Dr Chris Chaloner PhD FRCPath Consultant Paediatric Biochemist / Head of Clinical Biochemistry,

1. Your acute general hospital has recently merged with a neighbouring hospital providing neonatal and paediatric services. You have been asked by your Chief Executive to produce a plan for centralisation of Clinical Biochemistry Services on the acute general hospital site. Identify the important issues and discuss an appropriate model for provision of services for the neighbouring hospital Dr Chris Chaloner PhD FRCPath Consultant Paediatric Biochemist / Head of Clinical Biochemistry, Central Manchester Foundation Trust

2. Above all else… • In your answer, you should make very clear that your number 1 priority is Patients and Patient Safety. There must be no detriment to patients being cared for at either of the existing facilities. This applies to both the existing service and the merging services

3. This is a big change… • This represents a very big change and it will be an emotional wrench for some people. Do you know how to manage and deliver change? If not you will need help.

4. Change management… • Do everything you can to ensure that the stakeholders ‘own’ the process • Look for ‘bright spots’, practices or people who are exemplars of what you want to achieve and bring them / their practices to the fore • Don’t focus too much on the people who will never agree, they will drain your energy for little benefit. Instead encourage the staff who are wavering or who are already in agreement to ‘own’ the process and drive it forward • Identify key opinion leaders on each site and set them the objective to deliver a safe and effective merger • Engage with staff on each site from the beginning and explain your plans • Invite suggestions and observations from all staff • Find the feeling – relate the change on an emotional level by identifying opportunities to improve quality for patients, develop peoples’ skills, some staff may live nearer the core site so might be better for travelling childcare, opportunities for exposure to new and interesting technologies and clinical scenarios etc • Script the key moves – identify milestones and guide your transition group using the scripted moves as a guide (but be flexible enough to change your script as things develop) • Run an away-day for brainstorming

5. Option Appraisal… • An Option Appraisal against objective criteria will also help • Analyse, Think then Change • Because evidence is the most powerful change agent

6. Option Appraisal… • Most obvious solution is a ‘hub and spoke’ arrangement. The question presumes that the Acute General Hospital is the preferred ‘hub’ but this may not be the most appropriate solution • You will need to consider the requirements of the clinical teams – is there a NNICU? A PICU? Other highly specialised services e.g. paediatric burns, paediatric transplant etc etc

7. Operational matters… • Take some time to focus on quality of service and consider especially how Clinical Liaison will work in future configuration • Engage with clinical teams and invite their comments and suggestions • Be clear to them that you will meet their needs and requirements in the new configuration

8. Operational matters… • For practical things, think about the 3 main phases: pre-analytical, analytical, post analytical

9. Preliminary data collection… • Matching Capacity to Demand across the sites • You’ll want to know more about the services currently offered • Demand vs Capacity including staff and equipment ie what is the capacity of each Laboratory in terms of • Staff • Equipment • If you’re planning to ship samples between sites, what is the capacity in Specimen Reception at each site? Now? Future? • Turnaround times, specimen rejection rates • Each Specimen Reception must be able to handle very small volume samples • Test prioritisation. Where? When? By whom? • Specimen Quality review – if go for a Hub-and-Spoke configuration, it’s harder to get a repeat if the problem is only recognised once a sample arrives at the hub lab

10. Option Appraisal… • Some Key Operational Issues • CPA Accreditation • POCT – in hospital and community • What is needed on-site and what can be shipped off site? • Tests for immediate patient management: usually ABGs (?co-oximetry), U&E, Glucose, Lactate, ?Ammonia, ?CRP, ? Troponin, ?Amylase • ‘cold’ work • Staff communication within and between sites • Staff Rotation within and between sites • Organisational changes and lines of staff reporting and accountability • HR Issues and Terms and conditions • Same banding for work of equal value • AfC conditions for OoH • EWTD compliance • Shifts versus on-call type pattern

11. Option Appraisal… • Pre-analytical • IT Infrastructure • LIMS • Test names • Units of measurement • Significant Figures • Age-related reference intervals • Reception • Knowledge, skills and experience • Clear SOPs and clear roles and responsibilities • Cross-site communication • Transportation • Core hours • Out-of-hours • Can Preanalytics prepare and analytics sample from the primary tube for paediatric samples? If not then need a manual workstream for processing

12. Option Appraisal… • Analytical • Sample stability for transport • Minimum volumes for analysis, reflex testing, indices (may consume significant amount of paediatric sample volume), repeat specimens • Commutability of results across platforms • Primary sample type Serum? Plasma? • General • Specifically for key analytes like creatinine (enzymatic vs Jaffe), albumin (BCP vs BCG), Potassium (serum vs plasma)

13. Option Appraisal… • Post-analytical • Reporting • Electronic? Paper? • Ensuring MLA, BMS and Clinical Biochemist training, and maintaining knowledge and skills, in paediatrics • Clinical Liaison • On site? Off site? Telephone? • IT Based advice systems e.g. lab handbook etc • Hypertext links to online interpretative resources eg LabTestsOnline, Map of Medicine etc