College of American Pathologists
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  Feature Story


cap today

Paper cutter: sleek reports link systems

May 2001
Anne Paxton

Edna Parker works for one of the largest independent laboratories in the U.S., but her predicament is increasingly shared by laboratory services in integrated delivery systems throughout the health care system. "We spend hours looking at proficiency testing results," says Parker, associate vice president and national quality assurance manager at Laboratory Corporation of America.

Her corporate office receives duplicates of the reports that go to all of LabCorp’s laboratories across the country. Upper-level management at LabCorp is interested in proficiency testing results, because they help determine whether a laboratory remains accredited. As a result, Parker’s own staff has been wading through the data to prepare the summaries.

"We probably have more than 175 labs enrolled in one PT program or another, and 30 in the Laboratory Accreditation Program," Parker said. "One of the reports we have done ourselves involves taking all the PTs for every location, entering them in the database, counting up how many challenges we had for the month and how many exceptions. So there are days when we get boxes of reports and we actually go through all that paper manually, and put the numbers in a spreadsheet."

Under a new program the College unveiled recently called CAP LINKS (Laboratory INtegration Knowledge Source), that work will be done for them. Designed to save time and resources for clients who manage multiple laboratories, CAP LINKS is a series of simple and easy-to-interpret reports and graphs, issued quarterly, that summarize data from four of the College’s Laboratory Improvement Programs: Surveys and Educational Anatomic Pathology and EXCEL programs, Laboratory Accreditation Program, Laboratory Management Index Program, and Q-Tracks.

CAP LINKS’ management reports will eliminate the drudgery of hand-prepared summary reports for LabCorp, which served as one of the pilot sites for CAP LINKS, Parker says. The comprehensive comparisons will allow LabCorp to assess performance in the individual laboratory, the company’s 10 operating regions, and throughout the company.

"We were really interested in not having to manually manipulate data. We wanted CAP to make us the ’one-minute manager,’" Parker says. CAP LINKS fills the bill. "CAP LINKS will let you look at performance from 30,000 feet of altitude down to the laboratory floor level." Earlier this year, LabCorp received preliminary versions of the reports to critique, and Parker reported they were happy with them and recommended only small enhancements.

Developed primarily in response to the surging number of systems with multiple laboratories, CAP LINKS is the brainchild of the College’s Project Management Team, which was formed several years ago to develop new CAP programs. The CAP Board of Governors approved an "integrated product" concept in 1998, and its implementation was overseen by the College’s Integrated Information Technical Advisory Team.

"We felt with the computer power we have at the College, we should be able to gather together management reports for the spectrum of laboratories that a system covers, and generate summary reports that would enable them to better manage the quality of the systems as well as of the individual laboratories, " says Thomas L. Gavan, MD, chair of the Project Management Team at the time the CAPLINKS concept was approved.

For laboratory managers who wish to stay informed as well as quality-conscious, CAP LINKS offers the "big picture," the executive summaries that make sense of the data. "The volume of paper that might be necessary within pathology departments can be considerably more than a responsible administrator can quickly review," says Franklin Elevitch, MD, chair of the technical advisory team overseeing CAP LINKS’ development and current chair of the Project Management Team.

"CAP LINKS will provide reports in a concise format so you can quickly see good quality and exceptions to quality, both at the laboratory level and at the corporate level," he says. The idea is to provide integrated information that would be useful through several organizational layers of the networks.

The program was designed to consolidate Surveys results in various disciplines, such as chemistry and microbiology, in terms of percentages that show the performance in each discipline, and compare those percentages to those of the overall system, Dr. Gavan explains.

"A pathologist or a laboratory manager in charge of quality would be able to look at these charts and graphs and tables, and be able to pinpoint areas where there may be deficiencies, to say, okay, in this particular laboratory or analyte across our system we don’t perform as well as in most everything else. Or the manager might conclude, 90 percent of my system is doing this well, but 10 percent are below par compared to the others."

With Surveys and EXCEL, for example, CAP LINKS will provide tables giving a laboratory performance overview that will allow a visual comparison of all sites. A subspecialty overview for all laboratories will help track performance by discipline, and subscribers will also receive exception reports organized by laboratory and by subspecialty/ analyte.

Similarly, for the Laboratory Accreditation Program, CAP LINKS will provide an inspection performance overview by laboratory. Managers will be able to track inspection performance by site and monitor phase 1 and phase 2 deficiencies. Deficiency listings by laboratory and by question will be part of the CAP LINKS accreditation series.

For Q-Tracks, CAP LINKS will prepare participant data summaries, performance indicator comparisons, and control charts to make it possible to evaluate and monitor pre- and postanalytical processes across all sites and quickly locate out-of-control data. Included will be the individual monitors, a comparison to system means, and the site’s ranking within the system.

