The Testing Process in Primary Care: Safety and Quality Implications for Improving Health Care (Text Version)

On September 14, 2009, Nancy C. Elder made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (856 KB). 

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Slide 1

The testing process in primary care: Safety and quality implications for improving health care

Nancy C. Elder, MD, MSPH
University of Cincinnati Department of Family Medicine
Funded by AHRQ K-08HS013914-04, 2005-2010

Slide 2

How I got interested in the testing process

• 2001: Me, new to town, week 1 in new medical practice.
• 21 year old woman, no period for 3 months, scared she may be pregnant!! (she is not).
• Review of medical chart (paper)
  • 6 months ago TSH = 29. (hypothyroidism).
    • Dr.'s note to MA: call patient and have her rtc.
    • MA's note: tried to call patient, no answer.
  • 3 visits in intervening 6 months for colposcopy and F/U of abnormal pap smear. None mention TSH.
• Me: "We screwed up."
• Reality: Lots of mistakes like this occur, but how many, causes, outcomes, interventions to improve are unknown.

Slide 3

The testing process in primary care

If you can't describe what you are doing as a process, you don't know what you're doing." W. Edward Demings.

A flow chart of the testing process showing:

• Test ordered.
• Testing implemented.
• Test performed.
• Test results tracked.
• Results returned to office and clincian.
• Response to test results by clincian.
• Test results documented and filed.
• Patient notified of test results.
• Patient monitored through follow up.

Slide 4

Are testing process errors really that important to quality?

• Frequent?
  • Error reports, interviews and observations, chart reviews.
• Adverse events and consequences?
  • Error reports, chart reviews.
• Hinder progress toward patient centered medical home and similar reforms?
  • Look at testing process steps relationship to PCMH characteristics.

Slide 5

"Frequency" and types of testing process errors

• Error reports from family physicians and staff
  • AAFP National Research Network (NRN) reporting studies (Dovey, 2002, Phillips, 2006, Hickner 2008)
    • 14 - 25% of ALL physician and staff reported errors were related to testing.
    • Testing process errors break down:
      • Ordering tests (12.9%).
      • Implementing tests (17.9%).
      • Reporting results to clinicians (24.6%).
      • Clinicians responding to results (6.6%).
      • Notifying patient of results (6.8%).
      • General administration (17.6%).
      • Communication (5.7%).
      • Charting or filing (14.5%).
      • Other categories (7.8%).

Slide 6

"Frequency" and types of testing process errors

• Observations and interviews with family physicians and staff (Elder, 2006, Elder, 2008, Elder 2009)
  • 18 focus groups of family physicians and staff identified problems with all steps in the testing process. Underlying contributing factors included
    • Not following procedures.
    • Inadequate systems.
    • Lack of standardization.
    • Communication problems.
  • 4 family medicine offices in SW Ohio overwhelming depend on individuals to work around testing process problems.

Slide 7

"Frequency" and types of testing process errors

• Chart reviews (ongoing)
  • In 261 test results in 8 offices in SW Ohio:
    • 74% had a clinician's interpretation.
    • 70% of patients were notified.
    • 53% of abnormal results had follow up plans.

• In 11 urban CHC offices in Chicago, only 61% of abnormal results for pap smears, mammograms, INRs and PSAs had appropriate follow up documented.

• Interviews with patients (ongoing)
  • Most patients have experienced results not received, not timely and/or not understandable.

Slide 8

Adverse events and consequences from testing process errors

• Error reports from family physicians and staff (Hickner, 2006)
  • Adverse consequences included
    • Time lost and financial consequences (22%).
    • Delays in care (24%).
    • Pain/suffering (11%) and
    • Adverse clinical consequence (2%).
  • 18% of events resulted in some patient harm
• Chart review (Ongoing)
  • In 11 urban CHC offices, more abnormal mammograms and INRs (70%)had documented follow up than did abnormal pap smears and PSAs (55%).

Slide 9

PCMH hindered by testing process errors

• PCMH evaluations consistently indicate that redesigning the delivery of care around a primary care PCMH yields an excellent return on investment:
  • Quality of care, patient experiences, care coordination, and access are demonstrably better.
  • Reductions in emergency department visits and inpatient hospitalizations that produce savings in total costs.
    • PCMH White House briefing document, 2009.
• Patient Centered Medical Home characteristics include:
  • Better Quality of Care.
  • Early ID and management of health problems.
  • Fewer unnecessary tests and procedures.
  • Higher patient satisfaction.
    • www.familydoctor.org

Slide 10

PCMH: Quality of Care

• Most common breakdowns in diagnostic process in closed malpractice claims (Phillips, 2004)
  • 55% failure to order appropriate test.
  • 45% failure to create a proper follow up plan.
  • 37% incorrect interpretation of a test result.
• Testing process steps:
  • Ordering.
  • Interpretation.
  • Follow up.

Slide 11

PCMH: Early identification of health problems

• Process of care failures in breast cancer diagnosis (Weingart, 2009)
  • Failure of patients to complete ordered tests a common factor in breast cancer diagnostic delays.
• Testing process step
  • Tracking.

Slide 12

PCMH: Fewer unnecessary tests

• Missing clinical information during primary care visits (Smith, 2005)
  • Clinicians reported missing laboratory results in 6.1% of all visits and radiology results in 3.8%.
  • 59.5% felt these missing results resulted in delayed care or additional services, including repeating tests.
• Testing process steps:
  • Tracking.
  • Documentation.
  • Patient notification.

Slide 13

PCMH: Higher patient satisfaction

• Patient preferences for notification of normal laboratory test results: a report from the ASIPS Collaborative (Baldwin, 2005)
  • Privacy, responsive and interactive feedback, convenience, and timeliness with detailed information are critical for patient satisfaction.
• Effect of providing information about normal test results on patients' reassurance: randomised controlled trial (Petrie, 2007)
  • Providing patients with information about normal test results before testing can improve rates of reassurance and reduce the likelihood of future reports of chest pain.
• Testing Process steps
  • Ordering.
  • Implementing.
  • Patient notification.

Slide 14

BUT... test result OUTCOMES are what really matter, right?

• Quality performance measures reliant on testing outcomes
  • HEDIS measures.
  • Ambulatory Care Quality Clinical Performance Measures for Ambulatory Care.
  • Pay for Performance.
• So why study the testing Process?

Slide 15

Importance of improving testing PROCESS

• Use of process measures to monitor the quality of clinical practice (Lilford, 2007).
  • Most suitable management tool for judging and rewarding quality.
  • Clinical outcomes are likely to be affected by factors other than the quality of care.
  • Outcome measures provide insufficient information about how to improve.
  • Assessment of process encourages universal improvement rather than focusing on outliers.

Slide 16

Summary: Testing process implications for improving health care

• Testing process errors are frequent and occur across all process steps.
• Adverse events and harm have been associated with testing process errors.
• Poorly functioning testing processes hinder practices from achieving PCMH standards.
• Studying processes is appropriate to monitor and reward health care quality.

Slide 17

The Future...

• What is necessary to improve testing process safety and quality?
  • Adoption of technology AND a culture of safety!
• Improving which steps give the most "bang for the buck?"
  • Identified errors of implementation and patient notification associated with harm and/or adverse events!
  • Follow up of abnormal results most often missing, but rarely identified by staff and clinicians!
• What interventions at what step will bring the most improvement to the testing process?
  • ??????????

Slide 18

Thanks!

• "We should work on our process, not the outcome of our processes."
  • W. Edward Demings.

Nancy C. Elder, MD, MSPH
eldernc@fammed.uc.edu