Introduction

Our hospital Cairo University Hospital serves about 600,000 students in all faculties and more than 10000 staff members and employees. It lies in Giza square surrounded by different faculties of Cairo University , being in such a wonderful place it serves many people other than those getting benefit from the insurance . As regard the emergency room it serves the whole population of the university and the neighboring area.

 The laboratory Department contains 4 units and a specialized ER lab. The ER lab plays a vital role in the process of rapid diagnosis of the critically ill patients especially those suffering from suspected myocardial infarction.

Quality planning project

Introduction of new Chemical Analyzer to ER lab
By:
Noura Mohammad Nagib Sara Ahmad Tarek Sarah Omar Tawfik

Steps of quality improvement project :

Step 1 Establish the project.

Step 2

Identify customers.

Step 3

Discover customer needs.

Step 4

Develop service.

Step 5

Develop process.

Step 6

Develop process controls / transfer to operations.

Step 1: Establish Project

A. B. C. D. E. Identify project. Establish project mission. Establish team. Verify mission. Plan the project.

Step 1

Step 1 : Establish project

A-Identify Project.
The basis for identifying the project is to establish a new chemical analyzer in the ER Lab for rapid diagnosis of the critically ill patients and to increase the service provided by the hospital Lab

Step 1

Step 1 : Establish project

B- Mission statement
Introduction of a new Chemical Analyzer Machine in the ER Lab in the span of 7 months. This device will serve the E.R patients, rapidly doing the urgent Chemical lab tests. The machine will be able to analyze all the basic Clinical Chemistry tests quickly, using recent technology in the industry. It will accomplish a rapid , accurate, safe , precise service for ER patients

Step 1 : Establish project

Goals
1. To reduce the Central lab turn around time for getting the Clinical Chemistry result from 45 minutes to 20 minutes. 2. To manage the ER cases faster, reducing patient related mortality to less than 3%. 3. To capture 40% of the market share in the field of Emergency management. 4. Increase customer satisfaction by at least 15%.

5. To increase the revenue of hospital as the project is expected to gain not less than 100,000 LE by the first year of operation.

Step 1 : Establish project

C-Establishing a team
It is a cross-functional team formed of Chief Executive officer (CEO) ,the quality director and a representatives from the following departments: ER department Lab department Nursing staff Reception Finance Purchasing department Supplier company Maintenance department

Step 1 : Establish project

Team Charter:
The team is expected to apply the steps of the quality planning process. Team members are to spend a 5 hours each week. The team will have access to resources. The ER nurses will be responsible for preparing the meeting agenda The team is supported and authorized from the higher management , arrangements are agreed upon for obtaining any additional resources if needed .

Step 1 : Establish project

D-Verify mission :
Our quality planning goal respects the five characteristics of the 'SMART' method as it is: Specific as it deals with service provided to ER patient who will need Chemical tests. Measurable to perform 3000 lab analysis/month=3% market share. Agreed upon after taking into account primary and secondary research and facts from our market share data, we do believe that the objectives set are achievable Realistic considering financial resources availably and manpower expertise Time phased it will be achieved in span of 7months .

Step 1 : Establish project

After the Team finished the Brain storming ,they began using their tools for planning the project .

1- Tree Diagram
In tree diagram each step is further defined by key activities and tasks to be done. The primary goals are subdivided to secondary project goals or activities and activities are subdivided to the major tasks that are most related to the first level goals.

B. Quality tool: Tree Diagram:Establish the project

Establish project mission

Verify the mission

Establish the team Plan the project Create a flow diagram Identify customers

Establish New chemical analyzer in ER lab

List customers and prioritize

Select sample s survey/interview key customers Design questions Send questionnaires/ arrange interviews List single dimension needs translate Determine unit of measure and sensors

Discover customer needs

Plan more data collection

Complete needs analysis

Develop the service

Develop features and goals

Determine methods Develop high level features and goals Develop detailed features and goals

Optimize features and goals

Determine method

Optimize
Publish final product design Publish final product features and goals

Identify operating conditions

Identify process anatomy

Develop the process

Select general process design Identify process features and goals

Design process flow diagram

Identify controls needed

Develop process controls / transfer to operations

Design feedback loop

Plan for transfer to operations

Step 1 : Establish project

2- Planning network
It is a highly useful tool for taking a complex or long term project and dividing it into specific tasks . Some tasks are performed sequentially while other tasks on different paths do not depend on each other and can be performed simultaneously. It is often developed based on a tree diagram

