Abstract
INTRODUCTION
The forces driving change at Peel Memorial Hospital (PMH) laboratory in 1992 were the same as those though out North America — that is a changing health care environment, changing laboratory and data processing technology and laboratory utilization. A strategic analysis, performed in 1992, identified the following strategies: automation, testing closer to the patient, organizational restructuring, work redesign, computerization, TQM/CQI, utilization review and regionalization.
BACKGROUND
“There's no point in paving the cow path” (Michael Hammer). This quote had significance for us at Peel Memorial as we embarked on our restructuring journey because it represented the need to re-examine and streamline our manual processes prior to automation and computerization.
Peel Memorial Hospital is a 350 bed, acute care community hospital, serving one of the fastest growing communities in the province. The Hospital has a Program Management/ Patient Focused Care structure. This structure was key to our restructuring success in that it encouraged independent, creative solutions as long as they were aligned with the strategic direction of the Hospital. Our strategies certainly were aligned in this direction.
Implementation of the strategies outlined in the SWOT analysis encompassed four distinct redesign phases:
Back to the Future 1992 – 1994
Patient Focused Care comes to PMH Laboratory 1994 – 1996
Paving the Path 1996 – 1997
The Next Generation 1997-
Back to the Future
This first phase of redesign included a reduction of two layers in the laboratory hierarchy with centralization of some supervisory functions and decentralization of others. Decision making to occur at the lowest level and the concept of self directed work teams was introduced. Decentralization of some of the former supervisor functions to front-line staff resulted in the establishment of the following work teams — Scheduling, QA, Safety, and five Technical Teams representing the traditional Lab disciplines. Team Leaders replaced Supervisors while coaching and developing replaced supervising staff. Hospital-wide CQI training for all staff and a Front-line Leadership course for Supervisors aided this process.
Cross-training during this phase enabled us to eliminate the spare capacity existing in the lab areas. We cross-trained 80% of the staff. Staff who could not be cross-trained were considered “core” to their area while cross-trained staff were considered “float”. Implementation of this cross-training increased productivity, decreased the territorialism that had existed within the specialized lab areas and enriched the technologist role within the laboratory.
Phlebotomy Services were decentralized to the Patient Care Groups with training and evaluation being performed by the laboratory. Savings to the hospital of this initiative was approximately $200,000.
Patient Focused Care Comes to PMH Laboratory
In this phase, the Oncology Clinic was moved to the laboratory. The excitement of this move was that it encompassed the “core” values and vision of PMH. The move was conceived at a lab workflow brainstorming session, and championed by front-line staff. It's completion was “Patient Focused Care” with a unique character. Patients were brought to the services — Laboratory and Pharmacy, instead of services brought to the patient.
Renovations in this phase included removing the wall between Chemistry and Hematology and creating an opening between Histology and Microbiology. We moved Cytology to the location between Microbiology and Histology. These changes facilitated the functioning of a multi-skilled and cross-trained staff and structurally prepared the laboratory for computers.
Automation in this phase included the purchase of a automatic cover-slipper and stainer. As well, the laboratory was computerized including order entry of requests and bar-coding of specimens.
Microbiology and Infection Control were integrated, with two technologists cross-trained into Infection Control (0.5 Fte) and a nurse hired (0.3 Fte) to form the lab component of a unique shared services arrangement which includes a teaching hospital.
Paving the Path
In this phase, lab staff identified opportunities to consolidate and organize laboratory testing by technology and service as opposed to the traditional laboratory disciplines. Focus groups looked at three different models and developed a PMH model incorporating common aspects of all three, one with a Rapid Response area and a Non-ergent area.
Next, focus groups plotted the flow of specimens through the new areas and designed these areas — placement of instruments, benches, terminals etc. to achieve the “best” workflow. We used the concept of different colored circles to illustrate workflow within the areas as well as to illustrate a staff “buddy” system that might facilitate the next stage of cross-training. For example staff originally trained in Chemistry would “buddy” with someone strong in Hematology.
Automation in this phase included Hematology instrumentation with a slide maker, replacement and expansion of the dedicated tube system to all emergency areas and CASPAR. CASPAR (Coulter Automated Sample Processor and Robotics) automated our pre-analytical procedures. The business plan for CASPAR and the Hematology instrumentation had a pay-back period of less than two years.
Regionalization the Next Generation
With the Laboratory Services Review (Provincial Government's review of the Laboratory System — LSR) and the Hospital Services Restructuring Commission's (HSRC) mandate for hospital restructuring, came the realization that the laboratory at PMH had gone as far as it could alone. For us to continue as a hospital based laboratory system we would have to look to partner with other organizations. We had already been meeting informally with two hospitals in our region so the progression to a more formal arrangement was relatively easy.
In the fall of 1996, KPMG was retained by The Mississauga, Credit Valley and Peel Memorial Hospitals to advise on the development and implementation of a collaborative and cooperative laboratory services model, one that would minimize duplication, decrease cost of service and strategically position us as a hospital based laboratory service.
The model we chose for Peel Region included Rapid Response Labs (RRL) at the three sites with centralized testing of Blood Bank, Microbiology, Cytology, and Chemistry/Hematology at one site (Credit Valley). Histology will remain at the individual hospitals until Pathology Medicine centralizes. CASPAR will be located at the centralized Chemistry/Hematology site.
Measurable Results
The measurable results of each phase were reflected at the end of the Phase in the next years budget, for example, the 1994/95 budget was $4.58 Million with 70.7 Fte (Figure 1).
Measurable results of each phase.
Included in these statistics are the addition of 0.8 Fte for Infection Control (Phase II) and the reduction of 6.0 Fte in Phase III because of the loss of some of our community work. As well the technical staff received a raise in this phase.
DISCUSSION
Restructuring at Peel Memorial Laboratory included implementation of the 1992 SWOT strategic plan with emphasis on work redesign and automation. Critical success factors of this restructuring were a process based on CQI principles and the introduction of Self Directed teams. It is the “team” environment, evident though-out the Laboratory, that visitors are most impressed with.
The phased approached we used lent itself well to our culture for a number of reasons, most important was that downsizing through phases allowed changes to be made through attrition so that staff remaining felt secure enough to be creative and supportive. This was important because we didn't want to lose the “best” people during the design phases. It is interesting to note the shortening of phase periods as we progressed, we attributed this to the increasing change in the external environment. The major achievements from this restructuring were: reduction in the dollars associated with labor and increased productivity.