Quality Perceptions of Microbiology Services

Transcription

1 CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASE Origial Article Quality Perceptios of Microbiology Services A Survey of Ifectious Diseases Specialists K. MICHAEL PEDDECORD, DRPH, 1 ELLEN JO BARON, PHD, DIANE FRANCIS, MT(ASCP), 1 AND JOSEPH A. DREW, BA 1 Opiios about the quality of their primary microbiology laboratory were received from more tha 500 practicig ifectious diseases specialists by a atioally distributed questioaire. Approximately 9% of the respodets' primary laboratories were hospital-based. These sophisticated users rated the quality of their microbiology laboratories to be geerally high, with bacteriology receivig highest scores ad parasitology the lowest scores. Fortuately, the most serious problems, such as failig to call a critical result ad culture mishadled i the laboratory, were experieced rarely. Laboratories directed by pathologists with specialty microbiology traiig, PHD microbiologists, ad Improvig the quality of cliical microbiology services is a high priority for laboratory directors ad microbiologists, as well as physicias who use this iformatio i patiet maagemet. 1 The defiitio of quality of health-care services cotiues to be the subject of much debate. I a era of icreased competitio, health-care reform ad cocer about costs, the tred toward a defiitio that balaces techical aspects of quality with those of cost ad customer satisfactio has emerged. Icreasigly, cliical laboratory quality improvemet reports are idetifyig turaroud time, as well as satisfactio 4 as importat idicators of performace. I this era, microbiologists ad laboratory directors must be icreasigly attetive to uderstadig customers' legitimate desires/demads. The use of the term "cliically From the 'Graduate School of Public Health. College of Health ad Huma Services. Sa Diego State Uiversity. Sa Diego, Califoria: ad 1 Departmet of Medicie. Uiversity of Califoria. Los Ageles. Califoria. Preseted i part at the aual meetig of the America Society for Microbiology, May 4, 1994, i Las Vegas, Nevada. The opiios expressed are those of the authors ad do ot ecessarily reflect istitutioal policy. Use of trade ames ad commercial sources is for idetificatio oly ad does ot imply edorsemet by Sa Diego State Uiversity or the Uiversity of Califoria. This study was fuded by a urestricted educatioal grat from Mario Merrel Dow Ic. Mauscript received April 4, 1995; revisio accepted August, Address reprit requests to Dr. Peddecord: Graduate School of Public Health, Sa Diego State Uiversity, Sa Diego CA ifectious diseases specialists were judged to be of highest quality. America Board of Medical Microbiology certificatio of the laboratory director was related to higher overall quality perceptios. Whereas physicia-customer opiios may ot directly measure a laboratory's aalytic quality, they are a importat performace measure o which laboratories ca base quality improvemet activities i both service ad aalytical aspects of performace. (Key words: Physicia satisfactio; Cliical laboratory quality maagemet; Physicia surveys; Cotiuous quality improvemet) Am J Cli Pathol 1996; 5: relevat" to describe laboratory practices that seek to optimize the quality ad cost effectiveess of patiet care is ot ew. 5-6 Oe beefit of icreased attetio to physicias' cocers is that a defiitio of quality must be appropriate for the etire "system of care." Although this approach is ot ew, it has bee give reewed emphasis by the developmet of cotiuous quality improvemet approaches i health-care settigs. 7 Use of Physicia Surveys i Quality Maagemet for Microbiology Services A extesive review of quality maagemet i cliical microbiology by Bartlett ad colleagues 7 provides a comprehesive overview of past ad emergig approaches to maagig quality. The vast majority of studies regardig the quality of microbiology has focused o the improvemet of the aalytic testig processes. Numerous studies o methods to improve specime quality are available, but few studies o improvig turaroud time exist. I recet years, may hospitals ad other health services orgaizatios have developed cotiuous quality improvemet ad total quality maagemet programs. 8 ' 9 Oe emphasis of these programs is a icreased attetio to uderstadig ad meetig the eeds of "customers." Although it is likely that may istitutios have udertake iteral surveys of their customers as pait of their quality improvemet efforts, few have bee published. Surveys represet a importat form of commuicatio betwee cliical laboratories ad the physi- Dowloaded from by guest o 0 September

