Based in Norfolk, Virginia, the not-for-profit Sentara system operates more than 100 sites of care with more than 2,800 hospital beds, including 12 acute care hospitals in Virginia and North Carolina. The system, which has a 3,800-provider medical staff, includes the area’s only Level I Trauma Center, advanced imaging centers, assisted-living and nursing centers, physical therapy and rehabilitation services, home health and hospice services, and medical transport and air ambulances.
Sentara Laboratory Services (SLS) is a key component of this outstanding, and growing, healthcare system. Sentara laboratories are dedicated to addressing and meeting the clinical diagnostic and monitoring needs of patients throughout Virginia and northeastern North Carolina. System wide, more than 700 Sentara clinical laboratory professionals are vital to the high quality of healthcare provided at Sentara’s 12 hospitals. In addition, SLS’s reference laboratory and consolidated laboratories, based in southeast Virginia, perform more than eight million tests annually, serving providers and patients throughout the region. The reference lab includes clinical diagnostics in hematology, chemistry, coagulation, microbiology, and transfusion as well as anatomic pathology services. Specialty laboratories include Molecular Diagnostics, Flow Cytometry, and Cytogenetics.
MLO asked those submitting nominations for the 2016 Lab of the Year award to discuss their lab in terms of six criteria: Customer Service, Productivity, Teamwork, Education and Training, Strategic Outlook, and Lab Inspections. SLS gave MLO waaaaaay more interesting information than we have space for in this article, but, to organize the article, we will use those categories as sub-sections—and review some highlights.
SLS has embraced the concept of consumer-driven healthcare and partnered with the Sentara IT team to educate patients in signing up for MyChart, the Sentara Healthcare app which allows patients to view their health information on their personal electronic devices. The SLS marketing department created a written step-by-step procedure that patients can use to easily check and see if their test results are available.
SLS recently implemented Epic Beaker and Haemonetics SafeTrace as its laboratory information systems (LIS). This provides a common platform across the organization of Epic hospitals and provider practices for a single electronic medical record. Laboratory staff have realized numerous efficiencies as a result. Workflows were adapted to maximize the efficiency provided by the two new LIS systems. The staff, utilizing the expertise from lab super users and IT, worked together to maintain the highest standard of quality healthcare during the transition.
Patients have benefited significantly from the standard platform. Additionally, they may present to any hospital, draw site, or physician practice and have all their medical information available to the healthcare team. Physicians also have access to patient results in Epic.
In recognition of the fact that the time patients spend waiting affects the quality of their healthcare experience, SLS has worked to reduce the amount of time patients spend scheduling procedures and blood draws. SLS partnered with the Transplant, Registration, and IT departments to change the scheduling process so patients can go to any Sentara facility to have draws and other tests performed. SLS also teamed up with the Imaging department to assist with specimen collection in order to expand the service line to patients at multiple points of entry. “Today’s patient has a choice; convenience plays a major role in the selection of laboratory services,” says Kathy Prussock, MT(ASCP), Laboratory Manager.
SLS has aggressively adopted automation to reduce turnaround times and increase productivity across the benches. The labs have implemented a line of high-volume chemistry and hematology instrumentation. An automated sample handler provides the chemistry lines with a continuous stream of samples. The design and workflow of the department ensure that testing never ceases and that the majority of testing panels are available at all times, thereby eliminating the need to perform batch testing.
SLS’s reference Hematology department implemented the automated Sysmex HST-N cell counting line, incorporating cell counters, slide maker, and slide stainer into the workflow. The new instrumentation and workflow improved the efficiency of the department even as the workload increased. This was followed by the addition of CellaVision’s automated differential reader, which significantly reduced the turnaround time for differential reporting.
Clostridium difficile infection (CDI) has been named a top clinical initiative at Sentara. The Microbiology Department, Infectious Disease physician group, and pharmacists work together to provide the right antibiotics to streamline therapy for the patient. In order to enhance detection of CDI, a two-step algorithm utilizing simultaneous detection of C. difficile glutamate dehydrogenase with toxin A and B followed by PCR testing, if indicated, is performed. This initiative allows quicker identification of C. difficile and control of processes and costs. “Microbiology underwent a renovation, leaned the department, brought anaerobe testing back in house, and expanded their hours of culture reading to two shifts. Processes are now more efficient, and there is a decreased turnaround time for antibiotic reporting, which supports our Antibiotic Stewardship Program, DNV-MIR certifications, reduction in CDI, and overall improvement of patient care,” explains Kathy Judge, MT(ASCP), Clinical Specialist of Microbiology.
