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Case study: redesigning a pathology laboratory

Stephen C Hall
CSci FIBMS – Pathology Technical Head of Service, Barnsley Hospital NHS Foundation Trust, 
Yorkshire, UK

The pathology laboratories at Barnsley Hospital NHS Foundation Trust are in a 570-bed teaching and research hospital, affiliated with a local university. The hospital serves 226,000 people in the Barnsley area and offers a range of acute services from A&E, maternity, general and specialist surgery to critical care, medicine, elderly people’s services and paediatrics. It treated almost 60,000 inpatients in 2009–10, nearly 72,000 people came to the hospital in an emergency and more than 263,000 people attended an outpatient appointment. These figures are anticipated to rise, particularly with a projected rise in the 65+ age group of 62.8% by 2016.

The pathology services are delivered as a strategic collaboration with a neighbouring trust. The combined population covered by this service is 498,000.

The Blood Sciences Laboratory at the hospital starting operating in March 2007. A laboratory redesign combined the disciplines of clinical biochemistry, haematology and immunodiagnostics into a single automated Blood Sciences facility. The laboratory was processing 1,600 chemistry and immunoassay samples, 800 full blood counts and 300 coagulation samples a day from the hospital and 50 GP practices. Efficient sample processing in the chemistry department had become almost unmanageable before the redesign because of the workflow of samples received and the inability of the previous laboratory instrumentation to deliver predictable turnaround times.

In need of system redesign
In 2005, the pathology directorate at the hospital began a procurement exercise to replace most of the analyser platforms in clinical biochemistry and haematology. The directorate was under pressure to meet a significant, recurrent cost-improvement target and facing an increasing workload and wage bill, a situation common across NHS laboratories.The trust was collaborating with a neighbouring laboratory and working towards a merged service model.

After years of cost improvements based on random savings, it was clear that a strategy for real reform was essential. The procurement would be the trigger for major change and the introduction of advanced pre- and post-analytical automation would be the catalyst.

However, the pathology management team was aware that automation alone would not deliver radical change, instead it should be one of the key parts of a strategy that included changing culture, working patterns and processes. The latter is the fundamental piece of the reform strategy. It is essential that laboratory managers understand their processes, identify deficiencies, streamline and consolidate and, wherever possible, establish a single process for routine activity.

Unblocking the bottlenecks
In the laboratories, there were multiple processes attempting to achieve the same outcome and a significant bottleneck of specimens at registration. All community pathology specimens arrived at midday, with samples standing for hours waiting to be processed.

There was significant variation in the time samples spent in centrifuges before analysis and a clear lack of analytical capacity to cope with the increased workload. The workforce was under significant pressure and morale was low.

The directorate realised that several parallel changes needed to be introduced in order to deliver radical reform. Projects were initiated to:

Implement and roll out an electronic requesting and reporting system (ORDERCOMMS) for GP surgeries and 
ward areas
Set up a GP specimen collection service under the direct management of pathology
Introduce an analytical solution that embraced the automation opportunities emerging in this area
Reconfigure the workforce to ensure that the right skills were available at the right time.

It was clear that all of these elements had to come together to deliver any real benefits.

The directorate targeted the GP community first rather than the inpatient environment. It was clear that a significant bottleneck existed as a consequence of the labour-intensive manual request registration, a task exacerbated by the huge volume of GP work arriving at midday.

There would be massive productivity gains if surgeries could be persuaded to generate a significant proportion of their requests electronically. So the Sunquest ICE system was chosen, configured and rolled out across the GP community.

The laboratories had to take control of the roll-out to ensure timely success. To this end, a small team was established and a champion seconded to drive this forward. This was a challenging but successful exercise. Presently (2010), 75% of GP requests from the local health community are generated electronically.

This exercise was repeated across the GP community of our partner NHS trust and, at present, about half of surgeries are using the system with full coverage expected by the end of this year.

A similar team prepared the hospital for the switch to ORDERCOMMS beginning in January 2010. Currently all wards, the emergency department, pre-assessment unit and children’s services are using the system.

