REDUCING TURN AROUND TIME IN CLINICAL LABORATORY

REDUCING TURN AROUND TIME IN CLINICAL LABORATORY

Diagnostic responsiveness is critical to providing optimal service in high volume patient care; this is particularly important in emergency and operating rooms. With 60-70% of the required information on a patient’s chart coming from laboratory test results, the demand for quick service is translated into aggressive time requirements for cycle times of ordered tests (Holland, Smith, & Blick, 2005). (1) In clinical laboratories, the time from when a test is ordered to when the results are verified is defined as the turnaround time (TAT). The effects of TAT have been studied to a high extent, with correlations being drawn between emergency department treatment and length of stay (Hawkins, 2007). (2) As a result, TAT is often considered the most significant measure of a laboratory’s service and is used by many clinicians to judge its quality. Along with accuracy and reliability, timely reporting of laboratory test results is now considered an important aspect of the services provided by the clinical laboratory. Whether or not, faster turnaround time can make any medical difference, patients and their physicians want reports as rapidly as possible. There is increasing pressure from clinicians to report results rapidly. Even though there are only sparse data, timeliness in reporting of laboratory results undoubtedly affects clinician and patient satisfaction as well as length of hospital stay. Improving turnaround time (TAT) is a complex task involving education, equipment acquisition, and planning. All the steps from test ordering to results reporting should be monitored and steps taken to improve the processes. Poor core laboratory performance that causes delays in diagnosis and treatment is an impediment to optimal patient care, particularly in high-volume patient care areas such as the emergency department (ED). Most easy way to reduce Turn-Around-Time is to purchase the high throughput analyzer. However, if the Sample Transportation System has enough intelligence and performance, it is possible to minimize the investment for analyzers. In other words, it will be an over investment if the user needs larger scale of analyzer to cover the poor performance of transportation system.

Definitions

The Clinical Laboratory Standards Institute (CLSI, Wayne, PA) is working on a document (GP35) aimed at the "development and use of quality indicators for process improvement and monitoring of laboratory quality." Review of the literature shows a number of approaches in defining TAT. In general, it has been categorized by test (individual assays or panels), priority (stat or routine) and patients served (inpatient, outpatient or ED).

Lundberg described the path of workflow from the ED to the laboratory as a series of nine steps: identification, order, collection, ­transportation, preparation, analysis, reporting, result interpretation and action for treatment. Howanitz, who has published widely on CAP survey results, has suggested that TAT be defined from the time physicians place the laboratory orders to the time the test results are available to the clinician. He suggests that the expected turnaround time goals should be expressed as a percentage of all results completed within a given time interval. However, to maintain a successful ED TAT program there is a need to consider both good metrics and the engagement of staff members to resolve outliers as they occur on real time. We define ED TAT as follows:

1. ED Performance (ED Interval)

Monitoring the ED's timeliness of performance during the pre-analytical interval order-to-receipt.

a) START: The time physicians place orders for laboratory examinations, including clerical time needed to receive and log laboratory orders in the hospital information system.

b) MIDDLE: It continues with the time needed to collect and transport patient samples to the laboratory.

c) END: When the laboratory assistants receive and log all collected samples in the LIS.

2. Lab Performance (Lab Interval)

a) Monitoring the laboratory's timeliness of performance during the analytical interval receipt-to-report.

b) START: When samples get delivered to the medical technologists work cells for processing.

c) MIDDLE: It continues with the time it takes to prepare, centrifuge and process patient samples by instrumental analysis. It includes the time needed for dilutions, retesting and notification of critical results.

d) END: When medical technologists verify and broadcast results to the medical staff in the laboratory information system.

3. Total Testing Cycle (ED + Lab Intervals):

Monitoring the collective effort by both the ED and lab to complete the total testing cycle, order-to-report. That is, the time it takes both to finalize all orders.

4. ED Outliers:

Delays found in the ED's preanalytical phase. Controllable and uncontrollable delays during ordering, collection and transportation of laboratory samples by ED personnel are included. A 10 percent allowance is included for orders that may take over 45 minutes to be processed by the ED.

5. Laboratory Outliers:

Delays found in the laboratory's analytical and post-analytical phases. Expected and unexpected delays during specimen receiving, processing, testing and reporting by the laboratory staff are included. A 10 percent allowance is included for samples that may take over 45 minutes to be completed by the laboratory

Outlier analysis is commonly used in industrial quality control as a method of determining reasons for system failure. In the clinical laboratory, outlier rates are expressed as the percent of total ­laboratory examinations failing to meet targeted reporting times. Improving TAT requires education of a wide variety of individuals, long-term planning, and completion of innumerable tasks. Small investments in the clinical laboratory resources may improve TAT and greatly improve clinicians’ efficiency, as well as help reduce required days of hospitalization for patients. Overall cost reduction, however, may be difficult, if not impossible, to prove. With limited exceptions,studies to date fail to show that decreased TAT improves thelength of hospital stay or patient care.(3,4,5,6)  Practitioners needsto become more efficient. From the clinicians’ viewpoint, it is easy to see the benefits of rapid return of results. With the appropriate information available, laboratory results can be explained to the patient and treatment adjusted all in one encounter, thus increasing clinician efficiency and patient satisfaction. If laboratory results provide essential information for patient diagnosis and treatment, it follows that more timely results will improve patient care. Patient outcomes undoubtedly are affected by delays in diagnosis. (7) It is important to remind those who allocate resources that laboratory results must be available not only for diagnostic use but

also before many treatments and procedures can be implemented. Thus, despite the lack of data, it is reasonable to assume that timeliness of laboratory results affects physician efficiency and hospital length of stay. Therefore, monitoring and enhancing timeliness of results reporting are fundamental to laboratory quality improvement.

