Q&A with John Park, MS, MT(ASCP)
Director of Laboratory Services
The Valley Hospital
Medical Lab Management: What are the essential operations taking place at your outpatient laboratory?
John Park: The essential services provided in our outpatient laboratory include basic blood work and other body fluid and solid analyses, such as urinalysis and stool samples. Some of these fall under pre-admission testing, including blood type and screen with crossmatches for pre-procedural patients. We also perform certain newborn screenings, which has been a somewhat nerve-wracking experience during the pandemic. The State of New Jersey requires a newborn screening process that involves placing drops of a newborn’s blood onto five specific spots on a card. The New Jersey Department of Health provides the cards, but the application of the blood has to be very precise; it cannot be cracked, oversaturated, or undersaturated, and it has to be completely within the circle. Otherwise, the state will reject the submission.
When a baby is born, there is a routine collection performed in the maternity department, from which the blood samples are added to the card. In the event a submission is rejected for any reason, the child needs to return to the outpatient lab for redraw, and this intensifies the pressure to submit a valid sample card. Redrawing patients is never a desirable situation, but doing so with an infant is particularly undesirable, especially during a pandemic. Fortunately, our outpatient staff is well versed in these requirements and have weathered the challenges of the COVID pandemic with a strong resolve. This highlights the versatility required of our outpatient laboratory staff, as they handle patients of all ages and needs in a direct engagement.
MLM: What changes made in response to the pandemic do you plan to keep in place as they have proved beneficial?
Park: At the beginning of the COVID-19 pandemic outbreak, we saw drastic reductions to outpatient (and inpatient) operations in response to various shutdowns. We continued to see only patients that were on a specific schedule for vital therapy monitoring, such as blood thinners (eg, coumadin), those receiving prothrombin time and partial thromboplastin time (PT/PTT) testing, or for certain therapeutic drug levels that require periodic review to avoid over or under medicating.
Throughout, we have operated under the mandates and guidelines of our state as they have evolved. For much of the last year, visitors were highly restricted throughout the hospital, but as restrictions have eased of late, we are now allowing one or two visitors during certain times of day. If the patient is in hospice, we are able to allow up to four visitors at the same time. While we want our patients to be comfortable and accessible to loved ones, managing the overall number of people coming in and out of a hospital during a pandemic is common sense. Otherwise, we continue to encourage frequent hand washing and a close attention to any altered body temperatures or illness symptoms. We expect these basic practices will continue.
As the outpatient lab works directly with patients, reintroducing foot traffic there has had to adjust for ongoing physical distancing. We reduced the number of available chairs from 15 to five, and that will remain for the time being. This is important because prior to the pandemic we operated primarily as a walk-in service, whereas we are now exclusively appointment based. We now know how many patients we will see at any given time and what their needs are. Notably, we do not turn away patients who walk in, but we highly encourage appointments through community outreach, and we plan to retain this model moving forward.
MLM: Has this helped reduce overall wait times and improved patient satisfaction?
Park: Absolutely, and this highlights an initiative we were already working on prior to the pandemic to reduce paper documents and move from a physical information trail to an electronic one in the outpatient lab. We do not want to place the onus on patients to relay a physical lab order from their provider, so we enabled the medical office to fax or email us an e-version of the test orders. When a patient arrives at the scheduled time, we look them up by name and already have the order on electronic file, which is subject to positive patient ID at the time. We are then able to expedite the registration and testing process.
MLM: Having gone through a relatively recent remodel of your outpatient laboratory, what changes were involved that have benefitted the organization thus far?
Park: We began that project well before COVID-19 emerged, so one primary driver for our remodel was that the facility itself was simply outdated. A review of Press Ganey patient satisfaction elements revealed lower than desired scores for the outpatient laboratory facilities and we also received similar feedback from our employees who utilize the outpatient lab for their testing needs. Fortunately, due in large part to our expanded outreach initiatives, we had available funds to remodel and update the outpatient laboratory service line.
A key aspect of the overall project was creating time efficiencies. Because wait times can significantly influence a patient’s overall experience and given that in many cases the process of registering a patient can take longer than a phlebotomy draw itself, we wanted to reduce registration times while also providing a fresh and modern environment for both our patients and our staff.
In another key initiative and as part of the overall transition to fewer paper-based methods, we removed paper sign-in forms and converted to a tablet-based, electronic sign-in process. Furthermore, when the patient is at the registration bay, they can view the data input in real time on a screen and be directly involved in acknowledging consent. They can see it happening on a screen as the staff member inputs information. This has practically eliminated traditional clipboard-and-paper document methods. In addition, these electronic sign-in and registration methods allow us to time stamp every modality in the total patient encounter. We know exactly when a patient has signed in, been registered, taken for draw or sample, drawn, and released. We can now review these averages and look for further improvement opportunities. Likewise, in the event of an issue, we can look back and see if there was a deviation involving a specific patient or testing process and improve from there. Having the ability to audit the process with hard data is quite beneficial.
