CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
ASSESSING WORKLOAD AND EMPLOYEE PRODUCTIVITY
FOR CLINICAL LABORATORY CONSIDERATIONS
A project submitted in partial satisfaction
of the requirements for the degree of Masters of Science in
Health Science
by
Nicholas D. Lombardo
June, 1976
The Thesis of Nicholas D. Lombardo is approved:
Anthony M. Ale-beer, Committee Chairperson
California State University, Northridge
1i
ACKNOWLEDGEMENTS
The author wishes to acknowledge his
appreciation for the guidance and advisement given
by Dr. Anthony Alcocer and Dr. Donald Hufhines in
the production and completion of this study.
Most of all, grateful acknowledgement
must certainly be expressed to Ms. Sally Peterson
Lombardo and Ms. Susan Peterson for their thoughtful support, patience, encouragement and clerical
assistance in reporting this study.
Without their
cooperation, this study would not have been possible.
iii
TABLE OF CONTENTS
Page
APPROVAL PAGE
ii
ACKNOWLEDGEMENTS
iii
LIST OF FIGURES
vi
LIST OF TABLES
vii
ABSTRACT
viii
CHAPTER
1.
INTRODUCTION .
I.
II.
1
The Problem and is Significance
3
A.
Statement of the Problem .
4
B.
Significance of the Problem
4
Limitations of the Study
5
Organization of the Paper
5
BACKGROUND AND SETTING OF THE PROJECT
7
III.
2.
. ..
I.
Review of the Literature
7
A.
The Work Study Field
8
1.
Historical Development
9
2.
Applications to Health Care
12
3.
Applications to Clinical Laboratory.
15
B.
Workloads
19
Summary of Literature Reviewed
25
Setting of the Project . . . . . .
27
C.
II.
Studies Related to Assessing Laboratory
Page
CHAPTER
')
32
METHODOLOGY
I-.----Furpose-e-f--t-h e P-r-oj-ec-t--.- -.----.---.c-.-----.-.-.-----.-.-.------.----.----.------}2-
II.
A.
The Project Objectives
32
B.
Definition of Terms
33
Sources of Data and Their Measurement.
37
A.
Method Study . . . . .
37
1.
Working Conditions
38
2.
Operations Analyses
39
B.
Work Measurement .
41
1.
Work Sampling
45
a.
Frequency of Observations
46
b.
Selection of Observation Times
4 7-
c.
The Observational Worksheet . .
48
2.
5.
51
a.
Expected Time Allocations
52
b.
Performance and Productivity Indices
54
Relative Value Assignments
55
RESULTS AND DISCUSSION OF FINDINGS
63
I.
Data Related to Process
63
II.
Data Related to Effort
66
III.
Data Related to Effect
71
C.
4.
Compilation of Performance Standards
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS.
78
:r.
Summary
78
Conclusions
81
Recommendations
82
II.
III.
BIBLIOGRAPHY
84
v
LIST OF FIGURES
Figure
Page
42
1.
Flow Process Analysis Summary
2.
Specimen Collection, Processing, Reporting
and Billing Procedures .
. .
.
43
3.
Processing of Typical Patient Specimen
44
4.
Activity Observation Worksheet
49
5.
Hourly Activity Graph
69
vi
LIST OF TABLES
Page
Table
... .
1.
Expected Time Allocation Data
.
53
2.
Relative Value Assignments for Hematology
58
3.
Relative Value Assignments for Biochemistry
4.
Relative Value Assignments for Microbiology
5.
Relative Value Assignments for Serology/Urinalysis
62
6.
Distribution of Work Sampling
67
7.
Laboratory
8.
Individual Monthly Performance Summary
9.
Performance and Activity Data . .
~..Jorkload
. . .
vii
.
.
.
.
60
61
72
. .
73
.
75
AtlSTRACT
ASS~SSlNG
WORKLOAD AND
EMPLOYE~
PRODUCTIVITY
FOK CLiNICAL LABORATORY CONSIDERATIONS
by
Nicholas D. Lombardo
Master of Science in Health Science
•
June, 1976
The central aim of this project was to demonstrate the
general applicability of industrial work study methods to a clinical
laboratory work setting.
Also, this project considered the question
of choice of output measures and their use in assessing laboratory
workloads and in evaluating technologist performance.
A review of available literature revealed that a work
measurement technique known as work sampling could be useful in
establishing reliable performance criteria against which to evaluate
technologist performance.
Also, it was shown that a "weighted" work
unit measure was more accurate for reporting and analyzing laboratory
production than a simple enumeration of the tests performed.
Consequently, a work sampling analysis was conducted at the
clinical laboratory that served as the setting of this project, and
a schedule of relative value assignments was developed based on the
following factors:
(1) the total technologist time required,
(2) the
skill qualifications needed, and ~3) the frequency of performance .
. viii
Standard laboratory performance was defined by profiling
the effective utilization of technologist time and skill according to
prearranged work and delay activity categories, and expected time
allocations were calculated to reflect the amount of technologist
time (input) that should be spent per relative value unit (output).
Consequently, by employing this mediated work unit measure,
the interfacing of work loads with manpower capabilities was enhanced
since there was no longer a lack of adequate definition of these two
variables.
Therefore, it is concluded that the total evaluative scheme
outlined in this investigation can, in fact, be used to effectively
measure and control the accomplishments of labor in a clinical laboratory work setting.
ix
Chapter 1
INTRODUCTION
The field of medical laboratory technology, and the subindustry supported by it, has experienced much change and innovation
over the years.
Only a few decades ago, in fact, the number of pro-
cedures performed in a typical clinical laboratory could be counted
on the fingers of one hand.
Yet, today, hundreds of analyses are
carried out routinely, employing assembly-line methods and sophisticated "space-age" technology.
Indeed, what was orre regarded as the
"last of the cottage industries" within the American health services
"system" can now be described as a highly technological "big business".
(3:269)
A combination of social, economic and scientific developments have contributed to the rising importance of laboratory testing
in the provision of health care in the United States today.
For
example, the passage of Medicare and Medicaid legislation alone created a dramatic increase in the demand for all kinds of medical services
during the last decade.
In particular, the aged, disabled and the
indigent, previously without virtual access to medical care, were thus
provided with the ability to seek and pay for it.
At the same time, there began a growing emphasis within the
medical community on the potential value of early detection of patient
health problems, thereby causing a movement toward more extensive
application of preventive measures with respect to ambulatory patients
and eve n "h ea 1 t h Y" populations, as a possible means of offsetting
1
2
future needs for inpatient curative care.
The need for a more scientific approach to the medical
diagnosis of disease and disorder was further encouraged by a growing
threat of malpractice litigation involving physicians in their practice of medicine.
In this case, the ordinary process of confirming a
suspected clinical diagnosis with a few discretionary laboratory tests
was now being augmented by a growing number of requests from physicians for almost any associated or symptom-related testing procedure
which the physician might eventually use to substantiate his diagnoses,
if need be, in a court of law.
Consequently, it can be said that such attitudes themselves
were significant factors contributing to the overall demand for greater laboratory testing, so much that in the last five years, this demand has gone up some fifty percent.
At the same time, the cost of
laboratory services continues to grow, both in terms of total laboratory dollars spent and as a percentage of the total national healthcare bill.
Annually, we now spend well over 115 billion dollars for
health care, and of that, more than 8 billion dollars goes for laboratory services.
(26:37)
This sudden growth in the laboratory field, however, has not
occurred without aggravating an already-existing shortage of qualified
technologist personnel needed to work in the many laboratories located
throughout the United States.
Indeed, optimal utilization of the
technological manpower in these laboratories has long been an economic
necessity, as evidenced by the fact that health manpower alone has
been absorbing at least one half of the average "health care dollar"
3
spent in this country over the past few years.
(7:21)
Growing pressures to rationalize this use of scarce, skilled,
medical and technical manpower and to contain the costs of American
health care in general, are thus forcing administrators of healthrelated operations to rely increasingly upon certain analytical and
quantitative managerial techniques which have been used by those involved in the management of other industries, in
some instances, for
many years.
Some of the applications of these techniques to the health
field are still subject to pilot testing and further refinement; but
others, whose usefulness has been demonstrated, can and should be
adopted by health services administrators in the interest of better
quality, more cost-effective patient care.
I.
The Problem and its Significance
One of management's major preoccupations in any enterprise
is concerned with the deployment of its resources, the most important
of which is people.
In order to attain optimal utilization of the
skills of these people, however, management must be able to fit the
job to the worker, and conversely, allow the worker to fit himself to
the job.
It follows, therefore, that the amount of work contained in
a job
antt, likewise
within entire workloads, must be clearly defined
and at the same time work guidelines and standards for acceptable
performance should be established against which to objectively evaluate labor's efforts.
4
A.
Statement of the Problem
With these ends in mind, the central aim of this project was
to investigate the general applicability of industrial work study
methods to a clinical laboratory work setting.
Specifically, this
project dealt with the problem of determining to what extent, if any,
such methods could be used to:
1.
standardize the basic work content contained
within the methods and the process of laboratory operations;
2.
profile the effective utilization of time and
skill as displayed by a staff of clinical
laboratory technologists in the performance
of normal diagnostic workloads; and
3.
establish reliable performance criteria against
which to evaluate the productivity and
effectivity of technologists' work efforts.
Also, this project considered the question of choice of
output measures and their use in assessing laboratory workloads and
in the calculation of laboratory productivity.
B.
Significance of the Problem
The dynamic nature of medical technology requires an evalu-
ative process which is not static but which is progressive.
Unlike
a manufacturing ope~ation in which practiced work methods are easily
standardized and, where the unit of output is most often in terms of
the tangible products produced, the schemes used to audit and control
work effort in a clinical laboratory are considerably more challenging
to design.
This is due primarily to:
(1) the fundamentally non-
repetitive and heterogeneous nature of much of the work acitivity
5
required of laboratory operatives today; and (2) the multiple compositions which make up most normal diagnostic workloads imposed upon
present-day clinical laboratories.
Nevertheless, despite the fact that certain facets of a
laboratory operation do not lend themselves to measurement, the need
to establish and make use of control measures still exists.
II.
Limitations of the Study
Today's truly professional manager concerns himself with
various administrative functions and activities that include planning,
organizing, staffing, supervising and controlling the work of others.
While it is important to view each of these and their
relationships with each other on an equal basis, nevertheless, it is
not the intent of this study to explore each of these in detail, but
rather to concentrate attention on the controlling functions and
responsibilities of the laboratory manager, and on his systems of
gathering and reporting needed performance data.
Finally, no matter how adaptable the general scheme proposed
in this study may be for use in other laboratories, it should be noted
that the findings of this study themselves were determined according
to the individual work conditions and operational circumstances which
prevailed in the specific laboratory setting that was studied during
the actual time period of this investigation.
III.
Organization of the Paper
Chapter 2 presents background information pertinent to the
subject of work study, as well as to the specific setting of the pro-
6
ject.
A review of available literature is provided which highlights
studies dealing with the development of the work study field, its
application to general health care, and its application to the clinical laboratory work setting in particular.
A separate section is
included which reviews studies related to the assessment of laboratory
workloads and documents various output measures that have been previously utilized.
Chapter 3 outlines the method of procedure that was followed
in the course of this project.
The project's purpose and objectives
are specified, along with various definitions of terms used in the
text of this paper.
Also included is discussion regarding the sources
of data and their measurement in this project.
Chapter 4 reports the findings and results of this project,
as the data relates to the process, effort or effect of studied
laboratory work activity.
Chapter 5 presents a summary of this report, conclusions
derived from the findings of the project, and final recommendations.
Chapter 2
BACKGROUND INFORMATION
I.
Review of the Literature
Unfortunately, little has been published in recent years
concerning the problem of assessing laboratory workloads and evaluating manpower performance for a clinical laboratory operation.
A
preliminary survey of available literature revealed that the most
useful research related to this subject has been directed to the
industrial engineer.
Thus, many laboratory managers have had little
exposure to the possibilities of applying work study methods to
laboratory operations.
With this in mind, the following review was undertaken.
Past studies were analyzed with regard to the above areas of concern
and were organized under two general topics for the sake of convenience.
The first section deals with the field of work study, and
includes:
(1) a description of the concepts and techniques of work
study; (2) an historical perspective of the development of work study;
(3) an overview of application of work study techniques to health
care activities; and (4) a detailed review of work study applications
to the clinical laboratory work setting.
A separate section highlights studies related to assessing
laboratory workloads and documents various output measures as well as
their utility 1n
· mon1tor1ng
·
·
1 a b oratory pro d uct1v1ty.
· ·
7
8
A.
The Work Study Field
Work study has been defined in various ways, yet its
meaning is congruent with other such terms as methods engineering,
work design and the well-established motion and time study.
(4:1)
In the broadest sense, work study can be thought of as the systematic
study of work systems whose mother function embraces the twin tech-
(31: 2)
niques of method study and work measurement.
Method study is concerned with how work is done and how it
can be done better.
The purpose of method study is to make the most
effective use of an enterprise's available resources (such as people,
space, material, plant and capital) through a critical analysis of a
work situation, possibly leading to a better workplace layout, or a
better work method design.
