SummarySt. Joseph Mercy Oakland Hospital redesigned laboratory work processes in their clinical laboratory by centralizing functions into one physical space with open, flexible architecture; standardizing the processing of specimens via automation and written work steps; cross-training staff; instituting daily huddles; and conducting periodic audits and performance feedback. The program improved or maintained turnaround times (despite an increase in specimen volume) and enhanced staff productivity, leading to a positive return on investment and roughly $950,000 in annual cost savings.Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including test turnaround time, test volumes, and staffing levels.
Developing OrganizationsSt. Joseph Mercy Oakland Hospital
Date First Implemented2006
The laboratory's initial workflow redesign occurred in August 2006, when the hospital purchased new equipment that allowed for automation of test processing. The relocation of decentralized laboratory functions to one centralized space prompted a second workflow redesign in October 2008.
Problem AddressedHospital laboratory operations often do not support a continuous workflow, leading to delays in test processing. Poorly designed operations and/or lack of automation are a major cause of these inefficiencies and delays.
- Long turnaround times, leading to low satisfaction and lengthy stays: Many hospital laboratories fail to process specimens quickly; a literature review concluded that improvements in turnaround time are needed in most hospitals.1 Another study of 11 hospitals found that laboratory turnaround times vary greatly by hospital and by type of test; hospitals also varied greatly by the percentage of turnaround times considered to be "outliers."2 Such wide variation suggests that meaningful improvements are possible.
- Inefficient operations and processes: St. Joseph Mercy Oakland's laboratory operations had many inefficiencies, including poor physical configuration of equipment, walls separating different sections of the laboratory, and similar job tasks performed in multiple locations. Additionally, lack of automation was an obvious problem. Technical staff, rather than a clerical staff member, were answering the phones. In general, a significant amount of non–value-added activities were part of the technologists' daily work processes. Furthermore, the technical staff in the clinical laboratory on the day shift were not cross-trained, and staffing was inadequate during busy periods.
Description of the Innovative ActivitySt. Joseph Mercy Oakland redesigned laboratory work processes by centralizing functions into one physical space with open, flexible architecture; standardizing the processing of specimens via automation and written work steps; cross-training staff; instituting daily huddles; and conducting periodic audits and performance feedback. Key elements of the laboratory redesign include the following:
- Centralization with open, flexible architecture, and staff consolidation: Previously, laboratory functions took place in three different rooms located on one hallway. Now, all laboratory functions occur in one large, open room, with strategically located equipment to enhance efficiency. (Workflow analysis helped to determine the optimal location for each piece of equipment.) For example, compatible functions (e.g., chemistry and hematology) are proximately located, with the area for incoming specimens located near the inlets on the automated equipment. Use of counters on wheels allows the laboratory to easily implement future configuration adjustments. All necessary infrastructure needs (e.g., electrical wiring, water, air, voice and data lines) to support the clinical laboratory are located in a floor trench covered by heavy metal plates; this improves employee safety as well as the aesthetics of the work environment. With the relocation to one space, clerical (nontechnical) staff performing the intake (preanalytical) step have been consolidated.
- Standardization of specimen processing through automation: State of the art testing equipment (e.g., chemistry analyzers) eliminates the need for staff members to manually load the centrifuges, analyzers, etc., with specimens. This equipment helps to ensure the standardization of work processes, thereby enhancing quality and safety and maintaining efficient workflow during peak processing times.
- Order prioritization: Under the old system, test processing would be interrupted when "stat" orders arrived. Now, all specimens are processed as received; faster turnaround times enable this approach. Automation, standardized work practices, labor balancing to peak volumes, and the elimination of batching specimens to ensure a continuous flow of specimens has allowed all specimens to be treated the same.
- Job instruction sheets: Job instruction sheets outline standardized work practices, listing specific steps for each job function related to test processing, thereby eliminating processing variation.
- Cross-training day shift: Before the redesign, laboratory staff members working on the afternoon and night shifts had been cross-trained due to the more routine nature of the work. Under the redesigned system, daytime workers have been cross-trained as well, thus creating more flexibility in test processing. Laboratory managers have also been cross-trained, allowing one clinical laboratory supervisor to oversee all functions, thus replacing the need for separate hematology, chemistry, and urinalysis supervisors. (Some highly technical functions, such as microbiology test processing, still maintain specialized staff.)
- Greater shift overlap: Work shift start times have been redefined to ensure greater overlap between the overnight and day shifts to accommodate greater test volumes during the peak morning hours. Labor balancing enables cycle times to be maintained to ensure the continuous flow of specimens across all shifts.
- Daily huddles: Brief (5 to 10 minute) meetings occur at 7:05 a.m. (with the night shift and day shift) and at 3:15 p.m. (with the day and afternoon shifts); another huddle will be instituted during the overlap of the afternoon and night shifts. The supervisor leads the huddle, which covers a variety of topics, including staffing challenges, equipment problems, quality issues, and staff acknowledgments.
- Centralized supply ordering and stocking: Supply ordering and stocking, previously divided by separate laboratory function, has been centralized to prevent duplicative orders. Supplies are stored on movable racks in a centralized area to maximize convenience for laboratory staff.
