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Enhance laboratory workflow to save steps and money.

Beware: Small savings in the lab may be expensive for the hospital. Examine the flow of laboratory operations in the context of the entire facility.

In these days of ever-decreasing laboratory funds and harder-to-find technologists, laboratorians are always looking for new ways to improve the efficiency of their operations. Often the purchase of new equipment seems to hold the answer. Yet in the absence of other changes, merely updating instrumentation will not necessarily enhance productivity.

A full picture emerges only with the analysis of laboratory workflow. If findings lead to the acquisition of new equipment, additional workflow analysis will help determine how the equipment would best be implemented. Among the elements crucial to understanding how work flows within the lab are sample mapping, test mapping, and workstation analysis, which were discussed by the authors in a previous article in MLO.[1]

The article presented here will examine the role of the laboratory as an ancillary service of the hospital and in relation to the needs of the lab's main customer, the physician. The goal is to stimulate fresh ideas that will ultimately yield laboratory services that are more valuable to everyone while reducing costs.

* Total quality programs. In many respects, the laboratory is a microcosm of industry. Each lab produces a product - the test result - whose value is determined by its quality, in this case accuracy and usefulness. Many companies in the United States, pressed by hard economic times, are now working harder than before to enhance quality by concentrating on the needs of the consumer; laboratories must do the same. To compete with other countries, American industry has been forced to adopt total quality management (TQM) programs; similarly, hospitals are instituting TQM to survive with fewer resources.

Successful quality improvement programs make services more attractive to consumers while lowering overall costs. The key word is overall. If a quality improvement activity that increases costs to the laboratory decreases total costs to the hospital, it is a success.

* Valuable to whom? The laboratory does not work in a vacuum. Its services can be considered excellent only after determining their quality as seen by those who consume them as well as by those who provide them.

Ideally, a test fully satisfies both parties all the time. Regrettably, this is rare. A radioimmunoassay batched once a week at relatively low cost might be highly valued in the laboratory yet shunned by clinicians for its long turnaround time. The physician might prefer a nonisotopic IA that had the same degree of accuracy and could be obtained on the same day or the same shift because it was performed in a continuous random access mode, while the lab considered it less desirable because its reagents cost more than those needed for the RIA. A well-run operation reconciles such opposing goals.

One good way to gather the information needed for such comparisons is to circulate a consumer value questionnaire to the physicians who use the laboratory. They might be asked to rate a list of factors related to service on a scale of 1 (least important) to 5 (most important). The list could include accuracy; fast TAT; reflex testing; sameday service; 24-hour, 7-day availability; cost to patient; cost to lab; and (for blood tests) volume of specimen needed. Ranking the same factors from the laboratory's point of view permits a quick and illuminating visual comparison that offers a fine start toward accommodating the needs of both.

* QSE. Figure I is a simple way of understanding how differently physicians and laboratorians might see two tests. The quality service equation (QSE) is an informal, decidely non-quantitative way of illustrating relative importance. View the scores from the consumer value questionnaire in light of the QSE.

* LSC. While the direct costs of running a test are usually highly visible to the lab, a physician's indirect costs associated with the same method are much less apparent. To make the disparity clearer, it is helpful to consider the laboratory service chain (LSC). This chain represents all the steps that occur from the time a test is ordered to the time its results are reviewed. Figure II lists typical steps in the LSC.

An overview of the process enlightens the laboratorian about the impact of a test on total costs as well as on isolated lab expenses. The LSC may incorporate actions outside the hospital, such as various kinds of work done in physicians' office laboratories POLs). Determining the LSC cost for a given method requires consideration of all steps involved - far more than the cost of reagents (Figure III). To the physician, turnaround time is the total time between an initial test order and result review. The time spent actually performing the analysis in the lab generally represents only a small fraction of overall TAT.

Test processing delays can cause a major interruption in the LSC, thereby increasing costs. Some of these expenses are readily apparent to both consumer and producer. For instance, long delay may cause a test order, including phlebotomy, to be repeated. Other expenses are hidden: aliquoting and storing a test to run at a later time and retrieving it for testing, answering a telephone call from a customer inquiring about the result, and receiving a Stat order for a test that is frequently delayed. In addition, when the result eventually arrives, the physician must take more time to review the chart.

Delays and poor service ultimately lead to loss of business. Any workflow adjustment that helps eliminate unnecessary steps or unfortunate consequences saves money and enhances the value of service.

* Diminished value. A dollar today is worth more than a dollar tomorrow. The same concept applies to the value of a lab test. As time progresses, the value of a test result declines. To understand this, consider the clinical decision-making process.

