The Strategic Plan for Children's National Health System: ICU/ER Satellite Lab Services

Prepared by
Ashley Lucci
May 4, 2014
HSCI 6241_Session Number
Strategic Plan for Children’s National Health
System: ICU/ER Satellite Lab Services

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Executive Summary
Children’s National Health System Division of Laboratory Medicine will implement
satellite laboratory services, within the hospital and an initiative to expand access and quality
care to our patients. The strategy plan is just a mere tool to secure our future in the area of
pediatric lab services while establishing measures to consistently track, trend and implement
quality improvement initiatives (Zuckerman, pp. 11).
Decentralized pediatric lab to services allow for increased access to patient care while
setting the foundation for all stakeholders (i.e. patient, clinician, lab staff) to “engage as
partners” in the care of our patients (U.S. DOH, 2014). Following the National Quality
Strategy Priority 2: Ensuring That Each Person and Family Are Engaged as Partners in Their
Care, the satellite labs will improve the clinician and patient experience by allowing them to
receive on demand access within the same unit as their visit. Having testing available without
having to leave the patients current location improves the safety and quality of their service
while allowing for the lab, clinicians and patients to manage their care more effectively. The
decentralized lab will focus on STAT (urgent) testing, predominately chemistry/hematology
test. All routine test will continue to be processed in the main lab to avoid overflow of
satellite labs.
Because of the challenges we are currently facing in regards to financial constraints
and budget restrictions, allocating resources and space will be based off the need for the
enterprise and the financial growth it will allow for the lab. With the current financial climate
we are looking to increase lab test and revenue from the satellite labs by working with our
stakeholders to improve our presence in the medical community. From the addition of the

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satellite labs we are looking to secure an “competitive advantage” (Su, Lai, & Huang, 2009)
based off our ability to perform specialty lab test for pediatric patients and offer additional
services that most of our competitors are unable. Our enterprise will not only allow for our
pediatric patients to have shorter turnaround times and improved resulting, it will give the
clinicians the ability to create better care plans with the patients from swifter and easy
accessible lab results.
Through this strategy plan, we will focus on the effects of the enterprise on the
quality and care of our patients while examining how CNHS financial climate plays a role on
the expansion of lab services. We have strategized around NQS priority 4: Promoting the
Most Effective Prevention and Treatment Practices For the Leading Causes of Mortality,
Starting With Cardiovascular Disease by making our primary focus to increase access to lab
services with shorter resulting time. Laboratory results are the basis to the clinician making a
diagnosis and treatment plan for our patients. Our enterprise is founded on the mission to
ensure our patients are receiving accurate diagnosis and safe treatment from accurate lab test.

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Chapter I - Overview and General Description of your Enterprise
Children’s National Medical Center began as a 12-bed facility in 1871 and later grew
into a major Health System in which it then changes its name to Children’s National Health
System (CNHS). Laboratory Medicine was developed amidst the expansion of CNHS and
has not only allowed for patients to have lab services on demand but gives physicians the
ability to develop diagnosis and administer treatment more rapidly.
During the 2013 Joint Commission audit of CNHS Lab, it was determined that the
clinical laboratory was in dire need of improvement. The survey revealed almost a hundred
risk and areas of non-compliance. The turnaround time for specimens were not under an
hour, specimens were unintentionally sent to incorrect third-party labs, specimens were lost
or incorrectly processed. Much of the issues were due to lack of training, management
oversight and lack of robust process. Such conditions initiated the idea to develop satellite
lab services in the hospital in order to reduce turnaround time and improve patient care.
In 2012 a concept was developed for an adaptable and versatile pediatric satellite
laboratory to service intensive care and trauma units in pediatric hospitals. The notion of a
decentralized lab came from extensive experience gained from sample processing
improvement projects and quality restructures of laboratories in both the healthcare and
clinical settings. After many failed attempts to shorten the turnaround time (TAT) for lab
results at CNHS, a diverse group of pediatric care providers, laboratory and quality personnel
in the facility came together to improve the services of laboratory testing from time of
physician orders to resulting of patient specimens. In 2014, all 8 personnel on the
decentralized testing project, launched for the first time, a lean project to shorten TAT while

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continuing to create their business proposal, lab models and raising capital to build in-house
satellite labs.
Current Focus and Purpose
The current focus is to gain hospital buy in, capital, and rollout the first full services
chemistry and hematology satellite lab in the ER by January 15, 2015. The creation of
satellite lab testing is to shorten the TAT of resulting in order to improve safety measures and
the quality of care for our patients. The change in laboratory services is also to lessen bottle
necking of urgent lab request from ER and ICU’s in order to give the lab more capabilities to
provide quicker and improved testing services to all other areas of the hospital including;
routine lab request for ER and ICU patients. Our aim is to deliver differentiated services to
people around the world that exceed the standards of our competitors.
Children’s National Healthcare System (CNHS) laboratory is a leader in pediatric lab
testing for inpatient/outpatient care, research, as well as preventative and specialty care
(Hematology, Diabetes, Genetics, Immunology, etc.), creating a system of safe quality lab
services to children not just in the Nation’s capital but providing services for infants and
adolescents around the world.
Our satellite lab services will enable quick diagnostic results through its ability to
provide services to smaller quantities of patients and being able to focus on urgent cases.
Together with nursing and physicians support, CNHS has been successful with the
implementation of a satellite laboratory for Hematology/Oncology which has shortened the

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TAT for chemo patients needing swift lab results for same day infusions. However this lab is
not a full service chemistry and hematology lab but our goal is to expand it to provide all
chemistry/hematology test.
Chapter II - Enterprise Mission and Purpose
The purpose of developing satellite labs at Children’s National Health System
(CNHS) is to decrease the time of STAT testing for critical care patients by bringing lab
services directly to the patient care area, while improving efficiency. Our mission has always
been and continues to be to deliver exceptional patient care by providing inclusive, pediatric
laboratory testing and diagnostic services with complete focus on innovation, education and
improving the health of children. While centralizing the lab maybe be considered lean and
cost effective our primary vision is to extend the quality of life for our patients through the
improvement of pediatric clinical laboratory services. CNHS Laboratory Medicine
demonstrates our values by:
 Dedication to the Patient
 Valuing the lives of our patients
 Equal Quality of Care
 Continuous Quality Improvement
As the nation's premier children's hospital laboratory, we strive to exceed our goals
through a standard of excellence in patient care. Our current goals are to:
 Increase patient satisfaction in trauma and critical care units by 5%
 Improving lab services through the creation of satellite labs, allowing for 15% more
test annually to be performed

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 Sustain operational (i.e. staffing, supplies, instrumentation, vendor services) cost and
access of capital after rollout of labs, to continue grow satellite services
 Increase quality of health outcomes by 12%
Currently CNHS satellite lab consist of both internal and external stakeholders
comprised of the following groups:
Internal
 CNHS Hospital and Laboratory: Is sole proprietor, as they own the lab and all
satellite services developed out from their core laboratory.
 Executive Management (CEO, CFO, COO, CCO, Nursing VP, and Lab VP):
Executive management also serves as part of the strategic planning committee which
will include representation from the hospital’s board. These individuals are crucial to
the approval and funding of the expansion of lab and lab services. They are focused
on an organizational and operational direction with concerns to policy implications.
 Patient care providers (Physicians/Clinicians/Nursing): All care providers are solely
CNHS employees who also serve on the planning committee with great influence to
decision making. Nursing generally performs POC testing which enables them to
have a deciding factor as to what type of lab services will be extended to satellite lab
test.
 Senior Management (i.e. Directors that oversee all lab operations including satellite
lab services): These individuals are Laboratory Medicine’s management team and are
represented on a smaller scale than board members or physicians. They play a large
role in the coordination of the strategic planning process for lab expansion and
measure performance and outcomes of the new lab services.
 Laboratory Medicine: Lab strategizes, researches and works on operational and
organizational task to expand services while providing input and recommendation
through to executive management. They are responsible for direct oversight of
services with constant updates and communication to both management and their
internal customers (care providers).

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 All: take part in research, strategy development and implementation to an extent even
if it is only oversight of the outcome.
External
 Patients and family members: The patient is the most crucial factor as all has to be
done with them fist in mind. The strategy must reflect a quality product for the
improvement of patient care. They are the first and last step in the process in order to
provide quality care, education, safety, and advanced medical treatments.
 CNHS Philanthropic foundation: Raises money to fund hospital improvements which
can be utilized towards the build out of satellite labs throughout the hospital. They
have a great deal of leverage and influence as to how philanthropy funds are allocated
 Community: The local community is part of our population that is able to utilize lab
services for routine patient care at low cost. While they are indirectly tied to satellite
lab services, they are still affected by decisions of lab services being extended to
other units as they may be able to have lesser wait times to have labs done at the main
lab with the main lab having less specimens to process.
 Research Department: Research currently end specimens to process at the main lab
for certain test, however they could at some point opt to have a satellite lab dedicated
to their human research projects in order to obtain shorter diagnostic times
Chapter III - Current State Organizational Strategy
CNHS Division of Laboratory Medicine will create a decentralized lab enterprise to
service the ICU’s and ER at our pediatric hospital. Although it is considered duplicate
services it can benefit the care and quality of testing for patients that need prompt lab results
for urgent treatment. All other lab specimens from various units and out patient’s centers will
be transported to the main lab that can also assist with overflow of urgent patient testing. The

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decentralized lab focuses on STAT (urgent) testing, predominately chemistry/hematology
test. We are working to reduce patient wait times for critical results, misidentification of lab
specimens, lost specimens and many other issues because of the limited resources (budget,
staff, space) of the main lab. Care for critical pediatric patients regardless of budget.
Children’s National Health System’s Main hospital will extend lab services through
the development of a satellite laboratory enterprise. Satellite labs and their processes will be
owned by CNHS main lab. They will perform limited STAT chemistry and hematology test
for improved turnaround time (TAT) of results. All units that receive a satellite lab will send
patients requiring STAT test to their satellite lab and all routine test will be completed in the
main lab. The establishment of extended service areas will enable improved diagnostic times
with a focus to improve patient care. Currently, the first location has been completely
designed and approved. The first satellite lab will be opened in our hematology and oncology
clinic. The build out will begin once the final business plan is complete with cost for the
build out, staff, supplies, and other overhead cost have been approved and budgeted for.
The workflow for laboratory testing will remain nearly the same except for the
transport processes and location of test to be run. As per protocol, the nurses will do their
routine patient draws and then transport their routine samples to the main lab via the
pneumatic tube or through the transport team. Their STAT hematology and chemistry
samples will be walked to their satellite lab within their unit, requisition time stamped and
handed off to the lab tech to time in, process and run the ordered test.

