Case Study Building a Patient Safety-Centered AP Lab

Case Study Building a Patient Safety-Centered AP Lab

Lean processes brought swift and impressive gains in productivity, patient safety and error reduction: Zero mislabeling errors in microtomy post go-live New accessioning process resulted in zero errors post re-design Workflow cost savings of $44,709/year Reduced turnaround time (TAT) by 24% in six months post go-live (average TAT is 1.6 days) Increased volume by 11% while also increasing the complexity of cases Integrated quality metrics and performance dashboards now drive daily management and improvements Decreased overall recut rate by 37% and significantly reduced overall reprocessing Eliminated six paper-based work lists, previously used for laborintensive manual tracking and safeguarding Lean lab technology supports a culture of safety in the AP lab Patient safety is a primary focus at Scott & White Healthcare, where Lean management and performance tracking foster quality improvements and a culture of safety throughout the system. In the anatomic pathology (AP) lab at Scott & White Memorial Hospital (S&W), leaders leveraged Lean workflow methodology to build a patient safety-centered lab that included automated instrumentation, barcoding technology and process standardization across multiple locations. Scott & White instituted a Toyota Lean management process, an overall approach for improving and leading the organization, says Robert Beissner, M.D., Ph.D., Pathologist and Chief, Section of Anatomic Pathology Informatics. We knew the goals of Lean production would serve the AP lab well. If we introduced single-piece flow protocols, barcode tracking and automation, and if we placed the power of improving the lab in the hands of our front-line employees, we knew we could improve laboratory efficiency and help preserve patient safety. Despite continuous increases in volume and case complexity, S&W enhanced patient safety and quality in the AP lab, all without the need for additional staff. If we introduced single piece flow protocols, barcode tracking and automation, and if we placed the power of improving the lab in the hands of our front-line employees, we knew we could improve laboratory efficiency and help preserve patient safety. Robert Beissner, M.D., Ph.D., Pathologist and Chief, Section of Anatomic Pathology Informatics Embracing patient safety To establish the foundation for a patient safety-centered, fully automated AP lab, S&W partnered with Ventana Medical Systems, Inc. (Ventana) to implement: The SYMPHONY system and the BenchMark ULTRA IHC/ISH staining system The VANTAGE workflow solution for barcode scanning, single piece flow technology and quality and performance metrics from accessioning through case assembly Substantial workflow improvements to streamline operations and increase productivity According to Arundhati Rao, M.D., Ph.D., Pathologist and Chief of Technical Pathology, creating a Lean AP lab at S&W was a logical and proactive step, given the ongoing expansion of S&W Healthcare. As the system grows and becomes increasingly integrated, solutions from Ventana help us continually streamline operations, increase productivity and deploy automatic patient safeguards in the AP lab.

To realize many time- and cost-saving benefits in addition to patient safety gains, S&W s AP lab instituted nearly 85% of the workflow changes recommended by Ventana workflow consultants: VANTAGE workflow solution data metrics Realized Workflow Improvements Task description Estimated benefit hours/year Realized benefit hours/year Realized cost savings/year Error resolution at embedding 195 195 Tech - $4,875 Reprocessing of incorrectly processed tissue 130 N/A N/A Work list preparation 780 780 Aide - $11,700 Block search time 87 N/A N/A Travel time for additional cassette printing 78 78 Tech - $1,950 Label printing time 468 468 Tech - $10,400 Slide initialing and/or handwriting time for all slide volume Histology and IHC travel time for microtomy slide production Time spent comparing slide to block at CA Management time to resolve errors in last 18 months 194 194 Tech - $4,850 361 N/A N/A 331 331 Aide - $4,634 150 150 Manager - $6,300 Totals 2,774 2,196 $44,709

