Download Laboratory Medicine - Health Care Tomorrow

South East Community Care Access Centre and Hospital Executive Forum (SECHEF)
Health Care Tomorrow – Hospital Services
Diagnostics & Therapeutics –
Laboratory Medicine
June 2016
*Version2-Revised June 9, 2106
Addendum-June 9th : Please see the attached and note the following change
Original Version June 2,
Revised Version-June 9th
Page 40
Total One Time costs, $ 1,190,200
Total Ongoing costs $500,000
Total One Time costs, $ 1,265,200
Total Ongoing costs $ 420,000
Table of Contents
1. Business Need……………………………………………………………………………………..4
2. Objectives / Outcome Expected………………………………………………………………....6
2.1. Vision……………………………………………………………………………………….….6
2.2. Understanding and Features of the Re-designed System……………………………….6
2.3. Vision 2020 for South East LHIN Laboratory Medicine…………………………………..9
3. Current Model and Operating Environment……………………………………………………11
3.1. Organizational Structure…………………………………………………………….………11
3.2. Staffing………………………………………………………………………………………..14
3.3. Salary and Supply Costs…………………………………………………………………...15
3.4. Microbiology and Histology Work Volumes………………………………………………16
3.5. Leading Practices / Benefits………………………………………………………………..19
3.6. Current Challenges………………………………………………………………………….20
4. Future State………………………………………………………………………………………..22
4.1. Service Model………………………………………………………………………………...22
4.2. Service Governance…………………………………………………………………………24
5. Management and Staffing Structure…………………………………………………………….25
5.1. Organization Structure………………………………………………………………………25
5.2. Leadership Roles / Responsibilities………………………………………………………..26
6. Regional Service Model…………………………………………………………………………..30
6.1. Opportunities / Projects……………………………………………………………………..30
6.2. Stakeholder Impacts…………………………………………………………………….…..35
7. Regional Benefits of New Model………………………………………………………………..37
8. Goals and Performance Measures……………………………………………………………..38
9. Savings…………………………………………………………………………………………….39
9.1. Future Frontline Staffing and Costs by Major Business Functions…………………….39
10. Transformation Costs……………………………………………………………………………..40
10.1.One Time and Ongoing Costs……………………………………………………………..40
10.2.Labour Adjustments…………………………………………………………………………41
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11. Human Resource Plan…………………………………………………………………………..42
11.1.HR Principles………………………………………………………………………………..42
11.2.Labour Relations Overview………………………………………………………………..42
12. Change Management……………………………………………………………………………43
12.1.Client and Staff Engagement………………………………………………………………44
12.2.Communication…………………………………………………………………………..45
12.3.Learning Opportunities…………………………………………………………………..…45
12.4.Ongoing Support…………………………………………………………………………....45
13. Implementation Strategies………………………………………………………………..……...46
14. Risk Assessment and Mitigation………………………………………………………………...47
Appendices
Appendix A: Integration Estimate…………………………………………………………………....49
Appendix B: Leading Practice Benefits……………………………………………………………..50
Appendix C: Proposed draft Histology changes for future consideration……………………….52
Appendix D: Capital Costs…………………………………………………………………………...53
Appendix E: Courier/Transport Requirements……………………………………………………..54
Appendix F: Metrics for Consideration………………………………………………………………55
This document serves as a strategic business proposal as part of the Health Care Tomorrow – Hospital Services project.
The recommendations are directional in nature and have been scoped to provide an order-of-magnitude assessment of
the opportunity for a shared service model for a Laboratory Services to be deployed regionally for the organizations in
the South East LHIN.
Note: All quantitative information presented is to provide reasonable order of magnitude estimates of current spend and
future opportunities for savings. Canadian Institute of Health (CIHI) MIS guidelines provides some flexibility regarding
accounting treatment of some expenditures which leads to some differences in how each organizations accounts for
some expenditures and thus comparability issues.
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1. 0 Business Need
The goal of the Laboratory Medicine working group was to explore consolidating the hospital
laboratories in the South East into a Regional Laboratory with the vision of creating a patientfocused, integrated, efficient hospital laboratory service that provides evidence-based, cost
effective, quality and timely laboratory testing.
Laboratories in all of the hospitals in the region have worked collaboratively over the past two
decades to standardize some equipment platforms, to provide continuing staff education, and
to collectively meet all accreditation standards. Working together, laboratory services such as
the Kingston General Hospital (KGH)/ Queen’s University Laboratory Outreach Program have
been established and grown to include technical and professional support in the laboratory
disciplines of hematology, chemistry, microbiology and pathology. This unique Outreach
program was recognized provincially as innovative in the provision of laboratory medicine and
provides direct benefits to our patients, staff, and physicians across the region.
In the current state, the hospital laboratories in the South East are operating separately, each
with their own governance and leadership. Various test menus exist at the six operating
laboratory sites for five hospital corporations 1 . Core testing is done onsite for all hospital
laboratories, and some hospitals in the South East refer a mix of reference level work into KGH
and some hospitals also refer work to other private laboratory partners.
Economic realities and evolving business practices in the Province, as actioned through funding
formulas, continue to drive fiscal challenges for acute-care and specialty hospitals. Until the
current year, hospitals and therefore their laboratories have had no inflationary increases over
the last four years. Although there were additional funds released in fiscal 2017 by the Province,
the increase received was less than one per cent for most hospitals. At the same time, wages
for unionized staff and costs for supplies continue to rise. This has been the equivalent of budget
reductions in the range of $2.0-2.4 million for laboratories in the South East across all seven
sites over the last five years. Faced with this reality, our laboratories have reduced their budgets
by a $2.5 million through technology improvements and efficiencies to balance budgets. As
discussed at the start of the Health Care Tomorrow – Hospital Services project, further budget
reductions by individual hospitals to meet these economic realities, without impacting services,
is felt by many to be unsustainable. Our working group examined the concept of a Regional
Laboratory to determine if there are opportunities to further increase efficiencies and value. Our
staff and physicians are very resourceful at delivering efficient, effective, quality services, but to
continue to deliver high quality services in the current environment we recognize we need to do
even more collaboration, work together, innovate, and eliminate as much waste as possible.
As has been described in early briefing documents provided to the boards, today, we do not
1
Hospital laboratories are sited as follows: one in Belleville serving all four QHC hospitals, in each of Perth and
Smiths Falls (serving PSFDH), one site in Napanee, one site at KGH serving Hotel Dieu Hospital and Providence
Care, and one site in Brockville
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have regional leadership or governance for our laboratories and while some of the laboratory
sites are connected via interfaces between their Laboratory Information Services (LIS), other
sites are not able to communicate electronically with their LHIN Laboratory partners. There is a
network to move specimens across the region between sites, but it is not optimized and does
not ensure timely delivery of samples in the way it would be needed for a more robust level of
test sharing.
As noted above, there has been ongoing ccollaboration between the hospital laboratories at a
voluntary level that has resulted in some standardization of equipment and processes. The
members of the Laboratory Medicine working group in both phase 1 and phase 2 of this Health
Care Tomorrow – Hospital Services project are committed to working together to optimize the
delivery of laboratory care to our patients. Strong supported collaborative working relationships
across the laboratories of our region will help drive higher quality, further equipment and process
standardization, improve clinical consultations, and provide cost efficient service to our patients.
We wish to optimize the utilization of existing resources and take advantage of any available
economies of scale. We also feel it is important to do this in a manner that every hospital
continues to have an ownership and real capacity to influence the development of a Regional
Laboratory. Laboratory Medicine is part of the complex clinical services equation that supports
patient care across the health system, it cannot be seen as a separate service, but must be
seen as an integral part of the hospital services at each site.
In 2010 the leadership in Laboratory Medicine in the region recommended a Regional
Laboratory be created. It was rejected due to the costs of implementation of a full Laboratory
Information System (LIS). Over the last 18 months, a working group of representatives from
seven hospitals in the South East LHIN has revisited and further explored the opportunity that
a Regional Laboratory system could bring to our patients. The group has refined the regional
model and has suggested key enablers to support implementation across the sites.
The entire Laboratory Medicine working group has worked hard to create this business plan
supporting creation of a Regional Laboratory for consideration by the Hospital Boards in the
South East LHIN. All members of the committee, with the exception of one, were able to
indicate their support for the directions contained in the document at our last meeting on May
31, 2016. The one member who was unable to provide support shared their concern that there
was insufficient information at this time to feel comfortable with the direction to consolidate
Microbiology Services from four sites to two sites. The working group discussed the concern
and reaffirmed the collective commitment to ensure the changes introduced by a Regional
Laboratory would need to be tested and evaluated to ensure they were able to address the
needs of each hospital site. It was noted that the appropriate laboratory staff and physicians
would be engaged to help develop the detailed plans for the proposed microbiology services in
the next phase of the project and if there were any quality or services issues that these would
need to be addressed before implementation. The working group agreed to reconvene in July
to debrief on the outcome of the June Hospital Board meetings and the LHIN’s Board
Meeting.
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2. 0 Objectives / Outcome Expected
2.1 Vision
Regional Laboratory Medicine will be an accessible, high performing laboratory medicine
program that is a valued clinical partner in the provision of high quality clinical service for patients
enabled by:

Strong regional accountability, leadership and governance;

Laboratory Medicine will be a full partner with all the other clinical services that are
offered at each clinical service delivery location;

Coordinated capital investment to support further standardization of equipment and
effective utilization management;

High quality laboratory medicine services through continuous improvement of processes
and adherence to best practice (e.g. auto-verification. This will enhance result
turnaround time to help with timely clinical decision making). The extent and scope of
savings that will be achieved by standardization has not been estimate or quantified in
this business case but is seen by the team as being important to consider to our capacity
to offset inflation and cost pressures in the upcoming budget years, if we are to sustain
our quality and level of services;

Utilization management of laboratory testing with a regional focus on test
appropriateness and test utilization;

Data management on a regional level to support decision making and system
optimization;

Accessible patient services- opportunities exist for implementation of technology that
could allow services to be offered to patients closer to home (e.g. tele-pathology, phone
consultations);

Enhancement of regional medical/professional support for clinical stakeholders;

Opportunity for a shared workforce to maintain competency and enhance recruitment
and retention.
2.2 Understanding and Features of the Re-designed System
Leadership and related governance will help drive the change in the Regional Laboratory
system. Managers and staff working together with common goals that have been clearly defined
within a regional context will provide direction, accountability, and a sense of purpose for the
new Regional Laboratory Medicine model.
Increased connectivity between laboratory sites will facilitate seamless transfer of information
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for patient care and leadership and governance is a required foundation to support the formation
of a Regional Laboratory.

The ideal infrastructure for the laboratories is a single Hospital Information System (HIS)
for all South East LHIN sites and a single Laboratory Information System (LIS) linked or
impeded into the HIS. However, this does not currently exist and even if approved in the
future, would take several years to implement. Fortunately, a solution has developed
over the last few years for Laboratory to Laboratory connectivity and this approach will
support the regional laboratory in the short term. This approach is now being utilized by
Providence Care and LACGH for movement of laboratory information between their sites
and KGH. At a minimum this level of integration solution must be in place to support a
Regional Laboratory. For example, any consolidation of Microbiology services is
dependent on this connectivity. Information from the testing lab will flow into the LIS at
the sending lab and patient testing information will be available through the sending site
HIS. This design is similar to approaches used by other regional laboratories in the
province.
Some of the features of the Regional Laboratory Medicine model we would aspire to create can
be described as follows, it will:

Utilize improved data management to inform system changes (e.g. data mining using
currently available tools propagated on a regional level, use data to inform performance
metrics and priority of process improvement initiatives and subsequent decisions);

Leverage unused capacity and improve access to laboratory medicine services;

Drive appropriate test utilization to provide downstream value within the patient care
continuum (e.g. support to clinical programs for QBP performance, P4R performance);
o
Examples of utilization initiatives include unusual test order gating, approaching
tests like a drug formulary (need approval to add tests), order set management
and elimination of daily testing.

Improve collaboration with laboratory professionals and stakeholders to design and
define lab orders, test utilization and appropriate tests for referral;

Through continuous process improvement, provide cost efficient and cost effective
laboratory medicine services thereby improving the quality of services to partner
hospitals;

Where appropriate, reduce any duplication of laboratory medicine services;

Where clinically relevant, improve test turnaround times which will contribute to improved
patient experience and outcomes (e.g. use point-of-care testing (POCT) if clinically
relevant and cost effective, ER departments will continue to ask for this technology in
their clinical area);
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
Maximize utilization of the existing technology;

Adopt new technologies that are available and are based on best practice and business
case justification;

Open new opportunities and new roles to staff members as we implement new
technology and approaches to laboratory utilization;

Work with staff to get them to work to full scope of practice;

Repatriate reference testing to region where this is efficient and effective – insource
reference lab tests;

Investigate a common reference laboratory to leverage any potential economies of scale
for better cost and service options; and

Provide a foundation to support future regional clinical collaboration to ensure laboratory
medicine services are available across the South East in a consistent and complete
service.
Quick wins*:
Process analysis and improvement will commence immediately and will have benefits but full realization will
take several years.
Send lymphoma cases to KGH site
Start repatriation of easy to do reference testing
Initiate region wide capital plan to ensure equipment and contract standardization
Launch request for proposal (RFP) for regional document system
Increase professional collaboration between microbiology testing sites
Automated tracking system for Histology at QHC (capital already approved) and Brockville if capital is approved
*implementation plans for quick wins will be checked and tested to ensure we maintain high quality standards,
maintain turnaround times and can provide cost savings
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2.3 Vision 2020 for South East LHIN Laboratory Medicine (more
specifically)
The geographic size and service design of our region requires that Regional Laboratory
Medicine be distributed across our South East LHIN. There are opportunities to consolidate
some laboratory medicine services to optimize services and cost, but most importantly to meet
our purpose and goals we need to be located where we are needed to support optimal patient
care. Therefore Core Laboratories (chemistry, hematology, transfusion services) will remain at
all six sites where they are present today – test menus will be optimized at each site and will be
designed to support the clinical program services on that site (e.g. need test menu to support
ER departments). Some additional details of that we envision for the Regional Laboratory design
are as follows:

The KGH laboratory site further established as reference Laboratory for reference
testing, reference/core service microbiology and reference/core histology;

Two Microbiology laboratory sites – at KGH site and at QHC Belleville (Selected 2
reference and core testing)3;

Microbiology work currently done at Brockville to be sent to KGH site, and some specific
tests added to the Brockville site core laboratory;

Microbiology work currently done at Smiths Falls to be sent to KGH site, and Smiths
Falls will have some specific tests added to core laboratory;

Further consultation with clinical microbiology will help develop a standardized protocol
for handling of C. difficile testing, blood culture and body fluid testing;

Limited Histology changes – Histology testing to remain at current sites in KGH, Belleville
and Brockville where they are currently processed. The working group has identified an
opportunity to consolidate testing for lymphoma cases from Belleville and Brockville to
KGH site. If this is successful further opportunities for histology sites to collaborate will
be explored in the future. For example we have discussed future histology service
models such as Pathology grossing and slide interpretation/consultation done on one
site with histology specimen processing work done at another. We will also explore
further consolidation of special stains/immunohistochemistry at KGH site for the other
two sites;

Standardization of equipment, technical support, and new technology is expected to
enable quality patient care closer to home;

Maximize use and capacity of existing technology - we have equipment today that is
2
Carefully and deliberately selected as most appropriate site for that time, recognizing that these site locations
could change in the future
3 Process for planning will bring together experts in impacted areas to ensure that high quality standards are
maintained
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underutilized and by extending some hours of operation we could reduce overtime on
some of the capital investments required. Each opportunity will be subjected to business
case analysis;

Appropriate investment will occur to optimize the system and improve quality and
efficiency e.g. specimen transport system will be improved given the opportunity we see
in developing a region wide service with scale to attract a professional provider of the
service;

Development of a single reference lab provider for South East LHIN esoteric/specialty
level testing will be evaluated to determine if it provides cost savings by utilize existing
capacity and will retain resources within the LHIN;

