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Benefits of cooperative efforts between the lab and a hospital wellness program.

Benefits of cooperative efforts between the lab and a hospital wellness program

Seeking to fill a public need brought together several formerly unconnected departments at our hospital and led us to mount a team effort on a scale we had never anticipated. In the process, we greatly enhanced interdepartmental communication and learned a great deal about the advantages of tapping into each other's very different areas of expertise.

Several years ago, when the National Institutes of Health presented its goals for lowering cholesterol levels nationwide, public interest in cholesterol rose considerably. Various departments in our 450-bed tertiary-care hospital, which has an active heart program, expressed the wish to provide cholesterol screenings using instrumentation that was then coming on the market.

It soon became clear that a program would be developed whether our laboratory participated or not. In my opinion, we were entitled and obligated to occupy a pivotal role in planning and implementing any cholesterol screenings to be offered by our facility. When I pointed this out to our pathologists and laboratory administrator, they readily agreed.

Those of us in the pathology department were aware of studies showing that the training received by operators of small screening instruments affects the quality of the results they produce.[1,2] For this and other reasons, it seemed appropriate that we should assist in setting the goals and objectives for the screening program.

Closely allied with the screening program from the first, we continued to be a dominant player in decision-making as the program evolved over the next few years. Our early contributions included the selection of instruments to be used, training the non-laboratorians who would operate them, and establishing the quality control program.

While attending to details, we intended to include the big picture. Helping to reduce the risk of heart disease in the local population would mesh with the outreach objectives of the hospital and the educational goals of the affiliated St. Vincent Heart Institute. * Philosophy. A cooperative program is driven by interest and works through communication. Initiating this communication enlists managers of other departments to contribute their time and expertise. Their involvement, preferably sustained by personal interest in the program's success, remains a key component throughout the process.

Ideally, the departments invited to participate are already committed to providing health education and community outreach. The more closely the screening project is aligned with each department's administrative charge, the more that department's involvement in the program will reinforce its own efforts as directed by management. It was in this framework that we developed the cholesterol screening program. * Getting under way. In 1986, just as we were starting our screening program, our hospital was approached by a company that manufacturers a low-cholesterol food product. The company was initiating cholesterol screenings in a number of large cities and asked our hospital to be the cosponsor in Portland. Although hesitant at first, we knew that if we didn't participate, the company would ask another hospital to do so. In today's competitive market, it would have been unthinkable to turn down the offer. We jumped in with both feet.

We expected the event to be a success, but underestimated the extent of its popularity. Nearly 4,000 people showed up - some 40 per cent more than we had expected. Because we had worked hard in the planning stages and all rolled up our sleeves to do what was needed, the problems of the overload were overcome and the screening was a solid success.

During the screening I remained available to answer questions from the public and to do the odds and ends no one else could get to. In the process I met with representatives from our state affiliate of the American Heart Association (AHA) who had come to observe our efforts in helping to provide the first major screening in the region. Shortly after the screening, I was invited to join a committee on cholesterol screening that they were about to form. On the agenda was a more ambitious undertaking: a multi-hospital citywide screening. * Recalled. With our knowledge reinforced by a major screening "experience," I called on our ad hoc committee once more. We began to prepare for our hospital's segment of the operation. The departments of adult health resources, wellness services, and occupational health again shared their interest and enthusiasm.

Our efforts coupled with those of the other hospitals and the AHA led to a screening of some 32,000 residents of Portland and environs during National Heart Month in February 1987. We had similar success when the program was repeated the following year.

In each of these screenings, a standard form served for consent and result reporting and as a takehome educational reminder. Follow-up on screenees identified as having high cholesterol levels during the first AHA screening showed that 65 per cent had consulted a physician within five months.[3] While these major screening campaigns were occuring, we continued to develop our own in-house program. The experience we gained in each helped our overall planning. * Laws. In developing the program, we researched state laws and regulations that affect public screenings. One of our first questions was whether Oregon law permitted a licensed clinical laboratory to perform lab tests requested by a nonphysician. We discovered that at that time, a clinical laboratory could perform cholesterol analyses only when ordered to do so by a physician. Oddly, the direct involvement of other hospital departments as sponsors of the screenings insulated the lab and put the cholesterol testing into an area not covered at that time by any state regulations.

Regs mandated by legislation passed in 1989 and expected to go into effect this summer will require any Oregon group or business intending to perform public screenings to obtain a health screen testing license from the State Health Division. The license will be renewable annually and will include qualifications for the director and provisions for inspection and accreditation.

The regs will include certain requirements long viewed as standard practice by laboratorians but not by all for-profit screeners. Requirements will include daily quality control analyses, participation in an external proficiency program, and educational and referral efforts that will accompany the report of the cholesterol "number" to screenees.

