Cover Story: Lab of the Year 2012
Meeting the challenges, serving the public: labs of the year 2012
By Alan Lenhoff, Editor
That is an encouraging message to report, as the annual celebration of National Medical Laboratory Professionals Week (NMLPW), April 22 to April 28, nears. (Visit the American Society for Clinical Laboratory Sciences website, www.ascls.org/?page=NMLPW, to learn more about National Medical Laboratory Professionals Week.) And it is a message that is underscored by the profiles that follow of the three winners of MLO's annual friendly competition for “Lab of the Year.” Our winner and two runners-up are all characterized by a strong devotion to patients and to colleagues and by an outreach to the communities they serve. They are labs of different sizes—one has about 120 employees, one has 34, one has five. They are from different geographic and demographic areas—one is in Los Angeles, one serves Oregon, one is in the city of Springfield, Missouri, and its environs. Their focuses differ somewhat as determined by the needs of those communities and the missions of the institutions. But their fundamental values are strikingly similar: they are dedicated to laboratory science, to professionalism, to teamwork, and most of all to serving the public health.
Winner: Kaiser Permanente Panorama City Medical Center Laboratory, Los Angeles, California
“WE'RE HERE TO MAKE LIVES BETTER”
Panorama City, an ethnically diverse district in the San Fernando Valley region of Los Angeles, is superbly served by the energetic staff members of Kaiser Permanente Panorama City Medical Center. The hospital lab has approximately 120 employees, serves a clientele of about 200,000 Kaiser members, as well as nonmembers who present there, and performs more than one million tests a year. It is part of a medical center that opened in 1962—meaning the Medical Center Campus is celebrating its 50th anniversary this year.
According to Operations Director May Ann Fodran, this laboratory stresses customer service, quality, and satisfaction above all. “Although we get our patients in and out of the lab quickly and efficiently, there is a huge emphasis on caring and quality,” she says. “We also emphasize patient identification, and at the end of the encounter, we always ask, Is there anything else we can do for you?' That is a consistent message throughout the organization.” Fodran states Kaiser Permanente's service credo: “Our cause is health, our passion is service, we're here to make lives better.' And that's truly what our lab team is about,” she adds.
Kaiser Permanente Panorama City Medical Center Laboratory was ranked first among 13 medical center laboratories in Southern California Kaiser, with 89% of surveyed patients indicating that they are “definitely satisfied” with the lab's overall service. The lab also ranked second in the region in patient wait time with 83% of patients reporting having waited less than five minutes for service. At the same time, the lab achieved the lowest percentage of member complaints in the region, with an almost unbelievably low 0.02% of members complaining, out of a total of more than 300,000 lab outpatient interactions. By our math, that means 60 people complained.
Prioritizing patient care
Kaiser Permanente achieved these phenomenal results by prioritizing a series of contributions to patient care that were clearly noticed and appreciated. Zero labeling error was achieved by the implementation of a wireless handheld positive patient ID system. The lab also actively participated in the area's Stroke Accreditation Committee, and has consistently achieved a turnaround time of less than 45 minutes for code stroke patients. Its critical result documentation was 99.7% compliance, and its blood culture contamination rate of 1.62%, including both phlebotomist and nurse draws—and representing more than 18,000 cultures—was below the national average of 3% by nearly one-half. Fodran notes that the lab “reaches out to the nurses and re-educates them, through in-service training,” to make sure that number stays low.
The laboratory has achieved these excellent numbers partly through the efforts of its Unit Based Team (UBT), which is composed of representatives of the lab management team, CLS, lab assistants, and receptionists. The team meets monthly to discuss lab issues and come up with workflow solutions. Among them were the following, which were implemented during 2011.
- A TAT Dashboard. This instrument monitored turnaround times for CLS and lab assistants, resulting in the Panorama City lab having the best ER TAT in the region.
- A color-coded system to quickly differentiate samples coming from the ER, surgery, and stroke patients. The implementation of this system improved the TATs for code stroke and surgical patients. The system allows prioritization and quick reporting of results when both precision and speed are needed most.
