FCHS Northside Mentorship: October 2017

Hospital Topics, 93(2):19–26, 2015

ISSN: 0018-5868 print / 1939-9278 online

DOI: 10.1080/00185868.2015.1052267

Improving Hospital Laboratory Performance: Implications for Healthcare Managers

LAQUANDA T. LEAVEN

Abstract. Laboratory services in healthcare delivery systems play a vital role in inpatient care. Studies have shown that lab-oratory data affects approximately 65% of the most critical decisions on admission, discharge, and medication. Laboratory testing accounts for approximately 10% of hospital billing. Re-ducing laboratory costs and improving laboratory performance would contribute to reducing total healthcare cost, which is one of the major goals for the U.S. healthcare delivery system. The objective of this paper is to review and analyze the di-verse research approaches applied to improve the performance of hospital laboratories in large healthcare delivery systems. The approaches reviewed include: lean, quality control, automation, and simulation modeling. In the conclusion, future research di-rections are presented, which include additional methods to be investigated to further improve the performance of hospital laboratories.

Keywords: hospital laboratory, performance, lean, automation

_Hospital laboratories have suffered many challenges, one being producing high-quality test results in the most efficient

and effective manner possible. One main target is to never decrease the overall quality of the care and service provided throughout the laboratory process, which is comprised of three stages: preanalytical, analytical, and postanalytical. A decrease in total quality and its negative effects on patient outcomes may cause economic loss (Pansini, Di Serio, and Tampoia 2003). The aim is to decrease costs while still maintaining quality. The need to reduce the

costs within laboratory medicine can be accom-plished by possibly reducing test requests (Vegting et al. 2012). Many researchers in this area have pro-posed a patient-focused care strategy, with a goal to increase the time that nurses and physicians spend in patient care and decrease the number of employees who have direct contact with an individual patient (Pansini, Di Serio, and Tampoia 2003). It is believed that this could decrease the amount of errors that are experienced. By implementing this strategy, im-provements through reorganization, re-engineering, and laboratory automation have been seen in the an-alytical stage. Improvements were also seen in the preanalytical stage by evaluating the workload and error rate of the phlebotomists. It could be presumed that better communication between physicians and hospital laboratory staff should take place within the preanalytical stage in order to experience continu-ous improvement throughout the entire laboratory process.

The rest of this article is organized as follows. First, the approach utilized for selecting the litera-ture reviewed is discussed. Then the different ap-proaches applied to improve the performance in hospital laboratories is presented. These approaches include, lean, quality control, automation, and sim-ulation modeling. Lastly, the directions for future research is summarized.

Laquanda T. Leaven is an assistant professor of Supply Chain Management in the Department of Marketing, Transportation and Supply Chain, School of Business and Economics, at North Carolina Agricultural and Technical State University in Greensboro, North Carolina.

METHODOLOGY

The literature search was conducted from Jan-uary 2011 through September 2011. Further ongoing reviews of literature updates occurred until the submission of this article. The literature search included articles utilizing (1) lean, (2) quality con-trol, (3) automation, and (4) simulation modeling to improve hospital laboratory performance. These four techniques are widely used industrial engi-neering improvement methodologies, which have proven to be successful in the manufacturing sec-tor. For that reason, a review of literature was per-formed to analyze the success of utilizing these same improvement techniques in the hospital laboratory sector.

An assessment of publications was completed using the following sources: ScienceDirect, Pro-quest, Emerald Journals, and PubMed. In addition, Google Scholar was used as an overall search engine for relevant literature. The selection process for the articles reviewed was narrowed down to publication year; only the most recent and relevant literature was included in the review process. This method allowed for the latest advances in improving hospi-tal laboratories, using the four techniques discussed previously, to be analyzed. Most articles included in this review of literature were published in the year 2000 and after.

