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Sonora Quest Laboratories pulling paper processes

August 2020—At Sonora Quest Laboratories, working backward has been a key strategy for leaping forward. Little by little, the Arizona-based integrated laboratory system has been retracing paper trails and assessing established processes as part of an ambitious plan to eliminate paper use across its seven commercial laboratories, 28 hospital labs, and more than 75 patient service centers.

Sonora Quest’s operational excellence, or OPEX, team undertook the project in 2018, says Jean Hammelev, vice president of operational excellence at Sonora Quest and Laboratory Sciences of Arizona. “We determined we had many opportunities to automate processes, reduce paper storage, and increase efficiencies,” she says.

A catalyst for the project was Sonora Quest’s plan to move its main laboratory, in Tempe, to a new building across the street, which occurred in June. The lab was eager to move toward paperless processes because of “how much stuff we had taking up space and inventory,” says Matthew Reinhard, Six Sigma black belt and manager of performance excellence at Sonora Quest and Laboratory Sciences of Arizona, who is spearheading the initiative. Hammelev gave a presentation on the project at the 2019 Lab Quality Confab conference last fall, based on Reinhard’s plan.

“In an integrated laboratory system like ours, processes extend well beyond the lab,” says Reinhard, which is why, in addition to OPEX, the project is run by Six Sigma project leaders and staff in quality and regulatory management and information technology. Billing staff, senior leadership, and other employees have also contributed input.

Jean Hammelev

The project team is using existing IT infrastructure and drawing on internal resources while occasionally querying Sonora Quest’s parent companies, Quest Diagnostics and Banner Health, for guidance. And while they aren’t on target to meet their original deadline, which required eliminating paper throughout the laboratory system in 2020, they have reduced hard copy paper storage by 85 percent. “When the goal was put forward, I don’t think we understood the scope of true ‘paperless’ and what it entailed,” says Reinhard.

In its effort to eliminate paper, the project team has “worked backwards,” Reinhard explains, by running reports with Sonora’s paper storage vendor to take inventory of every area of the integrated laboratory system that was sending paper to off-site storage and then reworking the corresponding processes to eliminate paper use.

But before taking this step, the OPEX team gained critical support for the initiative across Sonora Quest by demonstrating how a single process improvement reduced by half the integrated laboratory system’s paper storage. At the time, Sonora Quest was scanning and storing 50,000 to 75,000 paper copies of requisitions per day. Some of the staff initially were in favor of keeping the redundant paper storage step because requisitions would occasionally get lost, Reinhard explains. And while the number of missing orders was very low using the paper-based process—“we were consistently at a five sigma or above”—the OPEX team wanted to prove that storing hard copies wasn’t the solution.

Most of the missing requisitions, the team determined, were the result of problematic requisition processes in which a document inadvertently was not printed or had disappeared prior to scanning. Less than one percent of missing requisitions were found in paper storage. These findings helped the team make its case for its paperless system, which “was very error-proof and had a low defect rate,” says Reinhard. “We had a huge win right off the bat with that.”

After the team’s first success, Reinhard began collaborating with specific areas of the integrated laboratory system to overhaul their paper processes. The work falls into two categories, he says. Some processes have been fully automated, which means documents are auto-generated, or data from cloud-based faxes, emails, and DocuSign are saved automatically via an email-capture system and imported into virtual filing cabinets, a workflow that Sonora Quest built in collaboration with the secure document-management vendor Freedom Imaging Systems. Other processes have been partially converted—that is, paper documents are generated but they are retained electronically rather than sent to off-site storage. These documents are sent to central scanning and imported into virtual filing cabinets using the same workflow established by FIS.

The latter may not seem “as big a win as making something completely paperless,” Reinhard says, but it has made it easier to access documents it is required to keep for regulatory purposes. The FIS workflow also allows Sonora Quest to set retention periods automatically.

Matthew Reinhard

Some areas of the laboratory system had infrastructure that was easily transitioned to a paperless workflow, continues Reinhard, while the OPEX team is still innovating others. One example of the former: For genetics testing prior authorizations, the billing team receives documents from many sources. “We approached each source and developed a method for each of them to become electronic,” such as attaching documents to emails rather than using interoffice mail. “It seems so simple,” says Reinhard, “but a lot of the time it is.”

The project team also helped automate quality control documents for all laboratory departments. The QC documents are now reviewed and signed electronically using doPDF, a free software program that converts printable documents to PDFs. After review, documents are imported into a QC virtual filing cabinet and indexed by department, allowing staff from throughout the laboratory to easily access historical QC data.

Microbiology method and equipment validations too have been converted to paperless processes, Reinhard says. The team created a standard template in DocuSign that allows for entry of free text in lieu of drop-down indexing and that laboratory directors and others involved in the review process can sign electronically. Although the validations could be retained in DocuSign, they are being imported into a virtual filing cabinet to align with Sonora Quest’s systemwide approach to document storage.

Throughout the project, OPEX has encouraged the laboratory’s Six Sigma green belts, Lean practitioners, and frontline employees to identify paper-heavy processes and contact Six Sigma leaders to find paperless solutions. Laboratorians have been essential in developing paperless processes, Reinhard says, “particularly as we move into lower-volume processes in isolated pockets of our system,” such as creating a virtual workflow for monthly maintenance logs for laboratory equipment.

While the OPEX team has pursued multiple projects simultaneously across Sonora Quest, it has replicated workflows wherever possible. The billing department, for example, collects missing information on clients using the same system that has been developed for laboratory departments—information is received via eFax, saved using email capture, and retained in a virtual filing cabinet.

A similar process has eliminated paper standing orders at patient service centers. Orders that physicians once faxed to specific locations are now sent through a centralized fax line connected to an e-fax that can be accessed by any site. The data are retrieved via email capture and go into a FIS workflow to be placed on hold in a virtual filing cabinet. After patient testing is completed, the orders are exported into a requisition filing cabinet for retention. Sonora Quest patient service centers statewide can now access all patient orders at any time, Reinhard says.

“What we’re trying to do,” adds Hammelev, “is take the processes already developed and replicate them everywhere and anywhere we can before we start more projects.” And while Sonora Quest is working with a number of vendors on the initiative, in the future, it hopes to partner with a company that “approaches paperless from a system level,” Reinhard says, meaning “inputs, applications, and living documents would have a single retention space.”

As the project has moved along, Reinhard notes, he has received greater numbers of requests for FIS and other paperless processes from management and frontline employees. This has been valuable, he adds, because “it’s about engaging and breaking down silos across the board and finding the right contacts within each department.”

To meet each department’s needs, the OPEX team partners with IT. “We also include them intimately in the discovery process, as their knowledge of downstream processes for documents regarding reporting and cross application feeds is essential,” Reinhard explains. “They’re always onboard, they join the meetings, and they have great ideas.” Consequently, the OPEX team and IT staff are addressing Sonora Quest’s automation goals in collaboration with the IT consulting services vendor Disys by implementing robotic process automation in various areas of the integrated laboratory system. At CAP TODAY press time, the collaborators were also working on transitioning to intelligent process automation, which incorporates elements of machine learning into RPA.