The subject of work measurement, on the other hand,
time: the duration of work and its frequency.
~s
Specifically, work
measurement techniques are designed to establish the standard time
requirements for a
g~ven
item of work as carried out by a qualified
worker at a defined level of performance.
derived in this way can be used:
(13:2)
Work standards
(1) as a guide to labor requirements;
(2) to assist in work scheduling (3) as a basis for allocating labor
and machines in a new or revised work process;
payment of personnel;
(4) as a basis for
(5) as a basis for work control by comparing
expected performance with actual achievement.
(13:33-34)
Nevertheless, despite the diversity of techniques used in
work study, they all share a common objective, i.e., the purposive
management of men and their artifacts.
(18:4)
9
1.
Historical Development
Generally, these ideas which serve as the basis for work
study methods are themselves as old as the common sense upon which
they were founded.
In most cases, however, these.primitive ideas
and ways of doing work have over the years developed gradually into
more sophisticated methods which have finally been grouped and given
comprehensive titles.
Certainly, one could go back in history to
events such as the building of Pyramids and trace definite origins
of present-day work study techniques.
These were the beginnings of
a scientific approach to the management of work systems.
Yet, it is
generally agreed that the detailed enunciation of the principles of
work study and their widespread application in the modern world carne
at the end of the nineteenth century in that remarkable period of
industrial development following the end of the American Civil War
in 1865.
(31:3)
Indeed, this period had seen the birth of a host
of future work study pioneers, most notably of which included
Frederick W. Taylor (1865-1915) and Frank B. Gilbreth (1869-1924).
Known as the "father of scientific management", Taylor
is generally attributed with discovering the time study technique of
splitting a job into individual work elements which, when timed as
such, could be used as the basis for estimating the ~otal job time.
Taylor's real contribution, though, was his introduction of science
to the practice and management of human work.
By applying systematic
methods to work study investigations, he encouraged the substitution
of fact f. d.
- ln 1ng for rule-of-thumb procedure.
because of his efforts
'
(4:27-29)
Moreover,
the concepts of human work came to be recog-
10
nized as a proper subject of study, a study which has since continued
unabated.
(13:106)
Gilbreth, on the other hand, concerned himself with the
method of work and its improvement.
By applying his laws of motion
economy, Gilbreth sought to identify the "one best method" of carrying out a task
and then proceeded to put this to the test.
(4:31)
Through such analytical methods, he succeeded in showing that all
manual work could be broken down into a few recurring elements, and
that by analyzing work in this way, an understanding of the work
methods could be gained which could facilitate improvements.
(13:106)
The fundamental quality of Gilbreth's work is indicated. by the fact
that principles and techniques which he developed so many years ago
are still being used by industry today.
(4:34)
Further, the work of Taylor and Gilbreth inspired the
emergence of new specializations and techniques in work study, even
during their life times.
Indeed, men such as H. L. Grantt and A. B.
Segur, who had worked together with Taylor and Gilbreth, were introducing new developments in both disciplines of work study which had
now become known as work measurement and method study respectively.
(31:5-6)
Others, including Quick, Benner, Shea and Kowhler were
creating systems of Predetermined Motion Time (P.M.T.) to be used
for analyzing work motions, as well as for establishing time standards.
Later on, in the 1930's and the 1940's, a number of other
systems were produced independently such as the Methods-Time Measurement (M.T.M.) from Maynard, Stegemerten and Schwab.
(31:6)
trPWW'teM% 'W T? . r!l·
,··
T
m rcrr
•
I
t
,.
1 7
· w•wrrrr
'W frt:'F
11
Across the Atlantic, the work of Taylor, Gilbreth and their
colleagues who followed them, had likewise affected investigations by
men of equal brilliance - British, French and German - as their
countries subsequently reached industrail maturity.
L. H. C. Tippett,
an Englishman, made the most significant contribution to work study
by devising a technique based on statistical theory with which to
solve the managerial problem of measuring work of a variable nature.
Today, this technique is commonly referred to as work sampling,
because it employs sampling procedures and, in its simplest form,
consists of taking observations at random intervals or workers or
machines and noting the work state at that instant.
With work sampling it is possible to:
(13:113)
(1) determine the
percentage of a work day that a man or machine is working and likewise the percentage of time that he or it is idle;
time standard for an operation;
(2) establish a
(3) measure effective and ineffective
time spent; and (4) establish a performance index relative to
observed and expected results.
(17:36)
Also, in the field of variable work measurement, another
technique recently developed by the Wofac Corporation, called the
Variable Factor or VeFAC Programming, is being used to measure group,
ou.tput or group capacity in a work situation.
(31:6-7)
The use of
statistical methods, computerization, photographic and tape-recording
techniques is increasingly finding favor in the work study field, and
as new situations arise each day, new techniques will inevitably be
in demand ' s1nce
·
.
. a
emp 1 oyment of modern concepts and techn1ques
1s
Vital necessity.
(4:7)
12
2.
Applications to Health Care
The genesis of the work study movement in h~alth care, as
in any other industry, is to be found in the teachings of Taylor and
Gilbreth.
In fact, it is believed that Gilbreth was the first person
to apply industrial work study techniques in a medical care situation
when, shortly after the turn of the century, he applied his motion
study methods to a study of the interrelated activities of a team of
doctors and nurses engaged in a surgical operation.
However, until
the mid-1950's, application of work study analyses to the health
field was practically nil.
(25:59)
The nursing profession was the true pioneer in promoting
the use of work study methods in health care.
Although relevant
contributions were made by other health care professions, the initiative for the adaptation of industrial engineering concepts to analyze
health care activities came in a large measure from nurses during the
post-war years.
Indeed, more studies have been promoted by members
of the nursing profession than any other.
(25:63)
In particular, the two areas of nursing where work study
methods have been successfully applied are:
(1) direct patient care
procedures,-and (2) nurse-patient relations.
(25:63-65)
For
example, an early study by Abdellah and Levine (1) demonstrated the
utility of a work measurement technique known as "work sampling" and
applied it to the problem of collecting performance data concerning
the functions and activities of nursing staff.
Work meas
Four alternative
.
.
.
urement techn1ques were rev1ewed and compared accord1ng to
their suit b"l·
a l 1ty and practicality for use in this kind of work
13
setting.
It should be noted that three of these four techniques
involved variations of continuous time study methods, while the
fourth involved only intermittent observation, as in the context
of the work sampling methodology.
In reporting their conclusions,
the authors suggested that "for purposes of nurse utilization studies,
the intermittent method be used by virtue of the simplicity and
economy which this method possesses".
(1:16)
However, contrary to
accepted industrial engineering practice, the authors also concluded
that sampled observations, in this setting, did not need to be randomly selected, but instead suggested that observations be regularly
spaced.
The authors further reported that observer bias was negligi-
ble after the first few observations were taken
and that "the workers
did not deviate from their usual work patterns, even with the appearance of an observer".
(1:15)
Similarly, Burke and others (6) conducted a time study of
nursing activities in a psychiatric hospital with the intent of determining what proportion of attendant nurses' time was being spent
with patients doing prof~ssional and related tasks.
In making this
determination, the authors contrasted the usefulness of the work
sampling data collection method with that of the continuous "stopwatch" method, as applied to this kind of investigation.
Again, it
was determined that the work sampling method was preferred over the
continuous method of observation, primarily because the former method
required fewer observers and created less disturbance to those
observed.
I n d eed, work sampling was shown to be reliably effective
in finding out the amounts o f t1me
.
. . .
f or
spent on specl. f.lC act1v1t1es
14
various categories of nursing personnel.
On the other hand, the
authors pointed out that continuous time study methods should not be
completely ignored for such utilization studies, since such methods
can be helpful in uncovering related facts which might not be brought
out by the work sampling method.
(6:52)
Applications of industrial engineering principles to
pharmacies as practiced primarily within the hospital, has received
a modicum of attention in the past.
Such applications included pre-
packaging of drugs; improvements in systems, equipment and facilities;
forms design and control; and standardization of methods.
(25:176)
Dentistry has also utilized work study methods applications.
As early as 1942, Barnes and Speidel (27) collaborated to explore the
used of motion and time study in dental education.
Also, in the
mid-1950's, Mundel (20) produced a memomotion film of the dental
operatory based upon a work sampling experiment which received much
attention.
The late 1950's were years which saw the leadership for the
use of industrial engineering practices in health care shift from
nurses to hospital administrators
and the scope of organized methods
improvement programs assume hospital-wide proportions, often involving
research, education and professional practice.
During this period,
hospitals established a decided trend toward the staff specialist
approach to work study application.
In fact, the number of hospitals
known to have used full-time industrial engineers more than tripled.
In add· ·
ltlon to being more numerous, these staff specialist programs
of the 1960's grew in scope and in size.
Thus, the concept of the
15
hospital industrial engineering department emerged as a permanent
characteristic of modern hospital organization, even though in recent
years, some hospitals have tended to use consulting firms to either
supplement or take the place of on-going staff specialist programs in
(25:75-76)
this area.
3.
Applications to Clinical Laboratory
One of the first researchers to apply work measurement
techniques to examine performance within a clinical laboratory was
Allen.
(2)
In 1957, Allen investigated the time requirements for
each major group of testing procedures that were being performed in
eight different hospital laboratories.
Essentially, the time needed
per examination was arrived at by dividing the total technician time
spent by the work load performed.
The resulting standard times were
then adjusted for time loss and for time spent on non-laboratory
activities.
It should be noted that these standard time data were
compiled using the industrial "stopwatch" technique
and therefore
carried out in accordance with the continuous time study method.
In
addition, Allen reported that the time required to perform each test
group was subject to a number of variables, the most important of
which were:
(1) the division of responsibilities;
mechanization; (3) the size of the workload;
(2) the extent of
(4) the type of workload;
and (5) the work flow process and physical layout of the laboratory.
(2:123)
Owens and Finch (21) also emphasized the importance of
establ' h'
ls lng performance standards for managerial control purposes
in th ·
elr report of a laboratory operations study which they conducted
16
the same year.
In this study the authors attempted to calculate
"norms" for test outputs based on a· performance measure which the
authors called T.M.H.
(test output per man-hour) value.
Also pre-
sented was an overall performance index known as S.L.M.H. (standard
laboratory man-hour) which was devised to represent proportionately
how the average technician utilized the minutes that comprised an
average. laboratory man-hour.
The S.L.M.H., therefore, was the sum
of a number of individual standard time requirements projected for
various technologist work activities thought to be typical in each
of such departments as biochemistry, bacteriology, hematology and
serology.
The following activities were included:
time spent for specimen processing and testing;
(1) benchwork-
(2) collection
activities- time spent drawing blood and/or preparing the patient and
specimen for testing;
(3) reagent preparation- time spent for solu-
tion preparation and restoring;
(4) work place maintenance- time spent
for set-up and clean-up of work area; and (5) non-technical laboratory
assignments- time spent writing reports, telephoning, conferring, etc.
(21:102)
Showalter (24) was one of the first to deal with the posibility of enhancing laboratory performance by improving operational
efficiency.
This approach, as outlined by the author, involved the
application of industrial engineering principles of methods analysis
and work simplification, as part of a total methods improvement pro&ram that had been effected at the Memorial Hospital of Charleston,
Wes·t Virginl· a 1"n 1962.
And def lClencies
· ·
Work methods were analyzed for inefficiencies
' simplified and ultimately standardized.
Also,
17
staffing requirements were correlated with the distribution of workload and were based on information provided by a series of work
samples.
In fact, according to Showalter, "work sampling gave a
great deal of insight into the cost of duplicated effort, as well as
the cost of needless activitiy in the laboratory".
(24:76)
Un-
fortunately, not much information was made available concerning the
work sampling study or
the analysis of laboratory methods and
procedures.
Ozan (22) detailed an evaluation methodology that was used,
not only to audit technicians' work activity, but also provide an
outline of operational inefficiencies which, together, formed·the
greater part of a total laboratory performance improvement program.
Since the concept of performance measurement was now becoming more
understood and likewise a topic of great concern in the field of
laboratory management, Ozan attempted to develop a procedure that
would identify facts pertinent to the productivity and effectiveness
of laboratory technicians.
With the use of work sampling, inefficien-
cies were revealed and improvements hypothesized.
were subsequently established
Performance goals
and progress achieved toward attaining
these goals was reflected in a Laboratory Performance Index (LPI).
The LPI measure was calculated by dividing the expected total time
projected for the workload experienced over a certain time period by
the actual time spent for this particular workload during this
specified work period.
In the context of proper interpretation, it
is important to note that the numerator_- of this index was intended
to tefl
h
ect t e effects of implemented method improvements, whereas
10
the denominator indicated the actual performance time under all
possible shortcomings of the laboratory operations.
(22:74)
Bonin and others (5) presented a work index called a
performance factor (PF) which expressed workload in terms of the
average number of relative value units produced per man-hour during
a selected time period.
Relative value units were "weighted" work
unit measures of laboratory output which were used in lieu of the
quantitative "number of tests" unit_ and which were arrived at by
multiplying the proper weighted relative value assigned to each
particular test times their frequency of performance.
