Monitoring customer satisfaction is an important and

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1 CAP Laboratory Improvement Programs Hospital Nursing Satisfaction With Clinical Laboratory Services A College of American Pathologists Q-Probes Study of 162 Institutions Bruce A. Jones, MD; Molly K. Walsh, PhD; Stephen G. Ruby, MD Context. Monitoring customer satisfaction is an important and useful quality improvement tool and is required of most clinical laboratories in the United States. Objective. To survey the level of nursing satisfaction with hospital clinical laboratory services. Design. Participating laboratories provided information regarding laboratory demographics and practices. These laboratories then surveyed hospital nursing personnel regarding their level of satisfaction with defined aspects of laboratory service. Setting. College of American Pathologists Q-Probes laboratory quality improvement study in 162 hospital laboratories. Main Outcome Measures. Nursing overall satisfaction score (ranging from 1, not satisfied, to 5, very satisfied) and satisfaction scores for 13 specific aspects of clinical laboratory services. Results. One hundred sixty-two institutions submitted data from a total of 7033 nursing surveys. The overall satisfaction score for all institutions ranged from 2.5 to 4.6. The median overall score for all participants was 3.9 (10th percentile, 3.2; 90th percentile, 4.2). Nursing personnel were most satisfied with the accuracy of test results, phlebotomy courtesy toward patients and nursing staff, and notification of abnormal results. They were least satisfied with stat test turnaround time, laboratory management responsiveness and accessibility, phlebotomy responsiveness to service requests, and routine test turnaround time. The most important aspect of laboratory service reported by nursing personnel was stat test turnaround time. Conclusions. Most nursing personnel are satisfied with the clinical laboratory services that are provided to the patients in their care. Although test result accuracy is very highly regarded, there is room for improvement in several aspects of service, particularly in test turnaround time and laboratory management accessibility and responsiveness. (Arch Pathol Lab Med. 2006;130: ) Monitoring customer satisfaction is an important and useful quality improvement tool for clinical laboratories, health care organizations, and businesses in general. Most clinical laboratories in the United States are required to demonstrate assessment of customer satisfaction in order to maintain their accreditation. 1,2 Generally, patients and physicians have been the primary focus of these satisfaction surveys. Several previous College of American Pathologists (CAP) Q-Probes studies have investigated patient and physician satisfaction with laboratory services. 3 8 Information about nursing perceptions of laboratory services is unavailable, and nursing staff may be overlooked as customers by some laboratorians. Communicating physician orders for testing, collecting specimens, and following up on test results are some of the laboratory-related activities that nursing personnel attend to on a daily basis. Accepted for publication May 25, From the Department of Pathology, Henry Ford Hospital, Detroit, Mich (Dr Jones); Department of Biostatistics, College of American Pathologists, Northfield, Ill (Dr Walsh); and Department of Pathology, Palos Community Hospital, Palos Heights, Ill (Dr Ruby). The authors have no relevant financial interest in the products or companies described in this article. Reprints: Bruce A. Jones, MD, Department of Pathology, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, MI ( bjones2@ hfhs.org). Developing methods for enhancing constructive feedback from the nursing service provides an opportunity to identify areas for laboratory improvement. Using the well-established standardized approach of the CAP Q-Probes laboratory quality improvement program, which has produced more than 100 publications defining an extensive list of performance benchmarks in pathology and laboratory medicine, 9 this study was designed to evaluate overall and specific satisfaction of nursing personnel by evaluation of 13 different aspects of clinical laboratory services (Table 1). MATERIALS AND METHODS Participants in the voluntary subscription Q-Probes program of the CAP collected data for this study during the first quarter of The study material was composed of 3 parts: a standardized survey with instructions for its use, input form 1, and input form 2. The survey form provided the mechanism for nursing personnel to rate their overall satisfaction and their satisfaction with 13 specific aspects of clinical laboratory services. Evaluations used a scale of 1 to 5 with the following ranges: 1, not satisfied; 2, rarely satisfied; 3, sometimes satisfied; 4, usually satisfied; and 5, very satisfied. Laboratory participants distributed up to 200 surveys to full-time and part-time nursing personnel working in various locations in the hospital. Both managerial and nonmanagerial nurses were surveyed, as well as nurses from all 3 shifts. No additional definition of nursing personnel was provided. Participants were allowed to determine their own sam Arch Pathol Lab Med Vol 130, December 2006 Nursing Satisfaction With Clinical Laboratory Services Jones et al

