Summary of the survey of microbiology workload recording: Experiences and practices

Summary of the Survey of Microbiology Workload Recording: Experiences and Practices

Ann Robinson, Ph.D. Table 1. Median number of specimens per worker per year Division of Microbiology Laboratory size a Department of Pathology and Laboratory

Medicine Section 1-4 5-14 >14 HartfordHo~pital Bacteriology 5,100 (1,600-24,300) b 7,500(3,700-51,500) Hartford, CT06115 Mycobacteriology 2,000 (1,500-2,600) 1,800 (600-14,100)

Mycology 3,400 (1,700-7,600) 1,500 (200-14,000) Parasitology 2,300 (1,600-2,800) 2,000 (400-7,500) Virology NA c 3,000 (80-9,300) Serology 1,100 (300-225,800) 8'500 (500-30,000) Total 6,600 (1,300-22,300) 6,000 (650-29,400)

The announcement by the College of American Pathologists (CAP) to sus- pend further development of the workload recording method that it devised a number of years ago has created con- cern among some clinical microbiologists regarding the impact this decision might have upon their ability to justify existing and future laboratory staffing needs and regarding what, if any, workload recording system might replace the current CAP system. Since microbiologists will be better able to position themselves to defend the management of their laboratories if they know where they stand in comparison to others, a survey of microbiology workload recording experiences and practices was included with the January 1, 1993, is- sue of the Clinical Microbiology News- letter. The results of this survey follow.

Responses were received from 57 laboratories from the following geo- graphic regions: northeast, 21; south- east, 10; midwest, 10; northwest, 5; southwest, 9; and other, 2. The types of laboratories that responded included: community hospital, 37; university hospital, 14; private laboratory, 4; and other, 2. For the purpose of comparison with a previous survey from 1982 (1), laboratories were divided into three groups on the basis of the number of non-doctoral personnel: small, 1 to 4 (n = 11); medium, 5 to 14 (n = 30); and large, >14 (n = 16).

Personnel and Space Resources for Workload

In general, the small and medium- sized laboratories tended to process more specimens per worker than the large laboratories (Table 1). This may be the result of the greater number of CAP workload units expended on specimens in large laboratories (Tables 2,3) and is probably not a reflection of a larger non-specified workload in the

4,000 (2,200-11,900) 2,500 (1,000-5,300)

2,600 (1,400-11,100) 2,900 (1,2(g)--5,300) 2,100 (500-5,000)

7,700 (3,600-26,400) 3,300 (2,100-5,800)

aBased on the number of non-doctoral personnel.

bThe range of data submitted.

elnsufficient data to tabulate.

Table 2. Average CAP workload units per specimen

Laboratory size a

Test 1--4 5-14 >14

Bacterial culture Throat 10+4 b 11:1:5 125:8 Lower respiratory 16 5:9 19 5:11 25 5:12 Wound 19 5:12 22 ± 10 28 5:15 Stool 185:15 165:5 225:11 Urine 11 + 10 12:1:5 135:7 Blood 15 5:9 14 5:7 14 + 4 Anaerobic 17 5:10 21 5:11 16 5:8 CSF 14 + 8 17 + 8 23 5:13 Genital for Neisseria gonorrhoeae 11 + 5 11 + 5 10 + 3

Fungal culture 16 + 6 18 5:8 24 5:17 Mycobacterial culture 22 5:10 27 5:5 29 5:13 Ova and parasite exam 21 5:11 27 5:9 26 5:13


bData indicate the mean + 1 standard deviation.

Table 3. Median viral CAP workload units per test

Laboratory size a

Test 5-14 >14

Viral culture

Herpes culture only RSV rapid CMV early antigen Clostridiwn difficile toxin assay Rotavirus EIA Chlamydia culture

aBased on the number of non-doctoral personnel. bThe range of data submitted.

22 (15-59) b 27 (8-59) 8 (4-37)

28 (15-37) 10 (4-25) 9 (5-25)

21 (18-34)

43 (10-156) 18 (6--24) I0 (8-39)

42 (17--64) 14 (7-21) 8 (7-15)

22 (5-28)

Clinical Microbiology Newsletter 16:6,1994 © 1994 Elsevier Science Inc. 0196--4399/94/$0.00 + 0%00 45

Table 4. Median laboratory space (net square feet per worker) Laboratory size a

Section 1-4 5 -14 >14

Bacteriology 120 (45-393) 8 217 (111-400) 129 (61-196) Mycobacteriology 200 (NA) e 266 (I00-1,000) 162 (88-716) Mycology 200 (NA) 235 ( 140-1,000) 159 (117-322) Parasitology 150 (100-200) 140 (80-500) 163 (60--400) Virology NA 99 (f£l--1,000) 263 (108-500) Serology 485 (21X1--770) 133 (67-150) 368 (225-600) Total 120 (45-393) 156 (90-380) 166 (83-256)



Clnsuflicient data to tabulate.

large laboratories since the average per- centage of non-specified workload + one standard deviation was 25+13, 22+12, and 21_+9 for the small, medium, and large laboratories, respec- tively. The number of specimens per worker per year showed tremendous variability as exhibited by the ranges, regardless of the size of the laboratory or the section within the laboratory (Ta- ble 1). The wide variation may he attributed either to under- or over-staffing, to the extent of specimen work-up, or to miscalculated workload data. Approxi- mately twice as many specimens can be processed per worker in bacteriology and serology than in the mycobacteriology, mycology, parasitology, or virology sections of the laboratory.

