Benchmarking and Quality Management Indicators in Three Medi

7/28/2019 Benchmarking and Quality Management Indicators in Three Medi

http://slidepdf.com/reader/full/benchmarking-and-quality-management-indicators-in-three-medi 1/10

G E N E R A L P A P E R

Benchmarking and quality management indicatorsin three medical laboratories

A. Salas Garcıa Æ C. Vilaplana Perez Æ A. Calderon Ruiz Æ C. Gimeno Bosch ÆJ. Perez Jove Æ C. Sevillano Herrada Æ M. A. Bosch Llobet Æ X. Boquet Miquel

Received: 7 August 2007 / Accepted: 17 January 2008 / Published online: 12 February 2008

Ó Springer-Verlag 2008

Abstract The aim of this study was to calculate various

annual quality management indicators and implement themas a management tool in laboratories. The study was per-

formed in three laboratories over five years, from 2000 to

2004. These laboratories are part of the XHUP (Public

Hospital Network in Catalonia). We collected 20 annual

items over five years and calculated 20 annual indicators.

The Laboratory Manual Index Program from the College of

American Pathologists was used as a reference. We also

compared an analytical quality indicator versus produc-

tivity and calculated annual budget laboratory deviation.

The information obtained from these indicators provides

laboratories with a useful benchmarking tool to determine

the results of management change and understand the real

situation in laboratories. We found a lack of standardisation

in management data. A future area of work could involve

unifying some of the different characteristics.

Keywords Quality indicators Á Clinical laboratory

management indicators Á Benchmarking Á Budget

Introduction

In recent years, clinical analysis laboratories have under-

gone significant evolution. This has entailed a series of

changes that can be grouped into technological and

organisational changes. The technological changes in

automation and in information systems have led to the

incorporation of new diagnostic tests and a change in the

demand for laboratory services. These include the clients’

(patients, clinics, and health institutions) new quality

requirements, which must be met. Many of these changes

entail an additional cost for the clinical laboratory service.

The organisational changes, whether caused by technol-

ogy or by the different management models that have been

examined, also led to modifications in the interrelationships

between laboratories in the supply and demand of services.

These changes have coincided with a period of limited

financial resources. Therefore, laboratory staff have had to

make an effort to optimise their resources and avoid

increases in overall laboratory costs.

A spectacular change in quality requirements is also

occurring. Classic quality control in the analytical process is

giving way to total quality management—a process-oriented

focus that identifies the processes established in the labora-

tory—and the monitoring of these through indicators. This

change is noticeable in the increased implementation of

quality management systems, compulsory in the USA with

the Clinical Laboratory Improvement Amendments of 2003

Presented at the Conference Quality in the Spotlight, March 2006,

Antwerp, Belgium.

A. Salas Garcıa (&)

Planning and Quality Directorate, Consorci Sanitari de Terrassa

(CST), Terrassa Hospital, Ctra. de Torrebonica, w/out num,

08227 Terrassa, Barcelona, Spain

e-mail: [email protected]

C. Vilaplana Perez Á A. Calderon Ruiz

Medical Laboratory Department,Badalona Serveis Assistencials (BSA), Badalona, Spain

C. Gimeno Bosch Á J. Perez Jove

Medical Laboratory Department (CST), Barcelona, Spain

C. Sevillano Herrada

Management Control and Information Analysis (CST),

Barcelona, Spain

M. A. Bosch Llobet Á X. Boquet Miquel

Medical Laboratory Department,

Consorci Sanitari del Maresme (CSdM), Mataro, Spain

123

Accred Qual Assur (2008) 13:123–132

DOI 10.1007/s00769-008-0365-y



or voluntary under the ISO 9001:2000 standard certification

or the European Foundation of Quality Management,

depending on each country’s regulations. According to data

published by the Asociacion Espanola de Normalizacion y

Certificacion (AENOR), 2002 [1], 331 health-related com-

panies were registered under UNE-EN ISO 9001:2000, 20 of

these were clinical laboratories. In 2005 [2] the figure

reached 570, 88 of which were clinical laboratories. In thiscertification body alone, the increase was 72% for health

related companies and 340% for clinical laboratories.

The professional in charge of the laboratory must resort

to the use of tools that help in the organisation, manage-

ment, and administration of the service, and in the analysis

and assessment of their effectiveness [3–5].

In the testing area, laboratories are increasingly obtain-

ing data from both internal quality control and external

quality assessment programmes [6]. They then use this

information to define indicators that enable us to assess

analytical processes.