2 Laboratory Service Category* Table 1. Percentage and Aggregate Number of Ratings Very Usually Sometimes Rarely Not Not Applicable and No Response Accuracy of test results (2708) (3080) 8.3 (583) 1.51 (106) 0.70 (49) 7.09 (498) Stat test TAT (840) (2514) (1917) (852) (710) 2.80 (197) Accessibility of laboratory management (1238) (2197) (1385) 6.06 (426) 3.12 (219) (1560) Promptly answered telephones (1771) (2974) (1527) 7.11 (500) 2.69 (189) 0.97 (68) Abnormal results notification (2221) (2932) (1157) 4.89 (344) 2.42 (170) 2.93 (206) Routine test TAT (1008) (2530) (1443) 5.80 (407) 3.37 (237) (1398) Ability to answer telephone questions (1647) (3168) (1527) 6.29 (442) 1.85 (130) 1.58 (111) Laboratory management responsiveness (1120) (2226) (1452) 6.66 (468) 3.83 (269) (1492) Telephone courtesy (1951) (3046) (1420) 5.58 (392) 2.28 (160) 0.82 (58) Laboratory point of care testing support (1189) (2218) (1060) 3.13 (220) 1.54 (108) (2228) Phlebotomy courtesy toward nursing (2139) (2487) (920) 3.40 (239) 1.59 (112) (1132) Phlebotomy courtesy toward patients (2323) (2544) (737) 2.09 (147) 0.65 (46) (1231) Phlebotomy responsiveness to service requests (938) (1736) (1143) 5.10 (358) 2.76 (194) (2654) * TAT indicates turnaround time. pling distribution. The Q-Probes instructions provided a suggested method of random selection based on dividing the total number of nursing employees by 200 and using the result to determine the selection interval on an alphabetized employee list. Data from all surveys returned within 4 weeks or the first 50 surveys returned, whichever occurred first, were compiled by laboratories onto a summary input document. A second input document represented a general questionnaire regarding laboratory characteristics and was completed by laboratory personnel in order to help provide comparison of characteristics between laboratories. Statistical analysis of all data was performed by a CAP statistician. Participating laboratories received individualized performance reports as well as a detailed data analysis and critique of the study results. Statistical Analysis Satisfaction scores were calculated using the following equations. 1. Overall satisfaction score: (No. of Very Satisfied Ratings 5) (No. of Usually Satisfied Ratings 4) (No. of Sometimes Satisfied Ratings 3) (No. of Rarely Satisfied Ratings 2) (No. of Not Satisfied Ratings 1) for Overall Satisfaction / Total No. of Ratings (1 5) for Overall Satisfaction With Laboratory Services. 2. Percentage of very satisfied or usually satisfied ratings: (No. of Very Satisfied or Usually Satisfied Ratings for Specific Laboratory Service Category 100) / Total No. of Ratings (1 5) for Specific Laboratory Service Category. 3. Percentage of rarely satisfied or not satisfied ratings: (No. of Rarely Satisfied or Not Satisfied Ratings for Specific Laboratory Service Category 100) / Total No. of Ratings (1 5) for Specific Laboratory Service Category. The influence of the institutional demographics and practice characteristics from the second input form was evaluated for association with overall satisfactions and the percentages of rarely satisfied/not satisfied ratings and very satisfied/usually satisfied ratings for each laboratory service category. If a participant failed to answer a question for any of the demographics or practice characteristics listed, that participant s data were excluded from the database for that question only. Individual associations between mean overall satisfaction score and practice variables were investigated for the data using Kruskal-Wallis tests for discretevalued independent variables and regression analysis for continuous-valued independent variables. Variables with significant associations (P.100) were then introduced into a multivariable stepwise regression model. All variables remaining were significantly associated at the.05 significance level. Table 2. Characteristics of Nursing Survey Respondents Respondents, No. (%) Nursing position Direct patient care 5817 (92.8) Manager 451 (7.2) Inpatient nursing service location Medical 1316 (20.1) Intensive care 1130 (17.3) Surgical 790 (12.1) Emergency department 687 (10.5) Obstetric 601 (9.2) Pediatric 340 (5.2) Operating room 242 (3.7) Psychiatric 163 (2.5) Gynecologic 64 (1.0) Other 1213 (18.5) Primary shift Day (7 AM 3 PM) 4049 (64.1) Evening (3 11 PM) 997 (15.8) Night (11 PM 7 AM) 1271 (20.1) RESULTS Institutional Characteristics One hundred sixty-two institutions participated in this study, submitting data from a total of 7033 nursing surveys. Most participants (97.5%) were from the United States, with the remainder from Canada (2), Australia (1), and Singapore (1). An average of 43.4 surveys were submitted per institution (median, 50). The mean response rate was 41.3% (median, 34.5%), with a range of 11.9% to 100%. Table 2 lists the characteristics of the nursing respondents. Approximately 34% of participating institutions were teaching hospitals and approximately 18% had a pathology residency program. Within the past 2 years, the CAP had inspected approximately 85% of the laboratories, and almost 75% of institutions were inspected by the Joint Commission for the Accreditation of Healthcare Organizations. The median laboratory yearly test volume was , with 10% reporting volumes less than , and 10% reporting more than Table 3 displays other characteristics of participating institutions. All of the Arch Pathol Lab Med Vol 130, December 2006 Nursing Satisfaction With Clinical Laboratory Services Jones et al 1757

3 Table 3. Other Characteristics of Participating Institutions Institutions, No. (%) Institution type Private, nonprofit 100 (64.1) Private, profit 12 (7.7) State, county, or city hospital 12 (7.7) University hospital 11 (7.1) Governmental, federal 7 (4.5) Independent laboratory 3 (1.9) Other 11 (7.1) Occupied beds (43.4) (32.9) (11.2) (6.6) (5.9) Institution location City 77 (49.0) Suburban 40 (25.5) Rural 37 (23.6) Federal installation laboratory 3 (1.9) Governmental affiliation Nongovernmental 131 (84.0) Nonfederal governmental 18 (11.5) Federal governmental 7 (4.5) variables listed in Table 3 were included in the multivariate analysis, and none were associated with higher mean overall scores. Quality Indicators Overall satisfaction scores: the overall satisfaction score for all institutions ranged from 2.5 to 4.6. The median overall score for all participants was 3.9. Ten percent of participating laboratories received an overall score of 3.2 or less, and 10% of participants received an overall score of 4.2 or higher. Aggregate satisfaction scores: the aggregate results from the 7033 surveys submitted by all participating institutions are tabulated in Table 1. Percentage of very satisfied/usually satisfied ratings: The highest median percentage value of very satisfied/ usually satisfied ratings was observed for the accuracy of test results, phlebotomy courtesy toward patients, and phlebotomy courtesy toward nursing. The data distributions are listed in Table 4. Percentage of rarely satisfied/not satisfied ratings: the lowest scores reported were for stat test turnaround time, laboratory management responsiveness, routine test turnaround time, and phlebotomy responsiveness. The data distributions are listed in Table 5. The median reported number of laboratory tests per- Category Table 4. Distribution of Percentage of Very Satisfied/Usually Satisfied Ratings for Each Interaction Category All Institution Percentiles* 10th 50th (Median) 90th Accuracy of test results Phlebotomy courtesy toward patients Phlebotomy courtesy toward nursing Abnormal results notification Laboratory POC support Telephone courtesy Ability to answer telephone questions Promptly answered phones Routine test TAT Phlebotomy responsiveness Accessibility of laboratory management Laboratory management responsiveness Stat test TAT * Higher percentile ranks indicate better relative performance. POC indicates point of care; TAT, turnaround time. Category c Table 5. Distribution of Percentage of Rarely Satisfied/Not Satisfied Ratings for Each Interaction Category All Institution Percentiles* 10th 50th (Median) 90th Accuracy of test results Phlebotomy courtesy toward patients Phlebotomy courtesy toward nursing Laboratory POC support Abnormal results notification Telephone courtesy Promptly answered phones Ability to answer telephone questions Accessibility of laboratory management Routine test TAT Phlebotomy responsiveness to service requests Laboratory management responsiveness Stat test TAT * Higher percentile ranks were assigned to indicate better relative performance (ie, lower percentage of rarely satisfied/not satisfied ratings). POC indicates point of care; TAT, turnaround time Arch Pathol Lab Med Vol 130, December 2006 Nursing Satisfaction With Clinical Laboratory Services Jones et al

