1. Evolution of Strategies for
Survival and Growth in
Pathology and Laboratory
Medicine
Robert Boorstein, MD, PhD

2. Strategies for Survival and Growth
in Pathology of Medicine
 Consolidation
 Automation
 Specialization
 Quality Management and Integrated
Decision Making

3. Strategy
 A plan, method, or series of maneuvers or
stratagems for obtaining a specific goal or result
(dictionary.com)
 The science of military command, or the science
of projecting campaigns and directing great
military movements (Websters)
 The commitment of resources in support of the
mission in pursuit of defined and measurable
ends (NYU Stern Business School).

4. Strategies for Survival and Growth
in Pathology of Medicine
 Consolidation
 Automation
 Specialization
 Quality Management and Integrated
Decision Making

5. Types of Laboratory Consolidations
 Across institutions
 Within institutions, parallel services
 Within institutions, different services

6. Pressures for Consolidation (Push)
 Personnel Costs
 Equipment Costs
 Regulatory Burdens
 Demands for Space
 Closure of Residency Programs

7. Pressures for Consolidation (Pull)
 High- throughput, high capital cost
equipment
 Centralized and standardized LIS and HIS
systems
 Unified corporate leadership

8. Laboratory consolidations: Phase
1:Bellevue as reference lab
 Gouverneur (1997)
 Coler Goldwater
(1999)
 Metropolitan/Belvis
(1999)
 Morrisania (1999)
 Lincoln (1999)
 Harlem,
Renaissance (2000)

9. Development of a consolidated
laboratory network
Bellevue Hospital
Lincoln Hospital
Metropolitan Hospital
Harlem Hospital
Coler/GoldwaterHospitals

10.  New York City Health and Hospitals Corporatio

11. Laboratory Organization, South Manhattan
Healthcare Network and Generations
Plus/Northern Manhattan Health Network
 Large central referral facility on the
Bellevue site
 Full service specialized and routine clinical
laboratory services
 Full service academic anatomic pathology
services
 Stat and point of care services appropriate for
trauma, tertiary care and primary care
services

12. Laboratory Organization, South Manhattan
Healthcare Network and Generations
Plus/Northern Manhattan Health Network
 Acute care facilities
 Anatomic Pathology (surgical pathology,
frozen sections, cytology)
 Rapid Response Laboratories
 Chronic care facilities
 Rapid Response Laboratories
 Ambulatory care facilities
 Sample collection only

13. Flow of work to Bellevue
Bellevue Hospital Laboratory
Metropolitan
Belvis
(Rapid Response and AP)
Lincoln
Morrisania
(Rapid Response and AP)
Harlem
Renaissance
(Rapid Response and AP)
Coler Goldwater
Gouverneur
(Rapid Response)

14. Effect of consolidation, impact of
network on overall volume at Bellevue
Area Network %
Clinical Laboratories 60%
Surgical Pathology 5%
Autopsy 55%
Cytology 75%

15. Effects of Consolidation,
employee productivity
YEAR ACTUAL FTE WORKLOAD WORKLOAD/FTE
7/98 - 6/99 226.5 1,846,215 8151
7/99 - 6/00 256.5 3,968,427 15471
7/00 - 6/01 257.0 4,284,997 16673
7/01 - 6/02 253.5 4,635,763 18287
7/02 - 12/02 228.5 4,608,688 20169

16. Factors for successful consolidation
 Clear leadership
 At the organization level
 At the department/operations level
 Clear mission
 Information management
 Transport
 Flexibility

17. Factors for successful consolidation
 Clear leadership
 At the organization level
 At the department/operations level
 No turning back!!!
 Clear mission
 Information management
 Transport
 Flexibility

18. Factors for successful consolidation
 Clear leadership
 Clear mission
 Information management
 Transport
 Flexibility

19. NYCHHC Strategic Priorities
HHC has set several strategic priorities to insure that we continue the
improvements and innovations that have distinguished New York City's
public hospital system in the months and years ahead.
Patient Safety - HHC's multi-year campaign to reduce medical errors, prevent
infections, pneumonia and cardiac arrests.
Quality & Safety Performance - HHC publishes its quality record, inviting public
comparison with state and national performance averages.
Access to Healthcare - Providing Quality Healthcare for ALL New Yorkers.
Technology - HHC has marked its place as a medical innovator by investing in
advanced, integrated technology throughout its facilities.
Modernization - HHC's ongoing capital program to ensure that our public
hospitals continue to provide state-of-the-art medical treatment.

