The lobby of the Respiratory Department’s New Digs

If you are wondering why the athlete with a fractured femur or the cirrhosis patient needing a liver transplant or that child getting cosmetic orthomaxillary surgery are all heading off to Rochester, Minn, the answer is easy: Mayo.

In a world of managed care brands and HMO chains, the Mayo Clinic is an independent icon with superstar status. People who do not know one health care organization from another readily acknowledge Mayo’s prestige and its global clientele. What they may not know is that its pulmonary division has helped to create the standards for accurate measuring of lung performance, thanks to its staff and the director of its pulmonary diagnostic services, Carl D. Mottram, RRT, RPFT, FAARC, a recognized expert in the field.

Mottram was able to take a few minutes to talk about what sets his organization apart from the rest: “I think the thing that makes us unique is our commitment to high-quality patient care. We perform a high volume of procedures, yet we have quality system models in place to make sure that the data that we’re getting is accurate and reflects the patients’ underlying physiology.”

Most pulmonary function (PF) laboratories are housed within respiratory departments of hospitals, with maybe one or two PF testing systems, which are run by a handful of RT staff. Anything larger than this would be considered a big laboratory.

The Mayo Respiratory Care Team

“In our new laboratory space, we have 24 procedure rooms with a combined staff of 40 FTEs [full-time employees] where we see 150 to 200 patients a day—performing approximately 70,000 procedures a year. However, regardless of our size, we aspire to be a well-run, efficient, quality-driven diagnostic laboratory,” says Mottram.

Patient quantity at Mayo does not mean a corresponding sacrifice of quality. The pulmonary laboratory’s protocols allow the technologists to perform the proper tests for an individual at the lowest cost. “In moving into our new space we were able to make workflow process part of the design. That’s important to recognize, because most pulmonary labs don’t have that opportunity and we’ve been given the opportunity to design our lab based on our needs and wishes,” says Mottram.

The “space” Mottram is talking about is Mayo’s new pulmonary diagnostic center, a 16,000-square-foot area on the 18th floor of the building into which the lab moved in the first week of November 2007. The building, which was designed by Twin Cities-based Ellerbee & Associates, showcases a sleek design featuring polished wood, marble, artwork, and other appointments. Ellerbee has been the primary architectural designer of most of the Mayo buildings in Rochester.

Building a Legacy

Mayo’s track record in the pulmonary diagnostic arena dates back to the groundbreaking work of Ward Fowler, MD, Fred Helmholz, MD, Robert Hyatt, MD, and current medical director Paul Scanlon, MD, who have all contributed to the pulmonary diagnostic scientific literature. “Certainly, some of our founding physicians were involved in many of the initial studies that defined many of the tests we use today,” Mottram says.

Helmholz was involved in the first ear oximetry and nitrogen washout testing methods. Many RTs will recognize his name if only because of his contributions to the National Board for Respiratory Care (NBRC) and the AARC’s Sputum Bowl competition, of which the sportsmanship award bears his name. At the age of 93, he still comes into the clinic a few times a week.

While Mayo is responsible for industry milestones going back at least to the 1940s, one of the big ones for pulmonary testing occurred in 1959 when Hyatt first described the flow volume curve (FVC), a major diagnostic innovation for pulmonary testing’s most fundamental procedure: spirometry. Before that pivotal year, spirometry was graphically displayed by a volume time curve. But the FVC has a distinct advantage over its predecessor in giving a clear graphical view of what’s going on in the airways.

“Practitioners who review spirometry results of an individual can, with a glance, easily pick up whether someone has an obstruction regardless of what the numbered data yield. Clearly, [Hyatt’s] original description or identification of the FVC has enhanced the practice,” Mottram says. “We have a linked history to that procedure.”

In addition to the FVC, Hyatt was the first to describe respiratory muscle strength determination.

