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J Clin Pathol 1985;38:208-214

A study of workload units in five microbiology


laboratories
RY CARTWRIGHT,* JOAN R DAVIES,¶ C DULAKE,t RJC HART,t CA MORRIS,§
PJ WILKINSONII
From the Public Health Laboratories, *St Luke's Hospital, Guildford, tWilliam Harvey Hospital,
Willesborough, Ashford, Kent, tHeavitree, Exeter, §Royal Shrewsbury Hospital, IlDerrford Hospital,
Plymouth, and the ¶Public Health Laboratory Service Board, Head Office, Colindale, London NW9

SUMMARY A study of a modified Canadian unit system of measuring laboratory workload was

undertaken in five joint Public Health Laboratory Service and hospital microbiology laboratories.
Ten percent of the specimens received over six months were sampled, the number of units
expended on each was recorded, and the results were analysed on a central computer. The
process of gathering information in the absence of laboratory computers was time consuming
and, despite careful planning, differences were found in the recording practices of the
laboratories. The analysis of results did not lead to major changes in data gathering techniques
because the same information about laboratory workload could be obtained by collecting num-

bers of clearly defined specimens. Analysis of workload units could be useful for particular
purposes, such as comparing differences between laboratories using different techniques for the
same investigation or assessing the possible benefits of automation. It must be appreciated,
however, that workload units are measures of quantity not of laboratory performance.

For some years there has been dissatisfaction with laboratories. Within the laboratory this information
the methods of assessing laboratory work. They is necessary for the best allocation to be made of
have been criticised as being both inaccurate and manpower and space. It should be sufficiently pre-
uninformative. Attempts to improve the methods cise to enable assessment of trends in workload lead-
have led in Britain to redefinitions of requests and ing to the review of methods so as to provide, for
specimens and in North America to the use of work- example, information on the cost effectiveness of
load units. These different approaches may be a automation.
reflection of the different methods of financing Health authorities need information to allocate
laboratory work. resources between laboratories more rationally. If
The complexity of microbiological investigations costing of laboratory services to particular users,
compared with the more stereotyped and mechan- such as individual clinical disciplines, can be made
ised techniques used in haematology and chemical sufficiently accurate, realistic forecasts of the
pathology make for more difficulty in workload resource requirements of the laboratory can be
measurement. In general, the information required made to accommodate changes in clinical workload.
of a microbiology laboratory is the total workload, Accurate statistics of workload would be of particu-
the distribution of specimen types, and the work lar value to the Public Health Laboratory Service
entailed in the examination of each type. It may also (PHLS), in which there are a number of closely
be desirable to record the source of specimens and comparable laboratories, because they would pro-
to provide a means of costing the examination. None vide opportunities for the evaluation of different
of these measurements is of any value unless the methods and techniques as well as providing the
method of calculating the workload is reliable, administrative information already discussed.
reproducible, and provides for uniformity between Before the present study, discussion in Britain'
different types of specimen and between different about the Canadian unit system2 of measuring work-
load led to an experimental assessment of unit work-
load measurement in pathology by the South West-
Accepted for publication 9 October 1984 ern Regional Health Authority (SWRHA). A
208
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A study of workload units in five microbiology laborattories 209


number of combined PHLS and hospital Table 1 Examples of allocation of workload units (WL U)
laboratories were involved in the application of this to laboratory tests
project to microbiology, the funding of which ceased Test WLU Test WLU
after much preliminary work had been done. This
information was made available to us, and a six Microscopy Confirmatory tests
Gram film 3 Coagulase (tube) 3
month pilot study of a modified Canadian unit sys- Dark ground 10 Indole production 2
tem of workload measurement was carried out in Fluorescence 5 Nagler plate 8
five laboratories, each of which provided a diagnos- Wet film 2 Sugar fermentation
(per substrate) 1
tic service and examined food and other environ- Procedures Sensitivity tests
mental specimens. The units were based on techni- Centrifugation 1 Direct 2
Slide agglutination 2 On culture 3
cal time only; no consideration was given to over- Dilution series 4 Stokes' plate 4
heads, the employment of other staff, or the capital Culture Environmental
and revenue costs of equipment. Each laboratory Aerobic plate 1-5 Methylene blue test 4
Anaerobic plate 2 Membrane filtration 4
collected its own data, which were analysed by the Enrichment 1 Weighing and
computer services department of the PHLS. For tuberculosis 5 homogenisation of food 10
Pour plate 5
Methods
The participating laboratories all performed a wide
range of microbiological investigations employing specimens a year, two examined about 100 000, and
commonly used manual methods at the time of the one 140 000.
survey, which were broadly comparable for each. The examination of a specimen implies the per-
Two of the laboratories examined about 60 000 formance of a number of laboratory manoeuvres

