To support a culture of quality and the implementation of standardized improvement initiatives throughout all DOH-Polk labs, a Lab Team Charter was adopted by the Polk Lab Efficiency Team in October 2016. It is reviewed and renewed by the team annually. The Lab Team Charter delineates the Lab Team's purpose, primary functions, scope of work, membership/roles, meeting schedule and process, and deliverables. According to the charter, the primary functions of the team are:
Assesses and maintains a sustainable culture of quality within the county health department (CHD) labs.
Strives to maintain standardized procedures in the CHD labs through communication and collaboration.
Develops, updates, and implements the Laboratory Systems Manual.
Conducts a review of laboratory quality through: quarterly meetings, Quality Control logs, Lab Competency Validation checklists & General Laboratory checklists.
From July 2015 to present day, the DOH-Polk Lab Team has met quarterly. It is comprised of Nursing executive management (Assistant Director of Nursing), eHIC Registered Nursing Consultant, Lead Lab HST, and Lab HSTs representing each clinic: the Haines City CHD, Lakeland CHD, Lake Wales CHD, Auburndale CHD, and the Bartow Specialty Care Clinic. Other internal participants who frequently attend the quarterly meetings include program managers and/or members of specialty areas (i.e., STDs, Hepatitis, HIV/AIDS Outreach, TB), Nursing Supervisors, Billing specialists, IT staff, Information Security staff, and Division Directors. Community collaboration includes representatives from the State contracted lab partner, Quest Diagnostics. The regional Quest Diagnostics representative has attended quarterly Lab Team meetings since April 2016 and often brings other representatives to discuss issues with lab materials/supplies, billing, transporting labs and to also share any new process changes or the latest lab offerings.
In December 2016, Joan Fitchett, the Director of Laboratory Services & Department of Gastroenterology at the Watson Clinic LLP conducted an informal audit of the lab at the Lakeland Clinic site. Watson Clinic is a very prominent, privately owned healthcare provider in the area. Joan stated via email, It was a pleasure meeting with you this morning and I am very impressed with your facility. I like how you have standardized your forms and reporting.” She gave recommendations and attached a few documents that the Lab Team modified and adjusted to fit their needs. Her recommendations were also incorporated to fit the health department.
DOH-Polk Nursing Administration recognized the importance of maintaining and supporting the Lab Team's efforts to provide standardized, quality lab processes by creating a Lead Lab HST/Lab Coordinator position in 2017. Lab Coordinator Duties include:
Co-facilitating the Quarterly Lab Team meetings with the eHIC Registered Nursing Consultant
Auditing Lab Quality Control sheets quarterly
Maintaining all Lab-related information, checklists, audit sheets, etc. on the Public Drive
Assisting with keeping the Standardized Lab Sheet current and relevant
Assisting with keeping the Lab Manual updated, useful and implemented
Providing annual competency check-offs for all staff that work in the labs (validator of competency skills)
Visiting the other CHD labs quarterly, or as needed, to standardize general lab procedures in all lab CHDs (best practices)
Email and/or phone communication to Lab Team members regarding any changes in lab processes/procedures from the State Lab, LabCorp and Quest
Continuing to foster/enhance community partner relationships with LabCorp and Quest representatives
Advocating any issues and concerns on behalf of all the Lab HSTs to Administration
Continuing to build/sustain a culture of quality in all laboratory services and being available by phone for any questions or concerns
In 2018, the Lead Lab HST/Lab Coordinator was awarded the DOH-Polk Employee of the Month and the Employee of the Quarter. Her relationship with Quest enabled DOH-Polk to negotiate more cost-effective prices of labs that are frequently ordered by clinic providers. Because of her efforts, the Quest representative was able to get better prices on 4 labs ($202 in total savings). Based on the number of times these 4 labs were drawn last year from June-December 2017, the estimated savings for the rest of the 2018 calendar year is $6642.