2 PEDDECORD ET AL. 59 Physicia Survey of Microbiology Quality cias ad other practitioers they serve. Surveys, although they are expesive ad time cosumig, are ivaluable methods for gaiig a broad cross sectio of opiio from the "customer group." The review of Bartlett ad colleagues 7 reported few systematic surveys of physicia perceptios of microbiology quality or reports of their quality cocers. I oe study, Pedler ad Bit surveyed a broad cross sectio of users i a well-defied service area. The mai limitatios of this study are its arrowly defied scope ad geographic coverage. I previous studies, we have employed systematic populatio-based surveys of physicias to idetify areas i which HIV, hepatitis B virus, ad T-lymphocyte subset testig could be improved." 1 The preset study requests the opiios ad experiece of a sample of physicia members of the Ifectious Diseases Society of America (IDSA) who report treatig patiets. We selected this opportuity sample because of their expertise i treatig patiets with ifectious diseases. We believe they represet a kowledgeable group of physicias who are well qualified to evaluate the quality of microbiology laboratory services they receive. The objective of this survey was to systematically collect iformatio from this group of kowledgeable physicias regardig their curret levels of satisfactio with ad prefereces for selected microbiology practices. I additio, we collected iformatio o their medical practice specialty, practice settig, type of laboratories used, laboratory director qualificatios, ad volume of microbiology specimes. Iformatio o culturig, susceptibility testig, ad reportig prefereces are reported elsewhere. 1 MATERIALS AND METHODS Sample Elected physicia members of the IDSA comprised the study populatio. Physicias who accordig to the 1990 IDSA membership directory were ot seeig patiets or participated i survey istrumet pilot testig were excluded. Also excluded was a sample of 505 physicias who were selected for participatio i a separate survey studyig the use ad quality perceptios of T- lymphocyte subset testig. 1 The remaiig 1,64 physicias formed the study populatio. This represeted about 70% of IDSA physicia members who met selectio criteria ad for whom curret addresses were available. Survey Questioaire A 8-page questioaire etitled, "Microbiology Service ad Quality: Is Your Laboratory Meetig Your Needs?" was desiged to: (1) collect demographic iformatio; () idetify problems with curret microbiology practices ad services; () determie practice ad reportig prefereces for selected types of cultures; ad (4) determie ways i which microbiology practices ad services for physicias ca be improved. A draft istrumet was revised followig pilot testig ad critique by 16 IDSA members. Two mailigs were coducted, September ad November 199. A edorsemet letter o IDSA statioary from Merle A. Sade, MD, Presidet of IDSA, was eclosed with the survey. Data Summarizatio ad Scale Costructio Physicia characteristics. Survey respodets were asked to idicate the approximate time they spet i practice specialty, type of practice settig, ad the umber of cultures they sed i a give moth to various types of laboratories. For some aalyses, it was ecessary to assig the respodig physicia to oe of several mutually exclusive categories based o a percetage criterio. These data were used to assig the physicia respodets to a primary specialty, primary practice site, ad the site of a primary laboratory. For example, if physicias spet 80% of their time i a uiversity teachig hospital ad 0% of their time i a private hospital, they were assiged to the practice locatio category of uiversity hospital. We tested classificatio criteria that raged from 90% to 50%. I all cases, the 60% criterio yielded the fewest missig values. Usig the 60% criterio, of the 505 respodets, oly 40 (9.7%), 60 (7.8%), ad 4 (0.6%) could ot be assiged to a primary specialty, primary practice site, ad site of primary laboratory, respectively. Microbiology Board Certificatio Status of Directors. If the respodig physicia did ot kow the America Board of Medical Microbiology (ABMM) status of the microbiology director, a attempt was made to idetify this based o the idetificatio of the laboratory which the physicia idicated. Idex of Microbiology Quality Survey respodets were asked to rate each specialty area, based o a scale from 1 to 5. A score of 5 idicated a excellet quality ratig. I the iitial aalysis, the quality ratigs for various specialty areas were highly correlated (all correlatios were greater tha r = 0.40, with may above r = 0.80). Because microbiology laboratories are usually a sigle operatioal uit with commo directio ad persoel, we chose to develop a sigle idex to measure the overall quality of the microbiology laboratory. The idex was computed as the Dowloaded from by guest o 0 September 018 Vol. 5 No. I

