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A second look at some clinical laboratory dogma.

Find out if you are willing and able to question the prevailing wisdom.

WITHIN ALL FIELDS of endeavor, including clinical laboratory management, you encounter some relatively rigid, but not necessarily correct, approaches to issues. These long-held beliefs or attitudes are relatively easy to identify in work conversations. The speaker usually prefaces his remarks by saying: "As everyone knows...."

Let's assume that some of these doctrines in the laboratory field that "everyone knows" are right are actually wrong. Some may never have been correct but gained currency because there was no ready evidence to dispute them when they originated, or they were created by some respected and generally unquestioned expert in the field. Other doctrines may have been originally correct but ceased to be valid because of changes in the field.

It's extremely tough to buck the prevailing wisdom. What's needed in any organization is a non-threatening way to discuss whether the current set of orthodoxies continues to be valid in today's rapidly changing environment. The process of "reframing" offers just such an opportunity.

Charles Handy, in his book The Age of Unreason (Harvard Business School Press, Boston, 1990), refers to reframing as a way to look at problems, situations, and people in novel ways. He suggests that by looking at events "upside down" and obtaining a new perspective, solutions to problems may become more obvious.

Let's take Handy's idea and apply it to some fundamental tenets relating to management and strategic planning for hospital clinical laboratories. Remember, the basic concept here is to confront the accepted dogma and say: "You are wrong now and may always have been wrong. I'm going to turn you upside down, wring you out, and extract any kernel of truth that may be imprisoned inside."

We'll start each reframing exercise by stating the currently accepted laboratory dogma, and then provide a reframing statement that turns the dogma upside down. You may or may not agree with us, but come up with good reasons for the position you hold. Who knows? Some of the old orthodoxies may still have some more miles left on them.

We need to introduce robots into hospital laboratories. Such automation of the laboratory assembly line will allow us to lower our cost per test and thus respond to cost-containment pressures.

A large portion of laboratory testing is going to be transferred relatively quickly to patient-care settings. It doesn't make sense to make large capital investments in rigid automated assembly lines in the centralized hospital laboratories. Even in large regional reference laboratories, the test menus and instrumentation are going to change so rapidly that laboratory processing will never be amenable to robotics. So invest your capital funds in compact analytical instruments, place them on carts, and wheel them to near-patient settings.

If most test orders are treated as ultra-Stat with 10-minute turnaround time, clinicians will never be able to take advantage of such a rapid turnaround time. The effort and resources to achieve this laboratory performance gain will be wasted.

The only way to know how much more efficiently clinicians can perform in a hospital setting with 1O-minute turnaround times for routine tests is to actually provide this service to them. They will rapidly learn how to take advantage of efficiencies in the new environment by packing more test-ordering cycles into the day or including test performance plus test interpretation into a single patient visit.

The most significant problem with near-patient testing is that the tests are not performed by adequately trained personnel. Nurses, for example, will always have difficulty performing quality control procedures.

This is "old think" to assume that quality testing can be performed only by laboratory personnel. If non-laboratory personnel do not perform up to laboratory expectations, they may in effect be balking at their incremental work assignments. Incentives have to be developed to motivate them. Under the evolving model of laboratory organization, a diverse group of personnel, not always directly controlled by the laboratory, will be performing tests. The managerial challenge for laboratory professionals will be to maintain the quality of testing in such an environment.

Near-patient testing will never be able to compete with the cost per test in the central laboratories.

Throw away your laboratory-based spreadsheets showing low reagent costs and the yearly amortization schedule for the large expensive analytical instruments in your central laboratory. The reason that near-patient testing appears to be so expensive is that the true cost to the hospital of having physicians and nurses scramble to acquire and act upon the test information is never taken into consideration in the equation.

Clinicians have an information overload problem.

The most significant problem clinicians have with regard to clinical laboratories is not that they are presented with too much information, but rather, that the information presented to them is inadequately organized and indexed. No one ever complains that the telephone directory contains too much information. This is because there are logical paths in the organization of the directory (e.g., last name, type of business) that allow the user to easily target the information needed. While installation of a state-of-the-art laboratory information system (LIS) can help organize lab test results for physicians, more work needs to be done in this area.

What hospitals need most are bedside terminals for data entry that can be reviewed by physicians and nurses.

