April 2010
Feature Story

Anne Ford

If necessity is the mother of invention, then the slumping economy has birthed a litter of millions. Just ask any laid-off worker who’s jury-rigged a broken toaster instead of replacing it, figured out that half a dryer sheet works just as well as a whole one, or started baking with bruised fruit instead of discarding it. For that matter, ask any laboratory manager who’s had to reengineer lab work processes to make the most of shrinking resources.

Of course, some larger, more financially stable laboratories are feeling the economic pinch to a lesser degree than their smaller or less wealthy counterparts. Which is not to say that well-off labs don’t have any work-process rejiggering to do—just that they’re more likely to be able to afford technological solutions that make that rejiggering easier.

Here CAP TODAY presents a handful of laboratories that recently revamped some of their work processes—some in response to economic pressures, others as part of a general effort toward greater efficiency and productivity. Their experiences and tips may help other laboratories figure out ways to make their dollars stretch, their medical technologists happy, and their quality of care excellent.

Heidi Riggenbach, CLS, MT (ASCP), might qualify as the laboratory version of MacGyver (the 1980s television character famous for improvising life-saving devices out of everyday objects). Not that you’ll catch her creating a piece of lab equipment out of a two-by-four and a stick of Trident, but her laboratory’s geographic, financial, and staffing situation has forced her to come up with creative solutions to her work process problems. The small hospital lab she directs, Barton Health Laboratory in South Lake Tahoe, Ca., serves an isolated mountain community, which, she says, many people have left in recent years to look for work elsewhere. “Because we are a small, rural area, the economy has hit us pretty hard,” she adds. Tourism is down, and only about 30 percent of the homes in Lake Tahoe are owned by full-time residents. “Our permanent residential population has shrunk dramatically over the past 10 years and continues to shrink.”

Then, too, the area’s resort-like nature means “we are really busy in the winter and the summer, but our shoulder seasons, fall and spring, usually drop off in volume. If we drop off too much, then we get into trouble.” Not surprising, then, that they’ve been asked to cut costs.

Sadly, those cost savings had to include staff layoffs in 2009. They’ve also included a switch from 10-hour to eight-hour shifts, meaning not only that laboratorians have less time to get their work done, but also that shifts no longer overlap—making it more difficult for Riggenbach to hold group meetings with employees from more than one shift at a time.

Why not pursue the cost savings said to stem from Lean principles? Though Riggenbach admires the Lean philosophy, she doesn’t think it’s practical to implement in her laboratory: “When you’re this small, it’s really hard to Lean down anymore, because you just don’t have the space to do it with. I know a lot of labs have done Lean, and that’s great, but most of the ones that have gone through major changes like that have been able to remodel at the same time.”

Instead, Riggenbach and her medical technologists have learned to scrutinize the laboratory’s layout, looking for any possible permutation of equipment locations that could result in greater efficiency. “The techs constantly ask, ‘What if we moved this machine here and this machine here? How easy is it to step from piece to piece?’ Some of the equipment they moved around in hematology has been really, really helpful as far as the streamlining of it.”

She has also been ruthless about paring tests from the laboratory’s menu that require too much manual time. “It is not realistic to have less staff and continue doing all of the manual tests,” she says. “Even if it brings in money, if it takes up too much staff time, we’ve had to eliminate it. We used to do chlamydia by DNA amplification. We got rid of that completely. Those have such high reimbursement, and there’s not another competing lab in this area, so we had quite a high volume, but somebody has to sit there and do all that pipetting and that testing.”

In addition, she’s seen some staff time free up as the result of an IT solution that electronically photographs a patient’s lab report and automatically sends it to that patient’s medical record. “The staff used to have to print out those reports and make copies, and now it happens automatically,” she says.

In general, it’s “constant monitoring” that keeps Riggenbach’s laboratory functioning as efficiently as possible. “You can’t just look at your processes every year,” she says. “You can’t sit back. With the economy the way it is, you have to be more proactive in doing it faster and trying to stay on top of it more frequently.” She periodically examines, for instance, the time of day a particular test is run and whether that timing meshes with the ordering physician’s needs. “We’ve really had to look at the actual timing of the test, especially the ones we have to batch, to try to make them hit the doctors at the right time to make them happy but make the workflow smooth with the limited staff we have,” she says.

