Summarised, verified and accessible: improving clinical information management for potential haematopoietic stem cell transplantation patients

Abstract

The Welsh Transplantation and Immunogenetics Laboratory (WTAIL) is responsible for managing patient work-up for haematopoietic stem cell transplantation (HSCT), the only potentially curative option for many haematological and non-haematological conditions. Work-up requires regular communication between WTAIL and the transplanting clinicians, facilitated by weekly multidisciplinary team (MDT) meetings, to agree decisions and proceed through each work-up stage. Effective communication and minimising error are critical, as transplanting cells from a suboptimal donor could have severe or fatal consequences for the patient. We reviewed our HSCT patient management and identified issues including staff dissatisfaction with the inefficiency of the current (paper-based) system and concern about the potential for incidents caused by errors in manual transcription of patient information and tracking clinical decisions. Another driver for change was the COVID-19 pandemic, which prevented the usual face-to-face MDT meetings in which staff would show clinicians the paper records and reports; the shift to online MDT required new ways of sharing data. In this project we developed a new central reference point for our patient management data along with electronic patient summary sheets, designed with an eye to improving safety and efficiency. Over several improvement cycles we tested and refined the summary sheets with staff and clinicians and experimented with videoconferencing to facilitate data sharing. We conducted interviews with staff from which we concluded that the new process successfully reduced transcription and duplication and improved communication with the clinicians during the pandemic. Despite an increase in workload due to build-up of active patient work-up cases during the pandemic, staff reported that the new summaries enabled them to cope well. A key initiative was creation of a 'Task and Finish' group that helped establish continual improvement culture and identified additional areas for improvement which have been followed up in further improvement projects.

Keywords: PDSA; efficiency; laboratory medicine; organisational; quality improvement; transplantation.

Figure 1

Process maps for HSCT patient work-up before project implementation (left) and after (right). Value adding steps are shown in green. Steps involving duplication (recording of patient/donor details on multiple forms) are shown in orange. These steps were deemed ‘necessary waste’ prior to the introduction of the new summaries because different staff used/recorded the information in different locations (ie, the forms could not simply be removed without a replacement system in place). Non-value adding steps are shown in red. We classified the ‘Expanded Typing Report’ as non-value adding when we established that the clinicians did not refer to the report, even though the information contained within it was reported to the clinicians at the MDT meeting and in the final ‘close out’ letter. This figure emphasises the removal of waste steps and forms. Some necessary waste remains with the required procedures for potential donors (Form 503 and the TXU software component), though we have made the population of 503 much easier. With new LIMS software we hope to remove these remaining waste steps through automation. HLA, human leukocyte antigen; HSCT, haematopoietic stem cell transplantation; LIMS, Laboratory Information Management System; MDT, multidisciplinary team; MUD, matched unrelated donor; SBT, sequence-based typing; TXU, Transplant Utilities; WMDA, World Marrow Donor Association.

Figure 2

4N Chart from Welsh Transplantation and Immunogenetics Laboratory staff interviews.

Figure 3

Application of 6S (anticlockwise from top image). (A) The 6S tool was applied as a first step to help formulate the project plan and design a summary sheet template. Existing paper forms and spreadsheets were reviewed in consultation with WTAIL staff and clinicians to identify essential data to record in the summary and data currently recorded on existing forms that was not helpful/required. (B) Prior to the QI project, patient files were kept on desks to prompt action from WTAIL staff, moved between different departments depending on actions being taken, or on a trolley for transport from the laboratory to the weekly MDT meetings. Staff often struggled to locate files and often had to search several areas to find them. (C) Following introduction of the summary sheets, files no longer needed to be transported to the MDT meeting and so we could organise them into a filing cabinet in alphabetical order. (D) Files no longer needed to be kept out on desks, or transferred between departments, to prompt actions; this was now achieved using the summary sheets. HSCT, haematopoietic stem cell transplantation; MDT, multidisciplinary team; QI, quality improvement; WTAIL, Welsh Transplantation and Immunogenetics Laboratory.