3 60 CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASE Origial Article sum of the six scores comprisig the quality perceptios i the specialty areas of bacteriology, mycology, mycobacteriology, parasitology, immuoserology, ad virology. The scores from all six specialty areas formed the Idex of Microbiology Quality. Reliability aalysis 14 cofirmed that the idex was iterally cosistet ad additive with the Chrobach's alpha statistic rages from 0 to 1.0 with levels greater tha 0.7 idicatig a high level of iteral cosistecy. Results for the reliability aalysis showed a alpha statistic of 0.87, well above the criterio level of 0.7. The resultat idex raged from 6 to 0 with a mea of 1.1 ad stadard deviatio of 5.6. Weighted Problem Score To measure the overall problems experieced with services performed by the microbiology laboratories, a idex was desiged to capture the type of problem, umber of times durig the last year the problem occurred, ad the potetial seriousess of the problem. We selected problem areas that would most likely be withi the direct cotrol of the microbiology laboratory. These icluded "culture mishadled i microbiology laboratory, uable to recollect," "icosistet culture iterpretatio amog techologists or microbiologists," "laboratory failed to call results of a critical culture," ad "report difficult to uderstad, laboratory called for clarificatio." Seriousess was measured o a score from 1 to 5, with 5 idicatig major potetial seriousess ad 1 idicatig mior potetial seriousess. The weighted problem idex was created by addig the products of the potetial seriousess ratig times the category of frequecy. I additio, the idex was weighted by the idividual physicia's mothly culture volume. Frequecy categories were 0 (score 1), 1- times (score ), 4- times (score ), ad greater tha (score 4). Reliability aalysis was coducted yieldig a alpha statistic of 0.7. RESULTS Respodet's Practice ad Laboratory Characteristics The overall respose rate was 40%. More tha 70% of survey respodets' primary specialty was ifectious TABLE 1. PRIMARY LABORATORY USED* Laboratory Type/Locatio Medical school/affiliated hospital Private hospital Group practice servig 4 or more physicias Large commercial Ifectious disease Small commercial Other * Physicia seds more tha 60% of cultures to this type of laboratory /o TABLE. MICROBIOLOGY QUALITY SCORE BY MICROBIOLOGY SUBSPECIALTY Specialty Area Bacteriology Mycology Mycobacteriology Parasitology Immuoserology Virology Overall score (poor) Percet Ratig i (excellet) Mea Score (5.56)* Vt.lues are percetages. I istaces i which oe or more specialty areas were ot rated, the group mea was substituted to assure that the case was ot lost. * Stadard deviatio. diseases. Aother 1.8% specialized i pediatric ifectious diseases ad the remaiig 15.% specialized i aother iteral medicie or other practice specialty. The type of primary microbiology laboratory is idetified i Table 1. More tha 5% of respodets used a medical school or affiliated laboratory, whereas 9% use:d a private hospital as the primary source of services. Very few respodets used large or small commercial laboratories as their primary laboratory type (Table 1). These lesser used laboratories were combied for subsequet aalysis. Approximately % of respodets worked primarily i a medical school or uiversity hospital eviromet. Aother 6% worked i private practice, 14% i a govermet health system, 11% i private hospitals, 6% workig i either a HMO or other health-care settig, ad the remaiig 9% i research or other opatiet care settig, such as admiistratio. Quality Evaluatios for Microbiology Specialty Areas Table summarizes quality evaluatios for six microbiology specialty areas. Respodets were asked to rate quality o a scale from 1 to 5, with 5 reflectig excellet quality. More tha 85% of respodets rated the quality of bacteriology services as either a 4 or 5. However, perceptios of quality were lower i other specialty areas. Respodets viewed the quality of parasitology services the lowest, with virology, immuoserology, mycology, ad mycobacteriology rated icremetally higher. Despite the relatively lower ratigs, oly a small proportio of physicias assiged the poorest ratigs to these specialties. For example, approximately 16% assiged ratigs of 1 or (1 = poor) to parasitology. For virology, immuoserology, mycobacteriology, ad mycology, Dowloaded from by guest o 0 September 018 A.J.C.P.-Jauary 1996

