St. Joseph Laboratory

Scope of Services for St. Joseph Regional Health Center Laboratory

St. Joseph Regional Laboratory is a full service laboratory serving patients of all ages. To ensure quality care, the laboratory is accredited by and follows the practices set forth by the College of American Pathologists (CAP), the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the federal Clinical Laboratory Improvement Act of 1988 (CLIA).

The main laboratory is located on the second floor of the hospital off of the atrium/lobby to the right of the elevator. The laboratory offers both inpatient and outpatient testing and maintains several collection sites outside of the hospital for easy access by outpatients. The laboratory consists of the Medical Director’s office, management offices and the following departments (approx. 4000 sq.ft.):

Blood Bank (Immunohematology)	Histology	Immunology (Serology)
Chemistry	Cytopathology	Toxicology
Coagulation	Microbiology	Urinalysis
Hematology	Special Chemistry

The laboratory is staffed 24 hours a day, 7 days a week with competent, trained individuals including certified medical technologists, certified medical laboratory technicians, phlebotomy technicians and support staff. The laboratory is staffed with a coordinator on all shifts. The coordinator is responsible for the operations of the laboratory and may be consulted if problems or questions arise. The laboratory coordinator may be reached at 776-2400. The laboratory coordinator is supported by the laboratory administrative team which includes the Assistant Director, the Administrative Director and the Medical Director.

Routine laboratory tests are performed constantly during each 24 hour period using a variety of automated and manual procedures, and requiring a range technical knowledge and equipment Some tests are batched and run on scheduled days because of low volume ordering and because they are not considered vital to the patient's immediate outcome. Laboratory procedures not routinely performed in this laboratory are sent to a reference laboratory approved by the Medical Director of the Laboratory and the Medical Staff.

The anatomical pathology department is staffed Monday-Friday from 8:00 am to 5:00 pm. A pathologist is on-call and available for consultation at all other times. The pathologist may be contacted through the laboratory. The pathologist should respond to a page or telephone call within thirty (30) minutes or less.

The laboratory has to set certain priorities to ensure that all patients are getting appropriate care in a timely manner. Response to laboratory orders take the following priorities:

1. Trauma Patients	5. STAT requests from areas other than ESD
2. Cardiac Operating Room	6. Urgent (Timed) requests
3. Emergency Services patients	7. Outpatients
4. Intensive care and surgical patients	8. Routine patient draws

The laboratory is computerized with the MEDITECH Laboratory Information System (LIS) that is interfaced to the Hospital Information System to facilitate information transfer to the patient's physician and hospital location. Communication also occurs directly between the physician and other hospital departments as needed. Computerization also facilitates the billing of patients in a timely manner.

The laboratory aims to provide fast service to each of the customers it serves. The following response times serve as general guidelines. The laboratory works hard to meet these guidelines for phlebotomy response but these goals may vary occasionally because of a diverse patient population and large number of customers served.

Response Guidelines:

Status Response Time

ER/Code 99 Immediate-15 min
STAT Immediate- 15 min
Urgent (timed specimens) 15 prior to 15 min after time specified (exact time preferred-especially for therapeutic drug monitoring
Now/ASAP Now/or as soon as possible
Routine Now -- 1hr from receipt of request
Accucheks ½ before - 15 min after time of request (0600,1100,1600,2200)

1. Emergency Services Department -- Turnaround time goal for ESD tests (those tests routinely performed in the SJRHC laboratory) is one hour from the time the order for the test is placed in the computer.

2. Inpatient Early Morning Run Results -- The majority of inpatient laboratory testing is performed in the early morning run. The laboratory has defined target times for verifying the results for each hospital location. The target times are dependent upon how many patients are seen in ESD during this time frame and the acuity of patients in the hospital.

The target times are:

A. ICU -- Early morning run resulted by 06:00AM

B. CCU -- Early morning run resulted by 06:00AM

C. Second floor (2 NO, 2 SW and 2 SE) -- Resulted by 07:00AM

D. Third floor -- Resulted by 08:00AM

3. Microbiology culture results:

A. Routine cultures have a preliminary result available 24 hours after the specimen is submitted. The final report may be available in as little as 48 hours or as many as 5 days depending upon the culture source and the number of organisms for identification and/or susceptibility testing.

B. AFB cultures are held for 8 weeks before a final report of negative is sent out. Positive cultures are reported as growth is found.

C. Fungal cultures are held for 4 weeks before a final report of negative is sent out. Positive cultures are reported as growth is found.

4. Pathology results on tissue specimens, bone marrows, or cytology specimens are usually available 24 hours after the specimen is submitted, excluding weekends. If special staining is requested on a tissue specimen, the results may be delayed for 48 to 72 hours to complete the special staining. (The pathology department operates Monday through Friday only).