Repatriate appropriate testing to KGH reference site if sufficient volume, if is cost
effective and improves test turnaround time for regional labs. We see several tests that
will be brought back into the region as result of this opportunity and again some cost
savings will result.
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3.0 Current Model and Operating Environment
Today we have six hospital based laboratories in our South East LHIN region helping meet the
needs of our patients and health care staff. To keep up with increasing demand on Laboratory
Medicine, we also find ourselves in the position of referring laboratory work outside the region
or to private organizations.
We are now exploring what a Regional Laboratory Medicine model would look like, and how to
approach executing on the proposed model, and what timeframes and investments would be
necessary. As noted above, there is strong collaboration between our hospital laboratories
already, but the working group is looking at ways of increasing connectivity, standardization,
process improvement, and operating structures to further improve services for patients and
clients across the region. Based on our review of models that exist and our own past experience
we are proposing that a Regional Laboratory for the South East is the best solution to meet our
needs.
3.1 Organizational Structure
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Current Test Volumes by Site
Site
Test Volumes (for all
Napanee
QHC
684,000
(LACGH)
143,000
PSFDH
208,000
KGH
2.5 million
Brockville (BGH)
379,000
tests performed in house)
(Data from LHIN document phase 1 HCT fiscal 2014)
*
Tests done on site.
Core Laboratory Services include Chemistry, Hematology, Transfusion Services (services
available 24/7 all sites). Some microbiology specimens/tests such as blood cultures, gram
stains and fluids are also performed in core laboratories after regular hours of operation.
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Services with Hours of Operation
Service
level
KGH
HDH
BGH
LACGH
Prov. Care
PSFDH
QC
Tertiary
care
academic
teaching
Laboratory
Limited
POCT, GI
Lab
Core lab
with:
-Micro
- Histology
Core Lab
Limited
POCT on
site
2 sites
4 sites
-Perth
Service
agreement
with KGH
-Smiths
Falls main
site with
Micro
-Bellevillecentral lab
with Micro
and
Histology
Service
agreement
with KGH
Blood
cultures on
site
Histopathology
and
microbiology
referred
Histo
pathology to
KGH,
Microbiology
at SF
-BancroftPOCT
-PictonPOCT
-TrentonPOCT
Ref lab
HICL other
Lab hours
24/7
KGH
GD
KGH
24/7
24/7
KGH
KGH
GD
24/7
24/7
(Perth oncall)
Micro.
7 days
7 days
Histo-
5 days
5 days
5 days
5 days
Refer to
Refer to
Gamma
KGH
BC only
5-6 days
7 days
pathology
Cyto
Note: KGH: Specialty testing includes-Cytogenetics, Molecular Genetics, Immunology
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3.2 Staffing (Current state (March 2015), does not include Pathologist
MD/Clinical Lab PhD positions)4
4
Staffing in the above table is reflective of phase 1 data gathering for fiscal 14-15. Staffing numbers fluctuate
over time. Please consider this table for comparative purposes only. Future detailed planning will use GL
financial data to ensure site accuracy around staffing complement.
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3.3 Salary and Supply Costs to All Sites 2011-12 to 2014-15
The table below outlines all the total costs for the laboratories in the region. Individual hospital
data is available. The table is provided to share scale and scope of the laboratory services in
the region, and a brief explanation can be found below the table.
FY 2011/12
FY 2012/13
FY 2013/14
FY 2014/15
Gross Expenses
$42,587,724
$46,767,255
$46,954,857
$45,766,848
7141010 LAB Administration
$1,353,346
$1,062,342
$563,800
$474,561
7141021 LAB Pre/Post Analysis
$302,898
$768,834
$1,149,074
$1,414,324
7141025 LAB Clinical Chemistry
$6,410,761
$6,430,416
$7,318,516
$7,373,297
7141030 LAB Clinical Hematology
$2,843,222
$3,049,035
$3,423,722
$3,261,487
7141035 LAB Transfusion Medicine
$1,679,209
$1,606,228
$1,740,898
$1,862,874
7141041 LAB Anatomical Pathology
$8,253,306
$10,685,047
$9,529,615
$8,851,005
7141042 LAB Cytopathology
$506,759
$574,401
$556,138
$584,369
7141045 LAB Clinical Microbiology
$3,407,936
$3,548,373
$3,506,646
$3,273,757
7141050 LAB Immunology
$1,005,672
$1,140,674
$1,362,569
$1,286,087
714108510 LAB Cytogenetics
$773,716
$762,785
$837,060
$880,413
714108520 LAB Molecular Genetics
$906,664
$1,120,553
$1,151,903
$1,368,949
7141099 LAB Combined/Muli Functions (Core
$15,144,235
$16,018,567
$15,814,916
$15,135,725
Income
-$7,428,526
-$10,214,458
-$10,285,434
-$9,531,283
7141010 LAB Administration
-$8,775
-$21,823
-$20,066
-$14,080
7141021 LAB Pre/Post Analysis
-$294,016
-$402,526
-$498,631
-$548,463
7141025 LAB Clinical Chemistry
-$1,431,515
-$1,688,751
-$2,488,741
-$2,273,044
7141030 LAB Clinical Hematology
-$320,380
-$350,511
-$576,989
-$555,185
7141035 LAB Transfusion Medicine
-$137,665
-$113,119
-$120,150
-$114,445
Lab)
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7141041 LAB Anatomical Pathology
-$3,793,627
-$5,985,833
-$4,962,219
-$4,083,225
7141042 LAB Cytopathology
-$80,574
-$102,458
-$119,274
-$122,536
7141045 LAB Clinical Microbiology
-$321,394
-$396,589
-$426,025
-$385,973
7141050 LAB Immunology
-$195,770
-$228,732
-$332,596
-$314,534
714108510 LAB Cytogenetics
-$14,980
-$14,431
-$2,634
-$2,286
714108520 LAB Molecular Genetics
-$17,373
-$23,065
-$21,798
-$70,992
7141099 LAB Combined/Multi Functions (Core
-$812,457
-$886,620
-$716,311
-$1,046,520
$35,159,198
$36,552,797
$36,669,423
$36,235,565
Lab)
Net Expenses
(Data source LHIN data repository)
Expenses at all sites have remained stable across four years 2010-11 to 2013-14. The
combined rate of inflation over the four years is 8.41 per cent. Wage increases and vendor
supply increases have been substantial over the period and have kept pace with inflation.
Funding to hospitals has not seen any inflationary increases in this same period. The
laboratories have absorbed approximately $1.5 – 2 million in inflationary pressure over this
period.
In addition, in 14-15, 15-16 and budgeted 16-17, QHC and KGH have realized savings of over
$2 million through changes that drive efficiency and system optimization. The smaller hospital
laboratories’ budgets have remained stable but have also absorbed inflationary increases.
The 2009 Health Tech report predicted that without major changes, the lab budgets of the South
East LHIN hospitals would grow to $51 million by 2019. Due to careful management,
improvements in efficiencies and strong continued efforts to balance budgets this has not yet
occurred.
3.4 Microbiology and Histology Work Volumes
Two of the areas often explored when regional laboratories are created or services have been
consolidated are Microbiology and Histology. Our region similarly has seen consolidation of
these services and previous reports done on Regional Laboratory services for our region have
identified these areas as well. Moving forward, the working group is committed to evaluating our
future impact on the system to ensure that changes occurring from consolidation maintain or
exceed our high quality standards and turnaround times.
The distribution of the tests helped us develop our model and look at ways to accommodate
each site via the two Microbiology Labs plus expanded Core testing. We also settled on retaining
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the Histology at three sites in favour of developing a model that will ensure we create a service
that will support the evolving clinical system that is yet to be developed. In the mean time we
can build further cooperation and collaboration among our sites.
Note: This is SPECIMENS performed in house.
Data gathered during phase 2 from site managers.
SE LHIN Microbiology
KGH*
specimen volumes 14-15
QHC
PSFDH
BGH
LACGH**
Blood cultures
31232
8160
1543
1645
Urine cultures
14652
8983
4570
5806
34011
MRSA screen
11550
10199
2319
4619
28687
VRE/ESBL
122
5640
2636
2474
10872
Fluid culture (inc CSF)
3578
908
150
159
4795
Throat culture
1642
838
1408
529
4417
Wounds superficial culture
1787
1290
468
243
3788
Sputum culture (inc Bronch)
2286
994
59
119
3458
C difficile
1410
1299
146
208
3063
Vaginal exam/culture
1434
879
340
155
2808
Anaerobic culture
2453
261
10
20
2744
Stool culture
1178
811
177
187
2353
Group B Strep culture
1087
172
11
1270
Misc cultures
548
319
152
152
1171
Totals
74959
40753
13978
16327
147640
% of Total
51
28
10
11
100
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1623
Total
44203
Notes:
* There is additional work done at KGH that is not reflected in these totals (mycology, molecular, virology)
** LACGH positive blood cultures are sent to KGH
Volumes reflected by specimen volumes do not reflect complexity and related workload
SE LHIN Histology
KGH
QHC
PSFDH
BGH
LACGH
Total
Surgical Cases
37552
12157
XX*
7148
XX*
56857
Specimens
38484
12721
Cytology (regional volume)
10950
XX*
# Blocks
90035
32793
12513
135341
IHC tests
18125
2550
XX*
20675
Special stains
4534
1922
1112
7568
Frozen sections intraoperative
3343
3
7
3353
Autopsies
305
6
3
314
Consults
1437
% of Total by Cases
66
volumes 14-15
7148
XX*
21
XX* specimens sent to KGH, volumes included in KGH volumes
KGH already set up as reference lab for PSFDH and LACGH
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XX*
10950
1437
Notes:
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XX*
58353
13
100
3.5 Leading Practices / Benefits
The following is a list of leading practices that have been or are being implemented in the sites across the
South East LHIN. Appendix A provides a full description of each of these initiatives.
We have already established some consolidation of select laboratory services in the south east,
including:

QHC Lab Consolidation has created a sub -region within our South East LHIN;

Lennox and Addington Hospital sends microbiology and histo-pathology work to KGH;

Perth &Smiths Falls District Hospital sends histo-pathology to KGH;

Hotel Dieu Hospital and Providence Care send their laboratory work to KGH.
Other best practice adopted or developed at some of the regional hospitals in the region
includes:

Standardization of coagulation instrumentation and related processes and standards of
practice (SOP) development (e.g. across all sites);

POCT Technology implementation (e.g. QHC);

Decision support tools (e.g. data mining capabilities at QHC);

Microbiology MALDI_TOF technology (e.g. KGH and QHC);

Microbiology equipment standardization (e.g. QHC, KGH, PSFH, Brockville);