Lawton and others (19) also used an index of productivity
based on a ratio of the total relative value
units (output) pro-
duced during a specified time period to the available man-hours
(input) consumed during the same time period.
This index (or Pro-
ductivity Indicator) seemed to offer useful evidence of personnel
productivity measurement by representing productivity as the amoung
of output (total relative value units) per unit of input (labor time).
Elwell (11) discussed such laboratory productivity measures
in his study of seventy-five public health laboratory work groups in
an effort to reveal the factors which caused differences in productivity from one functional group to another.
Firstt of all, Elwell
considered the notion that possibly these measures themselves were
inadequate.
The author warned that relative value units may be
adequate for one laboratory but inappropriate for another, since
Weighted values are often average measures.
should b
Also, man-hour figures
.
e measured ln terms of the net hours available rather than
19
the gross hours, since it was found that only eighty-four percent
of the total .amount of time available each day in the laboratory
was used for laboratory work.
(11:24)
In the final analysis,
productivity was clearly related to the amount of monthly fluctuation
in incoming workload.
The author concluded that laboratory super-
visors might increase productivity by taking advantage of peaks and
valleys in diagnostic workload by allowing the technologist employees
time away from the bench to pursue other interests during slack hours.
Therefore, forcasting of day-of-week and hour-of-day peaks and valleys
in workload was stressed by the author.
Still, though, the author
hastens to point out that there is much misunderstanding and confusion surrounding the concept of productivity measurement among
(11:24-25)
laboratory managers today which must be eliminated.
B.
Studies Related to Assessing Laboratory Horkloads
Currently, it is said that the methods of
~valuating
laboratory workloads are as variable as the testing procedures which
compose such workloads.
Therefore, both the methods of calculating
workloads and the testing methods themselves need to be standardized
if there is to be any uniform approach to the analysis of laboratory
performance.
(28:36)
Most laboratory administrators have been in agreement for
a number of"years that a composite record of the work done, based on
the numbers of specimens processed,does not
of itself
give suffi-
cient information for judging the total work activity. or; especially,
the char
Obviousl
acter of the work performed in a laboratory.
(29:74)
Y, a raw count of the total tests performed cannot reflect the
20
intricate nature and variability of some laboratory procedures, since
no element of discrimination is used to differentiate the procedures.
(28:36)
Therefore, because of the variety of conditions and circumstances which may affect this kind of work output, it is indeed misleading and inaccurate to measure laboratory activity solely on a
quantitative basis.
Moreover, quantity, by itself is too non-descript
a measure for the determination and management of laboratory performance
and in the computation of laboratory workloads.
(14:665)
Based on this general premise, several studies were conducted in an attempt to derive a more realistic measure of labor accomplishment for use in reporting clinical laboratory workloads.
For
example, an early study conducted by Starkey (29) suggested that
workload be assessed in terms of work units evaluated according to
a measure of time.
Comparative ratings in terms of technicians' time
per test were developed for each type of test being performed in
laboratories at that time and were arrived at by taking observations
of technicians of varying experience, working in several different
laboratories
and recording their test outputs according to prear-
ranged type categories.
Resulting work unit "scores" were then
assigned to each test relative to the estimated average amount of
technicians' time demanded to perform each test individually.
According to the author, this "point scoring system" was generally
accepted at that time to be the only practical method available for
eomparat·
- lVe assessment of labortory workloads.
(29:77)
However, at about the same time, the Canadian Association
21
of Pathologists (8) published its version of "unit values", similarly
based on the amount of time needed to accomplish each procedure.
By
averaging the reconunended figures of its divisional members and pathologists across the country, the Association collectively compiled a
schedule of unit value designations in which each unit represented
ten minutes of time, with approximately seven minutes of each unit
arbitrarily assigned to the technical aspects of a test, while the
remaining three minutes signified average time consumed for clerical
activities, preparatory and clean-up duties and other non-technical
(8:62)
jobs.
Six months laster, Warren (30) reported a schedule of
laboratory units which was accepted by the College of American
Pathologists and published
members.
for the first time in a bulletin to its
Based on a system that was in use at a Boston Hospital
laboratory, the unit values were calculated to reflect the amount
of effort expended by the technical, clerical and aide personnel
in performing various laboratory procedures.
As in the Canadian
study, unit values were designed to be numerical equivalents to the
amount of time needed for such functions as specimen processing,
calculation, logging and recording of results, as well as actual
test analysis.
Supportive activities included such things as solution
Preparation, glassware washing, quality control and clean-up.
Although both the Canadian and American systems were subsequently
modified in keeping with changes in laboratory practice, nevertheless,
both st d"
.
.
u les 1ns1nuate professional acceptance of the belief that
Simple
.
enumeratlon of procedures was inadequate for the measurement
2L
of \·mrkload
and that "weighted" units were more suitable and reliable
for assessing levels of activity of laboratory personnel.
(22:70)
With the advent of automation into the methods of laboratory
operation, the frequency with which each testing procedure was performed had itself become a factor which needed to be imposed in any
calculations of weighted work units.
The major reason for this is
that rarely-requested and esoteric procedures tend to interrupt
normal laboratory work schedules since they are necessarily done on
an individual and/or manual basis.
(14: 666)
\.Jith this in mind,
Hainline (14) proposed a system for reporting laboratory workload
which went beyond previously proposed systems which weighted only for
the factor of time.
In so doing, the length of time necessary for
an average technologist to perform a particular test determination
was additionally modified to account for the following related
factors:
tions;
(1) the length of time necessary to do duplicate determina-
(2) the skill involved; and (3) the usual frequency with which
each test was performed.
It should be noted that the total time
estimates included not only the basic analysis time (measured by
using industrially-accepted stopwatch techniques), but also included
arbitrary estimates for the average preparation time and the average
calculation time necessary for each general test type.
In the end,
time-skill-frequency (TSF) units were calculated, and subsequently
used to detail laboratory activity.
(14:666-668)
Besides this new work unit, another noteworthy contribution
of the Hainline study was an analysis of work done over a five-year
period in which the author compared the weighted TSF unit system of
23
recording workload with the usual quantitative method, based solely
on the number of tests performed.
Whereas comparisons showed the
total number of determinations carried out over this period rose
thirty-eight percent, this same increase in workload, expressed in
TSF units, exceeded sixty-five percent.
The main reason for this
difference in productivity determination was revealed by an examination of the actual distribution of tests requests.
Since more
sophisticated testing techniques and equipment had been installed
during this time period, a greater number of high unit-valued tests
which were relatively new at the beginning of the study, were requested in lieu of the usual low unit-valued procedures.
Consequently,
this different mix of test requests, when combined with the obvious
quantitative increase in test volume, was responsible for the
resultant difference in productivity gains, because this influence
could not normally be accounted for using only the raw count method.
(14:670)
Most recently, Bonin and others (5) developed a weighting
systems of "relative values" for reporting laboratory workloads with
applications specifically for public health laboratories.
As in the
past studies, relative values were numerical equivalents calculated
for each test and, in theory, established each test's relationship to
a chosen unit, in this case, a relative value equal to one (1).
Furthermore, relative values were weighted work unit measures and as
such, were dependent on the following predetermined factors:
tim
·
e required to perform the test procedure;
(1) the
(2) the qualifications
of the technologist; and (3) the complexity of the technique and
24
decisions involved.
Logically, a test with a low relative value
typically designated a diagnostic procedure that a person or a machine
could perform quickly and easily.
Conversely, a high relative valued
test indicated a difficult, time-consuming determination that probably
required a great deal of expertise.
(5:112-113)
In reporting this investigation, the authors concluded that
an informational system based on relative values offered a more
objective and reliable basis for decision-making, when judged in
perspective with other workload reporting systems.
In addition, the
authors demonstrated how relative values could be used in the
accounting of costs per funcional area in the laboratory, in monitoring
performance, and in determining staffing requirements.
(5:117)
An associated study discussed in a paper by Lawton and
Elwell (19) portrays a relative value structure which considers:
(1) the time required to perform the examination; (2) the complexity
of decisions and qualifications of the technologist; and (3) the
frequency of performance of a particular procedure.
Unfortunately,
very little detail was offered regarding the data collection and factor development aspects of the investigation.
However, the authors
indicated that subjective judgement was a necessary ingredient in
establishing the measures of complexity and frequency, and that the
validity for each factor and the corresponding weights were tested on
a Pilot basis by a number
Values were intended.
of laboratories for which the relative
The most significant contribution of this
study Was the array of applications of relative values that was related ·
ln terms of actual experience, rather than hypothesized.
25
~)pcci fically,
(J)
the authors illustrated the use of relative values:
(or measuring workload over-time;
(2) as an indicator of pro-
ductivity; and (3) for estimating the cost of laboratory testing.
(J 9: 207-208)
C.
Summary of the Literature Reviewed
The preceding review of literature presented select studies
which relate to assessing workload and/or evaluating operational
performance with regard to clinical laboratory considerations.
From
this, a number of preceptive generalizations were apparent.
For example, it was generally agreed by laboratory managers
that no consistent relationship ever existed between the most traditional and customary laboratory workload measure, expressed in terms
of the work unit known as "the number of tests performed", and the
actual quality or character of work activity experienced.
Furthermore,
most gradually recognized over the years that any evaluation of work
activity utilizing this measure was valueless except possibly in
making comparisons of the same for a single laboratory under identical
work conditions and circumstances.
Unfortunately, this ideal situa-
tion is not totally practical in most instances.
Consequently, as a
challenge to the the custom of portraying workloads on the basis of
quantity alone, a number of admininstrative authorities attempted to
develop other more realistic methods of record-keeping.
A study of the history of laboratory reporting systems
revealed that, in fact, many different schemes have been hypothesized,
employed and eventually discarded.
In any event, most researchers
expressed the view that "weighted" factors themselves might best be
26
computed for each laboratory according to unique setting, methods
and/or personnel characteristics peculiar to each laboratory.
Signif-
cantly, the single most fundamental factor taken into account in every
"invented" work unit scheme dealt with the resource of time in some
way.
Generally, it was shown that comparative time estimators need
to reflect not only the basic analysis time for each testing procedure,
but should make provisions for the amount of time consumed in the conduct of essential non-technical activities as well.
The best reporting systems differentiated the esoteric
procedures from the simple, routine procedures by weighting certain
associated factors for such things as the amount of training and
background skill required of the technologist in order to perform
each specific test, and the particular sophistication demanded in the
way of equipment and instrumentation for each determination.
Also,
the complexity of test methodology and the importance of technical
decisions involved for each procedure was given consideration.
Finally, the frequency with which each test was performed was also an
important factor which itself was incorporated into the best of the
weighted work unit schemes reviewed.
Admittedly, there are other operational factors which might
also have been integrated into past or future schemes.
However, the
expected return.in added specificity as a result of further factorization does not appear to be significant enough to matter.
it is the opiriicin· of
Therefore,
this writer that, in general, any workable
method for determining the relationship of various testing procedures
to overall laboratory workload must have, as its basis, a system of
27
weighted unit values, computed from formulae which depict the variables of time, skill and frequency.
One should not assume this to be
the "perfect" unit of measurement for comparative assessment of
laboratory workload, but rather one should recognize and take advantage of the many practical advantages this weighted unit system offers
over other work units whose quantitations which may be either inadequate or cumbersome.
With regards to the application of work study methods for
workload and performance evaluations, there is strong evidence that
the work measurement technique of work sampling can be quite useful
in ascertaining data related to weighting factors, and for use in
determining laboratory work standards and productivity expectations.
Secondly, the industrial engineering principles of methods anlysis
and work simplification were shown to be readily adaptable to a
clinical laboratory work setting.
As part of a total operations
improvement program, they can help create a more efficient, effective
and uniform operation.
Finally, it was shown that an index of pro-
ductivity based on a ratio which compares output (total relative value
units produced) to input (net technologists' man-hours consumed) is
the most suitable performance measure with which to monitor the
effective performance of both management and technologist work staff
in the laboratory.
II.
Setting of the Project
This study was conducted at a proprietary, non-hospital,
clinical laboratory which serves various medical providers within the
greater Los Angeles medical community.
The basic function of the
28
laboratory is to perform various diagnostic testing procedures or
assays on certain biological specimens submitted to the laboratory,
and to report the results of these tests to the requestor as soon as
possible.
Generally, the laboratory services physicians--either in
their private practice offices, at extended care facilities, or
through skilled nursing homes--by providing an extensive courier
arrangement for pick-up and delivery of specimens and tests' results.
At the time of this study, the laboratory was owned and
operated by two bioanalysts and employed an average of fifteen fulltime and ten part-time employees.
In addition to the co-directors,
the composition of the full-time work force also included five licensed laboratory technologists, one supervisory technologist, two
technologist assistants, five clerical personnel and two office
managerial staff members.
Within the part-time employee group were
four couriers, one glasswasher, two office assistants and three mobile
phloebotomists.
In all, the total combined work force consisted of
twenty-five persons.
The laboratory technologists, all females with an average
age of 37 years, were the primary subjects of the work sampling analysis.
All had previous experience in either hospital or other commer-
cial laboratories prior to their employment at the laboratory under
study.