Maintaining the Gold Standard

Mottram personally strives for excellence by contributing regularly to the pulmonary diagnostics field by means of serving in professional organizations, writing for publications (including this one), or delving into his primary clinical interest of cardiopulmonary exercise testing. As he succinctly puts it: “I champion good, quality testing—period.” Mottram has served on the AARC’s Clinical Practice Guideline Committee, and the Quality Systems and Laboratory Practices Committee of the Clinical and Laboratory Standards Institute (CLSI, formerly known as the NCCLS), where he has assisted in writing guidelines that help drive good quality testing.

The laboratory also continues to be involved in research. The laboratory staff, Mottram, and the respiratory therapy students did a poster for their senior research project—entitled “A Comparison of Two Methods for Monitoring Airway Responsiveness Before and After the Administration of Methacholine,” involving the methods of spirometry and impulse oscillometry—and presented it at the AARC meeting in Orlando, Fla, on December 1-4.

As testing becomes more sophisticated, Mottram wants to ensure that professionals appreciate the basic physiology behind the data as well as adhere to the standards for measuring it accurately.

“In the past 20 years, we’ve had testing modalities like body plethysmography become more commonplace in laboratories throughout the country and the world,” he states. “Prior to a couple of decades ago, that device was seen only in research settings. Now it’s in the hands of many practitioners, so they have to know a little bit more about the physiology of how those devices work and how they interact with the patient.”

The Mayo Experience

The PF laboratory does more than test patients and process data. It is an essential link in providing care for the patients who come to the medical center. The Mayo Clinic PF laboratory is dedicated to testing and sending the results in a timely manner to the medical specialist who then determines a diagnosis. With 33,000 employees at the Rochester campus—Mottram calls the Mayo Clinic “a city within a city”—a specialist can be found within the Mayo network instantly.

The result of Mayo’s reputation and healthy endowment is that the clinic continues to draw the best and brightest. “Our technologists are our greatest asset. They are very patient focused and abide by Mayo’s primary mission: ‘The needs of the patients come first,'” Mottram says of the laboratory staff. “They enjoy their work immensely.”

Mayo’s pulmonary patients run the gamut, which means that practitioners coming through here—from RT students, to pulmonary and critical care fellows, to visiting clinicians—receive a degree of experiential learning that is unsurpassed because of the diversity of patients and the processes that they observe.

“They rotate through the lab for a month or so, and, with the large volumes, get to see the type of diagnostic tests associated with a vast array of pulmonary disorders,” Mottram says, “and that experience will never leave them.”

Making It Happen

The challenge for any nonprofit is securing funding, and Mayo goes about it in a variety of ways. “The institution as a whole is designated as a nonprofit,” he says, “but as far as our contribution to the bottom line, certainly, we are a revenue-generating entity within our division.”

Does the clinic prefer Medicare versus private-insurance payors? It’s a moot point.

“Anybody who comes here to seek medical care is typically taken care of, and they find the appropriate funding for those individuals,” he says. “Mayo has done a lot of charity work and is a very benevolent institution in general. It’s not uncommon for patients to come from all over the world, and Mayo will accommodate them to the best of its ability to assist them with their medical care.”

As with any reputable institution, fiscal integrity is the result of the quality service—not the other way around. It all boils down to the clinic’s high level of care, and Mottram repeatedly emphasizes the importance of adhering to guidelines in order to maintain the consistency of diagnostic procedure, whatever a patient’s pulmonary condition may be.

“From a work processes perspective, our technologists use protocols to provide appropriate testing for our patients,” he says. “Part of that is to be as efficient as you possibly can to keep your costs down and to meet the needs of your customers, who, from our perspective, are both the patients and the physicians that we serve.”

What may come across as management-speak applicable to any business is, in fact, a health care mantra any professional might abide by. Specifically, finding medical solutions in situations where every second counts.

“Our institutional guideline is to be able to provide an appointment within 48 hours of [a patient’s] physician visit and provide the results the same day of testing, and we are usually more successful than that,” Mottram says. “That’s part of the quality modeling. Not only is it a question of performing the test correctly but how quickly you can get the results to the patients, clinicians, and/or their medical records so that the physician can act on those results, and we have a lot of good processes in place that allow us to do that.”

Andrew Lentz is a former associate editor for RT. For further information, contact [email protected].