Weathering staff turnover, controversy, and a public health emergency, the Oklahoma State Public Health Laboratory transferred to a new facility in the midst of the COVID-19 crisis.

By Ann H. Carlson

There is never an ideal time to move a clinical public laboratory that serves an entire state—but try doing it at the height of a global pandemic. In the fall of 2020, as the world grappled to contain the COVID-19 virus, the Oklahoma State Department of Health (OSDH) made the controversial decision to relocate its Public Health Laboratory to a larger, newer facility in Stillwater, a city more than 65 miles away from its original location in the state’s capital, Oklahoma City.

The move immediately raised eyebrows, particularly concerning the lab’s new location. The tenth largest city in the state (population 48,134)1, Stillwater sits about an hour’s drive northeast of the capital, a distance that caused an estimated one-third of the lab’s employees to choose not to move2. 

Still, the advantages of the new space, now located in a former Devon Energy Corp. field office building3, outweighed the negatives for the department.

“The building in which we housed the Public Health Laboratory had become very outdated and needed a lot of work just to be a safe place for the testing to occur,” says Jan Fox, deputy commissioner of health preparedness at OSDH. “We had to find a better facility, and it just happened that the opportunity in Stillwater became available at the right time. We had the option to take on a very nice building with a lot of land, and so it just made sense to make that move.”

Meeting the Challenge

While many were surprised by the timing of the move, which coincided with the first year of the pandemic, the push to find a new home for the Public Health Laboratory had been years in the making. Although centrally located in the state capital of Oklahoma City—the largest city in the state with a population of 687,7254—the original laboratory was cramped and outdated. In 2017, state lawmakers had approved bonding capacity to allow for the building of a new facility, but, unfortunately, nothing came of it5.

In October of 2020, Governor Kevin Stitt announced the decision to move the laboratory to a facility in Stillwater that could house both the Public Health Laboratory as well as the newly formed Oklahoma Pandemic Center for Innovation and Excellence (OPCIE), with a focus on improved public health responses tailored to the needs of the state’s rural, urban, and tribal communities. The initiative, including the Public Health Laboratory’s relocation costs, would be funded by a legislature bond and relief bill money.”

The idea was to create a central campus devoted to human, animal, and environmental health.

“The OPCIE was initiated to make sure that we have access to new technology,” says Pravin Mishra, PhD, MBA, who came on board as chief operating officer of the Public Health Laboratory and the OPCIE in late 2021. “We are working hand-in-hand with the Public Health Lab and supporting their efforts to bring new assays and new technology on board.”

The management of both entities is handled by Prairie One Solutions, a nonprofit subsidiary of the Oklahoma State University Research Foundation3.

“While OSDH has the funding that provides for the salaries and provides administrative oversight of the employees, Prairie One does the training, they coordinate the schedules, and they do all of the technical supervision for us,” Fox says.

The $7-million facility in Stillwater officially opened in March 2021. At 37,000 square feet, the new laboratory is more than triple the size of its former home in Oklahoma City, which was a modest 11,000 square feet spread across three floors.

In addition to being larger with room for growth, “It’s a beautiful building,” according to Fox.

The transition of equipment, specimens, and personnel from the Oklahoma City facility to the current space took approximately 15 months to complete, and the laboratory is still working to bring back some of the testing that had to be outsourced during the transition. With the majority of specimens coming from county health departments throughout the state, the Public Health Laboratory offers testing for COVID-19, sexually transmitted diseases, and newborn screening, among others.

The move presented a variety of challenges to the Public Health Laboratory leadership. Not only did the team have to work quickly to hire and train new staff, but they also had to outsource the majority of testing to other states during the transition. While coordinating the move, the lab also had to ramp up its COVID-19 testing capabilities. To add to the complexity of planning for the move, unexpected problems arose. For example, an anonymous complaint led to a surprise federal inspection last fall. The OSDH says it is now in compliance with the correction plan it received from the Centers for Medicare and Medicaid Services6,7.  

Despite these challenges, Fox maintains the move was worth it. “I think the biggest problem was just simply that we were in the middle of a pandemic when the move occurred. So, that wasn’t really optimal timing,” she says. “It was hard and stressful, but it greatly increased our capacity for testing, which we needed. So, it was worth what we had to go through to deal with the pandemic and a move all at the same time.”

The lab has been up and running for nearly 18 months now, and Mishra notes that there are many advantages to the new facility.

“We have sufficient staff members to run all the tests that we offer currently,” he says. “We have access to cutting-edge instruments. We have a proper infrastructure. We have a better facility and additional space for future growth.

“We also implemented policies to handle workflow and to report issues appropriately and in a timely fashion, and we are constantly working with our partners to establish more proficiency, new assays, and innovative workflows,” he adds. “We are also working on partnering with vendors to provide us access to new technology.”

Hiring and Training New Public Health Laboratory Staff

One of the most pressing challenges during the move was making sure the new location was fully staffed.