Educational backgrounds differed in that three out of five
held bachelor's degrees, while the others had only associated technical degrees.
However, all were fully licensed clinical laboratory
technologists with a minimum of four years prior laboratory experience.
Sixty percent of the technologist staff had less than one year's
29
seniority at this laboratory, a fact which reflected an existing highturnover rate of technologist personnel, and which served as a major
motivation for this study.
During the first month of 1975, therefore, the management
of the subject laboratory decided to undertake a critical examination
of the laboratory and its operation.
Formal preparations and planning
were begun immediately despite the commonly held beliefs that:
(l) the
laboratory was performing with at least average efficiency; (2) the
testing methods being utilized were both professionally accredited
and technologically current; and (3) the general services and actual
test results were of acceptable quality.
Following managements
rejection of the suggestion to enlist the services of an outside
consulting firm, it was decided that planning and direction of the
program were to be a joint effort between the in-house managerial and
technical staffs.
An uncounted number of meetings followed and many hours were
spent discussing, questioning and researching in an effort to "thinkthrough" the project.
For the most part, economic considerations de-
termined the degree of training that could be received or made available to the members of the study group regarding work study methods.
Finally, details were outlined pertaining to the method of
procedure that was to be followed towards the resolution of the project.
It was decided that the project was to proceed according to
Planned "phases".
These phases were outlined as follows:
RPase 1 - Preparation and Planning
a.
Determine the usefulness and expected return
30
b.
c.
d.
of such a project.
Decide whether or not to proceed (if justified).
Choose the correct course of action.
Announce and explain the conduct of the project
to entire staff.·
Phase 2 - Operations Analyses
a.
b.
c.
d.
e.
Evaluate work methods and testing procedures
in the laboratory.
Analyze space requirements and equipment placement.
Examine working conditions and employee morale.
Appraise job content according to personnel
requirements.
Schedule implementation and completion improvements before entering next phase.
Phase 3 - Work Sampling Activity Analysis
a.
b.
c.
d.
e.
f.
Conduct preliminary analysis to preview study design.
Classify work elements into general activity
categories for study.
Design data tally sheet needed to record observations.
Estimate required number of randomized observations.
Determine data collection time span and observation
time.
Make observations and compile data for analysis.
Phase 4 - Establish Group Performance Standards
a.
b.
c.
d.
Determine total output of relative value units
from production data.
Determine total man-hours from time cards for
study time period.
Calculate normal time spent per relative value
output for each work and delay activity based
on percentaged derived from work sampling.
Apply allowance factor for personal, fatigue and
delay allowances to normal time calculations to
give performance standards.
Phase 5 - Calculate Relative Value Assignments
a.
b.
c.
d.
Compile a list of all diagnostic procedures performed.
Measure average basic analysis times for certain
key tests performed.
Estimate the factors of test complexity and frequency.
Complete the calculations of weighted relative value
for each test.
31
Once objectives and general plans had been agreed upon, a
meeting of laboratory personnel was called to explain the intended
project objectives, what was to be
expected.
done~
and what benefits could be
The laboratory technicians in particular were fully ap-
prised of the techniques to be used, since they were to be the center
of attention for the work sampling analysis.
At the same time, their
individual and collective importance to the success of the study was
emphasized and all were assured that no one would lose his/her job
as a result of study evidence for a cutback in manpower.
Normal
employee attrition would gradually fulfill this need if proved
necessary.
In as much as there already existed a positive understanding
between those conducting the study and those being studied, no real
difficulty was experienced in gaining total acceptance of the study
and complete cooperation.
Chapter 3
METHODOLOGY
This chapter will review the purpose of the project, the
project objectives, and definition of terms used in reporting the
project.
In addition, the data collection process is described
according to the sources of data and the method of analysis.
I.
Purpose of the Project
This project was undertaken to study the general applic-
ability of industrial work study methods to a clinical laboratory
work setting.
Specifically, the purpose of the project was to
employ techniques of method study .and work measurement to:
A.
1.
standardize the basic work content contained
within the methods and the process of laboratory operations;
2.
profile the effective utilization of time and
skill as displayed by a staff of clinical laboratory technologists in the performance of
normal diagnostic workloads; and
3.
establish reliable performance criteria against
which to evaluate the productivity and effectivity of technologists' work efforts.
The Project Objectives
An essential step in any managerial planning activity is
the definition and ordering of objectives.
At the very least, the
objectives of this project were to include the following:
1.
To reduce the amount of non-productive activity,
both voluntary and inherent, which may have been
expressed in the performance behavior of the
technologists themselves and/or through their
work methods.
32
33
B.
2.
To examine the utilization of time by the
technologist staff of the laboratory and to
determine why non-productive time may be
occurring and to what extent during the average accepted workday.
3.
To establish standard time data for each
testing procedure performed by the laboratory, particularly for those tests which
are repetitive and which comprise the greater part of normal workloads.
4.
To define standard performance in terms of
expected time allocations for various selected work and delay categories of technologist
activity while performing normal workloads.
5.
To evaluate the cyclic variations and activity
patterns associated with the distribution of
workload and general technologist performance,
and as depicted in the average composite workday.
Definition of Terms
l.
Industrial Work Study Methods: A generic name for
those management techniques (particularly method study and work
measurement) which are used in the examination of human work in
all its contexts and which lead systemanticlly to the investigation
of all the factors that affect t·he efficiency and productivity of a
particular work situation.
2.
Clinical Laboratory Work Setting: A place equipped
and staffed to perform testing and analyses of various biological
specimens for purpose of diagnosis and treatment of disease and disorder, and/or to engage in research essential to medical advancement.
3.
Method Study:
The systematic recording and critical
examination of existing and proposed ways of doing work, as a means
of developing and applying easier and more effective methods or
procedures of doing work (preferred work methods).
34
4.
Work Measurement: The systematic determination, through
the use of various techniques, of the amount of physical and mental
work, in terms of work units, in a specific task.
Generally, the
amount of time needed for a qualified worker to carry out a specified
job or series of work activities at a defined level of performance.
5.
Basic Work Content: The amount of work "contained"
in a given product or service and usually measured in terms of manhours or machine-hours.
6.
Clinical Laboratory Technologist: A person employed
in a clinical laboratory to perform various chemical, microscopic
and bacteriologic tests in order to obtain data for use in diagnosis
and treatment of diseases.
Job knowledge includes an understanding
of the use and limitations of laboratory equipment and apparatus,
familiarity with standard laboratory methods and techniques and basic
knowledge in the fields of bacteriology, hematology, serology, and
other biochemistry curricula.
7.
Work Load: The amount of work expected from or per-
formed by a work force during a specified period of time.
Workload
is usually expressed in terms of the tangible products produced, or
services rendered, and almost always of the basis of quantity.
8.
Performance Criteria: Standards which provide a means
of determining what performance behavior and productivity expectations should be, and upon which a judgement or decision concerning
the same may be based.
~-
Productivity: The ratio of the sum of the total output
produced by an operation compared to the sum of the total input.
35
10.
Effectivity: The degree of accomplishment towards
achieving maximum outcome with minimum effort.
Also, relative success
in producing standard performance for normal workloads.
11.
Management: The organization and control of human
activity directed towards achieving specific ends.
12.
Operative: The workers of an operation; for example,
laboratory technologists are the operatives performing analysis
functions in a clinical laboratory.
13.
Man-Hour: A measurement unit ot time taken to carry
out an operation or to produce a given quantity of product or service,
vis-a-vis, the labor of one man for one hour.
14.
Relative Values: Numerical equivalents assigned to
each diagnostic procedure performed by the laboratory technologists
and weighted in this study with regard to:
quired to perform each procedure;
technologist skill invloved; and
test is performed.
(2)
(3)
(1)
the total time re-
the technique complexity and
the frequency with which each
A diagnostic test with a low relative value
would indicate that a person with a low skill level could probably
perform this test quickly and easily.
On the other hand, a high
rel~
ative value would indicate a difficult, time-consuming test requiring
a great deal of skill.
15.
Relative Value Units: Weighted work units portraying
the "character" of the work done, as well as the quantity of work
done.
Relative value units are determined by multiplying the number
of times a certain diagnostic test is performed by the respective
Value rating assigned to the test.
36
16.
Expected Time Allocation:
Theoretical potentials re-
fleeting acceptable use of time by the operatives of an operation as
determined by the managerial staff, and to be used in judging expected
time requirements in performing expected work loads.
17.
Performance Indicator:
A ratio of the expected total
time, expressed in terms of man-hours to the actual total time spent
in performing a given work load over a specified time period.
This
percentage measure is a reflection of the effectiveness of the work
effort under controlled working conditions.
Performance Indicator
18.
Actual Total Time
(Man-hours)
Expected Total Time (Man-hours) X 100
Productivity Quotient:
An index expressing the sums
of the output produced divided by the sum of the total input.
There-
fore, a comparative assessment of the total relative value units performed during a specified time period divided by the total available
man-hours consumed during the same period of time.
Productivity Quotient
19.
Work Sampling:
Total Relative Value Units
Total Available Man-hours
A technique in which a large number
of instantaneous observations are made over a period of time of a
group of machines, processes or workers.
Each observation records
what is happening at that instant and the percentage of observations
recorded for a particular activity or delay is a measure of the percentage of time during which that activity or delay occurs.
(Activity
sampling is also known as ratio-delay study; observation ratio
study;
snapreading method; random observation method and work sampling.)
20.
Flow Diagram:
A diagram which shows the location of
specific activities carried out and the routes followed by workers,
37
materials or equipment in their execution.
21.
Work Process Chart:
Charts in which a sequence of
events is portrayed diagrammatically by means of a set of process
chart symbols to help a .person to visualize a process as a means of
examining and improving it.
22.
Basic or
Also known as a Flow-Process Chart.
Normal Time:
The actual time required to
carry out an element of work by a qualified worker at a normal pace
and defined level of quality.
Determined by observation using a
stopwatch.
23.
Standard Elemental Time:
The total calculated time
in which a job should be completed at standard performance; basic
or normal times adjusted by allowances for unintentional delay,
personal, and fatigue considerations.
II.
Sources of Data and Their Measurement
A.
Methods Study
The future success of any operation is said to be dependent,
to a large degree, upon the continual improvement of its methods and
the constant up-grading of its resources.
With this in mind, a
methods study was performed to verify the quality of the working conditions that prevailed and to examine the efficiencies of work methods as they existed.
Specifically, analyses of operational circum-
stances were designed to determine whether:
(1) the most effective
equipment and instrumentation were being used;
(2) the best work flow
process and physical laboratory layout prevailed; (3) preferred work
procedures and contemporary testing methodologies were installed; and
(4) personnel supervision was satisfactory.
38
The writer felt that this approach would help to provide
not only more uniform circumstances and conditions for doing work in
the laboratory,but also the necessary basis for appointing standards
of acceptable performance that could be used to compare past, present
and future levels of laboratory work activity.
1.
Work Conditions
Within a given set of working conditions, it has been shown
that the amount of work done in a day is dependent upon the ability of
the worker to perform prescribed tasks, and the speed at which he
works.
Obviously, the speed at which a worker will work is related
directly to that person's inclination or "will-to-work", which itself
is affected by many things.
One of the most important influences is the physical
environment in which a worker may be required to perform.
According
to Barnes (4), the essence of performance is normally a direct function of the quality of operational working conditions.
Moreover, by
eliminating as many undesireable conditions as pos.sible, worker morale
can theoretically be heightened, and productivity likewise improved.
Consequently, to initiate this project a thorough inspection of such things as lighting, ventilation, temperature, noise,
sanitation and general safety considerations was performed with the
thought of enhancing the personal comfort and mental·attitude of the
laboratory workers and reducing the extent of physical and psychological fatique from doing this kind of work.
The following list of
questions reflects some of these concerns:
(a)
Are provisions made for the technologists to
39
work in either a sitting or standing position
when applicable?
(b)
Is good housekeeping maintained throughout the
laboratory?
(c)
Are the length of the normal working day and
allowed rest periods realistic?
(d)
Are there any health or safety hazards associated
with the methods in force?
(e)
Is there suitable temperature control so as to
maintain a comfortable, ambient temperature in
the workplace at all times?
(f)
Is the ventilation in the work areas adequate
so that fumes and odors are not evident?
2.
Operations Analyses
Ideally, a method suitable for routine use should be specifie, accurate, precise, rapid, inexpensive and should require small
quantities of specimen and minimal working space.
Based on this
definition, the various diagnostic procedures provided by the study
laboratory were examined and judged.
Data included a complete meth-
ods description of the key and most commonly requested tests performed by the technologists, as well as the current procedural manual which outlined the non-analytimlwork methods employed by the
laboratory personnel in conducting essential day-to-day functions.
The objective of this review
was to determine if, in fact, the most
practical and accredited methods were being utilized.
Furthermore,
by examining the specific work content in this manner, it was hoped
that this investigation would lead to the development of more simplified or improved methods and eliminate inherent inefficiencies that
might have been heretofore unnoticeably present.
40
However, because of financial limitaiions, the application
of work simplification techniques and principles of motion economy
were restricted for the most part to a rather fundamental level of
analysis.
