During onsite observation of lab staff and current state processes, along with data collection and analysis, the Accumen Lab Excellence team will identify areas of opportunity to reduce waste and streamline processes. After recommending changes or best practices, the team also assists with the implementation of changes. This can include all phases of the laboratory process, from pre-analytical (ordering, collection, patient identification) to analytical (processing, testing, resulting, equipment) to post-analytical (calling critical results). This can also include areas outside of the laboratory, such as observing and implementing changes among nurses collecting specimens, analyzing providers’ orders, or making changes to bone marrow collection support taking place in interventional radiology. All changes are implemented only upon decision-making by lab and hospital leadership teams. Support also includes project management for the team and data analysis over time to monitor and ensure sustainment of improvement results. Potential areas of focus and their benefits include:
is entails assessing the physical space and observing motion and transportation. In Lean, motion of staff and transportation of specimens or supplies are identified as two of the key Wastes or Non-Value Add activities. Accumen will recommend relocation of equipment and/or supplies to reduce steps, motion, and transportation. Creation of Spaghetti Diagrams aid in capturing the Current State as well as Future State options.
Storage of specimens takes up key real estate in the lab, whether scanned into racks in fridges or utilizing a vendor’s refrigerated storage module (RSM). Accumen can obtain lab orders and results data from your Lab Information System (LIS) to analyze and quantify the timeframes when add-on tests are ordered and performed. At many clients, for example, chemistry specimens are kept for 7 days, but data analysis reveals that 99.9% of testing is ordered within 4 days. This provides the opportunity to reduce specimen retention policies to <7 days, increasing storage space and making specimen retrieval easier.
Accumen can review ordered tests data to ensure appropriate use of “Stat” and “Timed” priority to optimize specimen collections. The team can also assist with creating communication materials for providers to change their practices.
Phlebotomy Swarm or Sweeps is a team-based approach to the inpatient morning run collections. Its many benefits include reducing opportunity for patient identification error, reducing batching of specimens and evening flow to and throughout the lab, reducing collect-to-receive turnaround time (TAT), better coordination of phlebotomy resources, balanced workload, increased peer support for difficult sticks, increased productivity, opportunity to reduce labor cost, and most importantly, improved patient satisfaction with less disruption to patient rest and healing. Accumen’s services include everything from phlebotomist training and simulation, to on-hand support during the morning run implementation, to data monitoring of performance.
Blood collectors frequently draw extra tube(s) from patients in addition to those for lab tests ordered by providers (“rainbow draws”). Perception is that these will be used for testing, saving patients from a second stick, however data show that 87-95% of these do not get used. This provides no value to lab nor patients, instead creating waste in collection time, lab time, supplies, storage, and disposal. Most importantly, patient impact includes prolonged discomfort, wasted blood, and potential contribution to hospital-acquired anemia. Accumen can lead an improvement initiative from start to finish, including data collection/analysis, implementation, and monitoring improvement and sustainment.
Bone marrow collections are often supported at bedside by lab techs, but the process likely presents opportunities for improvement. Example clients have found that one collection results in >80 minutes of lab tech time. On average only 42% of this is Value Add and “top of license.” Much of it is waiting, inefficient, or better delegated to non-technical staff. Accumen can lead an improvement initiative from start to finish, including observation and value stream mapping, work sampling and value analysis, development of Standard Work and training plans, implementation, and monitoring of improvement and sustainment.
If there is an automation line in the lab, optimizing its use is key to minimizing the manual in-lab and loading of specimens. This may include working with vendors to enable all relevant features. If there is not an automation line, instrumentation may instead have auto-receiving to avoid manual steps. Other areas of optimization include whether additional testing equipment should be interfaced and/or auto-verified based on volumes, as well as whether a barcode scanning system should be used to archive specimens to reduce time spent retrieving tubes from storage.
Implementing auto-verification or auto-validation, and maximizing A/V rate, reduces unnecessary review of results by lab techs. Accumen will use lab orders & results data from your LIS to calculate A/V rate in terms of percentage by department, bench, instrument, and/or test, and investigate the opportunity to increase A/V rate by updating criteria. In Gen Lab benches, 92-93% A/V is ideal and <85% is a significant opportunity. In addition to reducing unnecessary work by techs, maximizing A/V rates has also improved client receive-to-result turnaround time (TAT).
Lab equipment’s Maintenance, Quality Control (QC), and Calibration are key activities that must be completed regularly; however, they are frequently time-consuming and error-prone processes for staff (particularly on the chemistry line, depending on vendor). Cycle Time Reduction (CTR) is a Lean strategy to identify waste within a process and reduce the overall task time. Frequently steps of the process can be eliminated, done outside the cycle, started earlier, or completed faster. Results have included an improvement of approximately 60 minutes per line, for a total of 120 minutes of downtime avoided.