APPROACHES APPLIED TO IMPROVE

HOSPITAL LABORATORY PERFORMANCE

In the literature, a variety of studies have been conducted to improve the performance in hospital laboratories. The current studies utilize lean prin-ciples and quality improvement, where the focus is to eliminate waste and develop quality metrics to ensure safe, efficient, and effective processes. Addi-tional research studies have been performed using simulation modeling as an improvement technique, where the focus is to simulate and analyze different situations to determine where the most cost sav-ings can be achieved. The automation approach is a technique that focuses on implementing automated workstations in hospital laboratories to increase re-source utilization and minimize laboratory errors. In the following sections, the methods applied to im-prove hospital laboratories are discussed in detail. Table 1 provides a synopsis of the research studies reviewed.

Vol. 93, no. 2 2015

Applying the Lean and Quality Control Approach to Improve Hospital Laboratory Performance

Many clinical laboratories have incorporated the lean and quality improvement strategy to increase patient safety and improve quality and workflow (Elder 2008; Serrano et al. 2010). It is essential to have constant improvement in these areas. In order to track improvement, many studies have incorpo-rated quality measures and indicators (Nevalainen et al. 2000). The quality of the staff’s performance, as well as the quality of the laboratory testing, is essential to a patient’s safety. If a phlebotomist has poor performance, this will produce poor test re-sults (Westgard and Westgard 2006). Quality im-provement should be incorporated in every facet of hospital laboratories. This includes each stage of the entire testing process. The laboratory information system is also an important entity and tool utilized in the entire testing process. Effective laboratory information systems could support further health-care quality improvement (Harrison and McDowell 2008). In terms of improving quality, medical staff members do not thoroughly understand the bene-fit or purpose of having quality control methods in place. Many researchers have stated, to alleviate this problem and have well informed healthcare pro-fessionals, training programs should be established (Nakhleh 2006). Training programs help with the transition of making hospital laboratories contin-uous improvement environments. Studies have in-dicated, incorporating lean practices into hospital laboratories result in a decrease in turnaround time (Raab et al. 2008) and an increase in lab accuracy and efficiency (Das 2011). Table 2 provides a syn-opsis of the lean and quality studies reviewed.

In a research study performed, the lean methodol-ogy was applied to a hospital laboratory preanalyti-cal process (Persoon, Zaleski, and Frerichs 2006). Many of the laboratory’s customers (physicians) were not pleased with the turnaround time for re-ceiving a patient’s test results. The researchers be-lieved that the overall cycle time could be reduced if the preanalytical stage was improved. Their goal was to report 80% of laboratory tests in less than 1 hr and to no longer acknowledge a distinction between stat and routine tests. In their process redesign, they incorporated the concept of single piece flow, which indicates all activities must be performed on each object undergoing the process before the work starts on the next object. This method removes the notion

HOSPITAL TOPICS: Research and Perspectives on Healthcare

TABLE 1. Synopsis of Literature Reviewed

Approach	Problem	Study

Lean	Testing process cycle time too long	Persoon, Zaleski, and Frerichs 2006
Lean	Negative patient experience/long wait time	Melanson et al. 2009
Lean	Takes too long to receive test results	Zito and Stewart 2008
Lean	Large number of blood stream infections	Shannon et al. 2006
Lean	Laboratory test defects	Zarbo and D’Angelo 2007
Lean	Poor performance in the lab	Serrano, Hegge, Sato, Richmond, and Stahnke
		2010
Lean	Lack of processes standardization	Raab et al. 2008
Lean	Pap testing and diagnostic inaccuracies	Raab et al. 2008
Lean	Lack of validation measures for testing	Das 2011
Quality	Large number of medical errors	Raab 2006
Quality	Laboratory data misleading	Nevalainen et al. 2000
Quality	Poor laboratory test quality	Westgard and Westgard 2006
Quality	Lack of laboratory information systems	Harrison and McDowell 2008
Quality	Lack of understanding the role quality plays in	Nakhleh 2006
	surgical pathology
Quality	Defects in microbiology laboratory	Elder 2008
Automation	Excessive errors in preanalytical phase	Da Rin 2009
Automation	Current centrifugation system runs slowly	Yavilevich 2002
Automation	Excessive errors associated with specimen sorting	Holman, Mifflin, Felder, and Demers 2002
Automation	Increased staff workload	Tornel, Ayuso, and Martinez 2005
Automation	Staff shortage and excessive errors	Melanson, Lindeman, and Jarolim 2007
Simulation	Need to reduce costs in laboratory	De Capitani, Marocchi, and Tolio 2002
Simulation	Increased workload effecting staff performance	Goldschmidt, de Vries, van Merode, and Derks
	time	1998