Specimen tracking for histo-pathology (e.g. KGH);

Reduction of specimen collection errors (e.g. KGH);

Chemistry automation – (e.g. KGH large track system);

Transfusion Safety Officer (e.g. KGH);

Consolidated immunohistochemistry testing (e.g. KGH);

Molecular testing to support infectious disease service and infection control (e.g. QHC
and KGH);

Auto-verification tools (e.g. KGH and QHC).
Each of these best practices offer opportunities to further leverage and bring benefit to the
region.
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3.6 Current Challenges
Service Delivery challenges (order is not reflective of importance):

Fiscal challenges are ongoing and it appears funding shortfalls will occur in both the
near and distant future;

The limited transportation system across the region has not been optimized for a timely
or efficient Regional Laboratory system;

There is limited IT connectivity between sites with limited existing interfaces between
the numerous LIS systems in use within the region – this limits data management
between sites and can cause transcription errors if information must be entered
manually into the system;

There is no specimen tracking technology across most sites in the region. This is
especially important for histology and has become an expected best practice for all
laboratory services. This will be a priority for the working group to resolve;

There is no common document management system that can be used across the
region– this is essential for a Regional Laboratory program or any other regional
service;

There is no capital planning on a regional level. Funding streams are varied by
corporation (hospital vs foundation) with limited available funds. This further restricts
equipment standardization and realizing possible financial savings from bulk
purchase(equipment standardization was successful in the mid-2000’s timeframe but
has not been followed until recently for hematology when standardization was followed
for coagulation instrumentation);

SOP standardization has not been done due to limited equipment standardization and
limited incentive;

Need stronger regionally shared Clinical / Medical advisory leads to support
standardization, quality improvement, and best practices;

There is no standard approach for Medical /technical consultation at each site. This is a
big issue to help maintain quality. OTN could be explored to facilitate this need;

Funding streams differ between organizations;

Clinical services offered differ between organizations;

There is no common data management system;

There is no common reference laboratory;

Need to maximize use of POCT technology where cost effective and clinically required;
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
There is no regional level of HR planning for recruitment, retention, and staff sharing;

There are multiple collective agreements across the region, with varying compensation
clauses for things like call back. These could be standardized in the region;

As clinical services expand there is little flexibility in the system to absorb any
additional work.
Many of the above challenges would need to be addressed by the new leadership and
governance and the lack thereof has been a major hurdle to moving forward with any
of the solutions to these problems.
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4.0 Proposed Future State
4.1 Service Model

Core Laboratory services (chemistry, hematology, blood transfusion services) will
remain at QHC Belleville, KGH site, Perth and Smiths Falls hospitals (PSFDH), Lennox
and Addington hospital (LACGH) and Brockville hospital (BGH).

Microbiology services will be consolidated and specimens will move from Brockville and
Perth and Smiths Falls hospitals to KGH site. Some microbiology tests that are
performed 24/7 will be maintained in the core laboratory sites at PSFDH and BGH.

Histology services will continue to be provided in Kingston, Belleville and Brockville. The
Histology team will look at quick win projects including sending lymphoma cases to KGH
from BGH and QHC. An extensive engagement will also take place with medical and
technical staff to determine the possibility of areas that could be consolidated in the
future. We will pilot any proposed changes at a single site to ensure they will not
negatively impact patient care or the availability of laboratory professionals to provide
support to the clinical services.

Reference laboratory services to be consolidated and tests repatriated as appropriate.
Some tests that are currently sent to private laboratories could be done on an extended
test menu at the KGH site. This would improve turnaround time and save money. Where
private laboratories provide a better, more cost effective solution a coordinated regional
wide agreement would be negotiated to improve services for all sites.
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The test model below demonstrates that there is a hierarchy of options to be considered by
the Regional Laboratory as it looks at solutions to optimizing services, and central to that
equation is that the patient needs are met.
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Benefits:

Ensures patients are well served by doing tests they need locally and in a timely
manner;

Provides cost savings through consolidation of low volume high cost at referral site;

Keeps funding allocated for laboratory services within the South East LHIN;

Improves efficiencies through removal of unnecessary cost and duplicate testing
infrastructure.
4.2 Service Governance
Service governance for the Shared Service Organization is being developed by another working
group. It is our understanding that ultimately the Laboratory management team will report to a
Vice President within the Shared Service Organization. The SSO will report to a SSO Board
which will have accountability to the Hospital Boards. We also understand there will be a Clinical
Counsel within the SSO that will support the SSO Governance and Leadership, including
providing hospital representation to interact and guide Laboratory Medicine and other SSO
services. We also envision having a Laboratory Advisory Council that will provide more direct
advice regarding issues related to laboratory best practices, service performance etc., which will
be populated by hospital and expert members.
Further information on service governance will be provided as it is finalized and approved.
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5.0 Management and Staffing Structure
5.1 Organization Structure
The structure we envision for the Regional Laboratory is similar to other Regional Laboratory
structures and also meets the legislated requirements. We have added in a Regional Quality /
Utilization & Safety Coordinator and a Business Development & LIS Coordinator, both of these
roles are part of other leadership roles today but are acknowledged by all of us to be
underdeveloped as a result. Dedicating positions and time to these areas is seen as one of the
major benefits a Regional Laboratory can bring to the region. We have not quantified the benefits
these roles will bring to the region, nor the risk reduction they will contribute to, but feel strongly
that they must be part of the new design. It should also be noted that the Medical Director, while
accountable to the Vice President, will also have responsibilities to support and work with
academic and clinical leadership (e.g. Chief of Staff).
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5.2 Leadership Roles / Responsibilities
As is the current laboratory approach in the region, the Leadership structure will continue to be
closely aligned to the laboratory medical leads. The structure will support the regional shared
services laboratory model. Some of the attributes we are committed to designing into the service
are the following:

All sites will have supervisory support and a local leadership presence in hospital;

Roles will be standardized across all sites with clear role descriptions and related
duties/accountabilities;

Span of control and geographical limitations will be taken into consideration;

There will be initial investment in staffing with flexibility to change and optimize the model
as the shared services model continues to mature;

Success of implementation of the regional lab is dependent on knowledgeable and highly
skilled leaders in each laboratory discipline;

Each hospital laboratory will have one senior or charge technologist on site who will be
supported by their respective Site Manager;

Site Managers, Regional Managers and Coordinators will report to the Regional
Operational Director;

Regional Operational Director works closely with the Regional Medical Director who
jointly report to the Vice President who works within the structure of the shared service
organization.
Regional leadership model proposed includes:

Regional Operational Director;

Regional Medical Director;

Hospital based Chiefs of Laboratory Medicine and Specialty Heads;

5 Regional Managers (Discipline Specific) and 3 Site Managers;

2 Regional Coordinators;

Represents transition needs, would likely change over time.
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Proposed Leadership Model
Leadership position
Director
Current budgeted FTE
Future FTE
Beyond 2020
1.7 (4 people)
1
7
8
May adjust the # manager
positions once Regional
Laboratory matures
0.0
2
As above
8
11
TBD
(several directors are responsible for
areas other than lab)
Regional Discipline Managers/site
managers
Coordinators
Total
Change
+3
The increase in leadership is required in order to deal with the change management workload
and to help drive system changes through leadership. The managers will have a regional level
of responsibility and will be expected to travel to all sites to ensure knowledge and understanding
of issues, to ensure a high level of visibility and to ensure engagement with staff and other
stakeholders. We anticipate a review of the structure will be ongoing, but expect it will undergo
a full review in 2020, and if the transition is complete the roles should be reviewed again.
Proposed Staff Changes
Staff level positions
31.8
Change
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26.2
-5.6
May reduce the # senior/charge positions once
Regional Laboratory matures
Costing for Proposed Leadership Model
Position
Current state
Vision 2020
Reduction
Addition
Cost savings
or additions
Directors
1.7 FTE 4 People
1
-$80,000
Managers
7
8
1
+$100,000
Coordinators
0
2
2
+$170,000
Staff positions
31.8
26.2
0.7
(note use existing
people, positions are
upgraded)
5.6
Savings
-$504,000
-$314,000

As Regional Laboratory matures, leadership structure will be further streamlined;

Charge tech, senior tech positions are not required for areas where work is
consolidated, e.g. microbiology;

Staff positions are streamlined with technology and workflow efficiencies.
Proposed Leadership model provides the following benefits:

Managers (non-union) have several staff reporting to them;

Coordinators (non-union) have minimal staff reporting to them;

Both roles have regional level responsibility;

Quality and Utilization Coordinator- provide leadership and direction for quality
management activities, help drive standardization with corresponding quality and
efficiency, and help coordinate utilization initiatives;

Helps smaller sites with technical and medical expertise (e.g. service chief for
hematology helped coordinate and provided advice to coagulation standardization to
meet laboratory accreditation requirements);