4 Table 6. Relationships Between Demographic Variables and the Mean Overall Satisfaction Score No. of Institutions Median of the Overall Satisfaction Scores No. of laboratory tests, y 300, ,001 1,200, ,200, No. of calls received in clinical laboratory, d Table 8. Nursing Service Location Average Overall Satisfaction Ratings of Nursing Service Locations No. of Ratings Average Overall Satisfaction Rating Psychiatric Surgical Other Medical Pediatric Operating room Gynecologic Obstetric Emergency department Intensive care Table 7. Laboratory Practices Relating to Laboratory Telephone Call Response Institutions, No. (%) Laboratory s response to calls regularly monitored Yes, available by shift 10 (6.5) Yes, but not available by shift 4 (2.6) No 139 (90.8) Telephone conversations monitored Yes, some are monitored 11 (7.2) Yes, all are monitored 1 (0.7) No 141 (92.2) Automated answering system used Yes 45 (29.6) No 107 (70.4) formed per year was , with 10% of the laboratories reporting fewer than , and 10% reporting more than The median number of full-time equivalent (FTE) laboratory personnel (testing and nontesting) employed was 58.1, with 10% of the laboratories reporting less than 17.0 and 10% reporting more than A median number of 200 telephone calls were received per day, with 10% of the laboratories reporting fewer than 50 and 10% reporting more than 500. The median number of laboratory personnel dedicated to answering telephones was 3; 10% of the laboratories reported no dedicated telephone personnel, and 10% had more than 15 telephone personnel. Table 6 lists the relationship between laboratory test volume and number of telephone calls per day, and the reported overall nursing satisfaction scores. Institutions performing fewer tests, and those receiving fewer telephone calls, reported significantly higher satisfaction scores (multivariate regression model, P.006 and.003, respectively). Table 7 lists reported laboratory practices relating to telephone call response. Two productivity ratios laboratory tests per FTE and the number of telephone calls received into the laboratory per telephone FTE demonstrated no association with the mean overall satisfaction scores (multivariate regression model, P.32 and.23, respectively). The calculated ratio of the number of complaints per million laboratory tests also exhibited no association with the mean overall satisfaction scores (multivariate regression model, P.74). Most institutions (83.0%) utilize a generic complaint form, with the remainder using a laboratory-specific form (7.2%) or no standard form (9.8%). Most participants reported that phlebotomy was performed by both laboratory and nursing personnel (89.5%), Table 9. Aggregate Percent of Most Important Laboratory Interaction Category* Most Important Category Respondents, No. (%) Stat test TAT 2432 (37.8) Accuracy of test results 981 (15.2) Abnormal results notification 523 (8.1) Telephone courtesy 487 (7.6) Phlebotomy responsiveness 455 (7.1) Phlebotomy courtesy toward patients 404 (6.3) Routine test TAT 364 (5.7) Ability to answer telephone questions 292 (4.5) Promptly answered phones 183 (2.8) Phlebotomy courtesy toward nursing 94 (1.5) Laboratory management responsiveness 94 (1.5) Accessibility of laboratory management 71 (1.1) Laboratory POC support 55 (0.9) * TAT indicates turnaround tme; POC, point of care. with 85% of the phlebotomy performed by laboratory personnel in the median laboratory. Only 10.5% reported that phlebotomy was performed exclusively by nursing personnel. Significant differences were found between nursing service locations and the level of overall satisfaction. Nurses in emergency departments and intensive care units reported the lowest satisfaction, and psychiatric nurses reported the highest satisfaction ratings. Table 8 lists all of the overall satisfaction ratings by nursing service (Kruskal- Wallis test, P.001). When reporting which laboratory service category was most important to them, more than one third of the nurses selected stat test turnaround time. Table 9 lists the categories reported as most important by the nursing personnel. Table 10 lists the service categories with their mean overall satisfaction ratings. Table 11 lists reported customer service practices of the participating institutions. There were no significant associations between customer service practices and overall nursing satisfaction (Kruskal-Wallis test, P values ranged from.42 to.97). There was no significant difference in overall satisfaction by shift ( 2 test, P.16) or by nursing position, that is, management versus nonmanagement ( 2 test, P.09). COMMENT The median nursing overall satisfaction score for clinical laboratory services (3.9) was similar to that of a previous Q-Probes study of physician satisfaction with clinical laboratory services (4.0), 3 but somewhat less than the satis- Arch Pathol Lab Med Vol 130, December 2006 Nursing Satisfaction With Clinical Laboratory Services Jones et al 1759

