September 2011
Feature Story

Anne Ford

Chalk it up to competitive instinct, sheer self-consciousness, or just human nature: When we know someone’s watching us, we do a better job. Ask any speeder who’s ever slowed down to a prudent 55 MPH upon glimpsing a highway patrol car. Or just ask Neil Crowson, MD.

“Whenever you monitor a process, it improves—if and only if people know you’re looking,” says Dr. Crowson, president of Pathology Laboratory Associates, Tulsa, Okla., and clinical professor in the pathology, dermatology, and surgery departments, University of Oklahoma. He’s the former chair of pathology at Tulsa’s St. John Medical Center, with which PLA is affiliated.

By “process,” Dr. Crowson means “anatomic pathology specimen processing.” By “people,” he means “pathologists and laboratory technicians.” And by “improve,” he means “shave four to five hours off the average time it takes to produce a slide.”

Four to five hours? Yes. Since 2009, when he and his colleagues at Pathology Laboratory Associates implemented an operational process improvement strategy for anatomic pathology specimens, Dr. Crowson has seen not only a drop in turnaround time but also far fewer errors that affect patient care. The aim of the OPI, as he calls it, was to increase productivity and safety by improving the AP specimen tracking process and by reducing employee stress with more predictable workloads.

Pathology Laboratory Associates and its allied corporation, Regional Medical Laboratory, had already implemented a major process improvement in 1981, when a 100 percent review system was instituted for each of the 100,000 surgical specimens now processed annually. “Every single case is seen by at least two pathologists,” Dr. Crowson explains. “In our operation, two pathologists have to make the same exact mistake for it to impact the patient. We have reduced the significant error rate, by which I mean an error that impacts patient care, to 0.07 percent of cases.” In comparison, “detection of clinically significant diagnostic errors in the pathology literature ranges from 0.26 to 1.7 percent of all cases interpreted.” With two or more pathologists seeing every case, he says, “due diligence is performed for each patient result.”

This time around, Dr. Crowson and his colleagues began their OPI efforts with a good old-fashioned system analysis. “Managers sat down with the people who actually do each technical job,” he explains, “from the courier, to the technician who logs the specimen in, to the person who grosses the tissue, to the person who puts the tissue on the processor, to the person who takes it off the processor, to the one who cuts it,” and so forth, all the way to sign-out of the report at the pathology workstation. After each step of the process was identified, a bar-code system was implemented so each staff member could record precisely when he or she began and completed that step, or “gate.”

Then, too, the bar-code system ensures that specimen containers are matched to tissue cassettes in the gross room and that blocks are matched to slides in the histology laboratory. “At each embedding station, we have graphical user interface computer screens that are touch-sensitive and 2-D bar-code readers to match every slide to every block,” said Dr. Crowson in a “Best Practices in AP” talk at the May meeting of the Compass Laboratory Leadership Group, a group of laboratory leaders from not-for-profit integrated delivery network health care systems. “The technologist gets a warning signal and cannot proceed if there is not a complete match. The same thing occurs at the gross pathology bench.” The bar-code system also helps staff track down missing specimens: “If a specimen is not accounted for, we know who the last person was who touched it and when.”

The data obtained through bar-code scanning are uploaded to a data warehouse—a computerized system that tracks dozens of data elements for each specimen, such as the number of minutes spent on it at each point in the specimen processing cycle. Those data are then analyzed, so that “we could identify the time it took to get 90 percent of the specimens through each gate in the process,” he explains. “We started matching the volume of specimens to the number of FTEs available to do the work per hour. And then we optimally staffed so we had the same throughput per FTE in every hour of the business day. As soon as you staff appropriately, the throughput increases in speed, and you will find that you’ve reduced the number of minutes it takes to get 90 percent of those specimens through the gate. Having achieved a reduction, you reset the time target.”

Did the laboratory technicians resent having someone look over their shoulders, as it were? Initially, they were uneasy, he says, “but once they realized that the intention was to focus on the process and not the people, and that the process was not an evaluation tool, the fear factor vanished.” It helped, too, that the technicians knew they weren’t the only ones being monitored.

“For roughly eight years, we’ve been monitoring all of our pathologists,” Dr. Crowson told the Compass Group members. “We measure the time it takes to sign out a skin biopsy, a breast biopsy—lumpectomy or mastectomy—a colon biopsy, et cetera.” That way, “the pathologists are playing exactly the same game as our techs. You never ask your troops to do what you’re not prepared to do yourself.”

As it turned out, the troops ended up thrilled with the new process, largely because of its success in eliminating workflow bottlenecks. “We’ve been remarkably successful in reducing the impact of boluses that used to make our staff frantic by readjusting our staffing so that the stressors on those staff diminished,” said Dr. Crowson later in his talk. “And their productivity and their job satisfaction skyrocketed.” In November 2009, the target time from courier drop-off to specimen accessioning was 30 minutes, “but the first half of that month we almost never met it. We began to meet it toward the end of the month, and in November 2010, we met it almost every day.”

What is the result of all these changes? When he arrived in 1999, PLA did roughly 30,000 surgicals. “Now we do 100,000 cases annually. In the past we were lucky to get 90 percent of the slides to the pathologist by 1 PM for sign-out. From October 2010 to the first week of March 2011, that time was advanced to around 8 AM. By the third week of March, we were down to 7:30 AM; over the course of 10 days, the process had improved half an hour. There will come a time at which we can’t improve processes any more. We’ve grown the practice about 40 percent in the last five years, and we have the same number of pathologists, but most are going home at 6:00 PM instead of 8:30 PM. We’re getting the right slide matched to the right cassette, and I can be virtually certain that the tissue sections I read are actually on the correct patient—every time.”