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Changes in workload recording for 1984.

Changes in workload recording for 1984

Efforts to promote greater consistency in measuring laboratory workload and productivity, to make more unit values available and update earlier values, and to broaden management use of such data highlight the 1984 edition of the College of American Pathologists' workload recording manual.

The expanded manual numbers nearly 150 pages and features a plethora of new and revised unit values. There's more information plus graphs in the management applications section, including a discussion of workload ratios that may gain in importance under prospective payment. The manual has also been streamlined. Two standard sections that contained values that are no longer relevant to laboratory operations have been deleted.

Probably the most significant development is the establishment of the "e' of extrapolated unit value. The International Workload Committee, consisting of representatives from the CAP Workload Recording Method Committee and the Canadian Laboratory Workload Measurement Committee, may assign an e value to a tab procedure or instrument before standard time studies are performed.

The value is calculated in part from components of previous time studies and similar procedures or instruments. That contrasts with permanent and temporary unit values, which are based on actual time study data for the procedures and instruments involved.

Several factors prompted the creation of the rather unconventional e value. For one thing, the dwindling number of voluntary time studies has resulted in a crisis situation. This slowdown in accumulation of data is unfortunate but understandable. Committee members realize that laboratorians are hard pressed to justify performing time studies when routine work begs for completion.

Equally disturbing are the method compromises--unit value substitutions or arbitrary deletions and additions of values--now commonplace in many laboratories. It is difficult to fault laboratorians for making these compromises, since use of CAP workload units to justify staff levels and instrumentation has become a very real necessity. When the CAP has not yet assigned a unit value, many laborations are forced to formulate a best guess--and no two laboratories wind up with the same guess. The resulting patchwork throws off comparisons among laboratories.

Hence the committee agreed that values could be assigned to instruments or procedures pending standard time studies. E values should increase consistency and uniformity in use of the workload recording method.

They are indicated in the manual's procedures list by the letter a immediately preceding the CAP code number and the value. For a sampling of e values in microbiology, see Figure I.

The College is continually establishing additional e values; these will be announced throughout the year in the CAP's bimonthly publication, Counterpoints.

The CAP also added some 50 new or revised permanent and temporary unit values to the manual, many of them outlined in Figures I to VII. Blood bank and histology underwent the biggest overhaul in the past year.

For example, 13 blood bank line items in the 1984 manual reflect unit value changes. These revisions were recommended by i,Unohematology experts on the International Workload Committee following a careful review of data generated from recent time studies in blood banks across the United States and Canada. The new data indicated that unit values assigned to many high-volume procedures needed to be decreased. The crossmatch value, for one seemed to be a historical holdover that hadn't kept pace with developments in blood banking. It was reduced by almost 50 per cent in the latest manual.

Those CAP committee members who are expert in blood banking expressed concern because the majority of the time studies considered were conducted in Canada. Extensive standards of practice in blood banks, transfusion services, and donor centers throughout the United States increase the required amount of documentation. Since Canadian blood bankers do not face as much paperwork, they are able to complete procedures more quickly. Consequently, the "84 CAP manual shows higher blood bank unit values than those slated for publication in the upcoming Canadian schedule.

Decreased unit values result in a decreased workload and ultimately in decreased productivity. The percentage of this decrease will vary depending on the volume and scope of the services provided.

Figure VIII demonstrates how the workload coordinator at a hypothetical hospital-based transfusion service would recompute 1983 workload and productivity in 1984 CAP terms--identifying the procedures that had been reevaluated, substituting the new unit values, and then calculating the new workload and productivity. The resulting 19 per cent decrease is probably greater than average, due to the number of reevaluated procedures performed in this blood bank. Decreases of 14 to 15 per cent should be more common.

A lab director must understand that these new unit values will provide more accurate information on actual productive staff time and thus ultimately allow for the better management of resources. It is also important that hospital administrators and funding agencies understand that a decrease in workload attributed solely to the new unit values does notimply that there should be a staff reduction. Rather, the productivity level expected from the blood bank should be reconsidered.