“When we made the move, it caused a lot of concern for the employees that would then have to commute or relocate,” Fox says. “So, we did lose a lot of staff.”

This meant looking to local communities and universities for qualified new employees. “We hired the majority of people from Stillwater and surrounding areas, but we do have a handful of people who still commute,” Mishra notes.

The original laboratory employed a staff of 49 dedicated laboratory professionals, who had been with the department for a number of years. Many of the Public Health Laboratory’s current 37 employees are new hires.

“I think the biggest problem with that is just the loss of historical knowledge,” Fox notes. “The majority of people at the lab are new and don’t really have that historical perspective. So, that was one problem that we encountered.”

One way the Public Health Laboratory aims to rebuild and guard that institutional knowledge is by cross-training the staff. For example, Mishra notes that PCR testing is used for both molecular testing as well as for newborn screening workflows in the lab, so it makes sense to train technicians in both areas.

“That’s kind of essential in a state like Oklahoma. We don’t have the number of employees that a lot of states have,” Fox says. “We have to have cross-training. It’s just a good business model.”

Cross-training not only allows the lab to offer uninterrupted service, but it also builds individual expertise and confidence. “Cross-training and passing proficiency tests definitely allows laboratorians to grow,” Mishra says. “This method also supports the efforts in all areas of testing in the Public Health Laboratory.”

Part of this training is teaching staff how to report and learn from mistakes. Mishra is particularly proud of “root-cause analysis” policies that encourage staff to look at past mistakes and work as a team to make meaningful improvements to procedures and services based on those lessons.

“We always say that if you see something, say something,” he says. “We believe in transparency. We know that behind every specimen, every sample, there’s a patient. So, we treat these samples as if they are our own family members.”

Taking care with both the hiring and training processes results in a dedicated, loyal staff. “The people that work in our lab are very committed to doing their jobs, and they understand the responsibility they have to the citizens of Oklahoma,” Fox says. “They do a really good job.”

While both Mishra and Fox note that the laboratory has enough employees to cover the testing currently being performed, more staff will be needed as more specialized testing is brought back in-house. Recruiting for some positions, such as those that require scientific knowledge in microbiology, for example, can pose a challenge for rural-based laboratories, Fox shares.

Fox says recruiting will soon be underway for Public Health Laboratory positions related to molecular testing. “A lot can be said for developing relationships with the people that you’re trying to bring here,” she says. “You generally get people who want to raise a family in a nice setting and go to a really good school. We have a really good cost of living.”

Expanding Newborn Screening at the Public Health Laboratory

One of the primary responsibilities of the Oklahoma State Public Health Laboratory is newborn screening for the approximately 52,000 babies born in the state annually, according to Mishra.

To ensure this vital service went uninterrupted during the move, the OSDH hired PerkinElmer, a Waltham, Mass.-based company and a leading global supplier of newborn screening products, to provide screening equipment and training to employees in the new location.  

The Public Health Laboratory moved existing and new equipment to Stillwater, which allowed the state to screen newborns for five new disorders (X-ALD, a combined SMA/TREC screen, Pompe, and MPS-I). The ability to screen for these five conditions brought the lab into full 2021 compliance with the Recommended Uniform Screening Panel (RUSP) suggested by the U.S. Department of Health and Human Services. The laboratory in Oklahoma City continued to screen newborns until the new lab in Stillwater was operational, which resulted in no disruption of newborn screening.  

“We have a total of 59 conditions that we screen for, which is pretty significant,” Mishra says. “These are rare, but lethal conditions and we want to identify them early. So, I would say we have improved significantly since we moved here, and we have expanded as well.”

Fox notes that the laboratory has put a lot of effort into decreasing false positives and bringing back test results earlier in the day so that staff can communicate these time-sensitive results to parents in a timely manner.

“How we communicate the results can make a big difference and have an impact, and we have to keep that in mind,” Fox says.

Being a Good Neighbor

During the move, most of the Public Health Laboratory’s testing had to be outsourced to other states at some point. PerkinElmer Genomics also provided an outsource option for its expanded newborn screening services, while the lab completed their installation and validation to ultimately bring screening back in-house. Fox estimates that 70% of all testing has been brought back in-house so far, and the laboratory is still working on bringing back the outstanding 30%, which includes some rarer testing needs such as for tuberculosis and anthrax.

“I’m really proud of how we’ve been able to bring testing back pretty much on the timeline that we had set out,” Fox says. “We are currently doing pilots to bring back HIV and syphilis testing. After that, we will just have our molecular testing left to bring back. So, I feel like that’s a lot of work that has taken place in a short amount of time, and I’m very pleased that we’ve been able to get it this far.”

The new facility will have to be modified to bring back all testing to the Stillwater site.

“Our main focus is bringing back the remainder of the testing,” Fox says. “We do have to do some construction to get everything in place to bring back molecular testing. It requires BSL-3 level equipment, and currently we don’t have that capacity. So, we’re going to have to build that and make that happen.”

