Strategies for Growth and Survival of Pathology Departments

Evolution of Strategies for Survival and Growth in Pathology and Laboratory Medicine

Robert Boorstein, MD, PhD

Strategies for Survival and Growth in Pathology of Medicine Consolidation Automation Specialization Quality Management and Integrated

Decision Making

Strategy

A plan, method, or series of maneuvers or stratagems for obtaining a specific goal or result (dictionary.com)

The science of military command, or the science of projecting campaigns and directing great military movements (Websters)

The commitment of resources in support of the mission in pursuit of defined and measurable ends (NYU Stern Business School).


Decision Making

Types of Laboratory Consolidations

Across institutions Within institutions, parallel services Within institutions, different services

Pressures for Consolidation (Push)

Personnel Costs Equipment Costs Regulatory Burdens Demands for Space Closure of Residency Programs

Pressures for Consolidation (Pull)

High- throughput, high capital cost equipment

Centralized and standardized LIS and HIS systems

Unified corporate leadership

Laboratory consolidations: Phase

1:Bellevue as reference lab Gouverneur (1997) Coler Goldwater (1999) Metropolitan/Belvis

(1999) Morrisania (1999) Lincoln (1999) Harlem, Renaissance

(2000)

Development of a consolidated laboratory network

Bellevue Hospital

Lincoln Hospital

Metropolitan Hospital

Harlem Hospital

Coler/GoldwaterHospitals

New York City Health and Hospitals Corporation

Laboratory Organization, South Manhattan Healthcare Network and Generations Plus/Northern Manhattan Health Network Large central referral facility on the

Bellevue siteFull service specialized and routine clinical

laboratory servicesFull service academic anatomic pathology

servicesStat and point of care services appropriate for

trauma, tertiary care and primary care services

Laboratory Organization, South Manhattan Healthcare Network and Generations Plus/Northern Manhattan Health Network

Acute care facilitiesAnatomic Pathology (surgical pathology,

frozen sections, cytology)Rapid Response Laboratories

Chronic care facilitiesRapid Response Laboratories

Ambulatory care facilitiesSample collection only

Flow of work to Bellevue

Bellevue Hospital Laboratory

Metropolitan (Rapid Response and AP)

Belvis

Lincoln (Rapid Response and AP)

Morrisania

Harlem (Rapid Response and AP)

Renaissance

Coler Goldwater (Rapid Response)

Gouverneur

Effect of consolidation, impact of network on overall volume at Bellevue

Area Network %

Clinical Laboratories 60%

Surgical Pathology 5%

Autopsy 55%

Cytology 75%

Effects of Consolidation, employee productivity

YEAR ACTUAL FTE WORKLOAD WORKLOAD/FTE

7/98 - 6/99 226.5 1,846,215 8151

7/99 - 6/00 256.5 3,968,427 15471

7/00 - 6/01 257.0 4,284,997 16673

7/01 - 6/02 253.5 4,635,763 18287

7/02 - 12/02 228.5 4,608,688 20169

Factors for successful consolidation

Clear leadershipAt the organization levelAt the department/operations level

Clear mission Information management Transport Flexibility


Clear leadership At the organization level At the department/operations level No turning back!!!

Clear mission Information management Transport Flexibility


Clear leadership Clear mission Information management Transport Flexibility

NYCHHC Strategic Priorities

HHC has set several strategic priorities to insure that we continue the improvements and innovations that have distinguished New York City's public hospital system in the months and years ahead.

Patient Safety - HHC's multi-year campaign to reduce medical errors, prevent infections, pneumonia and cardiac arrests.

Quality & Safety Performance - HHC publishes its quality record, inviting public comparison with state and national performance averages.

Access to Healthcare - Providing Quality Healthcare for ALL New Yorkers. Technology - HHC has marked its place as a medical innovator by investing in

advanced, integrated technology throughout its facilities. Modernization - HHC's ongoing capital program to ensure that our public

hospitals continue to provide state-of-the-art medical treatment.