of batching. How the work would be accomplished in the preanalytical stage was redesigned using four rules of the Toyota Production System (TPS). The results of the preanalytical stage redesign in-dicated significant improvements in the laboratory test turnaround time by approximately a 30% re-duction. Phlebotomy customer (physicians and pa-tients) satisfaction and workflow are important fac-tors to consider in any type of clinical laboratory.

In the study of Melanson et al. (2009), they fo-cused on how to improve the overall patient experi-ence and methods to optimize the blood collection process in outpatient phlebotomy using lean tech-niques. The main problem faced at the Brigham and Women’s Hospital, the teaching affiliate of the Har-vard Medical School, was the excessive wait time patients had to experience before being served by a phlebotomist. There were also other problems that had to be addressed such as nonessential work func-tions, inefficiency of non–blood-drawing activities, and reordering process steps. In order to address these problems, a lean expert team implemented a Kaizen Event (continuous improvement) in the out-patient department of this facility. They removed many non-value added work steps in this process

and were able to conclude by implementing these improvements, patient wait times decreased from 21 min to 5 min.

Another study was performed that focused on how to incorporate lean practices into a clinical laboratory (Zito and Stewart 2008). The problem addressed how to reduce the turnaround time when sending patient test results back to physicians. The facility was using a batching mechanism for test orders, which adds a delay to receiving the test re-sults for certain orders. The authors proposed that a single-piece flow system be adopted in this clini-cal laboratory. The single-piece flow system would allow each order to be handled and processed sep-arately rather than having to wait for all other ele-ments in a batch to be processed. When orders are performed in batch, multiple possibilities exist for errors to occur, which would require rework for the phlebotomists. The researchers of this study were able to implement the single-piece flow system for many floors of the hospital, which allowed the batch sizes to be kept to a minimum. From the process re-design, the lean team saw a significant improvement and reduction in the turnaround time for sending test results to physicians.

22 Vol. 93, no. 2 2015

TABLE 2. Synopsis of Articles Reviewed for Lean and Quality Approach

Study	Objective	Approach	Recommendation	Results

Nevalainen et al. 2000 Identify the problems with the		Quality	Normalize data to	Significant improvements
	laboratory data		parts-per-million	needed
			defects
Persoon et al. 2006	Reduce total testing process cycle	Lean	One piece flow/	Cycle time reduced By 30%
	time		removes batching
Shannon et al. 2006	Determine cause of blood stream	Lean	Implement best	50% reduction in infections
	infections		practice policies
Raab 2006	Reduce medical errors/increase	Quality	Work flow process	Defects decreased from 9.9%
	safety		redesign	to 4.7%
Nakhleh 2006	Increase the understanding of the	Quality	Provide training	More knowledgeable, informed
	role quality plays in surgical		programs to staff	staff
	pathology
Westgard and	Assess the quality of laboratory	Quality	Quality of	More intense quality control
Westgard 2006	tests		laboratory tests
			requires
			improvement
Zarbo and D’Angelo	Determine the cause of defects in	Lean	Implement ∼100	Defects decreased from 30% to
2007	tests		process	12.5%
			improvements
Zito and Stewart 2008 Reduce time to get results to		Lean	Single piece flow	Reduction in turnaround time
	physician		system
Harrison and	Evaluate hospital LIS	Quality	Continue to invest	Improved healthcare quality
McDowell 2008			in state of the art
			LIS
Raab et al. 2008	Implement lean for pap testing	Lean	Create a one piece	Improved pap test quality and
	and diagnostic accuracy		workflow and	diagnostic accuracy
			record process
			completion with a
			lean checklist
Elder 2008	Investigate the importance of	Quality	Refine the quality	Reduced cost and improved
	implementing quality/six sigma		of the process	quality
	techniques
Melanson et al. 2009 Improve patient experience with		Lean	Remove non-value	Wait time decreased from 21 to
	laboratory		added steps	5 minutes
Serrano et al. 2010	Increase patient safety and	Lean	Implement process	Achieved the CAP ISO-15189
	laboratory performance		redesign	accreditation
Das 2011	Determine how to develop	Lean	Apply validation	Improved accuracy
	validation measures for testing		measures for all
			tests