Transforming practices and changing philosophies in pathology System and protocol changes of this magnitude required significant leadership momentum to achieve and sustain gains. The technical staff was initially resistant to change a common change management hurdle that S&W AP lab leadership overcame with a not-so-common approach: they appointed Lead Pathology Assistant, Carol Beth Taylor, MHS, PA(ASCP), HTL(ASCP), to drive change and champion implementation of the VANTAGE workflow solution in AP. It may be unusual for a PA to fill that role, but it was effective, explains Taylor, who says she is accepted as a leader among her peers in grossing but also trusted not to force change that makes their jobs harder. I m the one that has to do their work if they re not here, so I m in the trenches with them. They saw that as assurance that a Lean lab really would be good for us and safer for our patients. Another reason it made sense for the Lead PA to manage implementation throughout the AP lab: as Taylor puts it, grossing is the pivot point for every specimen, that critical link between accessioning and histology where all inputs must be in place and completely correct in order for others to handle their processes more productively and accurately. And yet, manual double- and triple-checking paper logs was the norm before automation. It was a very high stress environment before automation and tracking, explains Taylor, who is responsible for tracking potential errors and taking corrective actions. Before barcode tracking, PAs, residents and pathologists double-checked the work that was done before the specimen got to grossing and provided detailed specimen instructions for histology via multiple communication methods, including email and handwritten notes on histology logs. At that time, we didn t have a tool that enabled us to protect our employees, our practice, our institutions and ultimately our patients, Taylor says. Now the VANTAGE workflow solution allows us to do just that. Implementing single piece flow and barcoding in accessioning relieved this burden on the grossing station substantially by eliminating batching and the threat of mix-ups. As leaders we knew automation was part of a broader commitment to patient safety, and it would allow us to detect and modify high-risk processes, says Taylor. But letting go of all those old safety nets was hard for our grossing staff to accept at first, until they saw for themselves how unnecessary all those paper logs and handwritten notes had become. As leaders we knew automation was part of a broader commitment to patient safety, and it would allow us to detect and modify high-risk processes. Carol Beth Taylor, MHS, PA(ASCP), HTL(ASCP), Lead Pathology Assistant

Illuminating not forcing the difference between then and now Understanding the technical staff s reluctance to turn away from the manual tracking system they relied on so heavily for years, Taylor allowed the transition to happen naturally, even after go-live. Instead of forcing an abrupt end to the old way of life in grossing, she requested that grossers perform their duties using both old and new processes duplicative work, essentially, but also a hands-on learning experience that quickly illustrated how unnecessary and nonvalue added those labor-intensive safety nets had become in the lab s new era of automation and barcode tracking. It was amazing to watch everyone figure it out for themselves, Taylor explains. Most saw on day one where they could eliminate checklists, but the next day, light bulbs really went off when the calls with questions from histology went away. Taylor estimates that barcode tracking has saved the grossing lab an average of 45 minutes per day in time that was previously spent correcting inaccurate information on histology logs. Prior to automation, re-entering instructions in the lab information system (LIS) was yet another step for grossers, one that often wasn t done accurately due to time constraints. Now, grossers can see patient demographics to confirm accuracy as soon as they scan a block, and they can input accurate, real-time instructions in the system for histology at the bench. Getting histotechs on board with protocol standardization In histology, Ary Franklin, HT (ASCP), Lead Histotech, says empowering her team to contribute ideas toward process change fostered buy-in from her staff throughout implementation. Because she believes some of the staff s reluctance early-on came from their lack of understanding about how much things really needed to improve, she countered their trepidation with an openly positive attitude, staying vocal about her willingness to try automation and see how it works. Then, when the time was right, she included their input in the standardization of protocols. In microtomy, we made our own decisions as histotechs for what our protocols would be with the new technology, says Franklin. Standardizing our own processes, as opposed to being told exactly how to do it by someone outside our station, gave us ownership of the new path ahead of us. Throughout implementation and in the days following go-live, Taylor and Franklin say philosophies shifted as employees realized they were being empowered to change work processes to better protect patients and themselves from errors. They quickly understood they could trust new automated work processes and stop double- and triplechecking every action. Now we operate in a culture of safety, not fear, says Franklin.

