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The role of the laboratory in a patient-driven system.

A clinical partnership program that clusters support services around the patient benefits the laboratory as well.

In a typical hospital setting, a tremendous amount of time is wasted in waiting for a phlebotomist to arrive, an ECG to be done, an x-ray to be scheduled, laboratory test results to be communicated - and many other things. At Mercy Hospital and Medical Center, we decided to put a halt to much of the waiting. In the system we intended to institute, all the work of patient care would revolve around the needs and availability of patients. Accommodating the departments that provided services would become a secondary rather than a primary concern.

The two of us represented the lab on an institution-wide committee of administrators and department representatives. The committee's goal was to train staff members from many departments to be nurse assistants, a potentially difficult task given the issue of crossing occupational lines. Both of us would help integrate phlebotomists from the lab into that program. The committee understood that not every step in implementing such a nontraditional plan would necessarily be welcomed by staff and management at our 500-bed teaching hospital. We also took care not to violate any state (or, in the CLIA era, Federal) law specifying which duties can be performed by which employees.

Our system ultimately helped the lab by expediting specimen delivery through reducing the morning flood of orders, shortening turnaround time, decreasing the number of Stat test orders, increasing respect for the lab on the part of other departments, and creating a spirit of team building that continues to improve workflow several years later.

* Clinical partnership. In implementing the idea, familiar in nursing as the nurse-extender concept, we faced the task of developing systems that would bring as many services to the bedside as possible. Figure I summarizes aspects and advantages of the program. At the heart of our efforts was a partnership between an RN and another health care professional who has been newly trained to perform patient care tasks previously handled by other support services. The pair manage all patient needs, coordinating efforts to save time while streamlining care. The partners are closely in tune with the patient's schedule - when his or her meals are served, for example, and how any dietary restrictions may affect blood draws.

What we call our Clinical Partnership Program was born in 1989. Staff members were excited about the opportunity to provide continuity of care in a more intensive way than before. We felt that the program would encourage a close bonding of care givers to patients, since a core of seven or eight patients would be cared for throughout their stays by the same nurse and clinical partner.

We were enthusiastic about the prospect of timing ECGs, vital signs, phlebotomy, basic oxygenation therapies, and similar functions according to the needs and convenience of each patient. There would be no more wakeups for blood draws, meals interrupted for ECGs, or long waits for the respiratory therapist to arrive to relieve shortness of breath. Occupational and physical therapists could come to the floor, if not to the bedside, thereby making it unnecessary for patients to travel downstairs and wait once they arrived there.

What happened next was the most important change for all of us: the development of synergy. * Interdisciplinary teams. Developing the training program required many hours of meetings among representatives of seven hospital departments: dietary, environmental services, laboratory, nursing, pharmacy, respiratory therapy, and transportation. Delegates worked together to integrate their respective systems to support the new concept.

These meetings marked the beginning of a new era for our facility and all its support services. We strengthened our spirit of cooperation and mutual respect while gaining a better understanding of our own significance to patient care. We came to understand how hard it can be to deliver a hot meal to a patient at the right time. We learned how stressful it can be for a nurse to be asked to assume respiratory therapy functions - and for the respiratory therapist whose turf is being invaded. The group from the laboratory explained to the others that turnaround time for a blood test starts with the physician's order, progresses through phlebotomy (often difficult), may grind to a halt due to a lost tube or a transporter who arrives late, and can fail altogether if labeling or timing is incorrect or undocumented - all before the specimen reaches the central laboratory. * Shifting gears. Under our Clinical Partnership Program, we altered some job assignments and practices. One change was to have more than half of the phlebotomies formerly provided by the lab performed on the hospital floors. This move did not eliminate the need for all laboratory phlebotomists. The lab retained blood-drawing responsibility for some areas, several of which will be gradually phased out, and had to continue to provide blood draws for our lab's ever-growing outpatient service.

Our phlebotomists, who train nurses and other clinical partners (such as ECG technicians) in blood drawing techniques, are called to troubleshoot difficult draws. When the Clinical Partnership Program began, seven phlebotomists enrolled and were transferred to it. All the phlebotomists retained by the lab were cross-trained as laboratory computer operators and specimen processing personnel.

Five of the retained phlebotomists enrolled in a special urinalysis program created by our group in cooperation with the undergraduate medical technology program at the Chicago campus of the University of Illinois. The phlebotomists continued to work at the hospital part time while attending basic lectures and participating in labs for six weeks. In some cases, work schedules were adjusted to allow this. After completion, the phlebotomists were certified by Mercry Hospital to perform urinalysis. This newly enfranchised group helped alleviate the shortage of registered MTs in our lab while obtaining a much-needed growth opportunity and morale booster for themselves.