7/3-10/3

Planning Network
6/2-13/2 8days 21/1-5/2 1/1-20/1 20days Create flow diagram 16days Select sample

4days

Send questionnaire

23/3-22/4 7/3-22/3 31days 16days

List customer &prioritize

interview 6/2-6/3

List single dimension needs

30days
Design questionnaire 7/3-22/3 16days Plan more data collection

23/4-8/55

23/5-7/6 16days Determine unit of measure & sensor

8/6-12/6 5days Select high level service features & goals

13/6-17/6 5days Developed detailed service features & goals

18/6-22/6 5days Determine the design of process anatomy

16days translate

23/4-22/5 30days Place on service design spreadsheet

CRITICAL PATH: The path with the largest total elapse time labeled by blue colors. Lost time for any of these tasks would put the entire project behind schedule

23/6-27/6 5days Develop process flow diagram

28/6-4/7 7days Construct detailed process features & goals spreadsheet

5/7-7/7 3days Develop feedback loop

8/7-10/7 3days Develop process control spreadsheet

The overall project days = 192 days

Step 2: Identify customers

A. B. C. D. E. F. Construct a high level flow diagram Construct a detailed flow diagram Create a list of all external customers Create a list of all internal customers Prioritize customers lists Vital few customers

Step 2 : Identify customers

ER physician making a lab request ER nurse takes the suitable sample for the requested test Porter delivers sample to the ER lab
ER lab req

Detailed flow diagram

NO

Sample taken correctly and suitable for testing?

yes

Lab chemist records the requested test and related information in the ER lab register

ER lab reg

Lab chemist performs the test on the sample and reads the result

Step 2 : Identify customers

B Lab chemist delivers the result to the lab dr
Lab DR calls the ER phys and report him
yes

Is the result critical?

NO

Lab dr interprit the result and write the report

ER lab report

Lab porter takes the report and deliver it to the ER phys

Step 2 : Identify customers

Internal Customers
ER physician

External Customers
ER patients
Families of patients. Supplier of medical equipments Ministry of health. Health insurance organization. Market.

Customer chick list

Porters. ER nurse. Administration staff. ER lab doctor.

Financial staff
Purchasing,. Lab chemist Infection control team

Step 2 : Identify customers

Impact (Prioritization) Matrix

It organizes data into sets of items to be compared. The diagram graphically shows relationships and/ or evaluates the strengths of relationships between the items in each set. The team brainstormed a list of possible criteria to use in prioritization the external and internal customer

Step 2 : Identify customers SELECTION MATRIX FOR PRIORITIZATION OF EXTERNAL CUSTOMERS

Customer Revenue Impact Shut us on our down image 9 3 9 1 1 1 Decrease Bring morbidity new & mortality business 9 3 1 9 3 9 Total

Patient Suppliers Patients families

9 9 9

37 19 29

MOH
Market Insurance

3
9 9

1
9 9

9
1 1

1
1 1

1
3 9

15
23 29

Scale : 9 ( very strong ) 3 ( strong) 1 ( weak)

Step 2 : Identify customers

SELECTION MATRIX FOR PRIORITIZATION OF INTERNAL CUSTOMERS
Customer ER physicians. Revenue 9 Impact on our image 9 Shut us down 1 Decrease morbidity 9 Bring new business 3 Total 31

porters
ER lab physician Admission staff ER nurse Finance staff purchasing Lab chemist Lab clerk Inf. cont team

1
9

3
3

1
1

3
3

3
3

11
19

3 9 9 9 9 3 3

3 9 1 1 9 3 3

1 1 1 1 3 1 3

3 3 1 1 1 1 9

3 3 1 1 1 1 1

13 25 13 13 23 9 19

Scale : 9 ( very strong ) 3 ( strong) 1 ( weak)

Step 2 : Identify customers

Vital few customers were identified as follows: Patient ( ext.) Patient families ( ext.) Insurance (ext) ER physicians ( int.) Lab chemist (int) ER nurse(int)

Vital few customers

Step 3: Discover customer needs

A. B. C. D. E. Plan to collect customer needs Collect list of customer needs in their language Examine and prioritize customer needs Translate their needs into your language Establish unit of measurement and sensors

Step 3 : Discover customer needs

Understanding customer needs

The team decided to collect the needs of the vital few external and internal customers. They prepared different customer questionnaires and conducted face to face interviews with the customers.