The need for these considerations, all of which were factored into both our program and the AHA-sponsored programs, was reinforced by the Inspector General's November 1989 report, which studied the prevalence and conduct of public cholesterol screening. During the past year I have become increasingly involved with the legislative and regulatory process governing health screenings. I have found these to be areas of opportunity in which laboratorians can get involved as concerned professionals. To see how their own states have mandated licensing, interested lab workers may wish to consult the map in Figure I. * Spreading the word. Among the early assignments of our steering group was to examine potential contacts and available settings. Advertising by our hospital has traditionally been low key and we have followed that pattern. The fact that our hospital-based program has screened some 20,000 people in three years trumpets our success loudly enough.

From the beginning, our occupational medicine department, which was already in close contact with managers of companies in the area, pointed out that sponsoring on-site screenings helps employers fulfill their health education goals and show their concern for employees. Interest from this area continues to be steady.

Our Senior Health Program incorporated cholesterol screening into its wellness outreach visits to senior citizen centers. This increased the participation in the program, which was designed to encourage the elderly to participate in maintaining or improving their own health. Cholesterol screening thus helped promote a program that increases older people's familiarity with the hospital before they need its services.

More recently, screening has been made available in an Adult Health Education Resource Center located in an adjacent medical office building. When an instrument is not otherwise scheduled, a simple sign announcing "Cholesterol Screens Today" has evoked strong response. The Wellness Services department routinely does screening as a part of its fitness and wellness programs. They also have done screenings at open house and mall health fairs.

Frequent contact with key members of the medical staff was another key to success. The National Cholesterol Education Program emphasizes the need to educate physicians; a screening program is one catalyst for that process.[4] Education of physicians as well as of the public was integrated into screenings. This approach increased the medical community's responsiveness to our continuing screening activities.

Our administration took a look at the public's positive response to the large-scale screenings and our ongoing program and has responded positively to our requests for support. They recognize that the screenings reinforce the hospital's relationship with the surrounding committee and have approved the addition of three instruments to our original one. * Vendors help. As is the case in many laboratories, lines of communication already existed between our lab and the major suppliers of portable analyzers. Selection and installation were smoothed by laboratorians' familiarity with the best ways to choose instruments and with the importance of obtaining guarantees of support from the manufacturer.

Vendors can now save those getting started a great deal of time by providing checklists, forms, and instructional and educational materials either free or at a nominal charge. Bolstering these materials are publications generated by the AHA itself. * Teaching opportunities. Providing solid instruction - perhaps indoctrination is a better word - to the screening crew at the very beginning gave our program a strong foundation. We devoted two three-hour sessions to teaching six health care professionals from the cooperating departments - a trained pool to be tapped as needed. These sessions started with a review of the different forms of cholesterol found in the body and the medical reasons for screening. A discussion followed of the variables involved in collecting specimens and operating the analyzers. Hands-on experience and follow-up teaching within the cooperating departments took place as well.

The lessons gave our intended screeners confidence about the procedures they would perform. Understanding the rationale behind cholesterol screening would later help them answer screenees' questions. Their air of confidence at the screenings, coupled with evidence of safe technique, created an atmosphere comforting to persons about to be screened.

QA activities, with which laboratorians have long been familiar, are becoming more widespread in other areas of medicine. This development, prompted in part by JCAHO efforts, has made it easier for the lab staff to give instruction in QA practices and in the use of quality control materials to non-laboratorians involved in the actual screening. Follow-up with the other departments after the lab has evaluated QC data brings QA full circle: We provide the QC materials; other departments generate the test results; we look at the numbers and interpret them. By building rapport into the planning and instructional phases of a program, we have established a pattern of cooperation that helps keep it running smoothly. * Who does what. It's not always easy for the laboratorian who is busy with many other daily responsibilities to get involved in screening programs. Time saving is a big motivation to involve non-laboratorians in a cooperative program. Other health care professionals are already trained to meet and teach the public, two critical factors in screening.

In our program, the other departments schedule times and places and negotiate charges for the screenings. Costs for screenings done on contract depend on the type of screening to be done; the types and extent of support personnel needed, such as dietitians; and other activities, such as blood pressure screening, that may be requested by sponsors.

It is the planning department's responsibility to make sure trained staff are available and that ample ancillary supplies are on site when needed. Departmental coordinators must handle the logistics of arranging for space, setting up and dismantling the screening apparatus, and controlling human and vehicular traffic.

Our lab has designated one technologist as liaison for cholesterol screening. He coordinates storing and scheduling instruments, ordering reagents, determining the other supplies needed, and disposing of contaminated waste. Each instrument leaves the lab with an instruction manual, a QA/QC log book, and appropriate quality control material. * Everyone gains. Participating in programs that include several area hospitals and are planned by a regional group, such as the AHA, has many benefits. If the program is truly cooperative, each hospital can retain all the benefits of visibility. The nature of the program, in providing services to the community at large, promotes coverage by local newspapers and radio and television stations.

