High Volume Reference Lab Implements Lean Principles to Improve Turnaround-Times and Satisfaction

Sunrise Medical Lab, Hicksville, New York
Perspective by Elaine Hinds, MS, MT (ASCP)
Microbiology Manager

Summary Results:

  • Median turnaround-times (TATs) reduced by 10 hours
  • Reduced TAT for Urine cultures in 3rd quartile by 22 hours
  • Reduced the number of re-incubated cultures
  • Increased satisfaction among clinicians related to their ability to implement patient therapies more quickly

Workflow Optimization is a service, offered by bioMérieux Performance Solutions, which applies Lean/Six Sigma principles to the microbiology lab. This service typically involves 3-5 days of observing the lab at its current state - the physical layout and the manner in which samples are processed. The deliverable is a roadmap outlining how the lab can improve processes to reduce waste and improve efficiency, while simultaneously increasing the quality of results and reducing errors. In June of 2010, the Sunrise Medical Lab in Hicksville, New York partnered with bioMérieux to apply Lean/Six Sigma processes. Just six months later, the results on turnaround-times and clinician satisfaction have been significant.

About Sunrise Medical Lab

Sunrise Medical Lab (SML) is an independent, full-service clinical and anatomical pathology laboratory serving the New York Metro area and it surrounding communities for over 35 years.

SML offers a broad spectrum of clinical and anatomical pathology services-all designed to provide physicians and their patients with the most accurate and diagnostically meaningful results. SML is fully licensed and accredited by the College of American Pathologists (CAP), New York State Department of Health, the Center for Medicare and Medicaid Services (CLIA), U.S. Department of Health and Human Services (Medicare), and the Pennsylvania Department of Health.

The Drive for Change

SML is a large reference laboratory that provides microbiology testing for many private physicians and nursing homes, as well as some area hospitals. In June of 2010, the lab was under a great deal of pressure to seek out better efficiency and change some processes due to numerous internal and external factors, including:

  • Physicians demanding quicker TATs
  • Physician desire for better outcomes and reduced length of stay
  • Increasing costs; decreasing reimbursements
  • Reduced operating budgets
  • Expansion of in-house test menus
  • The move to a new, much larger facility (increased from 30,000 sq. ft. to 87,000 sq. ft.)

SML sought to face these challenges without increasing costs and without compromising quality. Physician clients were concerned about TATS, particularly on the weekend and the Sunrise staff routinely faced a huge workload at the beginning of each week. With lab management unable to hire additional staff to address client demand, they needed to look at potential methods and processes for improving lab efficiency in order to optimize their workflow.

The lab team reached out to the bioMérieux Performance Solutions team to arrange an assessment and identify ways to get the most out of SML's existing staff.

Redefining and Eliminating Waste

The team looked immediately to how workflow could be better optimized in order to allow the lab to accomplish more with its existing staff. One of the areas that the team discovered the opportunity for significant gains was in the elimination of waste - in this case removing all non-value added activities. These ranged from wasted motion between stations to the existence of backlogs of requests that existed largely due to how the lab scheduled its shifts. In order to make the most impact, it was decided that all Lean/Six Sigma activity would first be focused on urine cultures, which make up 48% of our total work volume.

Improving Urine Culture TATs

Prior to our implementation of the lab optimization principles, our lab would typically receive urine specimens between 4 p.m. and 5 a.m. Our night shift would set up the urine cultures.

Improving Urine Culture TATs - Microbiology Pathway

Our day shift would then begin reading the cultures at approximately 3 p.m. This often ended up being several hours too soon, resulting in the need to re-incubate cultures, delaying results.

Re-incubated Urine Cultures - Microbiology Pathway

In June 2010, our median TAT for urine cultures was 38 hours. However, the 3rd quartile is greater than 61 hours - 23 hours more than the median. (See below)

Urine Positive TAT (hours) - Microbiology Pathway

This means that a significant portion of the cultures were taking just under an entire day longer than others. Our job was to understand why this was happening and correct the issue.

We decided to look at how samples were received and processed throughout the week.

Positive Urine TAT by Weekday - Microbiology Pathway

This graph represents a statistical analysis of the set of data presented in the previous graph. The green line is the average, the red line indicates statistical significance.

Here we see that specimens received on Monday-Wednesday had a much faster TAT than specimens received Thursday-Saturday.

Positive Urine TAT by Shift Received (hours) - Microbiology Pathway

As seen in the graph above, we also found that specimens received on evenings had a longer TAT than those received overnight.

Implementing Process Changes

It was clear that the way we staffed to read and process our urine cultures was impacting TATs, so with the help of the bioMérieux Performance Solutions team, we began to make some important changes, such as:

Changing when urine cultures are read:

  • Urine cultures are now plated earlier, starting at 9 p.m.
  • Reading begins at 7 p.m., allowing for 18-24 hours of incubation

Standardizing urine workflow:

  • P.M. Shift:
    • Staff hours changed from 3 p.m. start time to 6 p.m. start time
    • Urines read in groups according to set up times
    • Positive cultures are fed into VITEK® 2
    • Negatives - Finalized
  • Day Shift:
    • Start times change from 6 a.m./ 7 a.m. to 8 a.m. and later start time
    • Positive cultures are finalized
    • ESBL result used from VITEK 2 except for a few exceptions
    • Eliminate Vancomycin screen agar
    • Stop printing all results

Process improvements:

  • Changed policy for accepting VITEK 2 identifications to 80 percent confidence
  • CNS if no identification on first attempt - call it Staphylococcus coagulase negative
  • Installed Observa and PC software on VITEK 2

Improved Workflow Results in Improved TATs

Just six months later we have seen significant improvement to the 3rd quartile TATS as a result of our implementation of lab optimization principles. By changing when we prepared and processed our urine cultures, we were able to reduce the number of re-incubated cultures as well as the number of touches and repeats for the cultures. Below, we see a side-by-side comparison of our urine culture TATs in June 2010 versus November 2010. You can see that the 3rd quartile TATs are reduced from 61hours to 42 hours.

Improved Workflow Results in Improved TATs - Microbiology Pathway

TAT Comparison

TAT Comparison - Mircobiology Pathway

Our work to improve our workflow and find new efficiencies in the lab did not end in November 2010. We view our lab optimization program as a living, evolving process of continuous improvement. As of August 2011, we've managed to shave another three hours off of our urine culture TATs and are beginning to see improvements in other areas of the lab.


Improving Urine Culture TATs - Microbiology Pathway


Improving Urine Culture TATs - Microbiology Pathway


By implementing the recommendations from the Workflow Optimization provided by the bioMérieux Performance Solutions team, SML saw an across the board reduction in TATs of 10 hours. Even more impressive, our 25th percentile improved from over 61 hours down to 39, a 37% decrease.