Clear leadership Clear mission

At the level of organization At the level of the department Within each division

Information management Transport Flexibility


Clear leadership Clear mission Information management

Single system across all facilities Commitment to paperless ordering and resulting Bar-coding of all samples

Transport Flexibility


Clear leadership Clear mission Information management Transport

Essential Responsive to client needs Reality based

Flexibility


Clear leadership Clear mission Information management Transport Flexibility

Planning cannot predict all eventualities At go live, willingness to adjust while moving forward Can judiciously skip less critical components of a

consolidation, as long as key objectives are attained

Factors inhibiting successful consolidation efforts Failure to recognize and respect clinical

needs of new clients In conclusion, our system has benefited from the consolidation efforts and the

implementation of the TLA system. The actual dollar savings are predicated on the remaining hospitals coming live and their willingness or ability to make the necessary staff reductions. Although our system remains in the growth phase, we have realized our efficiencies in TAT for those hospitals brought live. Clinical Chemistry 46: 751-756, 2000

Labor instability Politics, institutional and community Unpredictable events

The real world

Consolidation, Phase 2: Coordinated Delivery of Laboratory service to all sites Integrated management structure (2001-

2002) Standardization of test menus, normal

ranges, and clinical indications (2003) Standardization of all major laboratory

systems (2003-2008) Automation of accessioning and sample

handling at referral sites (2003-2008?)

Phase 2, continued

Autopsy to Bellevue (2002+) All Lincoln cytology to Bellevue (2003)

Internal Consolidations

Pediatric and Adult Hematology Serology and Immunoassays Anatomic Pathology

Benefits of Consolidation

Reduction of unit labor costs. Reduction of unit capital costs. Reduction of unit space costs. Standardization of quality at high level.


Decision Making

Increased Role of Automation in the clinical laboratory

Reduction of manual processes

Reduced error rate in aliquotting and specimen movement

Improved turnaround time Reduction in sample

volumes needed for analysis

Benefits of automation

Run more tests. Test in fewer sites. Operate with fewer instruments. Retain lower operating costs. Employ relatively less skilled labor. Use more automation in a paperless

environment. http://www.devicelink.com/ivdt/archive/99/07/010.html

Automation strategies

Total laboratory automation (i.e. Beth Israel, NY Cornell, North Shore, Mt Sinai).

High upfront capital costs (10-20 million) High demand on IS infrastructure

Networked, modular, incremental automation (HHC model) Highly efficient analytical instruments, handling high volumes with redundancy

Automated sample handling, and sorting, utilizing tracked systems Automation at referral sites

Core laboratory

Steps in automation

Front end processing

Transfer to analytical systems

Distribution to analytic instruments

Analytical instrumentation

Verification

Back end processing and storage

Thinking about automation

What is the real goal of automation? If the goal is labor saving, which steps really use

the most labor? If the goal is quality or time savings, automating

which steps will give those benefits? If the goal is to increase capacity (and thus

reduce unit labor costs), is the business really available, and what are the barriers to serving new customers?

Assessing success in automation

“Laboratory A” core lab currently processes 2500–3000 tests per day. Since it implemented automation with robotics, the lab has increased test volume by 20%, reduced sample turnaround times by 11%, and saved $100,000 in staff salaries.

http://www.devicelink.com/ivdt/archive/99/07/010.html

Return on investment

Total laboratory automation often consumed $15-20 million in Capital costs for acquisition, site preparation, relocation and transition costs.

Which of the successes are due not to the main automation, but to concurrent processes that make sense independent of TLA?

Laboratory Workload and Cost sharing

80% of the costs in the laboratory belongs to the pre- and post analytical processes, only 20% to the analytical part...

Factors for success

Work station consolidation Front end automation (accessioning,

centrifugation, aliqotting) Improved informatics (bar coding, no

paper) Changes in labor rules

Steps in automationFront end processing

Accessioning, centrifugation, aliquotting

Transfer to analytical system

Distribution to analytic instruments

Analytical instrumentationWorkstation Consolidation

Verification

Back end processing and storage

Remote order entry, bar coding

Electronic Reporting

Recipes for failure

Extended delays in implementation due to complexity and demands on IT

Loss of leverage with vendors Lock in old technology Increased need for high paid staff Inability to reduce staff Failure to reach planned, and paid for, growth

“The lab currently processes 4000 tests per day, and has the capability to expand to more than 25,000 tests per day”

Factors essential for laboratory growth, perhaps more important than automation

Work station consolidation Front end automation Specimen ID and tracking Billing and Collections Transport Customer Service

Automation can follow growth: Modular incremental automation Minimal upfront capital or site preparation

costs. Equipment amortized into reagent

purchases. Scalable Ongoing instrument modernization

Automation can follow growth

Analyzer Interfaces

Lab Area Manufacturer Model

Chemistry Beckman Coulter DxCAU

Roche Modular

OCD 250, 950

Abbott /Toshiba Aeroset, 80FR, 200FR

Immuno Beckman Coulter DxI

Abbott AxSym, Architect

Siemens Centaur

Tosoh AIA21

OCD Eci

Fujirebio Lumipulse F

Coag Beckman Coulter TOP-LAS

Stago Sta-r

Sysmex CA-6000

Heme Beckman Coulter LH 750/755

Sysmex HST

Urinalysis Siemens Atlas

Sysmex UA-2000

Siemens Atlas and Centaur Stago R

OCD 950, 250, ECIRoche Modular

Individual Components

Trademarks are property of the respective Manufacturers

Sample Management

A1c Testing

Single Testing and Sample Management Workstation!

