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Specimen pathway analysis aids quality and efficiency.

One approach to improving hospital services is to analyze them from the patient's perspective. Patients view hospital services as coordinated activities under one roof. Each individual interaction, from parking to billing, reflects the image of the hospital as a whole. To move reality closer to this impression, the laboratory can reorganize many disjointed activities toward a more efficient overall flow. Registration for laboratory and radiology services, for example, should be coordinated.

A similar approach can be taken by the laboratory in assessing the specimen pathway. This article aims to define key laboratory activities that present such an opportunity for channeling the work stream.

The product of a review as proposed here is to define new activities and to redefine old ones. Many laboratory practices generate work without improving quality. Not all activities associated with improved quality are cost-effective. Certainly not all potentially cost-effective activities are being undertaken in any given laboratory. Only a thorough analysis of laboratory activities makes it possible to determine which activities are both cost-effective and associated with quality.

This article will not discuss the ultimate means of improving laboratory efficiency, which is to reduce inappropriate test ordering. Nor will this article examine such related issues as improved instrumentation and information systems, bar coding and dynamic interraces, and enhanced staff training and motivation.

1. Directions and instructions

To collect a specimen, the laboratory must direct the patient to the appropriate area. Outpatients must be told where the laboratory is located, how to get there by various means of transportation, where to park, which elevators to use, and where their families or friends can wait. One laboratory with which I consulted addressed the problem by printing directions to each of the three phlebotomy service stations and giving copies to physicians in the community for' distribution to their patients.

The physician or a staff member at the physician's office must inform each patient about any special collection requirements, such as the need to fast beforehand. Patients need to know how long the specimen collection is likely to take. Because patients undergoing a glucose tolerance test must sit still for three hours or more, patients with young children should be advised not to bring them along unless another adult can accompany them as well.

To help physicians advise their patients appropriately, the laboratory should carefully spell out all such requirements in a manual distributed to all physicians' offices. The manual must be updated regularly to reflect changes. One good method is for the laboratory to print patient instruction sheets and give them to ordering physicians, who then distribute them to patients. Such directions should be printed in all languages spoken by local non-English-speaking populations of any substantial size.

For specimens to be collected by the physician, a laboratory manual must define specimen collection and storage requirements. If a specimen is rejected for a reason such as collection in an improper container, the report should indicate the proper container for recollection. The manual should include a laboratory phone number to call with questions.

Standards for specimen labeling are essential to assure accurate labeling of specimens. Even the most accurate lab result is useless if the specimen is misidentified.

Some patients and physicians may want to know lab charges in advance, particularly for patients who are self-paying and for those with copayments. This information should be readily available to physicians and registration personnel and must be updated as needed. Some health organizations have exclusive laboratory contracts and payment is on a capitation basis. In this circumstance, lab charges are not defined.

What happens if all the above preparations are not made? Patients may have to return to have specimens re-collected; test results initially obtained may be suboptimal; or charges may not be reimbursed by the insurance carrier. The ultimate potential result is loss of business. Busy physicians prefer to deal with labs that assist them in the process of laboratory testing.

2. Registration

Registration information should include only what is necessary. The information should be easy for the patient to provide and should appear in logical order. For example, it is not uncommon for a patient to write his or her first name in the space designated for surname. It is possible to eliminate that error by providing large printed directions and boxes that are clearly separated. In one lab where [ worked, we continued to ask for the patient's mother's maiden name--even though this information was never used for outpatients--until someone noticed this and deleted the question from the form.

Another laboratory with which I have been affiliated created an abbreviated registration form on a computer program to minimize the number of screens and thus the number of redundant entries. If the patient's name was required in different parts of the form, the computer operator could move it about without rekeying it. It is wise to keep to a minimum the use of multiple numbers, such as Social Security, insurance, hospital, and encounter account (assigned visit) number. Restraining such proliferation is especially important in computer systems, which love to duplicate numbers.

The registration form should allow sufficient space for each response. All too often, the patient is forced to write so small that the information becomes illegible. In fact, handwriting is frequently illegible even in large boxes. Preprinted requisitions, typewritten orders on requisitions, and bar coding are but a few solutions.

One laboratory of my acquaintance sends to each physician office forms on which the physician's name and phone number are listed. The intent is for the laboratory to have easy access to this information in case a point about a test needs to be clarified.

It is often wise to provide forms with checkoff boxes for test ordering. Such a format helps eliminate the common confusion in deciphering what the physician really wants. For outpatients, clearer communication can lead to increased ordering, which translates into increased revenues.

3. Consolidation of draws

Far more repeat phlebotomies than necessary are performed every day. Since inpatients are often being treated by several physicians at once, it is imperative that past and future orders be reviewed before additional draws are made. Duplicate orders frequently lead to unneeded repeat sticks. When direct order entry is incorporated into laboratory and hospital information systems, physicians should be trained to place lab orders directly.

