CME/SAM. Time Study of Clinical and Nonclinical Workload in Pathology and Laboratory Medicine

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1 Time Study of Clinical and Nonclinical Workload in Pathology and Laboratory Medicine Martin J. Trotter, MD, PhD, 1,2 Erik T. Larsen, MD, 1,2 Nicholas Tait, CMA, MSA, 3 and James R. Wright, Jr, MD, PhD 1,2 Key Words: Workload; Time study; Personal digital assistant Upon completion of this activity you will be able to: develop a continuous self-reporting mechanism to assist with laboratory workload and staffing allocations. list major categories of work in pathology and laboratory medicine. compare time spent in each category among laboratory medicine subspecialties. The ASCP is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The ASCP designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit per article. This activity qualifies as an American Board of Pathology Maintenance of Certification Part II Self-Assessment Module. The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose. Questions appear on p 895. Exam is located at CME/SAM Abstract We describe a detailed, cross-sectional, selfreport time study of laboratory physician tasks in a regionalized, multisite academic setting, using custom data collection templates programmed into personal digital assistants (PDAs). The 7-week study was completed by 56 medical and scientific staff (86% participation rate). Participants recorded 12,781 PDA entries of specific tasks completed during the study period. The mean number of entries per worked day per participant was 8.14 (range, ). Study results demonstrated that professional staff worked, on average, 53.5 hours per week. Percentage work time spent in each activity area was as follows: clinical, direct, 50.6%; administration, 18.5%; clinical, indirect, 9.5%; research, 8.2%; learning/continuing education, 5.3%; teaching, 4.9%; and quality assurance, 3.1%. These percentages varied significantly by laboratory medicine subspecialty and by type of academic appointment. The findings confirm that activities not directly involved with patient care, such as administration, quality assurance, teaching, research, and professional development, typically occupy 40% to 50% of a laboratory physician s time. Measurement of physician workload is a required component of workforce planning, workload distribution, staff assessment, and resource allocation. A detailed understanding of workload supports excellent patient care, public accountability, and overall health services planning. However, physician workload measurement in complex medical practice is difficult, and most workload indices do not accurately reflect actual duties performed. In pathology and laboratory medicine, measurement of physician workload is most intuitive for anatomic pathology, where several direct measures of diagnostic work performed can be counted (eg, cases, specimens, slides, and blocks). Published workload recommendations most commonly use these counting methods, often with adjustment for case complexity. 1-6 Quantification of other laboratory physician responsibilities is more difficult, especially in academic settings and in laboratory medicine disciplines such as hematopathology, clinical chemistry, and microbiology, where patterns of work differ significantly from those in anatomic pathology In all disciplines, nonclinical contributions, such as research, teaching, and administration, are difficult components to measure and analyze. As part of professional staff workforce planning for a large, academic, regionalized, multisite laboratory, we undertook a detailed, cross-sectional, self-report time study of laboratory physician tasks during a 7-week period, using custom data collection templates programmed into personal digital assistants (PDAs). The aim of this study was to accurately document all tasks performed by laboratory physicians so that every important role, not just direct clinical responsibilities, could be incorporated into future workload allocation and workforce planning initiatives. Am J Clin Pathol 2009;131:

2 Trotter et al / Pa t h o l o g y Wo r k l o a d Ti m e St u d y Materials and Methods Calgary Laboratory Services (CLS; Calgary, Canada) is a regionalized laboratory with a consolidated service delivery model, both community-based and at 4 acute care hospital sites, serving approximately 2,000 regional physicians, an immediate population of 1.2 million, and a primary referral catchment area of another 0.6 million. Annual test volumes at the time of this study (2004) were as follows: chemistry, 10,697,872; hematology/transfusion medicine, 3,022,512; microbiology, 548,660; anatomic pathology, 313,602 blocks; and cytopathology, 214,619 specimens. CLS is affiliated with the University of Calgary Department of Pathology and Laboratory Medicine, and most laboratory medical and scientific staff have geographic full-time (GFT) or clinical university appointments and are involved in teaching and research endeavors. As part of a comprehensive 5-year workforce plan, we undertook a detailed, self-report time study of laboratory