The shift of some phlebotomy to the floors helped in a number of ways. Within eight months, Stat orders dropped from 25% to 12%. After two years, most of the phlebotomy was drawn by the floors and the Stat rate was 9.5%. As a result, the turn-around time for routine tests decreased. The number of lab-related incident reports fell dramatically. The number of venipunctures per patient went down as well; so did the number of duplicate test orders. Blood specimens arrived in the lab in a more evenly dispersed pattern during the day, further reducing overall TAT for routine tests. * Labeling errors. Some errors were inevitable, As the less-experienced clinical partners became the principal blood drawers, the number of improperly collected or labeled specimens rose. Fortunately, the laboratory had strict specimen-rejection criteria in place as part of its QA effort. With specimen rejections mounting, we worked with the nursing department to correct collection and labeling errors.

We offered written materials and posters that illustrated specimen collection techniques. QA nurses were given the names of personnel within the lab who could help them out. Laboratorians conducted training sessions on the floors in some cases. The number of non-lab-related incidents also increased temporarily. Such setbacks reminded everyone of the importance of thorough training and monitoring in all areas. In hindsight, we wish we had implemented the program more gradually. We may have been too impatient to see our ideas in action.

As the program's first year drew to a close and the partners grew in experience, problems leveled off. Our carefully controlled QA process allowed us to respond quickly to potentially dangerous trends. The benefits of tearing down boundaries, getting to know each other well, and learning to integrate our systems amply justified the growing pains we experienced. * "Goal team." The lessons we learned in handling the rapid changes needed to support our patient-driven system have made it easier to plan for a future in which the laboratory will address the economic realities of the day without sacrificing quality. To accomplish this, laboratorians must actively participate in directing the appropriate utilization of our services.

We created a "goal team" within the lab to review lab utilization section by section and without preconceptions, acknowledging the creative opportunities inherent in change. Members of the team include the authors of this article and the assistant director, operations manager, systems manager, and computer manager. Other participants vary according to the lab section under consideration at the time.

Our informally structured team meets weekly for one hour to explore the best ways to use all material and human resources. Patient service remains the focus. Although the goal team quickly found many operational issues to tackle, we forced ourselves to contain our enthusiasm and address one realistic goal at a time. * Specimen handling. One element that we identified as a key to providing high-quality service in a timely manner was effective specimen handling. Our team was able to improve this crucial aspect of work-flow in many ways:

[paragraph] Telephone. All phone calls are now directed to one receptionist; inquiry calls no longer ring in testing areas.

[paragraph] Handling. Specimen receiving, sorting, and distribution are handled by one laboratory team.

[paragraph] Reassignment. Duties in the phlebotomy, computer, and specimen-receiving areas were reassigned after employees were asked about their preferences.

[paragraph] Setups. Microbiology setups were transferred out of the microbiology section to the specimen receiving area. Technical assistants, including cross-trained phlebotomists, were taught to perform the function.

[paragraph] Responsibility. Two supervisory positions were reconfigured. The operations manager now takes care of day-to-day operations in phlebotomy, specimen receiving, information and report dispersal, and referral lab issues. This manager directs problems to the systems manager, who recommends adjustments to workflow, interacts with hospital departments beyond the laboratory, and oversees quality assurance. The systems manager scrutinizes systems in their totality and smooths the interaction between sections and departments.

* Teamwork. Our efforts are yielding positive results. The team has enjoyed a new mode of sharing. While no individual receives sole credit for success, no one is held uniquely responsible if something goes wrong, either.

The laboratory continues to support the patient-driven concept by addressing utilization issues, streamlining systems, and pursuing total quality management. We see our work as part of the larger task of creating an efficient health care system that is more easily affordable by patients. The premise is that quality will be improved and costs reduced through proper management and use of resources. That is the challenge we are eager to meet with our continually developing patient-driven system.

DeMille is director of laboratory services, Fairfax Hospital, Falls Church, Va. When this article was writte, she was administrative director in the department of pathology of Mercy Hospital and Medical Center, Chicago, where Dr. DiMauro is department chairman and medical director. He is also clinical associate professor of pathology at the University of Illinois, Chicago.
COPYRIGHT 1992 Nelson Publishing
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Copyright 1992 Gale, Cengage Learning. All rights reserved.

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Author:DeMille, Kate; DiMauro, Jose
Publication:Medical Laboratory Observer
Date:Aug 1, 1992
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