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

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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 LabC

LS

RH

em

/On

c C

lin

ic (

inclu

din

g o

/clin

ic

serv

ices)

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

CLS

RH

em/O

nc

Clin

ic (

incl

ud

ing

o/c

linic

serv

ices

)La

b

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 work- flow

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.

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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

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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

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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.

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