Helps drive best practice across all South East LHIN sites;
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
Dedicated manager for clinical lab areas, with regional level responsibilities who work
closely with laboratory medical leads.
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6.0 Regional Service Model
6.1 Opportunities / Projects
Project
Comments
Implement leadership and governance structure and
clinical council structure to support integration of
regional clinical laboratory
Develop plan for either single or multiple employer
model
Specimen transport/courier system developed and
implemented

Includes specimen tracking so specimen is
instrument ready

Must meet current requirements for
specimen transport including biosafety,
specimen integrity, timeliness of
transportation, etc

Includes pathology tracking capabilities
from sending site, to testing site back to
reporting site
Each hospital area that currently has a regional network
(e.g. QHC) may not be impacted if scope of new courier
routes does not include this current network.
Must ensure specimen transport meets current
standards for transporting biologically fragile samples
within current turnaround times to ensure specimen
integrity and safety and quality for required patient care
needs.
IT connectivity to support communication of work
moved between sites will be developed and
implemented.
A HIS that includes a LIS is preferred, or a single LIS
would be next on the list. Preferred for the future and
part of IT Working Group looking at HIS offered for the
future
Consolidation of microbiology services
Microbiology samples will continue to be collected and
transported to QHC microbiology laboratory. Reference
level testing will be referred to KGH site and or QHC site
or Public Health Laboratories as best meets the need of
patients served and laboratory capacity to provide the
service.
1.
Send microbiology samples from Brockville
to be processed at KGH site
2.
Send microbiology samples from PSFDH to
be processed at KGH site
3.
Microbiology critical work to be done on
site at BGH and PSFDH. (e.g. blood
cultures, body fluids, gram stains)
Pilot Histology changes in practice
Set up an engagement with medical and technical
staff to further explore possible opportunities for
Histology consolidation.
Send Lymphoma cases to KGH as quick win.
Consolidation of Reference Laboratory testing out to
external vender across all South East LHIN Labs
This will require a future RFI and RFP.
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Any test sharing for Histology services deferred until
further medical and technical staff engagement has
occurred.
Will require participation and support of clinicians using
the services as well as MAC of the respective hospitals
Equipment standardization/regional level capital
planning and related technology updating (and
corresponding funding plan for capital purchases
and related foundation stakeholder involvement)
In some cases equipment may not be standardized if
volume does not justify larger equipment but test must
be done on site.
Contract management and standardization
Auto-verification development
The focus here is on high volume chemistry and
hematology testing, not lower volume and text based
testing such as in microbiology
Document control and SOP standardization
Develop POCT strategic plan for South East LHIN
laboratories. (consolidation/ connectivity and
technology development)
HR labour relations planning
Communications (ongoing)
Data management tools to support decision making
on a regional level
Quality management development
Clinical/Medical level support
Quality metrics and development (an initial draft has
been created with future lab advisory council to
advise on this)
Lab costing model* (this is in development)
Laboratory Costing Model
The pricing of laboratory tests and services for the Regional Laboratory is being built to deliver
on our desire to provide an efficient, effective, and quality service that is focused on the needs
of our patients and their care teams.
As we developed the approach the following principles helped guide our work. It must be:

transparent and understandable;

easy to implement and maintain;

approach is consistently applied;

reflect the true cost of the services (full cost);

costs are fairly distributed to hospitals.
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It is important that the pricing and the resulting information provided to hospitals and the
laboratory supports a sustainable model that we can continue to improve and adapt, it must
provide an accurate and true reflection of costs so hospitals and laboratory can make informed
decisions.
The model will capture the laboratory costs at each laboratory location (the six sites5) in cost
centres representing the laboratory services on site, and we will have at least one corporate
cost centre for region. At each of the six sites we will each capture the direct costs required to
operate the site: labour, supply costs, utilities, etc. in its cost centres. The corporate cost centre
will contain all costs that are shared and support the Regional Laboratory’s six sites, for example,
the cost of the Administrative Director (shared leadership); consider these shared overhead
costs that support all locations. These overhead costs will be allocated to the laboratory location
cost centres on an ability to bear (e.g. relative size (total direct costs) of each laboratory). It is
from these laboratory site cost centres that the seven hospitals have cost shares / prices will be
determined.
We have reviewed approaches used by other regional laboratories to allocate their costs to
hospitals. All the models we saw are variations based on measures of consumption; tests
ordered and services used. The most cost effective and efficient approach is to use weighted
laboratory test volumes to distribute the cost. In the past our region has often used LMS pricing,
or a derivative thereof, to charge for services rendered. The LMS prices are out of date and in
many cases significantly exceed cost. The utilization of weighted test volumes and actual costs
is simple and efficient for dealing with pricing of individual tests, and without time consuming
costly / pricing studies, there are limited other options. We tested a model utilizing a bottom up
pricing of actual tests, and found it time consuming and costly to complete. It requires significant
manpower and must be updated on a regular basis as practices change; very detailed. Given
we are looking at allocating the full cost of a laboratory site in our regional model we do not need
individual test costs, but can utilize total cost, which we have. We do need a weighting for this
model. The utilization of LMS weighted test volumes, applied consistently across the region,
becomes a viable option. Even given the fact our Ministry of Health and Long Term Care is less
than timely on updating the LMS weights for individual test, the consistent application of LMS
weights across our hospitals makes the approach a fair and viable method for weighting our test
volumes provided by each laboratory. With this model we will be able to distribute costs
consumed by each cost centre to the benefiting hospitals that received the services. We are
comfortable that the LMS weights provide an accurate distribution of cost and have tested this
fact between two sites with F2015/16 data.
As noted above, we will accumulate costs of producing tests at each cost centre location,
including the share of overhead costs. We will have total LMS weighted test volume by each
location, by requesting hospital, and therefore will allocate the costs of a laboratory site to the
benefiting hospitals. All the hospitals in the region will be treated the same using the same
5
The current hospital laboratories are Belleville (QHC site), Kingston (KGH site), Brockville (BGH), Napanee (LACGH), Perth, and
Smiths Falls (PSFDH). All these sites are retained as Operating Laboratories in the Regional Laboratory.
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pricing methodology. Also to be taken into consideration will be the overhead costs of the shared
services organization and its administrative functions and costs that would attribute to laboratory
medicine.
Transportation costs are a reality of laboratory services where some tests must be moved from
hospital to the laboratory site that will process the work. These costs will be captured and
charged to the requesting hospital as is the case today for referred out work. These costs are of
course part of the overall service equation and are considered as the regional laboratory works
to optimize services across the region to ensure timely and efficient delivery of services to the
patients and clinicians. Transportation’s impact on cost of service and timing of services would
be considered before any test location decisions are made.
In Phase 3 of HCT our plan is to build and test this methodology to be able to provide hospital
specific pro-forma financial statements to reflect the impact of the plans on each hospital utilizing
this pricing model.
We do know that some of the accounting infrastructure (i.e. cost centres) to fully support this
model would need to be built over the next year as several of our hospitals have limited structure
in place to fully implement right now. However, we do see capacity to implement the model as
the Regional Laboratory evolves. We do already collect the test data and LMS weights are
accessible, which are the key building blocks of this approach.
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Anticipated Phasing
Staging the projects is key to success implementation. We will learn and adjust as we move
forward through the stages.

Phase 3 Health Care Tomorrow project: Recruit key people to lead a transition team,
and begin the process of filling the top positions of the new organizational structure.
Create a detailed implementation plan and methodology to operationalize the Regional
Laboratory.

Year 1: Build Foundational project components – IT and courier/transport network
improvements, governance and leadership team development; and commence work on
standardization and reference laboratory test repatriation. Work on quick win projects.

Year 2: Continue standardization and reference Laboratory test consolidation and
repatriation; and commence microbiology consolidation, limited pilot testing of
histology/pathology opportunities, and POCT system development through regional
electronic connectivity.

Year 3: Complete microbiology consolidation and continue pilot testing of
histology/pathology practices.