physician activities during a 7-week period (November 6-December 23, 2004). The scope of this workload study included all laboratory physicians (n = 59) and PhD scientist members of the professional staff (n = 6). Of the professional staff, 56 completed the entire 7-week study (86% participation rate), 1 dropped out during the study, 3 were on extended leave (eg, maternity, long-term disability, sabbatical), and 5 declined to participate in the study or their data were not of sufficient quality for inclusion. The study design was approved by the Conjoint Health Research Ethics Board, University of Calgary. All participants were provided with a handheld PDA programmed with custom templates for entering details of work activities (Social Sector Metrics, Calgary). Activity categories were: clinical, direct; clinical, indirect; quality assurance; teaching; research; and administration and learning. Customized templates were developed for anatomic pathology/cytopathology, general laboratory, clinical biochemistry, hematology/transfusion medicine, and microbiology. Details of these templates are shown in ztable 1z and ztable 2z. Cross-sectional time studies should be interpreted in the context of the period during which the study was conducted. Seasonal variables can have a significant impact on data and results. In this study, each participant was asked to complete a 1-page assessment to frame the time study in the context of an entire year. Of the assessments, 23 (41%) were completed and returned. As part of this contextual assessment, participants were also asked to specify key projects or major tasks that they were unable to initiate or complete during the time study period. These included, eg, professional development, research and development, grant proposal preparation, policy and procedure development, and initiation of new assays/protocols. Results The time study was undertaken from November 6 to December 23, 2004 (47 days). Participants were 56 physicians and scientists within 5 laboratory divisions: anatomic pathology and cytopathology, 37; general laboratory, 5; hematology and transfusion medicine, 5, including 2 clinician scientists with PhD degrees; clinical biochemistry, 5, including 4 clinician scientists with PhD degrees; and microbiology, 4. The study participants included 24 academic department members with GFT university appointments and 32 members with clinical university appointments. The GFT group held the majority of research and undergraduate teaching responsibilities. Both groups were responsible for postgraduate medical education (resident training). Medical and scientific staff recorded 12,781 entries of specific tasks completed during the 7-week study period. Excluding entries made during time on call, tasks totaling 976,991 minutes (16,283 hours) were recorded. The mean number of entries per worked day per participant was 8.14 (range, ). Study results demonstrated that professional staff worked, on average, 53.5 hours per week, ranging from 47.5 in clinical biochemistry to 62.5 hours per week in microbiology. Contextual assessment of the time study revealed 3 important findings ztable 3z and ztable 4z: (1) The teaching workload was below average owing to the time of year of the survey (November-December). (2) The clinical workload was average. (3) Owing to time required for accreditation review preparation, several key, planned priority activities or projects were not undertaken during the study period; these included professional development; research and development (grant proposal preparation and policy/procedure development); and initiation of new assays/protocols, optimization of accessioning at 1 hospital site, and reorganization of referral testing. The consensus that clinical workload was at average levels is supported by data shown in ztable 5z, indicating that the November-December workload varied between 0% and 6% above the mean 2004 workload. For purposes of data analysis, all tasks recorded during periods on call were separated from the balance of time distribution analysis. Formal on-call programs were provided for anatomic pathology, neuropathology, renal pathology, general laboratory, hematology/transfusion medicine, and microbiology. During the time study period, 612 entries were made recording on-call activities; however, only 197 entries were for specific on-call tasks. The remainder documented on-call hours. On-call tasks required total hours, with an average of 2.5 hours per day, for all on-call programs combined. Similarly, 145 leave-of-absence days (7.1% of total time recorded), including vacation (5.5%), travel time (0.9%), conference leave (0.4%), and sick time (0.3%), were excluded from the time distribution analysis of tasks performed during worked days. 760 Am J Clin Pathol 2009;131: Downloaded 760 from