TAT Benchmarks

Laboratory professionals generally believe intralaboratory TATs of up to 60 minutes are appropriate; clinicians do not agree.(8,9) Clinicians consider TAT from the time the test is ordered to results reporting, whereas laboratory professionals usually use specimen receipt to reporting of results as the TAT.(10) Although it is difficult to monitor each of the steps from ordering a test to reporting the results, and often laboratory professionals are not in control of many of the processes, it is

important to view TAT from the clinicians’ viewpoint. TAT should be monitored on a regular basis, not only for the mean TAT, but also for results reported well beyond the average TAT (ie, outliers). Various measurement parameters have been used to express TAT, including proportion of acceptable results.(11) Mean and median TATs are not affected significantly by outliers, and, thus, they are not good statistical indicators for laboratories with good performance that want to improve further.16 Identifying outliers and looking for the root cause of these problems is an excellent approach to understanding and eventually eliminating untimely reporting of results. Another approach is to monitor inpatient test availability for morning rounds.4 Through the College of American Pathologists Q-Probes and Q-Tracks programs, national databases on a number of TAT parameters have become available. Recently, the College of American Pathologists offered 2 Q-Tracks TAT monitors: Stat Test Turnaround Time Outliers and Morning Rounds Inpatient Test Availability.(12)

At present, TATs for most stat clinical laboratory tests are less than 1 hour and 2 working days for most routine surgical pathology cases.18-20 Using report inquiry for CBC count reports as an indicator, data show that most reports for inpatients and outpatient tests ordered stat are requested within 4 hours.(13,14) Others make the point that timeliness in reporting early morning routine clinical laboratory test results is an important parameter. It is important to choose TAT goals that lead to improved patient care and clinician efficiency and to improved satisfaction for both patients and clinicians. Ideally, all common laboratory tests should be reported as rapidly as possible by methods yielding high quality results, and this currently means an hour or less from order entry to results reporting under optimal conditions. For effective management of resources and improvement in patient satisfaction, it is especially important to report outpatient results promptly.

The resolution of delays, measured in terms of outliers, is one of the most important benchmarks in meeting ED TAT goals. Resolving delays caused in ED TAT reflect efforts to provide diligent laboratory test results to improve patient care. This may be achieved by:

Ø  raising employees' awareness in tracking and resolving delays as they happen in real time,

Ø  motivating employees to achieve daily ED TAT goals by decreasing the number of outliers,

Ø  keeping employees informed with daily ED TAT reports,

Ø  recognizing staff members when ED TAT daily goals are met and

Ø  having an action plan to resolve delays that could be avoided or controlled.

Every hospital laboratory has its own ways of monitoring ED TAT. TAT data collection and ­outcome interpretation varied. This may be due, in part, to:

Ø  the different time frames used in monitoring ED TAT-in real time, daily, weekly or monthly;

Ø  the selection of different lab activity test menus used to monitor ED TAT;

Ø  the types of equipments used to examine patient samples;

Ø  different hospital and laboratory information systems used in tracking ED TAT; and/or

Ø  types of software products used to tabulate TAT data.

Strategy:

1. Define the services provided, such as urine analysis or blood analysis, and measure current turn times overall. Ask the customer to define her expectation and analyze the gap. Use the smallest measurement increment available, such as seconds or minutes. For example, the customer wants a turn time of 30 minutes for a hemoglobin blood test, and right now you are yielding 60 minutes. The objective in this case would be to reduce current turn time by 30 minutes.

2. Remove variation first. Define each major step of the process such as customer intake, computer update, sample drawn, sample labeled, sample tested, testing validated, results recorded, customer notified, and customer billed. Visualize entire process by creating a top-level flow chart. Instruct employees to handle every request with a uniform first-in/first-out process so that when a problem occurs it receives visibility. Focus on flow and do not allow employees to put work aside for clarification as these "exception situations" cause 80 percent of the variation in the outputs. Concentrate efforts on ensuring a consistent process even if the process isn't yet yielding the results you need.