- Coordinated employee tours of the Regional Reference Laboratory. These resulted in collaboration with regional lab staff in an effort to reduce specimen rejections, which led to Panorama City having the lowest send-out rejection rate in the region—0.1%.
Panorama City also can show results that demonstrate the best average ER turnaround time among Kaiser Southern California medical centers. The laboratory met the regional TAT goals for the entire year:
Maximizing productivity and quality control
Productivity is another area in which Kaiser Permanente Panorama City demonstrably excelled. Every month, each lab manager/supervisor, along with a staff member, performs four to six observations to ensure workplace safety. Safety regulations are observed religiously to avoid employee injury—particularly with regard to ergonomics, footwear, cleanliness, clutter reduction, and disposal of waste. Out of the total of 120 employees, Panorama City had only two accepted claims of on-the-job injury in 2011, for a total of just three work days lost; and not a single needlestick accident was reported for the entire year. “Safety is one of the key elements for attendance,” Fodran says, “and it is one of the main things that we focus on in our UBT. In 2011, we were the number one laboratory in the region for workplace safety.”
In addition, nearly half—47%—of Panorama City lab employees received recognition for having excellent attendance in 2011. The lab consistently ranked in the top five among all of the departments in the Panorama City Medical Center for lowest rate of last-minute sick calls. This measure of employee satisfaction and morale was consistent with the high level of satisfaction recorded by an annual employee survey.
Quality control is a very high priority at Panorama City. The lab participated in inter-laboratory QC programs for BioRad Chemistry and Beckman Coulter hematology. Stability studies validated thaw and refreezing performance on specialty immunoassays, reducing wastage and leading to a savings of $1,200. The lab achieved 99% accuracy on proficiency testing for regulated analytes. Innovations made along the way included the elimination of printing of the BioRad peer group's monthly reports; the reports were saved in .pdf format and reviewed electronically. This saved some 2,400 pieces of paper annually. In addition, the revision of the Chemistry Policies and Procedures to conform to Clinical and Laboratory Standards Institute (CLSI) analytes table format reduced the size of the chemistry procedure manuals by 250 pages. The QC programs also provide the lab with valuable comparative feedback.
Continuing education is also an element of quality control, and Panorama City has stringent requirements for its personnel. Twelve units of continuing education are required annually of all Clinical Laboratory Scientists, who must renew their licenses every two years to work in this College of American Pathologists (CAP)-accredited lab. The lab also has a training-and-competency program. “We not only do training and competency on the scientists,” Fodran points out, “but our managers do training and competency, as well as the lab assistants/phlebotomists.”
Serving the community
The UBT and management team have found time amid all this activity to create poster boards for different sections (e.g., hematology, chemistry, blood bank, phlebotomy, and urinalysis) for display during Lab Week and other times. Posters that detailed non-blood specimens were also created for the nursing unit, in an effort to reduce specimen rejection. “We will continue to use them as information tools,” Fodran says. Lab personnel also hosted tours of the laboratory for Panorama City staff, including physicians.
MLO asked Fodran about community service performed by her lab. She pointed to Kaiser's Mobile Health Van, which is set up frequently at previously announced locations. More broadly, in the context of being good corporate citizens, Panorama City participates in Habitat for Humanity projects and marathon runs for good causes. Lab employees are encouraged to participate, and most of them do.
Looking to the future, Fodran sees the lab as well positioned to continue to provide excellent patient service despite anticipated economic challenges. She also notes that Kaiser Permanente Panorama City Medical Center Laboratory is currently considering automation options. Fifty years in, the lab is just beginning to realize its potential—and serve its patients.