Yet, it should be pointed out that a number of select tests
were examined in great detail.
These tests included those analytical
procedures which make up the greater part of normal laboratory workloads, and were identified by a review of past test request information.
The review is summarized as follows:
(1) in the Biochemistry
Department, where some fifty different tests are performed, three
tests account for about one-half of the workload;
(2) in Hematology,
where over twenty different tests are carried out, two-thirds of the
typical work volume consists of just three tests;
\3) in Serology,
where about a dozen tests are conducted by technologists, only one
test accounts for almost two-thirds of the usual test requests; and
(4) in the Urinalysis Department, where about a dozen tests are also
performed, only four tests make up almost 95% of the average daily
workload for this department.
Obviously, since these most frequently requested tests comprise such a large portion of the normal workload, it was felt that a
good indication of the laboratory's basic work content could be
obtained by analyzing the process of the methodologies for these
specific tests.
Therefore, continu<Dus observations were made of the
subject technologists as they each performed the above tests. The
essential job elements and their proper sequence of performance were
identified by eliminating wasteful activity and by combining or
changing steps in each operation.
At the same time, the required
41
individual and aggregate times for each step in the particular methodology were noted and depicted using a flow-process or work-process
chart.
example
Such procedural summations were recorded as shown by the
chart presented in Figure 1 (See Page 42) which describes
the various activities involved in performing an individual routine
white cell count using manual methods.
The overall laboratory operation itself, including specimen
collection, processing, reporting, and bill procedures, was studied
and diagrammatically represented as shown in Figure 2 (See Page 43).
From this, one can readily trace the different ways a test request
might have been generated and subsequently handled from the time the
specimen was taken from the patient through the final billing process.
In Figure 3 (See Page 44), a more specific work flow diagram
is presented to show the sequence of events involved in the actu'al
processing of a typical patient specimen in the laboratory.
ln so
doing, the paths of movement associated with the work and data flow
procedures could be reviewed in order to gain a better insight into
what could be considered as optimal organization and arrangement of
manpower and equipment with respect to laboratory layout.
B.
Work Measurement
Work measurement has been defined as the application of
techniques designed to establish the time for a qualified worker to
carry out a specific task at a defined level of performance.
The
first two factors, "qualified worker" and "specific task", are
concerned with the way the job is organized and operated.
Setting
the best conditions as standard practice automatically generates the
42
Figure 1
Flow Process Analysis Summary
SUBJECT
PROCEDURE:
EQUIPMENT:
Routine White Blood Cell Count
Pipette, WBC Solution, Pipette Shaker, Counting Chamber, Microscope.
NO. DESCRIPTION
ACTIVITY
-----
TlMt.
(MIN.)
l
Obtain blood specimen tubes from storage area
00~0\7
0. 15
2
Arrange blood tubes and result tickets in numerical order
orJoo-v
0.09
3
Pick up specimen tube
4
Shake specimen tube
5
Remove rubber stopper from specimen tube and pipette blood
0.20
6
Place stopper in specimen tube and return tube to work
0.11
7
Draw WBC solution into pipette
00~
0.08
8
Place pipette on shaker
c&o-v
0.05
9
Remove pipette from shaker
000~ 0.06
10
Place contents from pipette into counting chamber
0~\7
0.09
11
Place pipette in soiled storage
-~00\7
0.02
12
Place counting chamber in microscope
ooo9;7
0.06
13
Count white blood cells
0~\l
0.64
14
Record results or count on corresponding result ticket
15
Remove counting chamber from microscope
a
16
Clean counting chamber
:~ bOO'V
17
Seperate completed result ticket
r~~00\7 0.02
18
Transport result tickets to storage area
~O'V
19
Deposit original tesult ticket in box for delivery to
i~OO'V
~OOO'V
0~0\7
1'o6D'v
area ~OOV'
proper nursing station and the duplicat copy for filing
21
Clean pipettes
22
Return clean pipettes to work area
23
Store clean pipettes at work area
--
IJOO'V 0.06
-
Transport soiled pipettes to sink
''ooov
O~D'V
oo~_'V
Q
!NSPECI!ONS
0
MOVES
0.08
0.12
0.15
0.08
0.35
rooor:\'V 0. 14
0000~ 0.06
2.76
TOTAL
OPHATIONS
0.05
•(ooo'V 0.07
r--
20
0.03
0
DElAYS
0
PHM. STORAGE
\J
43
Figure 2
Specimen Collection, Processing, Reporting, and Billing Procedures.
Drawing station
collects specimen
Physician
collects specimen
Laboratory
collects specimen
I
I
I
Mail to
laboratory
Laboratory
pickup
Receptionistclerical
I
I
Deliver to main
laboratory via
courier, or mail
Deliver to
laboratory
via courier
or mail
I
Receptionistclerical
I
I
I
·I
I
Clerical!
Clerical!
I
l
Sample preparation!
I
Performance!
I Report
I Bill
results
I
physician!
I
I
IBi.Ll third party/
I
I Bill
patient!
CLIENT
DISTRIBUTION
ENTRY ROOM
(
~
·_____,____.,~,~·;_ 0u~ 0~
TRA.,SMIT
RESULTS
BIOCHEMISTRY
MICROBIOLOGY
~
SPEC.
STORAGE
I
l...r-r--t-
.
REPORT
I
SORT BY
CLIENT AND
ROUTE
·~
~6
DELIVER
TO
CLIE.'IT
Y~IT
•
;
.....
l
HEMATOLOGY
~~
I
LOCAL
_e
~ORJ<
IN PROCESS
DISPLAY
STE
SEROLOGY/URI HALYS IS
Y--1
CLIENT SERVICES
.
lfi' .
I
1..
---1----..,
SPEC.
STORAGE
lrro-
\1'
WASTE
SPEC.
STORACE
~
~~ ~ASTt
Figure 3
Processing of Typical Patient Specimen
~
..,_
45
degree of uniformity and environmental stability that makes measurement feasible, and the resulting time standards useful as tools in
planning and controlling operational performance.
(18:102)
With this in mind, the work measurement aspect of this work
study investigation was preceeded by a method study of the laboratory
to confirm that conditions and work methods were, in fact, right for
the creation of performance standards.
Since much work activity in
the laboratory does not easily lend itself to direct measurement,
the decision as to which work measurement technique to use was
considered carefully.
Indeed, certain laboratory work assignments
are often varied and long in duration, and laboratory workloads can
be quite irregular at times, or difficult to quantify.
Instead of the continuous time study method, therefore,
a somewhat lesser known technique was employed which, in some cases,
has shown to be even more accurate and economical for gathering facts
about performance behavior.
(3:546)
This technique is called
activity sampling, or in the context of most work situations, simply
referred to as "work sampling".
1.
Work Sampling
The principal work measurement technique selected for the
collection of data in this aspect of the study was work sampling.
Basically, work sampling is a catchword for a measuring
device in which a statistically competent number of instantaneous
and random observations are taken, over a period of time, of a group
of machines, processes or workers.
cords what was seen to have happened
Each individual observation reat that instant, and the
46
summation of these observations enables one to depict the general or
(18:209)
instantaneous activity state of those being observed.
The theoretical basis of work sampling is devised from the
statistical sampling facility provided by the mean and standard
deviation of a binomial distribution that closely approximates a
normal curve.
An appropriate and randomly chosen sample will thus
tend to have the same distribution pattern as the population of
infinite observations from which it has been drawn.
(17:52)
Provided that the conditions and time period studied can
properly represent the actual situation, the percentages of time that
a subject is observed to be working, idle or engaged in some other
activity, can reasonably be relied upon as a basis for drawing conclusions and taking action.
Although the uses of work sampling are quite extensive,
its applications include mostly those work situations where knowledge
of the percentage of time spent on a set of activities can:
itate factual assessment of existing conditions,
(1) facil-
(2) indicate worth-
while areas for improvement, or (3) assist in the computation of time
standards for manning, planning and control.
a.
(18:215)
Frequency of Observations
The total number of observations to be made is dependent
upon the confidence level and desired degree of accuracy of the data,
since sampling always introduces a degree of error in estimation.
Fortunately, the accuracy of the results can be controlled within
tolerable limits with any required level of confidence if no bias
in sampling exists.
47
For purposes of this study, the writer assumed that the
precision of the sampling would be more than satisfactory if the final
results could be kept within an error of ±2.5 percent in 95 cases out
of 100 (95% confidence level).
Subsequently, a preliminary sampling was completed in order
to extract information relative to the work and delay categories of
activities to be observed; estimates for expected percentages of
time spent on each activity were obtained.
The number of readings
required, measured at the 95% confidence level, was then calculated
by using the following formula:
Where:
N
s
p
number of observations required
precision interval (accuracy)
activity percentage estimate
4 ( 1 s2 P
N
p )
From this, it was determined that approximately sixteen
hundred observations had to be made to achieve the desired accuracy
and to avoid overlooking significant findings.
Consequently, an
intensive, four-week data collection period was necessarily appointed
to commence on February 2, 1976.
b.
Selection of Observation Times
In selecting clock times for this number of observations,
a stratified sampling was structured in a way so as to provide a
representative depiction of the typical work activity experienced in
the laboratory on an average workday, yet still satisfy the requirement of randomness in making these observations.
Based on the total number of observations, it was determined that sixteen sampling rounds per day had to be made.
Therefore,
48
one observation of each of the five technologists was made once
each half-hour of each hour, between 8:00A.M and 5:00P.M., Monday
through Friday.
In advance,
howeve~
a table of random numbers was
used to appoint the specific minute in which a particular observation
was to be taken for each half-hour time block.
(17:108-111)
It
should be noted that in an effort to avoid bias and to maintain
validity in sampling, "dummy" runs were made frequently throughout
the four weeks of observations so that the technologists being observed would not alter their behavior each time the observer
presented himself.
For such runs, the observer simply walked through
the work area, pretending to take and record observations, but not
actually making use of these in the final analysis.
c.
The Activity Observation Worksheet
The design of the activity observation worksheet that was
used in this work sampling is presented in Figure 4 (See page 49).
Both the nature and number of work and delay categories to be observed, as well as the number of subjects to be observed, were factors governing the degree of detail that was incorporated.
Generally,
the productive or non-productive status of the technologist's observed activity served as the point of reference that was used in the
breakdown of the fundamental work and delay categories.
At the same
time, the various subsidiary tasks were categorized and arranged as
technical, non-technical and ineffective along a time-of-day axis.
As such, the observation worksheet was used to portray overall proportions of time spent in the sixteen work and delay categories selected.
These work and delay categories were selected based
Activity Observation Work Sheet
I
PRODUCTIVE WORK
1 1
u
NON-PRODUCTIVE ACTIVITIES
Date
00
Observer
~0
"y'{)-
.o
~-q,
-.v'Y
~0-<,
TIME
INTERVALS
8:00-8:30
s: Tr=--9-:-oo
9:01--9:30
-9 :3 1--10 : 00
lO:UI-10:30
10:31-11: ou
~%
.j,'{)-
~~4,-<,0<$:-
'Y
~:>
-<..,.;;;
I
.()-'V
0
'Q00
'?"
'o-
0-<,
~0
::<::;0
.o
C)
-.v'Y
v-''?
0-'Y
<~.,_o'V
,..,_v
c?
~0
0--<,
«;-0~
t-::1
f-J·
00
c
'i
(1)
~
Tr: or=-rr:3o
n :Jr.:..-12: ou
12 : 0 1-12:30
T2 :Jl..: 1:00
-1:Ul=--E30
1:31--2:00
-2:01- 2:30
2T:rl- -JTOO
--:r:Gl- T:30
J:Jf:...- 4!00
4:01=- 4:30
4 :~r=-s:o-o
DAlLY
TOTALS
~
1.!:
~0
on the findings of the preliminary sampling that was conducted and in
consultation with the laboratory supervisor, director and the technologists themselves.
The gross work and delay activity categories
were appointed and defined as follows:
(1)
Operation of Automated Equipment - actual task
performance of automated testing procedures on
automated equipment;
(2)
Manual Testing (Routine and Esoteric) - nonautomated, manual activities necessary in the
conduct of manual methodologies;
(3)
Calculation and/or Recording Results - essential
clinical activity associated with the professional
determination and logging of test results;
(4)
Equipment Calibration/Maintenance - preventive
maintenance and start-up calibration or instrumentation activities using standards, controls and
other precision measuring devices done on either
scheduled or non-scheduled basis;
(5)
Telephone (Technical Consultation) - time spent
on the telephone interpreting tests results and
explaining methodologies;
(6)
Instructional Communication (Staff) - communication within and between technical staff members
of both an instructive and constructive nature;
(7)
Preparation of Work Area - every type of activity connected with setting up and organizing work
place;
(8)
Reagent Preparation - all tasks included in the
chemical preparation, stocking and handling of
useable reagents;
(9)
Transporting Materials - any activity associated
with the selection and transfer of materials such
as glassware and instruments from storage to the
work area or otherwise;
(10)
Clean-Up - all activities involving cleaning and
janatorial jobs necessary for maintaining sanitary
and neat working conditions;
~•mrmemmemrrrmarrrrtWT1fflr1ft"!W¥W:ZrtNtiiterttr~mr~r-~··~~!&~~~~~~~~·~~~~~miWO;J,;~'{~~~~~A~~--,.
