UTMB Laboratory
Pre-analytical Time
Improvement
November 5, 2010
1
The Team
• Alexander Indrikovs
• Anthony Okorodudu
• Jeffrey Richards
• Bert Nash
• Theresa Friloux
SPONSOR:
• Donna Sollenberger
CEO, UTMB Health System
2
Aim Statement
By September 1, 2010, decrease by one hour the
time at which Sample Management completes
processing of outpatient samples.
3
Why We Selected This Goal
• Outpatient work accounts for 2/3 of all lab tests
• Most of these samples arrive in the laboratory
between 5 PM and 11 PM
• Prolonged outpatient processing delays inpatient
testing
• Laboratory automation is approved for FY11. For
maximum benefit, we must have a continuous
flow of specimens into the automated line.
4
Scope of UTMB OUT PATIENT SERVICES:
TDCJ Units, Regional Maternal & Child Health Clinics, & UTMB Community
Based Clinics
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Courier Arrival Times
2400
2300
2200
2100
2000
Route # 5
Route # 5
Route # 1
1900
Route # 3
1800
Route # 4
Route # 2
1700
1600
Route # 6
Route # 2
1500
1400
6
Clinical Laboratory Workflow
EDTA
tubes
Sort
Sample
tubes
Receive
into lab
Load
centrifuge
Bottleneck > 70% of
pre-analytic
time
Unload
centrifuge
Decap
Label
aliquot
tubes
Aliquot
Sort
Walk to
analyzers
Pre-Analytics 70% of turnaround time
Load
analyzers
Analytics / Post-Analytics 30% of turnaround time
Store
racks
Archive
tubes
Find
tube
Recap
tubes
Load on
analyzer
Walk
to storage
area
Verify at
LIS
Unload
analyzers
Unload
analyzer
Verify/
Manage
exceptions
Recap
tube
Rerun
exceptions
Archive
tubes
Locate
exceptions
Verify
at LIS
Store
racks
7
Pre-printed Labels
8
Tube Sorting
9
Time of Day Last Samples are Ready for Analysis
April-July 2010
14.00
12.00
10.00
8.00
Time
Time Out 6.00
Mean
+2 SD
4.00
-2 SD
2.00
0.00
22.00
-2.00
Date
10
Sources of Lab Errors
11
Process Evaluation
People
Process
Process
People
SOPs inadequate
Staff in SM not adequately trained
Inadequate training materials
SOPs written prior to transition to interfaced testing
Orientation not well-organized
order entry
processesentry processes
Multiple
order
Staff in SM not adequately trainedMultiple
Most SM Staff not highly educated
Different processes for individual clients
Clients not knowledgeable about packaging
& submission requirements
Workstation pending lists inaccurate
Orders placed for uncollected samples
Errors and delays in preanalytical processing
compromise full benefits
of planned laboratory
automation
TDCJ samples not bar-coded
Suboptimal use of information
technology system
Orders placed more than once
Clients not trained about the requirements?
Staffing not adequate or aligned with workload?
High turnover
Tecans, frequently fail
Staff not knowledgeable on maintenance and repair
Multiple sample packing systems
Different clinics have their own preferences
Inconsistent leadership in SM
Errors and delays in preanalytical processing
compromise full benefits of
planned laboratory automation
system
No team leader on the night shift.
Training not ongoing
CES lacks parts and expertise maintain Tecans
CES not accountable for Tecan
performance
TDCJ samples not bar-coded
BC printers not available in units
Equipment
Equipment
Supervision has not had clear accountability since rebuilding
Suboptimal use of information technology
No one to divide up work on the night shift
Management
Management
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Previous Receiving and In-Lab System
Print
Manifest
Use
Manifest
to “In-Lab”
Print
CERNER
Labels
Courier
Arrives with
patient
samples
Verify
Receipts
with courier
Find manifest;
Match Samples
with labels
& Label Tubes
Walk to
Analytical
Area
Tecan:
Aliquot &
Sort
Tecan:
Decap
Tubes
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Interventions
• Installed bar code label printers at 85 Texas
Department of Criminal Justice (TDCJ) units
• Trained TDCJ staff on use of new labeling
process
• Piloted new sample accessioning process with
one TDCJ route
• Implemented new process with all Regional
Maternal Clinics
14
New Receiving and In-Lab System
X
Print
Manifest
Use
Manifest
to “In-Lab”
X
X
Print
CERNER
Labels
Courier
Arrives with
patient
samples
Pre-Receipt processing
Modified
Streamlined from 9 to 6 steps and modified
3rd step in new system
Walk to
Analytical
Area
Verify
Receipts
with courier
Tecan:
Aliquot &
Sort
In-Lab Samples,
Print Labels
And Place on Tubes
Tecan:
Decap
Tubes
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Benefits of Improved Process
• Standardize to one process for receiving all
interfaced orders
• Decrease errors by printing labels and labeling
tubes on one patient’s samples at a time
• Finish processing Outpatient samples before AM
Inpatient samples arrive in the lab
• Allow testing areas to monitor pending workload
• Eliminate batch processing to provide continuous
flow of samples to the labs
16
Time of Day Last Samples are Ready for
Analysis
April – July 2010
September – October 2010
Time Out
10.00
4.00
0.00
17
Summary
Measure
April –July 2010
Sept 15-Oct 29
Mean Time out
04:22
1:05
Standard Deviation
02:37
0:29
18
One Measure of Success:
Turn Around Time (TAT) for Potassium
May 18, 2010
Oct 26, 2010
4.8
2.2
SD (hrs)
6
2.5
% Completed within 4 Hrs
of in-Lab
68
90
Average TAT (hrs)
19
ROI: Financial
• Decrease in Sample Management overtime by 46% in
September, 2010 or cost reduction by $994; extrapolated to
$12,000 per year
~
• Redirected effort of Client Services staff spent on
troubleshooting order errors; now used for answering physician
and/or provider phone calls
• Gains in technical efficiencies/redirection of labor: to be
determined
• Potential impact of improved TAT on ALOS: to be determined
20
ROI: Patient Safety
• Decreased pre-analytical errors with resultant
increased reliability of lab results
• Improved TAT can result in faster decisions for
patient diagnosis and treatment
21
Next Steps
• Train all Sample Management staff in new
process - completed
• Fully implement new process for all outpatient
samples - completed
• Monitor new process for error rates and
turnaround time - ongoing
• Implement Automated Track System – submit
RFP
22
Thank You!
• Sample Management Division at UTMB
• CMC Laboratory & Information Service Teams
• UTMB Pathology Client Services Team
• Regional Maternal & Child Health Clinics
Thank you for your time!
23