“WE'VE SEEN TURNAROUND TIMES DROP ACROSS THE BOARD”
Serving the cities and towns of the Willamette Valley in northwest Oregon, the first runner-up in the “Lab of the Year” competition is also dedicated to service—in a widespread area comprised of the county seat of McMinnville and surrounding towns, including rural communities. “Our primary market area is about a 25-mile radius,” says Director of Marketing and Public Relations Dan Hinmon, “and approximately 70,000 to 90,000 people live in that area.” The laboratory, which employs a staff of 34 and performs approximately 250,000 billable tests annually, is focused on the customer service experience. The lab participates in the facility's outpatient satisfaction team and works with the hospital's admission department to refine the process for laboratory outpatients so they can get in and out faster. Processes developed in 2011 have touched other departments too, e.g., having been extended to mammography services.
Reducing turnaround times
By working on laboratory processes, the Willamette Valley Lab reduced the turnaround time for Troponin tests by 44 minutes at year's end, 2011, to an average time of below 30 minutes. This has positively impacted the time needed to diagnose acute MI, which in turn impacted the throughput of the ER. It also prepared the facility for new core measures to be introduced in 2012. “We try to turn around our tests the same day, very quickly, so that the physicians can make their decisions,” says Director of Laboratory Services Karl Kamper. “We've seen turnaround times drop across the board.”
In 2011, the lab brought in additional transfusion medicine testing, including gel technology, reducing the amount of time needed to get blood from the reference laboratory for positive antibody screens. The lab also focused on urinalysis, and worked with the Joint Replacement Institute of Oregon to ensure that appropriate cultures were reflexed prior to joint replacement surgery. This has helped to maintain a low post-operative infection and complication rate.
Teamwork has been the key to these successes. Willamette Valley incorporates lab assistants, technologists, and leadership into teams to make decisions regarding workflow and other procedural issues. The lab has partnered with Radiology and Short Stay services to expand point-of-care testing into these two departments, improving their patient experience and flow.
Efficiency and productivity have been consistent and measurable. During the past two years, laboratory teams have had a significant impact on order and requisition management, outpatient flow, specimen processing, and specimen delivery, as well as on reorganizing the laboratory after remodeling and after the introduction of new testing equipment. Throughout 2011, the lab maintained productivity measurement for the hospital. It did this even with an increase in outpatient testing of 5.6%, and it came in 3% under budget.
Enhancing quality management
At the same time, the laboratory's quality management program has expanded to include bench technologists in quality projects, procedure development, and direction of laboratory operations. By including the technologists responsible for the work, the lab has been able to standardize reporting for microscopic exams, (differential, urinalysis, gram stain, etc.) and improved procedures to the point that their robustness was recognized by a CAP inspector during the inspection cycle.
These innovative procedures have allowed the lab to go beyond traditional quality control, and to effectively control the processes in the department, follow up on trends from report review, and respond to physician concerns or questions. Quality control includes adjustment of decision criteria regarding instrument selection and proficiency testing. Willamette Valley's robust approach to quality control and improvement has shaped the laboratory's culture (no pun intended) into one in which a high level of performance is expected and achieved. This culture is also supported by the requirement that technologists and lab assistants complete a minimum of ten hours of continuing education annually. “Most of them far exceed that minimum requirement,” notes Kamper.
Innovation has become the norm at Willamette Valley too. Several years ago, the lab implemented a quality tracking system within the LIS for easy tracking of delays, errors, and other events associated with patient testing. The system has proven to be easy to use, and it was adopted in 2011 by other laboratories within Willamette Valley's system for inclusion in the new HIS/LIS system that will be implemented later this year. The lab also has instituted Lean processes which, according to Kamper, “improve the quality of services and also allow us to take on additional work without additional staffing.” It also has a goal of beefing up auto-validation in 2012, and is making instrumentation decisions with that in mind.
Giving back to others
Willamette Valley also partners with the local university medical technology and phlebotomy programs in Oregon to provide training, both in the classroom and in the lab during student practicums. There is an active program of job shadowing, internships and externships, and Kamper notes that eight current employees have come through university affiliations.
The close-knit team of Willamette Valley Medical Center Laboratory Services works for the community too. One example that Kamper is proud to refer to is work that the staff does to support active members of the military from the area: “For many years during Lab Week we have gathered a care package' for various units. We were given an award as a Patriotic Employer from a division of the Department of Defense in recognition of the support we have given both to those serving overseas and the families left back at home.” The lab also contributes to the local food bank and supports the local cancer foundation, which helps families affected by cancer meet expenses.
