By Sarah Schmelling
When you find yourself comparing your laboratory to old “I Love Lucy” reruns, you know you have a problem. Ken Blick, PhD, ABCC, NACB, director of clinical chemistry and information systems at Oklahoma University Medical Center (OUMC), says that before the laboratory installed an automation system, lab operations were a little too much like the episode where Lucy and Ethel had to box candy that came through on a conveyor belt. Everything was fine until someone sped up the process, and before you knew it, Lucy and Ethel were throwing the candy in boxes, and eating and stuffing in their clothes what they were unable to box fast enough. “And you’ve got the supervisor in the middle saying, ‘Can’t you work faster?’” Blick says.
The point is, “You can take very dedicated people and put them in a situation where you have poorly designed legacy tools that worked well when there were only a few samples arriving in the lab, but now that the volume has increased, you’re trying to take the same solutions and apply them to different problems,” Blick says.
The OUMC lab, which serves two adult teaching hospitals, a children’s teaching hospital, and two ambulatory care facilities, serves as a supreme example of how automation can completely change the process of testing patient specimens. Working primarily around a system developed by Fullerton, Calif-based Beckman Coulter, the lab automated its chemistry line in March 2004 and hasn’t looked back since. The system includes a Power Processor sample-processing system connected to centrifugation units, three Synchron LX20 Clinical Systems, immunoassay analyzers, and a 3,020-tube storage unit. In addition to reducing the Lucy-like stress on the lab’s staff, installing the automation system has greatly increased efficiency, while also saving the medical center money, Blick says. “I’m not seeing much of a downside to getting rid of all the bad stuff and moving on to doing a better job.”
The pre-automation problems the OCMC lab faced were immense. First, Blick says, the equipment was generally old—in some cases 15–20 years old—and the processes were all based on traditional laboratory practices, where everything is done manually and on paper. “We had all these manual processes, including order entry. We had a transport team that would go around and get specimens that nurses collected, and the specimens all arrived in batches,” he says. “In the traditional laboratory, about 40% of the errors that occur are in these front-end batch processes—test orders, specimen collection, specimen delivery, specimen labeling, delivery to the lab, and data entry into the lab computer.”
He says that all of these processes can cause huge delays. “If you have poor processes like this, and you’re depending on people to do all the decision-making and take all the steps, you tend to have a lot of errors.”
When there are delays, you get more calls from physicians asking for test results who get angry when they don’t get answers, he says. This leads to more stress on lab personnel. “So then they try to speed up the work, but they’re speeding up a process that’s poorly designed to begin with, and you get more errors from that,” Blick says. This can then lead to people calling in sick because they don’t want to come to work. “We had one person who was ordered by her physician to get another job because her lab job was too stressful and it was affecting her health,” he says.
The batch process also caused problems when a physician would call in wanting to add another test to a previously delivered sample. “The tech would have to go find it in a thousand other samples in the chemistry area,” he says. Then there might not be enough of a sample left to do an additional test, and the lab personnel would not have permission to take another sample from a patient, so they would spend sometimes days tracking down the physician to take another sample. All of this complexity would frustrate everyone involved—including the patients.
“So the patient has stayed an extra day and a half in the hospital waiting for us, and everybody’s waiting for the lab test so they can send the patient home,” Blick says. “And then this patient is occupying a bed, waiting for the results, and everything starts backing up, patients are backing up in the ER, and people are leaving without being seen.”
All of these issues made it clear to Blick and laboratory personnel that things had to change. “We had a lot of legacy solutions, lots of workstations, lots of manual processes,” he says. “We realized we had to do something to change the way we were running the laboratory. We had to take a look at all of the processes involved in doing a laboratory test and getting the results back to the physician rapidly.”
Blick realized that if the lab could increase efficiency, this would benefit other departments, especially the emergency department, and then it would improve the care of patients, “where laboratory data provides the linchpin for diagnosis and treatment.”
Blick says that before setting up the automation system, the lab could have simply bought new chemistry analyzers that showed improvement over those they had in place. Instead, they decided to take a look at the entire operation. They realized their best bet was to find a front-end processor that could automate all of the preanalytical steps, such as load balancing and sorting, centrifugation, and removing caps from the tubes. They would also have a “stockyard,” or refrigerated storage system, that could organize the bar-coded samples, saving the lab technologists from having to search through racks. “So through the system comes an electronic order from the physician … and the order comes through the track system, the track recognizes the sample, it takes the lid off, and then it brings the sample to the correct instrument to do the test,” Blick says. “The sample goes to the appropriate instrument, it checks the volume to see that there’s plenty there, it looks for clots, and it alerts the technologist if there’s a problem. If there isn’t a problem, it goes ahead and does the test, puts the sample back on the track, the sample goes back to the stockyard, and the results get posted.”