Note. LIS = Laboratory Information Systems.

Approximately 200,000 patients contract blood-stream infections from catheters each year. These infections have caused a mortality rate of approx-imately 18%. Researchers applied the TPS strat-egy to the central line placement and mainte-nance (Shannon et al. 2006). Through an in depth analysis, the root cause of the bloodstream infections many patients were suffering from was determined. Best practices were developed to eliminate or at the very least reduce the number of infections that oc-cur. Within a year, healthcare facilities saw a 50% reduction in infections by implementing the best practice techniques.

Raab (2006) addressed reducing medical errors and increasing patient safety in anatomic pathology laboratories using quality tools and techniques. The researcher defines patient safety as freedom from accident or injury resulting from the delivery of healthcare. A medical error is described as the fail-ure of a planned action to be carried out as intended or the use of the wrong process/plan to achieve a goal. One challenge in decreasing medical errors noticed by the author was the lack of standardiza-tion of quality assurance procedures across laborato-ries. In order to overcome this challenge, a process improvement team developed a plan to incorpo-

HOSPITAL TOPICS: Research and Perspectives on Healthcare

rate TPS principles into the laboratory practices. The goal was to obtain a defect free test result for each patient. A one-by-one workflow process was created so that the test specimen was immediately accessioned, processed, and finally screened. After implementing this process redesign, the number of defects decreased from 9.9% to 4.7%. This data in-dicated that the TPS process improvements resulted in higher quality testing and a decrease in medical errors.

In the study of Zarbo and D’Angelo (2007), the authors determined there was approximately a 30% defect rate in the pathology department. Each pro-cess and procedure was thoroughly investigated to determine the cause of such defects. The researchers took the Henry Ford Production System strategies and applied them to the pathology department in order to reduce the amount of waste and rework encountered. After the implementation of nearly 100 process improvements, the number of defects reduced from 30% to 12.5%.

Applying the Automation Approach to Improve Hospital Laboratory Performance

Many research studies have discussed the impor-tance of automating certain stages of hospital lab-oratories (Holman et al. 2002). Automation pro-vides an opportunity to experience a decrease in errors faced in laboratory medicine. Research has shown with automation implemented in laboratory facilities, the total turnaround time and errors ex-perienced could be greatly reduced (Tornel, Ayuso, and Martinez 2005; Melanson et al. 2007). Table 3 provides a synopsis of the automation studies re-viewed.

In a research study conducted by Da Rin (2009), it was discussed how a reduction in errors could be obtained through proper workstation design. As in many studies, it was concluded most of the errors in the entire testing process occur in the preanalyt-ical stage. Therefore, of the three stages (preanalyt-ical, analytical, and postanalytical) priority should be placed initially on the preanalytical stage. The author stated that automation of the preanalytical stage is a method of preventing and reducing errors. When selecting an automated preanalytical work-station, there should be certain performance and quality measures established, such as ensuring pa-tient and specimen identification. Da Rin proposed 13 components of a preanalytical workstation: spec-imen input area, sample identification, tube selec-tion, transport system, sorting routing device, au-

tomated centrifuge, level detection and evaluation of specimen adequacy, decapping station, aliquot-ter station, automated analyzer, specimen delivery, recapping station, and take-out station. Strict ad-herence to blood collection procedures is the most effective way to guarantee quality during specimen collection and specimen processing. The automated preanalytical workstation proposed by the author in this study was implemented at San Bassiano hospi-tal. As a result, this hospital experienced improved accuracy and clinical efficiency in its laboratory processes.