All in all, this is a lab that works extremely hard—but has fun, too. In its nomination form, the lab could not resist telling MLO that it won first place in the hospital's Halloween decorating contest “with a truly gruesome décor, including borrowing a real coffin from a local mortuary.”
“WE HOPE TO DECREASE THE SPREAD OF DISEASE”
Laboratorians know better—but the misconception endures among many people that sexually transmitted diseases are restricted mostly to big cities, particularly on the East and West coasts, and are relatively rare in the nation's heartland. In fact, studies have indicated that the transmission of HIV and other STDs may be increasing at a faster rate away from the population centers with which they may be most associated by the public.
That is one reason why the work of the second runner-up in the “Lab of the Year” competition is so important. The Springfield-Greene County Health Department Laboratory Services, by focusing on testing for STDs in Springfield, Missouri, and surrounding areas, is serving an urgent public need. With a staff of five, all of whom participate in proficiency testing at least once a year, the lab is available to a population of more than 300,000 people.
Filling an urgent need
“We are currently the only lab in our area that offers STD Express testing for patients,” says Senior Lab Scientist Machelle Petit. “We discovered that there is a big demand to have a quicker STD testing facility.” Petit and her colleagues responded to that need by starting their STD Express Clinic in 2010. The clinic is run by the laboratory for asymptomatic patients who wish to have noninvasive, confidential STD tests. Patients submit a urine sample to test for gonorrhea and chlamydia, and then their blood is drawn for HIV and syphilis testing. Most clients are in and out the door in 15 minutes.
All patients who come through the Express Clinic receive information pamphlets and are told when they should expect their results. This allows Petit and her staff to maximize the patient flow through the clinic, which sees about 90 to 160 people a week. This contrasts with a maximum of 16 patients a day, 3 days a week, that STD nurses in the clinic were able to see before the Express Clinic was established. “We have sped up the whole process so that we can see more clients in the same amount of time,” Petit says, “and we are now better serving the outlying areas.”
To function effectively, the laboratory requires not only first-rate procedural expertise and total dedication, but teamwork. The laboratorians work closely with the nurses, whom they notify when a test result is positive. At that point, the nurses call the patient who has tested positive back in for counseling and education. When the nurses have too many patients to see in a timely manner, the patients are given the option of seeing staff through the Express Clinic. Then Petit and her staff tell the patients when they can come back to see a nurse about any concerns they may have. Patients who test positive, Petit explains, are called and told they need to return, but are not told which disease they have tested positive for—so that, whatever the news is, they don't have to receive it over the phone, and without a professional to counsel them.
Branching out for the public good
The Express Clinic operates out of the lab's main facility, but it is branching out to other communities in the county in order to provide the service to individuals who are unable to make it to the main facility. “We see the demand for our services,” Petit says, “and we want to be able to offer them to as many people as possible.” Among all of the other issues involved in STD testing—fear, denial, concern about stigmatization—transportation itself can be a problem for some patients living in more remote areas. “We are taking a pro-active approach,” Petit says, “and through these clinics we are able to educate the public.”
The lab is also preparing to work with local school systems through a new satellite clinic to provide education and offer testing as necessary to students in high schools and middle schools, as these are target groups of concern. It is a sad reality that some young people contract STDs during their first sexual experience, she says—and education may reduce the incidence of that tragic situation.
The lab is known for its good works. When the Health Department set up a shelter after a massive ice storm in 2007, the lab helped with the shelter, and it also worked on the Emergency Response team after the lethal tornado that hit nearby Joplin, Missouri, in 2011. Looking forward, Petit and her organization are considering ways to partner with other facilities in the area as a way of working around financial constraints and adding further testing for communicable diseases.
Petit's main concentration and goal, however, is as clear-cut as it is vital: “By increasing the number of people we can see and test, we hope to decrease the spread of disease.”