impact of technology on micro and costs

8/6/2019 Impact of Technology on Micro and Costs

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Technology Impact on Cost 63

BLOOD CULTURE RECOVERY PROFILEManual vs. Automated SystemPERCENT

MANUAL

ASONDJ FMAMJJMonth 1993 - 94

q IGNIFICANT ISOLATES q IKELY CONTAMINANTSUniversity Hospital, CincinnatiFIGURE 1 Percent recovery of bacteria from total blood cultures collected using a monophasic-biphasic two-bottle setreceiving daily visual inspection versus recovery using a monophasic-monophasic plus resin two-bottle set receivingcontinuous monitoring via instrumentation (BACTEC9240 series; Becton-Dickinson Diagnostic Instrument Systems).

administrator under managed care sees twice asmuch glass as is needed to contain the liquid andwill move to downsize the glass.Laboratory managers may respond to budgetarypressures by looking toward technology to reduceboth materials and labor costs. Determining the truefinancial impact of technology application requiresdepth and breadth of perspective. Recognition thatthe budget of the microbiology laboratory is but afraction of the total laboratory budget and that thelaboratory budget is but a fraction of the total hos-pital budget also brings the recognition that strate-gies designed to save money only at the level ofmicrobiology expenses may be laudable but are nec-essarily limited within the context of the magnitudeof hospital expenses. Effort must therefore be di-rected to offering benefit in an integrated fashion,both laboratory and hospital-wide, and examplescan be provided that illustrate that the adoption of

technologies can directly lower microbiology ex-penses, lower overall laboratory costs, or help re-duce expenses on a hospital-wide basis. Certaintechnologies may actually favorably affect globalhealth care expenses, such as those that promotethe early recognition of active tuberculosis or sexu-ally transmitted diseases. However, such potentialeconomic benefits to society, if achieved at greaterdirect expenditures with minimal local dollar im-pact, would likely be provided by the hospital foraltruistic rather than financial motives. It is usuallyimpossible to have such societal savings reenter thehospitals pay line to offset expenses incurred.The following is a description of the efforts of alarge university hospital clinical microbiology labo-ratory to investigate the question, Can the applica-tion of technology help the laboratory to be botheffective and efficient, thus approaching the man-aged care objective of quality at lower cost? These


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J.L. Staneck

TABLE 2 Performance Characteristics of Blood Culturing, Visual VersusAutomated InspectionParameter Manual Automated

Testing intervalDetection mean timeDetection mode timeStaffing required

July-December 1993 January-June 199468 3748 241.5FTE l.OFTE

TABLE 3 Identification of Suspected Colony of Histop2asma capsulatum: Comparison of Methods andOutcomes

Method ReportTurnaround Time Laborcosts SUPPlYcosts TotalcostsCulture conversion: filamentous to yeastExoantigen extraction and identificationDNA hybridization probe (Gen-Probe)

14-28 d14 dSame day

$15.85 $6.64 $22.49$13.87 $8.80 $22.67$5.29 $32.12 $37.41

experiences are presented from the perspective ofthe author, functioning as the Director of Microbi-ology and Director of the Laboratory Medicine Di-vision, and include description of laboratory-wideefforts to deal with organizational change in the faceof economic imperatives prompted by an increas-ingly larger managed care environment within theCincinnati community.

AUTOMATED BLOOD CULTURINGIn January 1994, the University Hospital microbiol-ogy laboratory changed from a double-bottle (onemonophasic, one biphasic) blood culture protocolthat included daily visual inspection for microbialgrowth to a double-bottle (monophasic with andwithout resin) protocol that included the use of anautomated instrument for incubation of bottles andcontinuous monitoring for detection of positive cul-tures (BACTEC 240 eries: Becton Dickinson Diag-nostic Instrument Systems, Sparks, MD, USA). Ma-terials cost for the new bottles, even allowing for acapital lease arrangement built into the bottle cost,was similar to that of the older bottles, leaving laborcosts as the only area of possible savings. Table 1illustrates comparative calculations for the manualcompared with the automated approach in terms oflabor costs, predicated on data provided to the lab-oratory by the hospitals decision support depart-ment. According to the annualized data, it was es-timated that the labor savings for the automatedsystem would be minimal at 0.22 full-time equiva-lents (FTE) per year, or approximately $5000.

