June 2011
Feature Story

Anne Ford

It’s the sort of story that hospital administrators might tell around the campfire to scare each other: “A well-known scientist I knew set up a new lab one time,” recalls Leroy Mell Jr., PhD, MBA, HCLD (ABB), regional director of laboratories for Baptist Health Systems, San Antonio. “His administrator said, ‘How’s the lab doing? And oh, by the way, what CPT codes will you be billing?’ The director replies, ‘What’s a CPT code?’”

That’s an (admittedly extreme) illustration of a phenomenon that Dr. Mell is hoping to help remedy: the failure of some laboratory managers to understand the larger financial and administrative realities of the hospital. That’s why, as part of a short course called “Financial Management for Laboratory Professionals,” he will deliver a talk titled “Developing the Successful Financial Business Case to Lead Laboratory Change” at the AACC Annual Meeting and Clinical Lab Expo in Atlanta July 24–28.

Billed as the largest laboratory clinical exposition in the world, the AACC meeting is expected to feature 650-plus exhibitors in more than 1,800 booths, as well as a slew of lectures, symposia, short courses, and panels on a vast range of subjects. While many of those relate to laboratory testing, many others—such as Dr. Mell’s—pertain to managing business and people.

In a nutshell, Dr. Mell is hoping to help listeners learn how to best make their argument to administrators when requesting new laboratory instruments and other resources, because, as he points out, “if you go to admin and say, ‘I want to bring procalcitonin in-house,’ they’re going to say, ‘That’s fine and dandy, but give me a business case.’ You have to translate what you want to do into financial language that makes sense to the people who make the decisions. What is the financial impact that this decision is going to have on the organization?”

That’s a question, he continues, that laboratory managers sometimes don’t know how to answer, in large part because they don’t realize how much data are required to do so. “A typical example is if you want to bring a new test in-house which you’re now, say, sending to a reference lab,” he says. “What’s the cost effect of having more rapid turnaround time? Is that of paramount importance? If I bring this test in-house, will it cost me more, and if it’s going to cost more, how can I justify that? Well, it may cost more in the lab budget, but suppose it saves the hospital money in the long run. It’s not just the cost of that sip of reagent that goes into the instrument; it’s labor, it’s overhead, it’s cost of QC, it’s cost of repeating it. You have to get that data.”

Getting that data is all the more vital, he continues, when you consider that laboratories are generally small-budget items compared with, say, surgery. “You’ve got to compete with the big guys by being very, very exact and detailed, and showing definite cost savings or revenue increase,” Dr. Mell says. “You might say, ‘If you get us this instrument, I can save us $150,000 a year,’ and somebody from surgery says, ‘If you buy us this instrument, I can save us $15 million.’ It’s hard to compete against that, so you have to be on your toes.”

And to get on your toes, the first thing to know is how your finance department works, he says: “What are the ins and outs of how money is distributed? Who makes the decisions? What are the nuances of getting funds to be trickled down to the lab? Who do you have to talk to, and what do they want to see?” One of the first things a financial decisionmaker is likely to ask, he warns, is “Why are you having so much overtime? Why do you need these personnel?”

If all of this sounds like stuff everyone already knows, it’s not, Dr. Mell says. “We’ve had a lot of input, particularly from younger scientists, that they don’t get any of this material in their training,” he says. “Getting some type of training in the administrative side of running a lab, particularly finances—more people are desiring that, because they just don’t get it. If you’re a clinical chemist with a PhD, you know the science, but now you’re up against lab administrators who talk a different language. My experience is that if a lab director or manager fully understands what’s going on in the laboratory and can translate that into some type of business document, that’s received much better than, ‘I need to do this test because patients need it.’”

Another AACC speaker, Chérie Petersen, knows all about things that seem like common sense but aren’t. The distance education program coordinator for ARUP Laboratories’ Institute for Learning, Salt Lake City, Petersen will present a talk titled “Management Stra­tegies for Creating a Culture of Service Excellence in the Laboratory.” Too many laboratory managers, she says, are convinced that, first, “a culture of service excellence” and “customer service” are synonymous, and second, that customer service is “a common-sense-type behavior.”