Losing a specimen is a serious event in any lab, and SLS has introduced an initiative to directly reduce the number of opportunities for losing a specimen and the number of resources required in locating samples. As part of this initiative, the laboratory set out to find a waste receptacle that would fit in its current spaces. The receptacle was to have a solid top and a side opening so no specimens could accidentally fall into the can from counters above.
After a search of available receptacle models on the market, and after several model trials, it was determined that the best approach for the system would be to design and have manufactured a customized receptacle. The design included a single-sized removable lid with two separate openings on opposing sides. The standard lid would fit three different cans of varying heights and a single footprint size so that they could be used in different lab locations. The design was given to a manufacturer and prototypes were created. Once approved, the product was placed into production and several receptacles were put in place across the system of labs.
Laboratory services were critical components in two of the hospitals achieving DNV-MIR (Det Norske Veritas—Managing Infection Risk) certification. The DNV-MIR Standard adopts a structure based on 18 elements covering all areas associated with the design, operation, and management of healthcare facilities. The MIR Standard was developed by DNV to provide a framework to help organizations improve their management of infection risk. This standard is compatible with World Health Organization and U.S. Centers for Disease Control and Prevention (CDC) guidelines.
Two Sentara hospitals were the very first to achieve this certification worldwide. All of the hospital’s ancillary departments were recognized by the accreditation surveyors as providing outstanding support to the clinical nursing units and for their ability to communicate efficiently and consistently. Communication and collaboration were key components in achieving the certification.
One large project embraced in 2015 was the start-up of an Ebola Assessment Center at Sentara Princess Anne Hospital. In response to the Ebola outbreak in Africa and the sudden emergence of patients being treated in the U.S., Sentara was selected as an assessment center. A Task Force was developed to include the collaboration of many disciplines, and the lab was at the center. Much work was done to decide upon test menus, lab equipment, and staffing. Ten lab staff members went through intensive training in order to be able to work in the Center—training that included donning and doffing of personal protective equipment (PPE), specimen handling, equipment training, packing and shipping, waste handling, and test result distribution. Several point-of-care testing (POCT) staff provided training on POCT devices to members of the interdisciplinary team. An on-site assessment was conducted by the Virginia Department of Health and a CDC representative in October. When the Ebola crisis passed, the unit was renamed the Highly Infectious Communicable Disease Unit. “This has enabled Sentara to maintain a laboratory at the ready for any highly communicable disease that may be coming in the future,” notes Dan Scungio, MT(ASCP), SLS, CQA(ASQ), Laboratory Safety Officer.
Groundbreaking discoveries in healthcare have brought personalized medicine to the forefront. The SLS Hematology department partnered with a group of Oncology specialists to provide “targeted medicine” to improve the level of care delivered to hematology oncology patients. Through this collaboration, pathologists have been provided education on utilizing specific algorithms to render a diagnosis. The development of new physician order sets improved the processing or ordering of tests and reduced the number of unnecessary tests being performed. Currently, the Hematology department is reviewing the coagulation order sets to further eliminate duplicate and other unnecessary testing.
Teamwork has also been a key to improvements in the SLS labs’ blood banks. To meet the needs of the community, SLS Transfusion Service has developed sickle cell protocols. One example: as patients develop more antibodies, it becomes increasingly difficult for Transfusion Services to find compatible blood. “Our sickle cell protocol has been very advantageous in preventing allo-immunization to the Rh and Kell blood groups, which makes it easier to find compatible units of blood,” says Noel Janolino, MT(ASCP), Clinical Specialist of Transfusion Services.
Education and training
All new employees complete a thorough onboarding process at Sentara. They attend a standard orientation and then deploy to their lab departments, where they are required to demonstrate competencies prior to reporting test results. This includes the technical tasks, as well as general laboratory and safety competencies.