Depending upon the section and size of the ~ , the median space ranged from a low of 99 net sq ft/worker to a high of 485 net sq R/worker (Table 4). Overall, large laboratories had slightly greater space per worker than the medium-sized laboratories, which in turn had greater space than the small laboratories. It is interesting to note that, in general, more space was available per worker in mycobaeteriology, mycology, and serology than in bacteriology. The survey space data are comparable to those published in 1984 from a survey of 38 pathology departments in the United States with 10 or mo~ faculty members and providing service to a hospital with at least 300 beds (2).

Workload Recording The majority (73 to 81%) of labora-

tories, regardless of size, use CAP workload recording, although how the laboratories tabulate the d a3__a varies. Most (63%) small laboratories apply profile values. In contrast, the mid- sized and large laboratories did not re- port a single dominant method to collect data. The medium-sized laboratories use the following means to count CAP workload: profile values, 33%; individual count plus profile, 29%; average unit value, 19%; and individual count of all plates, tubes, and smears, 14%. The large laboratories use the following methods: individual count plus profile, 46%; profile values, 31%; individual counts, 15%; and other, 8%. The majority of respondents indicated that they will continue to use the old CAP workload recording system, even though CAP has withdrawn support for the system. A minority of laboratories will select another system with approxi- mately a third of the laboratories re- maining undecided as to what route will be selected.

Most (55 to 71%) respondents, regardless of laboratory size, think that workload recording and related issues are very important. Only 9% of the small laboratories and 7% of the large laboratories thought that workload was slightly important, and none felt that it was not important. The importance of workload is supported by the fact that more than 80% of the laboratories have either gained or lost personnel hours as a result of workload el a!& In the small laboratories, 36% gained hours, 7% lost hours, and 57% retained existing hours. In mid-sized laboratories, 36% gained hours, 19% lost hours, and 44% retained hours. Similarly, in the large laboratories, 42% gained personnel hours, 13% lost hours, and 46% retained existing hours. Of interest, 40% of small laboratories, 54% of medium- sized laboratories, and 50% of large laboratories had had their workload/productivity evaluated by an outside consultant. The vast majority of the consultants were retained at the request of hospital administration. In the small laboratories, 75% of the consultants spent less than 1 day in the microbiology laboratory, and the remainder spent 1 to 2 days. In the mid-sized and large laboratories, 86 to 88% of the consultants spent less than 3 days and the remainder spent 3 or more days in the laboratory. The minimal length of time spent by the consultants in the laboratory suggests that much of the data analysis is based on existing billing and workload data and that non-workloaded activities may be omitted from analysis. As a result of the consultant's analysis/recommendation, in the small laboratories 36% gained personnel hours,

Table 5. Median time spent on nonspecified activities Labcgatory size a

Activity 1-4 5-14 >14

Administration (%) 8 (0--18) b 11 (0-25) 7 (4-18) Quality assurance (%) 3 (0-15) 2 (0-11) 0 (0-7) Education (%) 0 (0-15) 0 (0--14) 0 (0-6) Students (% total personnet) 0 (NA) c 0 (0-36) 5 (0--40) Research and development (%) 0 (0-15) 0 (0-10) 2 (0-7)

aBased on the number of ram-doctoral personnel.


CNot applicable.

46 0196-4399/94/$0.00 + 07.00 © 1994 Elsevier Science Inc. Clinical Microbiology Newsletter 16:6,1994

Table 6. Comparison of 1982 versus 1993 survey results

Laboratory size a

1-4 5-14

1982 1993 1982 1993

>14

1982 1993

Specimem/worker/yr 4,100 6,600 3,900 6,000 3,400 3,300 Net sq ft/worker 128 120 113 156 114 166 Use CAP workload

recording (%) 75 73 88 75 64 81 Throat culture 11+1 b 10+4 14+6 11+5 16+6 12+8 Lower respiratory tract

culture 16+9 16+9 21+10 19+11 25+8 25:t:12 Wound culture 17+10 19+12 265:12 22+10 30+3 28+15 Stool culture 19+11 18+15 27+10 165:5 31:1:11 22+11 Blood culture 18+ 10 15+9 26+ 10 145:7 30+ 11 14+4 Anaerobic culture 175:10 175:10 225:13 215:11 315:13 16:1:8 CSF culture 16+10 145:8 205:9 175:8 215:6 235:13 Genital culture for

N. gonorrhoeae 115:7 11-1-5 155:8 115:5 155:7 105:3 Administration (%) 12 8 11 11 8 7 Quality assurance (%) 10 3 7 2 4 0 Education (%) 8 0 8 0 5 0 Students (% total

personnel) 12 0 11 0 8 5 Research and

development (%) 7 0 5 0 4 2 aBased on the number of non-doctoral personnel. bData indicate the mean + 1 standard deviation.