Year 4: Create a new strategic plan for the Regional Laboratory to guide the next four
years of development.
Activities that can be done in parallel are:

Costing model development;

Clinical Advisory Committee development;

Capital planning/standardization, HR issues, communication issue.
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Proposed service changes and related staffing – Microbiology
Microbiology changes including staffing
LACGH
No change already sending to KGH
Blood cultures remain on site. All positive
samples are sent to KGH.
PSFDH
Send microbiology work to KGH site
Blood cultures remain on site
Current staffing:
CSF and other fluids remain on site
1.3 MLT FTE
0.53 MLA FTE
Staffing changes:
0.77 MLT FTE reduction
0.53 MLA FTE reduction
BGH
Send microbiology work to KGH site
Blood cultures remain on site
Current staffing:
CSF and fluids remain on site
3.0 MLT
Staffing changes:
3.0 MLT reduction
QHC
No changes in microbiology
Savings
Staffing $306,600
Supplies and service agreements $100,000
Total: $406,600
Proposed Service Changes - Histology
Histology changes have been put on hold at this stage pending further engagement with
medical and operational staff. Key quick wins have been identified (e.g. Sending lymphoma
cases to KGH) and these will be implemented in the first phase but still require detail work by
the professionals involved in the work.
Appendix C outlines potential service models for histology that could be considered in the
future and for the team to review.
6.2 Stakeholder Impacts

Good for our client services (provides customer service to participating hospitals and
their laboratory users);
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
Sustainable service - Sustainable microbiology service with reference level support;

Sustainable histology services with shared medical level support;

Patient does not have to travel; specimen can travel;

Improved courier network to facilitate specimen and supply transport across the region;

All sites connected through point to point interfaces;

Cost savings for reagents and other supplies;

Regional quality management approach;

Shared SOPS and standardized equipment;

Technology advancements not otherwise possible due to low volume;

Better medical consultation.
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7.0 Regional Benefits of New Model

Client services (provides customer service to participating hospitals and their
laboratory users);

Sustainable microbiology service with reference level support;

Sustainable histology services with shared medical level support;

Patient does not have to travel; specimen can travel;

Improved courier network to facilitate specimen and supply transport across the region;

All sites connected through point to point interfaces;

Cost savings for reagents and other supplies;

Regional quality management approach;

Shared SOPS and standardized equipment;

Technology advancements not otherwise possible due to low volume;

Better medical consultation.
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8.0 Goals and Performance Measures
The following areas are examples of performance measures that can be considered for the
regional service delivery model that is proposed. The Laboratory Advisory council will consider
which KPIs are essential to include as part of the quality management program. Goals for the
Regional Laboratory Medicine program will be established at the operational, advisory council
and governance levels. Appendix F provides additional examples of metrics that could be
considered.
Goals
Description
Measure
Quality-Safety
Stakeholders surveys (e.g. physicians
and patients that use lab services)
3 surveys in calendar year as changes are being made
Customer
engagement
Service-Access
(note as changes are being implemented, satisfactions
levels may be lower until processes are stabilized)
Test turnaround times for tests that are
impacted by service changes
(microbiology tests, histology tests e.g.
CSF cell counts
CSF Gram stain
Check current TAT
CSF Cultures
Check current TAT
Blood culture positive report
Check current TAT
Pathology report
Check current state
Unlabeled and mislabeled samples rates
Quality
Specimen transport errors
# specimen bags returned with specimens (should be
returned empty)
100-200 blood cultures per 1000 ICU Patient-days
Blood culture utilization rate
<3%
Blood culture contamination rate
Learning and
development
Training and development on key
competencies
Metric to be established
Business
development
Activity based costing
Costing model to be established
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9.0 Savings
9.1. Future Frontline Staffing and Costs by Major Business Functions
Overall Savings
Microbiology
Histology
$406,000
$50,000 (target that shows commitment to make
histology more efficient. Further engagement with
medical and operational staff is required)
Leadership
$314,000
Standardization and contract management
$100,000
Reference laboratory repatriation and contract
$160,000
consolidation*
Total
Deduct operating requirements ongoing
$1,030,000
$420,000 (includes needs for beyond 2020, would
require full RFI and RFP)
( transport system/travel )
Annual savings
$610,000
A little over 2 years to realize savings on the one-time
investment of 1.3 M
ROI
(if histology proceeds with investigated level of
consolidation and this results in savings, the ROI will
be shorter)
*Note: Reference laboratory approx. 1.3 M – estimated to save 20%. Estimated $160,000 (estimated through consolidation, test repatriation to new
SELHIN Regional Laboratory and single reference lab provider. This is a very large project and will require time and effort to fully investigate current
spending, and to prepare a RFI/RFP).
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10.0 Transformation Costs
10.1. One Time and Ongoing Costs
Item
One time cost
Transition Team
$300,000
IT integration
$590,200
Ongoing cost
TBD
Incudes regional level document control software
Specimen transport system improvements
Implementation support
$400,000
$50,000
Additional travel costs to support Regional
$20,000
Laboratory
LEAN resource
Subtotal
Contingency 25%
Total
$75,000
$1,015,200
$420,000
$250,000
$1,265,200
$420,000
Note: Project management support will be required from the Health Care Tomorrow project office. Suggest this resource has a lab background.
Future technology development for consideration:

Expansion of histology tracking system between sites if histology consolidation occurs
in the future;

Urine screening and transport;

Semi-automated microbiology system for microbiology;

Explore technology for incubating blood cultures on site at QHC collection sites;

Explore methods for “pre-incubation” of blood cultures;

Tele-medicine including tele-pathology and tele-microbiology;

Facility development;

Labels produced at bedside for specimen collection;

Inventory management control system;
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
Voice recognition.
As a Regional Laboratory we see having the scale to adapt some of these new technologies
more quickly and therefore being about to benefit from the efficiency and improvements more
quickly.
10.2. Labour Adjustments
Labour adjustment is very difficult to estimate until final staff counts are established, a full HR
review is done and potential for retirement, early retirement, and other related severances are
determined and costed.
An estimated range of potential costs for severance are $300,000-$800,000 (this is very difficult
to estimate at this time and is only provided to remind stakeholders of the need to budget for
these costs. We see the changes in the laboratory being evolution, not revolution and therefore
see attrition as a major part of labour changes. Sites are already starting to use temporary
positions to fill roles to help mitigate the impact on staff and leadership.
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11.0 Human Resource Plan
11.1 HR Principles

Open and Transparent;

Communicate often;

Keep union leadership well informed;

Work towards single employer model over time;

It will likely be a hybrid ;

Leadership should be hired as early as possible once project is approved to proceed;

11 collective agreements – complex LR environment;

Need dedicated HR consultant for laboratory project;

3 unions.
11.2 Labour Relations Overview

Governed by employment standards act and common law;

Governed by Public Sector Labour Relations Transition Act (PSLRTA);

Governed by collective agreement language related to employment stability;

Avoid implications related to constructive dismissal;

Open and transparent process;

Where possible keep transition period as short as possible;
o
Impact on morale;
o
Can lose employees due to uncertainty.
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12.0 Change Management
We understand that most transformation projects fail to meet expectations. 70% of
merger/integration initiatives do not live up to the goals. We also understand that:

50-80 % of re-engineering projects fail in business re-engineering projects;

In IT only 9% of large IT projects are on time and on budget. Even then only 42% of
promised features are actually delivered;

It is hard work to prevent distinctive and siloed work environments and culture;

In a multi union environment, single employer can help by minimizing various union
locals and differences in collective agreements;

Need commitment from HR, Finance and IT to ensure the regional lab success as we
rely on these services and until there are regional services of this nature, one of the
hospitals will need to support us;

Significant process, resource and facility variation has been noted to leads to bigger
change management issues – 3 unions, 11 collective agreements;

To help mitigate we need:
o
Strong regional leadership;
o
Clear role clarity;
o
Need strong change management plan to mitigate Lack of trust/fear of losing
role identity and control ( Phase 3 to develop);
o
Need team to build consistent and clear work flow practices;
o
Consider succession planning as we develop new structures, particularly as
current laboratory staff members are able to retire within 10 years.
Staff & Culture

From site specific to integrated/coordinated/regional care;

Foster a sense of purpose for the shared service team;

Establish a regional identity and team while maintaining a connection to the individual
hospitals and clinical staff.
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Customer & Service Governance

From provider/customer centric to patient focused;

From local lab physician service to regional medical service;

Partner with clinical staff to enable change associated with introduction of regional
standards.
Strategy & Governance

Transition from service provider to strategic partner;

Lab governance as a strategic component of the overall hospital strategy(s);