5 Table 10. Relationship Between Most Important Laboratory Interaction Category and Overall Satisfaction Rating* Most Important Category No. of Respondents Mean Overall Satisfaction Rating Accuracy of test results Phlebotomy courtesy toward patients Ability to answer telephone questions Abnormal results notification Laboratory POC support Phlebotomy courtesy toward nursing Accessibility of laboratory Phlebotomy responsiveness Promptly answered phones Laboratory management Telephone courtesy Stat test TAT Routine test TAT * P.001, Kruskal-Wallis test. POC indicates point of care; TAT, turnaround time. faction level of physicians with anatomic pathology services (4.4). 4 However, the descriptors used for each numbered satisfaction response in these 2 previous studies were different from those used in this study. Overall, nurses were usually satisfied with clinical laboratory services, with a mean score of 3.8 of a possible 5 points. Laboratories provided the greatest level of satisfaction in the areas of accuracy of test results, phlebotomy courtesy, and notification of abnormal results. Nursing personnel were least satisfied with test turnaround time, laboratory management responsiveness and accessibility, and phlebotomy responsiveness. Of all the factors examined, the only factors associated with higher levels of nursing satisfaction were the lower number of tests performed and fewer telephone calls. Intuitively, this might be interpreted as laboratories with less workload per employee, allowing those laboratorians to provide a higher level of service, resulting in greater nursing satisfaction. However, when ratios of laboratory tests per FTE, and telephone calls per FTE responsible for telephone response were examined, they exhibited no association with satisfaction. It would appear that the ability of low-volume laboratories to create a higher level of nursing satisfaction is not necessarily related to less workload per employee. Laboratories with high productivity appear to be able to provide superior service, and conversely, laboratories with low productivity are also capable of providing poor service. The excuse that service will suffer if workload and productivity go up is not necessarily true in all circumstances. In addition, the lower number of telephone calls may be a reflection of better laboratory nursing communication, requiring less telephone-based interaction. Designing processes and developing a culture of good service can be done despite a high workload per FTE. There are likely to be other factors that were not identified in this study that allow laboratories with a lower volume of work to generate a higher level of satisfaction with their nursing staff. Because there was no correlation between satisfactory performance and the rate of complaints per tests performed, laboratory management should not rely on the Table 11. Customer Service Practices of Participating Institutions Institutions, No. (%) Laboratory personnel dedicated to customer support Yes 49 (32.5) No 102 (67.5) Frequency of regularly scheduled meetings between laboratory and nursing management Monthly 52 (34.0) Quarterly 10 (6.5) Daily 2 (1.3) Weekly 1 (0.7) Yearly 1 (0.7) Other 3 (2.0) No regularly scheduled meetings 84 (54.9) Frequency of laboratory-provided formal customer service training for laboratory employees Only offered to new laboratory employees 40 (26.5) Offered annually to all laboratory employees 39 (25.8) Offered every 2 3 years to 17 (11.3) all laboratory employees Other 12 (7.9) No formal customer service 43 (28.5) training Institution provides formal customer service training for all employees Yes 72 (47.1) No 81 (52.9) Laboratory monitoring of any of the following for performance improvement in the past 12 months?* Turnaround times 145 (94.8) Critical value notification 114 (74.5) Customer complaints 95 (62.1) Corrected reports 83 (54.2) Pending lists 66 (43.1) Lost specimens 64 (41.8) None of the above are monitored 3 (2.0) Frequency of laboratory surveys for nursing satisfaction Yearly 15 (9.8) Between 1 and 3 years 7 (4.6) Monthly 2 (1.3) Quarterly 2 (1.3) Other 18 (11.8) Not applicable, do not survey nursing satisfaction 109 (71.2) * Multiple responses allowed. formal complaint process to provide an accurate indication of nursing satisfaction with laboratory services. Many organizations have dysfunctional or ineffective processes for collecting and processing complaints. Some organizations are slow or ineffective in getting this information to those who can, and should, act on it. The process for generating a complaint may be time-consuming, and if there is the belief that it will receive little or no attention, there will be a significant disincentive to communicate dissatisfaction in this manner, which may actually foster a cycle of poorer relationships. The results of this study reveal that intensive care units and emergency departments, which demand a high level of service from laboratories, are the least satisfied with the current levels of service, whereas low utilization sites (psychiatry and surgical units) have higher satisfaction with 1760 Arch Pathol Lab Med Vol 130, December 2006 Nursing Satisfaction With Clinical Laboratory Services Jones et al