Some studies and publications suggest that this modelshould be used in laboratory management. They also

indicate that the feasibility of making comparisons between

laboratories should be assessed [7, 8].

Although laboratories are aware of existing recom-

mendations, they do not currently share one model to suit

all the different characteristics of each laboratory. These

differences are even greater between laboratories from

different countries [3, 9] and, in some cases, impede col-

lection and application of this data in real time.

Furthermore, in some laboratories, single financial items

maybe assigned to various internal or external cost centres. In

addition, laboratory staff can be contracted by different

entities under differentcontractual agreements. This situation

contributes to increasing the variability in this environment.

Official institutions [10] and scientific associations are

making efforts to reach a consensus on one set of specific

criteria.

The practical use of this study is to disseminate the

benefits of applying certain management tools in three

laboratories. This information will allow managers and

directors of health institutions’ laboratory services to

monitor their performance as managers of material and

human resources. These results will also help them to

assess their decisions in continuous improvement and re-

engineering processes, thus enabling them to make corre-

sponding changes and reorient the processes to guide them

towards the predefined goals.

Materials

Data from three laboratories with clear hospital orienta-

tions were collected from 2000 to 2004 inclusive. The

laboratories are part of the XHUP (Public Hospital Net-

work in Catalonia) and are linked to teaching hospitals.

Data were gathered and recorded following the recom-

mendations from the NCCLS document [5] and the

instructions from the CAP programme organisers [7], in

order to have harmonised indicators.

The basic information from the laboratories was

grouped by year. Papers published by some authors of this study were used as reference [8]. Primary data were

harmonised in order to have a common database and

homogenous indicators for benchmarking.

Laboratory descriptions

The participating laboratories were:

– Medical Laboratory Department, Consorci Sanitari de

Terrassa. This is an integrated, clinical analysis, hospital

laboratory with routine and stat testing services thatundertakes scheduled specimen collection from outpa-

tients. It achieved ISO 9001 2000 Quality Management

Certification in 2004. It is located in a 340 acute bed

hospital. The laboratory also services a prison hospital

with 32 beds, 34 primary care centres, and two specia-

lised primary care centres. The latter were integrated

without staff growth, but with an increase in laboratory

automation. They provide services to a population of

over 400,000 inhabitants. Six of these centres are

managed by the consortium and the others belong to

the Department of Health of the Catalan Government

that contracts our testing services through an agreement

with the consortium. At the beginning of 2003, a contract

was signed with an external laboratory, in which the

latter made a commitment to supply the reagents

required for health care activities. The cost of this

service is determined by the laboratory testing activity.

– Medical Laboratory Department, Badalona Serveis

Assistencials. This is an integrated, clinical analysis,

hospital laboratory with routine and stat testing services

that undertakes scheduled specimen collection from

outpatients. Its quality management system was not

certified during the study period. It is located in a 157

acute bed hospital. This laboratory also provides

services for 70 chronic beds and three primary care

centres, covering a population of 100,000 inhabitants.

During the study period, the management model

changed and five primary care centres were incorpo-

rated. At the beginning of 2002, testing services from a

basic health care area covering 13,400 inhabitants was

incorporated. An agreement, called the Management

Contract, was made with an external laboratory at

the beginning of 2001. In this contract, the external

124 Accred Qual Assur (2008) 13:123–132

123



10. Number of testing paid hours: number of hours paid

to personnel who work in testing. It includes the

number of hours spent on testing by personnel who

also perform other duties (sample collection, admin-

istrative, management). All the hours worked, and

those not worked (leave of absence, holiday, etc.) by

the entire personnel who performed testing activities

were counted and registered yearly.11. Total number of laboratory worked hours: number of

hours worked by all the laboratory staff. This includes

the hours of pure work but not the hours spent

teaching, in sessions or meetings, on vacation, on

leave of absence, etc.

12. Total number of laboratory paid hours: number of

hours that incurred a cost for the laboratory. This

includes pay for test technicians and other staff.

Vacations, leaves of absence, etc. are included.

13. Testing labour expense: total corresponding to item

10. Includes company costs, such as all national

insurance contributions.14. Total labour expense: total corresponding to section

12. Includes company costs, such as all national

insurance contributions.

15. Consumable expense: includes controls, reagents,

direct costs, office materials, etc. Telephone expenses,

indirect costs, and training are not included. In our

management models, some financial items (equipment

depreciation and equipment maintenance) have been

included in the consumable expense.