When was the last time that you witnessed a physician or nurse standing still in a hospital? These professionals--always on the move--will never tolerate physically fixed computer terminals, particularly if they are placed right next to patients, who will then be able to carefully observe their caretakers groping around the keyboard. The only acceptable hardware platform for physicians and nurses will be wireless palmtop computers that fit into belt holsters and travel with them as they travel around the hospital.

It's easy to distinguish a good laboratory from a bad one; the good lab always works up specimens to the "nth" degree.

A quality lab is characterized by doing what is necessary and appropriate for the patient, and no more. In an era of limits, patients and society derive no benefit from running up large, unnecessary lab bills. The cost-benefit ratio for laboratory testing is now the overriding principle. Less can be more, most often when procedures are guided by skilled laboratorians. The successful laboratory professional of the future will be rewarded for doing less--not more--testing.

When managing a hospital laboratory, the one thing we don't have to worry about is the cost of the real estate, that is, rent for the lab's physical space.

In many hospitals, the lab occupies a large area of valuable real estate that can often be reallocated to direct patient care activities with higher profit margins. There may be substantial benefits for the laboratory to move a portion of its operations off-site, such as to more modern or larger quarters with better parking for employees. Modern communication technology will make such a move feasible to most hospital-based users.

The shortage of well-trained certified medical technologists and histotechnologists is a major threat to laboratory medicine. More resources should be channeled by hospital, state, and national authorities into formal training programs that will eventually lead to degrees or certificates.

Formal programs that lead to certification or licensure are a two-edged sword. High quality is maintained by the process, but there may not be enough potential technologists willing to go through the formal training. And with far more jobs than applicants, salaries will rise disproportionately. Don't rule out on-the-job training as a way to fill technical slots, especially for histotechnologist and medical laboratory technician positions.

The secret to success in the laboratory, as in any organization, is to make your boss look better. If your boss succeeds, so will you.

Clinical laboratories are in an unprecedented period of change. Top quality leadership will be needed, and nothing will be gained by propping up inadequate managers. This doesn't mean that one needs to sabotage weak bosses; their shortcomings will usually manifest themselves soon enough. The key is to switch positions in order to align yourself with dynamic and bright leaders, or to set your sights on becoming one of the bright leaders yourself.

The most effective way to manage is by having detailed information--i.e., the numbers--at your fingertips. The whole concept of continuous quality improvement in based on management by fact.

Having large amounts of information is often much less important than knowing details about the information. This is sometimes called meta-analysis. Understanding the assumptions that underlie the numbers and the models used to manipulate them can help avoid inappropriate conclusions. For example, the yearly test volume for a laboratory over three years may show no growth, but an atypical event such as a nursing strike may have artificially decreased the demand for tests during the final year, masking a real growth trend and the need to expand laboratory capacity.

No hospital blood bank should ever draw its own blood. The numbers are just not attractive enough and the regulatory climate is too daunting. Besides, the regional blood supplier may resent the competition and retaliate in some way.

Many larger hospitals already have backed into a blood donor program, either because the regional supplier cannot satisfy local demand or to accommodate patient demands for autologous and directed donations. In such a setting, there may be excess capacity that would allow the hospital blood bank to draw limited numbers of volunteer donors at a reasonable cost. Any retaliatory threats against hospital competitors are always hollow; the blood collection business is too exquisitely sensitive to public relations issues for a regional supplier to make good on a threat to withhold services.

Strategic planning for laboratory operations is the job of senior laboratory management. Besides, supervisors, chief technologists, and bench technologists don't have the requisite skills to contribute to the strategic planning process.

Strategic planning provides the means to outperform competing labs in the area. Technologists (who work in the lab) often have a better feel for the need for operational improvements than senior management. They can contribute to decisions about instrumentation and suggest organizational innovations. You may have to cajole people gently to get them to think strategically, but it is productive to solicit ideas about strategic planning from a broad range of personnel. You may be pleasantly surprised at the good ideas that come forth.

Dr. Friedman is professor of pathology and director of pathology data systems and Napolitan is director of finance and administration in the department of pathology, University of Michigan Medical School, Ann Arbor.
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Title Annotation:examination of validity of beliefs
Author:Friedman, Bruce A.; Napolitan, Eugene J.
Publication:Medical Laboratory Observer
Date:Mar 1, 1993
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