Ideally, they could review on screen all previous results, including date and time, and a list of ordered specimens, both collected and uncollected. Physicians could then add tests for specimens previously collected or to venipunctures already ordered, thereby reducing the number of venipunctures performed on the same patient. Physicians could also reduce redundant orders by examining concise summaries of previous test results for each patient.

Some labs use "reflex" ordering for certain assays, by which a second test is automatically ordered when a result exceeds a predefined limit. If bilirubin levels exceed the upper limit of the reference range, for example, many labs fractionate the test. In another common example, a microscopic exam is performed whenever a urinary dipstick result exceeds predefined criteria. Some labs have extended such coupled tests to include evaluation of anemia and thyroid disorders. Offering physicians the option of reflex testing may help patients avoid additional visits to the lab while expediting lab evaluation.

4. Transportation

All specimens must be received in the laboratory intact. Unrefrigerated urine specimens, blood for coagulation testing, and other blood specimens destined for tests that require separation of plasma or serum from cells must be processed within specified time constraints. Otherwise, results will be erroneous. Specimens must be transported without being subjected to freezing or excessive heat, either of which can destroy enzyme activities and lyse cells.

To avoid these problems, the laboratory must establish mechanisms to transport and store specimens in a way that will maintain their integrity. Plasma or serum may need to be separated. Courier routes, both within and outside the facility, must be designed in terms of timeliness and maintenance of proper temperatures to prevent degradation of specimens. It is inappropriate for busy phlebotomists to draw specimens for three hours without stopping at intervals to send some to the laboratory for processing. In all cases of specimen storage and transportation, directions must be provided and instructions given to convey the importance of adhering to the rules.

With Stat specimens, time becomes a major component in providing high-quality testing. Mechanisms must be created that will enable the laboratory to complete Star assays without undue time pressure. For example, many hospitals use pneumatic tube systems to send specimens drawn at various sites directly to the laboratory with minimal delay.

Another approach is the use of whole blood analyzers, which eliminate the wait for clotting and centrifugation. Whole blood analyzers offer the ability to provide Stat tests with much shorter turnaround time than is otherwise possible. Some larger hospitals have resolved the Stat problem by establishing Stat laboratories in (or adjacent to) the operating room, emergency room, and intensive care units. The laboratory should operate these units to guarantee that the same high standards will prevail as are found in the central laboratory.

5. Instrument batching

Specimen batches should be collected on a schedule designed to meet the laboratory's goals for turnaround time. Instead, morning Stat orders are often delayed because routine specimens are being processed as Stats. Generally acceptable turnaround time for routine inpatient tests is four hours. Outpatient specimens can be assayed when convenient to meet the deadline for printing the outpatient report. It is inefficient to assay outpatient specimens at peak hours in the morning if the physician will not see the results until the next day. Thus, different specimens should be handled differently, depending on the situation. It is inefficient to set up frequent small batches that will fully occupy a medical technologist if batch sizes and schedules can be adjusted to maximize the lab's resources while meeting its goals. Computer systems may be useful in designing priority listings of pending work on worksheets.

6. Quality control

Many quality control (QC) procedures now in effect were established years ago to accommodate instruments and methods plagued with far more imprecision, a higher frequency of systematic and random error, and less stable calibration than is readily available today. The acquisition of newer technology requires a reassessment of premises on which the frequency of QC measures were based. For most routine chemistry analytes, the coefficient of variation is less than 3.0%. The frequency of true error detection is diminishingly low. Thus the criteria for run rejection should be loosened and the frequency of running QC should be decreased.

One step in revising such criteria is to determine which QC rules are being followed and what types of problems they have been helping the staff to identify. Some assays, such as cholesterol and albumin, require more stringent criteria than others, such as amylase and iron.

7. Repeats

In a survey I recently conducted of approximately 50 users of a particular large chemistry analyzer, the frequency of repeat analysis ranged from 1% to 10%. No correlation with the size of laboratory was evident, The frequency of repeat analyses correlated best with laboratory policy rather than with instrumentation or methodology.

Historically, many of the laboratories repeated analyses when the analyte concentration exceeded a predetermined limit. Often a specimen pour-off error was detected by this process. Today, many laboratories that use primary tube sampling, which does not involve pouroff, continue to implement the same policy. Yet the frequency of error detection by this approach is exceedingly low. A legitimate reason for repeat analysis might persist if the analyte concentration exceeds the linearity of the assay or if the laboratorian wishes to dilute a substance of interference such as high viscosity or icterus.

In defending the perpetuation of old practices, someone may argue that the results found with the specimens of assays being repeated are highly abnormal and that the laboratory wants to ascertain the validity of its work. Nevertheless, it is equally feasible that values of tests not being repeated also represent "abnormalities" for that patient. For example, repeating an erroneously reported glucose concentration of 500 mg/dl as 100 mg/dl may lead to inappropriate treatment followed by dire consequences. Furthermore, if all this work is being done in the name of quality assurance, then all results should be carefully recorded, compared, and examined in a search for opportunities to revise the defined limits. Unfortunately, such a systematic approach is rarely taken.