3 The contribution of each major task category to overall worked time is shown for all laboratory medicine disciplines in ztable 6z. Clinical duties (direct and indirect) accounted for 60.1% of worked time, and administration (18.5%) was also a significant component. Task distribution differed depending on subspecialty Table 7z and on university appointment type (GFT vs clinical) ztable 8z. For direct clinical duties, 15% were performed while supervising a trainee (resident, fellow, or medical student). ztable 1z Matrix for Direct Clinical Activities Anatomic Pathology Hematology General Laboratory Chemistry Microbiology Surgical Pathology General Hematology Operations Consultations Regular Service Gross specimen examination Peripheral blood smears Surgical pathology CLS medical and scientific staff Review CCMM report Review OR list Bone marrow sign out Cytopathology Non-CLS physician Bench rounds Frozen section Hemoglobinopathy Hematology Technologist Review MBE Chart/DI review Flow cytometry Chemistry Clerical Medical consultation Sign out Transfusion medicine Allied health professional Notification of external Report verification Lymphoma sign out Patient programs Formal consults Data retrieval Electron microscopy Review of reports Immunofluorescence Outbreak management Image analysis Molecular test interpretation ER/PR interpretation Autopsy Pathology Tissue Typing Extraregional Reports On Call Chart review Physician inquiries Maternal serum screen On-call hours Performing autopsy Technologist inquiries Serum protein electrophoresis Call back to lab Supervising autopsy Reporting Toxicology Medical consult Specimen blocking Blood-borne pathogen Brain cut exposure consult Preliminary report Technical staff consults Slide review External program Final report support Formal consults Report verification Cytopathology Molecular Community Services, Correspondence Nongynecologic Physician inquiries Client Services, Colposcopic biopsies Technologist inquiries Point-of-Care Testing Papanicolaou smears Reporting Intraoperative consultation Formal consults Cytogenetics On Call On Call Specimen triage On-call hours On-call hours Analysis and interpretation Call back to lab Critical values Reporting and verification Test approval Test approval Formal consults Phone consultation Consultation PBS review Cytology specimen handling Bone marrow review Travel Flow cytometry review Cytology specimen handling Travel On Call On-call hours Call back to lab Nonproductive time Perform autopsy Supervise autopsy Frozen section Rush specimen Cytopathology rush Phone consultation CCMM, Cerner Command Menu Microbiology; CLS, Calgary Laboratory Services; DI, diagnostic imaging; ER, estrogen receptor; MBE, microbiology entry; OR, operating room; PBS, peripheral blood smear; PR, progesterone receptor. Am J Clin Pathol 2009;131:

4 Trotter et al / Pa t h o l o g y Wo r k l o a d Ti m e St u d y ztable 2z Matrix for Indirect Clinical and Nonclinical Activities Administration Clinical, Indirect Quality Assurance Teaching Research and Learning Consultation Preanalytic Residents/Fellows Administration CLS Lab physicians Troubleshooting Administration Project management Committee meetings Other physicians Projects Preparation Human resources Meetings with staff Technologists Teaching Budgets Policy review Clerical staff Examination Meetings Correspondence Allied health professionals Institute Research groups Scheduling Travel time (in city) Patients Second opinion Correspondence Analytic Medical Students Grant Preparation University Procedure review Same as above Peer-reviewed Committee meetings Quality control review Industry Meetings with staff Data troubleshooting Government Correspondence Projects Presubmission review Patient Care Postanalytic Graduate Students Personal Projects External Agencies Conference Proficiency testing review Same as above Benchtop National organizations or Rounds Performance indicator review Clinical Provincial organizations Reporting review/enhance Data management Vendor interactions Troubleshooting Statistical analysis Other Projects Projects Indirect Medical/Scientific Publication Preparation Leave Development Committee work (specific to QA) Staff Abstracts Travel time (out of city) Implementation Meetings (specific to QA) Same as above Peer-reviewed manuscripts Conferences Review Communications (specific to QA) Non peer-reviewed manuscripts Sick time Internal quality audits/initiatives Book chapters/reviews Vacation time Incident reports and reviews Technical reports Utilization initiatives Conference proceedings Accreditation Invited addresses Literature Review Operations Staff Professional Service Learning-Group Same as above Journal editor/reviewer Pathology rounds Grant application reviewer CME rounds Grant review committee Other department rounds Scientific advisory Teleconferences committee Journal clubs CLS, Calgary Laboratory Services; CME, continuing medical education; QA, quality assurance. External Business Development Learning-Individual Organizations Patents Journal Same as above Copyright Online Contracts/intellectual Certification review property Technology transfer ztable 3z Contextual Assessment of the Time Study Period Activity No. of Responses Individual Comments Undergraduate teaching 13 No undergraduate students at this time of year Postgraduate teaching 13 No new clinical fellows in laboratory; supervision lighter than usual owing to holidays Other (specify) 6 Research, grant writing/reviewing missed 2 Vacation Based on the period in which the time study was conducted, the identified cyclical key activities were largely or completely missed. 762 Am J Clin Pathol 2009;131: Downloaded 762 from

