QA – QC Controls: Where is that specimen?

Sept. 1, 2011

The Pennsylvania State University Milton S. Hershey Medical Center (HMC) is a 450-bed level 1 trauma center in Hershey, PA. Its Department of Pathology Clinical Laboratory Specimen Processing Area (SPA) handles approximately 70,731 specimens per full-time employee annually. The laboratory has experienced a 5% annual increase in test volumes since 2009. The growth of its Cancer Institute and the construction of a dedicated children's hospital are expected to increase the test volumes even further.

HMC clinical laboratories went live with an automation system in May 2009, which is interfaced to a laboratory information system (LIS) via a middleware solution. The hospital information system (HIS) has a different brand of LIS. Inpatient electronic orders are received in the lab's LIS from the HIS, and these download to the middleware solution through which a separate interface allows the upload of results from it to the automation system and to an electronic health records (EHR) module.

The process flow through the lab's SPA involves many inter-related tasks, and staff members routinely use the LIS specimen-management routing and tracking package and the EHR module as part of their activities. Inpatient orders are transmitted to the LIS on documentation of specimen collection. Outpatient orders are manually entered from paper requisitions into the LIS order entry function. SPA staff confirms valid patient identifiers on specimens, and enter collection date and time for outpatient samples. The routing and tracking application assigns tests to individual containers (each with its own container identification number [CID]), captures the workstation or specimen's point-of-tracking location and records the tech code of the lab staff member who processed the sample.

A barcode label is generated for each CID and is used to label the respective tubes. One person is designated as the SPA expeditor and evenly distributes incoming samples to SPA workstations, collects the received samples, and places the barcoded tubes on to the automation system. Each tube is assigned a route from the automation system's software and is centrifuged, decapped, aliquoted, recapped, or sorted, depending on the tests requested.

The specimen-management routing and tracking application enables the lab user to identify the location of each CID from the time it is collected until the specimen is discarded. Aliquoted samples, generated by the automation system or manually decanted, are tracked by SPA staff to the next destination, the specimen point of tracking. Specimens can be housed in a specific rack in a freezer or refrigerator, or left at room temperature. The specimen-management routing and tracking also provides detailed processing instructions for each container, and gives lab staff the ability to batch specimens for transport to various laboratory departments. Staff members from lab sections that manually collect specimens are trained to periodically pick up from the designated racks and track these specimens to the individual work area.

Specimen retrieval has been enhanced: Identifying and tracking by unique CIDs through the specimen-management routing and tracking function provides an audit trail of all specimens “travels” throughout the lab. This eliminates guesswork as to where a specimen may be at any given time — from time of collection at outpatient phlebotomy drawing areas, from inpatient units, to SPA and various laboratory sections. This allows SPA staff to quickly find a sample and ascertain if it is possible to add tests. The routing and tracking function also allows SPA staff to quickly and accurately respond to provider inquiries with the current status of the specimen. Each step is identified by a tech code identifying the staff member who performed the task. Since a tech code is attached to each CID, inquiries can be directed to the individual processing the specimen. This is in contrast to the lab's former process: shouting out requests to the entire department.

Method

Because accurate tracking is vital for the routing and tracking function to work, a practical proficiency exam was developed to assess the competency of each member of the SPA team. Vilette Tribue, technical laboratory associate (TLA) collaborated with Andrea Haug, TLA II, who has an expanded role in LIS. Together, they brainstormed to develop a tracking practical. They focused on including as many scenarios as possible to mimic the actual work load SPA staff encounter every day. They deliberately re-created problems that SPA staff must handle.

The lab staff were required to review a three-page practical study guide prior to completing the hands-on practical. The study guide included numerous tracking functions such as creating a rack, reprinting rack identification numbers, adding specimens to a previously established rack, viewing CIDs within a particular rack, and reviewing a list of the most commonly used racks and spots. The tracking practical itself included 23 questions worth 100 points that required tracking of a specified CID to the appropriate specimen point of tracking and rack in order to receive full credit. The threshold for a passing grade was 80%. Remedial training was required for unacceptable scores, which included re-training, one-on-one assistance, and/or re-testing.