prior to the change and the 6 months following thechange to the automated system. Given that thecomparison involved nonparallel data sets, the onlydiscernible change possible would be a major shiftin the recovery trend. As illustrated in Figure 1,there appeared to be no such trend changes in thenumber of positive cultures detected. However, asshown in Table 2, the real value of the automatedsystem was shown to reside in a dramatic decreasein the average time for the initial detection of bac-terial growth. The decrease likely was attributable toa combination of continuous monitoring, constantagitation, and the nature of media used with theautomated system. The mean of 68 h with visualinspection fell to 37 h with the instrument. Moreimportant, the change in the mode of detectiontimes changed from 48 to 24 h. Therefore, in themajority of cases, the laboratory was reporting thepresence of an organism in blood 1 day earlier withthe automated instrument than with a visual inspec-tion approach. Although clinical outcomes of such achange are difficult to document, a positive effect onthe initiation, modification, and nature of the ther-apeutic response could be projected intuitively withattendant cost savings to the hospital. In addition,the change in the workflow allowed by the automa-tion approach resulted in a 0.5 FTE actual reductionin the staffing of the blood culture area, for a savingsin operational costs via time and benefits of over$20,00O/year.

INDENTIFICATION OFHISTOPLASMA CAPSULATUM

Performance was examined by tallying the num- The University Hospitals location in the Ohio Riverber of positive cultures detected in the 6 months Valley ensures that the dimorphic fungi Histoplasma


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TABLE 4 Comparison of Approaches to the Detection and Identification of Mycobacteria

Issue ConventionalCulture Culture plusDNA Probe

BACTEC 460 plusDNA ProbeAll Samples AFB Smear Positive

Time to identificationAST availability/costTime to AST reportNegative culture costPositive TB or MA1 costPositive non-TB or MA1 costAverage cost/caseCases/yTotal annual costCost (without AST) beyondconventional culture

P6 wkNo$7.89

$38.38$38.38$9.602963$28,445

3wkNo$7.89$26.61$38.38$8.462963

$26,067- $3378

7-10 dYeslS67.321420 d$16.42$52.14$82.63$18.722963$58,214$27,615

7-10 dYesl867.3214-20 d$7.89$52.14$82.63$9.732963$30,994$395

AST, antimicrobial susceptibility testing; TB, Mycobacterium tuberculosis; MAI, Mycobucterium avium-intracellular group. Total costincludes labor, materials, and AST costs ($2154 annually).

cupsulatum is a regular visitor to the microbiologylaboratory. Three approaches have been used overtime, corresponding to the availability of technolog-ical developments for identification of colonies sus-pected of being Hisfoplasma: (a) conversion of thefilamentous to yeast phase of the fungus in culture,(b) extraction and identification by immunologic as-say of the exoantigen specific for Hisfoplasmu, and (c)use of a commercial nucleic acid hybridization probefor the detection of ribosomal RNA specific to His-toplasma (Gen-Probe, San Diego, CA). Table 3 high-lights the detection time and the costs for labor andmaterials for each approach. Although on first in-spection the cost of the DNA probe is nearly doublethat of the other approaches, mitigating factors off-setting the higher cost include a 2-week reduction inturnaround time and a less hazardous procedurethan that required for the exoantigen test. Further-more, upon investigation, it was noted that the ex-

oantigen procedure frequently had to be repeatedbecause of technical problems or growth limitationthat yielded uncertain initial results. The conclusionwas that the application of the DNA technologygreatly accelerated turnaround time with its atten-dant benefits on clinical outcome and managementwhile engendering only incremental cost increases.The key to the economic use of expensive reagentssuch as those used in molecular techniques is theability to identify situations where the use of thereagent is most likely to have positive results andbenefits. Clearly, colony characteristics of Hisfo-plusmu served as such a parameter.

DETECTION AND IDENTIFICATION OFMYCOBACTERIUM TUBERCULOSISAmong the most popular technologies available be-yond classical culture and biochemical testing to

TABLE 5 Recovery of Mycobacteria: Profile at University HospitalJanuary-June 1994

Isolate No. AFB Smear Positive-Culture Positive No. AFB Smear Negative-Culture PositiveM. tuberculosis 10 6M. auium-intracellulare 4 21M. fort&turn 4 15M. kansasii 2 0M. marinum 0 3M. xenopi 0 2M. scrofulaceum 0 1M. gordonae 0 2Other Mycobacterium sp. 0 2

Total cultures = 1893 excluding blood cultures.