DATE IN OUT
P. H.; L. EXETER WS/241/50/01 SPUTA AND SPECIMENS FOR T.B.
CLER'CAL 037 SENSITMVITY ( CULTURE) 30' 224
VISUAL EXAMINATION 262 STOKES PLATE 225 LAB. NUMBER
HOMOGENISATION 093 BLOOD AGAR SUB 02 043
LIQUEFACTION/DIGESTION 131 CO2 044
METHYLENE BLUE STAIN 155 AnO2 044
DIRECT BLOOD AGAR 02 043 GRAM (CULTURE) 153 G.P. HOSP. HOSP. ENV. OTHER
CO2 044 X+'VDISCS 280
AnO2 044 BETA-LACTAMASE 021 TELEPHONED REPORT 241 |
CHOCOLATE AGAR CO2 '044 OPTOCHIN 182 SEND FOR PHAGE TYPING 183
CLED 043 BILE SOLUBILITY 023 " " FUNGUS 183
McC 043 SLIDE COAGULASE 039 " " HISTOLOGY 183
NALIDIXIC BLOOD AGAR 044 TUBE COAGULASE 040 " CYTOLOGY 183
MANNITOL SALT AGAR 043 UREA 251 REF. LAB. (EXTERNAL) 210
SAB C 270 043 AESCULIN 001
.,370 043 OXIDASE 184
SUCROSE BROTH 045 GERM TUBE 082
MYCOPLASMA MEDIUM 044 NaOH TREATMENT 242
BROTH CULTURE 045 LJ PLAIN 370 C 046
P
ED
PYRUVATE 370 C
GRAM (SPECIMEN)
ZN (SPECIMEN)
153
161 PLAIN 300 C
046
046
I
EOSINOPHIL STAII4 154 PYRUVATE 300 C 046
CENTRIFUGE 034 KIRCHNER 046
WET PREP (DIRECT) 159 ZN (CULTURE) 160
READ DIP SLOPE 054 LI 250C 046
WET PREP (SPUN DEPOSIT)
SENSITIVITY (DIRECT) 370
159
223
_ 370 C (DARK)
370 C (LIGHT)
046
046
I ~~~~~~
Jl
T I
., 300 223 450C 046
(CULTURE) 370 224 __ OXYGEN PREFERENCE 045

Fig. 1 Example ofa backing sheet.


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210 Cartwright, Davies, Dulake, Hart, Morris, Wilkinson


