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To lower costs, one lab takes automation to task July 2003 Like
many hospital laboratories, the one at Abington Memorial In 2000, the Abington laboratory participated in a benchmarking study using HBSI Action and found, to its dismay, that “we weren’t meeting our targets [compared with peers] for hours worked per billable test and costs per billable test,” recalls Kathryn Durr, administrative director of pathology. Moreover, Abington was adding outside clients, such as nursing homes, to boost volume and compete with the reference lab, but its existing instruments couldn’t keep up with the demand. “We needed to look at better instruments and processes to support taking on additional clients,” she says. Abington’s pathology department chair, Herbert Auerbach, DO, speaking in May at the Dark Report’s Executive War College, described the lab as having “run into a wall.” “We couldn’t increase our billables per worked hour. We were at the 50th percentile using HBSI data, and we weren’t making any improvements,” he told his audience in New Orleans. At the same time, hospital administrators at Abington Memorial, a 508-bed comprehensive medical center, were pushing the laboratory to cut costs. The lab runs more than 3 million tests a year, mostly chemistry, of which 42 percent are inpatient and 58 percent are outpatient. “We thought
we were pretty efficient in running assays,” says Dr. Auerbach,
who also spoke recently with CAP TODAY. He says the HBSI
data were skewed because Abington has a higher procurement cost
for outpatient tests than most of its peers because it provides
extensive phlebotomy services to its clients. But the hospital brass
disagreed. “They were lumping all our costs together and looking
at us versus our peers, and they just wanted to get [those costs]
down,” he says.
The pressures to cut costs while building volume led to a multiyear, two-pronged effort in which Abington Memorial’s laboratory reorganized its chemistry, hematology, coagulation, and urinalysis sections into a single core lab and followed that up by automating the majority of its tests there. With lab automation, Dr. Auerbach says, “we hoped to do it cheaper, faster, and better.” Task-targeted
automation Abington decided to bring in task-targeted automation rather than total lab automation. The idea was to automate one section of the laboratory at a time. Each section would get its own automated instruments targeted to its own workflow. That kept the price tag lower than it would have been for total lab automation and gave Abington the flexibility to negotiate with several vendors rather than one. “Task-targeted automation offers much better use of technologist labor,” Dr. Auerbach says. “We didn’t want to automate a bad process.” The aim was to simplify processes with automation to reduce errors and turnaround time and expand the test menu. The core laboratory represents 88 percent of lab charges, Durr told CAP TODAY. “We targeted areas for automation where we could get the most bang for the buck,” she says. “In terms of sheer volume,” Dr. Auerbach adds, “when you do chemistry and immunoassay, you’re doing 70 percent of your lab. Add hematology and you’re at 80 to 90 percent.” Hematology was the first to be automated. Abington purchased a Cell-Dyn WorkCell system from Abbott Diagnostics; it consisted of two Cell-Dyn 4000 automated cell counters, the slidemaker/stainer module or SMS, a recirculating track that transports the specimens using a rack-based conveyor, and the Navigator data manager. The incremental cost for the automation—excluding analyzer equipment Abington would have purchased anyway (for example, the Cell-Dyn 4000)—was about $200,000, Dr. Auerbach estimates. In evaluating
expenditures for automation, Abington estimated that for every $100,000
spent on automation it would have to save about $35,000 in costs
annually to compensate for the capital expenditure amortized over
five years and the estimated cost of a service contract. “To
translate that into how many worked hours we would have to save,
we used a simple formula,” Dr. Auerbach says. There are 8,760
hours in a normal year. A regular work year is 1,960 hours. “Therefore,
for example, if a piece of automated equipment could save one position
across all shifts seven days a week, that would result in a savings
of 8,760 divided by 1,960 or 4.5 full-time equivalents,” “In the
core lab area of chemistry and immunoassay we sought an integrated
solution,” he says. “We wanted an analyzer or system
of analyzers that would consolidate much of the testing onto one
platform.” Abington selected the Bayer Advia WorkCell, which
included two Advia 1650 chemistry analyzers and two Centaur immunoassay
analyzers. “Bayer was the first to offer an automated integrated
chemistry and immunoassay system. Before this, laboratories that
attempted to integrate chemistry and immunoassay testing had to
do it with customized automation,” he says.