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66 J.L. Staneck

TABLE 6 Expense Projections: Case Managementof Active Tuberculosis for a 3-MonthPeriod

Expense TypeActual

costPotential costcost Avoidance

TherapyHome nursing carefor IV therapyTotal Costs

$500 $600 $100$240 $2880 $2640$740 $3480 $2740

See text for case description.

grow and identify Mycobacterium species are the useof the nucleic hybridization technology (Gen-Probe)applied to the identification of acid-fast bacilli (AFB)colonies and the use of the BACTEC460 instrument,which incorporates the detection by radiometricmeans of growth of mycobacteria in a liquid cultureenvironment. The University Hospital laboratoryadopted the DNA probe for routine identification ofMycobacterium tuberculosis and Mycobucterium auium-intracellulare several years ago and more recently hasimplemented the BACTEC460. Table 4 compares sev-eral parameters of interest, including time to organ-ism identification, availability of antimicrobial sus-ceptibility testing, and costs (combined labor andmaterials) projected on an annual basis of four dif-ferent approaches. Included are: (a) culture on solidmedia followed by identification using standardmorphologic, growth, biochemical, and physiologicprofiles; (b) culture combined with the DNA probebased identification of M. tuberculosis and M. avium-intracellulure; (c) culture of all specimens in liquidmedia with detection using the BACTEC 460 andidentification using DNA probes as above; and (d)standard solid media culture with colony probeidentification along with selective use of the BACTEC46 0 for only those specimens for which the acid-fastsmear was positive. The data are interesting in thatuse of molecular probes for AFB colony identifica-tion actually costs over $3000 less per year than con-ventional media based procedures and shortensturnaround time by a mean of 1 to 3 weeks.Adoption of the BACTEC 460 would enable yetanother significant decrease in detection and iden-tification time and would allow the performance ofantimicrobial susceptibility testing for M. tuberculosisin a relatively rapid fashion, both important issuesbecause of the increased interest and incidence ofdrug resistance in this organism nationally. The pro-jected expenditure for these benefits, however, wasestimated to be greater than $27,000 above that foruse of conventional culture. Selective use of theBACTEC 460 with DNA probe identification was pro-jected to cost essentially the same as conventional

TABLE 7 Impact on Outcome Due to RapidReporting (Same Day as Isolation) ofIdentification and AntimicrobialSusceptibility Testing ResultsPatient Group

Parameter Same Day Next Day PMean length of stay 20.7 d 20.1 d NYMean length of stayfollowing culture 14.7 d 14.6 d NSPercent mortality total 8.8% 15.3% .016Percent mortality dueto infection 7.0% 12.7% .023Charges per patientTotal lab $4732 $6074 .0132Microbiology $843 $1240 .0006Pharmacy $4181 $5523 c.0005

Antibiotic $1063 $1354 .0044Other $6149 $7659 .0269Total costs $15,062 $19,256 .0118Not significant. Adapted from Doern et al (1994).

culture and identification (Table 4). Again, the prin-ciple of applying the higher-cost technology to spec-imens most likely to yield positive and/or useful re-sults proved to be cost effective. For example, thelaboratory does not routinely inoculate even smear-positive specimens into BACTEC if the patient haspreviously been diagnosed as having tuberculosisand is merely being monitored through the thera-peutic course.

The use of the BACTEC for only AFB smear-positive specimens runs counter to the spirit of cur-rent recommendations of the Centers for DiseaseControl and Prevention to reduce the length of timefor the isolation, identification, and susceptibilitytesting of M. tuberculosis (Tenover et al., 1993). Onecould argue that patients with smear negative, cul-ture-positive specimens would be subject to a delayin diagnosis with potential individual and publichealth consequences. To asset the reality of thisdrawback, a review of AFB smear and culture re-sults for a 6-month period was conducted and issummarized in Table 5. If one assumes that the mostserious threat amenable to therapeutic interventionmanagement to the individual or to the communityis the patient with undetected active tuberculosis,then six specimens yielding smear-negative, M. tu-berculosis culture-positive results exemplified thatpotential threat. In fact, the six samples representedtwo patients, each with three specimens submitted(three sputa from one patient and three bronchialwashes from another). In either case, the very lownumber of bacilli in sputum or bronchial wash sug-gested little threat to the general public and an un-


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TABLE 8 Cost Savings Due to Merging ofIndependent Virology Services intoExisting Microbiology-ImmunologyServices, University Hospital Cincinnati

TABLE 9 Cost Comparison of ChlamydialCulture and Direct DNA probe (PACEII: Gen-Probe) for the Detection ofChlamydia

No. FTEReduction Job Title

Per AnnumSavings(Salary +Benefits)

1.2 Assistant Director4.9 Medical Technologist1.0 Medical Technician1.0 Administrative secretary0.8 Laboratory ClerkTotalFTE, full-time equivalents.