The preanalytical stage is the most labor-intensive part of the overall laboratory testing process. In the study of Yavilevich (2002), the significant advances in blood testing accomplished in the last 30 years were discussed. Many of these advances have been through laboratory automation, but the bottleneck of the automated process remains to be the low speed of the centrifugation system. Centrifugation allows for plasma to be separated from the red and white blood cells. Current automation systems al-low for, on average, 500 tubes to be centrifuged per hour. Yavilevich proposed an even powerful lab-oratory automation system, Fast Spin technology, which will allow for 2,500 tubes to be centrifuged per hour through combining several parts of the preanalytical process into one unit. There are three parts to the Fast-Spin Module. The first part allows for separation, the centrifugal force then rotates the holders and tubes so they are in a horizontal posi-tion, and lastly once the centrifugation has stopped the holders and tubes return to their initial position. There are several advantages to the Fast-Spin prean-alytical module, which include decreased processing time and significant cost savings for hospital labo-ratories. Increased attention to automate hospital laboratories is due to the need to reduce healthcare costs, specifically laboratory costs. Automation is believed to greatly reduce the errors that are experi-enced in each of the laboratory stages. Converting a hospital laboratory to a Total Laboratory Automa-tion (TLA) facility is a gradual process and should begin with preanalytical automation.

Applying the Simulation Modeling Approach to Improve Hospital Laboratory Performance

In the study of De Capitani, Marocchi, and Tolio (2002), a simulation model is developed to analyze different scenarios considering personnel, preana-lytical devices, and management policies. The goal of developing a simulation model is to understand

24 Vol. 93, no. 2 2015

TABLE 3. Synopsis of Articles Reviewed for Automation Approach

Study	Objective	Recommendation	Results

Yavilevich 2002	Increase speed of	Implement fast spin	Implemented in
	centrifugation	lab module	preanalytical stage
	system
Holman et al. 2002	Decrease laboratory	Implement automated	Reduction in
	errors that occur in	preanalytical	laboratory errors
	the preanalytical	processing unit
	stage
Tornel et al. 2005	Decrease workload in	Implement automated	Staff workload was
	laboratory	system	decreased
Melanson et al. 2007	Select proper	Decide on chemistry	Decrease in laboratory
	automation systems	automation tool	errors
	for hospital
	laboratories
Da Rin 2009	Reduce errors through	Incorporate	Improved accuracy
	workstation design	preanalytical
		workstations

how the future system will work and to provide a performance and economic assessment, prior to implementation. The first component of the study focuses on data collection and workflow analysis. The second component of the study consists of sce-nario design and the model development. The final component is the simulation model validation and performance evaluation. The objective of the lab-oratory in this study is to minimize the total cost associated with the preanalytical stage. Three sce-narios were designed and the chosen scenario was the one with the lowest cost, while still meeting all constraints. The authors concluded that the op-timal scenario was Scenario B with one operator for the loading/unloading of the tubes and three operators for inputting requests. If this scenario is implemented in the preanalytical stage of hospital laboratories, there would be cost savings achieved of approximately 40%.

Management tools such as workflow analysis, workflow simulation, and scenario analysis are prov-ing their effectiveness in laboratory medicine. Sev-eral studies have been conducted and show the use-fulness of implementing such management tools in hospital laboratories. The goal of workflow analy-sis and design includes the adjustment of capacity and services, such that services are provided in the most efficient manner. High quality indicates that the level of work performed is done accurately, er-rors are minimized, and patients are satisfied. In a simulation study (Goldschmidt et al. 1998), it was determined that workflow analysis could be applied

in clinical laboratories using discrete event simula-tion. The purpose of the simulation was to analyze how a growing workload affects the service times of the staff. The results from the study proved to be very beneficial as it allowed for proper resource allocation within hospital laboratories.