(tests), which may involve microscopy, culture on a on the backing sheet while the specimen was under
variety of media, subculture, characterisation of examination.
organisms, assessment of antibiotic sensitivity, the When work on each specimen in the survey was
quantitative assessment of antibodies to a number of complete and the report signed, the backing sheets
antigens, and so on. A list of all tests performed by were separated and sent in weekly batches to the
the participating laboratories was prepared and each computer services department of the PHLS. There
test was allocated a three digit code, a name, and a the scores of WLU were added to the sheets and the
score of notional workload units (WLU). These information processed on a CTL 8046 computer
scores were allocated by one of three methods: (a) (Computer Technology Ltd, Hemel Hempstead,
acceptance of the units given in the Canadian sys- England). None of the participating laboratories had
tem2; (b) adoption of the unit value worked out in a local computer facility.
the South Western Regional project; and (c) prep-
aration of new scores for tests or methods for which Results
no unit values were available.
When method 3 was used the tests were carried All five participating laboratories provide a general
out in at least two laboratories by several members microbiology diagnostic service predominantly for
of staff with differing degrees of experience. The the examination of clinical specimens, of which
unit value for each test was the average number of about 70% were from hospitals and the remainder
minutes required to carry it out. The scores, how- from other sources; these included a small number
ever derived, were agreed by the participating of non-clinical specimens such as milk, water, and
laboratories. Where different laboratories used dif- food. Table 2 shows for each laboratory the esti-
ferent methods to perform a test, an appropriate mated annual workload (calculated from the 25
score of WLU was allocated to each method. Exam- week study period) expressed in terms of specimens
ples of the WLUs are shown in Table 1. and units. The proportion of different categories of
Specimens were classified into 14 groups and for specimen sampled and workload units generated by
each group an appropriate backing sheet was them in each laboratory is shown in Fig. 2. As
designed listing the tests likely to be used (for exam- expected, there was some variation between
ple, see Fig. 1). Additional sheets were used if laboratories but the patterns showed no appreciable
further tests were necessary. The specimen differences and all five laboratories could be
categories were: urine, upper respiratory, lower regarded as broadly comparable in the source and
respiratory, genital, wound, blood culture, cere- type of specimen and proportion of samples in each
brospinal fluid, faeces, mycology, tuberculosis, gen- defined category.
eral bacteriology, serology (including viral sero- For each category the mean workload units per
logy), virus isolation, and environmental microbiol- specimen was calculated for each laboratory and for
ogy (including food, milk, water). Specimens all laboratories. Fig. 3 shows the variation above
received for external quality assurance were and below the group mean. The specimens are
included in the appropriate categories. Throughout divided into three groups: (a) those in which there is
the study all specimens were allocated laboratory little variation between laboratories-for example,
numbers by the system normally used in the upper respiratory and urine; (b) those in which dif-
laboratory. The request form accompanying every ferences are moderate-for example, wound, faeces,
10th specimen in each numbering series was serology; and (c) those showing wide variation-for
attached to the appropriate backing sheet. Members example, lower respiratory, blood cultures, and
of the laboratory staff ticked the appropriate tests mycology.
An attempt has been made to explain the more
extreme differences above or below the group mean
Table 2 Comparability of laboratories: specimens and
and some of the probable or possible reasons are
workload units (WLU) listed below.
1 Lower respiratory tract. Laboratory C, unlike the
Laboratory Total Specimens Mean WLU Total annual others, routinely examined all sputum samples
specimens assessed per specimen WLU from new patients for the presence of acid fast
per annum* (thousands)
bacilli. The other laboratories entered all speci-
A
B
58 640
61480
2932
3074
19-53
13-19
1145
811
mens examined for acid fast bacilli (whether or
C 93 840 4692 16-09 1509 not specifically requested) in the category tuber-
D 96 800 4480 15-72 1522
1825
culosis.
E 131 460 6573 13-88 2 Blood cultures. Some laboratories scored each
*Estimated from a 10% sample over 25 weeks. inoculated broth in a blood cQllture set as one
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A study of workload units in five microbiology laboratories 211

No of specimens
sampled

- _lr
.. I

2932 3074 4692 4840 6573

Workload units
recorded f:::::: ,

51261 40 531 75475 76093 91226

ai] Urines 2 Respiratory a] Faeces W Others


E3 Wound and IN Tuberculosis E Serology/ U Non-clinical
genital virology
Fig. 2 Specimens sampled and workload Units generated in each laboratory.

Wound Cerebrospinal Serology/


Upper Genital on fluid Faeces assay
respiratory Urine ]. 4 4 4

-2 aio M r variation

Little variation Moderate variation -

Lower
respiratory Mycology
16 i, Blood .D-
1'U _
culture Virology. Culture/
11, Non- electronmicroscopy
gexg >s ciia
Tuberculosis clinical;

0l 0 0- Laliboratories
0- 0-
[DA
OB
Eu
oc
ED
-8
-9. C1E
Wide variation -13- -14.
Fig. 3 Variation between laboratories in mean workload units per specimen. Laboratory A did not undertake mycology
and laboratory E did no virology (culture or electron microscopy).
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212 Cartwright, Davies, Dulake, Hart, Morris, Wilkinson


