November 2012
Feature Story

Jan Bowers

In an era of having to do more with less, laboratories are holding their own when it comes to nurses’ satisfaction with their services. They’ve seen their scores edge higher in some service areas, according to newly released Q-Probes results, compared with scores found in a similar CAP study in 2004. But there’s room for improvement, and labs shouldn’t feel complacent about “pretty good” scores, says Kirsten W. Alcorn, MD, senior pathologist and medical director of transfusion services at MedStar Washington Hospital Center, Washington, DC, and medical director of blood donor services for MedStar Health.

“Overall, I was pleased to see the scores were generally high, which I think tells us we’re not doing a terrible job,” Dr. Alcorn says. “But they weren’t so high that we should think everybody loves their lab.”

A member of the CAP Quality Practices Committee, Dr. Alcorn co-authored the Q-Probes, “Hospital Nursing Satisfaction with Clinical Laboratory Services,” with Bruce A. Jones, MD, service chief and laboratory director at Henry Ford West Bloomfield Hospital and senior staff pathologist at Henry Ford Hospital, Detroit.

The survey of 3,127 nurses in 75 institutions measured overall satisfaction and satisfaction with 19 categories of laboratory service (see “Satisfaction by service category”). Based on a five-point rating scale, with five indicating “very satisfied” and one indicating “not satisfied,” the mean overall satisfaction score was 3.8—precisely what it was eight years ago.

The highest-scoring service categories were test result accuracy (4.36), phlebotomy personnel courtesy toward patients (4.29), and readability of laboratory reports (4.22). The lowest-scoring categories were laboratory management of problem specimens (3.53), availability of instructions for special test or patient preparation requirements (3.45), availability of the laboratory manual (3.44), and TAT for stat results (3.53).

Respondents were also asked which laboratory service category is most important to them. Test result accuracy topped the list, cited by 29 percent, with readability of laboratory reports cited by the fewest (0.6 percent).

Ironically, Dr. Alcorn is troubled by the highest-scoring category. Test result accuracy, at 4.36, she says, should score significantly higher than it did. “Laboratories, first and foremost, work really hard to make sure they’re getting good test results,” she says. “And certainly, for all the work we do to generate good and accurate test results, we would hope that pretty close to 100 percent of people believe our results. And at 4.3, that’s only a little over 80 percent.”

Why the misperception? The study was not designed to shed light on the reasons, but Dr. Alcorn maintains that labs can do a better job of educating nurses as to what a lab test means, and the efforts that go into making the test result scientifically and medically valid, reliable, and accurate. Then, nurses would be likely to develop a higher level of trust in the results, “just as laboratorians might be more trusting of nursing if they saw how many things a nurse is doing, and why the specimen might get to them in some sort of less-than-ideal manner.”

Education may also help boost satisfaction with what nurses cited as second most important: turnaround time for stat results. The weak score of 3.53 surprised one member of the Quality Practices Committee. Roberta Zimmerman, MD, clinical laboratory director of Grand Itasca Clinic & Hospital, Grand Rapids, Minn., who was not an author of the satisfaction study, theorizes that nurses don’t fully understand the steps involved in getting a lab result. “This is my experience with the nursing staff here,” she says of Grand Itasca. “They think when the order goes into the system, that’s when the clock starts ticking. Because for them, that is when the clock starts ticking. They have trouble understanding the preanalytical delays, so they think we’re very slow at times.”

Dr. Alcorn calls turnaround time “a chronic issue.” While she rates the TATs in her own laboratory very highly, she notes that some tests, such as a serum antibody screen, simply take longer than others, making a 10-minute turnaround impossible. She finds that when physicians and nurses become familiar with a particular test, their expectations become more realistic.

TAT for routine results received a better score of 3.83. Although labs may in fact be doing a better job of turning around routine tests, Dr. Zimmerman believes it’s more a matter of perception. “When you want that stat result, the patient is usually critical, or the physician is asking for the result, and the nurses are under more pressure. Time moves even more slowly than it normally would.” Among 10 nursing service locations listed (one being “other”), the two associated with the lowest overall satisfaction score, 3.7, were the emergency department and intensive care. Nursing staff from gynecologic and psychiatric locations tended to be most satisfied (4.3 and 4.2, respectively).

Should laboratorians put extra effort into explaining to nurses the pre- and postanalytical processes, and which tests are likely to take longer than expected? “I think that helps, and we certainly talk about education a lot,” Dr. Alcorn says. “But we see mass e-mails all the time, and people are flooded at orientations and annual competencies. The question is, how do you get that information out in a way that’s meaningful?” To improve actual performance (as opposed to perception), Drs. Alcorn and Jones recommend that laboratories evaluate the pre- and postanalytic phases, as well as in-laboratory turnaround time, and include nurses in the discussion and in any performance improvement plan.

More meetings with nurses might alleviate misunderstanding, Dr. Zimmerman says, adding that her laboratory invites all new nurses to tour the laboratory and ask questions. Those who do tour the lab come away with a better understanding of the activity that goes on inside the lab. They see “we have a small number of people getting specimens from all over and that we never quit working.”

That said, nurses are only half the equation. Laboratory personnel at every level need to embrace the concept of customer service, and that starts with measuring nurses’ satisfaction, Dr. Alcorn says. She and Dr. Jones present a tough assessment: “Laboratories do not appear to be highly interested in the satisfaction of this important group of customers,” they write. Nearly 74 percent of respondents said the laboratory doesn’t use nursing satisfaction as a quality indicator. Of the 37 institutions that do survey nursing satisfaction, about one-third do so at least yearly.

