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Where and how to improve laboratory operations.

Where and how to improve laboratory operations

The current economic climate is compelling clinical laboratories to become more competitive. Cost reduction is not enough: Laboratory resources must be allocated and applied to medical care in an appropriate, effective, and efficient manner. Operational changes are often necessary to move closer to these goals.

We will discuss three managerial functions that bear directly on this aspect of laboratory quality assurance. They are management of medical utilization, management of work flow, and implementation of new programs or service improvements.

It is the pathologist's responsibility to manage medical utilization. This entails examining the behavior and beliefs of physicians and clarifying medical staff standards to establish appropriate test ordering practices.

As a prerequisite, one must know how laboratory information is used in medical decision making, particularly for such nondiagnostic purposes as risk assessment, prognostic staging, and monitoring of therapy. Examples of nondiagnostic testing include CEA, theophylline, and digoxin assays. Carcinoembryonic antigen testing is used to monitor a patient's progress after the diagnosis has been made. It helps the clinician assess tumor burden and identify recurrence of carcinomas. Theophylline testing determines whether symptoms in cases of known asthma can be accounted for by either the disease or medication. That is, has the condition worsened, or is a dosage adjustment necessary?

Pathologists' activities will increasingly center on:

* Determining how laboratory resources are applied to patient management. Excesses are more likely to be found in this area than in testing to establish a diagnosis.

* Developing a strategic plan to achieve medical goals through systematic allocation of laboratory resources with minimum variation in use. The pathologist looks at the problems the medical staff encounters on a regular basis. As a physician and an administrator, he can discern patterns, present utilization recommendations to the medical staff, and develop a workable and standardized plan. The most important way a pathologist can change utilization of the laboratory is by instituting protocols, such as panels and algorithms, that tailor the lab's response to a need for its services.

* Implementing new standards by creating consensus through clinical studies when the literature provides inadequate data. Pathologist membership on our 538-bed hospital's nutrition committee led to last year's introduction of prealbumin measurement as a standard for assaying protein markers of nutritional status; until then, it had only been performed in certain research hospitals. The testing, at a prescribed frequency, is now mandatory in the hospital for monitoring patients who are on special nutritional support because it is clear that serum albumin and iron-binding capacity do not reflect changes in nutrient status. Effectiveness of this new standard is under review.

* Examining internal operations to determine whether laboratory performance is adequate to meet medical requirements. This includes evaluating the role of supervisors to determine their level of commitment, and assessing their staffing requirements to achieve different testing goals.

* Defining services in terms of medical outcome so that laboratory support can be reduced or increased for optimum effectiveness. This asks some difficult questions: What is the impact of laboratory data on patient care? Does a particular test or set of tests help initiate treatment sooner? Do other tests help avoid complications? By how many days is length of stay shortened as a result? We can better consider proposals to add or eliminate laboratory services if we can estimate their contribution to outcome, including potential reduction in cost to the patient and the hospital.

In order to carry out these activities effectively, pathologists will have to make use of improvements in laboratory information systems--most notably the capability of integrating file structures from different information sources.

Pathologists will also have to carry out focused surveys examining the patterns of laboratory utilization and identifying problems by looking for deviations from a definable standard. The focused survey zeroes in on one medical concern, such as GI bleeding, or a particular procedure. For example, the pathologist may evaluate the criteria for single-unit transfusions or investigate whether it is necessary to perform CK-MBs every six hours in myocardial infarct cases. If usage must be brought more in line with clinical need, the standard is rewritten.

There are also a number of institutional committees--pharmacy and therapeutics, among others--where a pathologist can assume responsible leadership for implementing change. For instance, the pathologist could team up with the chief of pharmacy to establish suitable protocols for new drugs. In that case, the pathologist might come into conflict with an infectious disease specialist who is essentially trying to maintain the status quo and sees no need for a broad discussion of the issues.

The conflict would be heightened when one tried to pare down the long list of available antibiotics to six or seven principal drugs. The purpose would be to evaluate these drugs for established use, quality of coverage, dosage and administration, and cost. Discussion of such concerns can move forward only if the parties have a clear outline of goals and a realistic cost breakdown.

The pathologist may also pursue myriad changes in laboratory operations, a process that involves continual discussion with medical departments. One example is decentralized hematocrit and potassium testing in our hospital to support the ambulatory surgery program. The laboratory purchased a portable analyzer and trained nurses to perform potassium tests on patients who are either hypertensive, receiving digoxin, or losing potassium because of a medication. The hematocrit is used to confirm that a patient about to undergo ambulatory surgery has a hematocrit of more than 33 per cent.

