Strategies for Growth and Survival of Pathology Departments

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Strategies for Growth and Survival of Pathology Departments

  1. 1. Evolution of Strategies forSurvival and Growth inPathology and LaboratoryMedicineRobert Boorstein, MD, PhD
  2. 2. Strategies for Survival and Growthin Pathology of Medicine Consolidation Automation Specialization Quality Management and Integrated Decision Making
  3. 3. 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).
  4. 4. Strategies for Survival and Growthin Pathology of Medicine Consolidation Automation Specialization Quality Management and Integrated Decision Making
  5. 5. Types of Laboratory Consolidations Across institutions Within institutions, parallel services Within institutions, different services
  6. 6. Pressures for Consolidation (Push) Personnel Costs Equipment Costs Regulatory Burdens Demands for Space Closure of Residency Programs
  7. 7. Pressures for Consolidation (Pull) High- throughput, high capital cost equipment Centralized and standardized LIS and HIS systems Unified corporate leadership
  8. 8. Laboratory consolidations: Phase1:Bellevue as reference lab Gouverneur (1997) Coler Goldwater (1999) Metropolitan/Belvis (1999) Morrisania (1999) Lincoln (1999) Harlem, Renaissance (2000)
  9. 9. Development of a consolidatedlaboratory network Bellevue Hospital Lincoln Hospital Metropolitan Hospital Harlem Hospital Coler/GoldwaterHospitals
  10. 10.  New York City Health and Hospitals Corporatio
  11. 11. Laboratory Organization, South ManhattanHealthcare Network and GenerationsPlus/Northern Manhattan Health Network Large central referral facility on the Bellevue site  Full service specialized and routine clinical laboratory services  Full service academic anatomic pathology services  Stat and point of care services appropriate for trauma, tertiary care and primary care services
  12. 12. Laboratory Organization, South ManhattanHealthcare Network and GenerationsPlus/Northern Manhattan Health Network Acute care facilities  Anatomic Pathology (surgical pathology, frozen sections, cytology)  Rapid Response Laboratories Chronic care facilities  Rapid Response Laboratories Ambulatory care facilities  Sample collection only
  13. 13. Flow of work to Bellevue Bellevue Hospital Laboratory Metropolitan Belvis (Rapid Response and AP) Lincoln Morrisania (Rapid Response and AP) Harlem Renaissance (Rapid Response and AP) Coler Goldwater Gouverneur (Rapid Response)
  14. 14. Effect of consolidation, impact ofnetwork on overall volume at BellevueArea Network %Clinical Laboratories 60%Surgical Pathology 5%Autopsy 55%Cytology 75%
  15. 15. 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 182877/02 - 12/02 228.5 4,608,688 20169
  16. 16. Factors for successful consolidation Clear leadership  At the organization level  At the department/operations level Clear mission Information management Transport Flexibility
  17. 17. Factors for successful consolidation Clear leadership  At the organization level  At the department/operations level  No turning back!!! Clear mission Information management Transport Flexibility
  18. 18. Factors for successful consolidation Clear leadership Clear mission Information management Transport Flexibility
  19. 19. NYCHHC Strategic PrioritiesHHC has set several strategic priorities to insure that we continue the improvements and innovations that have distinguished New York Citys public hospital system in the months and years ahead.Patient Safety - HHCs 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 - HHCs ongoing capital program to ensure that our public hospitals continue to provide state-of-the-art medical treatment.
  20. 20. Factors for successful consolidation Clear leadership Clear mission  At the level of organization  At the level of the department  Within each division Information management Transport Flexibility
  21. 21. Factors for successful consolidation Clear leadership Clear mission Information management  Singlesystem across all facilities  Commitment to paperless ordering and resulting  Bar-coding of all samples Transport Flexibility
  22. 22. Factors for successful consolidation Clear leadership Clear mission Information management Transport  Essential  Responsive to client needs  Reality based Flexibility
  23. 23. Factors for successful consolidation 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
  24. 24. Factors inhibiting successfulconsolidation 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
  25. 25. The real world
  26. 26. Consolidation, Phase 2: CoordinatedDelivery of Laboratory service to allsites 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?)
  27. 27. Phase 2, continued Autopsy to Bellevue (2002+) All Lincoln cytology to Bellevue (2003)
  28. 28. Internal Consolidations Pediatric and Adult Hematology Serology and Immunoassays Anatomic Pathology
  29. 29. Benefits of Consolidation Reduction of unit labor costs. Reduction of unit capital costs. Reduction of unit space costs. Standardization of quality at high level.
  30. 30. Strategies for Survival and Growthin Pathology of Medicine Consolidation Automation Specialization Quality Management and Integrated Decision Making
  31. 31. Increased Role of Automation inthe clinical laboratory  Reduction of manual processes  Reduced error rate in aliquotting and specimen movement  Improved turnaround time  Reduction in sample volumes needed for analysis