For the Laboratory Management Index Program, CAP LINKS will help evaluate financial performance of all sites by providing comparisons as well as an "individual site fingerprint cluster" giving a snapshot of site trends in cost, productivity, and utilization. One table, for example, compares manageable expenses to on-site standardized billable tests (SBT) across sites and relative to the system mean. Others list all sites’ ratios of SBTs to total full-time equivalents, and all sites’ ratios of inpatient SBTs to discharges.

Dr. Elevitch formerly directed a large hospital-based regional laboratory network called El Camino Labnet, located in Silicon Valley, Calif., and is now CEO of Health Care Engineering, a medical systems research and development firm in Palo Alto. He believes CAP LINKS will be helpful not only for large integrated systems but also at the regional level. "If I had had this tool that would integrate reports in four areas, it would have been a great help," he says.

Response from the pilot sites has been positive, Dr. Elevitch notes. "People like the graphical reports, they like focused information on the particular level of director and administrator, the tabular presentations of critical information, the exception report, and the quick identification of problem areas. They think it will save them a lot of staff time."

The target market for CAP LINKS is multi-hospital systems, academic medical centers with numerous testing locations, and the national commercial reference laboratories like LabCorp. But any organization with two or more testing sites can benefit—and demand for CAPLINKS is expected to grow.

"As health systems mature, there really is a need to organize quality management information and have it reported in a common format, so management can design and track improvement programs across multiple sites of operation," says Ronald Workman, MD, vice president of pathology and laboratory medicine for Sutter Health, one of the largest health systems in the country and one of the systems the College worked with to develop CAP LINKS. Sutter consists of 30 hospitals as well as ambulatory care and chronic care centers throughout northern California.

The quality assurance program for the 1,400 laboratories run by the U.S. military will be a major beneficiary of CAP LINKS. Dennis Lahl, Navy coordinator of the Center for Clinical Laboratory Medicine, part of the Armed Forces Institute of Pathology, is responsible for 329 of those laboratories. He’s looking forward to a program that will make his job much easier, especially in ensuring a consistently high level of service across all sites.

As an example of why the program is needed, he described a recent quality problem that arose in the military laboratories. "About one and a half or two years ago we discovered some labs were having difficulty with bilirubin. We track all failures, and since the number of failures is low, when we were entering them into our database we noticed most—almost all—of the sites were overseas. When we asked CAP if they saw a trend, they said no."

"We just wanted to see results from our overseas sites, but sometimes they are in the mail for three or four weeks, and when CAP went back and looked, they weren’t able to find a pattern. When you get summary results, it’s by instrumentation and methodology, not location. So if there are a tremendous number of labs in the U.S. doing this versus a handful externally, those numbers get lost in the shuffle."

"CAP LINKS could solve that problem," Lahl says. "Before, if you thought you had a problem with a certain analyte for various labs, you’d have to look at each and every lab Survey result report. With CAP LINKS you can get results either by lab or by analyte, so instead of having to look at 15 labs’ individual reports, I can just look at the category of bilirubin within one report."

Lyle Rosser, who keeps tabs on quality for 13 million tests a year, has been preparing, with the CAP’s assistance, his own version of what CAPLINKS will do.

"Partially collecting data, and then trying to coordinate it across labs, is very time-consuming," says Rosser, quality systems manager for laboratory systems with the Southern California Permanente Medical Group, which includes two regional reference labs, 11 hospital-based labs, and 65 medical laboratories.

"I had contacted CAP a number of years ago and asked if they could extract the PT data for our facilities because I knew they were sending it to the Health Care Financing Administration and to the state of California. So CAP e-mails me the data file for the PT testing for all our locations, then I go through and extract a report from that. The data comes in raw form, and I had to do a lot of manipulating of it for the spreadsheet. But we feel it’s very important that an organization of our size monitor our PT."

When CAP LINKS does this compilation for him it will save hundreds of hours of staff time, he says. "Everything I was doing manually took me two or three days each quarter to compile. Now it will come already done for me, and it will give me a lot more information than I was extracting just because I didn’t have time to do more."

"There are two values of doing it systemwide," he adds. "We’ve noticed in our regional lab and in the medical centers, when you get a new supervisor or manager, they may not place as high a level of importance on PT. A module may slip through, or they miss a time. So by tracking the whole system, when we see a problem come up we can alert the person with responsibility in that area, and if training is needed we can implement it right away before we get into trouble."

Systemwide tracking also puts results in the proper perspective. "In our reference lab, the lab director signs off on each module and reviews it, but when you’re doing 3,000 or 4,000 proficiency tests, it’s hard to get an overview of what’s going on. In one week you might see several failures, but departments like specialty chemistry, which has some toxicology, some urines, some immunology, and so on, do so many modules that an individual test failure is not significant—whereas in another department like cytology, where they only do five slides four times a year, one failure is a lot bigger issue."

"The other thing is that laboratories typically have trouble demonstrating their level of quality to people outside the lab. By having a tracking system for PT, you have something really handy to show you were tested by an outside organization with blind specimens, and here is your performance rating. Obviously your performance has to stay high for you to stay in business, but for folks who don’t understand the laboratory, this is a good way to show them what you’re doing."