The costs associated with the DOH-Polk Lab Efficiency Team include the pay raise given for the additional duties added to the position description for the Lead Lab HST/Lab Coordinator. This is minor compared to the thousands of dollars saved in total lab costs by the organization
In order to maintain a culture of quality and to standardized lab processes within all DOH-Polk labs, a standardized lab sheet (DOH-Polk Lab Order Form) is consistently reviewed and updated. The front page of the Lab Order Form has checkboxes for insurance type; an area to circle the program component, and a list of providers. The standardized lab sheet serves as means for the providers to order the labs they would like drawn. The ordering provider circles their name and initials next to it. There are 3 columns of labs. They are divided into sections: Cultures, Paps, Urine Tests and Alphabetical/Combination Tests. The name of the lab, the price of the lab, the specimen tube needed to collect the lab (color of tube or swab) and any other relevant information (e.g., age range of Paps and frequency) are listed. The lab codes for Quest and LabCorp are listed by each lab. The back page also has 3 columns of labs. In the first column, the labs are divided into sections for quick reference and to improve ease/efficiency of ordering: New OB, 28 Week Labs, 35 Week Labs, Family Planning Reproductive Health Visit/6 Week Postpartum, Pap Smear Information, Quad Screen, Pathology Report (for colposcopies). The second column contains labs for a Thrombophilia Workup, and commonly used High Risk OB labs. The third column lists commonly used Specialty Care labs divided into sections: Basic Labs, Annual Labs, New Patient Labs, Hepatitis Labs, Other Labs. On the bottom are a list of frequently used State Labs. The Lab Order Form is reviewed for lab relevancy, updated when lab codes and lab prices changes, and for changes in clinic provider staff. The eHIC Registered Nursing Consultant maintains change control and is responsible for making any necessary updates to the lab sheet, notifying the Lab Team members of the changes, and posting the lab sheet on the Public Drive. The most current Lab Order Form is found on the Public Drive so that all DOH-Polk staff can easily access the form.
Also located on the Public Drive is the Clinical Laboratory Policy; the Laboratory Systems Manual; Quality Control Logs; Laboratory Competency Validation Checklists; General Laboratory Checklists; Lab Team meeting agendas, meeting notes, charter, sign-in sheets; References and Guidelines; a copy of the CLIA license; and Quest Diagnostics price lists.
The Clinic Laboratory Policy (POLKP-390-28-17) was created in 2014 and reviewed and updated in May 2017. It is a local policy that sets forth guidelines for all DOH-Polk clinic laboratories. The protocols outline the expectation that health care providers demonstrate proficiency related to laboratory services and that those responsible for providing services follow the DOH-Polk Laboratory Systems Manual.
The Laboratory Systems Manual was designed to follow the regulatory requirements of the Centers for Medicare and Medicaid Services (CMS)'s Clinical Laboratory Improvement Amendments (CLIA) and standardizes all lab procedures. It is reviewed annually and signed by the Laboratory Director/DOH-Polk Director.
The Laboratory Systems Manual Table of Contents includes:
I. General Guidelines
Laboratory Terms and Abbreviations
Patient Test Management Process
II. Quick Guide - Cleaning and Maintenance Instructions
Blood Glucose Monitoring Systems
Coagulation Meter and HemoCue
8 Steps of Instrument Reprocessing (Sterilization Workflow)
III. Waived Tests User's Manuals
Blood Glucose Monitoring Systems (Accucheck Performa, HemoCue Glucose 201+, One Touch Ultra 2, Quintet AC)
Hemoglobin Detection – HemoCue Hb 201+
Urinalysis – Consult Diagnostics Urine Analyzer
Fecal Occult Blood
Urine Pregnancy Tests
Syphilis Rapid Tests
HIV Rapid Tests
IV. Equipment User's Manuals
Seiler Biological Microscopes
Wallach Star Colposcopes
Autoclaves – Tuttnauer and Midmark
Drucker Diagnostics Model 642E Centrifuges
Lab Testing Personnel: Waived & Non-waived Testing
Laboratory Competency Validation Checklist template
Quality Control Logs template
DOH-Polk Lab Efficiency Team Charter
Using the CDC's Ready? Set? Test! guidelines, Quality Control logs were created and are maintained monthly by the Lab HST at each clinic site and audited quarterly by the Lead Lab HST prior to the quarterly Lab Team meeting. The Quality Control logs document that the Lab HST attests that all supplies are within acceptable dates, all equipment cleaning has been done after each use/end of day per manufacturer's guidelines and maintenance performed as needed; and corrective action performed/documented when instrument malfunctions. Each Lab HST has a specific folder on the Public Drive for their clinic.