Step 3 : Discover customer needs

Questionnaire (for external customers)

Name: Sex: Occupation: Please check your answers & explain when needed:
1- How often do you visit the Cairo university hospital? 2. How many times did you come to our ER ? 3. Are you satisfied with our waiting time for results of our ER laboratory? satisfied Neutral Dissatisfied. 4. If you are not satisfied , please tell us why do u feel that way ? 5. How satisfied are you with our ER lab. Service? 6. How do you compare us with other similar hospitals providing ER lab. Service? 7. What suggestions do u have to improve our ER lab service?

Step 3 : Discover customer needs Some answers were as following :

4. If you are not satisfied, please tell us why do you feel that way? Delayed results of ER tests. Multiple sampling trials. Sometimes, there are errors in the reports. ER devices look somehow old, not recent. Delay in transporting samples to ER lab. Re-analysis due to lab mistakes or sampling mistakes. Painful, uneasy sampling. Unfriendly behavior of the personnel at the ER. Not all the ER tests are always available at the ER lab.

Step 3 : Discover customer needs

5. How satisfied are you with our ER lab service? Its location is easy to reach. Many ER lab residents available at the place. 7.How do you compare us with other similar hospital providing ER lab service? Same.
8. What suggestions do you have to improve our ER lab service? Updating the ER lab service.

Step 3 : Discover customer needs

Questionnaire ( for internal customers)

Name: Sex: Occupation:
Please check your answers & explain when needed: 1- Do you think that applying a new chemical analyzer in ER lab to avoid sending sample to the central lab is a good idea and why? 2- Do you prefer a nurse to take the sample or a Lab technician and why? 3- Do you think the presence of work instruction attached to any device is a good idea? Yes No Somehow 4- What are your requirements for a new chemical analyzer device? 5- Do you think a 24 hour,7 days week availability of this service is a must? 6- Do you think explaining what goes on to the patient is important, why? 7- Do you have any suggestion for a better lab service? 8- Do you need easy, rapid communication between ER dep and lab dep when there is a critical values?

Step 3 : Discover customer needs Some answers were as following

1- Do you think that applying a new chemical analyzer in ER lab to avoid sending sample to the central lab is a good idea and why? Yes it will decrease the TAT for central lab and will increase ability to rapidly diagnose and management 2- Do you prefer a nurse to take the sample or a Lab technician and why? A well , trained nurse 4- What are your requirements for this device? Reliable, results , safe , rapid , user friendly ,calibrated , regular maintenance. 5- Do you think a 24 hour,7 days week availability of this service is a must? Yes

6- Do you think explaining what goes on to the patient is important, why? Yes 8- Do you need easy, rapid communication with the doctor when there is a critical values? Yes

Step 3 : Discover customer needs

List of Customer Needs

(ext. & int. customers)

Short TAT for test result Accurate results with low error rate. Skilled lab chemist Taking suitable sample to prevent re sampling . Availability of all ER tests. Friendly device. Using latest, easier & updated technology. 24 h/7 days week ER device service. Safety. Enough training on ER lab chemical devices.

Step 3 : Discover customer needs

List of Customer Needs

(ext. & int. customers) Privacy & security. Written work instructions. Contact with ER device supplier specialist in case of any problem. Easy & rapid communication between ER dep and ER lab in case of critical values. Clarified criteria of ER device. Comfortable working environment ( availability of reagents & materials)

Step 3 : Discover customer needs

Translation of customer needs:

Needs expressed as features
Using latest, easier & updated technology. Short waiting for ER test results. Accurate results with low error rate. Safety Easy & rapid communication between ER lab and ER dep in case of critical values.

Needs expressed as benefits

Rapid, accurate & user friendly equipment. Lab. results arrive on time. The No. of reports repeated for not being accurate in relation to total No. of delivered reports per month. Provide manual for infection control. Following the instructions in this manual. Lab DR have to call immediately ER doctors in case of critical value.

Step 3 : Discover customer needs

Translation of customer needs:

Needs expressed as features
Availability of all ER tests. Contact with ER device/ supplier specialist in case of any problem. Customer satisfaction.

Needs expressed as benefits

All are ER test kits and devices should be available in the lab. Calibrate before starting work. Maintenance contract with supplier. No. of repeated customer/relatives visits/ year for the same or other service.