5. The laboratory will notify the nursing unit or ordering physician if a delay in testing or result reporting is anticipated. Delays may be caused by instrument malfunction, back-order of products or shortages of blood components. The laboratory staff will make the decision to notify the floor/physician if the delays are greater than may normally be expected or if there are delays caused by situations outside our direct control (disaster, nature).

The laboratory plays an integral role in the diagnosis and treatment of patients. Communication with patients and patients’ family members, physicians, and between departments is essential to provide each patient with the best possible care. On a daily basis the laboratory may work directly with many patients and one, or several, of the following departments to afford each patient high quality care consistent with the department mission.

The following are examples of the relationships:

Patients or Patients’ Family Members:

It is the goal of the laboratory to provide compassionate, quality service and to educate the patient and/or their family about laboratory tests and procedures. Education should improve patient health outcomes with better understanding of the test procedures and better cooperation of the patient and family. The responsibility for patient and family education lies with each laboratorian that has patient/family contact.

Nursing Service:

Communication regarding direct patient care, assistance with phlebotomies, test result communication and order entry

Hospital Information System Services:

Support of the Laboratory Information System

Emergency Services Department (ESD):

Direct care of emergency room patients which includes communication with ESD personnel, order entry, phlebotomy of patients and transmission of test results

Outpatients:

Direct care of outpatients, pre-surgical, and daystay patients, which includes communication with ESD personnel, order entry, phlebotomy of patients, and transmission of results

Imaging Services:

Phlebotomy of patients, transmission of results, and communication with personnel and radiologists

Patient Financial Services:

Registration and discharge of patients, billing of patients, and order entry

Infection Control:

Communication with IC practitioner regarding laboratory results

Medical Records:

Communication and dissemination of final laboratory results

Plant, Operations and Maintenance:

Facility maintenance and upkeep

Environmental Services:

Maintaining a clean and safe working environment in the laboratory, which includes: custodial care of floors, trash removal, and re-stocking hand washing supplies

Materials Services:

Providing supplies, instrumentation and support to operate the laboratory

Clinical Engineering:

Preventive maintenance, repair, and support of laboratory instrumentation

The above interactions are not totally inclusive. The circle of inter-action may vary from patient to patient and situation to situation. To be a successful provider of continuously improving healthcare, the department must remain flexible and able to alter the circle of interaction to cater to the patients needs.

Staffing:

St. Joseph Regional Health Center Laboratory is staffed with a mixture of 7-on/7-off, weekday, and weekend personnel. The 7-on/7-off, and weekday personnel are staffed for a variety of hours as appropriate to the workload and the employee’s employment status. Some weekend shifts are 16 hour compressed weekend-only shifts.

A PRN Pool is maintained in order to provide staffing on an "as needed" basis. These PRN staff members receive a thorough orientation to the hospital and lab and then are available to work when needed. This method allows for adequate staffing during busy periods without resulting in overstaffing during the slow periods.

Staff Education:

All laboratory employees are given sufficient orientation and training to enable them to work effectively in their assigned position. Each employee must complete the hospital and laboratory orientation checklists and be deemed competent at the end of the orientation period by the coordinator or technologist responsible for the respective department or task. Additionally, staff is provided in-house continuing education and encouraged to participate in external continuing education opportunities.

Staffing Schedules:

The Laboratory Assistant Director (AD) is responsible for advance scheduling of personnel for the department. The schedule is prepared at least one month in advance and is posted on the bulletin board in the main lab. The coordinators assist the AD to cover open shifts due to sickness, education training and emergency situations on a daily basis.

Requests for time off, such as paid time off (PTO), are requested in advance using the "Request for Schedule Change" form. Requests for changes of shift, or personnel on a shift, require completion of the form and notification of a Laboratory Coordinator. The Education Coordinator is responsible for the Medical Technology student schedules.

Skill Levels:

The laboratory is staffed with trained technical personnel whose educational and training requirements meet CLIA ’88 regulations and provide quality services to the patient.

The technical includes Medical Technologists (MT) or Medical Laboratory Technicians (MLT) who are registered by the American Society of Clinical Pathologists (ASCP), American Medical Technologists (AMT), and the Department of Human Services (HEW or HHS). All individuals are competent in the laboratory tests and procedures performed in the departments in which they are assigned to work. All technical laboratory staff is certified and competent to perform high complexity testing.
The phlebotomy staff undergoes a comprehensive orientation and training period before assuming their scheduled shift. They must be deemed competent at the end of their provisionary period. Phlebotomists are encouraged to become certified by the American Society of Phlebotomy Technicians (ASPT) or other certifying agency.
Other laboratory support staff receives the training and orientation specific to their department assignment.