$72,750$203,250$33,000$34,500$16,700$360,500

determined but presumed diminished threat to thepatient during the 3 weeks until culture was positiveand identity of the M. tuberculosis confirmed withDNA probe. From an expense standpoint, this strat-egy of using the BACTEC 460 only for smear-positivesamples allowed the benefits of the BACTEC workupfor the majority of specimens containing M. tuber-culosis while avoiding the expense for a number ofspecimens containing nontuberculous mycobacte-ria, as smears from patients with Mycobacteriumavium complex group and Mycobacterium fortuitum in-fection, in particular, yielded few positive results.The benefits of rapid detection are far less importantfor M. avium complex, a more indolent infection,than those achieved with early recognition of M.tuberculosis. Likewise, culture of M. fortuitum is gen-erally productive in a matter of days. There is con-siderable value in processing the smear positivespecimen through BACTEC for although the presenceof the AFB is already known, one can achieve re-covery and probe identification of the organism in arelatively rapid time frame. In addition, an M. tu-berculosis isolate is then available for immediate sus-ceptibility testing. Such an advantage is lost whenonly traditional culture is performed.The following case illustrates a nonlaboratory-related cost savings that accrued from the use of theBACTEC-DNA probe approach described earlier. Thepatient presented on 12 July 1994 with right-upper-lobe infiltrate and a history and physical examina-tion suggestive of tuberculosis. A positive AFBsmear was reported on 13 July 1994, and a BACTECbottle was inoculated. The patient was given isoni-azid (INH), rifampin, pyrazinamide, and ethambu-to1 plus amikacin because of a history of tuberculosis8 years before and fear of infection with a drug-resistant bacillus. On 18 July 1994, the BACTEC bottlewas positive and the organism was identified thatday as M. tuberculosis using DNA probe. INH was

DNACulture Probe Difference

Assay materialsLabor cosWTotal/assayCulture/y X 7000Savings/year = $35,140

$7.31 $3.92 $3.39$2.55 $0.92 $1.63$9.86 $4.84 $5.02

Data provided by hospital decision support system.

discontinued because of liver toxicity; streptomycinwas substituted for amikacin, and the patient wasdischarged on 21 July 1994 on quadruple drug ther-apy. The addition of streptomycin necessitated thescheduling of three home nursing visits per weekfor administration of this parenteral antibiotic. On27 July 1994, the laboratory reported that BACTECgenerated susceptibility test results indicating sus-ceptibility to INH, ethambutol, rifampin, and strep-tomycin, which prompted the physician to discon-tinue the streptomycin. Table 6. lists the actual costsof managing this patient versus the potential costsof management over a 3-month period (the time in-terval for which AFB susceptibility results throughthe county tuberculosis control laboratory wouldhave been available prior to rapid radiometric meth-odology at the University Hospital). A cost avoid-ance of over $2700 was realized primarily as a resultof savings in home nursing care costs.

RAPID BACTERIAL ANTIMICROBIALSUSCEPTIBILITY AND IDENTIFICATIONOne well-documented, randomized, controlledstudy on the impact of delivering antimicrobial sus-ceptibility and bacterial identification reports on theday colonies of the organism are available versus thefollowing day was published by Doern and co-workers (1994). Comparison was made of twomatched patient populations. One group of 273 pa-tients had reports issued through the usual hospitalchannels on the day colonial growth allowed test-ing. The second group of 300 patients had reportslikewise issued, but not until the following morn-ing. Data in Table 7, adapted from this study, sum-marize selected and important areas of changeamong the wide number of parameters studied ret-rospectively through chart review. Among the sta-tistically significant and favorable outcomes


