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Using Evidence-Based Layout Design to Enhance Workflow in the Clinical Laboratory

Healthcare Improvement Festival 2010 Presenter: Matthew Ethan Han

BACKGROUND ON THE CLINICAL LABORATORY

Services Level 1 SOC Comprises of phlebotomy stations, a laboratory and a payment counter Provides blood-taking services Analyzes STAT blood tests (eg. FBC, PT/INR, ESR...etc) Daily patient volume of 500 patients

MOTIVATION TO RENOVATE THE CLINICAL LABORATORY

Objectives for the Project 1

-National Demographics -Rise in Affluence -Growth in Knowledge Pool -Biochemistry line added

-Introduction of Computerized Physician Order Entry (CPOE) to phlebotomists

2

3

KEY CHALLENGES OF THE PROJECT

BROAD OVERVIEW OF THE WORKFLOW IN THE CLINICAL LAB

Average TAT* for `UNPAID' patients -24.2mins 95th Percentile -40.8mins

PAYMENT COUNTER

·Clerk keys in individual test codes into the computer & generates a bill ·Clerk calls for patient & does payment (cash, NETS, Credit card...etc) ·Clerk presses for a queue no. and gives to patient Average payment time -2mins 95th Percentile - 4.4mins

PHLEBOTOMY ROOM

·Phlebotomist presses wall mounted queue keypad to call for patient ·Patient enters room & blood is drawn Average blood-taking time -2mins (Similar to previous study) 95th Percentile - 5mins (Similar to previous study)

PAYMENT COUNTER

·Patient arrives & puts test order form/s into a tray in front of the payment counter ·Clerk takes the order & checks if patient has paid

Y 54.6%

Patient requires payment ?

Waiting Area

·Patient waiting for hardcopy results after blood-taking Average wait time -35mins Average no. of patients waiting per day - 37 patients

N 45.4%

PAYMENT COUNTER

·Clerk presses for a queue no. and gives to patient

Average TAT* for `PAID' patients -14.3mins

*TAT: Time of Arrival till Blood Test is completed Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

95th Percentile -29.2mins

PHASE I ­ DETERMINING THE OPTIMAL NO. OF PHLEBOTOMY ROOMS

A time motion study was conducted to collect the following data:

Data Blood-taking time Waiting time for unpaid patients to complete blood-taking Waiting time for prepaid patients to complete blood-taking Payment processing time Next-of-kin (NOK) ratio to patients No. of patients per day % of unpaid patients Average (Mean) 2mins 22.2mins 14.3mins 2mins 0.44 522 54% 95th Percentile 5mins 40.8mins 29.2mins 4.4mins

The date above was plugged into a computer simulation with the following variable factors & constraints:

Variable Factors Additional time for CPOE functions No. of phlebotomy stations No. of payment counters % of patients required to make payment before blood-taking Constants Seating Capacity No. of patients per day (Organic growth of 3% per annum over 10 years: (522*1.0310) ) Options 1min or 2mins 6 or 7 stations 1 or 2 counters 54% (current) or 20% Figures 53 seats 702 patients

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

A REALISTIC SCHEDULE FOR PHLEBOTOMIST STATIONS WAS ALSO USED IN THE SIMULATION MODEL

No. of operational phlebotomy stations

MAPPING OUT THE TOTAL NO. OF WARM BODIES AT ANY GIVEN TIME USING A TIME MOTION STUDY

Monday 8th June 2009 (Including NOK of 0.44)

Analysis Summary:

Shortage of phlebotomists from 7.30 - 7.50am & 12:00 - 1:30pm. Only 4 were taking blood at the 10.30-11am peak Payment is consistently a bottleneck throughout the morning, with average of 50% waiting to make payment Payment becomes an extreme bottleneck from 8:30 - 9.30am, with more than 75% of warm bodies waiting to make payment

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

MODEL SUMMARY ­ FEASIBLE PERMUTATIONS 6 counters 1 minute CPOE buffer

20% of patients who requires payment 1 payment counter Max no. of warm bodies 95th Percentile 50th Percentile 48 42 9 2 payment counter 47 42 8 54% of patients who requires payment 1 payment counter 104 99 63 2 payment counter 47 41 12