The laboratory competency program is standardized. Sentara has developed tools to meet the needs for the documentation of each method of competency performed. The College of American Pathologists (CAP) reports that competency is the most frequent deficiency cited during its inspections of laboratories. To address this issue, SLS developed a standardized competency process. A PowerPoint presentation was created to provide education on the CLIA regulations relative to competency and the qualifications required to be a competency assessor. The focus was to offer competency for a specific discipline at a specified time during the calendar year to ensure each laboratory is working on the same type of competency at the same time.
To compliment the competency initiative, SLS created an Education Department that fulfills the needs of the laboratory staff and students. The initial focus of the new department will be on standardizing and optimizing the orientation process.
SLS leaders say the strategic imperative for their system’s operations includes a focus on lab technology and efficiency and the creation of a lab formulary. “Our focus on technology has always been to ensure that we are using the best equipment to perform the job with our large volumes,” says Tabetha Sundin, PhD, MB (ASCP), Laboratory Director. “After making the selection for equipment that is scientifically sound and cost-effective, we strive to standardize the equipment across our health system. This allows us efficiencies such as collective bargaining power, and sharing of resources and best practices. With the ever-rising cost of operating a reference laboratory and impending reimbursement cuts, it has become critical to ensure the right tests are being ordered at the right time. We can control this better with the implementation of a laboratory formulary. This will help us keep cost low, while also providing the necessary results for patient treatment.”
Among the advances that are in SLS’s five-year plan is an increased level of automation in Microbiology, which has already begun with the purchase of an automated streaker and MALDI-TOF for organism identification. SLS is also looking into smart incubators, digital plate reading, and conveyor belts to pull plates to reading stations, as well as an RFID solution for specimen tracking and the implementation of digital pathology. Lab leaders will also be adding next generation sequencing (NGS) to the molecular diagnostics laboratory and bedside barcode collection and labeling this year.
They are also considering technology advancements that will have major workflow impacts. Hematology will move to a diluent system for concentrated reagents, and sed rates will be automated. The Cytogenetics lab will implement an automated cell harvester, an automated FISH dropper, and a cell separator. Anatomic Pathology is presently validating Peloris processors for dual tissue type protocols and anticipates the use of auto-embedders. Molecular testing is already seeing a shift to primary tube-to-answer testing, automating molecular microbiology testing.
SLS has had many years of successful inspections, and is both AABB and CAP accredited. Its Lab Quality Department has developed a strong quality system manual.
The Lab Quality Team is responsible for the development and maintenance of a safety manual for lab services, internal audits (quality and safety), investigations, compilation of facility-specific and system performance and process monitors (including turnaround times), and involvement with process-improvement and problem-solving teams. They serve as regulatory and accreditation resources and liaisons with accreditation and regulatory agencies.
The team conducts internal audits for every laboratory discipline and follows up on every finding to ensure that all are resolved and that actions are sustained. They develop LIS reports, and administer document control and competency programs. Members are certified auditors through the American Society for Quality (ASQ) and maintain their expertise with CAP, AABB, CLIA, ISO, and COLA requirements.
“This lab quality program has enabled SLS to achieve high scores with our inspection agencies. We consider each finding an opportunity for improvement and work hard to not have a repeat finding,” notes Lou Ann Wyer, MS, MT(ASCP), CQA(ASQ), Laboratory Director. “We track the total number of standards reviewed with each assessment to monitor trends and types of findings.”
Congratulations to all
Sentara Laboratory Services convinced the MLO judges that it was indeed the Lab of the Year for 2016, and we congratulate the lab and its leaders for delivering invaluable healthcare services to its patients. Congratulations, too, to the first runner-up and second runner-up labs (see below)—and to all who submitted nominations for their labs. Any lab that puts forth maximum effort to serve the public and the profession is a winner. In times of change for the healthcare delivery system in the United States, outstanding clinical laboratories are islands of excellence and stability in sometimes raging seas. MLO is proud to honor you all, and to be a voice for the profession.