Workflow improvements bring productivity and patient safety gains The VANTAGE workflow solution delivers greater visibility into operations. Staff now has advanced ability to track: All blocks and slides in the process (to know exactly where they are located and when they will be complete) Quality issues (to help identify process problems, eliminate waste and retrain staff when appropriate) Staff productivity (for performance evaluations and building new staff competencies) At each bench, lab automation has increased productivity and decreased error potential substantially: ACCESSIONING Reduced workflow from 11 steps to seven steps Single-piece flow ensured no specimen/label mix-ups Saved approximately eight hours a day previously spent on pre-sorting and pre-assigning accessioning numbers (4.5 minutes per case at an average of 105 cases per day) GROSSING Reduced workflow from 14 steps to 13 steps Eliminated potential for placing grossed tissue into the wrong cassette and subsequently conveying inaccurate information to histology Saved approximately 45 minutes per day previously spent correcting inaccurate information EMBEDDING Reduced workflow from 12 steps (with two value added) to 11 steps (with five value added) Saved approximately 45 minutes per day previously spent correcting documentation on accurate number of tissue pieces Saved additional time by eliminating the need to sort cassettes by priority and again by reading pathologist LABELING & MICROTOMY Reduced workflow from 17 steps (with six value added) to 11 steps (with eight value added) Saved nearly two hours per day previously spent pre-printing all required labels and initialing every slide to identify who performed cutting Standardization of work eliminated mislabeling CASE ASSEMBLY Reduced workflow from 14 steps (with four value added) to 10 steps (with six value added) Easy retrieval of information from the VANTAGE workflow solution saved approximately 76 minutes per day previously spent manually matching stained slides to cut blocks

Automated staining platforms boost productivity and quality S&W moved from dip-and-dunk to automated staining for three primary reasons: spikes in volume and case complexity, lower-than-average access to skilled lab personnel due to geographical location and the AP lab s expansion into additional sites. Seasoned techs began to retire, and meanwhile, our volumes and case complexity levels kept rising as the health system expanded, explains Dr. Rao, who says it made sense to move to automation as a way of overcoming those challenges. It s easier and more efficient to get an automated stainer than to train new, inexperienced personnel up to the levels of expertise our outgoing techs had. Productivity improved as a result of staining automation, as demonstrated by a 36% decrease in recuts performed for better stains. In addition, the AP lab continues to meet rigorous internal turn-around targets on a daily basis.

Implications for the future Patient safety gains were realized immediately once processes were automated and standardized, and the advantages of a streamlined path line will continue to present themselves going forward at S&W. Ongoing quality tracking With automated tracking comes greater visibility into department quality issues, as well as department and individual performance metrics. Since implementing the VANTAGE workflow solution, Taylor and Franklin regularly print quality metrics and share the data by posting it to a huddle board. This allows AP lab managers to continuously assess and target areas needing improvement. Lean lab processes soften the impending blow of reimbursement decline With increased capacity and efficiencies from lab automation, Lean labs like S&W are better positioned for anticipated reimbursement decline because wasteful steps and processes have already been eliminated or optimized. Similarly, as Dr. Rao points out, the ability to market the AP lab as a Lean, fully automated, patient safety-centered facility will help diversify their patient-payer mix an important, forward-thinking strategy in the face of decreasing reimbursements. Increased collaboration between labs at S&W Denise Spoor, S&W s Administrative Director of Clinical and Anatomic Pathology, says the AP lab s new technology and processes have allowed a more collaborative effort between the frozen lab and histology lab connectivity, she says, that was missing before the VANTAGE workflow solution because they never had access to metrics that show how it all fits together. I think they are working much closer as a team now to tackle quality and TAT issues. Now we have the ability to monitor all metrics to not only identify where targets aren t being met, but to also analyze why and what can be done to correct it. We are breaking down the silos of individual labs [e.g. molecular, cytogenetics, histology, etc.] to further position our organization as a regional leader in Diagnostic Medicine. Arundhati Rao, M.D., Ph.D., Pathologist and Chief, Technical Pathology

Fueling diagnostic leadership in the region As pathology leaders across the U.S. push for pathologists to diagnose conditions and prescribe treatments, S&W s AP lab finds itself ahead of the curve. We are breaking down the silos of individual labs [e.g. molecular, cytogenetics, histology, etc.] to further position our organization as a regional leader in Diagnostic Medicine, explains Dr. Rao. Implementation of lab automation, barcode tracking and Lean methodologies is a significant step forward for S&W Healthcare. S&W s AP lab now provides higher levels of quality and patient safety with the same levels of staffing. Productivity gains complement decreased error potential, and the result is a streamlined lab with processes, technology and staff behaviors that are aligned with the Lean management and patient safety goals of the larger health system. This white paper represents the customer experience at Scott & White Healthcare related to Ventana Medical Systems, Inc. and should not be construed as a research or quality project report. The data belongs to Scott & White Healthcare and may be presented for publication elsewhere.

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