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TABLE 10 Total Cost Contribution to UniversityHospital Competitive Cost ReductionProgram (Fiscal Year 19941995) bythe Department of Pathology andLaboratory Medicine as of December1994No. FTE

Reduction Job Category3.2 Managers11.1 Medical laboratory technologist4.2 Medical laboratory technician2.0 Histotechnologist0.7 Computer specialist4.4 Lab assistants2.6 Lab clerks0.2 Program coordinator1.0 Secretarial/clerical

Technical and clerical staffpositions vacant at start of10.4 fiscal year July 1994Total 39.8Annual total cost reductions (salary and benefits)= >$1,350,000

achieved by receiving reports a single day earlierwere decreases in patient mortality, whether or notdue directly to infection; total laboratory chargesand pharmacy charges, including antibiotics. Pro-jected annual reduction in charges would be -2.4million dollars had all data been available at the ear-lier period. Although emphasis under managed careand capitated fees is on cost not charge reduction,were the 2.4 million dollar savings in charges con-verted to the appropriate costs, the savings in ex-penses hospital-wide still would have been consid-erable.

CONSOLIDATION OFDRUG-MONITORING SERVICESHistorically, the measurement of different analytesmight take place in various laboratory sections de-spite a commonality of technical methods availablefor assay. Such was the case at University Hospitalwith the measurement of antibiotic levels in serum.Levels initially determined using bioassay ap-proaches in the microbiology section were subse-quently replaced with enzyme, and finally fluores-cence polarization immunoassays (TDX; AbbottLaboratories, Chicago, IL, USA). Such testing, how-ever, remained in microbiology for historical rea-sons. A review of the cost reduction potential ofconsolidating all TDX-based drug monitoringthroughout Laboratory Medicine served as an im-

perative for change. Since the advent of laboratoryinformation systems, access to antibiotic levels forconsultation purposes has not been a compellingargument to continue such testing in microbiology.Several factors influenced the decision to consoli-date therapeutic drug monitoring into the toxicol-ogy service of the laboratory, an area that alreadyassayed a number of nonantibiotic drugs using TDXinstrumentation. Over a $25,00O/year direct costsavings was projected by eliminating one TDX in-strument and having the remaining instrumentsused to capacity in toxicology. The staffing level inmicrobiology was reduced 0.7 FTE without anystaffing increase in toxicology. Instrument mainte-nance costs were reduced with fewer instruments.More attractive reagent pricing was sought throughconsolidated volumes. In summary, service re-mained unchanged, data were available to microbi-ologists, and on the whole, laboratory costs werereduced.MERGING OF LABORATORY SERVICESThe year 1994 found the city of Cincinnati and sur-rounding communities moving rapidly from early tomiddle stages of the managed care scenario withincreasingly greater numbers of the populace nowrepresented as covered lives in contracts drivenby their employers desire to contain health carecosts. An increase in managed care coverage fromapproximately 35% to over 50% of the greater Cin-cinnati population was projected by 1996. Capita-tion; carve outs; collaborations; and comparisons ofinstitutional quality, service, and cost abounded ashospitals that historically regarded each other incompetitive terms started speaking of and actingupon affiliations and alliances. In August 1994, acompetitive cost reduction program (CCRP) was in-troduced at the University Hospital. This followedan extended study by consultants who proclaimedthe need to implement a systematic and widespreadprogram of cost review, control, and reduction lestthe hospital fail to be competitive in the health caremarketplace. Widespread initiatives involving bothancillary support departments and clinical serviceswere put into place and immediate actions to reducecosts were undertaken that included retirement in-centives for staff; decreasing employee numbersthrough attrition and layoffs; analyses and improve-ment in productivity, program effectiveness, andclinical use; and better control of materials usage.The basic goals of the program were to become com-petitive in the managed care market, achieve oper-ational efficiency, and maintain clinical effectivenessand quality.Financial objectives were suggested at depart-


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PATHOLOGY AND LABORATORY MEDICINEFUTURE STRUCTURE--SUMMER, 1995

Primary Services Lablmmunohistochemist

igh Volume, Automated, STAT,Multi-Disciplinary Testing

__- _____LEGEND: 0 REPRESENTS SHARED AND INTERRELATED SERVICES0 REPRESENTSSUPPORTAREAS

FIGURE 3 Schematic of clinical laboratories of Pathology and Laboratory Medicine envisioned for 1995, representinga high degree of service integration resulting from cross training between disciplines, clustering of testing aroundcommon technologies, and structuring of a primary services core laboratory to meet the requirements of high volume,highly automated and stat testing inpatient requirements of the University Hospital.