4 PEDDECORD ET AL. 61 Physicia Survey of Microbiology Quality TABLE. OVERALL QUALITY INDEX BY EDUCATION AND TRAINING OF DIRECTOR Director Traiig Combiatio PHD microbiologist MD pathologist with specialty traiig MD ifectious diseases specialist MD other specialty No doctoral level director MD pathologist without specialty traiig F- 15.5: P < Mea Stadard Deviatio percetages ratigs of 1 or were 1%, 1%, %, ad %, respectively. Additioal aalyses were coducted usig the calculated Idex of Microbiology Quality. Mea overall quality scores were compared with specialty type, laboratory type, laboratory director, ad the certificatio status of the doctoral level director. A oe-way aalysis of variace techique was employed to measure differeces i mea quality scores amog laboratory types, laboratory directors, ad the certificatio status of the doctoral level director. There was o sigificat differece i quality by medical specialty of the respodets. Sigificat differeces i the overall quality idex were observed for differet laboratory director types. As displayed i Table, laboratories that have PHD microbiologist directors, those that have MD pathologist directors with specialty traiig, ad those that have MD ifectious diseases specialist directors had the overall highest quality ratig. Laboratories with sigificatly lower scores icluded those laboratories that had o doctoral level director ad those that had a MD pathologist without specialty traiig. Overall, quality ratigs differed amog primary laboratory types as well. Medical school affiliated hospitals had a mea score of.1 ad were viewed as havig the highest quality, followed by private hospitals with a mea score of Because of the small umbers of other types of laboratories (Table 1), these laboratories have bee grouped ito a sigle "other" category for these aalyses. This category has a mea quality score that is similar to the private hospital laboratory category. Board certificatio status i microbiology was also related to overall quality perceptios. Those laboratories that have directors with America Board of Medical Microbiology (ABMM) Diplomate status were rated as havig much higher quality that those without such certificatio or with certificatio status ukow. Laboratories with a ABMM certified director had a overall quality score of. ( is approximately 167) compared with 19.8 ( is approximately 44) for the other laboratories without a ABMM certified director. Laboratories where physicias did ot kow the ABMM status of their directors had a overall quality score of 0. ( = 58). Because of their icreased opportuity to observe problems, we hypothesized that physicias orderig more cultures would have lower quality opiios. These data fail to show ay relatioship betwee culture volume ad quality perceptio. Although those physicias with lower volumes of culture activity teded to have a better perceptio of overall laboratory quality, the differece i mea score was ot sigificat at P <.05 (Table 4). Problems ad Quality Ratig It was aticipated that physicias who reported greater umbers of problems with their laboratory would have lower overall ratigs. Table 5 provides iformatio o the frequecy ad potetial seriousess of selected problem areas. Overall, relatively few problems are reported. For all four categories, approximately half of respodets (6%, 4%, 46%, 4%) reported zero problems durig the survey year. Failure to call results of a critical culture was clearly the most serious problem with a average ratig of 4.6 out of a maximum of 5. Fortuately, this was the least frequet of reported problems with 6% ot experiecig the problem ad oly 8% of respodets reportig four or more occurreces durig the year. Difficult to uderstad reports were amog the most commo problem with 18% experiecig this problem four or more times durig the year. This problem had the lowest seriousess ratig with a average of.. Culture mishadlig i microbiology ad icosistet culture iterpretatio had mea levels of potetial seriousess of 4. ad.9 ad occurred quite ifrequetly, with just over % of physicias reportig experiecig these problems four or more times per year. To further evaluate the overall quality, quality scores were compared with perceived problems of laboratory services. The cut-off poits for the problems measure TABLE 4. OVERALL No. of Cultures =1 F=.4; P<. 07. QUALITY BY CULTURE PER WEEK Mea VOLUME Stadard Deviatio Dowloaded from by guest o 0 September 018 Vol. 5-No. I