16. Reference and/or referral test expense: cost of

analyses carried out in reference laboratories or

subcontracted independent laboratories.

17. Blood expense: cost associated with transfusion

products, whole blood, blood components such as

platelets, plasma, etc.

18. Manageable expense: total cost of items 14 and 15.

19. Total test expense: total cost of items 14, 15 and 16.

20. Total expense (tests + blood): total cost of items 14,

15, 16 and 17.

This paper does not present these primary figures but only

the calculation results derived from them.

Indicators: A series of indicators was determined on the

basis of the primary data gathered, according to previouscriteria. The indicators encompass three categories: pro-

ductivity, utilization, and cost-effectiveness. The quotients

in parentheses (Table 1) correspond to the previous pri-

mary data items. These ratios were used as indicators.

The ratios calculated are listed in Table 1, grouped into

productivity (indicators 1–7), utilization (indicators 8–10)

and cost-effectiveness indicators (indicators 11–20).

Benchmarking requires harmonisation of indicators in

the three laboratories. The number of people working

(testing and non-testing staff) was calculated by dividing

the number of hours by 40 (for 1 week) and by 52 weeks

(for 1 year). The 20* indicator is the 20 indicator corrected

according to CST activity. Testing activity originating in

the hospital and in the primary care centres managed by the

Terrassa Health consortium was included. The activity of

primary care centres not managed by the CST that con-

tracted our laboratory services was excluded.EQAS : The global analytical quality for each laboratory

was assessed by PGCLC organizer reports. Laboratory

results are classified as excellent, good, acceptable, and to

be reviewed. The number of results that do not need to be

reviewed (excellent, good, and acceptable) was used as

analytical quality indicator.

Budget : The budget deviation between budget allocated

to the laboratory and actual costs was calculated.

Management changes: During the study years, the three

laboratories started to apply management changes and use

benchmarking as a tool. The following changes were

implemented: outsource tests according to economicalcriteria and turnaround time, use only one reference labo-

ratory, unify consumable purchase using a single supplier

for the three laboratories, perform primary health care tests,

and increase automation. Nevertheless, the Terrassa labo-

ratory concentrated on primary tests while the Badalona

promoted the outsourcing strategy.

Results

The results are presented in two different groups. The first

group corresponds to the tables.Table 1 shows the indicators followed by a quotient in

parentheses that corresponds to the primary data used for

their calculation.

Table 2 corresponds to the evolution of external quality

assessment results that did not need to be reviewed. The

three laboratories have an indicator value superior to 95%.

Table 3 shows the budget deviation during the study

years. The Terrassa laboratory shows yearly actual costs

under budget costs (negative deviation). The Badalona and

Mataro laboratories show a positive deviation during most

of the study years.

In the second group, which corresponds to the figures,we show a series of indicators and their evolution over the

study years. We are aware that more graphs could be drawn

up from the items in Table 1. However, we leave this up to

the reader who is interested in specific aspects of this study.

We have chosen to focus on those aspects which we con-

sider to be most relevant.