In the face of all these constraints, she says, it’s crucial to work closely with staff. “I make sure I’m working out there with them on the bench and having conversations on almost a daily basis. As we have gotten busier because of staffing issues, I have to ask them to do more things. As long as they’re kept in the know, they are more willing to take on bigger challenges because they’re part of the team. They’re in my office constantly: ‘What about this kit? Can we get it cheaper there?’ It has to be a bigger team effort.”

A couple thousand miles to the east, the director of another, somewhat larger and much less isolated laboratory expresses similar sentiments. Bobbie Jenkins, MT (ASCP), is the director of laboratory services for the two-hospital MedCentral Health System in Mansfield, Ohio, and like Riggenbach, she emphasizes the importance of strong communication with staff, particularly when introducing new, more ­efficient work processes. “This last year has been a very scary time for workers. I think it makes them feel like we’re trying to preserve their jobs and gives them a feeling of security when they know we’re being efficient,” she says.

Unlike Riggenbach, however, Jenkins has not had to lay off nonclerical staff. And unlike Riggenbach’s, Jenkins’ laboratory has been able to invest in equipment—such as the Vitek 2 automated microbiology system it purchased last year—that allows it to do more work without having to add staff. Aside from the Vitek 2, which BioMérieux manufactures, the laboratory relies largely on Siemens equipment, says Jenkins, and that integration has led to greater efficiency. “We use their software here in the laboratory and also within the hospital for our HIS and clinical systems. Our ordering, reporting processes, nursing documentation—that’s all Siemens products,” she says. “I think through integration we’ve become, as a hospital, very efficient.”

She points in particular to Siemens’ Workflow/Rules Engine, which can be programmed to produce automatic alerts to nursing staff. “We historically have had to call things to infection control and to the floor—for instance, positive C. diffs and MRSAs —to alert the nursing unit,” Jenkins says. “Now, the alerts are automatically sent to the computers the nurses are using, and therefore we have eliminated hours and hours of phone calls that our microbiology department was making every week to alert the nursing units and infection control.”

Like Riggenbach, Jenkins has not seen the need to invest in formal Lean training. “A lot of us have been to seminars and meetings about Lean,” she says. “But we’ve had some workflow analysis done, and a lot of times they’re pretty impressed with the fact that without having any formal training, we’ve done a pretty good job of becoming as efficient as we can.”

In the future, Jenkins would like to expand the use of Siemens’ positive patient identification phlebotomy system, which wirelessly downloads phlebotomy orders from the LIS onto phlebotomists’ PDAs. “Let’s say the phlebotomist is up on the floor, and there’s a stat on one of the nursing units,” Jenkins says. “Before, we had to dispatch the phlebotomist by paging or calling them, but now they immediately see that stat order and just get to the patient’s room.” She would like to improve the safety and efficiency of the process even further by installing the technology onto the computers the nurses use at patient bedsides for blood bank blood administration and blood administration documentation. She expects that to happen in the next six to 12 months.

Mary Kolar, MT(ASCP), core laboratory coordinator for Alegent Health Laboratory Services, Omaha, has seen great strides in her lab’s average turnaround time in the past two years. It improved from 42 minutes in fiscal 2008 to 37 minutes in 2009, and so far in 2010, it’s at 28 minutes. She credits the intersection of two factors with that improvement: Lean principles and technological solutions.

“Just last year, we did a mini Lean project in the auto cell, which contains all our analyzers,” Kolar says. “In our Lean process, one tech verifies all the results that come off all the analyzers. We have somewhere between 70 and 80 percent autoverified, so the tech only has to look at 20 to 30 percent of results that flag. When we did our project, we moved our coagulation and hematology analyzers closer to our automation, making the area smaller so the tech had less distance to walk.” The specimen processors were taught to load the StreamLab analytical work cell more often, following single piece flow. “We really noticed a big difference in turnaround time. That’s the biggest thing we reengineered this past year.”

In that instance, it was the Lean analysis that led to using the technology more efficiently. But in Kolar’s experience, it can work the other way, too—that is, the technology can reveal areas in need of Lean analysis. “Right now we have a StreamLab analytical work cell for our automation, and we have two Vistas and a Centaur connected to it with an EasyLink computer. Using the EasyLink, I can see that there was a big blip in my turnaround time yesterday. I can then view how the StreamLab was loaded, and I can pull a graph that shows too many specimens were put on at once.” That alerts her to investigate why that happened and whether the problem is a process-related issue for which there is a Lean solution.