The general outpatients implementation is still outstanding. The process of registration using ORDERCOMMS allows for the application of LEAN principles. Requests and samples are handled once and quickly moved to the analytical phase. An experienced support worker can register and barcode label more than 150 requests an hour, a four-fold improvement in efficiency compared to the manual process.

The system has realised many benefits, the staff needed for registration has been reduced and paper reports are no longer provided.

Laboratory automation
In the procurement phase of the analyser replacement exercise, the team sought to replace equipment with newer, higher throughput alternatives. The team challenged suppliers to deliver a significantly expanded, totally automated laboratory within a budget that would make an appreciable recurrent saving.

After receiving the first offerings from suppliers, it was apparent that the extended solution was feasible. However, there were many proposals to add pre- and post-analytical automation to the process. These included:

Free-standing sample sorters for chemistry and immunoassay processing with manual transfer to analyser platforms, utilising support workers to move the samples around. Haematology analyser replacement only with no additional automation
Tracking for chemistry and immunoassay with or without on-board centrifugation. Haematology analyser replacement only with no additional automation
Full tracking for chemistry, immunoassay, haematology and coagulation.

The procurement team felt the best way to achieve radical change would be to implement the last solution, which would also become a catalyst for the required change management.

We awarded Siemens the contract to provide its ADVIA(r) LabCell Automation Solution under a managed equipment contract. The equipment doubled throughput for clinical biochemistry and provided sufficient capacity for the first five years of planned growth.

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The additional automation provided pre- and post-analytical sorting and a much-simplified process utilising Labcell sample racks in specimen reception to facilitate a “touch it once” approach.

Mixed samples from each order are placed in the racks and presented to the sample managers by the support staff that registered the request. The whole system is balanced for a predicted test mix that includes samples that require centrifugation and those that do not and it is imperative that samples are loaded in this way.

The whole system can load and unload mixed samples at a rate of 600 an hour with on-board centrifugation offering 480 samples an hour. With mixed-load trays containing samples requiring centrifugation and haematology samples that do not, at a ratio of two to one, the centrifugation throughput is not a bottleneck and the system is in balance. The system is multidisciplinary and must be resourced accordingly, making this the ideal catalyst for workforce reform.

A key benefit is the scalability of the LabCell. The system was initially configured for the anticipated growth of the local community chemistry and haematology workload (including immunoassy) with sufficient space to add coagulation at a later date.

As part of the development of the strategic partnership, the partnership board decided that all community pathology work would be processed at this hospital site. This required an additional chemistry analyser to be added to the LabCell and an additional haematology analyser for use for clinic work.

The laboratory has enough space to add a further five metres of track and extra equipment if required, allowing for a doubling of processing power.

The directorate management team decided to create a true Blood Sciences department consolidating the functions of clinical biochemistry, haematology, blood transfusion, immunology and serology. Clinical autonomy was retained, but the reconfiguration of the scientific and support teams meant that significant savings could be realised. The departments already shared a single reception function utilising multidisciplinary support staff and the implementation of the Blood Sciences LabCell necessitated an extension of this into the laboratory.

All of the staff in the departments that were to make up the Blood Sciences had been fully engaged in the whole procurement decision-making process and the vast majority believed in the change. The department identity was quickly established with name badges and signage changed.

All individual laboratory meetings were re-configured and delivered as Blood Sciences combined meetings. A Blood Sciences senior management team became a crucial group charged with delivering the cultural change. and creating a management structure that would be fit to lead the change. The new structure was implemented and immediately reduced managerial costs, fortunately as a result of retirements of staff 
members. Subsequent task-based analysis saw the introduction of a higher-level support grade given the title of biomedical assistant (BMA). This role has developed over time with more tasks being added to the grade.

A skills assessment is performed whenever a post becomes vacant to ascertain the grade of staff required. In several instances, the new BMA has been introduced instead of the previous biomedical scientist (BMS). However, a minimum number of BMS staff must be retained to ensure a quality 24/7 service is maintained. This skill mix has been successful and has resulted in a reduction of scientific grades and staff costs.