8. Alert limits and callbacks

Alert limits go by a variety of names, including critical and panic values. The limits vary from one institution to another. Some limits correspond to the upper linearity of analyzers rather than to a clinical level that indicates a need for intervention by a physician. The correct approach is to establish alert limits in conjunction with clinicians after soliciting feedback on what they need in order to provide prompt medical intervention. Different limits should be established and communicated for adult inpatients, pediatric inpatients, oncology patients, preoperative patients, and any other group for which a unique limit exists that would trigger immediate medical intervention.

Some laboratories include alert limits for iron and other assays for which immediate intervention is not appropriate. These limits should be eliminated.

Technologists spend consider able time calling back results re quested by ordering physicians Many laboratories call back all Sta results. For inpatients, the use c broadcast printers eliminates much of this work. It is imperative for the laboratory to maintain an accurate list of all office phone numbers and, if necessary, home phone numbers of the medical staff.

The laboratory must be kept informed about covering physicians. Too often, the ordering physician cannot be reached and no recourse is available. Frustration and wasted efforts within the laboratory can be reduced by keeping phone lists and coverage agreements up to date.

9. Printing

Print schedules are usually developed in the laboratory based on longtime policy and old equipment rather than on current capacity and clinical need. Laboratories can often generate individual reports for each physician, thus providing results to suit doctors' work patterns. Surgeons tend to make earlier rounds than internists, for example; when that is the case, reports should be sent to the surgical wards earlier than to the genera floors.

Such fragmentation may seem to create more work. By making re ports available when needed, how ever, the lab will eliminate a large number of calls from physicians asking for results. More important the lab will make it possible fo physicians to respond to results ex peditiously in diagnosis and treatment. This leads to improved clinical care and on occasion will shorten a patient's length of stay-- particularly desirable in cases of DRG-based reimbursement.

Laboratories should examine their print schedules for weekends and holidays, when reports may not be needed as often or at the usual weekday times because the work pattern of the medical staff is different.

The ability of laser printers and other high-speed printers to expedite operations is often underestimated. Printers now cost much less than they did even a few years ago. In one laboratory where l have worked, buying new printers saved nearly four hours of secretarial time per day that had been spent printing multiple copies of reports on an old, slow printer. Using a burster to remove the perforated edges and separate the pages of continuous-feed computer printout paper can save an enormous amount of labor.

10. Filing and storage

Laboratories tend to save everything much longer than they should. Spending time to file reports incurs substantial cost. The most egregious pattern involves saving multiple copies of reports. In one laboratory where I consulted, multiple copies of outpatient reports were saved in case of a computer crash. In addition to the worksheets, two copies of the report were printed. One copy was sent to the physician and the other was retained as a backup. In several years, the backup reports were never used. They stopped printing the reports in duplicate and developed another mechanism to reconstruct reports in case of a computer crash.

An alternative to such a procedure is to keep a photocopy of any report that is to be mailed, assureing that the laboratory needs a copy at all. Redundancy becomes excessive when a laboratory files away copies of preliminary, completed nonverified, and completed verified worksheets for every patient. Only verified worksheets with notes such as calculations that are initialed and dated should be retained.

For outpatients, some physicians prefer to have a copy of any laboratory result even if another result is pending, such as carcinoembryonic antigen (CEA), which may be set up only twice weekly. Other physicians prefer to wait for a completed report even if it means waiting an extra day or two.

A laboratory should be able to pull and discard preliminary reports for physicians who don't want them, even if the task must be handled manually. It would be far better, of course, to program the laboratory computer system to print only completed reports for physicians who prefer them.

Storing reports occupies precious space; space costs money. Computer systems tend to generate more paper than manual systems. One solution is to print copies for storage on thinner paper, Another approach is to place records on microfiche. Storage should be limited to records that are likely to be used. As with filing, however, the common tendency is to save everything. If technologists' comments are entered into a computer system, original printouts can be discarded in favor of discs and computer tapes, which require much less storage space than paper.

Storage files must be clearly labeled to expedite retrieval, an otherwise labor-intensive activity. In some cases, older records can be stored off-site. Look for local companies that are in business specifically to store the records of other businesses. Taking this approach will free space in the health care facility for functional activities.

* Worthwhile effort. Analyzing a laboratory's specimen pathway may lead to improved efficiency and quality. The more comprehensive activity of strategic planning involves examining the role of the laboratory in relation to its external environment.! in contrast, specimen pathway analysis provides insight into the internal environment of laboratory operations.

Laboratorians are encouraged to take the time to examine specimen workflow thoroughly, from start to finish. The resulting observations will highlight any deficiencies to be corrected. Priorities should then be established to decide the efforts that would most effectively streamline activities.

1. Raslavicus PA and Kaufman, HW Use strategic planning to reshape your lab's future MLO 22(5): 22 27, May 1990

The author is medical director of MetPATH NEW England, Cambridge, Mass.
COPYRIGHT 1992 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1992 Gale, Cengage Learning. All rights reserved.

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Author:Kaufman, Harvey W.
Publication:Medical Laboratory Observer
Date:Jul 1, 1992
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