Annually, the Lead Lab HST and eHIC Registered Nursing Consultant perform a Laboratory Competency Validation on the Lab HST(s) and all HSTs who assist with phlebotomy tasks at each clinical site. Lab staff are rated with a (C) for competent demonstration of the knowledge/skill/ability or an (N) for needs improvement (may require practice and/or assistance). A few of the assessed tasks include: patient preparation; patient identification; venipuncture processes; cleaning/maintaining lab equipment; specimen processing; accessing Lab Manual, current lab sheet, quality control checklists; and point of care testing. The General Laboratory Checklist assesses the lab environment, proper signage, personal protective equipment and overall lab hygiene/organization. The checklists are signed by the HST being assessed and the validator (Lead Lab HST). Copies are given to their Nursing Supervisors and Nursing Administration.
The Lab Team continually strives to standardize their lab processes using best practices. Lab HSTs attend the Infectious Substances Packaging and Shipping Training sponsored by The Bureau of Public Health Laboratories every 2 years to maintain their certifications. In addition, documents maintained on the Public Drive for easy access under References and Guidelines include:
CDC to Test or Not to Test? Considerations for Waived Testing
CDC Provider-Performed Microscopy Procedures: A Focus on Quality Practices
Nursing Practice & Skill: Phlebotomy Practices published by Cinahl Information Systems, a division of EBSCO Information Services, 2016
WHO Guidelines on Drawing Blood: Best practices in Phlebotomy
Florida Department of Health: County Health Department (CHD) Guidance on Testing Pregnant Women for Zika Virus Infection, August 2017.
After creating the Laboratory Systems Manual, future modifications include standardizing laboratory equipment as much as possible in all clinics, such as blood glucose monitoring systems and autoclaves. Currently, there are 4 different blood glucose monitoring systems and 2 different autoclaves. If staff members are asked to cover other staff members in different clinics, training on cleaning/maintenance/usage of equipment would be minimized since they would all be the same.
The Polk Lab Efficiency Team continues to have a reputation for maintaining a culture of quality regarding lab processes in the organization. Since the team quarterly examines the total numbers of labs drawn, the estimated costs of the labs drawn, and the providers who ordered the labs, it was identified in July 2018 that the new, part-time physician was ordering a significant number of expensive HIV/AIDS labs that he routinely ordered in the private sector and was also advising his APRN to order as well. This led to a discussion where the ordering of these labs may be overutilized and he agreed to reserve the more expensive HIV labs for patients he suspects have an increased resistance or who are more challenging cases. Data showed in the following quarter October 2018, that there was a significant decrease in the ordering of these labs at an estimated cost savings of $6821.
The Lab Team has also been asked by clinical leadership to provide a presentation of their Top 5 Lab Tips at the next Providers Meeting to communicate how lab processes can be improved and made more efficient with their help. In turn, a survey will be given to the providers to assess whether the Lab Order Form is easy to use; is an important part of their clinical process; and any suggestions for improvement. They will also be asked if they have a collaborative relationship with their Lab HST; and in what way can their Lab HST or the Lab Team improve their clinical efficiency and effectiveness.
The Polk Lab Efficiency Team will continue to meet every January, April, July, and October, on the last Wednesday of the month. Collaboration with the State contracted lab partner, Quest Diagnostics, will be maintained and the regional representative and other members of her team will continue to attend all Lab Team meetings.
The members of the Lab Team are committed to their DOH-Polk patients and constantly strive to provide the best quality care. Their efforts are recognized and celebrated at every quarterly meeting and their demonstrated culture of quality is acknowledged by the entire organization.