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Judgment to create satellite lab services was initiated by a team of patient care
providers from the Hematology/Oncology Clinic as well as lab administration by analyzing
current services, demand in services, units that see patients that usually require STAT testing
and other criteria. An assessment of lab needs, was completed in order to determine what
units can benefit front satellite lab services. The Emergency Department (ED), hematology
and oncology and the intensive care units will have the greatest impact as they see the
majority of patients that require critical and/or STAT testing most frequent.
Testing
The Satellite Laboratory Enterprise is not to deter testing from the core lab but rather
lessen the load of the core lab. The core lab has seen an increase in services over the last 10
years but has not been able to increase space or resources (storage, instrumentation and
staffing). It will also allow physicians to make quicker and better treatment decisions for
patients that possibly cannot wait long for treatment options. The following tests below may
result in shorter turnaround times for the following:
 Comprehensive metabolic panel (CMP)
 Complete Blood Count (CBC)
 Prothrombin/partial prothromboplastin time (PT/PTT)
These tests check for coagulation time, kidney function, liver function, proteins,
electrolytes, and various disease states to include anemia, leukemia and inflammatory
processes. These results are often needed in a short time frame. These results also determines

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the dosage for chemotherapy or heparin for patients with coagulation abnormalities such as
hemophilia.
CNHS has historically shied away from decentralized lab services as it does not
follow the “lean” model. It also can increase capital and overhead cost for the facility.
However with the industry changing with a focus on preventative care, quality of care and
patient satisfaction, CNHS Satellite lab services will decrease patient wait times while
enhancing our services for both our internal and external customers.
Currently the hospital has an extensive point of care testing program with the main
laboratory, which allows for bedside patient care. The satellite labs will only be focused on
chemistry and hematology tests that would otherwise need to be performed on larger scale
equipment with slower turnaround times for resulting patient specimens.
Staffing
Following the guidance of the American Society for Clinical Pathology (ASCP) a
workforce was created amongst lab management, nursing and physicians of the locations that
will have satellite lab services. The workforce was to determine the type and quantity of
testing required for their units in order for the main lab to adequately staff their satellite labs.
Similar to an ASCP (Bennett et al. 2014), we have focused efforts on a strong and skilled
workforce so that our personalized services are able to deliver judicial, precise, and safe
patient care.

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All 6 satellite labs will be staffed (See Image: 1) with 2 medical technologist 1 that
specializes in hematology testing and the other in chemistry. Only the Hem/Onc clinic is
staffed with phlebotomist as they also service other clinics on the Hem/Onc clinics floor and
the ED and ICUs exclusively have nursing staff draw from their patients.
Image 1: Children s National Health System Organizational Chart

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The phlebotomists are able to draw the specimens, order testing, process and send to
their designated satellite lab for testing. Our phlebotomist have 2 to 5 years’ experience,
minimum, in pediatrics. All of our chemistry/hematology medical technologist or scientist
bring at least 5 to 10 years’ experience in a pediatric clinical laboratory. They have a
minimum of a bachelors in a clinical laboratory science, biomedical science, or in a
life/biological science (biology, biochemistry, microbiology, etc.). Our medical technologist
also, all hold a medical scientist or technologist certification from either the National
Medical Laboratory Science Council or the American Society for Clinical Pathology
(ASCP).
Staffing has greatly impacted the enterprise as it has enabled us to provide quality
services from having educated professional staff perform pediatric lab testing. By requiring
staff to have a degree and certification it will put the satellite laboratory services in a stronger
position to expand and/or provide adequate testing and accurate results to physicians.
Technology
Our instrumentation and health information system have greatly benefited our
enterprise as technology has advanced. We have rolled out advanced Cerner systems
throughout the hospital allowing easy access to review patient results and place lab orders.
Cerner is utilized by the hospital and all ambulatory services. This system allows for staff to
order lab test. Orders are then transmitted to the lab information system (LIS), Sunquest. Our
LIS has enabled our laboratory to become more efficient by allowing our lab staff to
remotely manage data, generate critical result notifications to physicians via email, interface

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with lab instrumentation results to transmit automatically and electronically generate patient
results (Bennett et al. 2014). Such technological advancements will impact our satellite lab
services greatly as our staff will be able to perform laboratory duties with minimal assistance
or access needed to the main lab. They will be able to access our systems through computers
placed at every satellite lab workstation and can troubleshoot remotely from the lab. This is a
key process as the labs should be able to operate independently although they will be
following the same processes as our core lab.
Our choice of instrumentation will benefit the enterprise as it provides accurate and
timely results which impacts the physician’s clinical assessments of patients (Leman t al.
2004). Our Laboratory equipment just as the main lab is leased for 5 years with servicing
provided by our vendors. Some of our instrumentation will vary such as utilizing CLIA
Waived instrumentation. With satellite labs being in a smaller working space it was
determined that we must utilize smaller instrumentation than the main lab. Validation of
instrumentation will be conducted after each setup of satellite lab. Correlation studies for all
satellite lab instrumentation that differ from its counterpart in the main lab will be conducted
biannually to verify that the instruments perform on the same level and results are identical to
those in the main lab. The equipment in each satellite lab includes; Thermo Fisher Heraeus™
Primo™/Primo R Centrifuge, Beckman Coulter CX5 Pro Chemistry Analyzer, Sysmex XS-
1000i™ Auto Hematology Analyzer.
Mirroring previous studies (Leman et al. 2004), a process improvement model was
utilized to form and build the relationship amongst our stakeholders. Our key stakeholders
(Laboratory Medicine management team including chemistry and hematology coordinators,

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nursing and physicians from key areas) will work together on various levels to determine
processes, oversee changes, design layout of the labs, appeal for approval and capital
funding. Other stakeholders such as executive management, and infectious control have also
played a major role in the enterprise by understanding the need for quality lab services while
approving development in support of projects that will benefit our patient’s. They’re
relationship with our key stakeholders was vital in determining how the satellite labs will be
implemented and the benefit to patient’s.
Currently our organization has barely been able to sustain in the current model. With
various additions to the hospital, new outpatient centers and an increase in patients seen (both
in and outpatient), CNHS has had a fluctuation of increases in patient wait times and
turnaround times for lab test. This is what has prompted the creation of satellite lab services.
Although the hospital has expanded in the last 7 years the lab has not, nor has it received
funding or approval for expansion. With these issues verified, we have already had our first
satellite lab in operations for the last 2 years with the new expansion to that lab to take place
in the next fiscal year. The satellite lab has had great success in the current model but it now
is seeing patients from 5 additional clinics not just focused on our Chemo patients from the
Hematology/Oncology clinic. The additional satellite labs will not only improve access to lab
services, (Leman et al. 2004) it will improve the current model by being able to timely and
safe lab testing to greater populations.
SWOT
There are improvements that can be made from the implementation of satellite lab
services. However a major improvement we have focused on is that we will be able to

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decrease the current TAT from 45 min to 10 min from the time the processing lab receives the
specimen. Shortening the time of draw to result is critical as it will allow us to decrease our
discharge time (Lee-Lewandrowskias et al. 2009) as well as improve the time we are able to
diagnose and treat patients. Our satellite labs are able to lessen the incidents of complaints off
lost specimens or delayed resulting (Lee-Lewandrowskias et al. 2009) as we have been able
to eliminate the transport time, have unit focused lab processing and eliminate our high risk
children from being with our outside population of patients (i.e. those possibly with
contagious illnesses) in the main labs blood draw center.
Although the enterprise is patient focused on improving the care and services we
provide, it is also a potential weakness because without adequate planning and assets our
enterprise will take away resources (i.e. staffing, finances, space, and supplies) from both the
lab and hospital. Duplication of services will subsequently weaken the hospitals main lab
department as it is now having to generate more time and resources to ensure the
sustainability of the satellite labs, with limited resources in the main lab. Despite our
weaknesses CNHS has the strength and resources to improve on our lab processes. Even in
its current state with limited budget, staff and space the hospital has been able to operate its
core lab and single satellite lab, 7 days a week 24hrs a day. The enterprise will only
strengthen the service oriented structure of the main lab. The enterprise is a mere
enhancement to an organization that provides safe and accessible patient care to patients
around the country.
Our ability to process specimens at a swift rate will not necessarily lessen the wait
time or stay of patient (Leman et al. 2004) as the process for collecting and processing

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specimens is still weak. The clinical care side of the process must work to eliminate time
wastage point in the process from time the labs are ordered to being drawn by nursing,
including but not limited to: patient check in time, variances in patient account information,
orders incorrectly ordered, incorrect requisitions and specimen misidentification.
With us able to understand both our strengths and weakness, we are able to better
determine our areas of improvement that can shape our enterprise through growth and
sustainability. We have the opportunity to increase our laboratory business internally and
through our reference lab services since we will alleviate work from the central lab. This also
gives you the opportunity to reeducate nursing and our clinicians how to properly use our
laboratory information systems to accurately order lab test and view results.
The growth of the enterprise now gives us a window to reevaluate our current
systems to determine what we can improve upon as the lab process will not vary much
except the transport piece. As similar studies show (Leman et al. 2004), that we could
possibly include to our process is performing the blood draw and test prior to the patient
visiting with eh clinician for their evaluation. This will allow the clinician to have the results
to include in their exam process, rather than waiting after seeing the patient.
The enterprise of satellite lab services can be halted or consolidated back into a
centralized lab model if we do not improve the current workflow of processing samples from
the time of order to resulting. The over utilization of the satellite labs could also threaten the
goal of improved TAT and patient wait times as clinics not designated with a satellite lab may
try to utilize another units lab. They were not created for large testing accommodations