Collaboration by labs in different hospitals can help overcome rivalries. The program gives laboratorians a chance to serve their communities and institutions while enhancing the profession's image. In our case, we developed basic communication we had not had before and relaxed the stress of sharing a competitive market.

Whether in providing an areawide screening or a single hospital program, the lab can help insure a product of high quality by contributing to the screening program's philosophy and practice. If the screening staff will include non-laboratorians, as ours does, ongoing involvement by the laboratory helps build the staff's confidence because they know they will have excellent technical support.

The public is assured that the product received, an assessment of their cholesterol levels, is backed by the same laboratory that provides high-quality support to patients receiving care in the hospital. The lab becomes more visible and can be seen as a team player - a very important role in current hospital management environments.

By including other departments, the lab capitalizes on their public relations expertise and extensive contacts in the community. These professionals were already acquainted with many employers, staff members at community and senior centers, and representatives of other places with which the lab itself does not usually communicate directly.

Although the department staff and responsibilities have undergone changes since the St. Vincent screening program began in 1986, cooperation among the departments has continued without interruption. Because the pathology department charges only for the strips used, and the instruments have been purchased out of at least three capital equipment budgets, in a literal sense, the cholesterol screening program has served as a form of program management. The screenings have indirectly helped the other departments by providing "ammunition" to justify staffing. * Disadvantages. For the sake of balance, I have tried to think of drawbacks to participating in such a cooperative program - not an easy task, since our experience has been overwhelmingly positive. It can be uncomfortable to lose direct control and to fulfill the need for diplomacy; for us, it was not. Enlisting the right people as you build your program can help make certain problems disappear or fail to arise in the first place. We found the release of control and the exercise of diplomacy to grow easier with practice.

If there is a conflict in scheduling, the first department to have made its schedule takes priority while the rest negotiate with each other or borrow instruments from elsewhere. Personally, I have learned how much easier it is to persuade others by polishing negotiating skills and having a solid reason for one's position than by most other means.

One glitch that we hadn't anticipated was insufficient space for parking. Response to the first screening was so extensive that a number of patients attempting to park at the medical office building next to the hospital gave up and went home, thus missing their doctor's appointments. Adjusting our hours to include more evenings alleviated this problem.

A problem that arose in the citywide screening was the difficulty of ferrying supplies across town from one screening site to another when attendance was unbalanced between them. The second year of the screenings, the AHA hired a full-time courier. * Why labs? An objective of the National Cholesterol Education Program is for every adult in the United States to know his or her cholesterol level.[5] To satisfy public demand, groups are eager to provide cholesterol screenings. As laboratory professionals, we have the knowledge and expertise required to make it work. It is our duty and privelege to insure that the public receive high-quality screening results befitting the standards recommended last year by the NIH Workshop on Public Screening for High Cholesterol.[6]

At St. Vincent Hospital and Medical Center, a cooperative interdepartmental program has enabled our laboratory to achieve our goals for a public cholesterol screening program while helping other departments attain their own outreach aims. Laboratories across the country might do well to consider ways to reap the benefits of participating in a cooperative screening program.

[1.] Belsey, R.; Vandenbark, M.; Goitein, R.K.; et al. Evaluation of a laboratory system intended for use in physicians' offices: II. Reliability of results produced by health care workers without formal or professional training. JAMA 258: 357 - 361, 1987.

[2.] Lunz, M.E.; Castleberry, B.M.; James, K.; et al. The impact of the quality of laboratory staff on the accuracy of laboratory results. JAMA 258: 361 - 363, 1987.

[3.] Morris, C.D.; Menashe, V.D.; Anderson, P.H.; et al. Community cholesterol screening: Medical follow-up in subjects identified with high cholesterol. Prev. Med. (in press).

[4.] "Public Screening for Measuring Blood Cholesterol: Issues of Concern." Bethesda, Md., National Heart, Lung, and Blood Institute, Office of Prevention, Education, and Control, 1987.

[5.] Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Arch. Intern. Med. 148: 36 - 69, 1988.

[6.] National Heart, Lung, and Blood Institute, National Institutes of Health. Recommendations regarding public screening for measuring blood cholesterol. Arch. Intern. Med. 149: 2650 - 2654, 1989.

PHOTO : The hospital's first screening in 1986 attracted nearly 4,000 people.

PHOTO : Figure 1 State regulation of screening

The author is the clinical chemist in the department of pathology at St. Vincent Hospital and Medical Center, Portland, Ore.
COPYRIGHT 1990 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1990 Gale, Cengage Learning. All rights reserved.

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Title Annotation:Cholesterol Screening, part 4
Author:Anderson, Peter H.
Publication:Medical Laboratory Observer
Date:May 1, 1990
Previous Article:How we developed a microbiology training manual.
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