Interim strategy for active projects and planned projects.
12.1 Client and Staff Engagement
An overall engagement plan for Phase 2 of the Health Care Tomorrow – Hospital Services
project created opportunities for the working group to gather input from stakeholders from
October 2015 and June 2016, to inform the planning and decision-making process. This
ongoing engagement helped to support the client and staff engagement process by involving
stakeholders as early as possible in the future-state design. This process will continue into
Phase 3, Implementation Planning of the project, to help advise how the Regional Laboratory
will evolve and build on the existing strengths of each of the hospital sites.
The following engagement activities informed the development of the business cases/ models:
● a Regional Patient Advisory Committee was provided updates by SECHEF
representatives which helped ensure the patient/family voice was part of the HCT
planning process;
● Hospital/organization(s) each kept their leadership informed and involved in the
Hospital Services project through their regular leader meetings;
● A survey to all regional staff and physician in November 2015 had more than 900
respondents;
● Department meetings – Local hospital leaders provided face-to-face updates on the
current thinking of the Laboratory Medicine working group to all available staff in this
area in April;
● Summaries of the draft proposed future state and compelling case for change were
shared with all regional staff and physicians in April 2016. An open-ended survey tool
was included to allow input, with 633 people responding and 74 specifically on the
Laboratory Medicine working group summary;
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●
●
●
The working group solicited input in each of the hospitals in May 2016 from physician
and staff representatives to gather input on the proposed future state, as the
users/internal clients of our service;
Three regional forums for physicians were held during late May/early June 2016 to
invite physician feedback into the key concepts proposed in this and other business
cases;
Union leaders have been updated through written summaries and face-to-face
meetings.
The stakeholder input that was compiled from the above engagement activities has been
reviewed and discussed at working group meetings in order to inform the development of this
business case.
12.2 Communication
A communications plan will be developed consistent with the communications principles of
Health Care Tomorrow: Hospital Services i.e. to provide clear, regular and timely
communication that is respectful of those most affected or most likely affected by proposed
changes. A specific communications strategy will be required to support Laboratory Medicine
Services following approval by the Boards to help ensure clarity about what has been
approved and next steps. Similarly, communications strategies will support implementation
planning and delivery. This will include communication and engagement with stakeholder
groups and unions.
12.3 Learning Opportunities
As noted in the introduction, the ADKAR model has been used throughout the Health Care
Tomorrow: Hospital Services project to manage change. It will be important to ensure that
there is solid knowledge of the skills required to implement this business case.
Many users will require coaching and training to adopt standardized approaches, and/or
access staff who now may be located in different areas and create understanding on how to
work with new positions created and a new management structure. Similarly, staff who
currently support only one site may, in future, require orientation to and familiarization with
new sites in order to support newly expanded roles. The learning opportunities and needs will
be more fully considered as part of implementation planning.
12.4 Ongoing Support
As in prior phases of Health Care Tomorrow: Hospital Services, leaders will have an important
role in coaching and supporting staff. The need for ongoing support will be carefully
considered by the working group, in consultation with the HR Advisory Group and the Change
Management Steering Committee as part of implementation planning.
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13. Implementation Strategies
The reality of Laboratory Medicine being a wave 1 initiative raises the question as to how to
govern and oversee the development of the new regional operation before the new Shared
Service Organization (SSO) is ready. Concerns have been raised about the impact on cost of
operations of the Regional Laboratory if it has to carry the cost of SSO operation before other
services are included, and in respect the preparedness of the SSO to oversee a clinical
operation. An alternative solution that has been discussed, if the SSO is not ready, is that the
Regional Laboratory be overseen and operated by an existing hospital governance and
executive leadership, therefore avoiding additional overhead and allowing time for the
development of infrastructure to support a regional diagnostic service. Once more services
are ready and approved to transfer into the SSO and the SSO is deemed to be ready by the
Hospital’s CEO’s, the Regional Laboratory would be transferred into the service under a new
SSO executive lead. The selection of Hospital to govern and lead the Regional Laboratory
Medicine Services or the executive responsible in this transition period have not been
discussed to date and would be part of a process to be overseen by SECHEF CEOs in the
Implementation Phase for Wave 1 projects.
It is also our recommendation to the Hospital CEOs that dedicated resources will be required
by the Regional Laboratory Medicine Working Group to complete Phase 3, Implementation
Planning, as part of the project team. We will require the ongoing support of the Project
Secretariat used in Phase 2, but we see the need for the leads to be dedicated in this next
phase and more aligned to Regional Laboratory with subject matter expertise. The working
group has accomplished a lot of work this past year on the time allocated by staff across the
hospitals but more focused work is needed in this next stage. As soon as possible we would
like to move to formally filling the Director roles for the Regional Laboratory to lead the role out
of the implementation planning. We appreciate that CEO approval for these positions may
need to wait until after the first point of check-in with the Boards in Phase 3, but if we are
moving forward these positions will be critical to preparing the plans for implementing Year 1
of the Laboratory Medicine Services Business Case.
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14 Risk Assessments and Mitigation
Issue
Risk mitigation
IT connectivity not completed
A plan has already been established for site
connectivity. Detailed planning for this is pending
business case approval. We expect to roll out site by
site and build on past successes.
Courier / transport systems not established
Initial assessment has been completed and pending
Effectiveness of re-designed specimen transport
system will need to be monitored and measured to
ensure quality of specimen integrity and related
testing is not compromised.
business case approval, a RFI and then a RFP can be
issued to facilitate improvements in this area.
Quality metrics will be established to monitor
effectiveness of the transport system. The laboratory
Advisory Council will review metrics and ensure
specimen testing and related patient care is not
compromised.
Sufficient technology investment
A transformation plan has been completed and initial
investment is being sought as part of the business
case.
Availability of scalable platforms from vendors
The regional plan will incorporate standardization
where it makes sense and where technology will allow.
Buy in and support from management and staff
A full scale change management plan, engagement
plan and communication plan is being developed to
support information sharing and to help garner support
from laboratory staff.
Job security and impact on retention and
recruitment
As above. It is expected any job loss would be through
Each site not having an equal voice
Each hospital will have representation to ensure their
attrition and natural retirement options.
concerns and issues are addressed. The approach to
decision making and the governance to support the
regional decision making will be planned and
established during the implementation phase (HCT
phase 3, the next phase)
Funding for capital – timing of available funds
Pending business case approval, a capital plan will be
developed to ensure timing for the purchase of new
equipment and corresponding funding will be made
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available.
Shift in practice for medical staff
The change management and engagement planning
will include medical staff.
For any POCT changes, transfer of costs to
nursing
Any plans to expand POCT will be done in
collaboration with nursing and any impacted
stakeholders.
Laboratory licensing impact
Any relevant regulatory bodies such as OLA, MOH etc
will be engaged.
Notes:

Transfer of costs to nursing for POCT

Create capacity to add new services

Review costing model

Lab license changes
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Appendices
Appendix A: Integration Estimate
1KGH,
HDH, and Providence Care currently have access to full HIS integration (only Providence Care is using the
HIS in this way). For the purposes of Lab IT, orders from Providence Care flow to KGH LIS and results flow back
via interface to Providence Care patient chart. Since these 3 sites share a common HIS platform (two facilities on
one instance of QuadraMed), the patient’s chart can be visible to clinicians at all 3 sites. Providence Care is using
this to its full potential but KGH and HDH have not given all clinicians access to this full integration yet. Example:
Dr. Frank at Providence Care, when visiting a possible admission to Providence Care at KGH, can see all aspects
of client’s record that are in PCS. These results are all trended and graphed together since they share a common
testing platform at KGH.
2LACGH
existing interface is for transmission of microbiology orders from LACGH to the LIS at KGH and the results
back. Results from LIS at KGH flow back via interface to LACGH meditech. There is no sharing of the rest of the
record between sites.
3The
interfaces being proposed for PSFH, BGH, and QHC will be for orders from each of these sites into KGH and
the flow of results back from KGH to each of these sites. This eliminates the need for a paper requisition and sets a
scalable framework for future Lab IT expansion. This solution does not enable the sharing of the rest of the client
record between sites. For QHC – this interface is for the repatriation of some tests that are currently sent out to
Dynacare.
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Appendix B: Leading Practices and Benefits
Leading practice
Benefits
QHC lab consolidation
Quinte Health Care has already consolidated all laboratory testing services to a single
brand new laboratory at Belleville General Hospital. Point of Care Testing (POCT) is
utilized for testing at Picton, Trenton and Bancroft. All other testing including blood bank
and microbiology/histopathology testing is sent into Belleville. Physicians are now very
satisfied with POCT testing at the non-Belleville sites as it helps with short turnaround
time results for key clinical decision making and other non-urgent tests are still available
at the larger Belleville site.
QHC POCT technology
implementation
QHC has a well-designed POCT program meeting the needs of clinicians and patients.
All testing devices are tracked and connected to the LIS using middleware technology.
All results are included in the patient medical record. Quality management is performed
across all sites with a team of POCT specialists supporting this program, taking care of
monitoring volumes, quality management, training and technology development.
Microbiology MALDI-TOF
technology
KGH site and QHC site have new technology for the microbiology departments. This
has provided a standardized approach for mass spectrometry technology which allows
same day identification of microorganisms and contributes to earlier diagnosis and
treatment of infectious diseases. This has saved money and improves patient care.
Microbiology equipment
standardization
SELHIN microbiology department equipment is already standardized to the Biomerieux
platforms using Vitek and Bacti-Alert.
Specimen tracking for Histopathology*
Bar code-based tracking solutions, are now being used in pathology (AP) laboratories.
Tracking of AP "assets" (specimens, blocks, slides, reporting) enhances laboratory
efficiency, promotes patient safety, and improves patient care. The goal is to reduce
specimen processing errors as close to zero as possible.
Decision support – data
mining capabilities at QHC *
QHC has a very strong decision support team with the tools to data mine and produce
high quality informative reports to help make important clinical and operational
decisions. It has been recognized that this model should be propagated across the
LHIN to support broader regional decision support needs.
Reduction of specimen
collection errors (KGH site) *
KGH has successfully reduced specimen collection errors with a focused effort to
improve the collection process using value stream analysis. Laboratory results provide
essential data for diagnostic, monitoring and treatment of patients. Delays in laboratory
tests can be the result of specimens received in the laboratory that are unlabeled or
mislabeled. In either case this means unnecessary delay in treatment or decision
making. From a regional perspective it will be imperative to have specimens correctly
labelled.
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Chemistry automation –
KGH site -large track system
KGH has introduced a new state of the art automated track (“TRACK”) effective May
2016. Laboratory results are used to make clinical decisions around admissions,
discharges and diagnosis so it is imperative that results are available in a timely
manner. There were several specific goals with the implementation of the TRAC, those
being;