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(Monti et al. 2012) or to service other units other than the 5 designated ICU’s and the
Hem/Onc Clinic.
However our greatest threat local reference laboratories. Our market is saturated with
various other labs that patients can get lab test completed. If we do not improve our
processes, programs and standards for lab collection and processing we will lose business to
outside labs provide the same services for around the same cost and are covered by
insurance. However it is not just about the business it about maintaining a trusting
relationship with our patients.
Chapter IV - Market Assessment
Affordability
Children’s National Health Systems (CNHS) Lab has an obligation to maintain
affordability as much as quality. Currently our lab services touch several communities with
varying income ranges, however our main lab and current satellite lab service a high percent
of our surrounding urban neighborhoods and low income families. Research has found that
(Muela et al., 2000) quite often patients may be willing to pay to cover their healthcare cost
but they are unable to financially. CNHS is dedicated to ensure all patients have access to lab
services regardless of financial status. CHNS Satellite labs will remain accessible to this
community including maintaining current cost. In order to control back end cost, for supplies
and instrumentation, CNHS satellite lab services will seek competitive contracting with our
vendors. This will allow us to maintain economically modest in test prices, for our patients.

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Service and Access
Our satellite labs were developed with both our external and internal customers in
mind. Our patients will have access to our satellite labs when they are in the care of their
providers on any unit pertaining a satellite lab. However access for our care providers is just
as important. Satellite labs at CNHS will give care providers quicker diagnostic and
treatment ability by minimizing the time it takes to get specimens such as reducing time to
transport and accession specimens.
CNHC Laboratory Medicine will leverage our competitive edge of having convenient
lab locations strategically placed within all the intensive care units (ICUs) and the emergency
department (ED). What also makes this lab model competitive is that we are a part of a major
health system and located within a large 300 hundred bed pediatric hospital which will help
our satellite labs quickly gain market share. Because we are run by the hospital rather than
being a subcontractor, we are able to use the hospitals major marketing and PR resources for
advertising and community outreach.
CNHS Satellite Laboratories' competitive edge is convenience. In the clinical lab
industry it is hard to differentiate yourself from competitors because all have a similar
foundation of basic levels of care and performance which make it hard for us to distinct
ourselves from others:
 Private and State owned insurance plans are accepted, otherwise many patients could
not use the services.

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 Swift analysis; chemistry and hematology tests are completed and reported within 30-
60 min with a window of 24-48 hours for all other test except genetic testing.
 Accurate and precise results are provided.
If these basic, foundational levels of performance are met, then you are competitive.
This is why convenience, service and access is so important and why it is an effective way of
distinguishing CNHS Satellite labs from other labs.
Marketing
CNHS Satellite Laboratories will undertake a marketing strategy of employing 3
means of communicating its new locations:
 Direct mail. CNHS physicians at our main site, will receive a flyer announcing the
opening of our satellite labs and detailing the services offered. A list of physicians is
easily obtained through CNHS intranet (i.e. department directory or paging database).
 Personal introductions. to all physicians and nurses that service the units that will
have satellite lab services. The Chief of Lab Medicine, QA Lab Director and Lab
Operations Director will schedule visits to all of the applicable units as a way of
introducing the services to the doctors and answering questions. This will provide lab
personnel an opportunity to develop a personal relationship with the care providers,
something that is useful and valuable for service providers.
 Email. Reminders of implementation dates of, will be sent in a general email for all
nurses and physicians in order to ensure all care providers receive a notification even
if they are currently not on a unit with a satellite lab.

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 Brochures. Brochures will be disbursed in all areas of the hospitals that have hig
patient volume such as patient clinics, ED and intensive care units. Patients can pick
them up at the check in desk. The brochures will contain a high level view of our
satellite labs including our services, testing panel, hours of operation and our mission.
These will be kept in circulation as long as the satellite labs are in operation, as a
friendly reminder to patients. Because of the hospitals strict poster policy we will not
utilize posters as a communication tool.
Issues
In recent times the U.S. healthcare cost have risen, leaving an untapped population of
patients that cannot afford healthcare services including laboratory testing. This sets us up
with the challenge of possibly being denied reimbursement for lab testing which can range
from a few hundred dollars to thousands of dollars based off the test and how many test
physician orders.
Ordering laboratory test in excess has caused a financial loss for CNHS. There are
various reasons for the excess ordering such as specimens being lost, discarded for regulatory
reasons or because test were incorrectly ordered. Our primary reason for not being
reimbursed from managed care providers has been that our provider’s order too many
redundant test (Bishop et al., 2010) which has caused insurance companies to refuse
reimbursement of only 46% of the full cost of the lab test.
One important aspect to address is our issue of interfacing between our laboratory
information system and our electronic health records (EHRs). The Affordable Care Act

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(ACA) has mandated “a process for meaningful use of laboratory data throughout the
medical care continuum” (Hinrichs and Zarcone, 2013) as well how lab results are being
transmitted between our LIS and EHR. This is to allow physician’s to accurately receive their
patients results in a timely manner. It also will allow for improved reporting to our public
health authorities for test such as for influenza, STD’s, pneumonia and other test that help
epidemiologist with tracking, trending and preparedness of possible outbreaks. However
CNHS has not been able to fully interface our systems or harmonize our process, because of
the cost to pay for the interface as well as limited licenses they have for all staff to have
adequate access. Our capability to acclimate to electronic data exchange will be a major
factor in the services we obtain from other public health facilities and our local department of
health. We must be able to have a sold and secure system that will allow us to collect,
validate, process and transfer data to other care providers or the DOH which will allow for
better tracking and tending of diseases or possible outbreaks (Hinrichs and Zarcone, 2013).
Beginning in 2014, the ACA required health insurance to cover services it considered
‘‘essential health beneﬁts’’ (Bagley & Levy, 2014) which applies to laboratory services ,
however the new expansive coverage could raise insurance cost and limit the type of
services patients seek because of the increased cost. This can inhibit the efforts to increase
access and care to people as well as limit the lab services people seek.
Opportunities
With challenges comes chances. CNHS is the only hospital in the DC Metropolitan
area that is solely pediatrics. We have the pediatric market locked down. We have recently

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gone from Children’s National Medical Center (single hospital) to a health system with 2
hospitals and over 10 outpatient centers. With the expansion of the hospital has come the
expansion of laboratory services. Unlike our competitors we are able to offer various lab
services such as lab draws, testing and capabilities to operate as a reference lab. Currently
CNHS Lab is the only pediatric lab in D.C. that offers specialty programs for pediatric
testing such as genetic testing, lab testing for child protective services and preventative
disease testing.
With the ACA expanding healthcare coverage to millions of uninsured, the model of
our lab and extensive services has enabled us to be a premier laboratory service site for a
growing patient community in DC, MD and VA. With the expansion of ACA many of our
current and new patients are able to acquire additional lab test and health screenings because
of additional coverage for lab services. Which can also lessen the expenses out patients will
have to incur.
It is important that the lab understands that our key external customers are infants and
children through the age of 19 years old and that currently we are their main source for care.
Marketing will shift to social networking, advertisements on bus/trains stops and school
drives where we do lab test and blood drives at schools and centers within the community.
Such a strategy is to build relations with the families of our patients and gain the trust of the
patient itself.
Chapter V - Enterprise Economic Model for Sustainability

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The analysis in this section should focus heavily on potential changes associated with
emerging ideas in healthcare delivery and reimbursement (depending upon your enterprise)
and how those may impact the economics of your enterprise. Such an analysis should include
potential remedies, suggestions, and alternative approaches designed to sustain the enterprise
in the face of such change. As you craft the final version of this chapter, you will have
integrated any financial implications that emerged from your market assessment, legal and
regulatory evaluation, quality improvement research and initiatives, and outcomes of your
future state initiatives.
A. Overview of the Current Source of Revenues and Expenses
Children’s National Health System Laboratory is a for profit division of the hospital
including our enterprise of satellite laboratories. We are set up as a “fee for service” (Loring
et al., 2013) laboratory in which we charge for all test performed and resulted. Because our
enterprise is a for-profit institution, we have various revenue streams. Specifically, our
primary revenue source are reimbursements from managed care providers (i.e. Aetna, BCBS,
Prudential, Medicare etc.), with our secondary source of income from self-pay patients. The
satellite labs will not provide reference lab services such as our main lab, which limits the
revenue we will be incurring. If tests are performed but not resulted we cancel and credit the
test, to avoid illegally billing.
The satellite labs will be developed from hospital capital. Capital funding will cover
the structural cost and instrumentation. This also includes permits, installation and other
resource for the initial build out. The Division of laboratory medicine, per protocol, covers

24
the cost of materials (reagents and lab supplies), vendor service agreements and staffing.
Funding for to staff the satellite labs Staffing comes directly from the main labs budget
because the phlebotomist and medical technologist will report directly to their respective
units within the lab. To receive capital funding we are required to submit a proposal that
entails an estimated cost of the lab addition, purpose, explanation of how it will improve the
safety, care and/or access for patients. Although our initial expenses are covered under the
capital funding, annually the lab must maintains economic stability in order to maintain as
we spend over a million dollars annually on supplies, reagents, contracts and staff salaries as
noted in Table 1. Laboratory expenses can become costly especially when we incur wastage
from discarded or canceled test, because of reagent cost and instrument maintenance cost.
We will monitor expenses monthly to keep oversight of the annual lab budget while
analyzing areas of the lab where we can cut cost to stay in budget.
CNHS satellite laboratories will be a pediatric lab service provider to patients both
domestically and/or internationally that seek treatment at the hospital for both intensive and
urgent care services. The goal of is to provide unceasing reliable services for our patients and
pediatric care providers, such as:
 Pediatric lab services
 24-hr lab testing and support
 Electronic reporting systems
 Designated, trained staff to each individual areas with backup support from core-lab

