Organizing Specimen Processing for High Quality and Efficiency
An Interview with Linda Nesberg
Patient Safety Focus first interviewed Linda Nesberg, operations manager at Mayo Medical Laboratories, in July 2009. In that interview, she described a system for reducing errors related to handling manual requisitions. The system follows Lean principles that Ms. Nesberg used in the computer manufacturing industry before she switched to the healthcare field. A version of the Mayo processing system has been successfully implemented in a variety of labs in the U.S., including the lab of the physicians who conducted the current interview. In this follow-up interview, Ms. Nesberg speaks more generally about proper receipt and processing of specimens and their associated test orders.
Erin Grimm, MD, and Michael Astion, MD, PhD conducted this interview.
When you arrived at Mayo, how was specimen receipt and processing organized?
The Mayo Reference Laboratory was growing rapidly when I arrived. At the time, there were three job categories: laboratory assistants, lead technologists, and supervisors. The laboratory assistants processed specimens, and when they encountered a problem, they either attempted to resolve the issue or they referred it to a lead tech or a representative within our client services section. Common problems at the time were those confronting any lab, such as missing data on the requisition, specimen mislabeling, and improper specimen containers. The lab did not have a standardized process for dealing with specimens that required extra work before processing.
Why was a change in workflow necessary and what benefits did you hope to realize?
The reference laboratory was experiencing double-digit growth per year. Further defining duties and separating tasks were necessary to efficiently deal with the increasing workload. My goal was to separate the problem cases from the general work flow so that the routine work moved through more efficiently and with fewer errors (Figure 1).
Sorting Routine Specimens into a Fast Lane Lets Value Flow
When looking at workflow issues, do you use any particular approach to problem solving?
Yes, we incorporate Lean principles. One of the general principles of Lean is to remove bottlenecks in order to reduce delays, which is one of the main forms of waste in processes. Therefore, we wanted to create a system in which problem cases did not block the flow of routine cases.
What organizational changes did you institute to help workflow?
I defined additional job categories to separate the duties of the employees responsible for keeping the pace of specimen processing moving from those who were specifically selected to deal with problem cases. The current organization of specimen processing is that a supervisor is in charge of 35-40 people. Also under a supervisor are three or four lead techs. The lead techs are divided into two categories, slow-lane lead techs, who handle exceptions, and fast-lane lead techs, who are in charge of facilitating the work flow of the laboratory assistants and keeping the pace of routine processing on target. There are also other job classifications. One is the lab specialty assistant, who while supporting the lead techs, also aliquots all specimens. Another is the operation scheduler, who monitors daily volumes and determines appropriate staffing schedules to handle those volumes. In this system, the laboratory assistants are on the front-line, and they can process cases without dealing with delays caused by problem cases. The supervisor’s job is to ensure employee well-being. Supervisors help administer training for new employees, provide employee counseling, and triage personnel issues, such as time away from work. They also organize and administer process improvements and quality initiatives.
How did you accomplish the reorganization? Was it hard for the lab staff to accept this organizational change?
Change is always difficult for some people, but there were also benefits to graduated positions in the system. Previously, a career track for job advancement was not well-defined. Now, there are job classes with increasing levels of responsibility and increased pay. In addition, the more specific job descriptions allow personnel to gravitate towards the type of work they most enjoy.
In terms of managing the more difficult changes, the largest initial change was that laboratory assistants no longer handled problem cases. Some were delighted, but others saw the problem solving as an integral part of their responsibility and missed that aspect of the job. We made a concerted effort to help everyone understand how the new system improved patient care, and we emphasized that above all high-quality patient care is our goal. Patients benefit from efficient, high-quality laboratory results. While specimen processing is not the area of the lab actively reporting test results, our contribution to patient care is efficient, error-free processing.
How do you provide feedback to staff on how the lab is doing?
We have large display monitors that show employees our success at reaching our processing timeline goals. The monitors provide real-time feedback to our laboratory assistants, showing them their contribution to our goal of providing rapid, high-quality results.
You mentioned that you created a special job category called operations schedulers. What is their role in the laboratory?
When I first arrived, I noticed that predicting daily processing volumes was not a priority. When I investigated and created some reports, I found that workload followed predictable patterns. For example, we first estimated work volume on a Tuesday by looking back at the data for the last four to six Tuesdays and found that these numbers were a reasonably accurate predictor of volume. Since then, we have also predicted volumes based on orders, many of which are interfaced into our laboratory information system. We pull this data shortly after midnight and create a report that indicates our incoming volume for the day. A hospital with computerized physician order entry could have access to similar data since morning blood draws can be pre-ordered.
Why do you have a special job category for aliquoting?
There are two reasons why I separated this task into its own job category. First, I wanted to ensure quality care. Manual aliquoting is prone to error. In a Lean workspace with a 5S process, this type of task receives greater emphasis so as to eliminate any unnecessary materials and/or objects from the work flow. Second, I wanted a record of the number of aliquots performed, and there was no way to quantify this metric until the job category was separated out from the other processing duties.
How do you handle error reporting?
An important characteristic of our error reporting system is that we separate external errors, such as incomplete client orders or client errors, from errors that are true processing errors. Both types of errors are recorded using a similar software tool, but the systems are separate. We do this because knowing the rates of pre-analytic errors or exceptions helps us accurately predict our overall processing times. Both error reporting systems rely on a software application that assigns an individual issue number to each problem case. That issue number references a file containing the error report and a log of all information related to that case. We record the issue number from our issue tracker with the specimen identification number in the LIS. This way, the LIS can reference a more detailed report. This is particularly helpful when you need to determine the reason behind quality issues.
How do you assure that information about problem cases is not lost at the shift change?
The error-reporting software is an issue-tracker system that allows us to transmit information between shifts. It works as follows: problem cases are removed from the fast lane and handed, with preliminary information, to the slow-lane lead tech. This tech then submits the problem to client services by opening a new issue report in the system. Specimens with unresolved issues at the end of the shift are moved physically to specific hold areas inside the lab. Client services continuously monitors the documented issues until they are resolved, and they only close an issue in the software after it is resolved. As long as the issue is open, client services will work on it, no matter the shift. Lead techs who are concerned about a case in the hold area can check the most recent status of each issue by looking up the specimen ID or issue number in the error-reporting software. At the shift change, the lead tech only needs to communicate non-specimen specific issues. This communication is done via a short checklist designed in-house to ensure that nothing of importance is missed.
Does the approach to specimen processing that you describe here apply mostly to large-volume labs, or could it be applied in any size lab?
Lean as the umbrella approach to problem-solving is applicable to any size lab. In addition, the specific principles discussed above—separating problem cases from the routine work flow, tracking problem cases without loss of information, predicting workload and matching staffing to that workload, organizing staff into logical groupings, and isolating and standardizing error-prone work—will help any lab improve efficiency, decrease turnaround times, and reduce errors.
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Engineers in the clinical laboratory. Clinical Laboratory News. 2009: 35 (1) x.
Erin Grimm, MD, is a resident in the Department of Laboratory Medicine and Anatomic Pathology at the University of Washington, Seattle.