Far from it, Petersen says. First, there’s much more to creating an environment in which excellent service is the norm than just encouraging employees to “be nice, be more patient, and do the right thing.” And second, leaving customer service to common sense is a mistake: “How many people do you know who don’t have common sense? Without customer service training, often customer service is left up to what your mama taught you, and what your mama taught you has great variability.” But thinking that you can increase your laboratory’s dedication to service excellence just by implementing formal customer service training is an error, too, she says. “A lot of times managers just say, ‘We need some customer service training, because our employees aren’t handling calls into the lab very well. That’s the kind of solution managers tend to throw at their employees, and that really isn’t the way to culturally change an organization to being customer-driven.”

Instead, managers should seek to reform their laboratories’ overall culture, Petersen says. That begins with considering what a culture really is. In her view, “it’s based on traditions, storytelling, folklore, and celebration.” So, if you want to create a culture of service excellence, you might begin sharing stories of times when employees went the extra mile for a customer, or you might change your view of what occasions should be celebrated in the workplace. “We celebrate people’s birthdays,” she points out. “But when we bring a new analyzer online or bring a new test in- house, it mostly goes unnoticed, uncelebrated, undocumented. We should be celebrating those things, because they are at the core of our accomplishments and generate a commitment to the meaningful work we’re doing.”

Another vital first step, Petersen says, consists of simply defining service excellence. “A lot of times, it’s ambiguous what the expectations are,” she says. She encourages organizations to develop a statement of service excellence and then integrate it into job descriptions and annual performance reviews. Among the additional strategies she suggests is tracking and trending customer feedback the same way you would performance metrics on turnaround time or QA—and not just by conducting customer satisfaction surveys, either. While surveys can be valuable, they can also be dated and costly to conduct. And, in her view, the information they provide tends to be general and diluted. That’s why she suggests using surveys in conjunction with impromptu feedback from dissatisfied customers, which, since it usually occurs at the same time as the service failure, tends to be more specific (not to mention free).

Laboratory managers may also be interested in “Turning the Lab on its Head: McGregor and Maslow Enter the Lab,” a brown-bag session scheduled to be led at AACC by Martin Kroll, MD, chief of laboratory medicine at Boston University School of Medicine. Dr. Kroll became interested in the theories of sociologist Douglas McGregor and psychologist Abraham Maslow while studying modern management techniques. In Dr. Kroll’s experience, McGregor and Maslow’s theories of management have not been widely implemented in most workplaces, including the laboratory—but they should be.

In a nutshell, McGregor and Maslow postulated that humans crave meaningful work, that they have an internal capacity for creativity and ingenuity, and that by recognizing these truths, managers can get the best out of their employees. If you doubt the truth about craving meaningful work, “look at people who are doing a good job in health care,” Dr. Kroll urges. “Why are they doing it? You work long hours, you work with gunk, you work under poor conditions, you often don’t get much respect. They do it because there’s a big motivation in terms of helping other people. They think they make a difference. The money is less important than the goal of what they’re doing.”

So how can a manager acknowledge that in the workplace? For one thing, “Let people be creative,” Dr. Kroll advises. “Let all the workers have some type of say in what’s going on. Years ago someone wrote that if you’re going to design something, you want to get the people who actually work with it and ask them questions about the details. Because you never know when someone will say, ‘If you put a wing nut here, it would be so much easier to work with.’ So you end up with the best product possible. And in the laboratory, information is the product.”

Then, too, it’s wise to “give employees the sense that they do have impact,” he continues. “A lot of times, somebody high up [in an organization] tries to hog the impact factor. Maslow says that you get a much better performance if you let everybody feel as if they have impact. The more they feel that way, the better they perform.”

The “impact factor” will be one theme of another AACC brown-bag session, “Third-World Clinical Chemistry: Short-Term Medical Missions for the Clinical Chemist,” to be delivered by Kevin Foley, PhD, MT. Dr. Foley, who is director of clinical chemistry at Kaiser Permanente NW Regional Laboratory, Portland, Ore., has volunteered his professional services on trips to developing nations such as Honduras and Haiti. When colleagues back home hear about his experiences, he says, they often respond with, “I’ve always wanted to do that,” but assume that they don’t have the right skill set. This talk, he hopes, will help convince them that they can, in fact, make a difference to people in need of medical care overseas.

