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Debugging a laboratory outreach program.

Debugging a laboratory outreach program

Six months after our 220-bed hospital combined laboratory operations with those of a 200-bed hospital, we decided to go further and bring outpatient services into the joint venture. The lab consolidation had lowered costs by eliminating duplication of tests; this new move aimed at generating more revenue.

Competition from large out-of-town laboratories had fragmented the local market of about 200 physicians served by our two institutions. Many clinicians told us they would prefer having outpatient analyses performed by technologists they knew and trusted. In addition, if the same instruments handled their outpatient and inpatient test work, these clinicians could better interpret results because normal and abnormal ranges would not vary.

For the laboratory, the outreach program was an opportunity not only to strengthen the consolidation but also to keep well-trained technologists locally employed. Unless we did something, we faced a loss of personnel to the out-of-town labs.

Among their many decisions, management planners created a part-time marketing position, which could be expanded as outpatient business grew. I was ready for a new challenge, so I asked for the job. The laboratory director approved my request, and we agreed that I would spend one day a week marketing the services of the laboratory, while continuing as microbiology supervisor the other four days.

I was to work with laboratory administration, participating in the activities of a steering committee formed to direct and monitor progress of the outreach services. This committee consisted of two pathologists (out of the four from the combined laboratories), the technical director of each lab, and two hospital assistant administrators.

My first task was to survey physicians--in person, by phone, and in writing--and find out what tests they wanted the laboratory to add. Pending the outcome of the survey, the laboratory upgraded its menu with new hematology and chemistry panels and thyroid function tests. A manual prepared for physicians' offices defined all of our tests, specimen requirements, approximate turnaround time, and prices.

For courier service, we contracted with a local taxi company to transport specimens to the laboratory on an "as needed' basis. Within a few weeks, this service would expand to a regular daily schedule for some clients.

Soon I was on the road, calling on physicians' offices and clinics with freshly printed business cards, manuals, and collection kits and tubes. At each office, I discussed our commitment to timely collection, testing, and reporting of accurate results.

Initial calls were to offices our laboratory had already served to some extent in the past. It was enjoyable meeting people I had spoken to many times on the phone. This prior acquintance got me easily past receptionists to a physician or business manager.

Doctors and nurses alike candidly revealed what they liked or did not like about reference laboratory services. Office staff members were also helpful. For example, they pointed out that older individuals sometimes had trouble filling out patient information on our test ordering forms because the spaces were so small. In response to these and other comments, we reprinted the forms with bigger spaces for partient information and with a reorganized listing of tests. The latter feature made it easier to check off procedures most frequently requested.

Physicians' offices wanted us to expand profiles and add other tests available only at distant labs, sometimes on an infrequent basis. Out-of-area labs, for example, ran certain thyroid function tests just once a week. With sufficient volume, we could perform the tests more frequently and still provide a cost-effective service.

Within a few weeks, I had put together a rather lengthy list of things we could do to support our outreach to the community. Because area physicians were meeting with someone interested in their welfare and willing to follow through, more and more of them shifted their support to our program.

But success also brought problems to our actively growing organization. We began to see conflicts emerge between laboratory personnel and the new marketing program. Here are the ones that were most troublesome and the solutions that followed:

Staff becomes overworked. Faster, more personalized service tailored to client need built up volume rapidly. Couriers brought in increasing numbers of specimens, each of which had to be accessioned, divided between the various departments, and tested. Reports clogged the overworked computers; then they had to be sorted into envelopes to be distributed to the physicians' offices. Technologists already working near capacity to meet inpatient demand were stressed by the extra workload. Enthusiasm for the outreach program started to wane, and tempers began to flare.

Success in bringing in business made me somewhat unpopular with the overworked staff. The laboratory director simply could not add personnel quickly enough to keep pace with a 30 per cent increase in volume.

Most of the work came in the evening and had to be turned around by morning. We rescheduled some day staff and tests to the evening shift. Part-timers and staff members on call were asked to fill in the gaps. When volume remained high for a few months, the laboratory director was able to justify hiring more staff, eventually increasing the laboratory's full-time equivalent total from 50 to 65.

Marketing is in a hurry. I wanted to see clients' needs met as soon as possible, but the laboratory required time to get new tests on line and to corrdinate outpatient work with the inpatient schedule. Technologists knew that without proper lead time to prepare for the changes, work would suffer, and we might lose our new business.

I learned early on not to promise a new service until I had a chance to discuss its with everyone --administrators, technologists, even the couriers. If we decided to go ahead, we set a realistic date that we could pass along to our customers as the actual start of service.

A good example was our desire to provide profile results from one of the chemistry analyzers in a timely manner to attending physicians and private practices. It seemed no matter how we scheduled the run, someone was disappointed. Attendings wanted the early a.m. draws included on the run. But if we waited for the morning collection to be processed, results on serum collected from physicians' offices the night before would not be reported until early afternoon--and those doctors wanted results on their desks as soon as the office doors opened.

The solution was to operate the chemistry profiler twice daily. Each run, hewever, meant duplicate controls, lengthy procedures before and after testing, and a certain amount of wasted reagents. We justified the additional expense after carefully weighing the costs and benefits to the laboratory and physicians.

Special requests run into snags. We had established convenient pickups for most offices, but special requests from physicians sometimes called for immediate pickup and delivery to the laboratory. Problems arose when couriers were stuck in traffic or held back in offices because the office staff had not yet processed the special specimen. Even more frustrating was getting the specimen to the laboratory and finding that the test run had begun without it. If the test was offered only once a day, the anxious doctor had to wait overnight for results.