  32. 32. 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
  33. 33. 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
  34. 34. Steps in automationFront end processing Transfer to analytical systems Distribution to analytic instruments Analytical instrumentation Verification Back end processing and storage
  35. 35. 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?
  36. 36. 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
  37. 37. 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?
  38. 38. 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...
  39. 39. Factors for success Work station consolidation Front end automation (accessioning, centrifugation, aliqotting) Improved informatics (bar coding, no paper) Changes in labor rules
  40. 40. Steps in automation Front end processing Accessioning, centrifugation, aliquottingRemote order entry, bar coding Transfer to analytical system Distribution to analytic instruments Analytical instrumentation Workstation Consolidation Verification Back end processing and storage Electronic Reporting
  41. 41. Steps in automation Front end processing Accessioning, centrifugation, aliquottingRemote order entry, bar coding Transfer to analytical system Distribution to analytic instruments Analytical instrumentation Workstation Consolidation Verification Back end processing and storage Electronic Reporting
  42. 42. 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”
  43. 43. 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
  44. 44. Automation can follow growth:Modular incremental automation Minimal upfront capital or site preparation costs. Equipment amortized into reagent purchases. Scalable Ongoing instrument modernization
  45. 45. Automation can follow growth
  46. 46. Lab Area Manufacturer Model Individual Components Chemistry Beckman Coulter DxC AUAnalyzer Interfaces Roche OCD Abbott /Toshiba Modular 250, 950 Aeroset, 80FR, 200FR Immuno Beckman Coulter DxI Abbott AxSym, Architect Siemens Centaur Siemens Atlas and Centaur Stago R 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 Roche Modular OCD 950, 250, ECI Urinalysis Siemens Atlas Sysmex UA-2000 Trademarks are property of the respective Manufacturers
  47. 47. Single Testing and Sample Management Workstation! Sample Management CBC, Diff,A1c Retic Testing Tes ti ng Smear staining Smear preparation  Frees-up non-productive labor!
  48. 48. Strategies for Survival and Growthin Pathology of Medicine Consolidation Automation Specialization Quality Management and Integrated Decision Making
  49. 49. What drives Specialization Build on existing expertise (supply) Meet needs of existing clients, leveraging existing transport, IT, and customer service relationships (demand)
  50. 50. Specialization High volume, High value High volume, Low value Low volume, High value Low volume, Low value
  51. 51. Programs built on ExistingStrengths Cytology Neuropathology Cytogenetics Hemoglobin Analysis Tuberculosis GC/Chlamydia
  52. 52. Programs built de novo based onclinical need HIV, HBV, HCV viral loads Maternal Fetal Defect testing Lead testing GC/Chlamydia/HPV Colon Cancer Screening Colon Sentry
  53. 53. Molecular Virology
  54. 54. Integrated cytogenetics analysissystems
  55. 55. Tuberculosis
  56. 56. Amplified GC/Chlamydia
  57. 57. Approach to specialization High volumes Push modular automation using experiences across disciplines Based on clinical demand
  58. 58. Approach to specialization Clinical and translational research
  59. 59. Project Findings Show AsianAmerican New Yorkers Have a HighBurden 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.
  60. 60. Strategies for Survival and Growthin Pathology of Medicine Consolidation Automation Specialization Quality Management and Integrated Decision Making
  61. 61. Leadership in Patient Safety Goalimplementation Patient and specimen ID Critical Values
  62. 62. Test use rationalization CK-MB vs troponin Lipase vs amylase Algorithm based thyroid function testing
  63. 63. Involvement in core measures related toquality and reimbursement Diabetes management and HgbA1C Nosocomial infections Timeliness of treatment of pneumonia Stat TAT
  64. 64. Bellevue Hospital Center South Manhattan Healthcare Network 462 First Ave & 27th St, New York, NY 10016ER Turnaround Time Timeline Emergency/STATS Test TAT Timeline (minutes) 0 16 56 89Order Draw Received Resulted Order to Draw: 16 minutes Order to Received: 56 minutes Order to Resulted: 89 minutes Draw to Received: 40 minutes Draw to Resulted: 73 minutes Received to Resulted: 33 minutes
  65. 65. Roles in new programs HIV screening Stroke program
  66. 66. Lincoln Medical and Mental Health Center Stroke Monitor 2007 MONTH # OF STROKES CBC TAT < 15 PT/APTT TAT <30 BMP TAT<30 COMMENTDECEMBER 2 4 14 29 JANUARY 6 3.4 21.6 18.6 one stroke specime trax to BBFEBRUARY 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 14SEPTEMBER 11 2.8 19.8 17.6 chem4hml-ptptt-1qnsOCTOBER 10 4.6 14 16.5 chem1 heml-ptptt-2qnsNOVEMBER 11 2.9 14.9 11.9DECEMBER 5 8 17.4 19.6
  67. 67. 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.
  68. 68. Conclusions People are crucial Success is built on common vision Resources must be committed Needs and solutions are local
  69. 69. 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.

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