20. Factors for successful consolidation
 Clear leadership
 Clear mission
 At the level of organization
 At the level of the department
 Within each division
 Information management
 Transport
 Flexibility

21. Factors for successful consolidation
 Clear leadership
 Clear mission
 Information management
 Singlesystem across all facilities
 Commitment to paperless ordering and resulting
 Bar-coding of all samples
 Transport
 Flexibility

22. Factors for successful consolidation
 Clear leadership
 Clear mission
 Information management
 Transport
 Essential
 Responsive to client needs
 Reality based
 Flexibility

23. Factors for successful consolidation
 Clear leadership
 Clear mission
 Information management
 Transport
 Flexibility
 Planning cannot predict all eventualities
 At go live, willingness to adjust while moving forward
 Can judiciously skip less critical components of a
consolidation, as long as key objectives are attained

24. Factors inhibiting successful
consolidation efforts
 Failure to recognize and respect clinical
needs of new clients
 In conclusion, our system has benefited from the consolidation efforts and the
implementation of the TLA system. The actual dollar savings are predicated on
the remaining hospitals coming live and their willingness or ability to make the
necessary staff reductions. Although our system remains in the growth phase, we
have realized our efficiencies in TAT for those hospitals brought live. Clinical Chemistry 46: 751-
756, 2000
 Labor instability
 Politics, institutional and community
 Unpredictable events

25. The real world

26. Consolidation, Phase 2: Coordinated
Delivery of Laboratory service to all
sites
 Integrated management structure (2001-
2002)
 Standardization of test menus, normal
ranges, and clinical indications (2003)
 Standardization of all major laboratory
systems (2003-2008)
 Automation of accessioning and sample
handling at referral sites (2003-2008?)

27. Phase 2, continued
 Autopsy to Bellevue (2002+)
 All Lincoln cytology to Bellevue (2003)

28. Internal Consolidations
 Pediatric and Adult Hematology
 Serology and Immunoassays
 Anatomic Pathology

29. Benefits of Consolidation
 Reduction of unit labor costs.
 Reduction of unit capital costs.
 Reduction of unit space costs.
 Standardization of quality at high level.

30. Strategies for Survival and Growth
in Pathology of Medicine
 Consolidation
 Automation
 Specialization
 Quality Management and Integrated
Decision Making

31. Increased Role of Automation in
the clinical laboratory
 Reduction of manual
processes
 Reduced error rate in
aliquotting and specimen
movement
 Improved turnaround time
 Reduction in sample
volumes needed for
analysis

32. Benefits of automation
 Run more tests.
 Test in fewer sites.
 Operate with fewer instruments.
 Retain lower operating costs.
 Employ relatively less skilled labor.
 Use more automation in a paperless
environment.
http://www.devicelink.com/ivdt/archive/99/07/010.html

33. Automation strategies
 Total laboratory automation (i.e. Beth Israel, NY
Cornell, North Shore, Mt Sinai).
 High upfront capital costs (10-20 million)
 High demand on IS infrastructure
 Networked, modular, incremental automation (HHC
model) Highly efficient analytical instruments, handling
high volumes with redundancy
 Automated sample handling, and sorting, utilizing tracked
systems
 Automation at referral sites
 Core laboratory

34. Steps in automation
Front end processing
Transfer to analytical systems
Distribution to analytic instruments
Analytical instrumentation
Verification
Back end processing and storage

35. Thinking about automation
 What is the real goal of automation?
 If the goal is labor saving, which steps really use
the most labor?
 If the goal is quality or time savings, automating
which steps will give those benefits?
 If the goal is to increase capacity (and thus
reduce unit labor costs), is the business really
available, and what are the barriers to serving
new customers?