Step 3 : Discover customer needs

Customer Needs Spreadsheet:

Step 3 : Discover customer needs

Customer Vital few Using latest, technol ogy
1

Short waiti ng time

9
1

accurate results

Commu Availabilit nic. for y of all ER critical tests values

3 9 3 9
9

24 hrs,7 days week ER device service

9 3

safety

written work instructi ons

1 9

Patient Lab chemist Patient families ER nurse ER physician

9 9

9 3

9 9

9
9

3 9

1
9

1
9

9 1

9 1

insurance
Total

1
26

3
40

3
42

1
34

3
34

3
34

3
40

1
22

Scale : 9 (strong) 3( medium ) 1 ( week)

Step 3 : Discover customer needs

Prioritized list of needs

of external and internal customers
1- Using latest, easier, updated technology 2- Short waiting time for test results 3- accurate results with low error rate 4- safety 5-Easy,rapid communication with the ER physician in case of critical values 6- 24 hrs,7 days week ER device service 7-written work instructions 8- contact with the device supplier specialist in case of any problem.

Step 3 : Discover customer needs

The team recognized that some of the needs collected from customers were broad and required further definition in order to be addressed. So, the team decided to review the list of needs and break them down to a precise enough that a single response to each need could be developed. They used a needs analysis spread sheet to do this.

Step 3 : Discover customer needs

Needs analysis Spreadsheet:

Step 3 : Discover customer needs

Primary needs
Safety

Secondary needs
Proper infection control system

Tertiary needs
Implementation of infection control system in the ER lab Establish policy & procedure for infection control Well ventilated Properly cleaned Implementation of safety measures for taking sample Providing a budget for buying the machine and vacutainer materials. Training courses for ER nurses on vacutanier. Dividing the day to 3 shifts for the chemist

Rapid service

Rapid sample withdrawal by the ER nurse. Buying a new machine using the recent updated technology. 24h/ 7 days available lab Chemist. Adequate calibration for the machine. Well trained lab chemist Qualified lab doctors.

Accurate results

Checking the machine manual for required QC & calibration. Training courses for the Chemist. on the machines. Choosing doctors with highest qualification & past experience in ER lab.

Step 3 : Discover customer needs

Primary needs Comfortable service (24hrs,7 days available) Secondary needs All ER tests are available. Available kits & reagents. Sample taking once. Tertiary needs Providing a budget for buying a new machine doing all ER chemical tests. A store for the kits & reagents inside the ER lab. Trained ER nurse on taking sample. Written work instruction Easy operation on the device Provided patient with needed information Effective treatment. From manual Education Accurate result

Customer satisfaction

Step 3 : Discover customer needs

Determine units of measures and sensors:

Customer need
Rapid service Accurate results

Unit of measurement
ER lab T.A.T for chemical analysis less than 20 min. Complaints of ER physicians. No. of tests repeated.

Sensor
Numbers of ER results than took more than 20 min. Monthly questionnaire ER physician. No. of tests repeated per month.

Comfortable service
Customer satisfaction

Yes/no
No. of new patients using our service.

Complaints report
Customer survey monthly random. Direct communication with customer to view their satisfaction.

Step 4: Develop the service

A. Group together related customer needs B. Determine methods for identifying product features C. Select high level product features and goals D. Develop detailed product features and goals E. Optimize product features and goals F. Set and publish final product features and goals G. Set and publish final product design

Step 4 : Develop the service

Group together related customer needs:

The team should prioritize and group together those needs which relate to similar functionality (clustering the needs) Tool: Affinity diagram

Step 4 : Develop the service

ER lab. Staff2 High quality needs ER chemical tests Safety needs Training needs Reports

Affinity diagram

Qualified doctors
Available porters Well trained lab chemist

Latest Rapid results technology

Rapid results Accurate results User friendly Regularly maintained Accurate results

Sample taking once

Qualified lab doctors.

Provided patient with needed information

All ER tests are available

Well trained lab Lab report with chemist no errors

Short ER lab turnaround Accurate results Well trained ER time nurse All test kits available

Daily calibration

Step 4 : Develop the service

Determine methods for identifying service features:

Brain storming: to identify product features.
Benchmarking: to make a point of comparison or measure what our
competitors have achieved with their ER lab matched to us.