Marketing was instrumental in educating clients to allow for pickup and delivery delays and aim for scheduled test times. Once physicians' offices grasped the importance of having materials ready to go when the courier arrived, they cooperated fully.

Cost saving forces rethinking. The two hospitals' lab staffs had to get used to trading reagents back and forth and stocking reagents in bulk packages. Initially there was some grumbling, but everyone realized this would be a way to keep costs down, helping the laboratory stay competitive in an aggressive market atmosphere.

Limitations disappoint some staff. Although we wanted to provide many tests we had not offered previously, it is sometimes not efficient for a smaller laboratory to try to do everything. Some technologists were disappointed to learn that the new tests they had looked forward to implementing as part of the outreach program were just not feasible, given the volume. Until requests for these tests grew sufficiently to justify new instrumentation, they would be performed more efficiently at reference laboratories.

Routine chemistry, hematology, urinalysis, and simple culture procedures remained the bulk of our work. But bench assignments were rotated so that technologists could enjoy what diversity we had.

Specialists want special profiles. Reference laboratories were developing profiles for different medical specialists; to compete, we had to do the same. Urologists wanted chemistries that included tests of no interest to rheumatologists. Some ob-gyns wanted pregnancy tests combined with blood glucoses, while others preferred expanded profiles that included genital cultures for various pathogens. In all, we added 18 new panels, including 12 in hematology.

Computers had to be reprogrammed to accommodate these requests. In-services, meetings, and posted reminders on how to order and process the profiles helped us meet these increasingly complicated demands on the lab.

Menu may be less cost-effective. Some physicians desire the best of both worlds--screening methods combined with conventional definitive tests. For example, we had traditionally offered an overnight culture for group A beta hemolytic strep, but some physicians sought a rapid test so they could place their patients on appropriate therapy sooner. For negative specimens, they wanted a definitive culture as a backup.

From a marketing point of view, this approach made sense. While some technologists prefer to identify all pathogens in a throat culture, clinicians often feel that only the group A beta hemolytic streptococci are truly pathogens. Therefore, delaying results while the laboratory searches for other organisms is considered an unnecessary hindrance to the medical management of the patient. So we offered both procedures even though some laboratory staff members felt this was not cost-effective.

MDs complain about data overload. Some physicians were getting more data than they could handle. For example, many did not use the extensive parameters automatically printed by our automated hematology analyzers. Values such as MCV, MCH, and MCHC were meaningless to doctors who were primarily interested in hemoglobin and hematocrit for their usually "normal' patient groups. Technologists long used to reporting results for acutely ill patients were reluctant to delete information they thought could be useful.

Eventually, we convinced the laboratory staff that our client physicians were trying to reduce office staff confusion about charting these values. The solution was to leave the "extraneous' information off reports to physicians' offices. Only those values requested were reported.

Along the same lines, some doctors complained that our laboratory produced too many reports. Inpatients often had multiple specimens analyzed each day, and the computers were programmed to produce several interim reports that we would then chart throughout the day. In busy doctors' offices, overworked clerks and nurses had little time to sort and replace interim reports with final results. They requested that we hold test reports until all the work was completed.

To that end, we forwarded hematology, chemistry, and urinalysis results the same day these tests were performed. In microbiology, any interim results of value were made available on a separate report.

Money's short at the outset. Often, a new business is somewhat underfunded until it proves its staying power. It seemed that we were always short of money, though the work was obviously expanding. Updating of one of our manuals dragged on as we awaited funds to add a secretary and a word processor. And we badly needed a computer-analyzer interface in chemistry to cope with the increased workload.

Our solution was to bombard the fiscal office with data supporting our requests for new equipment and additional staff. Technologists, for example, kept records of inpatient versus outpatient tests run on a particular instrument. That information, along with forecasts by physicians of future test volume, was presented to the technical directors of the laboratory, who passed it on to the comptroller.

"You didn't tell me.' With 100 or more clients and an equal number of laboratory staff in two separate facilities, communication was bound to break down occasionally. One group might then be unaware that a schedule had changed or that an instrument was not functioning.

Communication needs to be fact, effective, and documented. The best solution--more desk staff dedicated to handling the telephones--was never fully implemented.

Marketing, therefore, took to the phones when there was a problem. We called every office on affected routes when bad weather or car breakdowns delayed pickups. On those rare occasions when the computers went belly up, we called in all abnormal results to physicians' offices and advised that normal results would follow as soon as we could implement our backup procedures. When instruments failed to function, we let the affected offices know right away.

Because informal communication is important when developing trusting relationships, I sat down with laboratory staff members at coffee and lunch breaks and kept them posted about the good things that were happening on the outside. The compliments received from clients belonged to all lab employees, and we made sure they heard them.

We also held weekly meetings with the technologists and lab assistants to brief them on new accounts that would be coming on line and get their input on how we could better handle tests or internal procedures. This helped everyone feel a part of the team and reduced some of the problems associated with separate departments working alone toward their own goals.

Careful planning and open communication lines are essential when major change occurs in the lab. For our laboratory outreach, clients and technologists benefited from the rational approaches taken to resolve the conflicts brought on by rapid growth.
COPYRIGHT 1986 Nelson Publishing
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Copyright 1986 Gale, Cengage Learning. All rights reserved.

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Title Annotation:effect of marketing pressures on medical staff
Author:Harris, Patrica C.
Publication:Medical Laboratory Observer
Date:Nov 1, 1986
Words:2263
Previous Article:Quality control in the new environment: automated hematology.
Next Article:An LIS is not all pluses.
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