So now no staff is involved in any of these areas, Blick says. This reduces the chance of errors; posts results more quickly; conducts add-on tests easily; and, most importantly, often enables the patient to go home sooner.
“We’ve taken a process that was poor at best, and that required lab personnel to search for things. It was stressful, caused people to call the lab and have unpleasant exchanges, and everybody was unhappy. Now, we’ve got a technology that takes a poor process and turns it into a really slick one,” Blick says.
Meanwhile, patients don’t have to provide additional samples because so much information is taken and saved in the initial specimen. “So there’s less trauma, less taking of blood. We’re maximizing the sample,” Blick says.
The system also solves the problem of priority testing, wherein a physician would require a stat test on a sample, but would have to work around the lengthy batch process. “It turns out that since we don’t have any batches, all of the results are coming back, there’s no cue,” he says. “So routine work is going back just as fast as the stat testing. All of a sudden, we have a continuous flow of samples through the lab … so we have no need for prioritization of testing.”
This meant the lab had quickly cut out 48 manual processes. “You can do a lot of work when you get rid of batch processes and think about your laboratory as an information system,” Blick says. “We could eliminate all of those processes where we were touching things, putting things in racks, and delaying the reporting of data.”
Now, Blick says, the laboratory is much less like “Lucy,” and more like the Disney film “Fantasia,” where a multitude of animated brooms carry buckets of water and do all of the work more efficiently. This has certainly benefited the medical center and even the patients, but it has also helped the technologists within the lab.
The technologists can now use the time that was previously taken up by manual lab processes to do much more necessary work. “I don’t need somebody to put a specimen on an instrument,” he says. “What I need is my techs to get involved when there’s a problem to solve.”
The system also allowed the lab to eliminate part-time staff, while bringing in additional assays that had previously been sent out, because now technologists had more time to work on them. “We’re using our technologists to add value to other areas of the lab,” Blick says. “The idea is to put our techs into obvious areas to add value to the hospital.”
This also means the techs can now develop additional skills, which makes them more satisfied with their work. “We can challenge them, and give them new tools so they can grow professionally,” Blick says.
Jobe Dubbs, public relations manager for Beckman Coulter, says labor concerns like these are causing many laboratories to seek automation systems. “Because of the labor shortage, you have fewer people available in the lab to perform testing and all of the labor-intensive preanalytical steps,” he says. “Automation is able to offset the labor shortage and actually help labs reposition personnel in other areas of the labs to do what they do best, which is interpreting test results.”
According to Beckman Coulter, because of its system, the OUMC laboratory was able to decrease its staffing needs by five full-time employees, saving more than $291,000 per year, and reducing overtime pay by 60%. Because of its increased efficiency, the lab was also able to close a satellite laboratory. This resulted in savings of $1.5 million per year, and a reduced need for sent-out tests, saving $240,000 annually. Blick says the lab is 15%–20% more efficient in terms of the number of tests per paid hour. Moreover, turnaround-time targets are close to 97%, up from 82% prior to automation. The laboratory is so pleased with the system that it is currently installing an additional hematology track.
Blick says choosing Beckman Coulter for the lion’s share of the new system was an easy decision to make. The well-established company is the market leader in laboratory-automation systems, and he says it was the only company to provide a complete processing system, as opposed to just parts of it. “If you go through a piecemeal process, you get piecemeal results,” he says.
Installing a system like this, he says, all comes down to the overall vision of the laboratory. “My vision is that laboratory data is worthless if it doesn’t get back in time for the clinical decision-making,” Blick says. “If that’s true, you have to make an effort to ensure the process flows efficiently.”
He adds that the lab will continue to evaluate the processes, because they never want to stop improving; however, in general, they received “much more than we paid for.”
Plus, the lab staff look much less like frustrated Lucy Ricardos and are genuinely more happy. “I caught some people smiling in the lab the other day,” he jokes. “The phone doesn’t ring anymore—it’s a huge payoff. It’s just a better place to work now.”
Sarah Schmelling is a contributing writer for Clinical Lab Products.