5 ztable 4z Contextual Assessment of the Time Study Period Based on the Study Period, the Following Key Activities Were Activity Lower Than Average About Average Busier Than Average Can t Say Regular clinical workload On-call clinical workload Other workload (specify) 6 (teaching/research) 1 3 (accreditation preparation) 0 4 (no grant deadlines) 0 2 (quality assurance reviews) 0 Individual comments are in italics. See additional comments in the Results and Discussion sections regarding poststudy contextual survey. ztable 5z Clinical Workload Volumes During the Time Study Mean Monthly Workload November/December November/December Mean November/December 2004 Discipline Increase Over Mean 2004 (%) Surgical pathology Specimens 11,800 12,270 11,750 4 Cases 6,900 8,572 8,300 3 Cytopathology Cases 17,000 20,000 18,800 6 Hematology Total tests 210, , ,500 2 Chemistry Total tests 730, , ,000 2 Microbiology Total tests 45,500 47,600 47,500 0 Discussion Understanding workload and specific tasks and duties of laboratory physicians is an important component of workforce planning and workload allocation. This cross-sectional, self-report time study provides detailed, quantitative information on activities of 56 laboratory medical and scientific staff during a 7-week period, with more than 16,000 hours of work recorded by using handheld PDAs. For all areas of the laboratory, but especially in the clinical pathology disciplines of general laboratory, clinical biochemistry, hematology and transfusion medicine, and microbiology, this approach provides unique insight into roles and responsibilities that are impossible to extrapolate from other metrics, such as test volumes. Time Distribution for All Medical and Scientific Staff The major categories of activity used in our study are similar to those used by the PathFocus Pathology Practice Activity and Staffing Program offered by the College of American Pathologists: (1) surgical pathology, (2) cytopathology, (3) autopsy pathology, (4) clinical pathology consultation/interpretation, (5) administration and management, (6) miscellaneous, (7) professional development, (8) teaching/ training, and (9) research. 11 Time away from practice (leave of absence) is by far the greatest contributor to the miscellaneous category. CLS is a large, regionalized, laboratory model resulting from the consolidation of university hospitals, teaching hospitals, and independent laboratories; thus, our time study results are best compared with the mean values for all group practice categories in the PathFocus survey. This comparison is shown in ztable 9z. Overall, the results are comparable, although indirect clinical activities are difficult to classify and are likely captured in several PathFocus activities, including miscellaneous and administration/management. It is important to note that direct clinical activities (surgical pathology, cytopathology, autopsy pathology, and clinical pathology in Table 9; 47.0% vs 49.2%) and administration/management activities (20.1% vs 22.8%) are very similar in our study and the PathFocus survey, respectively. Our self-report time study results are also comparable to data for laboratory specialists from the self-report questionnaire in the Canadian 2004 National Physician Survey ztable 10z. 12 Time Distribution for Laboratory Medicine Subspecialties Time distribution for major task categories differs among laboratory medicine subspecialties (Table 7). Direct clinical activities occupy more than 50% of a pathologist s time in anatomic pathology and general pathology and typically less than 30% of a physician s time in the clinical disciplines of hematology/transfusion medicine, chemistry, and microbiology. Conversely, indirect clinical activities require 12.4% Am J Clin Pathol 2009;131:

6 Trotter et al / Pa t h o l o g y Wo r k l o a d Ti m e St u d y to 32.3% of time in the clinical subspecialties but less than 10% in anatomic pathology and general pathology. General pathologists at CLS participate in surgical pathology, cytopathology, chemistry, hematology, and extraregional consultative support but are not part of the microbiology service. A ztable 6z Summary of Time Spent in Major Categories and Specific Activities Category (% Total Time)/Task or Activity Category Time (%) Clinical, direct (50.6) Surgical pathology 62.6 Cytopathology 10.4 Hematopathology 8.9 Autopsy pathology 7.6 Microbiology 5.4 Chemistry 2.3 Cytogenetics 1.7 Miscellaneous 1.1 Administration (18.5) Miscellaneous 25.0 Correspondence 22.6 Staff meetings 18.6 Committee meetings 13.0 External agencies 9.0 Travel time (in region) 5.5 Policy development/review 4.5 Scheduling (rota) 1.4 Vendor interactions 0.5 Clinical, indirect (9.5) Consultations 31.8 Correspondence 26.0 Patient care rounds 17.3 Literature review 15.0 Projects 9.8 Research (8.2) Manuscript preparation 41.4 Research