- Performance feedback: Managers perform periodic audits to ensure that staff follow the steps outlined in the job instruction sheets and provide immediate feedback to staff after the audit on their performance. Overall laboratory performance measures, such as test turnaround times and test throughput measures, are posted on white boards that hang in the laboratory. During the feedback review session, employees are encouraged to provide feedback to the supervisor on how the process could be improved. A continuous improvement philosophy is used to drive change and the exchange of ideas.
- Encouraging continuous improvement: Employees are encouraged to submit process improvement suggestions in writing to the laboratory's continuous improvement committee, which meets weekly; a committee member meets with the employee to discuss his or her suggestion. Approved changes are incorporated into the job instruction sheet to ensure continued standardization.
Context of the InnovationSt. Joseph Mercy Oakland Hospital is a 426-bed community hospital that processes approximately 1.6 million laboratory tests annually. The hospital is part of the St. Joseph Mercy Health System in Michigan, which is a part of the Trinity Healthcare System that owns or manages 45 hospitals, 379 outpatient facilities, 26 long-term care facilities, and numerous home health offices in 7 states. Hospital and laboratory administrators recognized numerous obvious inefficiencies in laboratory test processing (cited earlier in the Problem Addressed section) and wanted to design a more efficient laboratory. In August 2005, hospital administrators purchased automated laboratory processing equipment (e.g., chemistry analyzers) so that the hospital could reduce the number of tests outsourced to a reference laboratory. Handling the increased volume of in-house testing (approximately 66,000 tests annually) required staff retraining and workflow redesign. Even after these changes, however, efficiency remained suboptimal, largely because laboratory functions (e.g., chemistry, hematology, urinalysis) still occurred in three separate rooms located along one hallway. In October 2008, the laboratory moved to one large space, allowing for a reduction in redundancies and staff cross-training.
ResultsBetween 2006 (pre-implementation) and 2009, the laboratory improved or maintained turnaround times (despite an increase in specimen volume) and enhanced staff productivity, leading to a positive return on investment (ROI) and roughly $950,000 in annual cost savings.
Moderate: The evidence consists of pre- and post-implementation comparisons of key outcomes measures, including test turnaround time, test volumes, and staffing levels.
- Faster turnaround: Turnaround time for complete blood counts has fallen from 18 minutes to 12 minutes, a 33-percent reduction. Other turnaround times have been reduced slightly or maintained, despite an increase in specimen volume and a 22-percent reduction in technical staff. This has improved productivity and has reduced cost per unit of service.
- More productive staff: The reduction or maintenance of turnaround times has occurred even though the number of full-time technical staff has fallen by 22 percent across three shifts, and the volume of tests has increased by approximately 8 percent, between 2006 and May 2009.
- Positive ROI, driven by significant cost savings: A positive ROI was achieved within 4 years, driven by total cost savings of roughly $950,000 a year, including $250,000 from moving test volume from a reference laboratory to the onsite laboratory and $700,000 from enhanced staff productivity.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Selecting vendor and instrumentation: In early 2005, laboratory leaders chose a chemistry analyzer vendor and selected instruments to be purchased.
- Implementing new instrumentation: In September 2005, the new analyzers were implemented and staff members received training on their use. After 10 months, the initial chemistry analyzers were replaced with larger ones that could handle more volume.
- Implementing automation: In August 2006, partial automation was achieved in chemistry testing only, and staff members received training accordingly.
- Cross-training staff: In early 2007 (roughly 18 months before the laboratory consolidation), all staff on the day shift received cross-training to ensure staffing flexibility.
- Training on Lean principles: A Lean expert (called a "sensei") employed by Trinity Health held workshops to train the laboratory managers and staff on performance improvement and workflow redesign. The expert also provided the job instruction sheets and various other templates to help the laboratory start their "Lean journey."
Resources Used and Skills Needed
- Staffing: The program required no new staff.
- Costs: Development costs consisted primarily of the expenses associated with updating equipment; a minimal amount of staff overtime was also required to plan the redesign. Lean training did not require incremental expenditures because the expert worked for Trinity Health.
Funding SourcesSt. Joseph Mercy Oakland Hospital
Getting Started with This Innovation
- Plan for physical changes: Changes such as relocation and placement of new equipment should be mapped out before implementation. St. Joseph Mercy Oakland created a detailed map of how best to locate equipment based on a comprehensive workflow analysis.
- Ensure staff support by sharing data: Staff members may resist changes such as automation and cross-training. Communication on the potential quality, safety, and efficiency benefits of these changes (e.g., the potential to reduce turnaround times) can help staff understand the justification for redesign. In addition, highlight the potential for standardized work process steps to improve quality, and help staff members understand the expectations regarding their performance.
Sustaining This Innovation
- Continue communicating: Managers and staff should continue to communicate to ensure continuous quality improvement and ongoing employee support for departmental changes.
Contact the InnovatorJohn Hilton
Director of Laboratory and Respiratory Services
St. Joseph Mercy Oakland
44405 Woodward Avenue
Pontiac, MI 48341
Innovator DisclosuresMr. Hilton reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
Manor PG. Turnaround times in the laboratory: a review of the literature. Clin Lab Sci. 1999;12(2):85-9. [PubMed]
Holland LL, Smith LL, Blick KE. Reducing laboratory turnaround time outliers can reduce emergency department patient length of stay: an 11-hospital study. Am J Clin Path. 2005;124(5):672-4. [PubMed]
Available at: http://www.medscape.com/viewarticle/515559
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Original publication: December 09, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: October 29, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.