Frees-up non-productive labor!

CBC, Diff,Retic Testing

Smear preparation

Smear staining


Decision Making

What drives Specialization

Build on existing expertise (supply) Meet needs of existing clients, leveraging

existing transport, IT, and customer service relationships (demand)

Specialization

High volume, High value High volume, Low value Low volume, High value Low volume, Low value

Programs built on Existing Strengths Cytology Neuropathology Cytogenetics Hemoglobin Analysis Tuberculosis GC/Chlamydia

Programs built de novo based on clinical need HIV, HBV, HCV viral loads Maternal Fetal Defect testing Lead testing GC/Chlamydia/HPV Colon Cancer Screening Colon Sentry

Molecular Virology

Integrated cytogenetics analysis systems

Tuberculosis

Amplified GC/Chlamydia

Approach to specialization

High volumes Push modular automation using

experiences across disciplines Based on clinical demand

Approach to specialization

Clinical and translational research

Project Findings Show Asian American New Yorkers Have a High Burden of Hepatitis B Infection NEW YORK, August 9, 2005 –The

Center for the Study of Asian American Health at New York University School of Medicine, the central coordinating agency for the NYC Asian American Hepatitis B Program has received a total of $2.6 million to continue its work in screening, educating, vaccinating, and treating Asian Americans in New York City for hepatitis B. $1.7 million of the grant is from the New York City Council with the remainder as matching funds from the New York State and City Departments of Health. The Program is a made up of a coalition of healthcare and community-based organizations across the city.


Decision Making

Leadership in Patient Safety Goal implementation Patient and specimen ID Critical Values

Test use rationalization

CK-MB vs troponin Lipase vs amylase Algorithm based thyroid function testing

Involvement in core measures related to quality and reimbursement

Diabetes management and HgbA1C Nosocomial infections Timeliness of treatment of pneumonia Stat TAT

Bellevue Hospital Center South Manhattan Healthcare Network

462 First Ave & 27th St, New York, NY 10016

Draw to Received: 40 minutes

Draw to Resulted: 73 minutes

Received to Resulted: 33 minutes

Order to Resulted: 89 minutes

Emergency/STATS Test TAT Timeline (minutes)

Order to Draw: 16 minutes

Order to Received: 56 minutes

Order Draw Received Resulted

0' 16' 89'56'

ER Turnaround Time Timeline

Roles in new programs

HIV screening Stroke program

Lincoln Medical and Mental Health CenterStroke Monitor 2007

MONTH # OF STROKES CBC TAT < 15' PT/APTT TAT <30' BMP TAT<30' COMMENT

DECEMBER 2 4 14 29

JANUARY 6 3.4 21.6 18.6 one stroke specime trax to BB

FEBRUARY 6 3.2 24.8 19.4 1 hmlz,1 not announced

MARCH 11 3.2 20.7 17 1 stroke with only Coag Reque

APRIL 8 2.7 14.9 14.3 2 hemolyzed

MAY 8 5.5 17.2 15.4 2 hemolyzed

JUNE 6 4.2 11.2 13.8 1 chem hemolyzed

JULY 13 3 17 18.5

AUGUST 12 3.5 20 14

SEPTEMBER 11 2.8 19.8 17.6 chem4hml-ptptt-1qns

OCTOBER 10 4.6 14 16.5 chem1 heml-ptptt-2qns

NOVEMBER 11 2.9 14.9 11.9

DECEMBER 5 8 17.4 19.6

Driving home quality principles

New pathology system, LIS and Anatomic Remote order entry with bar codes Results to Doctors’ queues Voice recognition at grossing. Integrated reporting Double label, computer directed cassette labeling Etched slides with barcodes.

Conclusions

People are crucial Success is built on common vision Resources must be committed Needs and solutions are local

Future trends

Laboratory Consolidation Driven by Resource Issues, personnel and capital

Oversight of test utilization Accountable Care Organizations, Insurers, Capitation

Algorithm based results Competition from sole source branded products

Brca1, OncotypeDX, etc.

Strategies for Growth and Survival of Pathology Departments

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