25
Table 1:
Satellite Laboratory FY 2013 Income Statement
*Per Lab Test (CNHS receives avg. 46% of total reimbursement
per cost of test)
Children's National Health System
Revenue Income (incl. patient & insurance reimbursements)
Cost of Test (Test performed in 2013: 1.2 million ran annually for ED and ICU's)
Retic ($3.02 per test) $1,304,640
HFP ($2.85) $1,231,200
CBC -auto ($3.02 per test) $1,304,640
CBC-manual ($3.02 per test) $1,304,640
BMP ($4.05 per test) $1,944,000
CMP ($3.15 per test) $1,360,800
Gross Revenue $8,449,920
Operating Expenses Amount
Startup Cost
Construction, equipment, computer, etc. $500,000
Salaries and wages
2 Full-time Medical Technologist $116,000
Benefits $67,560
General/Administrative
Annual Proficiency Test Survey $330
Administrative duties $4,000
Test Supplies
(Reagents, tubes, centrifuge supplies, disposables, kits) $1,340,000
Equipment
Equipment Service Contracts $18,460
Thermo Fisher Heraeus™ Primo™/Primo R Centrifuge $5,697
Vitros 350 $7,211
Sysmex XS-1000i™ Auto Hematology Analyzer $10,500
Total Expenses $1,569,758
Total Revenue $6,880,162
*The income is based off 46% reimbursement of the actual test cost. Our total revenue is based off the subtraction of our
annual expenses against the gross income of CNHS lab.
B. Financial Outlook and Maintaining Economic Viability in the Future

26
There are various reasons that we will see a financial impact that can hurt our budgets
and revenue for both our satellite laboratory services and our main lab. The greatest impact
we have as of today is the changes in managed care policy on reimbursements for laboratory
test. Managed care providers currently never reimburse the hospitals lab for the full cost of
the lab service secluding patient craws and testing. Certain test can cost hundreds of dollars
to perform and when we are only being reimbursed for about half of that cost then we are
taking a huge loss because majority of the patients we see pay for their services with their
health insurance.
Over the last 2 decades we have grown tremendously from expansion of the main
hospital, adding outpatient centers and expansion of our ICU’s. With the physical growth we
have doubled the patients we see daily and almost tripled the amount of lab test performed.
The creation of satellite laboratories will increase the amount of lab test, however research
has shown (Benge et al., 1997), that managed care providers have reversed their
reimbursement rate for lab test and policies on how many test per patient can be performed
within the same day especially for duplicate testing. Subsequently, lack of improvement of
management care, payment approval policies has often leaves both the patient and/or our
hospital obligated to cover the remaining cost which can be a small percent or the entire
amount.
Although we are caring for more patients and have increased productivity for lab
testing we have not been approved to increase FTE leaving our staff with adequately staffed
worked groups. As of March of 2013, the main lab has decreased productivity consequently
effecting revenue. This is due to a change in the FTE our cost for lab test has not decreased

27
effecting and with decreasing managed care reimbursements and/or patient payments we will
continue to be financially impacted (Benge et al., 1997). Adding satellite labs to our services
will enable us to grow the lab staff with focus on each individual ICU and ED. This will
impact the main lab greatly, as it will allow for us to increase our services to our outpatient
centers, other laboratories, university hospitals and local community. Increase testing and
payment for those test can allow for the affordability of additional resources such as FTE,
instrumentation and supplies.
Our organization is under a major transformation in light of loss of revenue and
economic changes over the last few years. CNHS have introduced Transformation 2018,
which for the laboratory has already had a great impact on budget and expenses. We are
required to cut 2% of expenses in various areas such as staffing cost (i.e. new hires and
overtime), services and/or supplies needed to operate. The transformation focuses on various
items such as research, expanding services, community outreach, implementing new
electronic health systems, but the major objective internally is revenue. Our goal is not to just
break even, but actually bring in revenue that can pay debt and be used to improve our
organization.
Although we are bringing in a steady income annually, we are required to cut because
our parent organization are making financial changes to decrease their overall debt. We are
only 1 source of income to the hospital meaning that although we bring in revenue to cover
additional staff, space or supplies, it is not enough to improve the hospitals financial burden.
Our cuts will allow more of the labs revenue to go back to the hospital.

28
Financial impacts could potentially affect both our patients and care providers.
Although we will not increase cost per test, for patients, if the is not an increase in revenue
from our satellite laboratories, spending more than we profit could push the closure of
laboratory services including our satellite labs. This will limit the access patients have to
testing as well as the time they and their care providers receive results for diagnosis and
treatment.
Economic sustainability is not easy with industry competition, the current changes in
healthcare and managed care policies especially in the current financial climate of Children’s
National Health System. However it is vital for CNHS to compete for new markets
(Catarella, 2004) in the heavily populated D.C. metro area. With us expanding our presence
outside the metropolitan area, we have gained more patient access and increased the test we
perform. Our satellite labs will be able to maintain growing ICU and ED populations at the
main hospital. This will also allow for us to expand the main lab services in “outreach
testing” by marketing ourselves as a reference to facilities such as university hospitals, other
pediatric hospitals and private practices, for routine testing and health screens (Catarella,
2004). With a fully functional lab, including special testing services such as virology and
genetics, we have the ability to perform many test that some of our local competitors do not
have the capabilities to perform currently.
Our enterprise is working towards expanding services to be able to see more patients
and perform more test that would otherwise be missed, delayed or cancelled due to the longer
turnaround times in the lab. Just as other laboratories are committing to lab expansion,
expanding fee-for- service testing (non-point of care) will enable us to capture additional

29
revenue especially with our high claim denials from Medicare and managed care providers
(Loring et al., 2013). This can be a way to retrieve some of that lost revenue.
As noted before, one of the hospitals major strategic plans within the transformation
is the implementation of electronic health systems including an improved laboratory
information management system (LIMS) . According to Woong-Sub and colleagues (2005)
such as strategic plan will increase inpatient and outpatient lab revenue by improving
diagnosis, treatment, customer service and quality. They also note that although it can reduce
cost and competition from our local market, it may not necessarily increase productivity
(2005). Because of local competition and the emergence of reference laboratories, such
strategic plan to electronically result and report results will allow us to handle a larger test
volume as well as possibly improve patient care and provider satisfaction as research
conducted by Catholic Health System, found (Bauer and Bozzard, 2009).
With budget and hiring restrictions, additional financing o will be challenging. After
initial rollout we will only have to budget for the cost to run the test and for lab supplies,
decreasing our financial needs greatly after the first year. However our hospital has a contract
with a finance auditing group to determine ways for us to cut cost and increase revenue.
Since the audit they have frozen all hiring and budget increases. This can block additional
funding in the circumstance we need to replace a lab tech that leaves or purchase new
equipment. With the restrictions, most appeals for additional capital will be denied. In order
to balance the current need of our enterprise we need to improve our quality systems and
manage risk in order to limit the rate of error and incremental cost (Hamza et al., 2013). It is
vital to balance the amount of test based off the resources we have including staffing.

30
Chapter VI - Quality and Continuous Improvement: Health Outcomes and
Organizational Effectiveness
The ACA as it Relates to Quality
The Affordable Care Act was the first step to increasing access to healthcare while
improving the quality of patient care. In 2010, when the ACA was enacted, it became a major
driver of patient protection. Although the ACA contains various provisions, some of their
primary goals are quality improvement. To drive such change, they enforced new regulatory
requirements such as reporting of quality measures (Madison, 2012). They also created the
Patient-Centered Outcomes Research Institute (PCORI) (Fontenot, 2013) in order to trend
outcome measures. The goal of developing PCORI was to utilize medial evidence for
improved healthcare delivery. Utilizing ACA principles is important in laboratory medicine
because it can assist clinicians with standardizing treatment plans and diagnostic methods.
The National Quality Strategy
In 2011, The National Quality Strategy (NQS) was issued by Agency for Healthcare
Research and Quality on behalf of the U.S. Department of Health and Human Services.
Developed as a guide for quality improvement and methodology for quality measure. To
accomplish cost efficient and quality health care NQS utilizes their “6 priorities” (U.S. DOH,
n.d.) which is focused on industrywide quality issues and the systemic concerns of the
consumers. The National Quality Strategy National Quality Strategy’s 6 priorities are as
follows (U.S. DOH, n.d.):
 Making care safer by reducing harm caused in the delivery of care.