3. Measure each sub-step in the process to see how long it takes. In this case, we find we have 5 minutes for customer intake, 20 minutes waiting, 7 minutes for blood draw, 1 minute for labeling, 2 minutes for analysis, and 20 minutes waiting before clerk notifies customer of results. In this case, the waiting or queue time is what is eating up turn time. Adjust process to minimize wait time. To do this, identify areas that exhibit waste, such as overproduction (making things unnecessarily like copies), delays (waiting), transportation (moving data or equipment), wasted motion (walking, non-value added keystrokes), inventory (mismanaged, not enough, too much) and making defective products (adding work to something already defective). Develop ways to streamline process and communication flow by re-timing or moving work, consolidating tasks, getting rid of non-valued activities, and adding machines or personnel.

4. Benchmark competitors' laboratories to compare how they handle clinical laboratory services. Investigate opportunities to apply new software, new technologies and methods to improve accuracy and responsiveness. Make sure measurement systems are consistent between provider and customer. For example, the customer may measure the process up to the point that they receive the results whereas a provider may measure the process up to the point of payment. Examine the real needs of the desire to drive down turn times and address these specific areas each time.

5. Control the process by measuring inputs to make sure steps within the process remain consistent. Investigate anomalies and figure out why problems occur. Be proactive against variation by improving training and hiring methods. If one technician takes longer than another, find out why. For example, during the blood draw stage, the patient is brought to the room, a tourniquet is wrapped around his arm, the technician takes the needle in one hand and a swab in another. After swabbing the area, the technician penetrates the vein with a needle, and releases the tourniquet and then draws the blood. They take the pre-formatted label and affix it to the blood sample and set it in the test area. Another technician talks incessantly, draws the blood the same way but instead of labeling and putting the blood sample in the test area, they walk the customer out the door, and forget to put the sample in the test area until an hour later. This would be the variation that needs to be eliminated to improve the process.

6. Shift the bell curve slowly and methodically, incrementally. If the goal is to reduce turn times by 50 percent or 30 minutes overall, then work to reduce seconds off each step of the process. Set realistic upper and lower control limits by examining current yields. For example, if the blood draw process takes 7 minutes on average, set the lower limit to 60 seconds and the upper limit to 420 seconds. Any time a blood draw takes longer than the 420 seconds, figure out why and eliminate the problems. Each time a task within the process is perfected to take less time, the overall turn time will be reduced, getting you closer and closer to your goal.

Regular audit of data helps in the evaluation of the efficiency of the laboratory and hence corrective measures taken accordingly would be helpful in providing better service to the physicians and patients

Thus, many have predicted that the use of point-of-care testing will increase, but the question remains whether point of- care testing is the most efficient and effective means of producing test results.(15) Currently, technologic advances are occurring that can make large improvements in central laboratory TAT a reality. Now is the time to improve timeliness not only as a strategy but also as a duty to all of our customers, clinicians and patients alike. There are constant pressures to make trade-offs, to compromise, and to change strategy. Timeliness of results reporting is too important an issue to fall prey to these pressures.

1)     Hawkins, R. C. (2007). Laboratory turnaround time. Clinical Biochemist Reviews, 28(4), 179-194.

2)     Holland, L. L., Smith, L. L., & Blick, K. E. (2005). Reducing laboratory turnaround time outliers can reduce emergency patient length of stay. American Society for Clinical Pathology, 124, 672-674.

3)     Steindel SJ, Jones BA, Howanitz PJ. Timeliness of automated routine laboratory tests: a College of American Pathologists Q-Probes study of 653 institutions. Clin Chim Acta. 1996; 251:25-40.

4)     Steindel SJ. Timeliness of clinical laboratory tests. Arch Pathol Lab Med. 1995;119:918-923.

5)     Saxena S, Wong ET. Does the emergency department need a dedicated stat laboratory? Am J Clin Pathol. 1993;100:606-610.

6)     Kost GJ. Connectivity: the millennium challenge for pointof-care testing. Arch Pathol Lab Med. 2000;124:1108-1110.

7)     Kenagy JW, Berwick DM, Shore MF. Service quality in health care. JAMA. 1999;281:661-665.

8)     Hilborne LH, Oye RK, McArdle JE, et al. Evaluation of stat and routine turnaround times as a component of laboratory quality. Am J Clin Pathol. 1989;91:331-335.

9)     Howanitz PJ, Cembrowski GS, Steindel SJ, et al. Physician goals and laboratory test turnaround times. Arch Pathol Lab Med. 1993;117:22-28.

10)  Weinstein S. Quality in pathology laboratory practice. J Qual Clin Pract. 1995;15:121-126.

11)  Valenstein PN, Emancipator K. Sensitivity, specificity, and reproducibility of four measures of laboratory turnaround time. Am J Clin Pathol. 1989;91:452-457.

12)  College of American Pathologists. Q-Tracks, Q-Probes [brochure]. Northfield, IL: College of American Pathologists; 2001.

13)  Burke MD. Laboratory test turnaround time and the needs of medical care. Am J Clin Pathol. 1997;108:367-368.

14)  22. Winkelman JW, Tanasijevic MJ, Wybenga DR, et al. How fast is fast enough for clinical laboratory turnaround time? measurement of the interval between result entry and inquiries for reports. Am J Clin Pathol. 1997;108:400-405.

15)  Kane B. Point-of-care testing: instant gratification? Ann Intern Med. 1999;130:870-872.