The comments that best describe the indicators from

Table 1 are presented in the discussion section. Neverthe-

less, we would like to mention certain aspects that can be


123



Table 1 Annual indicators

Item 2000 2001 2002 2003 2004

1. Number of tests performed in the laboratory/testing workers a 76,905 84,153 92,935 98,145 101,821

Primary data (2/10) b 62,283 50,640 60,392 76,972 82,128

c 60,162 68,950 77,285 81,101 84,971

2. Number of tests performed in the laboratory/total workers a 58,086 59,900 66,151 69,859 72,476

Primary data (2/12) b 49,393 37,980 42,275 50,032 49,046

c 39,106 44,817 50,235 52,716 55,232

3. Testing workers/total workers (%) a 75.53 71.18 71.18 71.18 71.18

Primary data (10/12) b 79.30 75.00 70.00 65.00 59.72

c 65.00 65.00 65.00 65.00 65.00

4. Number of tests performed in the laboratory/total worked hours a 30.35 30.64 36.11 38.56 38.55

Primary data (2/11) b 27.72 23.21 30.13 30.75 30.49

c 19.38 22.21 24.90 29.17 27.38

5. Number of tests performed in the laboratory/total paid hours a 27.93 28.80 31.80 33.59 34.84

Primary data (2/12) b 23.75 18.26 20.32 24.05 23.58

c 18.80 21.55 24.15 25.34 26.55

6. Total worked hours/total paid hours (%) a 92.00 94.00 88.08 87.11 90.40

Primary data (11/12) b 85.67 78.65 67.46 78.23 77.35

c 97.00 97.00 97.00 86.89 97.00

7. Number of tests performed in the laboratory/total number of tests (%) a 99.32 99.17 99.29 99.24 99.25

Primary data (2/1) b 99.03 92.86 92.68 94.31 94.53

c 98.41 98.44 98.18 98.07 97.88

8. Number of tests performed on hospital inpatients/total number of bed days a 5.13 5.53 5.43 5.75 5.85

Primary data (4/7) b 5.96 5.90 5.18 5.68 6.26

c 5.40 5.34 5.57 5.88 6.01

9. Number of test performed on hospital inpatients/number of discharges a 30.78 31.68 32.55 33.53 32.05

Primary data (4/8) b 34.07 34.01 30.92 31.64 32.25

c 31.58 35.90 34.82 36.03 35.48

10. Number of test performed on hospital outpatients/number of outpatient visits a 1.38 1.36 1.35 1.41 1.55Primary data (5/9) b 3.13 2.54 2.72 2.34 1.99

c 3.11 2.99 3.04 3.08 2.91

11. Testing labour expense ( €)/number of tests performed in the laboratory a 0.44 0.40 0.37 0.40 0.39

Primary data (13/2) b 0.43 0.44 0.43 0.47 0.31

c 0.50 0.46 0.45 0.48 0.48

12. Total labour expense ( €)/number of tests performed in the laboratory a 0.58 0.61 0.58 0.62 0.61

Primary data (14/2) b 0.54 0.62 0.61 0.65 0.56

c 0.77 0.70 0.70 0.74 0.75

13. Consumable expense ( €)/number of tests performed in the laboratory a 0.65 0.65 0.52 0.55 0.53

Primary data (15/2) b 0.57 0.44 0.53 0.57 0.60

c 0.58 0.54 0.66 0.89 0.92

14. Manageable expense ( €)/number of tests performed in the laboratory a 1.23 1.26 1.10 1.17 1.14

Primary data (18/2) b 1.13 1.07 1.14 1.22 1.16

c 1.35 1.25 1.35 1.64 1.66

15. Total expense ( €) (tests + blood)/total number of bed days a 6.84 7.43 6.53 7.33 7.26

Primary data (20/1) (4/7) b 7.59 7.25 6.75 8.02 8.43

c 9.07 7.90 8.91 9.80 10.26

16. Total expense ( €) (tests + blood)/number of discharges a 41.06 42.61 39.15 42.78 39.76

Primary data (20/1) (4/8) b 43.41 41.79 40.28 44.69 43.45

c 53.07 58.04 61.66 66.24 67.13

Accred Qual Assur (2008) 13:123–132 127

123



observed in the evolution of some of the indicators. The

indicator for item 3 shows us the relationship between the

testing workers with respect to total laboratory workers.

This relationship was stable in the Terrassa and Mataro

laboratories. However, the number gradually decreased

in the Badalona laboratory. The Terrassa laboratory had

the best ratios for the number of tests per outpatient visit

(item 10).

The Terrassa laboratory had the highest level of pro-

ductivity, followed by Mataro and Badalona.

The highest demand per discharge was found in the

Mataro hospital. However, this indicator remained stable.

The Badalona and Terrassa hospitals started from different

levels in 2000, reaching the same level in 2004.

The expense per test has increased in the Mataro labo-

ratory in the last two years. Meanwhile, the Badalona and

Terrassa laboratories experienced variation in the first

years followed by a small change. The Badalona and

Terrassa laboratories had very similar cost per test in the

last three years.

The best evolution was seen in the Mataro laboratory, as

the labour cost component of the total cost of each test was

reduced. This same trend was observed in the Badalona

laboratory. In the Terrassa laboratory, an initial increase in

the first two years was followed by a period of stabilisation.

Data about health institutions were provided by the

respective financial departments. These costs are not homo-

genised since each consortium has its own calculation

criteria.

Figure 5 shows the cost evolution in each laboratory

with respect to the total cost of the health institution on

which it depends. Only the direct laboratory costs were

included in this study.

Although the costs per test in the Terrassa and Badalona

laboratories were very similar, these laboratories had very

different levels of testing activity. TheMataro laboratory had

the highest costs and an intermediate level of testing activity.