31
 Ensuring that each person and family are engaged as partners in their care.
 Promoting effective communication and coordination of care.
 Promoting the most effective prevention and treatment practices for the leading
causes of mortality, starting with cardiovascular disease.
 Working with communities to promote wide use of best practices to enable healthy
living.
 Making quality care more affordable for individuals, families, employers, and
governments by developing and spreading new health care delivery models.
These priorities are to progress the NQS 3 aims to improve health care:
 Better Care: Improve the overall quality, by making health care more patient-
centered, accessible, and safe.
 Healthy People/Healthy Communities: Improve the health of the U.S. population
by supporting proven interventions to address behavioral, social and, environmental
determinants of health in addition to delivering higher-quality care.
 Affordable Care: Reduce the cost of quality health care for individuals, families,
employers, and government.
The 6 priorities focus on improving patient health outcomes through quality
initiatives that employ “clinicians, patients and provider organizations” to assure efforts are
aligned with the 3 national aims (U.S. DOH, 2011).
Although CNHS Division of Laboratory Medicine strives to meet all 6 of the national
priorities, priority 3: Promoting Effective Communication and Coordination of Care, has
become a major initiative for us as we are working to improve our communication between
our patients and our clinicians. While we are in the midst of enhancing our current health
informations systems, our goal, mirroring that of NQS priority 3, is to create process that
require shared accountability between our care providers and the health care systems to
progress the quality of care we deliver (U.S. DOH, 2014). In order to meet our goal, we will
improve the interface between our electronic health systems and our laboratory information
system as well as consolidate the rest of our electronic resulting systems so that we have a

32
harmonized program amongst only 2 systems that give lab staff and clinicians improved
access to patient data. We also will improve lab and clinician communication by setting up a
program to notify care providers of critical results, system issues or any other matters
pertaining to patient’s lab test. It is important we maintain quality lab results and patient care
so that we may give our patients superlative treatment and continue to offer premier services.
The Need for Improvement
The turnaround time (TAT) for STAT (urgent) labs, hospital wide, has been at an
average of an hour. During this time, patients have to sit idle for long periods of time to be
seen by our physicians because they must wait for lab results for clinicians to diagnose
and/or prescribe medications. Idle time is both wastage for clinicians and patients. That time
takes away time allowable for other patients to receive care.
There are various breakdowns in the process, from time of lab order to time of
resulting, such as incorrect orders, mislabeled specimens, transport batching, processing
errors etc. Such process issues also add to the increase specimen TAT. However these same
process issues also effect the people performing the processes such as stresses of staff
(Safwat, 2013) having to rerun or reorder test, fix account information, having to wait to treat
patients and so forth. Prior to the implementation of a Decentralized chemistry and
hematology lab for the Hematology/Oncology clinic, the clinic/lab workflow functioned as
noted in Image 2:

33
Current Lab Orders Workflow: Specimens that are Transported Directly to Core LabCLSR
Hem/OncClinic(includingo/clinic
services)
Lab
Phase 2
Patient Testing
Needed
Specimen
Collection Ordered
Nurse Collects/
Draws Specimen
Patient Drawn
by Nurse?
Yes
CLSR Hem/Onc Lab
staff conducts patient
draw
No
Nurse Takes
Specimen to Hem/
Onc Lab draw
station
Nurse Time stamps
and manually puts
time of draw on
Greencard (If
greencard
required)
CLSR staff Time
stamps and manually
puts time of draw on
Greencard (If
greencard required)
CLSR completes order
entry for specimen(s) in
sunquest
Specimen Transported
to Hem/Onc Lab or
Main Lab
Specimens
Processed by
CLSR
 Patient
cannot be
found by
CLSR
 Limited Lab
staff
availability
Bottleneck:
Handling
specimen
collect for
all clinics
 RN: Batch
specimen
dropoff
 Unlabled Req.
&/or Specimen
 STAT Unknown
 Account # s
incorrect
 Incorrect face
sheets
 Limited lab
staff
 Only 1
Ordering
station
 Specimens
Batched
tubed or
walked
down
 Missing specimens
 Aliquoting errors
 Bin sitting
 Label error
resolving
Specimens analyzed
and resulted
 Core lab not
assisting w/
backlog
Key:
Issues
Process
Decisions
Image 2: * Current workflow (previous for Hem/Onc clinic) for lab test, from time of patient draw to resulting
of specimens. Double click object for increased sizing >
Although the workflow and TAT has improved for the Hematology/Oncology
(Hem/Onc) clinic since the addition of a decentralized lab, other critical care units are still
being hindered by long wait times for labs. It is important to get STAT times for the ICU’s
and ED down to 30 to 45 minutes by mimicking the workflow and lab setup in the Hem/Onc
clinic.
There is more than the need for clinicians to have faster turnaround times. There is
also a dire need to reduce waste, provide quality service and increase efficiency in laboratory
testing. While healthcare reform is still on the for front, it is the goal of CNHS to utilize this

34
platform change the way we deliver our lab services and improve health outcomes for our
patients. As research shows (Safwat, 2013) the issue in resulting labs in shorter times does
not just rely on lab technology it equally relies on the process being efficient and the people
performing the process. Such research as influenced our initiatives to focus on technology
advancements, staff and our improving our workflow. The quality initiatives noted in the
next section show our desire to continuously improve our services through process
streamlining, to both enhance quality, safety and accessibility of lab testing.
Initiative I: Process
Improving the process has taken various levels of assessing and altering to the
workflow. Because of the workflow variances amongst several hospital units, it is important
to harmonize and lessen the amount steps needs to have STAT chemistry lab test performed.
We will continue to benchmark TAT while tracking processing variations and testing errors.
The process will change as follows:
 Transport of specimens will decrease since the labs will be in the various units
 All requisitions will be tracked at specific time points for to monitor
turnaround time
 CLSR will no longer order all lab test, only samples they draw
 Satellite lab will only process samples from their unit
Additionally decentralized testing offers the ability to increase all other samples to be
tested in the core lab especially for high census in the hospital and/or during a major
epidemic. Improving the workflow and applying satellite labs to the intensive care units
including the ED will not only save time for the clinicians but it lends itself to improving
patient satisfaction. Our initiative is in alignment with NQS priority 3: Promoting Effective
Communication and Coordination of Care, in order for our communication and processes

35
between the lab and care settings offers improved quality of care and services to our patients.
Please see Image 3 for our improved workflow.
Image 3: Improved Workflow
Decentralized Lab Workflow
CLSR
Hem/OncClinic(includingo/clinic
services)
Lab
Phase 2
Patient Testing
Needed
Specimen
Collection Ordered
Nurse Collects/
Draws Specimen
(Time stamps req.
w/collection time)
Patient Drawn
by Nurse?
Yes
CLSR Hem/Onc Lab
staff conducts patient
draw
(Time stamps req. w/
collection time)
No
Nurse Takes
Specimen to
satellite lab on unit
Lab Tech
completes
electronic order
entry
(Time stamps req.
w/receipt time)
CLSR competes
electronic order entry
Specimen Transported
satellite lab or Main
Lab for routine or
other test)
Specimens
Processed by
CLSR
The electronic
ordering system
has a data field
which tells the
staff where the
patient is
located
specimen
collect for
only
designated
unit
(i.e. ED or
ICU)
RN drops off
specimen to lab
after each draw
Patients Account
Reconciled during
check in
Two ordering
stations per
unit to decrease
processing time
Specimens sent directly
after drawn & ordered
via pneumatic tube
which is setup in the
draw rooms next to the
ordering stations
 Missing specimens
 Aliquoting errors
 Bin sitting
 Label error
resolving
Specimens analyzed
and resulted
Core lab assist in
processing during
overflow of
specimens
Key:
Improvements
Process
Decisions
Utilizing patient satisfaction surveys and conducting a process improvement project
we will focus on the National Quality Strategy Priority: “Specific health considerations will
be addressed for patients of all ages, backgrounds, health needs, care locations, and sources
of coverage” (Department of Health and Human Services, n.d.). An improved workflow for
laboratory testing is to ensure the needs of our patients are met with quality and
consideration. Our satellite lab services operate with the same fundamentals as the core lab as
that they will services all of our patients and promoted services to potential patients globally.
Method for Performance Measure

36
Measure Title Median Time from Specimen Draw to Specimen Result Time for
Admitted ED Patients – Reporting Measure
Median Time from the blood sample being collected and sent to the
laboratory to the results being electronically resulted and available on
the clinician’s computer.
Measure Description Time from the blood sample being collected and sent to the
laboratory to the results being electronically resulted and available on
the clinician’s computer-for Admitted ED patients
Objective To reduce the wait time for clinicians to receive patient results and
the “time patients remain in the emergency department (ED) can
improve access to treatment and increase quality of care”. It can
decrease the time patients have to wait to be diagnosed and/or
receive treatment. This possibly can improve both access and quality
of care to the patient. Because ED’s often face overcrowding, this
will help to determine if decentralized labs are a factor in the
reduction of overcrowding.
Type of measure Process
Numerator Statement Admitted ED Patients receiving a lab work-up, ordered for urgent
chemistry and/or hematology, performed in a decentralized lab, not
done point of care or through the core lab.
Criteria for numerator
compliance
 Arrival Date
 Arrival Time
 Urgent Lab Orders
 Date of Lab Draw
 Time of Lab Draw
 Time of Labs Resulted
 Time of Treatment and/or Diagnosis
 ICD-9-CM Principal Diagnosis Code
 Observation Services
Denominator Statement ED Patients admitted to an ICU where lab work is ordered and
resulted to.
Criteria for Denominator
Compliance
 Arrival Date
 Arrival Time
 ED Departure Date
 ED Departure Time
 ICU Admission Date
 ICU Admission time
 Date of ICU Lab order

37
Denominator Exclusions  No Admission Date
 Not ED Patient
 No urgent lab Orders
 Routine Lab Orders
 Patients who leave Against Medical Advice (AMA)
Measure Exceptions Patients who leaves ED prior to lab work-up
Patients whose ED admission was not documented
Patients whose lab orders are verbal, not documented
Sampling
Check if no sampling –
use all eligible cases
According to Joint Commissions Specifications Manual for National
Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13)
through 12-31-13 (4Q13) “Hospitals are not required to sample their
data. If sampling offers minimal benefit (i.e., a hospital has 80 cases
for the quarter and must select a sample of 76 cases) the hospital may
choose to use all cases”.
All eligible cases will be utilized in order to avoid sampling
variations (Zaslavsky, 2001).
Timeline Measuring for 6 month periods for 18 months total
Type of Score Count
Data Source and Data
Collection Methods
Check all apply
Medical record
Clinical database: Name
_______Cerner______________________
Laboratory
Electronic Health Record
Level of
Measurement/Analysis
Who or what is being
measured
Population
National
Program
Quality improvement organization
Applicable Settings Check all that apply
Emergency Department/Urgent Care
Other (Please describe): pediatric hospitals

38
Data Cleaning Data cleaning steps:
1. Define error types;
2. Identify occurrences of errors;
3. Correct errors;
4. Document error occurrences and error types;
5. Modify data entry and translation procedures to reduce future
errors.
These steps are completed in order to ensure accurate and complete
data.
After reviewing all allowable data sources, if is determined that a
“value is not documented, i.e. “missing,” or is unable to determine if
a value is documented, the abstractor should select the “UTD -
Unable to Determine,” value. The data elements Admission Date,
Discharge Date and Birthdate require an actual date for submission
into the data entry tool and “UTD” cannot be selected as an
allowable value. For Yes/No values the allowable value “No”
incorporates the “UTD” into the definition. For data elements
containing more than 2 categorical values and for numerical data
elements (i.e., dates, times, laboratory values, etc.), a “UTD” option
is included as an allowable value and is classified in the same. Files
that contain any invalid and/or missing data will be rejected” (Joint
Commission, 2013).
Priority Areas
Check if measures does not address a
listed priority area
Check all that apply
IOM Priority Area(s):
Additional Priority Area(s):
Health Information Technology
Patient Safety
Disparities
Opportunity for Improvement Based off the current process and resources of our ED
there “is still room for improvement [such as] TATs in
the satellite laboratory could be further reduced by
implementing practices and policies of EDs with
superior performance. These include using a STAT
centrifuge, use of plasma rather than serum and
automatic printing of specimen labels and assignment
of accession numbers at the time of sample collection”
(Dhatt et. al, 2008).