Table 3 Ranking of laboratories by total specimens, total are collected and analysed will depend on the pur-
workload units (WLUs) and WLUlspecimens poses for which they are required and whether the
Total specimens Total WLUs Mean WLUfspecimen information gained justifies the expense of collecting
it. It is well recognised that counting requests alone
A (lowest)
B
B
A
B
E
is a crude and often misleading measure of work-
C C D load. This is particularly the case when an attempt is
D D C made to compare the workload in different pathol-
E (highest) E A ogy disciplines, some of which use automated tech-
niques and others use predominantly manual
methods. Improvements have been attempted by
specimen while others scored all the broths weighting the requests by average test to request
inoculated from the same blood as a single ratios. A more detailed but time consuming method
specimen. Laboratory D had a relatively high of assessing laboratory workload, such as the Cana-
isolation rate from blood cultures necessitating dian system, records the units of work for each test
on average more tests for identification and anti- or procedure on each specimen. The Korner report3
biotic sensitivities than the others. This was concluded that the Canadian system did not over-
probably a reflection of samples from specialist come the problems inherent in a weighted request
units (renal transplant and immunocompromised number count and recommended that numbers of
patients). requests only should be collected by health
3 Mycology. Laboratory B, unlike the others, was authorities for the Department of Health and Social
unique in employing a scientist with a substantial Security. The decision whether to gather any addi-
commitment to mycology. Laboratory A did not tional information should be left to individual health
undertake mycology. authorities. The debate on obtaining comparative
4 Tuberculosis. Laboratory A did the preliminary statistics about activity and the use of resources has
work on specimens for isolation of Mycobac- continued in Britain with the publication4 of per-
terium tuberculosis and passed all suspect cul- formance indicators over a range of health district
tures to a separate reference laboratory nearby. functions.
5 Non-clinical. Laboratory B provided a "flight This study using a modified Canadian workload
meal" test service for a major airport. unit system has compared five combined public
6 Virology. Laboratory E did not offer a virus cul- health and hospital microbiology laboratories. We
ture or electron microscopy service. A higher appreciated from the outset that the information
proportion of neutralisation tests was performed would relate only to the work associated with the
by laboratory C compared with laboratories A specimens examined. It did not include media prep-
and D. This difference reflects a local epidemic aration and wash up, administration, research and
of virus associated illness. development, internal quality control, consultation
Table 3 lists laboratories in rank order according time, or training. The measurements were all of
to the total number of specimens, the total workload quantity and not quality and thus the study assessed
units, and the mean number of workload units per workload and not performance.
specimen. The order is closely similar for total The determination of the unit values chosen was
specimens and total workload units but there are affected by the mechanisation of tests, on whether
appreciable changes in ranking when workload units tests were performed individually or in batches, and
per specimen are considered. on the experience of the staff. Some procedures
Additional data collected but not presented here were given alternative unit values depending on the
included the following: (a) source of specimen (gen- methods used. When the results were analysed it
eral practitioner, hospital inpatient, hospital out- became apparent that the values assigned for certain
patient); (b) the mean number of specimens per procedures required revision as the total workload
family doctor, per 100 deaths or discharges, per 100 for some specimen groups was not proportional to
outpatients; (c) distribution of workload throughout the actual time spent on those specimens. This was
the week. particularly evident for urine, which comprised the
greatest number of specimens examined in each
Discussion laboratory. Minor errors in the unit values of even
small procedures were amplified out of proportion
A realistic and accurate assessment of laboratory and thus distorted the pattern of the workload of the
workload is necessary for effective distribution of laboratory. We also realised that accuracy and time
resources between laboratories and for good taken in recording workload could be improved by
laboratory management. The extent to which details grouping certain routine procedures. This would
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A study of workload units in five microbiology laboratories 213