in tissue culture recovery of Chhzydia prompted achange from culture to the use of a direct DNAprobe (PACE 2; Gen-Probe) which not only permit-ted decreased test turnaround time compared withculture but projected a favorable labor and materialssavings of over $35,000 annually (Table 9). Most im-portant, service changes to the clinician and clientusers were transparent as neither quality, response,nor quantity of service was felt to suffer.Throughout Laboratory Medicine, particularly inthe areas of clinical chemistry, radiobiology, endo-crinology, and toxicology, similar consolidation pro-cesses had either been ongoing for the prior 2 yearsor were initiated in response to the CCRP. The mag-nitude of dollar targets and need for an accelerationof cost reduction efforts helped crystallized thoughtregarding the future direction necessary to achieve

efficiency and effectiveness. Certain tenets wereadopted, including the dissolution of traditional di-vision barriers based on scientific discipline; theclustering of testing around common technologies;cross training of technical staff for multiple workassignments transgressing historical laboratoryboundaries; centralization of specimen processingand handling as a prelude to robotics; functionalintegration of specialty laboratory functions wherecost and technology made sense; employment of au-tomation; and commitment to a primary services orcore laboratory delivery model. The challenges offollowing these tenets and bringing about substan-tive change to the organization without precipitat-ing chaos are enormous. Human resource pro-cesses, regulatory concerns, physical plant limits,delivery of quality laboratory science, maintenance


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of staff morale, perpetuation of academic teaching,and investigative missions are among the manycomplex issues that require careful attention and de-mand creative solutions. Keeping staff informedand seeking the appropriate participation at all lev-els of the organization greatly increases the likeli-hood of successful outcomes. The financial advan-tages may be considerable. Salary- and benefit-related reductions achieved to date are shown inTable 10. A contribution of over $1,350,000 in an-nual operating costs as of December 1994 was madeby the hospital-based laboratory services toward theUniversity Hospital CCRP goals.

TABLE 12 Key Elements to SuccessfulManagement of Change andAchievement of Effectiveness andEfficiency Under the FinancialPressures of Health Care ReformActivity Comment

Communication

Participation

PRIMARY SERVICESLABORATORY MODELCluster testing

Given ambitious financial goals, the need for pro-cess redesign was obvious. An attractive service de-livery model was thought to be one in which allinpatient high-volume laboratory testing, particu-larly in the areas of hematology, chemistry, and tox-icology, and the majority of stat requests ordered forthe inpatient population of the hospital, could befocused into one physical location, staffed withtechnical personnel functionally interchangeable atall work stations. One important key to this conceptwas the centralization of specimen reception andhandling into this area. Great advantage could thenbe taken of information technology, including com-puter instrument interfacing, sample bar coding,and future robotics applications. Processing person-nel would also be efficiently used. The name primaryservices laboratory (PSL) was coined to suggest thatthe focus of the laboratory was the provision of nec-essary services on a 24-h basis to the inpatients ofthe hospital. It was envisioned that the PSL wouldserve as a platform for all other laboratory opera-tions, centralized or decentralized. Employment ofautomation and consolidation of testing using ran-dom access analyzers well suited to the type andvolume of service demands was felt to be essentialto operational and financial success. The proposedtest menu for the PSL is listed in Table 11.

Cross training

Collaboration

Outcome analysis

Professionalstance

Attitude

Share in a timely and completefashion the mission, vision,and direction to all levels ofstaffEncourage dialogue and activeentrance of staff intoplanning anddecision-making processChoose technologies withmultiple assay capabilities

and maximize capacityEncourage transfer of skillsamong personnel acrossdisciplines to maximize

flexibility of schedulingPromote among directors andmanagers a unified missionthroughout the laboratory,allowing the development ofexpertise within specialtydisciplines withoutattachment to territories

Examine issues and makedecisions focusing onoutcome, letting process be ameans, not an endIntegrate the laboratorians intoappropriate aspects ofhospital activities, planning,and decision making

Maintain forward and flexibleoutlook, question allassumptions, rethinkprocesses, support dynamicmodels, and welcomechallenges as opportunities

