Trends
The 17 Signs of a Struggling (Losing) Laboratory
Earlier this year, a study characterized the common issues facing health care organizations that are not considered high quality or highly reliable. In management literature, we spent a lot of time studying success stories - can we learn something from the failures?
The 17 Signs of a Struggling (Losing) Laboratory
Sten Westgard, MS
November 2018
Earlier this year, there was a study published in the BMJ Quality and Safety:
Characteristics of heathcare organisations struggling to improve quality: results from a systematic review of qualitative studies, Vaughn VM, Saint S, Krein, SL et al. BMF Qual
In it, the authors attempt to find some common themes in healthcare organizations [ed: I'm American, I don't spell like the British journals] that are not the success stories that routinely get lauded in the scientific press. But what they are trying to glean is that there are lessons to be learned from the losers as well as the winners in quality management. Yes, it's exciting to read about the latest star in the quality management firmament - but we can learn equally well from those peer institutions that are down to earth.
Now we should note, as the authors do, that this is a qualitative study of other qualitative studies. They started by looking at a pool of more than 1,700 possible articles, and narrowed it down to just 33 relevant unique studies. Then from 33 papers they tried to distill the common challenges that hospitals and organizations face in their quality improvement efforts. What they decided is that there are 5 main domains of with a total of 20 themes.
Now I'd like to apply that to US laboratories specifically. And point out just how common these struggles are in laboratories within the US and worldwide. Note that I will narrow this down further, eliminating 1 domain and 3 themes that have to do with external relations. I will focus on just 4 domains and 17 themes.
Domain |
Theme |
Notes |
Common to all Labs? |
| Poor Organizational Culture | Fragmented Accountability | The connection between test result and clinical care is indirect. Senior management is distant from the laboratory and lacks the ability to understand the technical challenges. The laboratory staff lack the permission and the power to align interpretation to care. | Yes |
| Non collaborative | Clinicians frequently have little communication beyond the receipt of numbers. Discussion over interpretation of results may be exchanged between clinicians and laboratory staff, but this is for unusual results, not routine results. | Yes | |
| Hierarchical | The authority gradient is steep. Clinicians are frequently given vast authority and deference, while laboratory staff are typically wary of challenging how results are used. | Yes | |
| Disconnected leadership | Pathologists running laboratories often stick to the "anatomical" side, delegating the clinical pathology side to a non-MD. Administration of the clinical side, the higher offices of the organization that are outside the laboratory, is even more distant from the bench level. There is little comprehension of how difficult laboratory testing is, nor how many resources are required to consistently deliver reliable results. | Often | |
| Inadequate Infratstructure |
Minimal QI systems | The use of root case analysis and other formal quality management tools is rare. A "fire fighting" mode of workflow is more typical - just deal with the crisis of the moment, put off long term analysis and planning for quality until the (nearly always un-realizable) future. | Often |
| Insufficient staffing and high turnover | While turnover may vary from institution to institution, the technologist shortage in the US and several other mature economies is well documented and pervasive. They are not making new technologists fast enough. This is not as big a problem in developing economies or in countries where the cost of lab labor is low. | Yes | |
| Underdeveloped information technology | IT innovations are often last to penetrate the laboratory, and the IT priorities of the greater organization frequently trump the specific needs of the patient. The vast hospital IT systems frequently have poor laboratory modules. To get very narrow, the informatics necessary to manage QC remains antiquated - with some systems still incapable of providing full assessment and/or customization of QC for each test. | Yes | |
| Lack of resources | Overall, the laboratory is an "ugly step-child" to use a crude metaphor. Its priorities come behind most other departments. Labs are chronically, globally, permanently in a state of budget cuts, cost cuts, staff cuts, etc. | Yes | |
| Lack of coehsive mission and vision | Conflicting mission | The mission of healthcare is often at odds with the margin requirements of the business. Quality and Care is often in placed opposition to compliance and reimbursement. | Yes |
| Externally determined priorities | The laboratory has very little power to set its own goals and priorities. Typically the budget is set by the administration, and the resources of in zero-sum competition with other clinical departments. This usually means the lab is the last to get its wish list. | Yes | |
| Poorly defined goals | Goals of laboratory testing are typically focused on the budgetary aspects and profitability / productivity metrics, without connection to any patient safety or treatment success goals. More narrowly, there is often no standard analytical performance goal for testing. Labs don't know how good their tests need to be to truly help patient care. If goals cannot be defined, how can labs take steps to improve? | Yes | |
| Vision of mediocrity | Despite rhetoric to the contrary, most laboratories focus on compliance with regulations and cost cutting as their main organizational goals. Neither of these is likely to increase staff morale. | Yes | |
| System shocks | Senior Leadership changes | As C-Suites turn over, labs are even more neglected. | Sometimes |
| Financial difficulties | Major disruptions in reimbursement rates in the US dramatically reduce the revenue labs will be able to charge. Similar budget pressures in single-payer healthcare systems often slash test fees. Labs seem to be a continuous target for cost reduction, even thought they represent a very small spend compared to other hospital expenses. | Yes | |
| Mergers and reorganizations | Caused by the above, many organizations are attempting to survive reimbursement changes by merging, eating or being eaten by larger healthcare system. As these mergers occur, laboratory priorities fall further down the list of the larger system, and individual labs find they have less automony to make critical decisions | Often | |
| New EHR | A recent article by Atul Gawande notes that clinicians in general hate their new productivity tools (the EHR), but the situation can be even worse for the laboratory. The introduction of a massive new informatics solution can dramatically change the way the laboratory operates, for good but sometimes for ill. | Often | |
| Major scandals | ER waiting times and hospital waiting lists, adverse events with patients, these are far more common with the clinical side than the laboratory side. There isn't that much major attention paid lab issues. The last real laboratory scandal was the Maryland General case in Maryland. Theranos' dramatic rise and fall was more of an industry failure than a lab failure | Uncommon |
You may disagree with these characterizations. After all, it's my qualitative analysis of a qualitative analysis of qualitative analyses. I've visited a lot of labs all over the US and the world, we receive a lot of email, and what I conclude is that the "average" US laboratory has the deck stacked against it. Ten out of the seventeen signs of a struggling organization are permanent conditions of the laboratory. By default, I believe, laboratories are always struggling - the architecture and foundation of the laboratory within US healthcare is a structural fault. It's rare to find a highly successful laboratory, and certainly we can learn much from success stories. But it may be a useful discovery to acknowledge that, by the strange route of finanical and policy decisions that govern US healthcare, labs have been uniquely strained.
None of this should really be surprising. I dare say any business or organization, inside healthcare or out, is always going to face difficulties and challenges in its attempt to remain a going concern. Why should healthcare be a safe haven from all the vicissitudes of business, economics, politics? What makes us think we should be immune from all the stresses that every other organization commonly faces. The study may simply be affirming, in slightly more academic guise, what most laboratory professionals have long felt in their gut: the playing field is not even and it is getting worse. For all the miracles of productivity and effectiveness labs deliver, the lack of recognition, the declines in revenue, are poised to keep the lab in chronic crises to come.
But you are free to use this as a "Cosmo Quiz" style assessment, a pop psychology ranking of your organizational dysfunction. If you think misery loves company, this may be of some solace for you. If you believe in the mission, if you're ready to keep fighting, if you have the drive to tackle challenges, well this is a list of the things you need to improve.