Figure 7 shows that the increase in testing activity was

accompanied by an increase in productivity in the Mataro

and Terrassa laboratories. A comparison of the three lab-

oratories shows that productivity levels rose as the size of a

laboratory or the degree of automation increased (as a

result of the testing activity increase). Nevertheless, the

biggest change occurred in the Mataro laboratory, in which

the increase in productivity due to the increase in activity

was higher than in the Terrassa laboratory.

In the Terrassa laboratory, there was a decrease in the cost

per test as productivity increased. This trend was reversed in

the Mataro laboratory, as increasing productivity raised the

Table 2 Analytical quality indicator

2000 (%) 2001 (%) 2002 (%) 2003 (%) 2004 (%)

Terrassa 95.3 97.0 96.6 95.1 96.8

Badalona 99.4 96.3 95.8 95.7 96.6

Maresme 96.5 97.1 97.4 98.0 96.7

Table 3 Annual budget laboratory deviation

2000 (%) 2001 (%) 2002 (%) 2003 (%) 2004 (%)

Terrassa -0.6 -5.4 -7.6 -4.0 -3.6

Badalona 7.08 -2.48 9.95 17.2 7.74

Maresme 6.67 2.12 6.78 4.54 -5.51

Table 1 continued

Item 2000 2001 2002 2003 2004

17. Total expense ( €) (tests + blood)/number of outpatient visits a 1.85 1.82 1.62 1.80 1.92

Primary data (20/1) (5/9) b 3.99 3.12 3.55 3.30 2.68

c 5.22 4.83 5.38 5.66 5.50

18. Reference + referral test expense ( €)/number of tests performed in

reference + referral laboratories

a 9.03 4.51 5.12 4.65 4.01

Primary data (16/3) b 10.95 5.50 5.50 5.50 5.50

c 14.81 16.21 14.81 3.21 3.81

19. Blood expense ( €)/total expense ( €) (tests + blood) (%) a 4.19 4.27 6.41 6.18 6.27

Primary data (17/20) b 3.85 9.13 8.56 8.15 7.53

c 7.19 8.59 9.66 9.36 9.79

20. Total expense ( €) (tests + blood)/total Hospital expense ( €) (%) a 7.49 7.23 7.10 6.92 6.60

b 4.46 3.65 3.76 4.59 4.17

c 4.70 4.69 5.17 5.04 4.63

20*. Total expense ( €) (tests + blood)/total Hospital expense ( €) (%)

Corrected

a 3.37 3.25 3.20 3.11 2.97

a Terrassa Laboratory, bBadalona Laboratory, cMataro Laboratory


123



cost per test. There was no clear trend in the Badalona

laboratory.

Discussion

This study describes the longitudinal trend in efficiency,

labour productivity, and the utilization of three clinicallaboratories. As in the study published by Valenstein et al.

[11], we also met with a series of limitations, some of

which entail the exclusion of specific costs attributable to

the laboratory. We agree with Garcia in the chapter Lab-

oratory Benchmarking [9], that some costs can be difficult

to quantify in our laboratories. Such costs include cleaning,

waste treatment, energy resource, water consumption, etc.

The ratios obtained are overall averages (the cost of a

test), and do not include the level of difficulty or com-

plexity of the tests. But the three laboratories perform tests

of the same level of complexity with a different level of

automation, depending on the testing activity. High com-plexity tests (DNA, gas or liquid chromatography tests,

etc.) are sent to the same external reference laboratory.

Nevertheless, we believe that undertaking this type of

study is a positive step. Such studies can be perfected over

time. It is important to consider the diversity and variability

inherent to each clinical laboratory. This diversity means

that each laboratory has a different starting point. There-

fore, it is essential not to assume that the laboratory with

the lowest cost per test is better managed. What is most

important is the progress in each laboratory over time, i.e.

its own internal benchmarking.

During the five-year study period, the total test activity

of the laboratories grew between 9 and 10% per year, as

can be observed in Figs. 6 and 7. These values are slightly

lower than in other types of study, such as [12]. The gen-

eral increase in activity was due to intrinsic growth,

resulting from the increased utilization of laboratory ser-

vices owing to better test availability and greater

physicians’ demand. This increase was also due to a second

type of growth, which simply resulted from the increased

test volume owing to new diagnostic laboratory tests. This

demand also increased as new primary care areas were

incorporated, through either the hospital management or

service contracts.