39
Clinical Practice Guidelines
 For process measures,
evidence that the
measured clinical or
administrative process let
to improved health or
cost/benefit.
Check if measure is not related
to a clinical guideline
 "In just 2 years after implementation of the Lean
program, the CNMC microbiology lab has achieved
significant improvements in efficiency. The early
results are a streamlined staffing and workflow
system and a lab designed to maximize both personnel
and equipment.” (Safwat, 2013).
 It has been “found that a satellite laboratory based in
the [ED] have a profound impact upon [TAT] for
blood results. Previous studies have… shown quicker
results, but rarely has this flowed into quicker journeys
for patients…[and] that satellite lab[s] now provide a
useful service to the [ED] that has improved both the
timeliness and quality of patient care” (Leman et. al,
2004).
 “Prolonged laboratory turnaround time (TAT)
contributes to prolonged length of stay in emergency
departments. Establishing satellite laboratories in EDs
staffed by laboratory technologists is one approach
towards reducing TAT” (Dhatt et. al, 2008).
 “The establishment of the ED satellite laboratory
decreased transportation time, within laboratory and
total TAT” (Dhatt et. al, 2008).
Measure Testing/Current
Performance
For each test, summarize the
testing including statistical
results, sample characteristics
and size (patients and sites),
method, and any modifications
as a result of the testing.
If Measure has not been
tested, summarize testing
plans
We have piloted this measure in the Hematology/Oncology
clinic. Appendix A represents the most current month of data
from implementation on Dec. 1 2013.
The testing includes CBC, CMP, WBC for our cancer patients.
We sample every child that has lab orders for urgent testing.
Although the data has improved along with the workflow,
there is still room for improvement such as improving the
ordering and processing process to electronic from manual so
that we have more accurate times the labs are ordered, drawn,
processed and resulted.
Pilot/field testing
If measure is in current use, provide data on measure
performance

40
Initiative II: People
Staffing at children’s is a critical factor at making the program of satellite laboratory
services successful. It is not just about quantity but rather the quality and competency of lab
and clinical staff. We will work to slightly reduce core lab staff by floating staff to certain
ICU or ED satellite labs while acquiring additional medical technologist.
Aligned with NQS Priority 1: Making Care Safer by Reducing Harm Caused in the
Delivery of Care (U.S. DOH, 2014), investing in the education of staff will play a major role
in our technical methods being followed accurately to ensure we reduce potential patient
harm in the delivery of lab services (i.e. blood draws, sweat test, processing). Nursing and
clinicians will receive training on how to order and transport the lab test including timing
samples in, noting the order/draw/transport times on the requisition and viewing electronic
results in Cerner. It is also important to provide visuals such as information sheets, cue cards,
bright stickers with directions or other indicators as reminders to follow the process.
Mirroring similar studies (Shepard et. al, 2009), CNHS division of Laboratory
Management and our Laboratory Information Systems unit will roll out an educational
program for each division with a satellite lab beginning with the ED. It will have lean
principles and will be hands-on, allowing staff to perform the process on test samples. The
Hem/Onc Satellite lab will be where we perform much of the practical training, since it is
already functioning. Because CNHS is a high census hospital with various units that will

41
obtain a satellite lab, training will be conducted in a 6 month window for both the day and
evening shifts, finishing with a an electronic competency assessment. Competency will be re-
assessed biannually for the first 2 years and annually thereafter.
Once qualified lab staff are acquired, they will receive traditional lab, quality and
safety training. However they will receive additional education on the lab process for their
satellite unit in order to understand their role, how the processes differs from core lab and
how to meet the needs of both the patients and clinicians including their median time to
process samples. We look to include national initiatives to improve laboratory technologist
while keeping up with new technology and trends in healthcare. We are working to promote
and develop skilled personnel through improved processes, education and laboratory
advancements (Bennett et. al, 2014).
Our initiative mirrors NQS quality strategies since “quality improvement will be
driven by supporting innovation, evaluating efforts around the country, rapid-cycle learning,
and disseminating evidence about what works” (U.S. DOH, n.d.). To improve our services
and the quality of our care, we first must improve our workforce through learning. Robust
training will also reduce preventable lab errors and incidence of adverse health care-
associated issues related to inaccurate or inappropriate lab testing (U.S. DOH, 2014.
We must enable them to learn and have access to adequate data and tools to enhance
the care we give to patients. In order to do this CNHS, will not only ensure that staff meet the
competency requirements but that we will provide accurate and timely patients results for

42
quicker diagnosis and treatment plans to be developed. As well as giving them access to the
lab information management systems to make ordering and finding results simpler.
Method for Outcome Measure
After clinical and lab staff have been trained and assessed, for 12 months data on
biannual competency assessments will gathered. We will used this data to determine those
that need additional training, assistance or rework of their roles. Trends will help us to
determine if the workflow is functional or too complex for the staff. A survey will be
generated to the staff to determine their stress levels performing with the new process as well
as any issues in the workflow they feel can be improved upon. Lastly an in-service will be
conducted on 3 separate occasions, to have face-to-face conversations with the clinical and
lab staff to determine the pros and cons in the workflow and feedback on ways to improve
upon. By reducing the steps in the process and alleviating past issues in the workflow we
look to see a reduction in delays, through a review of the hospitals productivity report that
comes out monthly.
Initiative III: Lab Accessibility and Technology
Since CNHS has expanded so has the range of test provided and patients we care for
daily. However the core lab has not expanded space, staffing or increased instrumentation to
be able to run the extensive amount of test, daily, that we do currently. In alignment with the
National Quality Strategy Priority 3 (Department of Health and Human Services, n.d.)
“Coordination among primary care, behavioral health, other specialty clinicians, and health
systems will be enhanced to ensure that these systems treat the whole person”, we will work

43
with the clinical units, hospital administration, and the families of our patients to not only
purchase the adequate testing equipment and supplies but to determine how to appropriately
meet the needs of both our patients and care givers.
Our priority to adequately coordinate amongst the respective hospital units is vital to
our success with planning patients care plans, test reporting and treatment plans. Each of us
plays a role in providing quality service to the patient. We will not meet our target if we do
not work in a harmonized manor with the same goals in mind. Not meeting our targets will
ultimately
As CNHS looks to expand their decentralized testing program (i.e. POCT) adding
automated chemistry and hematology testing will not only enhance our clinical lab program
but it will expand lab availability outside their normal scope of services. With the adequate
laboratory technology we will be able to lessen clinician wait time, offer lab work to an
increased amount of patients and limit the amount of patients missing appointments due to
the long wait for results.
CNHS Division of Laboratory Medicine is working to address the communication
and functional gap amongst the various divisions that initiate and provide lab testing. In order
to mend the imparities each designated satellite lab will contain chemistry and hematology
instrumentation that is not only user friendly, it will be a feasible size and low maintenance
such as internal QC’s (Di Serio et. al, 2003) automated calibration, and interfaced with our
laboratory information management system.

44
Decentralized labs not only positively effects inpatients in the designated critical care
units but current outpatients and potential families will now have more access and quicker
result times for lab results performed in the core lab. Because the core lab will not increase in
size, staffing and technology, lessening their workload will allow for routine testing to now
be performed at an optimal manner. Decreasing operations in the core lab, from the various
ICU’s and ED, will allow for us to offer more services to the rest of the hospital, local private
care providers and local outpatient clinics. While research consistently shows the benefit of
shortened turnaround times from the recent rollout of the decentralized lab in the Hem/Onc
clinic we have seen that clinicians are able to diagnose and treat patients quicker, patients do
not leave due to long wait times and chemotherapy patients are able to be infused on
schedule.
Performance Measure
Quality Measure Development Template
Measure Title
STAT Chemistry Testing for ED Patients - Overall Rate
Measure Description Rate of STAT chemistry test for admitted ED patients compared to
the rate of STAT chemistry test for ED patients, performed in the
core lab prior to satellite lab services.
Type of measure Access
Numerator Statement Numerator Statement: Admitted ED patients with STAT chemistry lab
orders who have lab test performed in there satellite lab
Criteria for
numerator compliance
 Admission Date
 STAT chemistry lab test
 Labs performed after June 1, 2014
Denominator
Statement
Admitted ED patients with STAT chemistry lab orders who have lab test
performed in the core lab.

