"The world as we have created it is a process of our thinking. It cannot be changed without changing our thinking." -- Albert Einstein
The world of hematology has been changing steadily over the past fifty years with the rapid evolution of automated platforms from the first electronic blood cell counter. The first automated hematology line made its debut in 1989, with subsequent industry innovation pushing the hematology world forward. As more options become available, the need to understand the implications of each alternative has become paramount; labs often turn to industry resources to help "peel the onion" of hematology automation decisions. The consulting services offered by most vendors has filled this need, but labs still face making the ultimate decision alone and the multitude of options has made that decision increasingly complex.
So what's the solution? It lies in Einstein's core wisdom -- in order to change the world we have created, we need to think and envision a new paradigm.
The World We Have Created: Hematology Workflow
A key motivator in labs these days is improving hematology workflow to reduce turnaround time (TAT). Efficient use of labor and financial resources, while balancing the need to improve quality has become the associated conundrum with TAT.
It is important for labs to understand workflow of specimens in their operations. Workflow is really a three dimensional problem in most labs. Not only does the lab need to understand two dimensional spaghetti diagrams, showing how tubes and techs are moving around, they need to add the third dimension of boluses of workload with service level demands.
Commercial labs have the advantage of maximizing their capacity by smoothing the boluses due to extremely high volumes and a larger production window measured in 8-10 hour windows vs. 15-20 minutes in the hospital laboratory. The true challenge for the hospital laboratory manager is to increase productivity while meeting service level demands. While manufacturers claim to improve workflow, staff resistance to change often makes the decision of hematology automation very difficult.
Four keys variables need to be assessed in a hematology workflow automation decision:
- Service level demands (i.e. turnaround time plus workload)
- Technology advantages
- Patient outcomes
The basic promise of automation is that all specimens will be automatable with less labor, improved TAT and lower production costs. However, this is not the case for most hematology laboratories. While it may be true that hematology automation in today's hospital laboratory can take the specimen from delivery to laboratory to results in the clinician's hands in under 15 minutes for 80% of the testing volume, laboratories are faced with 10% to 15% of specimens that are short draws and micro draws that are not part of the routine workload. Hematology automation does allow for a consistent and desirable TAT for these exception samples, yet is this TAT meeting the customer's ever changing needs?
The Process of Our Thinking: Workflow Consulting
This is where consulting services step in. Many labs appreciate the magnitude of the workflow problem but do not have the trained staff or time to undertake analysis of the solution, so they look for consultants to facilitate the process of "thinking about it." All of these consulting offerings bring much needed scrutiny to the hematology operation in the facility, which opens the eyes of staff and management alike to new possibilities. Yet many still become bogged down in the decision making process and overwhelmed by the magnitude of the proposed change, eventually succumbing to "analysis paralysis."
Changing Our Thinking: Sometimes Less is More
Faced with too many choices and not enough information to accurately determine the probability of success, hematology decision making today is moving to an iterative model. Rather than trying to solve all the issues in one fell swoop, new workflow solutions are more modest in scope, enabling labs to break the decision into smaller steps, while still improving efficiency, productivity, quality and cost. It is often in the labs' best interest to consider this more tempered approach.
So what are some innovative ways of improving workflow? Several new concepts exist which can greatly improve workflow without the need for expensive automation expenditures, such as:
: Much improvement in efficiency and productivity can be gained in the analyzers themselves, not just increasing the speed of the analyzer but getting the right parameters on the first pass. For example, getting six-part differentials with immature granulocytes, immature platelet assessments, and reticulocytes on the first pass will reduce potential reruns or manual procedures. Reruns, repeats and reviews are the most time-consuming part of hematology; the ability to minimize these interruptions to workflow is often more important than the Time to First Result (TFR).
Get it passed on the right first: Traditional spaghetti diagrams in labs highlight a key workflow issue: hematology lines load on the left and return on the right; chemistry lines load on the left and return on the right. For night techs this is an issue; lots of sneakers get worn out moving between these two lines. It is important to look for systems that have configurable designs, including loading protocols and the ability to bend outward or inward, go around pillars, and reach drains within 25 feet of the line. The overall size of the system also impacts the efficiency of the workflow. Smaller is better, opening up walkaways and aisles for egress. The automation should be capable of meeting the labs current and future needs as opposed to the lab changing to meet the automation demands.
On-demand metrics reporting: Middleware software that enables on-demand metrics reporting can enhance the lab's ability to measure the impact of automation and standardization projects by providing immediate insight to key metrics such as turnaround times, test counts, result validation rates, and rules and results statistics.
- Get it right on the first pass
Changing the World of Hematology Workflow: Two Case Studies
The proof is in the pudding, as the old saying goes. There are a number of labs making the transition to a slimmed down version of hematology workflow and enjoying the benefits of the iterative approach.
