Utah Public Health Laboratory Customer Service Quality Improvement Project

By August 31, 2013, increase knowledge, understanding, and use of the UPHL services by staff of the Utah County Health Department (UCHD) by at least 50%.

In some areas of the laboratory, test requests and revenues have been decreasing. In addition, many discussions among the UPHL director and LHD health officers, epidemiologists, nurses, and environmental health specialists have demonstrated that there is confusion and a lack of understanding, especially about how UPHL can assist LHDs during outbreaks and disease investigations. Past approaches (presentations at meetings, attendance at discipline-specific meetings, state/local conference calls, etc.) have not closed the gap in LHD understanding of UPHL services and how to access the wide array of testing currently available. The director of UPHL selected this project for reasons described previously.

LHDs depend on laboratory test results for many of their core community-level public health services. These include infectious disease control, well child programs, health promotion (cholesterol, blood pressure, etc.), and environmental protection (water, soil, etc.). Learning and applying QI methods is helping laboratory staff better understand the needs of one of their most important customers, LHDs. The Plan, Do, Check, Act (PDCA) methodology provides an effective approach for identifying and prioritizing appropriate solutions for serving these needs. QI methods and tools provide a disciplined and efficient approach proven to be a useful way to improve processes. To truly understand gaps in services delivered to LHDs and barriers keeping them from being able to fully benefit from services, UPHL needs an objective, data-driven method. This approach must include both UPHL subject matter experts and LHD customers to best use the methods and tools enabled in a QI project.

Laboratory Root Cause Analysis (Affinity) Knowledge of Services Available • Learn about services (tests provided) from the fee schedule spreadsheet. • Not everyone knows about or has access to the fee schedule. • Fees (prices) • Services available • Getting on the Internet to see the fee schedule to learn about services provided is not always convenient in the clinic. • The fee schedule is long and difficult to understand. • The lack of understanding or the time required to run tests creates perceptions about slow turnaround time (staff want appropriate expectations for timing for receiving results). • Staff would like a list of how long each type of test should take. • Staff want to better understand specimen specifications. • They do not always understand what is required to grow a specimen quickly. • Staff want to better understand specimen specifications related to receiving isolates. • Staff need an understanding of when a sample arrives at the laboratory. • To better understand turnaround time, staff want to better understand what has to be done and how long the tests will take. Use of Services • Staff do not always know what tests are available. • Some staff believe that tests are too expensive and use the fee schedule to judge pricing, do not know about volume discounting, and perceive that there is a disconnect between the price on the fee schedule (those ordering the tests) and the billed amount (those paying the invoices). Convenience of Services • Staff believe that services could be more convenient. • Turnaround time • Typing • For hepatitis, staff provide prophylaxis for hepatitis type B only. They need to know which type before administering treatment. • The courier needs to come in to get samples from the refrigerator. • Timing (1 day can make a big difference) • Frequency • Arrangements • At least two refrigerators are needed; Category Class B-level tests require separating samples (different refrigerators). • What about separation in the courier vehicle? • Testing equipment/supplies • Other laboratories provide these, which compensates for differences in pricing. • Fear of backlog slows down the turnaround time on results. • For example, with the West Nile virus, immediate spraying is needed. • For example, with hepatitis, additional testing or immediate prophylaxis is needed. • Reverse courier services • The courier brings additional supplies on demand, and the laboratory staff send samples. • Knowledge of supplies • As tests change, staff need to know about appropriate supplies. • For example, staff need clarity on types of tubes to be used for specific tests. • Pricing is not always the only consideration. • Convenience, turnaround time, and sample equipment are also factors. Pricing of Services • Staff believe that tests are too expensive (see the previously listed causes). Testing Equipment • Other laboratories provide testing support (sample containers, ice chests, test tubes, and other equipment for drawing and sending samples [test tubes for blood and swabs]). • Supplies expire (staff do not want to have unnecessary supplies that become unusable). • The required supplies change (as tests change, sample and equipment requirements change). Results Are Too Slow • The courier causes a delay. • Pickups are infrequent (only on Monday and Thursday). • Pickups need to occur at least three times per week. • Staff prefer daily pickup. • Environmental health pickup is now around noon. • It is needed later in the day when the scientists come back from the field (staff prefer ~4:30 p.m.). • Samples should be refrigerated. • The courier should call in advance to check whether pickup is needed. • Tests get bundled with Intermountain Medical Center's (IMC's) tests and are delayed by IMC pickup. • Tests are picked up between 10 a.m. and 11 a.m. (too early for staff to have full days’ tests ready). • Staff do not want tests to have to wait overnight. • Staff prefer a pickup time between 3:30 p.m. and 4:00 p.m. • Staff want tests unloaded at the laboratory and started the day they are collected at the clinic. • Facilitate arriving at the laboratory before close of business, so tests can be started on the day that the sample is taken. Priorities for Testing • Staff need to establish priorities for which tests should be rushed. • Fast turnaround time is needed for results that are more urgent than others (some tests require immediate action; for example, rabies [treatment] and West Nile virus [spraying]).