Excluding the cost of the analyzers, which Abington would have had to buy regardless of whether it automated, the additional cost of the integration, track, sample manager, and requisite software was about $400,000 to $500,000, he says. Dr. Auerbach says having data managers as an interface between the automated analyzers and the laboratory information system has several advantages. Previously, the LIS would treat results from each of the analyzers as different methods. “But with a data manager,” he says, “the data from four different instruments are consolidated, and therefore reruns, reflex testing, and autovalidation can be managed more easily before results are passed to the LIS.” The
payoffs In addition, worked hours per billable test declined from about 0.2 in 2000 to 0.15 in late 2002. The target was to be at least at the 35th percentile on the HBSI benchmarking data for hours per billable test, and by the third quarter of 2002 Abington had achieved that. Billable tests per FTE showed about a 20 percent improvement between late 2001 and late 2002. “We’ve climbed to 13,000 annual billable tests per FTE,” says Dr. Auerbach. “We can be semicompetitive with Quest,” the nearby reference laboratory. Salary and supply costs and worked hours per core lab test have all declined. Multiple instruments can share one tube of a patient sample, reducing cost and the volume of biohazardous waste. The total direct cost of the average lab test, including labor and supplies, has dropped from $9.13 to $7.96, Durr reports. The lab has also been able to consolidate its floor space usage. “We have most of our testing in a very confined area,” Dr. Auerbach says, though that required a new look at heat load and air-conditioning and similar things. Turnaround times
plummeted. For example, on the Advia WorkCell for chemistry analysis,
69 percent of tubes are sampled, archived, and sorted in the sample
manager in less than six minutes. Stat results are available in
22.3 minutes and routine results in 24.1 minutes. (Those are median
times.) Overall, the median stat turnaround dropped from 52 to 43
minutes after automation, while routine turnaround times dropped
from 100 minutes to In chemistry, which represents three-fourths of the lab’s workload, 95 percent of test volume can be processed on one system, including 56 serum assays, 18 urine assays, and seven fluid assays. In hematology, 62 percent of CBC results are autovalidated, so that technologists spend their time managing only the exceptions. The automation
process can be managed from PCs within the laboratory. “We
use keyboard video mouse technology, known as KVM switches, to control
everything from PCs,” Dr. Auerbach says. Using a matrix type
of KVM switch technology, the lab could integrate any analyzer that
uses a PC or Unix workstation as a front-end controller, and thereby
gain full control of the analyzer from multiple access points in
the lab. And the new systems are robust. “Over 18 months of
use we’ve seen less than 24 hours of downtime,” he says. The
glitches “Automation requires a whole new skill set in your medical technologist,” Dr. Auerbach adds. “They were used to knowing exactly what they put on each instrument. Now they have to feed the automated workcells and keep a continuous flow going, and manage the exceptions. They have to think about integration.” Medical technologists’ training in computer information systems has been limited, he notes. “They probably receive some training in their didactic curriculum, but in their practical year of training, their informatics experience will depend on the lab they trained at,” he says. They have to be prepared for a networked computer environment, and be able to work in the traditional role of medical laboratory scientist and to understand the informatics involved in an automation system. “The technologist has to be able to recover from a computer lockup or system crash without having to call the help desk,” he says. Under the nonautomated workflow, Durr adds, technologists and technicians would run one machine and do each test separately. With automation, “there was a different dynamic,” she says. “Now they had to share data and interact with other team members. They had to respond to the person who was running the data manager.” Dr. Auerbach and Durr acknowledge that although upfront training was provided to the technologists and technicians, the lab underestimated the training needs, not just on the new equipment but also with new processes. Says Dr. Auerbach: “You can’t just buy a vendor’s solution and think it’s done. You have to work to get those FTE reductions. You have to figure out how to change your workflow.” However, says
Durr, “You really can’t experience it until you do it.
At some point you have to take the plunge.”
Abington continues to tweak the automated systems. “We’ll be adding plasma as an option soon,” Dr. Auerbach says. Other projects include expanding autovalidation, consolidating the menu, refining how reagents and tubes are managed, stocking the system to make sure there’s enough of everything throughout the day, and offering computerized clinical alerts on important results via the hospital information system. “We want to expedite delivery of test results to physicians,” he says. In summary, Dr. Auerbach recommends that any laboratory considering automation take the following steps:
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