6 laboratory service. This also may be a reflection of the service pace in such locations. Although most hospitals utilize both laboratory and nursing personnel to perform phlebotomy, the majority of phlebotomy is still performed by laboratory personnel. Phlebotomy courtesy received generally high marks, but there was much less satisfaction with phlebotomy responsiveness, suggesting a targeted opportunity for improvement. Prior to this study, most participating laboratories did not survey nursing satisfaction with laboratory services. Thirty-four percent of laboratories did have monthly meetings with nursing representatives. However, there was no association of these activities with nursing satisfaction. Reassessment of the content and resultant actions of these meetings may be needed because it does not appear that they contribute to greater nursing satisfaction. Most laboratories are providing customer service training to their employees. However, it is again evident that a well-intentioned activity may be failing to provide the desired results because customer service training had no association with raising the level of nursing satisfaction. Customer service training is a worthwhile and expected activity, but the details and content of its application need to be reexamined. Laboratories can educate employees in the concepts of customer service, but placing them into a working environment with flawed and suboptimal processes can prevent the application of the concepts learned. An overwhelming number of physicians responded that the quality of results was the most important aspect of clinical laboratory service (76.2%), 3 but only 15.2% of nursing personnel reported this as the most important aspect. Stat test turnaround time was reported by 37.8% of nurses as the most important aspect of laboratory service. Although 95% of laboratories responded that they monitor turnaround time, this is the area of least satisfaction. Clearly, the mere monitoring of turnaround time does not equate with improvement and better service. Working with the nursing staff to establish realistic turnaround time standards, and a serious examination of preanalytic, analytic, and postanalytic aspects of turnaround time, can result in a plan of action to improve service and customer satisfaction. In some circumstances, however, the issue may be unrealistic expectations by the nursing staff. Improved communication, education of the nursing staff, and clarifying reasonable turnaround time goals unique for each institution may manage unrealistic nursing expectations. If improving turnaround time is still considered a primary goal for optimal patient care, there needs to be a cooperative effort to secure the necessary resources and make institutional process changes to accomplish the desired goal. In summary, most nursing personnel are satisfied with the clinical laboratory services that are provided to the patients in their care. Although test result accuracy is very highly regarded, there is room for improvement in several aspects of service, particularly in test turnaround time and laboratory management accessibility and responsiveness. High expectations and lower reported satisfaction from nurses in the emergency department and intensive care units are important to consider when designing and modifying processes to provide optimal laboratory service to these areas. References 1. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Pathology and Clinical Laboratory Services. Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 2005:PI College of American Pathologists. Laboratory General Checklist: Laboratory Accreditation Program. Northfield, Ill: College of American Pathologists; GEN Miller KA, Dale JC. Physician satisfaction with clinical laboratory service, 99 03: Q-Probes. Northfield, Ill: College of American Pathologists; Zarbo RJ, Nakhleh RE, Walsh M. Customer satisfaction in anatomic pathology. Arch Pathol Lab Med. 2003;127: Steindel SJ, Howanitz PJ. Physician satisfaction and emergency department laboratory test turnaround time. Arch Pathol Lab Med. 2001;125: Novis DA, Dale JC. Morning rounds inpatient test availability. Arch Pathol Lab Med. 2000;124: Novis DA, Zarbo RJ, Saladino AJ. Interinstitutional comparison of surgical biopsy diagnosis turnaround time. Arch Pathol Lab Med. 1998;122: Steindel SJ, Novis DA. Using outlier events to monitor test turnaround time. Arch Pathol Lab Med. 1999;123: Howanitz PJ. Quality assurance measurements in departments of pathology and laboratory medicine. Arch Pathol Lab Med. 1990;114: Arch Pathol Lab Med Vol 130, December 2006 Nursing Satisfaction With Clinical Laboratory Services Jones et al 1761