Basic research: to explore the feasibility of the product and product

features

Market experiments: introducing and testing ideas for product

features which allow us to analyze our team's recommendations. This is done through focus groups to compare our expectations with the actual market requirements.

Step 4 : Develop the service

Select high level product features & goals:

Service features Trained Lab chemist Calibrate d machine Regular mainten ance Available Service test

Customer needs

Qualified lab physicians

Machine Latest tech

Safety Rapid accurate comfortable Written work instruction Customer satisfaction Availability of all chemical tests

9 9 9 1 9 3

9 3 9 1 1 3

9 9 9 3 3 3

9 9 9 3 3 3

9 9 9 3 3 3

1 9 1 3 1 9

1 int. & ext quality proficien cy?

3 Accurate results longer life span

Service feature goals

Well trained Lab chemist

41

Master Degree

Model 20102011

Service available 24/7

Total

27

45

37

39

33

Step 5: Develop process

A. Review product goals B. Identify operating conditions C. Collect known information on alternate processes D. Select general design E. Identify process features and goals

Step 5 : Develop process

The main activity: Process anatomy Process flow diagram Process features & goals spreadsheet

Step 5

Step 5 : Develop process

Process development is the activity which determines how our lab service will be delivered, the aim of process development is to provide the operating forces with means for meeting operating goals

Step 5

Step 5 : Develop process

Process anatomy
It is a coherent structure which binds or holds the process together. It guides the flow of the work from start to finish.
Shows in schematic form where the various subprocesses reside, how they are linked together, and where the inputs enter and the outputs go.

Step 5 : Develop process

Item
Process anatomy
Macro process

Process
Chemical analyzer

Process anatomy
Assembly tree

Sub process

Lab request
Withdraw sample Performing the test

Assembly tree
Procession Procession

Report

Procession

Step 5 : Develop process

Patient Administration Process anatomy Admission
Assembly tree

Medical / record Main lab

Investigation

Nursing Physician Lab chemist

Lab report Lab register

Finance

Step 5 : Develop process

Lab request HIGH LEVEL FLOW DIAGRAM (PROCESS ANATOMY)

Withdraw sample

Safety measures

Preparing the patient

Performing The test

Calibrate the equipment

Report

Delivering the report

Writing the report

Step 5 : Develop process

Process features & goals spreadsheet

The process features can be categorized under procedures, methods, equipments and supplies, materials, people, training and knowledge and other resources. The process goals are like other goals should be SMART

Step 5 : Develop process

Process features
Service features Service goals Well trained for (2weeks) Lab chemist Master Degree Procedure O People * equipment O Material O

Process features and goals spread sheet

Trained Lab chemist Qualified lab physicians Machine Latest technology Calibrated machine

Model 2010-2011

int. & ext quality proficiency Accurate results longer life span Service available 24/7

Regular maintenance Available Service test Process goals * Very strong # strong O weak

90 % of results achieved

95% of people do the required job

95% of equipment do the required job

90% of material r available

Step 6:Develop process controls / transfer to operations

A. Identify controls needed B. Design feedback loop C. Plan for transfer to operations

Step

Step 6 : Develop process controls/transfer to operations

Feedback loop
Feedback loop is the tool for monitoring the actual performance of a process and keeping it performing as it was designed

Step 6 : Develop process controls/transfer to operations

Step 6 : Develop process controls/transfer to operations

Process control spreadsheet

This tool will enable the team to identify:1. The control subject. 2. The target goal 3. Criteria for taking action 4. Who takes action 5. What action they take 6. Where they do it 7. When they do it 8. How they do it

Step 6 : Develop process controls/transfer to operations

Process control spreadsheet

Control subject Target goal Criteria for taking action who what where when how

Functioni ng device
Calibrati on and set errors Long TAT

100% accurate device

100% pt satisfactio n

Brock down of any device More than 3% error

Senior nurse
Head of lab dep

Call the maintenanc e

More training to staff

Mantainence dep.
Organization management

immediatel y
After 1 m of completion of initial training Once discovered

By phone

Formal request

Max 20 min

More than 20 min

Head of Lab dep

Diagnose of the cause of delay Calls for more training nurse

ER lab

Standard method

% of multiple sampling trials

Rapid, Painless sample withdrawal from the first time

More than 10 % of cases need more than withdrawal trial

Head of ER

Organization management

After one month of training

Formal or oral request