projects 35.3 Grant preparation 12.1 Administration 7.1 Professional service 3.7 Business development 0.3 Learning (5.3) Group 52.1 Individual 47.9 Teaching (4.9) Residents/fellows 34.8 Medical students 24.0 External organizations 17.3 Medical/scientific staff 12.8 Graduate students 7.2 Technical/operations staff 3.9 Quality assurance (3.1) Indirect # 55.6 Analytic 26.4 Postanalytic 12.8 Preanalytic 5.2 On-call activities and leave of absence time excluded (see text). Includes client services, community services, extraregional work, and point-of-care testing. Includes data entry for time study, preparation for annual review, and other minor activities. Refers to travel time between laboratory sites during the workday. Lower than normal owing to administrative workload pressure, ie, accreditation preparation. Administration specific to research and not included in the administration category. # Examples include accreditation preparation and inspection, internal quality assurance initiatives, utilization initiatives, incident reports/review, and meetings specific to quality assurance. significant time commitment was required in all disciplines for laboratory and university administrative duties. Study participants included 2 pathologists in senior administrative roles (department head and vice-president for medical operations) and all 5 division heads; thus, we believe the results accurately reflect administrative/management time requirements for a large academic department with high clinical service volumes. Time spent on administration is comparable to the PathFocus results (22.8%) 11 and somewhat higher than the 2004 National Physician Survey findings (15.5%). 12 The Division of Clinical Biochemistry showed an administrative component of 33.4%; however, in this relatively small division (5 members), 1 of the members was in a senior management role with approximately 95% of the time dedicated to administration. Hours Worked Study results demonstrated that laboratory professional staff worked, on average, 53.5 hours per week. Worked hours are comparable to findings in the 2004 National Physician Survey for anatomic pathology (48.7 h/wk), general pathology (44.15 h/wk), and microbiology/infectious disease (55.25 h/wk). 12 The mean total time worked per week for all subspecialties in Canada was 50.7 hours, and specialists in another area of diagnostic medicine (diagnostic imaging) worked an average of 48.3 hours per week. In Alberta, the mean selfreported physician workload is 52.3 hours per week. 12 Academic Faculty and Clinical Faculty Medical and scientific staff at CLS, through the affiliation with the Department of Pathology and Laboratory Medicine at the University of Calgary, have GFT academic appointments, with protected time for research and teaching, or clinical appointments, with minimal protected time but with the expectation of participation in resident education. As expected, the activity profiles of these 2 groups differed (Table 8). Direct clinical activities occupied considerably less time for academic faculty (36.8%) compared with clinical staff (60.5%), and, conversely, research (14.6% vs 3.0%), formal teaching (8.4% vs 2.1%), and direct clinical time with trainees (29.9% vs 7.6%; data not shown) required a greater time commitment from academic faculty. Use of PDAs PDAs have many applications in health care, 13 and studies show that PDA use by physicians has an adoption rate of 45% to 85%. 14 However, PDA use often involves more administrative and organizational tasks than those related to patient care. 14 PDAs have been used for physician workload analysis (N. Tait, Social Sector Metrics, verbal communication, March 1, 2007) and provide an excellent self-report tool that is closer to real-time observational time-motion studies than questionnaire-based studies Laboratory physicians 764 Am J Clin Pathol 2009;131: Downloaded 764 from

7 in our study easily adapted to use of the PDA, although dedicated time was clearly required for data entry, and misclassification of activities, while not easily quantifiable, was considered a minor concern. Limitations and Bias Cross-sectional studies are subject to several forms of bias, including selection bias. We believe that our study participation rate of 86%, inclusion of all laboratory subspecialties, and results from the contextual assessment support the conclusion that measured workload is representative of true workload, with the exception that undergraduate and postgraduate teaching times are likely underestimated, as are some indirect clinical and quality assurance activities (see later text). Self-report studies are also subject to an inherent bias ; however, unlike information recorded in many organizational behavior self-report studies (eg, stress levels, substance abuse, and job satisfaction), self-report of workload would not usually be considered socially undesirable ztable 7z Time Distribution for Major Task Categories by Laboratory Discipline All Divisions Anatomic Pathology General Laboratory Hematology Chemistry Microbiology Clinical, direct Administration Clinical, indirect