:. ;_.-:-~""'~ .•. ~·~~-~.,,,_. __ ,.,~-'<·--~·~·-
51
(11)
Walking - walking in the laboratory without a
load or discernable purpose other than the
performance of work activity;
(12)
Talking - verbal communication which is social,
non-job related and not in the general line
of duty; and
(13)
Absent from Workplace - absence of any worker
from the laboratory work area, except for
illness or excused leave, including personal time.
By analyzing the utilization of time in this fashion, it
was possible to determine why non-productive activity was occurring
and to what extent it was occurring during the average "accepted"
workday.
Also, this examination provided a data base with which to
better define standard performance according to these work and delay
categories.
2.
Compilation of Performance Standards
Competence, in the industrial sense, is measured by the
time it should take to perform a job of known work content to a
standard level of quality using defined methods.
Known as "should-
take" times, these theoretical potentials can be used to designate
expected time allocations and ultimately to indicate how well actual
results compare with performance expectations.
The development and accurate specification of these
standards, however, require first that certain issues be resolved.
For example, in this study, capacity estimates had to be defined
in accordance with the present technical resources, and had to be
adjusted for the improvements inaugurated during the methods study
portion of this investigation.
Also, the patterns and distribution
of test request habits of client physicians had to be reviewed to
~
52
establish normal expected work loads.
Once resolved, however, study was begun in order to define
standard performance according to the utilization and delay knowledge
from the prior work sampling analysis.
a.
Expected Time Allocations
Expected time allocations were designed to portray how the
laboratory's technologist staff was expected to spend its time satisfactorily performing average diagnostic workloads.
Specifically,
these data reflect a ratio between the expected input of technologist
time for each unit of laboratory output, and are based upon the observed percentages of time spent on the various work and delay activities delineated by the prior work sampling analysis.
Furthermore,
since laboratory output was being measured in terms of relative value
units, these standard time data were thus expressed as "minutes per
relative value unit" and calculated using the following formula:
(Min 1
)
R.V.U
(%of time spent/ category) X (total man--hours) X (60 m:in/hr)
Total Relative Value Units Performed
In Table 1 (See page 53), expected time allocations were tabulated
according to the particular work and delay categories and shown in
Column Ill.
Normalized allocation data,
(i.e., observed time adjusted
to refle~t true normal pace) are displayed in Column #2 and were arrived at by applying an effort rating factor of 85 percent to the
observed time data in Column #1.
It should be pointed out that the
effort rating was based upon impressions and opinion of the observer
Table 1
Expected Time Allocation Data
fI'
I
WORK AND DELAY CATEGORIES
i
I
....:l
<:::
::_)
H
z::r::
u
w
~
MIN/R.V.U.
OBSERVED (l)
u
w
~
I
I
I
z
MIN / R . V. U .
STANUARD*i< ( 3)
Operation of Automated Equipment
0.31
0.264
0.295
Manual Testing (Routine & Esoteric)
Calculation &/or Recording Results
Equipment Calibration/Maintenance
Telephone (Technical Consultation)
Instructional Communication (Staff)
Pre2aration of Work Area
0.36
0.11
0. 12
0.06
0.03
o.o2
0.306
0.094
0.102
0.051
0.026
0. 01/
0.343
o. 105
0.114
0.057
0 .029
0.019
1. 01
0.860
0.963
0.09
0.05
O.Ot)
0.071
0.043
0.068
0.086
0.048
0 .076
0.22
0.188
0.210
0.10
0.12
0.16
0.07
0.0t)5
0.136
0.136
0.059
0.095
0.114
0.152
0.066
0.45
0.3(j2
0.427
1. 68
1.428
1.600
TOTAL TECHNICAL
:::r::
MIN/R.V.U.
NORMAL* (2)
ReaRent Preparation
Transporting Materials
Clean-Up
0
z
w
:>
H
~
I u
>::::1
f;L.
f;L.
w
z
H
TOTAL NON-TECHNICAL
Walking
Talking
Idle
Absent from Workplace
TOTAL INEFFECTIVE
GRAND TOTALS
~-
*Normal times calculated by applying an effort rating of t)5% to the observed times;
**Standard times calculated by applying a 12% total allowance for personal, fatigue and delay factors;
l
I
I
I
I
l
V1
w
54
in conducting the work sampling analysis, and also the democratic
admissions of the technologists themselves.
Finally, in order to make these performance data more realistic and complete, standard expected time estimates for each category werercalculated by applying a 12 percent total allowance for
personal, fatigue and unintentional delay considerations, and shown
in Column #3.
Together, these expected time allocations were thus a depiction of standard performance or performance as it should be.
As
such, therefore, it was felt that these data could be used as a means
of determining the reasonableness of present and future staffing,
while also providing obvious criteria against which to evaluate technologist performance.
b.
Performance and Productivity Indices
Knowledge of the state and level of performance of the
laboratory technologists can be effectively monitored by utilizing
certain performance and productivity evaluation indices.
For example,
one indicator that was used in this project compared the expected
total time associated with a given workload to the actual total time
spent for the performance of that particular workload over a specified
period of time.
This in index, or Performance Indicator, (P.I.) was
derived by the following equation:
(P.I.)
Actual total time
(Man-hours)
Expected total time (Man-hours)
X 100
Theoretically, realization of 100 percent should be considered standard performance, while anything less represents substan-
::>5
dard performance.
Certainly, it would be desireable to achieve stan-
dard performance levels on a continuous basis in the laboratory, however, in reality, this is not always possible in such work situations
with variable workloads.
Likewise, another work index that was used to evaluate perfprmance in terms of productivity is called the Productivity Quotient
(P.Q.).
This index relates the average number of relative value units
(output) per unit of technologist time (input), and is expressed by
the following formula:
(P .Q.)
Total Relative Value Units
Total Number of Man-hours
It should be noted that proper interpretation of the values
obtained from these indices may be useful to indicate the possible.
presence of a problem with staffing, or to find fault within the
operation itself.
In any event, fluctuations should have an assigna-
ble reason or cause.
Therefore, the effectiveness of these devices
is dependent upon proficient translation on the part of management.
C.
Relative Value Assignments
A review of the available literature concerning the question
of choice of output measure as it relates to the needs of the clinical
laboratory revealed that a more descriptive measure for work load
sholid be devised, beyond that which was based on quantity alone. (14:
·665)
Furthermore, it was shown that a system consisting of weighted
unit scores or relative values is much more appropriate and accurate
for the reporting and analysis of laboratory production, and that
these purposes are best served when unit values are calculated for
Sb
the particular conditions as they exist for each specific laboratory.
(28:36)
With this in mind, the writer undertook the development of
a more s.ophisticated data gathering and reporting system which could
differentiate test loads in consideration of the following predetermined factors:
(1.) the total technologist time required,
(2) the
skill qualifications needed, and (3) the frequency of performance for
each procedure.
In the calculation of unit values, however, the most important of these factors was the amount of technologist time that was
required to perform a specific testing determination.
Based on the
standard time data compiled in the methods study aspect of this investigation, basic analysis times were established for selected procedures which comprised the greater part of the average daily diagnostic workload for the laboratory under study.
Also, for those pro-
cedures which could not be easily standardized, pVerage basic analysis
times were estimated from a number of individual timings of each of
the laboratory's technologists according to how many tests could be
performed per man-hour.
If a measurable
amount of time could be
saved by performing multiple determinations at one time, a second time
estimate was measured to reflect the effects of this "hatching" factor.
In weighting the factors of skill and frequency, arbitrary
arithmetical equival€nts were assigned to each procedure with respect
to prescribed formulae.
For example, simple tests that required very
little skill and which could be learned with a minimum of instruction
were given a value of between 0.3 and 0.6 equivalents.
Tests demand-
57
ing intermediate skill were assigned values between 0.7 and 1.0; the
higher the value assigned, the greater the skill required.
The frequency factors were weighted in accordance with the
following:
(1)
For less than 1 test per day, a factor of
1.0 was assigned.
(2)
For 1-2 tests per day, a factor of
0.9 was assigned.
(3)
For 3-10 tests per day, a factor of
0.8 was assigned.
(4)
For 11-12 tests per day, a factor of
0.7 was assigned.
(5)
For greater than 25 tests per day, a factor of
6.0 was assigned.
Thus the relative value assignments for each test were
calculated by the following:
Where:
tl
t2
T
T
and,
s
F
basic analysis time for one determination
basic analysis time for multiple determination
time factor
tl
+
t2
2
skill factor
frequency factor
Relative Value Assignment
=
(T) (S) (F)
In presenting a list of the diagnostic procedures with
their realtive value assignments, the tests were categorized according to thedepartmentwhere they are performed.
Table 2 (See page 58)
is a compilation of the various tests performed by the Hematology
department of the laboratory.
Unit values range from 1.25, for a
hemoglobin determination, to 10.00 for a sickle cell electrophoresis.
58
Table 2
Relative Value Assignments for Hematology·
TEST
COD.!'.: NO.
RELATIVE VALUES
COMPLETE BLOOD COUNT
85010
3.25
DIFFERENTIAL COUNT
85040
l. 25
HEMOGLOBIN
85050
l. L.S
HEMATOCRIT
85055
l. L.5
EOSINOPHIL COUNT
85330
3.L.5
ERYTHROCYTE COUNT
~50L.O
2.50
RETICULOCYTE COUNT
85640
2./5
PLATELET COUNT
85580
3.00
SEDIMENTATION RATE (E.S.R.)
85650
L..5o
PROTHROMBIN TIME
85610
J.OO
SICKL.l'.: CELL (SCREEN)
<;5660
3.50
SICKLE CELL (ELECTROPHORESIS)
99200
10.00
RH ANTIBODY TITER
8602')
7.00
RH FACTOR
86100
J.OO
BLOOD TYPING: A, B, 0
~601)0
3.00
TYPING AND RH FACTOR
8601)5
5.50
L. E. CELL EXAMINATION
863~0
7.00
LEUKOCYTE COUNT, TOTAL (WBC)
~;50JO
l. 25
RED CELL INDIC.!'.:S
85020
2.00
MALARIA SMEAR
87000
6.00
PROTHROMBIN TIME
8.':>610
3.00
FIBRINOGEN
~5375
5.50
59
Tests performed in the biochemistry department are displayed
in Table 3 (See page 60).
Relative values range from 2.00 for a
serum glucose determination, to 15.00 for a test used to detect antinuclear antibodies.
Table 4 (See page 61) lists the tests carried out by the
microbiology department.
One can readily notice that unit values for
these tests are generally higher than unit value assignments in most
other departments.
In fact, the average relative value assignment
in microbiology was almost 7.25 for the entire list of tests performed.
Finally, tests performed in both the serology and urinalysis
areas of the laboratory are listed in Table 5 (See page 62).
Here,
a basic urinalysis is rated a 2.00 value, while a serological test
called a flourescent treponema! antibody (FTA) is assigned a 15.00
value.
Development of these relative value assignments made it
possible to thus express workload in terms of total numbers of
relative value units, instead of just a simple tally of.numbers of
procedures, arrived at by taking the raw count of each test type
multiplied by the unit value assignment.
bO
Table 3
Relative Value Assignments for Biochemistry
TEST
ACID PHOSPHATASE
ALKALINE PHOSPHATASE
ALBUMIN (SERUM)
AMYLASE
ANTI-NUCLEAR ANTIBODIES (ANA)
AUSTRALIAN ANTIGEN (HAA)
BILIRUBIN (TOTAL)
BILIRUBIN (TOTAL AND DIKECT)
BLOOD UREA NITROGEN (BUN)
CALCIMU (SERUM)
CALCIUM (URINE)
CHLORIDES (SERUM)
CHLOKIDES (URINE)
CHOLESTEROL (TOTAL)
CHOLESTEROL (TOTAL AND ESTEKS)
CREATINE PHOSPHOKINASE (CPK)
CKEATININE CLEARANCE
CREATININE (SERUM)
CREATININE (URINE)
FKEE THYROXINE
GLOBULIN
GLUCOSE (SERUM)
GLUCOSE (URINE)
CLUTAMIC OXALACETIC TRANSAMINASE
GLUTAMIC PYRUVIC TKANSAMINASE
HYDROXYBUTYRIC DEHYDROGENASE
IRON (TOTAL SERUM)
IRON AND IKON-BINDING CAPACITY
LACTIC DEHYDROGENASE (LDH)
LIPASE
LIPIDS (TOTAL)
LIPOPROTEINS (ELECTROPHORESIS)
LITHIUM (SERUM)
LITHIUM (URINE)
MAGNESIUM (SERUM)
MAGNESIUM (URINE)
PHOSPHORUS (SERUM)
PHOSPHORUS (URINE)
PROTEIN BOUND IODINE (PBI)
PROTEIN (ELECTROPHORESIS)
POTASSIUM (SERUM)
POTASSIUM (URINE)
SODIUM (SERUM)
POTASSIUM (URINE)
THYROID AUTO-ANTIBODIES
TRIGLYCERIDES
URIC ACID (SERUM)
URIC ACID (UKINE)
CODE NO.
