The catalyst for improving microbiology specimen management was the receipt of bronchoalveolar lavage (BAL) specimens in the wrong container and with incorrect or incomplete order information from the operating rooms. With a new surgeon performing BAL procedures, we decided to meet with one of our OR nurse educators to discuss their process for handling BAL specimens. This then unveiled that the OR was using something of a “cheat sheet” to indicate what containers to use for what specimens, and it contained incorrect information for BALs, as well as incorrect handling procedures for other microbiology specimens. With this new understanding, laboratory leadership determined that changes were necessary.
Identify the Issues and Establish Goals
At Dartmouth-Hitchcock Medical Center, headquartered in Lebanon, New Hampshire, we are fortunate to have access to a unique program through The Value Institute Learning Center (VI) (see SIDEBAR). Upon learning of the multiple issues related to microbiology specimen handling in the OR, the obvious next step was to work with the VI to set up a process improvement project based on the tried-and-true DMAIC framework: Define, Measure, Analyze, Improve, and Control. We then created a project team comprising two microbiologists, a microbiology lab assistant, an LIS assistant, two OR nurses, an EHR analyst, and a pathology assistant. We also had the benefit of input from a VI Learning Center coach throughout the duration of the project. This team effort was vital to the project’s success.
In reviewing the processes for OR microbiology specimen handling, we were able to identify the basic, governing problems. Our OR nurses, scrub techs, and surgeons did not have current and easily accessible resources to efficiently and accurately place microbiology orders, consistently obtain appropriate specimen labels, and ensure the use of appropriate containers. These realizations lead to the establishment of two overarching goals:
All clinical disciplines are aware of the importance of collecting, handling, and managing appropriate specimens the first time, and how doing so has a beneficial impact on patient outcomes and patient care.
Practical Detriment in Microbiology
Notwithstanding the technical confusion caused by, for example, a specimen being placed in the wrong container or improper labeling, such activities have specific detriment in microbiology applications. Improper handling can stunt the growth of certain pathogenic bacteria or disable the growth of significant quantities. If incorrect ordering is included in the electronic health record (EHR), cultures may be over-or underworked, rendering subsequent bacterial identification and anti-microbial susceptibility testing clinically irrelevant, often necessitating calls for additional work and delaying diagnostic rendering.
Create a Process Map
Breaking down the specimen management process from the OR into standard channels of supplier, input, process, output, and customer (SIPOC) (see FIGURE 1), our process starts with the provider giving a verbal order to the OR nurse, and ends when the microbiology lab receives the sample. The initial step was disconcerting, as the laboratory was under the impression the provider entered the orders directly. We also learned the surgical techs were involved in collecting specimens from the surgeons, yet lacked the necessary training on which containers to use.
Listen to the Voice of the Customer
Given the codependent relationship between microbiology laboratorians and OR clinicians, process improvement required gaining an understanding of each area’s concerns. We met with small groups of OR nurses and inquired about the challenges they faced when ordering a microbiology test, what stressors were involved in the process, the availability of helpful resources, and their general and frank opinions about the service provided by the laboratory.
Concurrently, we met internally in the microbiology lab and discussed our own challenges and stressors, as well as the state of available resources for help when an incorrect specimen or order is received. As with the OR nurses, we discussed our perceptions of OR operations and ways in which any negative perceptions could be improved.
Identify Common and Uncommon Results
After meeting with all parties, we broke the primary issues down into five basic categories:
To begin addressing these problems, we made a critical-to-quality (CTQ) tree (see FIGURE 2). Beginning with the basic need and flowing through drivers, critical characteristics, and specifications, we were able to clearly define the proper methods for ordering testing in the EHR and preparing a specimen for delivery to the lab.
Ordering a Microbiology Culture
After drilling down to more detail in the OR ordering process, we identified three actions with the greatest potential for error: finding the correct order, selecting the correct container, and printing and placing the correct label on the correct container. We discovered there were numerous practices for each of the first two actions, and labeling could be interrupted by several factors.
To find an order, nurses consulted in the EHR a facility list, a preference list, or a favorites list, or they would call the laboratory or ask a co-worker. Likewise, nurses would consult a co-worker or call the lab if they had questions about what container to use. Failure to print a label had multiple causative factors, from the systemic (patient not yet registered to a specific room, so the label will not print unless a “collection task” is performed, and not all nurses understand how to perform this process in the EHR), to the mundane (computer and printer not mapped, or printer out of labels).
Root Cause Analysis
As we entered the Analyze phase of the DMAIC format, we constructed fishbone diagrams mapping the three primary issues: OR nurse does not know how to find and place the correct order in the EHR, OR nurse or scrub tech does not know what container to use, and label does not print or takes too long to print. For each scenario, we employed another proven Lean Six Sigma concept known as the 5 Whys. Five is an arbitrary number, but the concept is that you continue to probe the underlying actions of an error-prone task until you find the causative source(s); keep asking “why?” until the situation is clear. At that point, you fix the elements that can be fixed. Again, collaboration is key to this process. Be sure to solicit all suggestions for improvement at this stage from all involved staff members, as front-line personnel are often the greatest resource for improvement ideas.