Research Learning Teaching Quality assurance Data are given as percentages. On-call tasks and leave of absence time excluded from the major task categories (see text). ztable 8z Time Distribution for Major Task Categories by University Appointment Academic Appointment Geographic Full Time Clinical Clinical, direct Administration Clinical, indirect Research Learning Teaching Quality assurance Data are given as percentages. On-call tasks and leave of absence time excluded from the major task categories (see text). ztable 9z Comparison With PathFocus Activity Time Allocation 11 PathFocus (All Practice CLS Study Activity Categories) (%) (%) Surgical pathology Cytopathology Autopsy pathology Clinical pathology Clinical, Indirect 8.9 Miscellaneous Administration/management Professional development Teaching/training Research CLS, Calgary Laboratory Services. Leave of absence included. Activity not included in PathFocus survey. Major component is leave of absence. Includes quality assurance. Equivalent to learning category in the CLS study. ztable 10z Comparison With 2004 National Physician Survey Data for Laboratory Specialists 12 Activity 2004 National Physician Survey (%) CLS Study (%) Direct patient care without teaching component Direct patient care with teaching component Teaching/education Indirect patient care Administration Research CME/CPD (learning) Other CLS, Calgary Laboratory Services; CME, continuing medical education; CPD, continuing professional development. Excludes leave of absence/vacation. Includes quality assurance. Am J Clin Pathol 2009;131:

8 Trotter et al / Pa t h o l o g y Wo r k l o a d Ti m e St u d y or highly sensitive, characteristics that often increase reporting bias. 21 Participants may certainly overestimate their workload, but underreporting is also a consideration if participants are extremely busy and recording activities at infrequent intervals, leading to inaccurate data. A recent study suggests that surgery-rotation medical students significantly overestimate work hours, compared with measurement using a PDA-based, self-report activity log. 17 Use of a PDA also reduces recall bias associated with questionnaire-based, self-report studies. Reporting variance in our study was not thought to be significant for 4 reasons: (1) Typically, studies of 10 weeks or shorter do not experience a significant change in the number of entries per day. (2) Results from national or provincial surveys of average hours worked are generally comparable with data in our study (see earlier text). 12 (3) General standards of ethics are upheld among health professionals. (4) A tacit degree of peer awareness of colleague hours of work is likely to enhance accurate reporting. The results of our workforce study indicated that medical and scientific staffing was only 80% of that required, given workload volumes and other required duties (data not shown). It is anticipated that with adequate staffing levels, participation in learning, teaching, research, and quality assurance would likely increase. The direct clinical workload and time required preparing for laboratory accreditation resulted in lower recorded participation in many indirect clinical and quality assurance activities (Table 2), important components of laboratory medicine practice, especially in the clinical pathology subspecialties. In particular, project development, implementation, and review and indirect quality assurance activities were underreported during the study period (Table 6). This cross-sectional, 7-week, self-report time study provides detailed information on time required for specific activities performed by laboratory medical and scientific staff in a large, academic, regionalized, consolidated Canadian laboratory. Study results are concordant with questionnairebased surveys in the United States and Canada, provide more information on specific task detail within the major work categories, compare laboratory subspecialty practices, quantify direct clinical activities with and without trainees, and allow comparison of academic and clinical staff time distribution. The findings emphasize the significance of activities not directly involved with patient care, such as administration, quality assurance, teaching, research, and professional development, that typically occupy 40% to 50% of a laboratory physician s time. From the 1 Department of Pathology and Laboratory Medicine, University of Calgary; 2 Calgary Laboratory Services; and 3 Social Sector Metrics, Calgary, Canada. Supported by Calgary Laboratory Services. Address reprint requests to Dr Trotter: Dept of Pathology and Laboratory Medicine, University of Calgary, Calgary Laboratory Services, Research Rd NW, Calgary, Alberta, Canada T2L 2K8. Acknowledgments: We gratefully acknowledge the participation and support of all laboratory medical and scientific staff who took part in this study. References 1. Haber SL. Kaiser Permanente: an insider s view of the practice of pathology in an HMO hospital-based multispecialty group. Arch Pathol Lab Med. 1995;119: Suvarna SK, Kay MS. 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