MLM: Were regulatory or accreditation concerns part of this overall process?
Park: Having been involved in approximately 12 inspections in my career, it has been my experience that the outpatient laboratory does not receive a significant amount of attention from inspectors. Certainly, there are inquiries about policies and procedures relative to that practice area, such as phlebotomy and other patient sample collections, and maintenance of annual competencies is emphasized. Otherwise, the outpatient lab does not tend to be an area of inspection focus for either The Joint Commission or CAP. That said, both organizations include increasing patient satisfaction as an institutional goal and doing so was a primary driver of our project.
MLM: With an increasing emphasis on clarity and transparency, has the outpatient lab enabled greater education for patients?
Park: That is a great question and we have certainly seen a more educated patient population in recent years. We do provide handouts for certain tests and most patients contact the lab ahead of their appointments to see if they have any special instructions. We also have general information on our website including instructions for basic procedures such as a 24-hour urine collection or to determine fasting times before a cholesterol panel.
In a recent initiative, the outpatient lab worked with our hospital’s communication team to create a custom QR code that directs a patient to an information and education page on their smartphone, including appointment scheduling. These shortcuts tend to be utilized by the more technically savvy patients seeking a more sophisticated lab encounter.
MLM: Are there other initiatives undertaken in the outpatient lab that have proven beneficial?
Park: One excellent example is a program called Joey’s Friend. This program provides a special contact number to the parents or guardians of patients with special needs in order to best accommodate their clinical encounters. In some cases, a patient with special needs might require multiple encounters at the hospital—imaging, physical therapy, blood work, etc—and each of these encounters can pose substantial stressors for that patient, particularly pediatric patients. Through this program, a parent can call the number and a staff member will not only schedule all necessary actions, but also indicate and arrange for any special accommodations. Times of day and numbers of people involved may have significant influence over a patient’s encounter, and our goal is to welcome and provide comfort for everyone who comes through our doors.
MLM: Moving forward, what other technologies are you looking to bring to bear in the outpatient lab?
Park: In the past, we used a number of different methods for positive patient ID, but we are moving to a new system that involves a handheld smart device for our phlebotomists. Upon arrival in the outpatient lab, a patient is banded with a bar code that can be scanned with the camera of a smart device. When it is time for that patient’s service, the phlebotomist or technician will scan the code with the handheld device and it will bring up the patient’s information, which is then confirmed with the patient. This information includes a list of all ordered tests, and once the ID is confirmed by the patient, the device initiates label printing for those specific sample containers or blood vials.
This service now extends beyond the outpatient lab and throughout the hospital. If a patient has just had services in another clinical area (eg, radiology), that encounter will also be tracked and made available for subsequent providers to review through these handheld devices. Likewise, because front-line staff can access patient information through these devices, there is little to no need for phone calls to the lab for test results or status updates. Instead of having to refer to a central LIS or electronic medical record, providers can access relevant patient information whenever they need to. This technology has enhanced our communication abilities throughout the organization.
Lastly, we have also incorporated an application-based program that provides third-party translation services in the event of a language barrier. Through the app, we can access live interpreters to validate a patient-encounter communication in a foreign language. These types of services are enabled through smart, integrated technology.
MLM: Since completing the remodel and implementation of new technologies in the outpatient lab, how have these projects affected satisfaction ratings externally and internally?
Park: We think very well. We have received positive feedback from both patients and employees, and despite the extraordinary challenges of this past year, our ability to remain flexible and provide excellent outpatient service to our community and our staff has been a point of pride. The changes we made during the remodel continue to facilitate our operations in a number of ways.
As part of the remodel, well prior the COVID outbreak, we included partitions and privacy barriers between the registration bays. Obviously, this was beneficial when the pandemic hit and we had to implement other distancing measures. Subsequently, in April of 2020, we began offering antibody screening for all employees within the organization—approximately 5,000 medical staff and auxiliary employees. We took this on via the outpatient lab and utilized an online module to schedule registrations and to temper the potential for crowding. Many of the changes we made during our remodel benefitted us during this process and enabled us to perform the blood draws and run antibody tests, free of charge. We feel this has brought tremendous value to our organization; a subject not lost on our administration.
MLM: Is there any advice you might give another facility considering a remodel or rebuild of their outpatient laboratory operations?
Park: Listen to your patients and listen to your staff, who are often patients themselves. Whether it is through a survey model like Press Ganey or a more informal discussion with front-line employees and those who are most informed on the needs of the outpatient lab, take this input and apply it to the project. Understand that tastes and needs will change, and unexpected events (such as a pandemic) could radically alter how we administer health care. As a front-line service provider, the outpatient lab may be more susceptible to those changes than other clinical areas, so an eye toward flexibility is essential.
Lastly, focus on the practical, not the trendy, and always keep an eye out for process improvement ideas in the outpatient setting, including devices that promote transparency, privacy, and security, while minimizing waste.
John Park, MS, MT(ASCP), is the director of laboratory services at The Valley Hospital in Ridgewood, New Jersey.