The Nebraska Medical Center
Kathy Salerno, MT(ASCP), is Core Lab Manager at The Nebraska Medical Center, a 621-bed hospital. They do 900 CBCs per day, which can balloon by an extra 1,000 tubes per day with the frequent health fairs. They launched hematology automation in 2005 without connectivity to chemistry. In 2006, the lab went through a major LEAN process and subsequently has had assessments done by different vendors, including an assessment of chemistry workflow in 2008 which was very beneficial.
In discussing their recent experience with upgrading the hematology operation, she notes, "At first we looked at replacing everything at once. At some point, we decided to break the decision into smaller pieces. We built in redundancy and fixed connectivity with our hematology middleware system first, then tackled upgrading the line through the addition of three new analyzers the following year." They went live in May, 2013.
Salerno notes that having the right consulting team makes a big difference. While many vendors provided insightful solutions, the ultimate choice boiled down to a consulting team that was willing to work on her team's timeline and provide incremental solutions. "The consulting process was a really good experience. Interactions with the techs have to be good; personality is really important to draw out the techs who need to be comfortable working with the consulting team."
One benefit was that the cancer center, which faced a previous challenge of not getting absolute neutrophils quickly enough, now gets results faster with an average TAT of 11 minutes from receipt to result. The process is now much smoother in the morning and stress levels are reduced. The true test was a health fair (with its 1,000 extra tubes) that took place one day after the implementation, but everything went well.
She also noted a major side benefit, "These days all core labs are constrained on space, and supplies take up so much room. Our new reagent system replaced big reagent containers with small cell packs reconstituted onboard. It has saved storage space, and techs no longer need to haul heavy cubes up a carpeted hallway. That's a big plus!"
The implementation went smoothly also. "It totally blew my mind having someone coordinate the entire implementation in one day. That was huge. Finally something lived up to all the hype! It is one of the smoothest implementations we have ever had," said Salerno.
This new iterative process has facilitated change management. "I'm fortunate in having really good staff. We went through many changes with minimal resistance. Overall, my staff would say this is really good change, and that helps future decisions."
University of Iowa
Another hematology operation at the University of Iowa, a 760-bed tertiary acute care hospital, had similar experiences with upgrading their hematology workflow. According to Mary Capper, MLS (ASCP) SH, Supervisor, H/H and Jeff Kulhavy, MLS (ASCP), Assistant Lab Manager of the Core Lab, the hematology workload is 1,000-1,200 lavender tops per day and 400 blue tops.
"In 2007 we needed automated hematology workflow. We wanted auto-validation and wanted to eliminate 'hand' moving. We found the only manufacturer with tubes online- no one else had it- so we put a high speed line in the core lab and one on the 'Alpha' line in the cancer lab," said Capper. "This worked great until the cancer center moved to a new location; it was still on campus but further away. And they did not leave space for a lab in the new facility so we had to relocate the Alpha line back to the core lab, 12 feet away from automated lab line. We did this for 14 months; the cancer center wanted special treatment with special techs dedicated to their Alpha line. We worked with consultants on designing a better configuration so we could process without the duality. We looked at another high speed line, 'a super line,' but we didn't have the space so we decided to merge the two systems into one. It uses less 'hands on,' we don't have to worry about delivering results in two places, and it has built in redundancy."
In this case the consulting solution didn't involve any new equipment. It optimized what they already had, providing the right-sized solution for her lab-consolidating two systems into one.
"April 30, 2013 was moving day. The line itself had to be moved and shifted 90 degrees. Jeff Geller, MT(ASCP), Laboratory Solutions Consultant, Sysmex America, had to provide schematics and CAD architectural drawings. It affected multiple disciplines, including urinalysis, coagulation, and hematology. I was amazed- they did it in a day and we were never truly down," said Capper.
Capper stresses that consulting has to be more than floor plans. It has to involve an extended commitment to implementation and project management. "It is a behavioral science and the consulting team needs to gel with the techs."
And most importantly, the consultants need to be okay with recognizing that the best path forward may not entail an instrument purchase but a reworking of current configurations. The end result from the techs' perspective: "They absolutely love it! They love the change in the end."
Both labs advise that successful implementation and change management depends on involving the staff early and consistently. It is important to communicate timelines and who is responsible- the more involved and aware they are the smoother it will be. As Kathy Salerno notes, "Sometimes you think you said something but you find out later it wasn't clear or the message got lost. Keep communicating!" Keep an open line of communication and get feedback. Mary Capper sums up the key to successful change management, "As managers we want them to make decisions so we need to lead them down the path to where they are empowered."
The brave new world of hematology workflow automation underscores Einstein's insight: In order to change that world, we have had to change our thinking, not only about the systems we use but the processes we employ to achieve that transformation.
Allen A. Wozniak, Sr. is SC solutions services manager, Sysmex America, Inc.