As a strategy to avoid rising laboratory costs, the

number of infrequent and highly complex tests sent to other

laboratories went up notably. This cost was greater when

the laboratory was smaller or had a lower level of activity.

The Terrassa laboratory had an average outsourced testing

annual growth of 10%, while that of Mataro was 18% and

Badalona 57%. Indicator 7 (number of tests performed in

the laboratory/total number of tests, expressed as a per-

centage) remained stable for the Terrassa and Mataro

laboratories. However, this was not the case for the

Badalona laboratory, which implemented a strategy to

outsource diagnostic testing.

Total test expense in the three laboratories grew at

varying annual rates (primary data, item 19). The increases

were: Terrassa laboratory 4.8%; Badalona laboratory 8.6%;

and Mataro laboratory 10.8%. This growth can be broken

down into the corresponding total labour expense and theconsumable expense plus reference and/or referral test

expense. If this is done, the average annual increase in total

labour expense in the three laboratories appears in the same

order: 8.7% for Terrassa, 7.8% for Badalona and 7.2% for

Mataro. The rest of the costs, the consumable expense

and the external laboratories expense, contribute to this

difference.

Figure 1 depicts a 5 and 8% increase in the annual

productivity average in the Terrassa and Mataro laborato-

ries, respectively. This trend was not observed in the

Badalona laboratory, which had the lowest level of

productivity. This is because the Badalona laboratoryunderwent restructuring in 2001. They started to outsource

samples they could no longer process. Subsequently, they

recovered these tests and simultaneously increased their

workforce, resulting in a slight trend to increased produc-

tivity (2002 and 2003).

Figure 2 shows an indicator of utilization by medical

services. Different trends are observed according to the

laboratory. A series of factors that are not under the lab-

oratory director’s control have an impact on these

indicators. These factors basically depend on the hospital’s

other cost centres.

Figure 3 shows the manageable expense cost (cost per

test conducted in the laboratory). It includes all the costs

that in one way or another are controlled by the laboratory

managers. This figure primarily comprises the direct costs

of total labour expense (item 14—primary data) and

0

10000

20000

30000

40000

50000

60000

70000

80000

2000 2001 2002 2003 2004

year

O n - S i t e T e s t s / T

o t a l w o r k e r s

MATARO BADALONA TERRASSA

Fig. 1 Evolution of productivity per person


123



consumable expense (item 15—primary data). Both were

calculated according to LMIP of CAP [7]. Furthermore, in

the consumable expense we also included laboratory

equipment maintenance and repair expense and laboratory

equipment lease and rental expense, similarly to the study

conducted by Benge and others [12]. The trend was to

maintain the cost per test, with small fluctuations due to

the increase in productivity (Terrassa) or to laboratory

restructuring (Badalona). The Mataro laboratory shows an

increase in this indicator in 2003 and 2004.

Figure 4 depicts the percentage of labour expense within

the manageable expense. As in study [12], this indicator

was below 60% during the study years. Decreasing trends

were noted in the Badalona and Mataro laboratories, and an

increasing trend was observed in the Terrassa laboratory.

This can be explained by the fact that most of their activity

(routine testing) comes from centres with a laboratory

service contract, thus reducing the amount of consumable

expense per test.

Figure 5 shows laboratory costs with regard to the total

consortium cost. The figures were under 5.5% throughout

the study years for the three laboratories. Although there

was no clear trend in the Badalona laboratory, the value

remained around 4%. In the Terrassa laboratory, a positive

tendency to drop below 3.5% was observed.

Figure 6 shows the activity as compared with the cost

per test conducted in the laboratory. A lower level of total

activity, as in the Badalona laboratory, did not necessarily

imply higher costs. The impact of contracting testing

activity with primary care units was observed in the case of

the Terrassa laboratory, as they perform longer analytical

runs with a higher level of automation (economies of scale)

(Fig. 7).