He modeled his program after that of American Medical Laboratories Inc., of Chantilly, Va., which many Kaiser laboratories around the country use for reference work. What was unique about AML’s quality assurance was the level of coordination, he says; a large staff tracked problems, kept tabs on monitors, and followed quality controls in all the departments, in part because the laboratory had clients all over the East Coast and, with different requirements in place for New York, Florida, and other states, had to be ready for 12 to 15 inspections per year.

"If you look at programs with good quality assurance, number one, you’re in a constant state of readiness for inspections. You’re doing internal checks so there’s less of a last-minute rush to get prepared, and you have a higher level of confidence if there’s a surprise inspection," Rosser says.

In fact, one of the reasons Rosser’s position was created at Kaiser was to address the lack of followup on problems; there was no built-in mechanism to get back to the persons who registered the complaints. "A doctor might call and say our calciums don’t seem to be matching our clinical findings, or they had an HIV-positive result and when it was reordered it was negative, or a clinician might complain that the lab report format was not clear or something was not right," Rosser says. "We have a mechanism now. We actually acquired a computer program that tracks all of our problems."

Quantification has always been a mainstay of quality assurance, he points out. "What gets measured, gets done," Rosser says, quoting a favorite maxim of quality assurance pioneer Edward Deming. "When people see a bar graph come up at meetings and see their department compared to other departments, they pick it up really quickly. They all want to stay in the high 90s."

There’s no doubt that laboratories are contending with many more boxes of paper than they used to. Says Sutter’s Dr. Workman: "I think it’s fair to say that the hospital and commercial laboratory industries have had about a 10-year history of increasing government scrutiny and compliance intervention, with increasingly complex and demanding regulation."

Dr. Workman is head of Sutter Health’s Laboratory Integration Project, a three-year-old program whose mission it is to make pathology and laboratory medicine a cost-efficient, high-quality service that contributes financially to the system. "Integration," in his view, means that the laboratories are managed to a common standard of service, quality, and cost-effectiveness, and that they develop common management objectives, an interlinked quality system, and a common information system network. As part of integration, Sutter Health is moving toward having all of its facilities on the same laboratory information system. "More than half of our facilities are on the same LIS," he says. "The others will be standardizing in the future."

The CAP LINKS reports most interesting to Sutter are those of the LMIP. "That really is going to be used by many health systems to track their productivity and cost management programs and for peer group comparison purposes," Dr. Workman predicts. "Pathology and laboratory departments increasingly need to use organized, quantitative quality management information to achieve performance improvement goals."

Although Sutter is a nonprofit organization, "the difference between hospitals and commercial laboratories is narrowing," he says. "Health systems have to look beyond traditional hospital management objectives to develop their business and their performance improvement strategies. Many hospital networks are looking toward commercial performance improvement strategies or commercial laboratory partnering or affiliation. So the need for management tools like CAP LINKS is only going to increase."

For example, CLIA requires laboratories using the same information systems to perform analyses at certain intervals to determine if there is sufficient correlation between analytical methods for them to use the same reference ranges for clinical results. "It may be that the CAP LINKS program can allow them to use the PT testing information to meet this regulatory requirement," Dr. Workman says.

CAP LINKS also meshes with many laboratories’ plans to seek ISO certification. "Our laboratory system in Southern California is in year 2 of moving toward ISO certification," Kaiser’s Rosser says. "Basically it requires a higher level of coordination between all the systems within an organization and better documentation and document control. So we’re in the process of redoing all our documents to divide them into ISO categories of policies, processes, and procedures."

"Currently all our guidelines are mishmashed together. We were told we have good work instructions but haven’t documented a lot of our processes," he adds. "The goal right now is to be ready to apply for ISO certification in three to four years, and CAP LINKS would be one of our critical monitors. ISO requires a lot of self-assessment, and CAP LINKS offers a critical self-assessment tool."

Dr. Elevitch believes CAP LINKS will continue to prove its value in helping achieve goals like these. "I think the people at the College, in a relatively short period of time, have accomplished something that they made look easy to do but is very difficult: They have put together the mountains of quality and economic evaluation information from several different operational divisions of the College in a useful, understandable format."

The College’s structure gave it an advantage in developing the CAP LINKS program, Dr. Elevitch says-and not only because the CAP has a large information services division and a new computer system. "The major need in health care today is the integration of information throughout all the clinical services, and pathology leads the health care specialties in the organized management of data and information."

"But the College is also unique, since it’s a hybrid of a membership service organization and a producer of quality evaluation systems for the industry. It’s like having your own internal focus group. When our members became involved with these integrated networks in the late ’90s, the College responded to that, and CAP LINKS is one of the results."

Anne Paxton is a freelance writer in Seattle. For copies of sample CAP LINKS reports and/or more information about CAP LINKS, contact Anna Arons at the CAP at or 800-323-4040 ext. 7437.