5 6 CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASE Origial Article TABLE 5. FREQUENCY OF PROBLEMS EXPERIENCED BY TYPE OF PROBLEM, MEAN POTENTIAL SERIOUSNESS, AND WEIGHTED PROBLEM SCORE FOR SELECTED MICROBIOLOGY PROBLEMS Type of Problem u 0 Frequecies of Problem 1-4- : > * Mea Ratig of Potetial Seriousess Mea Weighted Problem Scored Laboratory failed to call results of a critical culture Culture mishadled i microbiology laboratory, uable to recollect Icosistet culture iterpretatio amog techologists or microbiologists Report difficult to uderstad, laboratory called for clarificatio Values are percetages. Mea of combied weighted problem score = * is smaller because of missig values i both measures. t Alpha statistic for the combied weighted problem score was were set to approximate the 5th, 50th, ad 75th percetiles. The mea quality scores were calculated for each of the four problem groups ad are displayed i Table 6. Quality scores are iversely related to the umber of weighted problems. To adjust for volume of cultures ordered ad thus the chace of observig problems with the microbiology laboratory, the problem score was adjusted by the category for umber of cultures. This volume corrected problem score was the divided ito four quarters ad the mea quality score compared for these four groups. Data preseted i Table 6 supports the hypothesis that quality ratig is related to the frequecy ad seriousess of reported problems. Whe physicias are categorized by the umber of problems, mea quality scores for these categories show a progressive liear declie as problem category icreases. Mea scores are statistically sigificat by aalysis of variace (P <.001). DISCUSSION Limitatios I evaluatig the results of this survey, we recogize the limitatios of ay survey research. Although the TABLE 6. OVERALL MICROBIOLOGY QUALITY SCORE BY CATEGORY OF WEIGHTED PROBLEMS INDEX CONTROLLED FOR CULTURE VOLUME Frequecy of Weighted Problems Few Some Moderate More frequet All groups ANOVA:F= 4.!:/>= Mea Stadard Deviatio overall respose rate was 40%, which is quite high for physicia surveys, selectio bias is always a cocer. Respodets may differ from the populatio surveyed. A secod importat factor is that our sample represets IDSA membership, physicias highly iterested i ifectious diseases. We assume that they are more kowledgeable customers of microbiology laboratory services. They may also be more critical ad have higher expectatios. Because the survey icludes oly physicias with a abidig iterest i ifectious disease, the geeralizability of these results is limited. Locatio of practice may also itroduce bias. Respodet physicias teded to practice i teachig settigs ad more tha half used laboratories i teachig hospitals. Comparability Oe of the difficulties i evaluatig these results is the lack of idustry-wide stadards or bechmarks for comparisos. Because this is a iitial survey of this topic ad group, time series data are lackig for this populatio o baselie data are available. Therefore, most of our aalysis is cofied to comparisos of satisfactio amog practice type subgroups, type of laboratory, ad laboratory director characteristics. Despite limitatios, results of this physicia survey ca be a useful adjuct to improvig performace ad customer satisfactio for most cliical laboratories. Use of Physicia Perceptios to Measure Quality Although the quality perceptios of physicias are ot a substitute for other measures of laboratory quality, they are a essetial compoet of quality measuremet. As orgaizatios evolve to a more customer-ori Dowloaded from by guest o 0 September 018 A.J.C.P.- Jauary 1996