36. Assessing success in automation
 “Laboratory A” core lab currently
processes 2500–3000 tests per day.
Since it implemented automation with
robotics, the lab has increased test
volume by 20%, reduced sample
turnaround times by 11%, and saved
$100,000 in staff salaries.
http://www.devicelink.com/ivdt/archive/99/07/010.html

37. Return on investment
 Total laboratory automation often
consumed $15-20 million in Capital costs
for acquisition, site preparation, relocation
and transition costs.
 Which of the successes are due not to the
main automation, but to concurrent
processes that make sense independent
of TLA?

38. Laboratory Workload and Cost sharing
 80% of the costs in the laboratory belongs to the pre-
and post analytical processes, only 20% to the
analytical part...

39. Factors for success
 Work station consolidation
 Front end automation (accessioning,
centrifugation, aliqotting)
 Improved informatics (bar coding, no
paper)
 Changes in labor rules

40. Steps in automation
Front end processing
Accessioning, centrifugation, aliquotting
Remote order entry, bar coding
Transfer to analytical system
Distribution to analytic instruments
Analytical instrumentation
Workstation Consolidation
Verification
Back end processing and storage
Electronic Reporting

41. Steps in automation
Front end processing
Accessioning, centrifugation, aliquotting
Remote order entry, bar coding
Transfer to analytical system
Distribution to analytic instruments
Analytical instrumentation
Workstation Consolidation
Verification
Back end processing and storage
Electronic Reporting

42. Recipes for failure
 Extended delays in implementation due to
complexity and demands on IT
 Loss of leverage with vendors
 Lock in old technology
 Increased need for high paid staff
 Inability to reduce staff
 Failure to reach planned, and paid for, growth
 “The lab currently processes 4000 tests per day, and
has the capability to expand to more than 25,000
tests per day”

43. Factors essential for laboratory growth,
perhaps more important than automation
 Work station consolidation
 Front end automation
 Specimen ID and tracking
 Billing and Collections
 Transport
 Customer Service

44. Automation can follow growth:
Modular incremental automation
 Minimal upfront capital or site preparation
costs.
 Equipment amortized into reagent
purchases.
 Scalable
 Ongoing instrument modernization

45. Automation can follow growth

46. Lab Area Manufacturer Model
Individual Components
Chemistry Beckman Coulter DxC
AU
Analyzer Interfaces Roche
OCD
Abbott /Toshiba
Modular
250, 950
Aeroset, 80FR,
200FR
Immuno Beckman Coulter DxI
Abbott AxSym, Architect
Siemens Centaur
Siemens Atlas and Centaur Stago R Tosoh AIA21
OCD Eci
Fujirebio Lumipulse F
Coag Beckman Coulter TOP-LAS
Stago Sta-r
Sysmex CA-6000
Heme Beckman Coulter LH 750/755
Sysmex HST
Roche Modular OCD 950, 250, ECI
Urinalysis Siemens Atlas
Sysmex UA-2000
Trademarks are property of the respective
Manufacturers

47. Single Testing and Sample
Management Workstation!
Sample
Management
CBC, Diff,
A1c Retic Testing
Tes
ti ng
Smear staining
Smear
preparation
 Frees-up non-productive
labor!

