By Leo Serrano, FACHE

West Tennessee Healthcare encompasses seven acute-care facilities, including the 697-bed Jackson-Madison County General, our lab’s first home. The Medical Center Laboratory is a separate business unit of West Tennessee Healthcare, the tenth largest public hospital system in the United States.

Leo Serrano, FACHE, with staff at West Tennessee Healthcare

West Tennessee began acquiring hospitals in 1989, but all the laboratories continued to operate independently. In November 1995, I was hired to integrate the laboratory and expand its outreach program.

Prior to 1996, we were a very traditional organization. The hematologists only did hematology and those in the chemistry section only did chemistries and ABGs. There was little or no cross training.

There were also sharply divided loyalties and an inefficient physical layout that revolved around “the wall.” Chemistry was on the right side of the wall and hematology was on the left side. There was little common ground, and the wall was largely to blame.

First-Pass Automation: Hematology
In 1996, we took our first pass at automating hematology with the Sysmex HST system, and it proved to be a great success. Today, we average from 1,000 to 1,500 CBCs in a 24-hour period, with only one person per work cell on the day shift.

There still was no cross training, but automation reduced our full-time employee (FTE) needs by five. Thanks to the hospital’s no-layoff policy, we didn’t let anyone go, but we did tell five people they would get the opportunity to learn new skills.

Second-Pass Automation: Chemistry
As we prepared to take our second pass at automation in 2000, we decided to change some processes before automating our chemistry section. In particular, we hired a consultant to help us justify automation financially.

In retrospect, I made one truly fortunate decision: I didn’t contract directly with the automation equipment manufacturer. Instead, I signed with a major instrument vendor that distributed the automation equipment. That saved us some major headaches 3 years later when our automation vendor filed for bankruptcy. The contract stipulated that our laboratory would be made whole if automation didn’t live up to its stated goals.

Automating our chemistry reallocated another three FTEs.We added some new procedures with the three saved FTEs, so we were making progress.

All specimens were now flowing in the same direction. Our hematology track ran down the center of the lab. Directly above it was the track supporting chemistry, immunochemistry, and coagulation. The wall was eliminated. It took much effort and time, but the staff began to cross train, which turned out to be very beneficial for the future.

Unfortunately, it was only after this long process of automation that we were properly introduced to Process Excellence by Ortho-Clinical Diagnostics. We made the mistake of automating everything before thinking about Process Excellence, but I am writing this so that others won’t make the same error.

Ortho’s Process Excellence and Our Third Automation Pass
As time went on, we outgrew our lab space. But it wasn’t until the hospital needed to expand that we got our chance to follow suit. To make room for the hospital’s new 10-story bed tower, it was decided that our new lab would be located outside the hospital campus. That made sense because at least half of our business came from outreach testing.

Architects and consultants told us we needed 60,000 square feet for our new lab. My CEO announced that we could afford only 40,000 square feet, however. As defined by Ortho-Clinical Diagnostics, Process Excellence is a combination of Lean, Six Sigma, and Design Excellence methods used together to improve operations. In order to squeeze 60,000 square feet of lab work into 40,000 square feet, we had to change our work processes. In January 2003, we tackled front-end processing and collections. I figured that if it solved my phlebotomy problems alone, it would take away 50% of my headaches.

Here is a summary of our Process Excellence changes.

Single-Piece Flow
When we did our front-end processing and phlebotomy changes, our phlebotomy changed from batches to one-piece flow. Single-piece flow also mistake proofed our specimen collection process and eliminated misidentification of patients.

Combined Inpatient and Outpatient Staff
We combined our inpatient lab office staff and our outreach client services staff. We also combined our inpatient processing staff and our outreach processing staffs. By combining our inpatient and outreach calls to a single call center, we now answer 95% of our telephone calls within five rings.

Displaced Staff Became Material Handlers
Using single-piece flow, specimens come in via a pneumatic tube system. Pending new automation, specimens are delivered to the work cells where they are centrifuged in small six-place units at each work cell. To avoid layoffs, displaced staff was converted to material handlers who distribute supplies and specimens and get rid of waste.

Phlebotomy Collections
Our phlebotomy collections per hour per FTE doubled from 5.1 to 10.3. Turnaround time from collection to receipt in the lab went from 27 minutes to an average of 6.3 minutes. Our goal is that all collections, with the exception of problem collections, will take no more than 8 minutes from the time the specimen is collected to the time the specimen is received in the laboratory. We graph and post the monthly results for all to see. Any employee who averages more than 8 minutes is highlighted in red. There is no punishment, but no one wants to be in red.

Patient Identification Errors
For 11 months, we’ve experienced zero documented patient ID errors by a lab employee. We are currently conducting a black belt project on labeling errors from the ER to deal with the way nurses, EMS, and ER personnel label the specimens they collect for us. It is impossible for hospitals with a trauma center to have all specimens collected by their lab staff.

Among the many changes in the core lab, nontrack instruments were repositioned into new work cells designed using Lean management concepts. Instead of being discipline based, work cells were positioned for maximum effect and minimum waste and motion.

For example, a technologist might work on an immunochemistry analyzer and a coagulation analyzer within the same work cell since both instruments essentially require the same processes.

Mini Lean Team Created
When we applied Lean to the central lab, it freed up three more people, who became known as our mini Lean team to supplement our core process excellence (PEX) team. We purposely chose people who were not management for this team. When we “leaned” the central lab, we created another problem, however. The CLS students we taught for the University of Tennessee-Memphis, and the students we taught for the MLT program at Jackson State were now being educated about obsolete technologies and processes. That’s what happens with Lean: you clean up one area, and open up another area for improvement.

Now we had to change our curriculum. We turned our mini Lean team loose to figure out how we could improve the teaching environment for students. Today, we turn out a better student.

Is Automation Necessary?
In November 2003, we reconfigured the layout of the central lab, and learned how to be Lean without automation. For example, we put small centrifuges in all the work cells. Still, this was hardly a Lean-friendly environment, because we were handling 5,000 to 7,000 specimens per day. We soon realized that automation is necessary if you don’t want to burn your people out, but it has to be the right automation, from a stable vendor.

Other Outcomes:
• In Central Lab, we’ve reduced our FTEs from 11 to 7 on the day shift. Second shift uses 7 FTEs, and third shift uses 4. At the same time, volume has increased by 30%.

• Turnaround time has improved dramatically, and the number of stat orders we receive has decreased to about 18%.

• The nursing homes we service saw 45% to 85% improvements in turnaround time with CBCs, Chem 7s, BNPs and TSH. We changed the way our couriers ran so that everything was dropped off and processed continuously in a single-piece flow.

We have a new Thermo track, which was designed around our Lean work processes and single-piece flow. Our Thermo system allows us to place our instruments where we need them, not where the automation dictates.

What have I learned from the long, bumpy road to get here? Automation is not a panacea. Processes are far more important, so forget the rules and look at your processes with fresh eyes.

Today, my CEO is a major proponent of the Lean design and management concepts that we started in the lab. When we began all this, he told the lab staff, “Folks, the train has left the station. You’re either on it or you’re under it, and I don’t recommend being under it.” The staff has been on board ever since. And this train called automation and Process Excellence has been a wonderful ride for us.

Leo Serrano, FACHE, is executive director of Laboratory Services, West Tennessee Healthcare in Jackson, Tenn.

The story of his facility’s rough but ultimately successful transition to an automated, more efficient lab was first told at the Dark Report’s 2004 Executive War College on Labs and Pathology Management.