After the three fishbone diagrams were finished, we met as a group and categorized the elements as one of four types: implement, possible, challenge, kill. As a result of this collaborative process, we were able to identify the most feasible and constructive improvement projects.
The following initiatives were deemed possible with varying degrees of difficulty from easy-to-access visual resources to more nuanced and time consuming training and education. Regardless, we felt these were all feasible and would improve our overall specimen handling process.
Specimen Container Drawer in the OR
We began by addressing the physical workspace in the ORs and clearly marking the container storage areas. This included the container name, a photo of the container, and a list of what tests are associated with that container and what size sample to submit. We accept and use several containers, so we made large laminated sheet of photos of all acceptable containers and attendant information, and placed that next to the nurse ordering computer (see FIGURE 3).
Education sessions were developed and presented to all OR staff on the various containers, their placement, the proper use, and the importance of these factors to proper microbiology testing. We targeted specific sub sections of the OR first and then presented to the entire group (see FIGURE 4). We also visited Dartmouth-Hitchcock’s Surgical Technology Program and presented our findings. Further, this material is now part of mandatory periop education given to all new OR nurses.
Microbiology Ordering in the EHR
To clarify and streamline the ordering process, we added more microbiology choices to the OR preference list. We also created a job aid in our document control system that outlines each surgical service order, the order definition, and the proper associated EHR order number. We then created laminated cards for each OR service, called Badge Buddies, that attached to staff member badges for quick reference (see FIGURE 5).
Managing the label printing process is multi-tiered. First, the patient must be registered in a room before a microbiology order label will print. As patients in the OR may not be registered to a room, nurses must perform a collection task in the EHR in order for the label to print.
We placed laminated cards at all the printers clearly indicating where supplies are kept and showing step-by-step, visual instructions for replacing label rolls. During the course of our workflow study, we realized that in the OR, the computer used to make microbiology and other lab orders was network mapped to the printer set up next to it. However, if a computer or printer was swapped out, the printer was not always remapped to the computer, causing further confusion and delay. Now, mapping is a forced function if a computer or printer is changed in the ORs.
Communicate Regularly and Continuously
Over the course of the project, roughly 6 months, the microbiology lab communicated regularly with OR staff. This was important, as we needed buy-in from all relevant parties for the improvements to be successful. We made a point to incorporate their input throughout the process as well to customize it to their needs. To ease the impact of process change, we performed a soft implementation and reviewed data for feedback. If an incorrect order is received or a container/labeling error occurs, we address the incident quickly with the staff member to help reinforce the new process. Since implementing our resource and education measures, the lab has seen a roughly 40% decrease in order and specimen errors from the OR.
Key realizations were made on both sides of this project. For the microbiology lab, we learned that the OR realizes a high turnover rate in its staff and this led in part to the lack of experience with the various specimen containers and ordering system nuances. Likewise, the quick-reference guides would expedite bringing new staff up to speed. Alternately, the OR staff realized that the microbiology lab does not use the same ordering system they do, and although they are interfaced, the systems are separate. In the past, OR staff would be frustrated when lab staff were unable to provide technical assistance with orders.
Although we were able to pinpoint workflow gaps and find effective solutions, the real success of these projects is measured in sustainability. In order to ensure the new procedures were followed, we created a system to track any deviances and record corrective actions (see FIGURE 6).
We continue to provide education on the value of proper specimen collection, handling, and management to surgical techs and perioperative nurses on a regular basis. To further the understanding between the microbiology lab and the OR, we are demonstrating the processing of frozen sections to OR nurse educators in our laboratory. Creating a better working relationship between the microbiology laboratory and the OR has reduced OR nursing staff anxiety over ordering and collecting microbiology specimens, and decreased the amount of rework in the microbiology lab. We are encouraging other areas of the laboratory to engage the OR in the same way.
Lisa LeBlanc, MT(ASCP), is a clinical laboratory scientist IV in the microbiology laboratory and virology lab team leader at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire, where she has worked for 27 years. With experience in both hematology and microbiology, she has been involved in numerous process improvement initiatives involving outpatient phlebotomy, microbiology, and specimen handling.
The Value Institute Learning Center
The Value Institute Learning Center (VI) is a venue for addressing the many process improvement projects at Dartmouth-Hitchcock Health System. The VI was created in 2011 to nurture employee problem solving skills. The system incorporates Lean Six Sigma (LSS) methodology via the DMAIC approach— Define, Measure, Analyze, Improve, and Control. As of early 2018, approximately 350 employees have been LSS Green Belt Certified and approximately 2500 employees have been Yellow Belt Certified.