Staffing Plan:

The laboratory is staffed 24 hours a day, 7 days a week. Each shift is staffed with a combination of technical staff (technologists, technicians), phlebotomists, histologists and support staff. The level of staffing has been adjusted to provide maximum efficiency with the least amount of staff possible. The laboratory administrative staff is in the lab Monday through Friday from 8 am to 5 pm. Coordinators are in the laboratory or on call at all other times. A laboratory administrator is on call at all times and can be reached through a pager.

Departments are routinely staffed as follows:

Shift	Department	Position	Number
Day (M-F)	Chemistry	MT	3.5
	Hematology	MT	1
	Blood Bank	MT	2
	Microbiology	MT	2
	Coordinators	MT	4
	Generalist Floater	MLT	1
	Secretary		1
	Phlebotomist/Secretary (includes Lab Stations)		6
	Phlebotomist		3
	Outreach Analyst	MLT	1
	Outreach Customer Service Representative		1
	Outreach Courier		1.5
	Transcriptionist		1.5
	Histology Staff	HT	2.5
	Student Assistant		0.5
	Pathologist*	MD	4
Evening (M-F)	Generalist Technologists	MT	3.5
	Coordinator	MT	1
	Phlebotomist		3
	Generalist Floater	MLT	1
	Specimen Accessioner		2
	Student Assistant		0.5
Night (Weekday & Weekends)	Generalist Technologist	MT	1
	Coordinator	MT	1
	Phlebotomist		2
Weekends**	Coordinator	MT	1
Day	Hematology	MT	1
	Chemistry	MT	2
	Microbiology	MT	1.5
	Phlebotomist		3
Evening	Coordinator	MT	1
	Hematology	MT	1
	Chemistry	MT	1
	Phlebotomist		2
Night	Coordinator	MT	1
	Hematology	MT	1
	Chemistry	MT	1
	Phlebotomist		2

*Pathologists are routinely in the laboratory Monday through Friday from 8 am to 5 pm. There is a pathologist on call at all other times to assist technologist with technical matters and work with other physicians as problems and questions arise.

**Weekend staff is reduced because the workload from outpatients, clinics and day surgery is greatly reduced and some laboratory departments are closed or provide decreased services during the weekend.

Staffing Adjustments:

Staffing may be adjusted on a daily or shift-to-shift basis based on need. The laboratory administrator, coordinators, or technologist in charge may call in extra PRN Pool or regular staff to handle increased patient workload, instrument problems, or emergency/trauma situations which the normal laboratory staff is not equipped to handle.

Permanent adjustments to staffing in the laboratory are based on need. Statistics are closely monitored for monthly test volume passing through the laboratory and overtime worked by staff. These statistics are used to justify additions to the staff. The statistics are presented to administration with the proper justifications when additional staff is required to manage increases in patient test volumes.

Another important justification for adjusting staffing is changing the services offered in the laboratory. The laboratory is continually updating the test menu, evaluating new methodology and instrumentation and offering new services to provide up-to-date, high-quality laboratory services to our patient and physician Guests.

Performance Improvement:

The laboratory performance improvement (PI) plan is focused on obtaining patient outcomes of the highest quality and providing services that meet or exceed the expectations of our customers. The focus on quality is incorporated in the organizational mission, vision, strategic plan, and values, further emphasizing our commitment to continuous improvement.

The Laboratory Medical Director is responsible for actively participating in the PI activities.

Assuring participation in and implementation of activities to improve the quality of laboratory services;
Sharing responsibility for developing and reviewing policies and recommending standards that influence the quality of patient care;
Evaluating the PI plan annually and recommending changes to the laboratory administrative staff; and
Establish and maintain communication with medial staff committees and individual medical staff members.

The Laboratory Administrative Staff are responsible for:

Monitoring and evaluating laboratory services and processes;
Pursuing opportunities to improve patient care and/or services;
Collaborating and coordinating patient care/services;
Encouraging staffs’ participation in PI training and activities; and
Resolving identified problems within the limits of their authority.

Laboratory employees are responsible for:

Participating in performance improvement activities;
Communicating performance improvement opportunities to supervisors;
Incorporating continuous quality improvement principles and values into daily work processes; and
Sharing their views on the laboratory’s performance improvement activities.

The monitoring and evaluation process is accomplished through routine collection of data and periodic assessment of problems. Data is evaluated to design and assess new processes; measure the level of performance and stability of important existing processes; identify areas for possible improvement of existing processes; and determine whether changes improved the process.

For more information, please contact:

St. Joseph Laboratory Services
2801 Franciscan Drive
Bryan, Texas 77802

979-776-2400

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