In addition to minimizing the Cycle Time of equipment maintenance through CTR, performing daily maintenance and QC at the ideal hour of day is crucial, especially with respect to the Inpatient Morning Run. Mornings are a key time for lab collections and testing, as rounding physicians want results to be available timely. Accumen can perform an assessment in this area and recommend the best time to perform maintenance on each line of analyzers.
Establishing QC stewardship mitigates the reporting of inaccurate results while also ensuring that all QC is ran per the College of American Pathologists (CAP) regulations. QC Stewardship is an opportunity if labs are utilizing out of date practices for running QC, using more QC and labor resources than necessary. Accumen Lab Excellence, in collaboration with Accumen Supply Chain, can identify and quantify potential cost savings in QC and labor, identify challenges related to accurate reporting and rerunning tests, and assist with implementation of best practices to minimize QC.
Performing manual diffs is time-consuming for techs and requires concentration. Minimizing manual diff rate reduces unnecessary work by techs. Accumen can utilize lab orders & results data from your LIS to calculate manual diff rate by site and investigate the opportunity to decrease that rate by updating criteria. The CAP guideline for manual diff rate is <15%.
Reducing unnecessary cord blood evaluations in blood bank reduces work by techs. Based on mom’s and baby’s blood types, cord blood evaluations do not need to be performed at every birth. With thoughtful alignment and buy-in among physicians, there is an opportunity to reduce testing by implementing new algorithms. This results in time savings among lab staff as well as supplies savings, as the impact on testing volumes is monitored over time.
Calling critical results to nursing or providers is key for the delivery of patient care but is almost always a time-consuming process for techs. A hospital’s Critical Value Policy may not address how often a Critical Value should be called after the first call, if consistent with previous results. Therefore, there is opportunity to review critical value policies and identify opportunities to reduce the number of repeat calls, i.e., set parameters on when a repeat call is not needed after the first notification. This reduces unnecessary work (non-Value Add, waste) for lab techs as well as nursing and providers.
Overall, the Accumen Lab Excellence team reviews and assesses the labs’ most time-consuming activities (walking, collections, processing, maintenance & QC, verifying results, manual diffs, cord blood evaluations, calling critical results, etc.) and has a Playbook of proven best practices to optimize them. The team evaluates the effort versus impact of every recommendation identified in order to create a prioritized improvement plan or roadmap. The team also identifies any strengths or best practices already in place and highlights those to leadership for possible roll-out across the system.
Solution: Hemolysis is the breakdown or destruction of red blood cells, caused most often by a traumatic blood draw. The resulting presence of hemoglobin can cause erroneous results in a multitude of lab tests. Specimens are rejected in the lab if the sample quality is insufficient to produce accurate results. This can cause a delay of care, unnecessary interventions, increased length of stay, and increased cost. In hospitals who utilize personnel other than lab staff to draw blood, the rejection rate due to hemolysis can be 30% or higher. The industry standard for samples rejected due to hemolysis is <2%.
Benefit: Through data analysis, direct observations, staff interviews, and procedure review, the Accumen Lab Excellence team uses their unique experience and expertise to assess collection processes and practices, determine the root cause of increased hemolysis rates, and develop and implement a comprehensive training/transformation plan to reduce rejection rates due to hemolysis. Progress will also be tracked over time to identify gaps and ensure success in the improved process.
Solution: In addition to hemolysis, other specimen rejection reasons include quantity not sufficient (QNS) or “short” draws, clotted samples, contamination, incorrect tube or container, and incorrect specimen type. Causes for these rejections can range from collection technique, improper education, and lack of resources.
Benefit: Using the same assessment techniques as described for hemolysis, Accumen can determine whether these causes for rejection are above industry standards and what factors are contributing to that trend, develop and implement a comprehensive training/transformation plan, and track progress to ensure success.
Solution: Specimen rejection and recollection can result in increased length of stay, inappropriate clinical intervention, delay of care, and/or a strain on resources. The financial impact associated with specimen rejection can also be considerable, including factors such as labor, supplies, communication time, and/or loss of existing or projected revenue due to poor patient and provider satisfaction.
Benefit: Accumen’s unique analysis tool calculates the cost associated with specimen rejection and recollection, and in turn presents the savings associated with rejection rate improvement. Calculating this cost can help the lab make the case for improvement through reducing the number of rejected or recollected specimens.