The "84 manual also features eight new histology line items and six line items reflecting unit value revisions. New cytogenetic unit values are especially noteworthy. Earlier editions of the manual contained only a limited number of unit values for chromosomal karyotypes. The "84 edition, however, includes four chromosomal karyotype line items with unit values dependent upon which types of specimens are submitted for analysis--amniotic fluid, bone marrow, skin, or peripheral blood.

Unit value revisions have also been made for various routine cytology procedures. These followed an International Workload Committee review of new cytology time study data.

Two new histology line items will no doubt be welcome additions to any laboratory's procedure file. These newcomers are: CAP code #88501, technical clerical assistant, and CAP code #88194, fine needle aspiration. The first carries a unit value of 10 minutes per specimen to cover previously unrecognized technical assistance given to the pathologist. This value is tallied whenever a technical or clerical staff member assists a pathologist at the cutting bench. The second addition has a unit value of t 6.0 per patient and should be tallied whenever a technologist has to leave the laboratory to obtain a fine needle aspiration specimen.

The manual's management applications section has also been updated to reflect changing laboratory trends. In previous editions, this section addressed the basic computation of paid, worked, and specific hours, as well as productivity figures based on each of these factors. The '84 manual not only covers this material but also discusses how to track the relationship between the laboratory's volume of activity (in workload units) relative to the institution's overall volume of activity. This relationship becomes increasingly important with the implementation of prospective payment based on Diagnosis Related Groups.

Several ratios can be used to monitor trends and patterns in use of the laboratory as a resource. These include:

Average workload units/patient day = total input WLU/total patient days

Average WLU/discharge or admission = total WLU/total discharges or admissions

Average WLU/physician = total WLU/number of physicians

The manual notes that trends found in these indicators may suggest opportunities for further investigation. Hospital administration, accunting, and the management engineering staff may provide ideas and additional data that shed light on underlying factors. Further studies might focus on workload units per patient over 65 or per DRG, as examples.

Other indicators can be used to evaluate the quality of workload data. For example, graphs of the total number of workload units and raw counts in a clinical laboratory may trace fluctuations from month to month, especially on a seasonal basis. However, the peaks and valleys should even out in a graph of the ratio between these two values. A marked change in the WLU/RC ratio most often indicates an alteration in data reporting that must be documented.

Finally, the committee's strong desire to publish current information predicated the deletion of two standard sections: 07 miscellaneous procedures and 08 radioisotopes. The miscellaneous section contained many respiratory therapy procedures with out-of-date unit values. The section on radioisotopes contained unit values for in vivo procedures that no longer reflected the state of the art in diagnostic radiology. Many procedures in these sections no longer or never were under pathology department control, and it was becoming increasingly difficult to obtain relevant time study data.

There you have the key changes in the 1984 manual. Keeping pace means no letup: The CAP Workload Recording Committee is already drafting a list of things to tackle the next time around and will meet later this month to discuss its agenda for the 1985 edition.

Table: Figure I; Revised microbiology unit values

Table: Figure II; New automated blood bank unit values

Table: Figure III; Revised blood bank unit values

Table: Figure IV; New automated chemistry unit values

Table: Figure V; New histology unit values

Table: Figure VI; Revised histology unit values

Table: Figure VII; New immunology unit values

Table: Figure VIII; Recalculating a blood bank's workload

A hypothetical transfusion service had a 1983 workload of 496,944 CAP units. Shown here is only that portion that changes this year because of revised unit values--such procedures as ABO cell typing--slide or tube, code number 86084, and crossmatching, 86166. The affected procedures accounted for 258,552 units in 1983 values and 164,364 units in 1984 values. That's a drop of 94,188 or a 19 per cent decrease in total workload, to 402, 756 units. Paid productivity, or annual transfusion service workload divided by annual paid hours (14,560), also drops by 19 per cent, from 34.1 minutes per paid hour to 27.7 minutes.
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Author:Barrett, Barbara Balkonis
Publication:Medical Laboratory Observer
Date:Jan 1, 1984
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