A clinical diagnosis consists of multiple steps and procedures. At times these steps are performed sequentially; at times they are run in parallel. Each facet of the workup contributes to the final diagnosis.

* Less valuable. Although a delayed result may contribute to the diagnosis, it becomes less important to the physician as time passes. During the wait, information obtained from other diagnostic techniques may reduce or eliminate the need for the initial test. The physician may decide to bypass the delayed test and proceed to the next step in the workup, perhaps referring the patient to a specialist. In the end, delayed results increase costs to the patient and third-party payers. This unfortunate practice may be the norm when the clinician knows that certain test results always take longer to arrive.

* More expensive. Unnecessary loops in the LSC, such as delayed results, increase costs to the physician's office. The clinician may not be able to make the diagnosis without the test result. Patients call to ask for their results, straining the office further. Such pressure precipitates repeated, time-wasting calls to the lab. Every chart left open to await late results must be reviewed by the doctor's staff to determine what is pending.

Yet the physician can't close the case until all data have been received and reviewed. Even an extra 10 minutes may add $20 or more to the bill when physician time is entered into the equation. Physicians do not delegate this responsibility since it is so closely linked to patient care. Failure to review an abnormal test result is the most common reason for quality assurance penalties from many Medicare professional review organizations (PROs), which scrutinize the quality of medical practice throughout the country.

Practice expenses are often very high in internal medicine, pediatric, and family practice settings. Anything that increases these costs diminishes the physician's satisfaction with the laboratory or hospital. Independent laboratories learned years ago that low price with poor service is an unsuccessful formula. Efficient labs understand that one aspect of good service is to make things easier for the clinician, who should need only minimal interaction with the lab.

Physicians practicing at hospitals also incur higher costs from late test results. Rounds are typically performed in the morning; testing decisions are often made at that time. Same-day results allow the clinician to plan the patient's care for the day to follow. Delayed results add to the physician's management time. Attending physicians, reimbursed per visit, receive more for initial visits. Having laboratory results available during early visits constitutes a more efficient use of physicians' time while improving patient care.

* Two approaches. Lab workflow has a significant impact on the LSC. Workflow can visibly improve operations in the lab and enhance the value of a test to the physician. In so doing, workflow can lower total costs, especially those external to the lab. To understand how this occurs, consider two approaches to workflow: batch versus continuous processing.

[paragraph] Batch. Considered desirable in that it is usually associated with a low variable cost per test, batch processing requires rigid cutoff times and equally tough staffing requirements to meet them. Hospital departments and physicians are forced to schedule test orders according to the dictates of lab, rather than the reverse, which is more conducive to optimal patient care. Night and weekend testing is often unavailable. Untimely lab results may contribute to extending patients' length of stay. Figure IV illustrates how even seemingly minor financial waste in the lab can cost the hospital a great deal.

In an outpatient setting, other costs may be associated with batch testing. A restricted processing schedule - such as once a day on Monday through Friday - makes it hard for the lab to compete with independent labs that provide faster service. Thus considerable revenue may be lost - a hidden cost.

Also expensive are phone calls to and from physicians, time lost in locating and inserting test data in patients' charts after discharge from the hospital, extra handling to store and retrieve specimens for batching, and the high cost of running a single Stat test. Batch processing exacts a high toll on running a single Stat.

[paragraph] Continuous. The preferred workflow design continuously processes specimens throughout the day. Reagents may cost more than those used in batch processing. By focusing on continuous processing, the laboratory can reduce many steps in the LSC. Fewer aliquots are needed, while specimen storage is eliminated. Test and staffing schedules remain flexible. Because results are available sooner, fewer phone calls will be necessary between the lab and the physician, who will benefit from having to review each chart less often. The net result is better service at lower total cost.

[1.] De Cresce, R.P., and Lifshitz, M.S. Selecting laboratory instrumentation. MLO. Part I: 21(2): 76-83, February 1989; Part II: 21(3): 73-75, March 1989.

Dr De Cresce is director of clinical laboratories, Rush-Presbyterian - St. Luke's Medical Center, and assistant professor of clinical pathology, University of Illinois, Chicago. Dr. Lifshitz is director of outpatient laboratories, New York University Medical Center, and clinical assistant professor of pathology, NYU School of Medicine, New York City. The authors publish a monthly newsletter, "The Instrument Report."
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:De Cresce, Robert P.; Lifshitz, Mark S.
Publication:Medical Laboratory Observer
Date:Apr 1, 1992
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