology and radiology)
• expansion of the types of test (more time sensitive to less time sensitive) results that are communicated within the time targets (red, orange, yellow).

Broad Mission Statement

Every patient treated in our facility, who receives diagnostic tests, will have the results of those tests communicated to the responsible provider in a timely and reliable fashion. The timing of the communication of any test results will appropriately reflect the clinical urgency of the results.

All critical results (lab, cardiology, radiology) will be communicated to the responsible provider with the expected outcome of having clinical action (documented in the medical record) within our defined time targets (one hour for “red” category).

AIM Statement

Short-term Aim:

• Increase the percentage of (red category) critical test results that are communicated within our time targets by 50% within 9 months

Long-term Aim:

• Every (red category) critical test result will be communicated to a clinician who can take action within 1 hour of when the results are available within 1 year
  and
• The critical test communication process will include all diagnostic test centers and all test types within two years

Measures

Identify the measure you will track to let you know if you are meeting your aims

• % of critical (red) test results communicated within our time targets (preferred measure); track every outlier that does not meet the time target

Choose Where to Start

Most hospitals have elected to start by examining their existing communication processes from the laboratory. For some, a medical error associated with the communication process has triggered a focused analysis of a specific type of test finding. Some hospitals completed a mini-FMEA process to assess the areas with the greatest potential for problems in their institution.

There are three key interventions:
1. Shorten the list; decide what tests values/interpretations require timely and reliable communication and establish explicit time frames (targets) for notification; if the list is short and indisputable, MD resistance to direct notification drops

Create an ad hoc group of both the department(s) generating the results and the physician group(s) receiving the results to mutually agree on what tests/interpretations are perceived as “critical”. Start by identifying a subset of laboratory critical test values that are both frequent and carry a high value for a prompt response, such as critically elevated potassium level or a low glucose level. The primary objective should be to shorten the list to a small subset of tests that all would agree represent a true clinical emergency; that is, those values/interpretations that indicate the patient is in imminent danger of death, significant morbidity or serious adverse consequences unless treatment is initiated immediately. These values/interpretations require immediate interruptive notification of the ordering provider or covering physician who can initiate the appropriate clinical action for the patient.

You may simultaneously create working groups of diagnostic test centers (cardiology and radiology) and receiving physicians while you are working on your laboratory lists. Some hospitals with obstetric services have also reviewed their processes related to critical findings from fetal heart monitoring.

2. Improve your ability to identify and reach the ordering provider or their covering provider

1. Link the patient with a provider or service at the time of admission
2. Create a forcing function at the point of test entry to identify the ordering provider
3. Decide who should be called when the ordering provider is not available; centralize the call schedule information; make this information available to entire clinical team

With a FMEA, many hospital teams identified a major failure mode in their ability to identify what physician was responsible for a particular patient at any given time. Further, clinical teams did not have universal access to information about provider coverage. By implementing direct physician notification, the testing areas can guarantee acknowledgement and document “read back” of critical test results.

3. Build reliability into your system to support clinical staff in their work

1. Define a “fail-safe” process to be activated when the responsible provider cannot be reached within the time targets
2. Design the acknowledgement process into your system; the sender is responsible for real-time tracking, and activating fail-safe if necessary
3. Use standardized communication tools; simple documentation tools make it “easy to do the right thing”

In baseline data collection, many hospital teams identified a deficiency in the documentation of the end point of the communication process of a critical finding; once the physician is notified, there is little documentation of the clinical decision that was made for the patient as a result of the critical test results/interpretation. To maximize patient safety, many teams monitor all elements of their performance, time out of the lab, time to MD notification, and time of a clinical decision about the test results for the patient. Often the clinical decision results in an order for a medication, an order to repeat the test, or some other intervention that serves as an endpoint. Many teams have also identified a group of test values that can be handled with protocols of standing orders for the nursing staff, insulin and heparin protocols, for example.

MOST IMPORTANT CRITERIA FOR SUCCESS

• AGREE UPON A LIST
• DEVELOP A MENTHOD TO ASSURE ACKNOWLEDGEMENT WITHIN THE TIME FRAME
• MEASURE WITH REAL TIME DOCUMENTATION
• DEVELOP A FAIL-SAFE SYSTEM

Begin Testing

Once you have identified a pilot area, you’ll want to begin small tests of change. We strongly suggest breaking the process down into small steps, so you will have narrow, focused tests to work out the kinks in the process. You can begin with just the first step, shortening the list and then introduce the phase of improving your call schedule. Some ideas to help you get started:

1. Pick one or two critical test findings to track to learn about your communication process. Follow a few tests all the way to documentation of a clinical decision; take what you learned about your communication process to get some ideas for testing.
   1. If nursing currently receives the critical test results, what does it take for the nurse to reach the physician?; how could we make this process easier

Testing ideas:

• Try a direct notification with a “willing volunteer” service;
  • Test dedicated beepers for critical test notification
  • Test dedicated role to receive critical test values;
  • Identify workflow issues; How does direct notification affect your process?; what difficulties arise when the physician is notified directly?; what difficulties arise when the lab calls the result to the nurse?;
  • De-brief the service members and revise the process based on what you learned
• Continue testing just the first step of the process, but try a direct notification with the cardiologists or radiologists; what problems with communication do they identify?
• Test different ways to document your process; what are team members currently using; what ideas can you test that would make the process “easier for them to do the right thing”; consider sticky notes, documentation logs, preprinted documentation forms; is your current process well documented by the clinical team members?

In the process of running your tests of change, you’ll get lots of input from your staff that will guide you in tailor the process to meet the needs of your organization.

A set of implementation planning tools are provided in the “Toolkit” section of this WEB site:

• Implementation Planning Checklist
• Worksheet for Reporting Tests of Change

The most important thing is to stay focused; start small and test each step of the process:

• One or two laboratory techs with the results of one patient to one ordering MD, on one unit, for one day; refine the test of change with one group, then use what you have learned from one group to begin testing with another group
• Test how communication process can be integrated most effectively with current work processes
• Thoroughly test communication process in paper format before automating
• Moving too fast to spread change to other areas can be a mistake; ensure smooth process first

Begin Testing

Notes on Project Phasing

Implementation of the Safe Practice Recommendations for Communicating Critical Test Results throughout your organization requires careful planning. Some hospitals have successfully implemented the change process over a one year period. For larger organizations this could be a very ambitious timeline given the number of core processes that may need to be changed.

For a big-picture perspective, you will need to develop a plan to move through each of the four major project implementation phases:

1. Pilot testing: working just in some small focus areas, identify small tests of change (plan), test (do), measure to know if the changes are an improvement (study), and refine the change based on what was learned from the test and prepare a plan for the next test (act).
2. Implementation: take a successful change and build it into the way the entire pilot unit does their work.
3. Spread: replicating and further refining the successful tests that have been implemented on the pilot areas into other parts of the organization.
4. Maintain the gains: continued focus and ongoing measurement is required to ensure that the safety practices remain an ongoing part of your work flow; the goal should be to “hardwire” the changes into your existing workflow processes so it becomes the way you do business.

Remember the importance of ongoing data collection (20 charts a month) of your two key measures to evaluate your ongoing progress.

• % of tests that meet the time targets
• Average time to clinical acknowledgment by the clinician responsible for action

Sample timelines and planning worksheets are provided in the toolkit section to support your long-term project planning efforts.

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