6 PEDDECORD ET AL. 6 Physicia Survey of Microbiology Quality eted service philosophy, formal surveys are a logical progressio i obtaiig this iformatio. As kowledgeable ed users or customers, ifectious diseases specialists' opiios should be regarded as highly relevat i judgig the quality of the microbiology laboratory. To a greater degree tha most physicia groups, the ability of ifectious disease specialists to practice state-of-the-art medicie is depedet to a great extet o iformatio provided by the microbiology laboratory. Oe dager of quality perceptios is that they may be based o a limited umber of aecdotal experieces rather tha a systematic assessmet. However, it would seem logical that over a exteded period of time a balace of good ad bad experieces would be achieved ad a stable summary opiio would be derived. Eve if physicias' quality opiios are a idepedet measure of a laboratory's performace ad are urelated to "aalytic" proficiecy, they still must be cosidered seriously. The ratioale for cocer over the importace of "perceptio of quality" is that this may ifluece the physicia's cofidece i the laboratory results. Oe cosequece of low cofidece may be uecessary reorderig of tests. For example, if the physicia believes, based o past experiece, that the laboratory is ulikely to recover a ifectious aget from a sigle specime the multiple specimes may be ordered to improve the chaces of recoverig the suspected ifectious aget. I the case of microbiology tests, low cofidece may lead to icreased prescribig of expesive, broad-spectrum empiric atibiotics rather tha relyig o the timely delivery of specific microbiologic iformatio that would allow better atibiotic targetig. Director Qualificatios ad Quality of Microbiology Although there is very limited empirical validatio, 15 covetioal wisdom holds that laboratories with more highly educated ad traied directors provide higher quality results. Physicias rated microbiology laboratories whose directors, either PHD or MD pathologists, who had specialty traiig i the disciplie as providig higher quality. Physicias rated lower those laboratories ru by odoctoral directors. The critical variable seems to be the specialty traiig, ot the type of doctoral degree. Although our survey did ot allow us to examie the issue of certificatio i detail, we foud that laboratories whose directors were Diplomates of the America Board of Medical Microbiology were rated higher tha those with directors of ukow or ocertified status. We did ot collect iformatio o other certificatios, such as the Special Competece i Medical Microbiology of the America Board of Pathology. It may be that this subspeciality certificatio would also be associated with higher quality ratigs. The associatio of specialty certificatios ad quality perceptio might be a topic for future research. Quality Perceptio ad Problems i Microbiology We hypothesized that the frequecy ad seriousess of problems would be related to quality ratigs. Data preseted i Table 6 cofirm the sigificace of the relatioship betwee weighted problems ad overall microbiology quality score. Sigificat differeces are observed with a tred toward high opiios of quality ad few problems. The umerical differece i meas, although sigificat, is ot great betwee the four groups. For example, eve the group of physicias with the more frequet weighted problems reported a overall quality score of 18.9, whereas the group with few weighted problems had a overall score of.5. Oe possible explaatio is that the overall quality score is quite "robust" ad is ot greatly lowered by a few problems. Our iterpretatio is that these ifectious disease physicias uderstad the workigs ad complexities of the microbiology laboratory i some detail. Give this uderstadig, they develop their overall quality ratig based o their logterm experieces with problems, commuicatios with the microbiology laboratory, the supervisor ad bech microbiologists, as well as the laboratory's overall ability to meet their patiets' eeds. As kowledgeable "customers," they are able to itegrate their log-term/overall experieces, ad evaluate the problems observed withi that experiece base. We believe the result is a relatively stable overall measure of quality. The physicias appear to be uderstadig of some miimal level of errors. If this speculatio is true, the good ews for microbiology laboratory directors is that it is the log ru cosistecy that builds a physicia's overall opiio of microbiology quality ot isolated problems. Customer Orietatio ad Redefiitio of Quality i Microbiology Uderstadig physicia perceptios of quality ad guidig quality improvemet efforts based o these perceptios are icreasigly importat to cliical laboratories. 916 Traditioally, assessmet of physicia satisfactio has bee limited ad was usually based o iformal discussios, as well as itermittet commuicatios such as complaits ad icidet reports. Icreasigly, more systematic methods of collectio are beig employed. We aticipate that formal surveys of physicias will be icreasigly importat i evaluatig quality ad service. Through its "Ageda for Chage," the Joit Dowloaded from by guest o 0 September 018 Vol. 5 No. I