48. Strategies for Survival and Growth
in Pathology of Medicine
 Consolidation
 Automation
 Specialization
 Quality Management and Integrated
Decision Making

49. What drives Specialization
 Build on existing expertise (supply)
 Meet needs of existing clients, leveraging
existing transport, IT, and customer
service relationships (demand)

50. Specialization
 High volume, High value
 High volume, Low value
 Low volume, High value
 Low volume, Low value

51. Programs built on Existing
Strengths
 Cytology
 Neuropathology
 Cytogenetics
 Hemoglobin Analysis
 Tuberculosis
 GC/Chlamydia

52. Programs built de novo based on
clinical need
 HIV, HBV, HCV viral loads
 Maternal Fetal Defect testing
 Lead testing
 GC/Chlamydia/HPV
 Colon Cancer Screening Colon Sentry

54. Molecular Virology

55. Integrated cytogenetics analysis
systems

56. Tuberculosis

57. Amplified GC/Chlamydia

58. Approach to specialization
 High volumes
 Push modular automation using
experiences across disciplines
 Based on clinical demand

59. Approach to specialization
 Clinical and translational research

60. Project Findings Show Asian
American New Yorkers Have a High
Burden of Hepatitis B Infection
 NEW YORK, August 9, 2005 –The
Center for the Study of Asian American Health at New
York University School of Medicine, the central
coordinating agency for the NYC Asian American
Hepatitis B Program has received a total of $2.6 million
to continue its work in screening, educating, vaccinating,
and treating Asian Americans in New York City for
hepatitis B. $1.7 million of the grant is from the New York
City Council with the remainder as matching funds from
the New York State and City Departments of Health. The
Program is a made up of a coalition of healthcare and
community-based organizations across the city.

61. Strategies for Survival and Growth
in Pathology of Medicine
 Consolidation
 Automation
 Specialization
 Quality Management and Integrated
Decision Making

62. Leadership in Patient Safety Goal
implementation
 Patient and specimen ID
 Critical Values

63. Test use rationalization
 CK-MB vs troponin
 Lipase vs amylase
 Algorithm based thyroid function testing

64. Involvement in core measures related to
quality and reimbursement
 Diabetes management and HgbA1C
 Nosocomial infections
 Timeliness of treatment of pneumonia
 Stat TAT

65. Bellevue Hospital Center
South Manhattan Healthcare Network
462 First Ave & 27th St, New York, NY 10016
ER Turnaround Time Timeline
Emergency/STATS Test TAT Timeline (minutes)
0' 16' 56' 89'
Order Draw Received Resulted
Order to Draw: 16 minutes
Order to Received: 56 minutes
Order to Resulted: 89 minutes
Draw to Received: 40 minutes
Draw to Resulted: 73 minutes
Received to Resulted: 33 minutes

66. Roles in new programs
 HIV screening
 Stroke program

67. Lincoln Medical and Mental Health Center
Stroke Monitor 2007
MONTH # OF STROKES CBC TAT < 15' PT/APTT TAT <30' BMP TAT<30' COMMENT
DECEMBER 2 4 14 29
JANUARY 6 3.4 21.6 18.6 one stroke specime trax to BB
FEBRUARY 6 3.2 24.8 19.4 1 hmlz,1 not announced
MARCH 11 3.2 20.7 17 1 stroke with only Coag Reque
APRIL 8 2.7 14.9 14.3 2 hemolyzed
MAY 8 5.5 17.2 15.4 2 hemolyzed
JUNE 6 4.2 11.2 13.8 1 chem hemolyzed
JULY 13 3 17 18.5
AUGUST 12 3.5 20 14
SEPTEMBER 11 2.8 19.8 17.6 chem4hml-ptptt-1qns
OCTOBER 10 4.6 14 16.5 chem1 heml-ptptt-2qns
NOVEMBER 11 2.9 14.9 11.9
DECEMBER 5 8 17.4 19.6

68. Driving home quality principles
 New pathology system, LIS and Anatomic
 Remote order entry with bar codes
 Results to Doctors’ queues
 Voice recognition at grossing.
 Integrated reporting
 Double label, computer directed cassette labeling
 Etched slides with barcodes.

69. Conclusions
 People are crucial
 Success is built on common vision
 Resources must be committed
 Needs and solutions are local

70. Future trends
 Laboratory Consolidation
 Driven by Resource Issues, personnel and capital
 Oversight of test utilization
 Accountable Care Organizations, Insurers, Capitation
 Algorithm based results
 Competition from sole source branded products
 Brca1, OncotypeDX, etc.