84060
84075
82040
82150
86050
99200
~22.)0
8L255
84520
82310
82340
82435
82445
~2465
82470
82.':>50
~2515
8'2565
82570
~3460
9Y200
84330
84365
844.':>0
84460
82110
~3540
84550
83625
(13690
83700
83715
83725
83728
83735
(14100
84105
83420
~4165
84140
84145
(142~5
84300
86370
8447.':>
84550
85560
85565
RELATIVE VALUES
4.25
2.50
2.00
3.00
15.00
8.25
3.50
4.00
2.25
2.50
3.0U
2.25
3.00
'2.7.':>
6.00
5.25
10.00
3.00
3.50
11.00
'2.00
2.00
3.00
2.50
2 • .)0
6.25
.).50
11.00
4.75
5.50
6.00
13.25
.).50
6.00
5.50
b.Ou
2.'25
3.00
3.25
11.00
'2.50
3.25
2.50
3.25
15. oo
5.50
2.00
3.uo
61
Table 4
Relative Value Assignments for Microbiology
TEST
CODE NO.
RELATIVE VALUES
CULTURE WITH IDENTIFICATION:
87050
10.50
~70YO
8.25
FUNGUS
~70b0
6.75
GONOCOCCUS
87190
.).50
SPUTUM
87085
10.50
~70~0
4.25
URINE
8/180
8.00
OVA AND PARASITES (FECES)
~7013
8.00
ROUTINE CULTURE AND SESITIV.
87095
10.50
GRAM STAIN
8700U
3.:L5
OCCULT BLOOD
82:.00
3.50
PINWORM (SLIDE)
~7025
3.25
TRICHOMONADS, WET MOUNT
87010
2.50
MONILIA (CANDIDA ALBlCANS)
87015
8.00
SEMEN ANALYSIS
~9320
1.).00
ACID - FAST (TH CULTURE)
~7100
lU.OU
ACID - FAST (TB SMEAR)
87020
3.25
BLOOD
BACTERIOLOGIC
~CREEN
THROAT (BETA STREP.
~CREEN)
b2
Table 5
Relative value Assignments for Serology and Urinalysis
TEST
CODE NO.
RELATIVE VALUES
ADDIS COUNT
81030
4.25
C - REACTIVE PROTEIN
~6140
3.l5
COOMBS TEST DIRECT
~6250
3.00
COOMBS TEST, INDIRECT
86l60
4.00
ANTISTREPTOLYSIN "0" TITER
~6060
6.00
HETEROPHILE AGGLUTINATiONS
86300
4.50
RUBELLA ANTIBODY
86394
~.ou
RHEUMATOID FACTOR (RA)
86360
3.50
VDRL (QUALITATIVE)
~6410
2.50
VDRL (QUANTITATIVE)
~64l0
5.00
URINALYSIS (COMPLETE)
81000
2.00
PREGNANCY TEST (URINE IMMUNO)
~3160
5.00
PORPHYRINS,
84120
5.L5
~4580
5.25
FEBRILE AGGUTINATIONS GROUP
o6010
15.00
FLUORESCENT TREPONEMAL ANTIBODY
86650
15.00
RM~DOM
UROBILI~OGENS,
(RANDOM)
Chapter 4
KESULTS ANU DISCUSSION OF FINDINGS
For purposes of analysis and discussion of findings,
study data were organized according to the following areas of concern:
1.
Uata Related to Process:
Refers to data
collected in the method study aspect of this
investigation which was associated with the
examination and standardization of the basic
work content contained within the methods
and process of laboratory operations.
2.
Data Related to Effort:
Refer~ to data
resulting from the work sampling analysis
which was used to profile the effective
utilization of the resources of time and
skill as displayed by the technologist
staff in the performance of normal diagnostic
workloads.
J.
Data Kelated to ~ffect:
Refers to data
used in the establishment of performance
criteria and its application in evaluating the productivity and effectivity of
the technologists' work efforts.
Most important, in reviewing these data, one should keep
in mind that the central aim of this project was to demonstrate
the application of work study methods to a clinical laboratory work
setting.
Consequently, emphasis was placed on the methodology of
this investigation rather than on its findings.
I.
Data Related to Process
The writer felt from the onset of the project that·it
would be of no use whatsoever to improve the work methods of the
63
64
technologists and/or the layout of their workplace (possibly saving
a minute here and a minute there) while hours were lost due to improper working conditions.
Therefore, the first task of the method study
phase was to investigate any faults that existed in the prevailing
work conditions.
From this inspection it was determined, for example, that
the lighting was insufficient in certain areas of the laboratory,
causing unnecessary eye strain to the technologists, especially in
the conduct of precision work.
Conversely, in other areas, the
brightness of the incadescent lighting was too intense, thereby producing undesireable glare and shadows.
Therefore, flourescent light-
ing was installed in these areas, and windows were added or modified
to permit the entrance of a suitable amount of natural light.
Similarly, a problem was discovered concerning the ventilation of air and the elmination of fumes and odors in the workplace.
Although the effective temperature of the ambient air was itself
usually at a comfortable level, circulation and filtration of the air
was inconsistent.
Moreover, fumes and odors permeated the laboratory
bench areas at times rather than being properly expelled.
As a re-
sult, it became necessary to purchase a larger and moreeffective air
conditioning system and to install an additional vent over the reagent-preparation work area.
A third major area in need of improvement with respect to
laboratory conditions concerned the house-keeping practices of the
I
technologist.
Both the obvious lack of tidiness, particularly in
the bench areas, and the cluttered aisles within the workplace caused
65
saftey hazards and a significant reduction in operatfugefficiency.
Consequently, a considerable amount of remodeling of the physical
plant was ordered along with the reorganization and relocation of
equipment.
Also, additional storage space was arranged permitting
the removal of certain supplies, reagents, glassware and specimen
collection nutrients that previously had been stored in and around
the bench areas.
A number of other changes and improvements were made as a
result of the method study investigation, some of which produced
measureable results, while others were intangible.
Careful study
of the testing methods that were being used at the time indicated
the need for introducing more automation into the work system.
Also,
it was found that a number of operations could be eliminated entirely
or that one operation could frequently be combined with another.
For
instance, in constructing the work process chart with which to analyze the method used in the performance of a white blood cell count,
several steps were modified in this manner, resulting in greater
technologist efficiency.
As shown in Figure 1 (see page 42), the
individual elements of the method and their sequence of performance
were identified along with the required time for each.
However, it
should be pointed out that because of the large number of different
tests performed by the laboratory, work process analyses were completed only on those tests most commonly requested, not the entire.
complement of tests provided.
Still, a great deal of data was ac-
cumulated, although only the above-mentioned example is included in
this report.
66
Once the repetitive work procedures had been standardized
as much as possible and the most preferred and efficient procedures
installed, the design of the overall operation itself was analyzed
for maximum utility of space, ease of operation and safety. Figure 2
(see page 43) presents a flow diagram of the basic functions involved
in the total operation.
Included are the functions of specimen
collection, processing, reporting and billing.
Figure 3 (see page 44)
presents a more detailed portrayal of the events which take place
during the processing of a typical patient specimen within the laboratory.
Such graphical representation of work and data flow made it
possible to review the paths of movement and specific routes taken
in the transmission of specimens and test results.
ling of patient specimens
Insodoing, hand-
was minimized as much as possible, and
the amount of paperwork required was also reduced.
This was due
primarily to a new test request form which was designed to allow
easier entry of test
requests, and which eventually led to a better
flow of specimens, and fewer clerical errors.
II.
Data Related to
~ffort
ln order to quantitatively audit the performance behavior
of the technologist staff, a work sampling study was conducted to
provide basic information regarding how the technologist staff normally spent its time in the conduct of work activity.
Once the sam-
pling observations had been made and recorded, percentages of time
spent in various activity and delay categories were calculated.
A
summary of these results is presented in Table 6 (see page 67).
Subsequent analysis of these results demonstrated that of
Table 6
Distribution of Work Sampling Observation Data
r;-·
WORK AND DELAY CATEGORIES
II OF
OBSERVATIONS
% OF
TIME SPENT
AVE. LAB.
MAN/HOUR
*'
MIN/R. V. P.
2:19
340
101
113
60
28
15
1?:J. 7?:l
21.36
6.34
I .10
1. 76
0.94
0.94
11.2 7
12.82
3.80
4.:2.6
1. 06
0.56
0.56
0.31
0.36
0.11
0.12
0.06
0.03
0.02
TOTAL TECHNICAL
Y56
60.05
36.03
1. 01
::c
Reagent Preparation
86
~
·~rans . . . orting ~-faterials
so
Clean-Up
76
5.40
j .14
4. 77
3.:2.4
1. 88
:2..86
0.09
0.05
u.08
:2.12
13.31
7.98
O.L2
Walking
Talking
_Mle
Absent From Workplace
96
112
149
67
6.03
/.04
9.36
4.21
3.62
4.22
.':>.6:2.
2.53
0.10
0.12
0.16
0.07
TOTAL INEFFECTIVE
424
:2.6.64
15.99
0.45
1592
100.0U
60.00
1. 68
.....<
<t1
u
H
§§
u
~
~
Operation of Automated Equipment
Manual Testing (Routine & Esoteric)
Calculation &/or Recording Results
Equipment Calibration/Maintenance
Telephone (Technical Consultation)
Instructional Communication (Staff)
Preparation of Work Area
f--·
I
f--
u
H
I
z0
z;
~
::>
H
H
u
::t:l
fJ:.<
fJ:.<
::t:l
zH
TOTAL NUN-TECHNICAL
GRAND TOTALS
*Average time spent on a work and delay category per relative value unit calculated by:
(%of time Spent/Category) X ~Total ManHours) X (60 Min/Hr) I Total Number Relative Value Units Performed
I
I
I
0\
-....J
68
1600 observations made:
(1) three-fifths (60.50%) were associated
with technical activities;
(2) one-seventh (13.31%) were classified
as non-technical in nature: and (3) more than one-iourth (26.64%) of
the observations were attributed to ineffective activity or idleness.
When these gross "work and delay" results were used to
depict a composite average laboratory man-hour, it was shown that
sixteen minutes per hour were ineffectively spent, while almost eight
minutes per hour were devoted to non-technical functions.
Together,
one can conclude that 24 minutes (40%) of the average laboratory manhour were lost to activities which might have been more suitably
performed by para-technical personnel or which ideally should not
have occurred at all.
In addition, the average amount of observed time applied to
the average unit of output (expressed as "Minutes/Relative Value Unit')
was calculated for each of the work and delay categories.
From this,
it was estimated that over one and two-thirds total minutes were
needed in performing a single relative value unit.
Cyclic variations and work patterns associated with the
distribution of workload and technological performance were revealed
by an hourly activity graph which is presented in Figure 5 (see page
b9).
Several important facts were brought out by this analysis.
For example, a wide range of variations in total workload seemed to
have created peak periods of activity to occur during the hours of
10:00 A.M. and 1L:00 P.M., and between l:OO P.M. and 4:00P.M. in
the afternoon.
Conversely, light losds were observed especially be-
tween noon and 2:00P.M. and also between 4:00 P.M. and 5:00 P.M. at
Figure 5
Hourly Activity Graph
100 -1--------~------~--~---.-------,-------,------,-------:r------~------
I
I
I
-
I
75 -
I
/'\...
I
/'
I
I
I
I
A
I
E
w
;:E:
H
H
IZ<
0
H
z::.J
50 -
u
~
::.J
~
:zs
0 - I
8:00
P R
pD U C T f V ~
I
~
12:00
1:00
I
P R0
9U C T I f E
\
~:OU
10:00
11:00
L:OO
3:00
4:00
j:OO
AFTEKNOON
MORNING
TIME OF DAY
o\0
70
the end of the workday.
Subsequently, it ~as determined that this
rather unbalanced work schedule was due directly or indirectly to:
(1) the improper scheduling of personnel,
load,
(2) the assignment of work-
(3) lax controls and supervision, and (4) sporatic and irregular
receipt of patient specimens.
The latter was the factor most respon-
sible for the fluctuations in workload; as a result, a more continuous
arrangement of courrier pick-up times was established to allow specimens to be brought in more frequently and at appointed times.
Another important situational factor that contributed to the
high incidence of observations related to ineffective activity was the
"feast-or-famine" character associated with the availability of manpower in the laboratory.
to render
Consequently, a coordinate plan was designed
a more balanced use of the technical staff, and to provide
measures needed to control the excessive and unnecessary technologist
coverage that existed at certain times during the workday.
Previous-
ly these objectives had been hampered by the lack of adequate definition of laboratory workloads and capacity estimates.
However, it was
now possible to quite accurately plan for and assign workloads, and
to schedule the required personnel.
Furthermore, rotation of job assignments as well as work
hours was attempted in an effort to make the delegation of work tasks
more equitable and the scheduling of workloads more compatible with
the abilities and composition of the available work force for the
particular time of day.
Job descriptions were reviewed and revised
as necessary,and additional training was made available to those who
needed it.
