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Performance Improvement (PI) Plan (Process Improvement Plan)

I. General Philosophy:

United Clinical Laboratories (UCL) has developed a continuous process to evaluate the function of important laboratory practices, procedures, and services and how they interact with other hospital or health care facilities; to identify changes that can enhance performance; to incorporate these changes into existing work policies, procedures, and services; and to monitor processes to ensure that improvements are sustained.

An important component of UCL’s PI plan is to create a culture where all employees understand PI; evaluate their daily work in terms of PI; and feel comfortable initiating topics, and discussing problems, even “near misses,” which they have observed or were involved in. Although UCL’s staff is historically known to be motivated to “do the right thing;” the PI Plan seeks to institutionalize this trait so that each employee, through their training and management example sees the improvement of the whole organization as part of their individual job. What individuals learn from their own observations can benefit all of UCL. Solving an immediate problem is important, but part of the solution is also answering: “How can we prevent this problem from occurring again, not only in my work environment but also throughout the sites of UCL?”

The Process Improvement (PI) Plan is designed to reduce unanticipated adverse effects and outcomes that can occur due to poorly designed systems, system failures, or other errors. High-risk and high volume processes are targeted for evaluation.

While patient and staff safety, and improved quality of work, are the primary goals of the PI program, it is understood that elimination of inefficiencies and reduction of costs by doing things right the first time will also occur in a successful PI program.

II. Sources of Information that can lead to Performance Improvement

1. Sources of knowledge about factors that might contribute to unanticipated adverse events and/or outcomes include the following:

A. Patient complaints and concerns

B. Physician and other clients’ opinions, complaints, and requests

C. Laboratory staff opinions and concerns

D. Patient, Physician and Client surveys

E. Analytical test proficiency surveys

F. Reported Erroneous Report Log entries

G. Sentinel events and near misses

H. Proactively identified areas of risk from “brainstorming and risk rounds”

2. Common areas of risk universally known to occur in the medical laboratory include:

A. Blood transfusion

B. Patient identification

C. Specimen identification and handling

D. Environmental safety (fire, chemical, falls, ventilation, sharps, etc.)

E. Analytical quality control

F. Transfer of information and effectiveness of communication (electronic, verbal, phone, paper)

G. Keeping current, adopting new technology, continuing education

H. Infection control (both patient and staff)

3. The process of evaluation includes collection of data (in numbers appropriate to the action or process studied); evaluation of data using statistical tools and techniques; identification of undesirable patterns or trends; and comparison, internally over time, or externally (to recent scientific, clinical, and management literature; established national practice guidelines or parameters; reference databases; or bench marking with other laboratories).

III. PI Committee Structure, Activity, and Reporting:

1. The PI committee is composed of the hospital site supervisors; the supervisor of histology, cytology, and microbiology; a pathologist; the Administrative Director; and others by invitation. The committee will meet at least quarterly.

2. Annually, the PI committee prepares an UCL-wide performance improvement risk and opportunity assessment. Pathology Associates determines which processes will be studied, and what the study design will be. At any time, newly identified risks or processes can be added to the study list. Spontaneous PI activity is documented in the lab site minutes and a highlighted copy of the minutes is forwarded to the chair of the PI committee for evaluation for applicability to other sites, and for inclusion in the PI activity report.

3. Reporting of PI activity is made to laboratory leadership and staff:

A. Pathology Associates meeting (at least quarterly)

B. Lab staff meetings (at least quarterly)

C. Board of Directors meetings (at least annually)

IV. Reference

1. The Joint Commission on Accreditation of Healthcare Organizations, Comprehensive Accreditation Manual for Laboratory and Point-of-Care Testing copyright 2007


i. March 2009 J.A. Brennan MD




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