Discussion

Each of the improvement techniques discussed in this article have proven to be winning approaches for hospital laboratories. Many authors of the literature utilizing the lean and quality control methods re-ported significant reductions in patient wait times (21 min to 5 min), blood sample defects (from 30% to ∼5%), and patient infections (an overall 50% reduction). The literature reviewed using the automation approach concluded hospital laborato-ries experienced an increase in staff/resource utiliza-tion and a decrease in laboratory errors caused by human inaccuracies. Lastly, the authors analyz-ing the use of simulation modeling to improve laboratory performance determined this approach would help to achieve proper resource allocation and cost savings of approximately 40%. Therefore, cost–benefit analyses performed by healthcare man-agers would indicate the frontend cost of imple-menting improvement initiatives utilizing the ap-proaches in this article would result in substantial benefits for laboratory facilities in healthcare deliv-ery systems.

HOSPITAL TOPICS: Research and Perspectives on Healthcare

CONCLUSION

As the healthcare industry continues to grow rapidly, obtaining efficiency and effectiveness within healthcare delivery systems has become a major pri-ority. In order to increase patient satisfaction and patient safety, hospital laboratories must improve their overall performance. The objective of this ar-ticle was to review recent and relevant literature on initiatives to improve hospital laboratory facilities. Most of the studies reviewed delivered improve-ments using lean strategies, quality control meth-ods, automation, and simulation modeling. Each of these approaches proved to be beneficial to both the patients and medical staff of hospital labora-tories. While conducting this review of literature, it was determined that there are not many stud-ies that have applied mathematical modeling meth-ods to improve laboratory processes and scheduling. Mathematical modeling has proven to be benefi-cial in many different areas of healthcare, which include surgery scheduling, medical resource al-location, outpatient appointment scheduling, and cancer screening. Because laboratory medicine is such a major component of the healthcare deliv-ery system, it is imperative to close this research gap.

Future research to be performed should include developing mathematical models to improve the performance in hospital laboratories. These types of models could be used for scheduling purposes to balance workload among the medical technicians and eliminate work overload that is often expe-rienced by many medical staff members. Math-ematical modeling could also be used to maxi-mize resource utilization in laboratory facilities, as this will allow hospital management to allocate re-sources in such a manner that will minimize over-all costs. It is also worth investigating, by doing a comparison analysis, which approach provides the most performance improvements and cost savings for hospital laboratories. This will allow hospital management to determine which improvement ap-proach should be implemented in their laboratory facility to achieve maximum efficiency and overall effectiveness.

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Westgard, J. O., and S. A. Westgard. 2006. The quality of lab-oratory testing today. American Journal of Clinical Pathology

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http://eds.b.ebscohost.com/eds/pdfviewer/pdfviewer?vid=2&sid=f2a895d6-1b76-4644-907f-1e6ec17e5dc9%40sessionmgr120
Leaven, L.T. (2015). Improving Hospital Laboratory Performance: Implications for Healthcare Managers. Hospital Topics, 93(2), 19-26 doi: 10. 1080/00185868.2015.1052267

It talks about improvements in medical labs to improve patient care. From reducing time which reduces stress and angst in patients to improving the quality of results giving the doctors more accurate information to present to the patients. This works hand in hand with my internship as I see some of these things implemented at Northside and am able to see the benefits such as “Automation [which] provides an opportunity to experience a decrease in errors faced in laboratory medicine.” “Many clinical laboratories [including Northside] have incorporated the lean and quality improvement strategy to increase patient safety and improve quality and workflow” This assessment of lab improvements and their effects will be critical for my capstone.

FCHS Northside Mentorship

Saturday, October 28, 2017

Assignment 11: Mentorship Write Up

Sunday, October 22, 2017

Assignment 10: Internship Update

Assignment 9: Reflection (Step 3 of Creating an Annotated Bibliography)