also permit adjustment of the group unit values to a nature of the five collaborating laboratories. All
more realistic figure. If, for example, all specimens were area public health laboratories receiving a simi-
of urine had a microscopical examination, protein lar range of specimens, most of which were
estimation, and culture, these tests recorded indi- examined by similar techniques. Under these cir-
vidually might qualify for three units but if grouped cumstances the workload is related to the total
might attract only two units. number of specimens received and further
The particular problem in microbiology, unlike refinements of measurement would be unlikely to
other laboratory disciplines, is that the work yield significant additional information. Table 3
required on a specimen cannot necessarily be shows that whether laboratories are ranked by total
determined when the specimen is received. The specimens received or by total workload units
results of initial tests may determine the next series recorded, the order is not significantly different.
of tests. The information which is provided with a Only if a laboratory received a substantial propor-
specimen may also affect the tests performed. The tion of specimens requiring examination by complex
examination of specimens from contacts, or for techniques would measurement of the work actually
confirming the absence of an organism after recov- done reveal a higher workload. Laboratory A had a
ery from an infection, may be more limited than the higher proportion of virology specimens than other
examination of a similar specimen when the laboratories, which accounts for the fact that it had
pathogen is unknown. On the other hand, when it is the highest mean workload unit to specimen ratio
known that a patient has travelled abroad a more (Table 3), although it had the lowest number of
extensive examination may be required. Even the specimens.
final report on a specimen is not an accurate We did not consider that analysis of workload
reflection of the work undertaken-for example, a units by source of specimen or by deaths, discharges,
negative result on a faeces specimen may have been or outpatient attendances would yield any more use-
produced only after extensive biochemical and ful information than was obtainable by counts of
serological testing of some non-lactose fermenting specimens. Although an analysis of the distribution
organisms. of work throughout the week is not recorded here, it
Because an accurate estimation of workload on an was apparent that different and misleading informa-
individual specimen cannot be obtained from either tion could be obtained depending on whether the
the request or the report it is necessary to record the work was related to the day the specimen was
actual work undertaken. Logistically, it was not received, the day most of the bench work was done,
possible to do this for every specimen, so a 10% or the day the result was issued. This is in sharp
sample was used in this study. This produced a sam- contrast to the situation in biochemical and
ple size of 3000 to 6000 specimens per laboratory haematological laboratories, where the workload
and was adequate to give an overall estimate of pattern can be clearly seen because the tests are
laboratory workload. Detailed information on usually completed and reports issued on the day
specimen groups with only small numbers-for specimens are received. The need to incubate cul-
example, cerebrospinal fluid-would require all tures for 18 h or longer means that estimates of the
specimens in this group to be included in the work undertaken on different days will differ
analysis. It has been suggested that the introduction depending on the recording days used. This needs to
of computers would enable the workload associated be taken into account if the information is to be
with each specimen to be measured. This would be used-for example, to assess staffing requirements
true only if every test undertaken was entered into for weekend work.
the computer. It is common practice, however, only What then is the value of using workload units if
to enter results and not all the steps entailed in they do not immediately answer all managerial and
reaching them; similarly several bacterial colonies administrative questions? One possible use is to
may be examined but only the presence of any rec- compare the amount of work different laboratories
ognised pathogen is recorded. devote to the examination of a particular type of
The regular collection of workload data relies on specimen. Although most of the wide variations
the cooperation of the staff. All the staff cooperated identified in this study resulted from a failure to
willingly in this study, encouraged by knowing that it define terms sufficiently accurately, they did show
was for a limited period only. The gathering of data some real differences in practice. Another potential
did mean a great deal of extra work for them, and use is to obtain a quantitative estimate of the bench
the accuracy of workload measurement by this time taken in an examination by manual methods to
method over longer periods might well suffer assess the likely advantage of automation. Although
because of this. other considerations such as capital and revenue
The results of this study reflect the broadly similar costs and speed and accuracy of reporting results
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214 Cartwright, Davies, Dulake, Hart, Morris, Wilkinson


would be included in such an assessment, it is impor- experience with us and gave invaluable advice. Our
tant to estimate what manpower resources might be head medical laboratory scientific officers, Messrs JP
liberated. Alexander, GF Down, TA Ford, R Human, DA
The PHLS has not continued with collecting Porter, and Dr RA Bassett played important parts in
workload data but uses specimen counts on one organising the trial.
selected day every month. The specimens are
divided by type and source. This study indicates that
the impact of any important changes could be
examined by measuring the workload entailed. References
It must be clearly understood by all who use or Morris CA. Trends in microbiology work-loads in the National
wish to use workload units that they measure the Health Service: England and Wales (1968-79). Health Trends
work actually done, not what should be done. Quan- 1981; 13:8.
tity and quality are not synonymous. It may be mis- Statistics Canada. Canadian schedule of unit values for clinical
laboratory procedures. Ottawa: Statistics Canada, Health Divi-
leading to assume that a laboratory which shows a sion, 1978.
low workload unit per specimen ratio is managed in National Health Service/Department of Health and Social Sec-
a more efficient, selective, or cost effective way. It urity. Steering Group on Health Services Information. A
may simply be that such a laboratory is under- report on the collection and use of information about hospital
clinical activity in the National Health Service (Chairman Mrs E
resourced to the extent that it is forced to provide a Korner). London: HMSO, 1982.
suboptimal service. 4 Department of Health and Social Security. Health services man-
agement performance indicators. London: DHSS, 1983.
We are grateful to the South Western Regional (DHSS Health Notice (83) 25).
Health Authority for making the results of their pre- Requests for reprints to: Dr RJC Hart, Public Health
liminary study available to us. Dr GT Mills and Mr Laboratory, Church Lane, Heavitree, Exeter EX2 5AD,
AD Kilburn generously shared their expertise and England.
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A study of workload units in five


microbiology laboratories.
R Y Cartwright, J R Davies, C Dulake, et al.

J Clin Pathol 1985 38: 208-214


doi: 10.1136/jcp.38.2.208

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