Surrounding the core of the PSL would be a hostof functional specialty areas focused on lower vol-ume and more complex testing needs, including themore esoteric test services offered primarily to out-side clients. These areas would not likely functionon a 24-h basis but would support the developmentand teaching missions of the department as well asallow for the maturation of professional expertise atthe staff level and professional consultation at thefaculty-management level. Testing services withinspecialty areas judged to be necessary or highly use-ful on a 24-h basis would be located in the PSL. Forexample, within microbiology, critical Gram stains,

india ink examinations for Cryptococcus, and initialprocessing of selected specimens such as blood andbody fluids would likely occur within the PSL attimes other than the first workshift. Opportunitieseither to cluster similar technologies or adopt thetechnologies of one specialty area to the needs ofanother would be continually sought to achieveeconomies of scale. The use of high-pressure liquidchromatography to assay antifungal drug levelswould serve as an example. Figure 2 provides aschematic representation of the historic functioningof both the clinical and anatomic pathology servicelaboratories as largely independent autonomous di-visions; Figure 3 foreshadows a projected view ofthe future under the new service model.


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FUTURE DIRECTIONSAs of this writing, alliances have been announcedbetween the University Hospital and three commu-nity-based hospital systems that will align in 1996under common administrative management. Al-though it is too early in the process to detail theeffect on laboratory services, there is a general un-derstanding that to achieve the necessary econo-mies, a degree of reengineering of support servicesamong four currently separate hospital facilities islikely. Whatever configuration finally results, it isthought that the PSL concept would be flexibleenough to support a variety of future delivery mod-els and allow each institutional site to meet its crit-ical inpatient service needs. The evolution of a cost-competitive regional laboratory network tiedtogether by common information technology amonginstitutions with marked differences in human re-source structure and operational history offers chal-lenges not unlike those encountered in the internallaboratory redesign efforts at the University Hospi-tal detailed earlier. Table 12 summarizes the ele-ments necessary for success, which appear to besimilar. Communication is absolutely crucial to pub-licize the institutional vision of both its service mis-sion and the need for global cost savings in a com-petitive market. Participation of the entire hospitalstaff in the design of the future is critical and enablesthe use of unique talents and the acquisition of trulyexpert knowledge. Clustering of tests around com-mon technologies for efficiency and economy Eur-thers financial benefits. Flexibility of personnelachieved through cross training in a variety of tech-nical areas allows maximum efficiency in meetingservice demands. Preservation of the laboratoryspecialists identity but not necessarily their terri-tory offers potentially the best of both worlds in

terms of maintaining expertise but lowering costs.Embracing an outcome-driven decision style en-courages sound judgment, avoids change for thesake of change, and allows processes to be viewedas tools rather than end points. Insistence that thelaboratorian become a proactive member of thehealth care team not only ensures the integrity ofthe laboratory profession but offers widespread ad-vantages to the overall medical mission and finan-cial objectives of the health care organization. Fi-nally, the adoption of a forward outlook thatquestions traditional assumptions allows flexibilityof action and demonstrates a willingness to embracechallenges as opportunities will help guarantee thatthe laboratory professional will be a participatoryarchitect of the inevitable new world order of healthcare delivery.

CONCLUSIONThe experience at the University of Cincinnati sug-gests that technology, when applied selectively andused wisely as a cornerstone for organizationalchanges, is capable of exerting a positive functionaleffect on service delivery, and adds to the efforts ofthe laboratory to contribute to a hospital-wide com-petitive stance amidst the financially challengingpressures of health care reform.

The author extends great appreciation to all members of themanagement team o f the University Hospital, Cincinnati. Inparticular, he thanks Steven Glenn for the calculation of themicrobiology-related cost data and Linda Hayden for the com-pilation of Laboratory Medicine information including the cre-ation of schematic drawings.

REFERENCESBailey T (1994) Managed care at work: the Rochester ex-perience. Management Briefs, Newsletter, Clinical Lab-oratory Management Association 16:l3.Tenover FC, Crawford JT, Huebner RE, Geiter LJ, Hors-

burgh CR, Good RC (1993) The resurgence of tubercu-losis: is your laboratory ready? J Clin Microbial 31:767-770.Doern GV, Vautour R, Gaudet M, Levy B (1994) Clinicalimpact of rapid in vitro susceptibility testing and bac-terial identification. J Clin Microbial 32:1757-1762.

impact of technology on micro and costs

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