45
Criteria for
Denominator
Compliance
 Admission Date
 Labs performed prior to June 1, 2014
 Routine Chemistry lab test
Denominator
Exclusions
 Patients whose labs were performed in the core lab
 Patients enrolled in clinical trials
 Patients whose admission date occurred prior to the satellite lab
implementation
 Patients without STAT Chemistry Lab orders
Improvement Noted
As:
An increase in the rate of testing in Core Lab
Sampling
Check if no
sampling – use all
eligible cases
According to Joint Commissions Specifications Manual for National
Hospital Inpatient Quality Measures Discharges 01-01-13 (1Q13) through
12-31-13 (4Q13) “Hospitals are not required to sample their data. If
sampling offers minimal benefit (i.e., a hospital has 80 cases for the
quarter and must select a sample of 76 cases) the hospital may choose to
use all cases”.
All eligible cases will be utilized in order to avoid sampling variations
(Zaslavsky, 2001).
Type of Score Rate
Data Source and Data
Collection Methods
Check all apply
Clinical database: Name
_______Sunquest______________________
Laboratory
Data Collection
Approach
 Satellite lab results for all admitted ED patients post Jun 1, 2014.
 Retrospective data sources for required data elements include lab
results and dates from the LIMS (Sunquest) for all STAT
chemistry test performed prior to June 1, 2013 via the core lab.
Level of
Measurement/Analysis
Check all that apply; if “Other”, describe.
Population
National
Program
Quality improvement organization
Applicable Settings Check all that apply
Emergency Department/Urgent Care

46
Measure Analysis This performance measure seeks to determine if the satellite lab has
allowed for better access to care and laboratory services. This measure
will allow for an analyzation of the overall rate of STAT Chemistry lab
test (ordered for admitted ED patients) performed in the satellite lab to the
total STAT Chemistry test that were performed just in the core lab for the
previous 2 years. This data will be used to determine if satellite lab
services has lessened he workload of the core lab, enabling more routine,
diagnostic or Non-chemistry STAT test to be performed in the core lab.
Opportunity for
Improvement
Although the turnaround time for specimens may decrease there is room
to improve on the process such as “taking all blood tests upon arrival of
the patient, rather than take a history, perform an examination, and then
think about what blood tests to do” (Leman et. al, 2004).
Clinical Practice Guidelines
 For access measures,
evidence that an association
exists between the access
measure and the outcomes of,
or satisfaction with care.
Check if measure is not related to
a clinical guideline
 “Overcrowding and prolonged patient length-of-
stay (LOS) in emergency departments (EDs) are
growing problems. We evaluated the impact of
…our ED satellite laboratory on 252 patients
before vs 211 patients after implementation. All
patients also underwent testing with the existing
central laboratory. Turnaround time (from blood
draw to result) decreased approximately 79% (~2
hours vs 25 minutes). The mean ED LOS declined
from 8.46 to 7.14 hours. Hospital admissions
decreased… ED discharges increased” (Lee-
Lewandrowski et. al, 2009).
 Improving access to diagnostics is an essential
component of the health services strategy to
improve access to emergency care. In particular it
is recognized that the time taken to obtain blood
results for patients in the emergency department is
a rate limiting step that can prevent them being
seen, treated, and either admitted or discharged
within four hours” (Leman et. al, 2004)
Chapter VII - Legal and Regulatory Evaluation

47
Laboratories within hospitals are required to follow just as stringent guidance’s as
their parent organization. For CNHS department of laboratory medicine although we are
accredited by Joint Commission (JC) we have always be required to operate under the
provisions of DC/MD/VA Department of Health (DOH) agencies in alignment with the
Clinical Laboratory Improvement Amendments (CLIA). DOH and JC draft their guidance’s
in compliance with the federal guidelines which is CLIA. CLIA regulates how we perform
test, manage our labs, audit, and technology use and control the quality of testing
performance. To operate in compliance with our accrediting agency, Joint Commission, the
following 3 regulations (Noted in Table 2) must be considered for this enterprise to.
Table 2:
Chapter: Human Resources
HR.01.06.01 Staff are competent to perform their responsibilities.
Chapter: Quality System Assessment for Non-waived Testing
QSA.02.12.01
The laboratory investigates and takes corrective action for
deficiencies identified through quality control surveillance.
QSA.02.07.01
The laboratory has its own quality control ranges with valid
statistical measurements for each procedure.
*Note: Joint Commission Standards: Accessible through their webpage via a controlled portal http://www.jointcommission.org/.
Per previous Joint Commission surveys, the requirements noted in Table 1, among
others, were considered our high risk areas and areas where we were either non-compliant or
partially compliant. CNHS Division of Laboratory Medicine must establish the proper

48
guidance’s and processes to meet both these JC standards and the applicable CLIA regulation
they are formed around.
The laboratory has implemented an incident management program which utilizes the
hospital’s Safety and Incident management system. The system allows us to submit incidents or
review incidents pertaining to the lab. You can electronically track and notify other effected
departments. The Incident details including patient information, investigation and contact
information is housed in the system however because we did not have a process for root cause
analysis, corrective actions and effectiveness checks we will implement a quality incident form
to capture these items necessary to monitor and measure the outcomes more accurately.
Joint Commission requirement, QSA.02.07.01, is the most difficult and time consuming
to implement. Although we are only using 2 instruments to perform non-waived testing in the
satellite labs, each test performed must have a procedure and quality control ranges with valid
statistical method. After our initial gap analysis it was noted some of our reference ranges were
from the manufacturer rather than control ranges that were created by us and validated by our
core lab. This is critical because it can have an effect on patient samples. For instance, using the
manufacturers range, an A1C (diabetes test) may raise a flag of high, based off their control
ranges however, if we have our own control ranges that have been validated on that particular
instrument, it can read as normal results. This is significant as it can influence whether a patient
is accurately diagnosed or treatment.
While ensuring regulatory compliance can be tedious, following state and federal laws
can be a major factor in the rollout of all of our satellite laboratory services. Legal guidance’s

49
are complex and take professionals in regulatory compliance to monitor and manage any
compliance functions related to laboratory services. We will add to the Quality Assurance team
a compliance supervisor in order to manage all regulatory processes and projects. The 3 legal
requirements that greatly impact our operations are the Fraud and Abuse laws, Billing and
Coding laws and Employment laws.
According to research performed by Otte and colleagues (2010), fraud and abuse laws
can greatly impact a laboratory when it comes to vendor management. They note (Otte et. al,
2010) that labs have to be mindful and analyze these laws including the Anti-kickback law
when it comes to all contractual agreements amongst vendors, employees and other contracts
regarding services and finances. During the purchase of our new instruments for the labs and
demoing instruments with vendors we will follow the same process we currently have in place.
All contracts must be reviewed and approved by both the Lab’s Operational Director and the
hospitals legal team. We do not allow employees to except any goods, regardless of monetary
amount, from our vendors.
Both the billing and Coding laws have been both the labs and hospital’s most difficult to
abide by as we are still functioning off 2 separate billing systems. We also have many manual
tests that can cause patients to be double-billed or inaccurately billed for services. Billing laws
protect patients and Medicaid/Medicare from being over charged. It can be difficult to remain
legal with such complex laws (Otte et. al, 2010) because of the type of coding required for
specific test and method for testing however regardless of being intentional or not we would be
committing fraud if we incorrectly bill. To ensure billing compliance we must implement 1
electronic system to capture lab results and bill. Also we must ensure that we are billing

50
adequately and fair. We will update our billing process and audit coding in our electronic
system to verify its accuracies and make any needed updates. We will continue to follow our
current practice of billing the same for all patients and not increasing the cost for test that can be
performed using various methods such as point of care or in the satellite lab on a chemistry
analyzer. Currently we are working on acquiring instrumentation that is interfaced with the
system so that results automatically upload to the interface and we are better able to monitor
testing that is ordered and resulted multiple times on the same patient sample for the same test,
as this practice is illegal.
The Centers for Medicare & Medicaid Services (CMS) is a government agency that we
are both monitored by and receive payments from because they are a government funded health
care program for our families and individuals with low incomes. While CMS does not focus on
laboratory operations they work to prevent fraud by monitoring our billing practices for
laboratory test. Because CNHS laboratory operates as an independent clinical laboratory, we
were considered moderate risk based of a categorization created by CMS when they
implemented new regulations on March 25, 2011, to “protect against fraud” (Senft, 2011).
Fraud prevention is a requirement by the healthcare reform legislation that rolled out in 2010.
The categorized set by CMS means that the organization will have to go through more rigorous
audits and document submission processes (Senft, 2011). The CMS requirements help to ensure
CNHS lab does not double bill for lab procedures, inaccurately bill managed care providers or
not equally charged all patients receiving the same service (Stoler, 2010). It protects both the
patient and health insurance providers. It also improves oversight over labs to ensure they have

51
complete oversight of lab processes and of physicians to limit over ordering of lab test (Stoler,
2010).
Business oversight must improve by focusing on quality control in the laboratory for
improved accuracy and analysis in reporting of patient data. According to the Joint Commission
(2014), CMS has introduced a new quality control requirement for clinical laboratories that is
currently optional however it will be mandatory after January 1, 2016. The new program for
quality control is The Individualized Quality Control Plan (IQCP) which replaces our current
program, Equivalent Quality Control (EQC). The new quality control plan means that a risk
assessment will need to be conducted for each test system. We must then create an
individualized quality control plan for each system and ensure we have adequate quality
supervision available. According to Joint Commission (2014) this new program is to not
improve the adequacy of testing but to be able to swiftly detect errors to ensure that our test
results are accurate for reliable patient care.
Chapter VIII – Strategic Plan Implementation and the Most Likely Future State
Communication Plan
Communication is a key factor in the success of our satellite laboratory services. With
laboratories being opened in various units of a major hospital, we will have to engage the
clinical staff through various forms of communication in order to ensure they understand the
transition process. All hospital staff will be notified of the open dates of the satellite labs,
their services and the units they will serve. Staff from the units themselves will be
communicated to on a personal level in 3 phases. They will receive procedural

