Advanced urinalysis technology and Lean management help a hospital lab improve productivity.

It is now axiomatic in the hospital lab industry that it takes two kinds of technology--not just one--to substantially improve the lab's productivity. The first type is information technology and robotics as embodied in automated analyzers. It is widely recognized that automation will yield disappointing results unless it is matched with input from a second "technology"--management science.

"Don't automate bad processes," the saying goes. This means that management experts should review processes to make them as efficient as possible before the lab purchases new instruments. Otherwise, the end product will be a lab that, despite all the state-of-the-art equipment, is still producing well below its potential.

The urinalysis section of the lab at Fairview Ridges Hospital in Burnsville, MN, exemplifies the successful application of the automation-plus-management-science approach. Like many labs today, Fairview used Lean management principles to evaluate the lab's overall processes and design to a maximally efficient workflow. One of the conclusions of the analysis was that the lab should automate where that was feasible, so that one staff person could monitor all the lab's core instruments.

That innovation meant replacing the lab's previous urinalysis instrument with a new analyzer that automated many processes that once had to be performed manually with the old system. Most importantly, the new analyzer automated microscopy. The previous system only automated the macroscopic aspect of urinalysis, not the microscopic. The new system automated the entire process.

Once the new system was installed, lab staff members began monitoring its turnaround times (TAT) to make sure they were within targets of under 25 minutes 90% of the time set for the lab's core instruments as a whole. The fact that the target is being consistently hit in the urinalysis section is a testimony to the effectiveness of Fairview's two-pronged approach.

Background

When applied to healthcare labs, Lean entails analyzing work activities or processes to eliminate waste, variation, and unnecessary motions that compromise efficient output. Lean was implemented at Fairview Ridges in Spring 2004, in large part because administration saw the need to improve the lab staff's efficiency and productivity. The project commenced with the training of key personnel in the application of Lean principles.

Following the education phase, work processes were videotaped and dissected second by second so that every inefficient motion could be "edited out" and a more productive form of working could replace it. Analysis of the tapes determined what was and was not needed on each workbench, where it was needed, and in what order it was needed. All work processes were standardized to minimize time-consuming variation and wasted motion. The hospital then reconfigured the lab and purchased appropriate instruments to implement the recommendations of the Lean analysis.

In the current design, instruments that make up what the lab calls its core are arranged in a circle, and in an order such that technologists can move from one instrument to the next without having to go back and forth. (Core instruments are those that perform the highest volume tests at Fairview.) Per Fairview Ridges' Lean evaluation, all the core instruments are automated and can be operated by one person. Thus, a single technologist per shift monitors the entire core, moving around the circle from one instrument to the next. All confirmatory tests which must be performed manually are done outside the core.

Fairview Ridges acquired the automated urinalysis system in mid-2006, because it was a much better fit with this workflow design than its previous urinalysis system. Most importantly, the new system transformed urinalysis into a process that could be performed by a single technologist, and its automated features eliminated several steps requiring human intervention.

For instance, it performs virtually all confirmatory tests automatically, without human involvement. With the older technology, lab staff had to do confirmatory testing and microscopy manually for many samples. The new system automatically sends nearly all samples directly from macroscopy to microscopy. It utilizes a digital camera that takes 500 photos of each specimen, a great improvement over the mere five to six views studied on samples stained separately in microscopic analysis. This feature alone--replacing an older, time-consuming microscopy process with automated digital photos--saves a minimum of 10 to 15 minutes of manual labor for each sample requiring microscopic analysis. It also enables the lab to have a smoother workflow, with no additional steps to prep the sample for microscopy.

Finally, the test strips for the previous analyzer could be adversely affected by interfering substances or intensely colored urines. The new analyzer eliminates those problems by using a different formulation and technology for its strips. Only a small percentage of patient samples need any additional manual testing. Thus, in several different ways, the selected system allowed the urinalysis section to meet the lab's Lean-based goals of minimizing human involvement, streamlining the workflow, and increasing staff productivity.

The proof is in the numbers

Lean at Fairview Ridges was not just a one-time fix. It is an ongoing process of continually compiling, reviewing, and reacting to TAT metrics. Additional efficiencies are sometimes found and implemented after an investigation of increased TAT. With the aid of a software program, Fairview measures TAT by tracking the highest volume test in each area; urinalysis, hemoglobin, potassium, PTT (partial thromboplastin time), and troponin TATs are monitored.