No common trends were observed in Fig. 8. However,

one must bear in mind the organisational models of each

laboratory and the changes partly caused by the change in

contract with an external laboratory that acts as an inter-

mediary with the diagnostic enterprises. In coming years,

as such changes are assimilated, the impact on these items

should be monitored. We also observed that the unit cost

0.00

0.20

0.40

0.60

0.80

1.00

1.20

1.40

1.60

1.80

2000 2001 2002 2003 2004

year

M a n a g e a b l e e x p e n s e

€ /

T e s t


Fig. 3 Evolution of manageable expense per test

0

20

40

60

80

100

2000 2001 2002 2003 2004

year

P e r c e n t o f L a b o r e x p e n s e


Fig. 4 Percentage within the manageable cost per test that corre-

sponds to laboratory personnel costs

0

1

2

3

4

5

6

2000 2001 2002 2003 2004

year

P e r c e n t o f L a b o r a t o r y e x p e n s e /

H o s p i t a l e x p e n s e


Fig. 5 Percentage of the cost of three laboratories with respect to the

total cost of the health institution

25

27

29

31

33

35

37

39

41

43

45

2000 2001 2002 2003 2004

year

N o o f T e s t s / D i s c h a r g e


Fig. 2 Evolution of demand per hospital discharge


123



per test did not just depend on economy of scale or on a

laboratory’s level of productivity—this should be born in

mind as it may arouse interest or become a source of

controversy. Thus, Fig. 8 shows that Badalona and Ter-

rassa laboratories present similar cost per test with different

productivity, thus implying that unit cost depends on more

factors than just economy of scale. The factors of com-

plexity, hospital and non-hospital origin, and the level of

automation, among others, are just as important—if not

more important—than volume in our laboratories.

We agree with Price [13], that these indicators do not

reflect the efficacy of the service offered. We believe they

are useful for internal benchmarking in order to analyse

organisational evolution over time. In addition, they are

valuable for external benchmarking if the criteria in the

laboratories can be unified.

Table 2 shows one of our analytical quality indicatorsprepared with EQAS results. This indicator remained quite

stable during the five-year study period; the laboratories

increased their activity and productivity (indicator 2 in

Table 1) without quality loss. Management indicators (cost

and productivity) should be considered with analytical

quality indicators. Laboratory management should not

merely be concerned with cost reduction and productivity

increase, but ensure good laboratory practice and analytical

quality.

Table 3 shows budget deviation but does not include

staff budget, as the Mataro and Badalona laboratories did

not have these data from the consortium direction. The

Terrassa laboratory manages its budget well, unlike Mataro

and Badalona that show a mostly positive deviation mainly

due to blood and blood-component costs and more testing

activity than expected. It may be interesting for laboratory

management in the future to include staff budget and

improve non-staff budget with the knowledge provided by

our results.

The productivity and cost indicators information proved

useful for deciding whether analytical tests should be

outsourced or processed in-house. During the study years,

some outsourced tests were conducted in our laboratories

when the cost indicator showed that it was profitable.

Likewise, changes were made to increase automation

and robotics when the indicators showed economic cost-

effectiveness.

In our study, the utilization indicators (8–10) show a

rather stable evolution, which we hope will be maintained

in future years. These global indicators will require

breaking down according to their medical origin, and

studying by means of tests correlated in order to reduce

unnecessary test determinations.

30000

35000

40000

45000

50000

55000

60000

65000

70000

75000

1.00 1.10 1.20 1.30 1.40 1.50 1.60 1.70

N

o . T e s t s / W o r k e r

00

04

04

04

00

00


Manageable expense € / Test

Fig. 8 Cost per analysis compared with the productivity per person

over the five study years. The year 2000 is labelled 00, while 04

means 2004

1.00

1.10

1.20

1.30

1.40

1.50

1.60

1.70

0 1.000.000 2.000.000 3.000.000 4.000.000

Total number Test

M a n a g e a b l e e x p e n s e € /

T e s t

0404

00

00

04

00


Fig. 6 Cost per analysis conducted in each of the laboratories with

respect to total analysis activity. The year 2000 is labelled 00, while

04 means 2004

30000

35000

40000

45000

50000

55000

60000

65000

70000

75000

0 1.000.000 2.000.000 3.000.000 4.000.000

Total number Test

04

0400

00

04

00 O n - S i t e T e s t s / T o t a l w o r k e r s


Fig. 7 Productivity of each laboratory with respect to the total testing

activity. The year 2000 is labelled 00, while 04 means 2004


123



Our experience with these indicators during the study

years showed us that they provide useful information to

plan strategic alliances. They are presently used by health

enterprises and non-health-related companies in order to

develop joint purchasing strategies or decide whether

specific tests should be processed in-house or outsourced.

Indicators 13, 14, and 18 are useful for such decision

taking. The concentration test referral strategy in one lab-oratory substantially reduced test price in the three

laboratories, as can be observed in indicator 18.

Another type of agreement that is proving positive for

increasing testing activity and reducing cost is to supply

testing services to primary health care centres that do not

have their own laboratories (indicators 1 and 14a).