Outsourcing is not ideal for several reasons, including the impact on billing. Although Fox notes that the Public Health Laboratory receives federal funding—including a large grant from the Centers for Disease Control and Prevention—billing for services is also a source of revenue.

“When your public health lab is up and running well, you generate some revenue because you can bill,” Fox says. “One problem is that during the transition, we weren’t able to bill because we weren’t running the tests. So, it resulted in some loss of funding, but that didn’t really impact our ability to provide testing because we do have the federal funds to back us up.”

Of course, the main impetus to bring back testing is the impact that outsourcing to its neighboring states, which are also struggling to keep up with testing demand from their own residents. “Other states are dealing with the same staffing shortages that we are, and it’s been ongoing for months,” Fox says. “Some of the states have had no choice but to tell us that they can’t accept samples after a certain date. So, we have had to do a lot of renegotiating with other states just to keep that going.”

Fox looks forward to reducing the burden on other states by bringing all the outsourced testing back in-house soon. In addition, the laboratory also plans to include a specimen storage facility with the aim to assist and collaborate with other labs in nearby states6.

“We have to be good neighbors,” Fox says. “Not only do we need to do our own tests so that other states don’t have to do it, but if other states need to send their specimens somewhere, we want to be stood up so that we can return the favor as needed.”

There are also plans to expand Stillwater’s testing capabilities, such as adding cannabis testing and agricultural panels as well, Mishra notes. “The overall goal is to improve the public health,” he says. “With Oklahoma being a uniquely agriculture state, the intersection between human health and agriculture sustainability is imperative to the health and well-being of Oklahomans. So, our goal is to offer the best tests and service we can offer to Oklahomans.”

Part of that is offering education to healthcare professionals about infectious diseases through the OPCIE and their university partners. “We are basically putting together curriculum to offer certification in disease prevention and infectious diseases to improve knowledge for healthcare workers,” Mishra says. “We also are collaborating with other vendors, including PerkinElmer, to develop new technologies that can rapidly detect new infectious diseases and also help us monitor that in real time at the ZIP code level.”

According to Fox, the OSDH is also working closely with the Public Health Laboratory to develop an emerging infections “surge plan” that will dictate how the department handles future public health emergencies and increased testing demand. Primarily, this plan will focus on COVID-19 surges; however, she notes these steps are likely to be relevant to other emerging diseases, such as monkeypox.

“That way, we’re not just reacting to the pandemic; we’re actually being proactive,” Fox says. “Public health in general usually flies under the radar. If we’re doing our job well, no one knows we’re here because we’re taking care of problems before they happen. So, the pandemic highlighted the importance of public health and especially the importance of having a good, sound, functioning public health lab.”

Featured Image: The Oklahoma Public Health Laboratory relocated from a cramped, outdated facility in the state’s capital to a larger, modern facility in nearby Stillwater. Photo: Oklahoma Department of Health

Ann H. Carlson is a regular contributor to CLP.

References

1. Quick Facts Stillwater city, Oklahoma; Oklahoma City city, Oklahoma. United States Census Bureau. July 1, 2021. www.census.gov/quickfacts/fact/table/stillwatercityoklahoma,oklahomacitycityoklahoma/PST045221

2. “Public Health Lab had issues with staffing, storing COVID-19 samples, CMS report shows.” Branham, Dana. The Oklahoman. Dec. 7, 2021. www.oklahoman.com/story/news/2021/12/07/oklahoma-lab-had-issues-staffing-storing-covid-samples-report-shows/6424222001/

3. “How Relocation, Privatization Compromised the Oklahoma Public Health Lab Mission.” Monies, Paul. Oklahoma Watch. Dec. 9, 2021. https://oklahomawatch.org/2021/12/09/how-relocation-privatization-compromised-the-oklahoma-public-health-lab-mission/

4. Quick Facts Oklahoma City city, Oklahoma. United States Census Bureau. July 1, 2021. www.census.gov/quickfacts/oklahomacitycityoklahoma

5. “Oklahoma Department of Health outsources management of public health lab.” Forman, Carmen. The Oklahoman. Dec. 24, 2020. www.oklahoman.com/story/news/politics/state/2020/12/24/oklahoma-department-of-health-outsources-management-of-public-health-lab/317845007/

6. “Public Health Lab working to bring back outsourced testing, expand capabilities.” Williams, JaNae. The Oklahoman. April 22, 2022. www.oklahoman.com/story/special/2022/04/22/public-health-lab-seeking-expansion-and-outsourced-tests-returned/7163791001/

7. “Federal Inspectors Clear Oklahoma’s Public Health Lab of Major Infractions.” Monies, Paul. Oklahoma Watch. April 25, 2022. https://oklahomawatch.org/2022/04/25/federal-inspectors-clear-oklahomas-public-health-lab-of-major-infractions/