cost savings for laboratory testing;

improved quality with respect to results turn-around-times;

improved staff and patient safety.
Transfusion Safety officer*
(currently at KGH only,
needed for other sites)
The Transfusion Safety Officer is accountable for collaborating with Medical, Technical
and Para-Medical and nursing personnel to identify, implement and evaluate strategies
for blood conservation, safety and quality assurance associated with the transfusion of
blood and blood products.
Standardization of
coagulation instrumentation/
processes/standard
operating procedures
The Regional inter-laboratory Hemostasis program ensures that all laboratory
equipment and reagents are standardized in the region reducing unnecessary costs
and supplies and the continuity of patient care. This was done by;
Lennox Addington hospital
sends microbiology and
histo-pathology to KGH* site

purchase of same family of laboratory instrumentation;

sequestering of the same reagent lot numbers;

sharing of policies and procedures.
This has helped to maximize the standardization of laboratory equipment, reagents and
supplies to achieve improved quality, cost savings through economies of scale, through
regional purchasing of reagents and supplies.
Perth Smiths Fallss hospital
sends histo-pathology to
KGH site
QHC sends cytology and
reference pathology work to
KGH site
Auto-verification
Auto-verification is partially implemented at QHC, is implemented in chemistry and
hematology at KGH site. This electronic decision tool can be further rolled out at all
SELHIN hospital lab sites. This software tool is used to send out normal lab results
without technologist input and review. This speeds up the release of normal lab test
results. This is now considered industry best practice.
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Appendix C: Proposed draft Histology changes for future
consideration
Note: These are not proceeding at this time. Further medical and operational management and staff engagement is
required to determine if there is agreement to proceed.
Send select histology specimens/cassettes after
Grossing technologists, pathologists remain at QHC and
grossing to KGH for technical processing. Send slides
Brockville locations. Before any change would occur in this
back to QHC and Brockville for pathologist
area the physicians and staff would need to validate and
interpretation and report generation.
test any model so no assumptions can be made at this time
about this model.
Possible IHC consolidation
Consolidate to KGH site, currently performed at both KGH
and QHC site. Brockville sends to KGH.
Might not save $ as cost per test is approximately the same
at the two sites. Vendor discussions would be needed.
LACGH
No change already sending to
KGH site
PSFH
No change already sending to
KGH site
BGH
Send Histology specimen
processing work to KGH site
Current staffing:
3.4 MLT to 1.2
Staffing changes:
2.2 MLT reduction
QHC
Current staffing
6.0 MLT/MLA
Staffing changes:
3.0 MLT/MLA
Potential Savings
Staffing $240,000
Supplies and service agreements $100,000
Total: $340,000
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Appendix D: Capital Costs
Annualized Amount
Earned Hours
EARNED HOURS - MANAGEMENT
AND OPERATIONAL SUPPORT
(MOS)
EARNED HOURS - MED
EARNED HOURS - UNIT
PRODUCING PERSONNEL (UPP)
Functional Centre Profile
OPERATING DAYS
WORKLOAD SYSTEM
S7402000 Diagnostic and
Therapeutic Workload System
Personnel Profile - Earned Hours
Earned Hours Details MED
Earned Hours Details MOS Earned Hours Details UPP
Personnel Profile - Head Count
MED HEAD COUNT - BY
OCCUPATIONAL CLASS - BY
EMPLOYMENT STATUS
MOS HEAD COUNT - BY
OCCUPATIONAL CLASS - BY
EMPLOYMENT STATUS
UPP Head Count - by
Occupational Class - by
EMPLOYMENT STATUS
Service Recipient Activity
Accounts
Autopsies Performed
CLINICAL LAB IN-HOUSE
INTERVENTIONS
LAB CLINICAL CONTRACTED
OUT INTERVENTIONS
MEDICAL IMAGING IN-HOUSE
EXAMS
Specialty and Priority Program
Profile
GENETICS
Workload
CLINICAL LABORATORY
SERVICE RECIPIENT WORKLOAD
DIAGNOSTIC STANDARD TIME
SERVICE RECIPIENT WL
NON-SERVICE RECIPIENT
WORKLOAD UNITS
Grand Total
FY 11/12
FY 13/14
FY 14/15
FY 15/16
550,889
69,887
557,760
67,858
551,335
67,408
549,981
74,326
530,464
71,270
6,172
474,830
6,779
483,123
12,610
471,317
6,617
469,038
6,830
452,364
38,671
4,604
34,067
34,067
38,334
4,266
34,068
34,068
40,653
4,486
36,167
36,167
40,595
4,418
36,177
36,177
80,740
4,364
76,376
76,376
551,036
6,172
69,909
474,955
352
1
557,927
6,779
67,888
483,260
340
1
551,428
12,610
67,422
471,396
353
1
550,151
6,617
74,391
469,143
356
1
530,752
6,826
71,310
452,616
354
1
45
42
38
41
45
306
297
314
314
308
7,304,692
7,606,973
7,501,841
7,209,289
7,554,202
241
6,449,862
246
6,727,769
358
6,460,817
291
6,202,640
240
6,555,124
854,589
878,958
1,040,666
993,291
986,356
13,067
12,482
6,952
7,350
6,536
6,985
6,154
6,952
21,199,845
7,350
23,905,623
6,985
25,777,154
6,154
24,453,484
13,780,591
14,012,214
14,484,344
14,495,468
330,004
330,004
6,536
24,821,42
5
14,342,86
9
197,080
206,974
206,978
7,089,250
9,563,405
11,085,836
9,751,038
29,652,437
32,674,307
10,281,47
6
33,473,57
1
34,134,511
33,156,150
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FY 12/13
Appendix E: Courier/Transport Requirements
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Appendix F: Metrics for Consideration
QUALITY
DIMENSION
Patient
Centered
MEASURE
Outreach Customer Satisfaction Survey
MRP
Target
>85%
Complaints
Complaints reviewed
1.00
Customer surveys of physicians & other users
Specimen transportation errors (needs definition)
Safe
Notification of Critical Result Reporting; Positive Blood Culture,
CSF Cell Count = 1 hr
Number of Reported Adverse Transfusion Rxn = graded as no
cause found
Number of Lab Employee Injuries/Accidents per month
0.90
1.00
1.00
Blood product/component transfusion audits
Timely
Effective
TAT STAT Automated CBC = < 30 min
30 min
TAT STAT K+ = < 60 min
60 min
TAT STAT PTT = < 60 min
60 min
TAT CSF Cell Count = < 60 min
60 min
TAT for Bone Marrows (non-referred) in Hematology = 7 days
0.80
TAT for Bone Marrows in Cytogenetics = 21 days
0.90
TAT Cytogenetics - Prenatal Specimens (Amniotic Fluid) = 21
days
TAT Molecular Genetics - Breast/Ovarian Cancer Full Screening
= 4 months
TAT Molecular Genetics - Cancer Hot Spot Assays = 14 days
0.80
>90%
TAT Non-Gyne Cytology Reporting = in 3 working days
0.80
TAT Overall Surgical Pathology Report = in 5 working days
0.80
TAT for Cancer Resection Synoptic Reports = 14 calendar days
of the day of surgery
TAT of Autopsies (hospital cases) = 120 working days
0.80
Discrepancies between organism(s) observed on Gram stain
and culture results
Absolute CD34 Count Correlation Between Immunology Lab
and CBS
Cervical Cytology recalls
0.01
FOBT Testing (CCO?)
Low risk cases having pre op lab testing (CBC, lytes, creat etc)
Bone marrow adequacy rate
Repeated tests that are normal (eg CBC, lytes, creatinine)
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>90%
0.90
0.90
Free T4 or T3 testing Audits/TSH Utilization Audits
PAP testing done <21 or >69 years of age
Efficient
Number of Mislabeled & Unlabeled Specimens Received from
Clinical Areas/Floors per month
Institute for Quality Management in Healthcare (IQMH) EQA
Survey Performance
Type and screen utilization audits
50.00
Blood culture rate /1000 pt days in ICU patients
200.00
0.10
Blood culture contamination rate
<3%
Proportion of single set blood cultures (goal ≥2sets)
0.00
Blood culture bottle fill volumes (% meet standard volume)
0.95
Pre-incubation time of blood cultures (average Mins)
10.00
% Expense/Revenue
0.00
Overtime hours
Sick Time hours
Attrition rate
<5%
Number of corrected reports
Work load units by discipline/lab area
Equitable
IVIG Utilization compliance rate
0.90
Testing Utilization according to best practice for disease
management
POCT Blood Gas QA Audit
10.00
TAT STAT Automated CBC Results Originating from HDH = <
30 min
TAT STAT K+, PTT and CSF Cell Count Results Originating
from HDH = < 60 min
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30 min
60 min