7 64 CLINICAL MICROBIOLOGY AND INFECTIOUS DISEASE Origial Article Commissio o Accreditatio of Health Care Orgaizatios (JCAHO) has embraced the cocept of cotiuous quality improvemet. 17 This total quality maagemet approach icludes direct iput from customers as a importat approach to measurig quality. It is coceivable that at some future date, satisfactio ratigs from customers will become importat sources of iformatio for accreditatio agecies or purchasers of health care. Uderstadig how to assess physicia satisfactio is a logical step i the developmet of total quality maagemet programs. 18 Survey techiques are also useful i uderstadig physicia perceptios, desires ad quality requiremets. Iformatio from formal surveys ca the be used to improve performace for both oaalytic as well as aalytic aspects of laboratory activities. Ackowledgmets. The authors thak David Scharf ad Ae Evosevich for their cotributios to the completio of this study. The authors also thak the physicias who completed surveys for this project as well as the ifectious diseases specialists who assisted them i improvig the pre-test survey istrumet. REFERENCES 1. Dorsey DB. Evolvig cocepts of quality i laboratory practice: A historical overview of quality assurace i cliical laboratories. Arch Pathol Lab Med 1989; 11: Hilbore LH, Oyek RK, McArdle JE, et al. Use of specime turaroud time as a compoet of laboratory quality: A compariso of cliicia expectatios with laboratory performace. Am J Cli Pathol 1989;9: Howaitz PJ, Steidel SJ, Cembrowski GS, Log TA. Emergecy departmet stat test turaroud times: A College of America Pathologists' Q-Probes study for potassium ad hemoglobi. Arch Pathol Lab Med 199; 116: Howaitz PJ, Cembrowski GS, Bacher P. Laboratory phlebotomy: College of America Pathologists Q-Probe study of patiet satisfactio ad complicatios i,78 patiets. Arch Pathol Lab Med 1991; 115: Bartlett RC. Medical Microbiology: Quality Cost ad Cliical Relevace. New York: Joh Wiley ad Sos, Smith JW, ed. The Role of Cliical Microbiology i Cost-Effective Health Care. Skokie, IL: College of America Pathologists, Bartlett RC, Mazes-Sulliva M, Tetreault JZ, et al. Evolvig Approaches to Maagemet of Quality i Cliical Microbiology. Cli MicrobiolRev 1994;7: Berwick DM, Godfrey AB, Roesser J. Curig health care: New strategies for quality improvemet. Sa Fracisco: Jossey-Bass, O'Coor SJ. Service quality: Uderstadig ad implemetig the cocept i the cliical laboratory. Cli Lab Maage Rev 1989,:9-5.. Pedler SJ, Bit AJ. Survey of users' attitudes to their local microbiology laboratory. J Cli Pathol 1991 ;44: Peddecord KM, Hofherr LK, Beeso AS, et al. Use of a physicia survey to idetify opportuities for quality improvemet. Cli LabSci 199;6: Peddecord KM, Hofherr LK, Beeso AS, et al. Physicia requiremets for quality i T-lymphocyte subsets. Aual Meetig of the America Public Health Associatio, Nov. 1, 1994, Washigto, DC. 1. Baro EJ, Fracis DP, Peddecord KM. Ifectious diseases specialists offer mixed opiios o may aspects of microbiology testig ad reportig practices. Poster sessio. Aual Meetig of the America Society for Microbiology, May 4, 1994, Las Vegas, Nevada. 14. Norusis MJ. Professioal Statistics Users Guide. Release 6.0. Chicago, IL: SPSS, Howaitz PJ. Use of proficiecy test performace to determie cliical laboratory director qualificatios. Arch Pathol Lab Med 1988; 11: Fisk RP, Freshley C. Marketig applicatios for hospital laboratory services. J Health Care Marketig 1981; 1: Simpso KN, Kaluzy AD, McLaughli CP. Total quality ad the maagemet of laboratories. Cli Lab Maage Rev 1991; 5: Macityre K, Kelma CC. Measurig customer satisfactio. I: McLaughli CP, Kaluzy AD. Cotiuous Quality Improvemet i Health Care: Theory, Implemetatio ad Applicatios. Gaithersburg, MD: Aspe Publishers, 1994, pp -16. Dowloaded from by guest o 0 September 018 A.J.C.P.-Jauary 1996