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

Slide presentation from the AHRQ 2009 conference.

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

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.

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


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

Nancy C. Elder, MD, MSPH

Current as of December 2009
Internet Citation: The Testing Process in Primary Care: Safety and Quality Implications for Improving Health Care (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


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