52
documentation, testing information, lab technical support info and rollout dates for their
units. It is important to “stress” (Frahm et al., 2007) the information we are communicating
so that it becomes more effective as we open the satellite labs. Communication will be rolled
out in 3 phases:
1. 6 months before roll out: Presentation via Hospital Management Meeting
2. Monthly- 4 months before roll out: Email Notifications
3. 3 days before rollout: Nurse/Physician team huddle (morning and evening shift) w/
all units acquiring a satellite lab
To initially communicate the rollout a presentation from our Chief of Laboratory
Medicine will be delivered via PowerPoint at the hospitals management meeting which
involves all levels of management staff. In order to keep the message fresh, we will initiate
email reminders 2 months later on a monthly basis until the labs open. The emails will be
brief notification describing when and where the labs will open as well as which type of
patients they will serve.
During phase 3, the staff will receive a 1 page lab plan in order to give them
operational details, lab support contact information and testing information (transport
guidance’s, allowed test, process time, specimen handling requirements). Research (Jacobs &
Duncan, 2009) has shown that brief descriptive documentation can assist nursing in better
understanding the workflow, while simultaneously decreasing process deviations.
As part of the hospitals closed loop communication program, we will administer a
survey pre and post satellite lab rollout and an annual survey. The surveys function as a way

53
to gauge the needs, wants and or issues our customers have with the enterprise. They also
serve as a way to measure the success of the satellite services from the view of the front line
staff, in the workflow (Karalapillai et al., 2013). The surveys will be administered to lab
staff, nursing and the physicians from the respective areas with satellite laboratories. We
want to ensure we are not just improving the turnaround time of patient specimens but the
overall quality of our services. The brief survey will contain questions aimed at how the
clinical team is adjusting to the new lab services, ways we can improve, and the positive
functions of the new program.
According to the National Quality Strategy Priority 2: Ensuring That Each Person and
Family Are Engaged as Partners in Their Care, communication amongst both the hospital
staff and patients will initiate a partnership that enables effective care management for the
patients (U.S. DOH, 2014). In order to comply, we will communicate to our patients of our
new services on our hospital TV network throughout the hospital, post bulletins in each
applicable unit and stock brochures at each of the welcome desk. By sharing our plans
throughout the entire development phase, patients will be able to make better shared
decisions with their caregivers as to what testing options they have including location and lab
test.
Implementation
Enactment of each satellite laboratory will be on the same day at the beginning of FY
2016. After communication is initiated we will begin the final build out of each site including
stocking of supplies and instrumentation validation, staff training and validation of testing
methods. We will utilize surveys to measure the success of implementation as well as

54
monitor any incident reports related to the satellite labs. The strategy to execute
implementation with limited issues or delay in rollout time, is to perform the following steps
(RidderHof et al., 2013):
1. Determine and organize specific testing for each lab
2. Develop laboratory workflow for testing and operations
3. Initiate procurement forms for funding resources
4. Setup billing coding
5. Setup resulting structure in the laboratory information system (Sunquest)
6. Validate testing platforms and perform correlation studies as needed
7. Train all applicable satellite lab staff
Future State
Our economic model will change over the next 5 years because of instrumentation
acquisition maintenance, supply demands and contractual agreements. Our instrumentation
will be paid-off which will alleviate funding to designate in to other lab operational cost. We
also have signed contracts with our vendors where we order a designated amount of test
products monthly (based off the average number of test we run a month) which in turn they
gives us between a 30% and 45% discount off reagent and test kits. This will reduce the cost
per test saving both the lab and patients money.
Although the enterprise will allow for additional testing, it will not necessarily
generate additional revenue. We must increase our patient census to incur more testing and
revenue, allowing for the core lab to add to their test menu. Adding to the test menu will

55
allow for the lab to perform more test on in/outpatients as well as increase reference lab
testing for other hospitals, university medical centers and laboratories that do not have the
ability to perform specialty test as we do.
As for staffing, there will be an economic change for personnel because based off our
union contract, our techs and phlebotomist are required to receive a 3% raise annually for a 4
year period which will be renegotiated in 2017. Not only will we have to repurpose funding
annually to budget for staff, we will also have to consider ancillary cost that will affect our
budget such as our laboratory information system (LIS). We are required by regulatory
authorities to make changes to our labeling module and we will be implementing new
programs to become more efficient, by utilizing additional modules in our LIS. However
each additional interface runs a $5000 and changes to modules can run us between 10 to
twenty thousand dollars.
There is a strong future for satellite laboratory services, however both the hospital
and lab management must work to increase testing capabilities and increase their presence as
a major reference laboratory in order to ensure continuous financial growth and operability.
With changes to regulatory policies and practices, it is vital we consider all possible changes
that can affect our lab enterprise. We must be flexible and consider new methodologies to
laboratory testing in order to sustain and grow (RidderHof et al., 2013).
Strategy Map
In figure 1, we have provided a coalesced form of our enterprises strategic map, to
provide a focused view of our strategy and vision.

56
Figure 1: CNHS Laboratory Medicine: Satellite Services Strategy Map
Financial
Because CNHS Division of Laboratory Medicine, is financially funded from
revenue of lab testing and capital from the hospital budget, we recognize our financial
limitations to expand our services including staffing, resources, instrumentation and space.
We must stay within our limits while ensuring we are providing robust, compliant services to
our patients. Although we do not typically receive philanthropic funding from the hospital, it
is a viable option to sustain our services, by applying for philanthropic funding or hosting an

57
annual event to raise funds. Because lab testing can be expensive for both the hospital to
maintain as well as the patient to receive, our process will consistently be reviewed and
follow lean principles to reduce operational cost and maintain steady billing cost for patients.
Customer
Maintaining a steady revenue and limiting financial loss, will allow us to
increase testing services to our current and prospective. Our ultimate goal is to expand our
satellite labs to all of CNHS outpatient centers to reduce cost and wait time of send-out test,
lab errors in processing and transport. By staying financially stable and under budget we are
able to enhance the services we provide for improved customer satisfaction. CNHS Lab
division recognizes the importance of our clinical staff and their need to provide value-added
consultations for their patients. With this understanding, we are working to provide
additional lab services to assist them in providing quality diagnosis and safe treatment plans
for their patients.
Internal Business Process
CNHS internal processes are derived from our drive to increase quality of
health outcomes and provide equal care to our patients. While our workflows are driven from
the principles of our values our goals give us the basis to measure the success of our internal
processes. We are working to change the current model of the laboratory services by
dedicating more lab sites directly to the location of patient care. Because we value the lives
of our patients we are looking to add to our testing menu without congesting our workflows
and streamlining our current processes for more efficient testing. CNHS Lab is working to

58
be the premier pediatric laboratory nationally, providing optimal care for our patients and
accessibility for our clinical staff.
Learning and Growth
CNHS is an academic based hospital that teaches our staff not to be just
exceptional but to ensure everything they do is the epitome of quality and safety. We have an
ethical obligation to exude excellence with incomparable patient care. We strive to choose
premium phlebotomist and medical technologist to service our patients by ensuring they
maintain applicable education (i.e. certifications, degrees, licensing) by providing funding for
education and training.
To optimize our relationship with our clinical staff we will maintain staff
meetings and quarterly surveys for organizational engagement in our enterprise; promoting
an environment of solidarity and value. This also allows us to educate the clinical staff on
changing policies, lab standards or economic changes that can effect operations.
Summary
CNHS realizes the challenges we face of increasing services with limited
capital and lab space. However they also understand the greater need to improve the quality,
care and access to our patients. Our strategy plan is our source to work through any
limitations we face during the development, implementation or operational phases by giving
us the foundation to continuously improve upon our enterprise. During the enactment of our
satellite labs we will monitor and update our strategic plan as changes to our current model
no longer are actionable or applicable to the enterprise. It is vital, regardless of circumstance,

59
we continue to be dedicated to the success of our enterprise while continuously pushing to
grow our presence in the patient community. Because change is inevitable, our strategic plan
remains flexible to evolve with the needs of our stakeholders and will be a compass to
change for the betterment of patient care. We have built our enterprise to withstand all
regulatory and industry changes in order to stay compliance and relevant in the arena of
laboratory services. The strategy of CNHS Laboratory will forever be evolving and
continuously working to uphold our mission to; deliver exceptional patient care by providing
inclusive, pediatric laboratory testing and diagnostic services with complete focus on
innovation, education and improving the health of children.
Chapter IX - Chapter X – References

60
Akdere, M. (2009). A multi-level examination of quality-focused human resource practices
and firm performance: Evidence from the US healthcare industry. International Journal
of Human Resource Management, 20(9), 1945-1964. doi:10.1080/09585190903142399
Bauer, C., & Bozard, C. (2009). Health information exchanges case history. Leveling the
playing field. How one health system competes with a national reference lab for
outpatient lab services revenue. Health Management Technology, 30(2), 14
Benge, H., Bodor, G., Younger, W., & Parl, F. (1997). Impact of managed care on the
economics of laboratory operation in an academic medical center. Archives Of
Pathology & Laboratory Medicine, 121(7), 689-694.
Bennett, A., Garcia, E., Schulze, M., Bailey, M., Doyle, K., Finn, W., & ... Zaleski, S.
(2014). Building a Laboratory Workforce to Meet the Future: ASCP Task Force on the
Laboratory Professionals Workforce. American Journal Of Clinical Pathology, 141(2),
154-167. doi:10.1309/AJCPIV2OG8TEGHHZ
Bishop, T., Federman, A., & Ross, J. (n.d). Laboratory Test Ordering at Physician Offices
with and without On-Site Laboratories. Journal Of General Internal Medicine, 25(10),
1057-1063.v
Buljanović, V., Patajac, H., & Petrovečki, M. (2011). Clinical laboratory as an economic
model for business performance analysis. Croatian Medical Journal, 52(4), 513-519.
doi:10.3325/cmj.2011.52.513

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