Utilization and cost indicators (8–10 and 15–17,

respectively) provide valuable information for the labora-

tory and consortium management to calculate the total

heath care cost as a health services supplier.

In our consortiums, the management capacity of labo-

ratory directors is limited. Referral laboratories and supplierof reagents are selected by the consortium top management.

Nevertheless, we believe that it may be interesting to

develop benchmarking programs with laboratories of sim-

ilar characteristics—by autonomic areas or organisations

such as XHUP in Catalonia. External benchmarking of

management indicators could be developed by scientific

societies with EQAS organisation experience.

Conclusions

The information obtained from these indicators is useful indetermining the results of management changes in these

laboratories and for understanding the laboratories’ real

situation.

We found a lack of standardisation in management data.

A future area of study may involve unifying some of their

different characteristics.

In our study, two of these clinical laboratories experi-

enced a significant increase in their labour productivity as a

result of primary care centres’ activity.

Having primary care testing activity contracts enables

laboratory productivity to increase and reduces the con-

sumable cost of the test price.Productivity increased without analytical quality lost in

the three laboratories.

The reorganisation of a laboratory, including taking the

decision of whether to continue conducting diagnostic tests

in-house or outsource them, enables the cost per test to be

controlled in the laboratories with lower activity.

The laboratory director with the consortium directory

must develop a complete annual budget plan.

Internal benchmarking helps fulfil some of the require-

ments to implement quality models, such as the EFQM, in

the laboratory.

Acknowledgments This work was supported by the Fondo de In-

vestigacion Sanitaria- FIS 04/1905; the Spanish Ministry of Health

and Consumer Affairs; and the Instituto de Salud Carlos III, Spain.

References

1. Asociacion Espanola de Normalizacion y Certificacion. Informes

AENOR: Certificacion y Normalizacion. Sector Sanitario 2002.

AENOR 2003, Madrid

2. Asociacion Espanola de Normalizacion y Certificacion. Informes

AENOR: Certificacion y Normalizacion. Sector Sanitario (2a e-

dicion). AENOR 2006, Madrid

3. Kieviet W, Blaton V, Kovacs GL, Palicka V, Pulkki K (2002)The Management of Clinical Laboratories in Europe: a FESCC

survey. Clin Chem Lab Med 40(3):312–319

4. Travers EM (1977) Clinical laboratory management. Williams

and Wilkins, Baltimore

5. Clinical and Laboratory Standards Institute (1998) Basic Cost

Accounting for Clinical Services; Approved Guideline. NCCLS

document GP11-A, v.18, N.14. NCCLS, Wayne

6. Ramon F, Alsina MJ, Alvarez V, Cortes M, Cava F et al (2004)

XXIV Programas de Evaluacion Externa de la Calidad de Bio-

quımica (suero) de la Sociedad Espanola de Bioquımica Clınica y

Patologıa Molecular. Quim Clin 23(2):41–97

7. Laboratory Management Index Program. Users Guide (2000–

2002) College of American Pathologists. CAP, Northfield

8. Salas A, Vilaplana C, Bosch MA, Gimeno C Fernandez R (2004)

Utilidad de un programa de evaluacion externa de la calidad de

indicadores de gestion en los laboratorios clınicos. Quim Clim

23(1):25–34

9. Garcia L (2004) Clinical laboratory management. ASM Press,

Washington

10. Instituto Nacional de la Salud. Subdireccion General de Desarr-

ollo (2001) Guıas Integradas asistenciales. Metodologıa para la

estandarizacion de actividades basadas en la calidad y en los

sistemas de clasificacion de pacientes GRD. Ministerio de Sani-

dad y Consumo, Madrid

11. Valenstein P, Praestgaard A, Lepoff R (2001) Six-year trends in

productivity and utilization of 73 clinical laboratories. A College

of American Pathologists Laboratory Management Index Pro-

gram study. Arch Pathol Lab Med, vol 125, September

12. Benge H, Csako G, Parl F (1993) A 10-year Analusis of ‘‘Rev-

enues’’, costs, staffing, and workload in an Academic Medical

Center Clinical Chemistry Laboratory. Clin Chem 39/9:1780–

1787

13. Price CP (2005) Benchmarking in laboratory medicine: are we

measuring the right outcome? Benchmarking Int J 12/5:449–446


123

Benchmarking and Quality Management Indicators in Three Medi

Documents

Transcript of Benchmarking and Quality Management Indicators in Three Medi