Le Bonheur Children’s Hospital Laboratory
Le Bonheur Children’s Hospital is a 255-bed pediatric hospital located in Memphis, Tennessee. The hospital and pediatric specialty programs care for more than 250,000 patients each year. Le Bonheur’s outstanding laboratory makes a vital and integral contribution to the institution’s success. Here are some marks of particular distinction, in the words of Le Bonheur’s Lab of the Year nomination:
- “Le Bonheur is a Level One Pediatric Trauma Center and phlebotomy is an important part of the trauma team. We respond to all ‘Trauma Stats’ and assist the team by accurately and completely labeling the specimens and personally delivering them to the blood bank and laboratory. This has eliminated unlabeled and mislabeled samples from traumas and ensures that the specimens arrive in the blood bank quickly.”
- “Every year our laboratory hosts a Symposium and invites all CLS and MLTs from the surrounding area to attend. We alternate each year between the Clinical Laboratory Symposium and the Laboratory Management Symposium. The symposium assists the staff with their required continuing education hours to maintain their license and, if desired, to obtain their Supervisor’s license.”
- “Our Blood Bank has accomplished some amazing things over the past few years. The TEGs were relocated into the blood bank to provide increased customer service for both the ECMO [Extracorporeal Membrane Oxygenation] program and for the open heart surgery program, and also in preparation of the cardiac failure/heart transplant program. Since the TEG is mandatory testing for the Berlin Heart protocol, this helped prepare Le Bonheur for these expanded patient programs.”
- “The laboratory integrated outpatient samples from our pediatric specialty clinics into primarily our core services department. These additional specimens increased our testing volume by 45 percent and were initially performed by current staff. As volumes have continued to increase, we did add one FTE to support the OP testing. This additional volume increased our efficiency and stabilized our laboratory productivity. Our turnaround time, quality results, and consolidated EMR (patient results from IP and OP testing are available to the physician) have increased physician satisfaction and patient safety.”
- “The Microbiology Department has implemented the Bruker MALDI TOF. We are now able to identify bacterial pathogens directly from a blood culture bottle within an hour of it becoming positive on the instrument. This enables the physician to prescribe the correct antibiotic versus a broad spectrum or ineffective antibiotic. Starting the correct antibiotic quicker potentially shortens the length of stay and improves outcomes. The MALDI identification also aids the physicians in deciding if a discharged emergency room patient needs to come back to the hospital for IV antibiotics immediately.”
- Our molecular diagnostics lab is designated one of two “Molecular Centers of Excellence” in the United States. We perform molecular testing primarily for infectious diseases and are in the process of validating next-generation sequencing for cystic fibrosis. We support transplant patients across the city by performing testing for the BK virus, CMV, HCV, etc. Our transplant and GI physicians have been very supportive of the gastric pathogen panel, which tests for 22 targets and results within an hour.”
Cape Regional Medical Center Laboratory
Cape Regional Medical Center (CRMC) is a 242-bed, acute-care facility located in Cape May Court House, New Jersey. In lab leaders’ own words:
- “The Lab at Cape Regional employs 30 technicians/technologists, a team of 15 in-house Phlebotomists, 10 outreach Phlebotomists, and a professional support staff consisting of three Client Service Representatives, two transcriptionists, and a dedicated courier for all our outreach clients.”
- “Our Lab may seem small, but it is quite a powerhouse! The number of reported tests completed every year is approximately 1.5 million; for example, we perform approximately 340,000 CBCs and more than one million Chemistry tests annually. Our outpatient volume constitutes 60% of our total volume.”
- “All clinical staff is cross-trained to work in at least two sub-sections of the Lab, and flexible scheduling occurs between the shifts to help accommodate staffing needs. During morning phlebotomy rounds, clinical staff work alongside the phlebotomy team to have results available to the physicians during their AM rounds. Phlebotomists assist the technicians/technologists by helping to load specimens on the robotics track systems in Hematology and Chemistry.”
- “The Lab has seen an expansion in patient-focused bedside testing by means of a collaborative and interdisciplinary team approach among several departments and locations. In the Emergency Department, we offer point-of-care glucose, urinalysis, and urine pregnancy testing. For our brain and heart rescue patients, we provide POC troponin and PT IN’s. In our GI Center, POC glucose and CLO testing is performed. The Laboratory, Nursing, Pharmacy, Interventional Radiology, and Wound Care Teams work together to provide a POC program that fits the needs of the department and patients it serves, as well as meeting all regulatory standards.”