Despite the efficiencies Lean has brought, Kolar’s laboratory has not entirely escaped the bad economy’s effects. “We’ve lost some of our volume due to patients not going to doctors as often,” she says. And when a technologist or technician leaves or retires, the person isn’t always replaced. Then, too, even if the economy were better, “it’s getting harder and harder to hire med techs,” she adds. “A lot of students come out of training and they never work as a med tech. They go right on to physician assistant programs, med school, or pharmacy school. That’s been kind of frustrating.”

In Kolar’s estimation, there may be a technological solution for that, too. She’s curious about the role remote monitoring might one day play in the laboratory. “You could have nontechnical staff loading instruments and make sure med techs are able to see what’s happening through a video camera and have monitors on their desks in a separate area or even a separate building,” she says. They could interact directly with the instruments attached to their computers and go to the area, if needed.

“The ICUs and CCUs at our hospitals are doing that right now through eICU. They have a building away from the hospitals, and they have nurses, doctors, physicians’ assistants, and/or nurse practitioners sitting and viewing patients’ monitors, and they have cameras in the patients’ rooms so they can actually look at the patient, if necessary. That allows the nurses in the ICU to do patient care, instead of sitting at the nurses’ station viewing monitors. So we’re looking at that kind of thing in our lab, and hopefully someday we can move to that and help with the med tech shortage.”

Richard L. Wong, CLS, MT(ASCP), administrative director of the core laboratory at Dameron Hospital Association, Stockton, Ca., is one of the lucky lab directors who has not been forced by the ailing economy to lay anyone off. “We’ve had days when the hospital had low census, and we’ve had the staff do lower workload days,” he says. “But those have been very few. We’ve been very lucky.”

But is it luck, or foresight and resources? When Wong’s laboratory was being built about three years ago, the hospital administration allowed him to “basically design the lab from the ground up,” he says. “I looked at our processes that were manual and tried to put in place an automated analytical process or look at ways we could be more efficient in each analytical phase. I was looking at the total process while I was designing the lab.”

Like Jenkins, Wong spotted an opportunity to improve the efficiency of the phlebotomy process in particular. “The first thing I recognized was that since we were going to be physically outside the hospital”—his lab sits across the street from the hospital, to which it is connected by pneumatic tube—“I had to have a way of communicating with the phlebotomists. My vision was that we had to go to an automated, at-the-bedside blood collection process. So we decided to go with the CareFusion Pyxis because it’s wireless. The phlebotomists are able to manage their draws on a real-time basis. As soon as the order’s placed in our hospital information system, it appears on the phlebotomist’s PDA for them to administer the blood collection portion at the bedside. They can pull up the orders for the different labs being ordered, and then generate the labels, draw the samples, and scan the samples. They’re tubed over to the core laboratory, which takes about 15 seconds or so.”

Next, Wong decided to implement front-end automation, which he obtained from Beckman Coulter in the form of the company’s AutoMate 800 system. “It essentially replaces the duties of receiving, centrifuging, aliquoting, and distributing those samples for the various analytical systems,” he says. “The ROI on that was three FTEs. It gave me the flexibility to move those FTEs to areas where I could not automate, such as micro.”

At the moment, Wong is overseeing the implementation of autoverification for chemistry and immunochemistry, as well as preparing for the July introduction of “an integrated system for hematology that will allow us to do autoverification and play into further utilization of our front-end automation.”

While Wong’s laboratory has not formally implemented Lean principles, he bore them in mind when designing it, he says. “An example of that would be that 75 to 80 percent of the work that comes in is either chemistry or immunochemistry. So I strategically placed our integrated immunoassay and chemistry analyzer three feet away from the AutoMate, so that once that sample’s processed, my lab assistant turns around and loads it onto the analytical analyzer. The hematology and urinalysis body fluids in the coag area are 10 feet away from the preanalytical analyzer. So there are reduced steps.”

Despite their varied locations, sizes, and resources, all four laboratories emphasize the importance of encouraging teamwork among medical technologists as much as possible—whether that’s because, like Riggenbach, the director must heavily rely on them to help brainstorm solutions to the problems limited funds pose, or simply because having workers who communicate well encourages overall operational efficiency. As Riggenbach says: “Keep the information flowing as much as you can, and they respect that and respond to that.”