This approach yields results in just five minutes and eliminates the ordering, collecting, and reporting delays associated with more comprehensive profiles. It also saves the hospital and third-party payers a great deal of money. Of course, physicians can still request a profile, and those patients admitted into the hospital's separate one-day surgical program undergo the usual preadmission battery.

We have also improved lab services in response to institutional needs, which has enhanced the lab's credibility. For example, the use of high-resolution protein electrophoresis with immunofixation to confirm monoclonal and biclonal paraprotein patterns has had a major impact on the practice of medicine at our hospital.

Four years ago, we used the five-band approach and sent out our immunoelectrophoresis testing. The switch to high-resolution made it possible to pick up previously missed monoclonals and an additional 5 per cent of patients who did in fact have a paraprotein disorder. Besides leading to earlier diagnosis and treatment, the procedural change reduced laboratory costs by eliminating the need to scan.

Let's turn now from management of medical utilization to work flow management in the lab. With a proper examination of work flow, we can define all the activities necessary to provide laboratory services, and we can see opportunities to eliminate bottlenecks and reallocate personnel.

This may result in a replacement of instruments to reorganize work flow and substantially reduce test costs. By switching to fewer chemistry analyzers with greater capability, we consolidated work stations in our lab and reduced the amount of logging. Fixed labor costs came down. The 90-day calibration frequency possible on one of our new instruments further cut technologist time and cut reagent costs.

Although chemistry and hematology have the highest level of automation in most laboratories, they are still prime candidates for change because they usually account for more than 85 per cent of lab volume. Reautomation of automated areas should be considered especially if there are at least three years of depreciation on existing equipment, a substantial volume of work, and a promise of restructured work flow that will free one or more staff members for reassignment. Creation of new services is, of course, another reason for a lab to reautomate.

Work flow assessment may bring about specification criteria for technological change, such as purchase of a laboratory information system. In fact, work flow is a major issue in the decision to computerize. Without the necessary interfaces with automated instruments, you can easily lose one minute per specimen in data entry time. This would cost us about 6,000 hours a year based on a daily volume of 1,000 specimens.

The following features will be essential for all laboratory information systems acquired in the future if they are to meet the demands of a competitive health care marketplace:

1. Relational data base management with integrated file structure. This enables a user to group all related information from various areas of the hospital and lab.

2. Distributed processing and networking through a shared data base. Distributed processing lets users in different parts of the lab carry out multiple tasks on the same data base at the same time. Networking extends that capability to communication between information systems--the laboratory computer with the pharmacy's system or the hospital mainframe.

3. Ease of installation and flexibility for subsequent modification.

4. Preservation of rapid response time.

5. Bidirectional flow of information and a flexible loading sequence on analyzers. An analyzer with a bar code reader can pick up a specimen ID, but only a flow of information from computer to analyzer would tie that ID to patient demographics. That marriage of information allows you to load specimens out of accession order.

6. Concurrent review of analytical results on-line while another test run is in progress.

Managing change requires purposeful innovation. We must overcome the inertia of a status quo mentality, and support performance and values that promote a continual improvement of services. That calls for the following:

* Establishing a value system. I posted a list of 10 commandments for our laboratory, starting with the fact that the patient is our first concern. But I sonn learned one of the other commandments impressed staff members almost as much--that it's all right to try out new ideas.

* Referencing the achievement of goals to the value system. Is patient care improved by a certain goal, for example?

* Creating performance expectations for all staff members, including supervisors.

*Striving for fair evaluations.

*Seeking out and rewarding innovation.

*Encouraging teamwork among the staff.

* Increasing the level of responsible participation at the bench. When technologists take on expanded duties or are encouraged to try new procedures, they gain confidence and become more motivated.

* Crating peer pressure at all levels for the acceptance of higher standards.

* Striving for better execution of planning and implementation of new programs.

It is much easier to describe such a system than to actually steer a staff toward a new direction. However, we have succeeded at our hospital for more than three years. The most important steps are continual reference to perceived missions and consistent communication of these values in guiding the laboratory operation.

Sometimes you will find that no matter how much you discuss a planned change, there is no movement toward carrying it out. You must then determine whether initiatives are stifled by ineffective management at the supervisory level, depriving the staff of a valuable opportunity for responsible participation.

You may also find yourself mediating a standoff between two factions. That is, one group of staff members is buried in the institutional narcissism that often comes after many years in the same laboratory. They like things just the way they are, and are oblivious to the changing environment outside their little world. In the other corner, you will find the more enthusiastic and adventurous staff members who are hungry for change.

Send out a clear message to one and all that you applaud outstanding performance and will support career development in your laboratory.
COPYRIGHT 1986 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1986 Gale, Cengage Learning. All rights reserved.

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Author:Bernstein, Larry H.
Publication:Medical Laboratory Observer
Date:Oct 1, 1986
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