7% lost hours, and 57% experienced no change in hours. In medium-sized laboratories, 8% gained hours, 31% lost hours, and 62% retained existing hours. In large laboratories, 42% gained hours, 13% lost hours, and 46% maintained existing hours. The greatest loss of personnel hours occurred in the mid-sized laboratories, although it is encouraging that laboratory personnel hours also can be increased as a result of consultant activity.

Survey respondents were asked to calculate the average CAP workload unit values for specimens and tests in their laboratory by adding the total ac- tual workload on at least 25 consecutive specimens of a given type and dividing by the number of specimens analyzed to obtain the average. The bacteriology culture, including Gram stain if rou- finely performed, fungal culture, mycobacterial culture, and ova and parasite data are summarized in Table 2. In general, the small laboratories expended less labor per specimen than mid-sized

laboratories, which in turn expended less labor per specimen than large laboratories. The large laboratories spent significantly more time on lower respiratory tract, wound, cerebrospinal fluid, and fungal cultures compared with the small laboratories. The additional workload can he attributed to either more complex cultures, greater extent of available services, or lack of cost con- tainment in the larger facilities. Aver- age CAP workload values were provided for viral tests by the medium and large laboratories (Table 3). The tremendous variability in the workload for a given test between institutions probably reflects calculation errors in con- junction with the lack of refinement of CAP workload recording for viral tests. However, once again the larger laboratories expended more labor per test than the smaller laboratories.

Since many essential laboratory activities do not have assigned workload unit values, respondents were asked what percent of personnel time was

spent on non-workloaded (non-specified) activities, including administration, quality assurance, education, and research and development. The magni- tude of the non-workloaded activities varied considerably from institution to institution (Table 5). Administration ac- counted for the majority of non-specified activities with median values varying from 7 to 11%. The large laboratories appear to have miscalculated non-specified activities since the median time spent on quality assurance and education was 0%, in spite of the fact that students represented 5% of the total laboratory personnel and JCAHO mandates the performance of quality assurance. The quality assurance and education time data from the survey are also low when compared with recent publications (3,4).

The comparison of the 1993 survey results with those from 1982 revealed some interesting trends (Table 6). In general, the number of specimens processed per worker has dramatically increased during the past decade, except in the large laboratories. The observed overall decrease in the average number of CAP workload units expended per specimen, since the last survey, un- doubtedly contributed to the apparent increase in productivity of the laboratory workers (Table 6). Particularly im- pressive is the reduction in average workload units for stool cultures and blood cultures in the medium and large laboratories. Not surprisingly, the percent of time spent on non-workloaded activities has been dramatically reduced with education and research and development becoming almost non-existent activities in the small and medium- sized laboratories. It may be many years before the long-term impact of this transi- tion is realized, both in terms of quality of care and lahoratory staffing.

Conclusions Claims by consulting firms and pres-

sure from hospital administrators to increase productivity underscore the need for clinical microbiologists to take a proactive stance on workload recording issues, including the generation of workload data. With the impending Clinton administration health care plan, workload and productivity calculations will

Clinical Microbiology Newsletter 16:6,1994 © 1994 Elsevier Science Inc. 0196-4399/94/$0.00 + 07.00 47

assume even greater importance con- comitant with increased fiscal con- straints. It is essential that significant effort be committed to defining and quantifying non-workloaded activities in each laboratory. Since all workload recording methods have limitations, it is incumbent upon clinical microbiologists to understand and explain the

limits toadministrators.

References

1. Bartlett, R. C. 1982. Results o f the survey of microbiology laboratory management: summary and com- ments. Clin. Microbiol. Newslett . 4:97-101.

2. Elin, R. J., E. A. Rober t s~ , and G. A.

Sever. 1984. Workload, space and per-

3.

4.

| l , - - - ,

sonnel of microbiology laboratories m

teaching hospitals. Am, J. Clin. Pathol. 82:78---84.

Forward, K. R. and G. L. Digout. 1992. Non-unit producing activities in a large microbiology laboratory. Am. J. Clin. Pathol. 98:287-290.

Bartlett, R. C. 1989. CAP workload recording. Clin. Microbiol. Newslett.

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Summary of the survey of microbiology workload recording: Experiences and practices