Results

A total of 30 SPA staff completed the practical in late fall of 2010. Of the 30 SPA staff, 63% are full-time employees, 27% are part-time employees, and 10% are temporary agents. The permanent employees consist of 22% MLS, 19% MLT, and 59% TLA. Of these permanent employees, 15% were within their six-month training introductory period. The 100% of the temporary agents had less than six months in the department (see Table 1, SPA staff mix.).

Discussion

SPA staff was given the opportunity to provide feedback after completion of the tracking practical. According to Linda Beachel, senior technical specialist (lead technologist), “The tracking practical did seem to improve confidence to work independently and productively, and we noticed a decrease in errors with all staff productivity.” Another TLA stated that the “tracking practical was wonderful; it creates ownership and responsibility, giving us an opportunity to help employees who need additional reinforcement and training in the tracking and racking of specimens. It was a wonderful idea that produced outstanding results.” A part-time TLA shared that she “now has the ability to assess my strengths and weaknesses in the racking and tracking process. The different scenarios helped improve my knowledge and the confidence to work independently.
I would like to see many more practical training in a 'hands on' fashion to help understand the process.”

Recommendations

To enhance the SPA tracking practical for the upcoming year, HMC's clinical laboratory plans to:

  • increase staff awareness of the importance of accurate tracking to increase and improve productivity and boost employee confidence in successful task completion;
  • test all SPA staff annually;
  • test new employees prior to their six-month competency evaluations;
  • evaluate trainers of new staff by using the tracking practical;
  • assign a practical moderator to monitor staff and to help clarify any of their questions while they are completing the proficiency exam;
  • establish a time limit of 30 minutes for the completion of the tracking practical;
  • mandate that test scenarios and answers not be shared with others until the entire department has completed testing;
  • include an opportunity for staff to provide feedback, including their recommendations and/or concerns about the tracking practical.

Table 1. Specimen processing area (SPA) staff mix. All SPA staff completed the practical within an eight-week period from October through November, 2010; 80% staff passed on the first attempt and 20% required remedial action. The final average SPA score was 95.3% (see Tables 2 and 3, SPA Practical Scores). (Note: Five initial scores were invalid due to staff attempts to complete the practical without a moderator and, inadvertently, cancelled previous results by everyone using the same test patients.)

Table 2. Specimen processing area practical scores – new staff.

Table 3. Specimen processing area practical scores by job classification.

Staff members of the Department of Pathology Clinical Laboratory Specimen Processing Area at the Pennsylvania State University Milton S. Hershey Medical Center in Hershey, PA, include the contributors of this article: Vilette L. Tribue, TLA, (also a certified medical assistant); Andrea M. Haug, BS, TLA II; Monica L. Straub, BS, MT(ASCP), supervisor, automated testing laboratory; Ruth A. Cheng, MBA, MT(ASCP), supervisor, specimen processing area; and William J. Castellani, MD, professor; medical director of clinical chemistry; director, pathology core reference lab; and associate professor, residency program director.

Acknowledgement: Michael Bongiovanni, MD, chief, Division of Clinical Pathology; professor of Pathology and Laboratory Medicine; and director, Clinical Laboratory at the Pennsylvania State Milton S. Hershey Medical Center, expressed a great interest in the development of a specimen processing area tracking practical, and believed that ours was the first of its kind. He was excited that Ms. Tribue and Ms. Haug embarked on what he called “a walk-on-water training practical for SPA!” Dr. Bongiovanni passed away suddenly and was unable to see the publication of this article. Contributors Vilette L. Tribue, Andrea M. Haug, Monica L. Straub, Ruth A. Cheng, and William Castellani would like to acknowledge his encouragement, assistance, guidance, and enthusiasm for this article.

Photo 115879330 © Karenr | Dreamstime.com
Photo 124723736 © Steveheap | Dreamstime.com
Photo 129549884 © Katarzyna Bialasiewicz | Dreamstime.com
Photo 159136554 © Alberto Masnovo | Dreamstime.com