The department must be staffed with the right grades, but these need to be available in the right numbers to meet the workload pressures that have developed outside the traditional busy times.

The reception staff are available to provide minimal cover up until midday, maximum staff until 5pm with a third working to 8pm.

Similarly, four biomedical scientists work until 8pm with two BMS taking over for night duty. In the latter period, all routine work is completed for that day and most instrument maintenance performed in preparation for the next day.

The reception area has been redesigned to improve workflow and support LEAN processing. All members of staff in this area have had LEAN awareness training and their procedures modified to ensure that specimen registration is in balance with the whole process.

GP specimen collection service
Whenever the directorate has conducted a satisfaction survey of its GP users, there are several recurring issues. In particular, the high numbers of high potassium results generating duplicate testing and patient concern and the number and timing of the specimen collections from their surgeries. Surgeries are opening longer and later, creating sample integrity problems due to the length of time some samples stand before processing.

The directorate started a procurement project for a new collection service dedicated to pathology specimen collection. The task for prospective companies was to provide a service that:

Utilised dedicated, temperature-controlled vehicles that met all the requirements of the carriage of dangerous goods act
Employed dedicated, trained drivers
Utilised digital time-stamping of pick-up times
Guaranteed a maximum journey time of no more than two hours from the first pick-up to delivery in the laboratory
Introduced a collection service that meets the needs of the GP surgeries
Created a schedule of runs that delivers collections to the laboratory in balance with the laboratory’s processing capacity.

Where we are now
The reform projects converged towards a start date of April 2010. The new complete process is now in place, working well and delivering the following benefits:

All GP surgeries have at least two collections
a day with a majority having three
The first collection arrives at 11.30am and 
the last at 7.30pm
There are nine collections routes from the GP communities of the two merged health communities as well as some out-of-district surgeries
No specimens are in transit for longer than two hours
Collections containing about 300 tubes are staggered to arrive every 30 minutes

At present, about half of the partner community work is coming through to this site, as only surgeries utilising ORDERCOMMS are processed here. This figure is changing rapidly as more of the partner GPs move to electronic ordering. It is envisaged that all the work will have transferred by the end of the year.

A minimum of four and maximum of six reception registration stations are in use at all times during the delivery period, which guarantees a registration rate of 600 tubes an hour. At full capacity, the Labcell can load and unload 600 tubes an hour (1,200 in total). The process is balanced and runs at full capacity from 11.30am until 8.30pm.

The application of extensive auto-validation rules in the new LIMS has significantly reduced the amount of time spent validating and authorising results. As a result of single-pass registration and labelling and automated processing, 85% of the workload passing through the Blood Sciences department is never touched by anyone other than a support worker.

Other benefits seen from the reorganisation are:

95% of all tests available on the analysers on the Labcell are reported within two hours of receipt
The Blood Sciences scientific workforce has reduced from 32 to 24 biomedical scientists
The registration staff numbers have fallen from 14 to 10
The biomedical assistant workforce has grown from nought to six
The staffing budget has released £350,000 of savings towards the cost improvement plan
The department has retained full CPA accreditation status in all disciplines and Blood Transfusion has gained full MHRA compliance
The number of elevated potassium results from GP surgeries (a marker of sample integrity) has fallen by 40% since the introduction of the new collection service
Repatriation of referral tests, the managed equipment services contract and initial partnership consolidation opportunities have realised a further £400,000 of savings, giving a total cost reduction of £750,000.

In 2007, there were 2,700 tubes processed every day in the department. In 2010, there are 4,200 tubes processed and this is expected to grow to 5,500 by the end of the year. It is not envisaged that the staffing establishment will increase.

Quality has not been sacrificed for efficiency
After several years of planning and hard work, the benefits of process reform are plain to see. However, we see this as the start of the improvement cycle and the team will continually strive to identify every opportunity to increase efficiency and pursue workforce alignment and development benefits.