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Benefits of a spreadsheet in microbiology.

We used to direct our energies exclusively toward accuracy and efficiency, but now many of us in the clinical laboratory field have also had to become more business-oriented. The change resulted when new Government payment policies transformed the hospital laboratory into a cost center.

Among the factors we find it necessary to monitor in our 259-bed hospital microbiology department are the cost of performing an average culture; the number of minutes it takes to complete such a culture; the types of specimens we are seeing from month to month and year to year; and the percentage of cultures performed for inpatients versus outpatients.

All of these can be readily tracked with a spreadsheet. For that purpose, we added the VisiCalc program (VisiCorp, San Jose, Calif.) to our software inventory. Our micrcomputer, which is put to many other uses as well, is an Apple IIe.

In order to calculate the cost of performing different cultures and the time required, we first itemized the culture techniques and related materials used in our laboratory. These are all entered in the first vertical column of the spreadsheet (Figure I). The second column contains the cost of each item used--for example, a blood agar plate, a culture swab. Gram stain reagent. In most cases we list the unit cost, but something like Gram stain reagent must be estimated.

The third column has CAP workload unit values for each technique. These are called RVUs or relative value units by the Maryland Cost Commission, which sets rates for all hospitals. The values used date back to 1982.

Although Maryland has a waiver from Federal prospective payment, the charges permitted by the Maryland Cost Commission are fixed. Included among its cost computations are the laboratory charges.

For most outpatients, laboratory charges are based on RVUs. The state sets a rate for each hospital lab--so many cents per RVU, or per a minute's worth of work.

Besides their role in rate setting, RVUs tell us about laboratory performance. We can compute the average time it should take to complete a specimen, establishing a standard to measure our efficiency during any particular period.

After all of these data are compiled, cost analysis becomes a matter of determining what techniques and materials are needed on average to complete any specific type of culture. Supply expenses for each procedure and RVUs or time consumed are already part of the spreadsheet.

A blood culture initially requires two bottles, a syringe, a blood culture prep kit, and a chocolate and a blood agar plate. If the blood culture is positive, a great deal more expense and work will follow, such as Gram stains, additional media, and identifications and susceptibilities. We separately computed the average cost of working up a positive blood culture and then multiplied that value by the percentage of positive blood cultures we had in 1983.

We then knew the cost of a negative blood culture and a positive blood culture, and the average per 100 submitted. With the RVU data, we determined how much time it takes to work up the average blood culture, and charges were established accordingly (Figure II).

All of the procedures and materials used in the different cost computations are listed in the spreadsheet (Figure III). If we change part of a technique, we can easily amend our computations because the bases for our costs and time are readily available. Similarly, we can record supply cost changes in the unit cost section shown in figure I. Computations for all of the cultures are adjusted in an instant, automatically.

Recently, we learned that a smaller hospital in our area, which we served as a reference lab, was going to discontinue its in-house microbiology testing. We summoned up our cost data and rapidly prepared a schedule of proposed charges for handling all of the hospital's microbiology specimens. Within one week, we reached agreement, wrote up a contract, and began doing their work.

The spreadsheet permits us to follow specimen and culture types over the course of time. This information helps us when we plan budgets and schedules. By noting how many specimens come from outpatients (Figure IV), we can also estimate how much income we are deriving from them.

We have been able to identify circumstances where a switch from inpatient testing to outpatient testing, improving the hospital's financial position, would be feasible. Rule-out strep work can often be done on an outpatient basis, for example. Members of the medical staff cooperate in their approach to ordering once they are apprised that a switch would be desirable. During the last year we have seen a significant increase in the ratio of outpatient to inpatient testing, due in part to changes in medical staff ordering and in part to new referral business we have generated.

Cumulative data give us insight into whether or not our present staff can handle expanded volume from inside or outside the hospital. Since different type of cultures require significantly different amounts of time to be worked up, it's important to track changing trends in the kind of work received. Our records are updated monthly.

Through the spreadsheet, we discovered that some cultures are in small demand. It would be imprudent to drop them from our menu, but we have accurately scaled down our purchases of media and reagents for these cultures. Similarly, we now have a much clearer idea of seasonal variation in specimen types submitted for culture.

We have no doubt that the spreadsheet will yield further benefits as we think of additional uses for it.
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Author:Manasse, Robert J.
Publication:Medical Laboratory Observer
Date:Jun 1, 1985
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