Patients and specimen samples showing up without orders was a common occurrence at the East Denver Medical Office lab.

In some cases, orders weren’t in the system because there was confusion between the provider and the nurse about who ordered the test. Other times, patients were directed to the lab without verification of a lab order; and orders simply expired.

This lack of follow-through was inconvenient for the patient, who would have to go back to his or her doctor, or wait for a lab employee to contact the department. In some cases, the patient would have to make a second trip.

So, the East Denver team decided to crack down and got a little creative.

They developed an “enforcement” theme and dressed up in police uniforms to issue citations to “violators” as they tracked patients with no orders.

Departments with the most improvement were honored with coffee and donuts. Those that met the criteria for sustained success were recognized with lunch.

OB/GYN went from 42 “violations” in a seven-week period to 34 in a 10-week period. Pediatrics went from 16 occurrences to a single one in similar time frames.

“At first, we didn’t give them (other departments) the specific data,” lab clinical manager Lucy Tyler says. “Then OB asked for it so we started giving it to everyone.”

The team found by tracking the data, they discovered who needed help, and they worked with that team to solve the problem. By showing each department when they were sending patients and specimens to the lab without orders, they could see they were part of the problem.

In some cases it was a surprise.

“This work supports X-ray and pharmacy, too,” phlebotomist Alma Lahti says. “It’s improving orders in other departments.”

Colorado’s asthma care coordinators discovered that children were refilling their medications at the lowest rate in the region. The group works alongside physicians and staff to provide education and outreach to Kaiser Permanente members with asthma or chronic obstructive pulmonary disease.

Inhaled corticosteroids help control asthma by reducing inflammation and mucus production. Asthmatics who use the meds daily experience fewer attacks, use their emergency medicine less and make fewer visits to the emergency room.

There are some common threads among patients, who don’t refill their prescriptions. These include the costliness of inhalers, the fact some patients are reluctant to take a steroid, and often patients stop medication when they start to feel better.

“It took us a while to identify the most important thing our UBT could do,” said Cindy Lamb, RN, an asthma care coordinator and member of UFCW Local 7. “It was definitely a learning process.”

So, the asthma coordinators decided to improve the refill rate through an outreach program and targeted members ages 5-17. They made phone calls to five members a week who had not refilled their prescriptions in more than four months. As part of the discussion they included talking points about the benefits of inhaled corticosteroids. They used trackers and scoreboards to monitor the outreach and keep everyone informed.

The seven asthma care coordinators were spread throughout the region, so they held weekly phone huddles to share progress and best practices. They highlighted the convenience of the mail order pharmacy, and provided members with prescription refill numbers as well as the telephone number to the pharmacy. This information helped patients refill their medications more promptly.

The team also had communicated regularly with pediatric physicians and other staff by phone, conversations, meetings, and email.

None of it happened overnight, but the team discovered the collaborative effort really helped the process. In all, they reached 1,100 patients.

“Give the process the time it needs,” said Asthma Care Coordination manager Leah Brines. “Resist the temptation to come up with solutions for the team and instead, guide the conversation, and encourage participation and discovery. The team, given the time and confidence, will find the solution.”