TAT data is evaluated for each shift. TAT is defined as the span between the time the sample is received in the lab to the time results are available electronically on the patient-care unit. The rationale for differentiating TAT by shift is that each shift sees different types of patients, different patient volumes, and different trends in tests that are ordered.

A Lean-oriented workflow re-evaluation can be triggered by either physician complaint or an upward trend in TAT metrics. The metrics are printed out daily and placed in a book for each shift to review. If the TAT goal of <25 minutes is not being met approximately 90% of the time, a technical supervisor re-examines the relevant process from a Lean perspective. Are steps being performed in the proper Lean order? Are technologists taking samples directly from the centrifuge to the analyzer, or are they adding other steps in-between? Is some necessary implement or other resource not readily available at the analyzer? Finding answers to these questions helps to pinpoint issues that need to be corrected. After identifying issues, technical supervisors make the necessary changes, whether this involves moving a supply or retraining staff. Staff members are also encouraged to make any necessary self-corrections after reviewing the metrics for their shift.

Again, Fairview Ridges replaced its older system primarily because the new one requires only one staff person to do the testing, and the value of the more automated instrument is also reflected in improved TAT. The previous analyzer performed macroscopic analysis within an acceptable time frame, but samples requiring microscopy met TAT goals an average of only 52% of the time. What is more, an estimated 75% of samples required microscopy, which meant that a substantial portion of urinalysis samples fell below Fairview's TAT standard.

Since implementing the automated urinalysis system, macroscopic results have met the TAT target as much as 100% of the time, and microscopic TAT times are also at satisfactory levels. In fact, the system is so dependable on its combined macroscopic/microscopic TATs that Fairview Ridges now uses automated microscopy on all urinalysis samples.

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The improved productivity in the lab's urinalysis section is also evident in the FTE (full-time equivalent) numbers. Lean essentially made it possible for the lab to reduce its FTEs from 35 to 33. No staff was laid off--the reduction was achieved through attrition. Recently, FTEs have risen back to 35, but only because the lab is processing significantly higher test volumes following a reorganization.

Although labor savings were the largest factor driving the acquisition of the new urinalysis instrument, Fairview Ridges is enjoying several other benefits of the analyzer's advanced technology. The analyzer does an excellent job identifying urinary casts--particles in the urine that can indicate renal involvement--and other problems. Because the previous analyzer required manual microscopy, centrifugation of the urine specimen was required, which can destroy some or all of the fragile casts, impairing the diagnostic quality of the microscope reading.

The new analyzer does not require the urine to be centrifuged. Because the urine is imaged with a digital camera instead, the casts are preserved and captured in the images. Plus, with 500 images per sample, data collected is statistically more accurate. In addition, the fast, accurate microscopy that is routine with the analyzer improves patient safety, because quicker discovery of renal problems contributes to faster diagnosis and treatment.

It also requires a smaller sample, which is an advantage with pediatric or low-volume specimens. The instrument allows technologists to dilute below-threshold samples and bring them up to appropriate volumes while maintaining the accuracy of results. All of the features mentioned above are advantages over Fairview Ridges' previous technology.

Postscript

The Lean project at Fairview Ridges was an eye-opener for lab management. Prior to the Lean evaluation, managers felt that workflow and lab layout were already efficient, but Lean uncovered a number of issues--and addressed them. Since the original Lean analysis, additional instrumentation has been acquired and set up using Lean principles. Further analysis is still needed to make sure the altered workflow is maximally Lean. Future plans also include autoverification of urinalysis results, which will significantly improve urinalysis TAT beyond its already excellent levels.

By Kari Amacher, CLS(ASCP)

Kari Amacher, CLS(ASCP), is a clinical laboratory scientist and lead technologist for urinalysis, microbiology, point-of-care testing, and reference testing at Fairview Ridges Hospital Laboratory in Burnsville, MN. The equipment chosen by Fairview Ridges to replace its old system was Iris Diagnostics' (Chatsworth, CA) iQ200 Automated Urinalysis System.