It isn’t that labs don’t care what nurses think of them, Dr. Alcorn says. Rather, labs are already juggling so many other quality management issues. “This is something that does not often rise to the top of the pile of concerns.” But with nurses having so much interaction with the laboratory’s front line, she says, labs should be concerned: “If we can make that interaction easier for them, they can do a better job.” For an individual hospital laboratory, one approach might be to use an instrument like Q-Probes to survey nurses more frequently than “once every 10 years,” she says with a laugh. But she admits to it being an ambitious undertaking, owing to the volume of Q-Probes data required and the complexity of gathering the data. “Plus, if you want nurses to answer your survey, you have to get on their radar too. They have to want to participate, and they have their own full docket.”

Dr. Zimmerman’s laboratory surveys yearly all its customers in the 45-bed Grand Itasca Hospital & Clinic: nurses, physicians, nurse practitioners, and physician assistants. “Often, being ‘Minnesota nice,’ no one tells you if they’re unhappy with you, but in an anonymous type of survey, they’ll let you know if something didn’t meet their expectations,” she says.

Responses about customer service training and personnel, or the lack thereof, were a red flag for Dr. Alcorn. Only about a third of the institutions provide formal customer service education for laboratory employees at least once a year, even though the median number of telephone calls fielded per day is 145, and about four percent of those are complaints. Asked if the laboratory has personnel dedicated to customer support, two-thirds of respondents said no. In addition, about 80 percent do not have an automated phone answering system and do not monitor incoming calls.

The customer service lessons that would benefit lab personnel are no different from those in other fields, Dr. Alcorn says. “It’s simply providing a good, competent ear and pointing the customer in the right direction without too much trouble—not putting them on hold for an excessive time, not being defensive about the result or the turnaround time, or whatever it is the customer is calling about. It’s giving an answer in a pleasant manner.”

At MedStar Washington Hospital Center, a 900-bed hospital, employees receive customer service training, counseling, and coaching. In addition, Dr. Alcorn’s laboratory has dedicated customer service personnel (two to five people, depending on the time of day) who field every type of request. “When a question needs technical assistance, it will get referred to someone in the laboratory,” she says. “But as you can imagine, many of the calls are, ‘What kind of sample do I need?’ or ‘When will the result be out?’—they don’t require pulling someone away from doing the testing.”

At Dr. Zimmerman’s much smaller hospital, “You hire testing personnel if you’re allowed a new employee.” Hiring someone to deal with customer satisfaction is a luxury the lab doesn’t have; instead, it tries to understand how the nurses feel about lab services through the annual survey. New hires are trained in customer service, however, “particularly our phlebotomists because they have the most patient contact.” In addition, Press Ganey satisfaction scores are used to judge how well the phlebotomists are doing. If the lab receives a complaint about a phlebotomist, “we sit down with them and kind of put them through charm school,” Dr. Zimmerman says.

A focus on people skills for phlebotomists, in the hiring process and in training, is a common practice that may be paying off. The study did not address customer service training specifically for phlebotomists, but phlebotomy personnel courtesy toward patients and toward nursing personnel had high overall satisfaction scores (4.3 and 4.1, respectively).

The lower scores for availability of instructions for special test or patient preparation requirements and availability of the laboratory manual may be explained by the high-pressure situations in which nurses find themselves. “What we’ve found is that many nurses forget that the manual is available on the hospital intranet,” Dr. Zimmerman says. “There’s pressure, they’re trying to get a question answered very quickly, and they don’t think to go on the intranet. Instead they call because it’s faster. We answer the phone and we answer the question.” In some institutions, Dr. Zimmerman adds, calling may in fact be the best way to get the information because the manual may not be readily accessible, well indexed, or clearly organized.

Dr. Alcorn, whose lab distributes its manual electronically and in hard copy form, agrees that many nurses pick up the phone because it’s faster and easier than looking up the information. Nevertheless, the co-authors write in the study’s analysis, it’s incumbent on labs to make sure the manual is available where nurses need it, that nurses know how to use it and where it’s located, and that nurses’ feedback is sought and incorporated as the manual is updated.

The 2012 Q-Probes nursing satisfaction study was designed to overlap with the 2004 study in 13 service categories, allowing the Quality Practices Committee to measure progress in those areas. “What’s encouraging,” Dr. Alcorn says, “is that labs that participated earlier and had taken those lessons to heart and done something probably had higher ratings overall.” While the 2012 study doesn’t show whether specific labs improved their scores, it does reveal that among the service categories the two studies shared, eight categories demonstrated statistically significant improvement in 2012 and none showed decline. Ten institutions participated in both studies, and eight institutions reported implementing changes in practice in response to participation in the 2004 study or publication of its results in Archives of Pathology & Laboratory Medicine.

Dr. Zimmerman commends the design of the study and the Q-Probes program as a whole. A focus on nurses’ satisfaction with laboratories is particularly important, she says, because 70 to 80 percent of medical decisions are based on a laboratory result, “and the nurse is right there with the patient.” If the nurse cannot get what is needed from the lab, patient care can suffer. “We’re all a team, and if one member is disconnected from another member, we have a problem.”