In as much as this action resulted in broader technical
71
abilities for the individual technologists, greater depth and total
flexibility in the use of these personnel was also afforded.
III.
Data Related to Effect
Prior to the initiation of this study, productivity data
had been maintained by the laboratory's supervisor based on historical
information and quantity alone.
Variations in total work load and
in the mix of tests requested thus affected the reliability of any
subsequent performance evaluations.
Therefore, a weighted system of assigned relative values
was developed so that total laboratory workload could be more accurate
depicted.
fn Table 7 (See page 72), the total laboratory workload for
a three-month period (February - April, 1976 is compiled by functional
area.
Totals are given for both the number of tests as well as the
number of relative value units performed during this period of time.
Notably, a comparison of percentages of totals for each functional
area show a considerable number of differences, particularly in the
microbiology and serology/urinalysis laboratory areas.
These probab-
ly resulted from the different weighting factors that were applied to
indicate the greater or lesser degree of skill and complexity involved
in tests associated with these departments respectively.
Relative value units were,also used to evaluate individual
technologist performance.
As an example, Table 8 (See page 72) shows
a performance summary for the month of February, 1976, in which the
five-man technologist staff performed a total of 28,015.65 relative
value units based on an input of 783 man-hours.
The average time
spent per relative value unit in toto amounted to 1.68 minutes.
.......--
Table 7
Laboratory Workload (By Functional Area) February - April, 1976
L A B0 RAT 0
HEMATOLOGY
Y
F UNC
BIOCHt:MISTRY
~
I 0 NAL
A R E A
MICROBIOLOGY
SEROLOGY/URINALYS
IITES~S
R. V.U.
IITESTS
11,396.25
1245
7,119.25
1460
2933
11,204.05
1190
7,044.80
5,:L48.60
3216
10,741.45
1148
16,3:!5.65
9188
33,341.75
3583
20%
42%
//TESTS
R.V.U.
//TESTS
WEBKUARY
1772
5,688.15
3039
MAtzCH
156SI
5,3~8.SIO
~PRIL
1610
rroTALS
4951
% OF
rroTALS
2L%
MONTH
K
R.V.U.
41%
16%
//TESTS
R.V.U.
3,212.00
7516
28,015.6.J
1302
3,38.J.2U
6SJ94
2l,OL2.95
6,38:::.85
1581
4,347.75
75.J5
:!6,120.65
21,146.90
4343
10,944.Y5
22,065
81,7.J9.L5
U%
100%
26%
20%
R.V.U.
TOTALS
100%
I
"'-l
N
Table 8
Individual Monthly Performance Summary (February, 1976)
TECHNOLOGIST
MANHOURS WORKED
It OF TESTS
A
156
152tl
56U3. 10
l. 67
B
151
l2i:l3
487tl.8~
l. tl6
c
160
b96
5940.00
1. 62
D
155
1549
53.J8.LO
l. 7 4
E
161
1560
6235.50
l. 55
TOTAL
783
7516
L8,U15.65
1.68
It OF R. V. U.
MIN/R.v.U.
*
I
--
*
Average time. spent per relative value unit per technologist calculated by:
(Total ManHours Worked) X (60 Min/Hour)
Total 1f Relative Value Units Performed
"'-J
w
74
Average individual time spent per relative value unit per technologist
ranged from 1.86 minutes per relative value unit to 1.55 minutes per
relative value unit.
In interpreting these data, however, it should be kept in
mind that it may not be entirely accurate to infer that one worker was
more productive than another in light of the dissimilarities in the
mix of physician test requests and the resulting workload assignments.
Moreover, even though relative value units can be helpful in overcorning these differences, nevertheless, the limitations of such comparisons at this level must be acknowledged.
This should not detract
from their usefulness as a simPle running check on technologist productivity, provided that these comparative data are collaborated with
other such indicators.
On the other hand, this same kind of analysis applied on a
mass basis can yield a very reliable indication of the general performance of a total operation.
Table 9 (See page 75) presents per-
formance and productivity data that were compiled during the period of
the work sampling analysis and the following two months of March and
April.
Typically, recovery of data was done on a weekly basis, and
included the input of man-hours, and output expressed in terms of
numbers of test and numbers of relative value units performed.
Of
particular interest is the amount of time which was spent per unit of
output, as well as the Performance Indicator (P.I.), and Productivity
Quotient (P.Q.).
Figures for the average minutes per relative value unit
showed a gradual decreasing trend during the time period, while the
Table 9
Performance and Productivity Data
February - April, 1976
WEEK
MAN-HOURS
NUMBER OF TESTS
NUMBER OF R. V. U.
MIN./R. V. U.
p. I.
P.Q.
1
198
2029
6702.85
1.77
75.04
33.85
2
196
1886
7081.35
1. 66
80.08
36.13
3
193
1791
6770.95
1.71
77.77
35.08
4
197
1810
7460.50
1.58
83.95
37.87
5
190
1822
7256.00
1. 57
84.65
38.19
6
183
1690
7175.25
1.53
86.91
39.21
7
186
1738
7489.90
1. 49
89.26
40.27
8
178
1634
7265.30
1. 4 7
90.48
40.82
9
175
1733
6939.00
1.51
94.73
39.65
10
177
2082
7478.90
1.42
93.66
42.25
11
181
1973
7337.90
1.42
89.87
40.54
12
173
1767
7200. so
1.44
92.26
41.62
13
168
1915
7411.75
1.36
97.79
44.12
I
!
---
-
-----
~-----
------------
'-J
li1
76
Performance lndicator \P. I.) and the Productivity Quotient (P. Q.)
showed a gradual increasing trend.
Specifically, minutes per relative
value unit were reduced by almost one-fourth, as nearly a half a minute per relative value unit appeared to have been recaptured and
hopefully redirected towards productive use.
lt was thought that a
better interfacing of staff capabilities with the demands of betterdefined workloads was most responsible for this increase in work
effectiveness.
In comparing the expected total man-hours to the actual
total man-hours consumed for the specified workloads, the Performance Indicator (P.I.) increased from approximately 75 percent for
the first week of this time period to almost 98 percent for the final
week of this time period.
It must be pointed out that the expected
man-hour calculations were based on an expected input of 1.33 minutes
per relative value unit which was thought to be a reasonable performance goal for the technologists to strive for under the circumstances
and conditions that had prevailed during this period of time.
Table 1 (.see page 53) depicts standard technologist performance in terms of expected time allocations, and shows that only
approximately one minute per relative value unit as being associated
with tasks of a technical nature.
Therefore, the writer estimated
that one-third of a minute, of the total one and two-third minutes
depicted for each relative value unit, might realistically be converted to effective and hence more productive use.
Finally, one of the most important results of this work
study investigation was expressed in the form of a gain in laboratory
77
productivity for this three month period.
As shown in Table 9 (see
page 73 ), productivity, measured in terms of the Productivity Quotient (P.Q.), showed an increase amounting to 3U percent.
Obviously,
there was a great deal of satisfaction felt as a result of this
achievement.
Chapter 5
SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS
A summary of this report, conclusions derived from the
findings of the project and final recommendations are presented in
this chapter.
I.
Summary
The central aim of this project was to investigate the gen-
eral applicability of industrial work study methods to a clinical
laboratory work setting.
Specifically, this project dealt with the
problem of determining to what extent, if any, such methods could be
used to:
1.
standardize the basic work content contained
within the methods and the process of laboratory
operations;
2.
profile the effective utilization of time and skill
as displayed by a staff of clinical laboratory
technologists in the performance of normal diagnostic
workloads; and
3.
establish reliable performance criteria against
which to evaluate the productivity and effectivity
of technologists' work efforts.
Also, this project considered the question of choice of
output measures and their use in assessing the laboratory workloads
and in the calculation of laboratory productivity.
Based upon a
review of available literature pertaining to this general subject,
a number of preceptive generalizations were revealed.
For example, concerning the question of choice of output
measure, researchers generally agreed that a more descriptive measure
78
79
needed to be devised, beyond that which is based on quantity alone.
(28:36)
It was shown that a system of weighted unit scores was more
appropriate and accurate for use in the reporting and analysis of
laboratory production, and that these purposes are best served when
unit values were calculated for the specific conditions and circumstances that exist in each particular laboratory.
(5:117)
Regarding the application of work study methods to workload
and performance evaluations, there was strong evidence that the work
measurement technique of work sampling could be quite useful in
determining
laborator~
work standards and productivity expectations.
Also, the industrial engineering principles of methods analysis and
work simplification were shown to be readily adaptable to a clinical
laboratory work setting.
(2:123)
With this in mind, therefore,a proprietary, non-hospital,
clinical laboratory was chosen as the setting of this project in order
to
de~onstrate
the applicability of work study methods to the clinical
laboratory, and to focus on their utility in evaluating technologist
productivity.
To provide information regarding how a technologist staff
should normally spend its time in the conduct of work activity, a work
sampling study was conducted.
Some sixteen-hundred random observations
were made of the five-man technologist work force and percentages of
time spent on various pre-defined work and delay activity categories
were determined.
Analysis of these results demonstrated that:
(1) 60
percent of the observations were associated with technical activities;
(2) one out of seven observations was classified as non-technical in
80
nature; and (3) more than one-fourth of the observations were attributed to ineffective activity or idleness.
When these results were
used to depict a composite average laboratory man-hour, 24 minutes
were shown to have been lost to activities which might have been
more suitably performed by para-technical personnel, or which ideally
should not have occurred at all.
Guided by this information, the
writer was able to determine why non-productive activity was occurring
and to what extent it was occurring.
The work measurement aspect of the study, however, was preceeded by a method study of the laboratory to confirm that conditions
and work methods were, in fact, right for the creation of technologist
performance standards.
Specifically, this method study was performed
to verify the quality of the work conditions that prevailed and to
examine the efficiencies of the work methods as they existed.
Setting
the best conditions and preferred work methods as standard practice
automatically generated the degree of uniformity of environmental
stability that was needed to make work measurement feasible.
It also
helped to specify definitive sources of inefficiency that were cause
for concern and in need of improvement.
Subsequently, performance expectations were outlined according to expected time allocations for each unit of output.
In order to
more accurately express output, however, a schedule of relative value
assignments for each test performed by the laboratory was necessarily
developed.
As such, these relative values were calculated in consider-
ation of the following predetermined factors:
gist time required,
(1) the total technolo-
(2) the skill qualifications needed, and (3) the
81
frequency of performance for each procedure.
Therefore, using
rela~
tive value units as the measure of laboratory output, standard time
data were expressed as "minutes per relative value unit" and were
arrived at by "normalizing" observed allocation data to reflect true
pace and effort.
These normalized allocation data, in turn, were
adjusted for personal, fatigue and unintentional delay considerations.
Thus, standard performance (i.e., performance as it should be) was
statistically defined and provided criteria against which to evaluate
technologist performance.
Finally, knowledge of the state and level of technologist
performance was afforded by utilizing certain performance and productivity indices.
A Performance Indicator (P.I.) was used to relate the
expected total time associated with a given workload to the actual
total time spent for the performance of that particular workload.
Likewise, a Productivity Quotient (P.Q.) was used to evaluate performance as an expression of productivity, and as such related the average number of relative value units (output) per unit of technologist
time (input).
Notably, a gain in productivity measured over a three-
month period amounted to approximately 30 percent.
II.
Conclusions
It can be said that the methodological and scientific ap-
proach conceptualized in the theme of work study offers a significant
control mechanism to clinical laboratory administrators which heretofore has not been adopted to any great extent.
Indeed, the process of laboratory work activities are, for
the most part, identifiable and standardizable and therefore
subject
to analysis using work study methods.
Furthermore, work study methods
and their application to a clinical laboratory work setting,as demonstrated in this investigation, proved to be of a workable nature and
generated a significant amount of reliable data useful in the assessment of laboratory workloads and employee activity.
Benefits from the
findings of this investigation included possibilities for improving
the distribution of professional capabilities in the laboratory, focusing on a more expeditious use of the limited resource of technologist
time.
Also, it appeared that a sense of proportion was added in
the distribution of workload requirements by employing a mediated work
unit measure for output.
Consequently, the interfacing of workloads
with manpower capabilities was enhanced, since there was no longer a
lack of adequate definition of these two laboratory variables.
Therefore, it is concluded that the total evaluative scheme
outlined in this investigation can, in fact, be used to effectively
measure and control the accomplishments of labor in a clinical laboratory work setting.
In proper perspective, one must recognize that
this is not meant to imply that this scheme is complete or absolute.
On the contrary, continued verification and revision may prove to be
necessary.
III.
Recommendations
Since manpower utilization constitutes a critical element
in the administration of health services, there must be a continued
determination and recovery of information pertaining to ways in which
to produce the same output of benefit and results with less expendi-
83
ures of time and money.
To facilitate this objective, it is hoped that the communication gap that exists between health services administrators and industrial engineers be bridged so that modern theories associated with
working administrative systems can be converted to practice.
Finally, it is recommended that further study be conducted,
in collaboration with other disciplines, giving special attention to
the development of additional worthwhile applications of work study
methods to the health care field.
84
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85
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