“People think, ‘Well, I’m not a surgeon, I’m not an internist, so I can’t do much,’” Dr. Foley says. And indeed, “if you’re a clinical chemist and you’re used to a high-throughput, large reference lab, you’re not going to be that useful in the field—but if you acquire just a few additional skills, you can become a very valuable member of the team.” For example, “generally, a PhD lab director isn’t going to have a lot of microscopy experience. I can’t think of one chemistry director I know who has a microscope in their office. But if you don’t have microscopy experience, you can ask your hematology staff to train you. If you are a med tech”—which Dr. Foley began his career as—“you can really draw on that training. A lot of what I do on medical mission trips is microscopy for parasites, CBC differentials, and urinalysis. Small POC serology tests can also obviously make a big difference. Bring an iStat or other portable analyzer and you’re a rock star.”

It’s good, too, for volunteers on trips like these to brush up on their pharmacology. “Knowing your drugs and having a basic formulary in your head is pretty useful when you’re down there, especially with regard to antibiotics,” Dr. Foley says. “I hate to downplay the role that the lab and physician can make, but to be honest, the single biggest impact for people is often simply giving them access to anti-parasitic medications. So being willing and able to serve as a pharmacist can be very useful.”

And then there are the tools that no amount of medical training can give you, such as a reliable translator. “You always assume that translators are going to be able to effectively translate, and that’s a bad assumption,” Dr. Foley says. “I recall spending 10 minutes just trying to have the word ‘yeast’ translated, for example. There are all sorts of iPhone and iPad apps to learn foreign medical terminology. Tools like that can help.”

Other things to be prepared for: paying your own way (“Most people think erroneously that somebody’s going to pay you to go to these places, but it’s always you footing the bill”); bringing your own microscope (“Microscopes can be a rare commodity and are often old or dirty or have inadequate light sources”); filling your luggage with equipment and reagents (not clothes); working with native medical staff who have usually received much less training than their counterparts in the United States; and, frequently, heat, bugs, and primitive living conditions. Still, in wanting to serve and thus making these trips, Dr. Foley says, “you find that you are the one who actually is most rewarded.”

Finally, “Where Is the Patient’s Specimen? Methods for Effective Quality Specimen Management/ Tracking” will be the subject of a brown-bag session by Nichole Korpi-Steiner, PhD, director for point-of-care testing and associate director of clinical toxicology and prenatal laboratory testing at UMass Memorial Medical Center, Worcester. Last fall, Dr. Korpi-Steiner’s laboratory completed a roll-out of a tracking system that effectively reduced the number of lost specimens. And by “effectively,” she means “by about 300 percent.”

The laboratory was motivated to implement the new tracking system, says Dr. Korpi-Steiner, after discovering that specimens were being lost. “That was in part because the previous specimen tracking system demonstrated gaps.” It used electronic and manual manifests to track specimens from numerous external locations—phlebotomy collection sites, outreach client sites, different campuses—to the central processing laboratory area, and between that processing area and testing sites, such as microbiology located on a different floor within the building or molecular testing in a different building altogether. “Though the tracking system was helpful, many and not all specimens were tracked, leaving the tracking system largely incomplete,” she says.

RFID specimen tracking technology can be an effective option, she notes, but for her lab a more cost-effective alternative was to develop and implement its own computerized specimen tracking method, one that involves scanning the bar codes adhered to each specimen upon entry into the testing area. When the specimen is scanned into that area, the person scanning also scans his or her ID badge, which tags the specimen as being delivered by that individual and creates a time stamp of delivery. “All of that information then goes into our lab information system,” she says.

In addition, her laboratory began tracking lost-specimen and misplaced-specimen rates. While they’re both important quality indicators, “lost-specimen rates provide little actionable information,” Dr. Korpi-Steiner points out, “because they don’t reveal anything about how or where the specimen was lost.” Whereas if a laboratory misplaces, then recovers, a specimen, “you can track patterns such as the specimen type, container, and stability conditions, as well as the location of the occurrence.” For example, her laboratory discovered that capillary pediatric tubes were often misplaced; because of their small size, they easily fell out of standard tube racks, so they are now put into standard-size carrying vessels that fit the racks. In addition, “misplaced specimens have also been found in dry-ice coolers for frozen specimens, so we’ve implemented periodic checks of the dry-ice containers,” she says.

To laboratories that want to reduce their own lost- and misplaced-specimen rates, Dr. Korpi-Steiner says: “The first step is establishing an effective method of reporting and communicating the lost and misplaced specimen occurrences so they can be entered into a database and be available for analysis. Once you start collecting the data and it’s effectively communicated with continuous review, the patterns become visible.”