2 minute CPOE buffer

20% of patients who requires payment 1 payment counter 65 59 41 2 payment counter 64 58 35

Explode > 131 warm bodies

54% of patients who requires payment 1 payment counter 2 payment counter 68 61 44

7 counters 1 minute CPOE buffer

20% of patients who requires payment 1 payment counter Max no. of warm bodies 95th Percentile 50th Percentile 40 31 7 2 payment counter 40 30 7 54% of patients who requires payment 1 payment counter 91 85 55 2 payment counter 41 32 10

2 minute CPOE buffer

20% of patients who requires payment 1 payment counter 47 42 12 2 payment counter 48 42 12 54% of patients who requires payment 1 payment counter 91 85 55 2 payment counter 47 41 15

MODEL SUMMARY ­ FEASIBLE PERMUTATIONS 6 counters 1 minute CPOE buffer

20% of patients who requires payment 1 payment counter Max no. of warm bodies 95th Percentile 50th Percentile 48 42 9 2 payment counter 47 42 8 54% of patients who requires payment 1 payment counter 104 99 63 2 payment counter 47 41 12

2 minute CPOE buffer

20% of patients who requires payment 1 payment counter 65 59 41 2 payment counter 64 58 35

Explode > 131 warm bodies

54% of patients who requires payment 1 payment counter 2 payment counter 68 61 44

7 counters 1 minute CPOE buffer

20% of patients who requires payment 1 payment counter Max no. of warm bodies 95th Percentile 50th Percentile 40 31 7 2 payment counter 40 30 7 54% of patients who requires payment 1 payment counter 91 85 55 2 payment counter 41 32 10

2 minute CPOE buffer

20% of patients who requires payment 1 payment counter 47 42 12 2 payment counter 48 42 12 54% of patients who requires payment 1 payment counter 91 85 55 2 payment counter 47 41 15

PHASE II ­ REDESIGNING THE PHLEBOTOMY ROOMS WITH ERGONOMICS AND EFFICIENCY IN MIND

Improvements after redesign -Rooms are enlarged to allow servicing of 2 patients comfortably -Privacy is enhanced with orientation of patient chairs to prevent direct line of sight -Phlebotomists are given individual computers and printers to allow for CPOE functions -Introduction of a conveyor belt system that eliminates the need for phlebotomists to hand carry specimen to the lab, hence: -Reducing TAT for blood-taking by eliminating walking time to and fro -Eliminating batching of specimens -Improving lab safety by reducing unnecessary movement significantly

PHASE III ­ REDESIGNING THE LAB USING SPAGHETTI DIAGRAM AND LEAN LAYOUT PRINCIPLES

CURRENT LAYOUT

Lab Bench BSC Lab Bench

Fridge

FUTURE LAYOUT

Pneumatic 74.57 tube

sq m

Lab Bench Lab Bench

LH Analyzer + PC & printer AT

Stainer

Sink with eye-wash

Lab Bench

Microscopy Microscopy

COBAS PC

Lab Bench

Cobas + PC

Sink Stainer

W ater tank

Waste

LEGEND Haematology flow Biochemistry flow Pre-sorted flow

Improvements: Single entry point for specimens and single directional (left to right) Double `L'-shaped lab bench design to minimize movement for Haematology line Mobile benches with wheels for future configurations if needed Pneumatic tube stations are brought beside the sorting area for quick launch Separate Haematology and Biochemistry lines clearly demarcated to avoid confusion

Fridge

Lab Bench

Thank you for your time

Back-Up Slides

METHODOLOGY OF THE TIME-MOTION STUDY

Patient's sticky label

Filled by Service Ops

Phlebotomy Room No. of NOK waiting with them: _______

CLINIC ____

Patient Arrival Time (Done by Service Ops)

Registration Counter Patient needed to pay?

Hard-Copy of results given Patient was not around to collect when results were 1st ready

Time in Time

Time Out

Time in

Time out

Time given

Filled by Service Ops

Filled by Counter staff

Filled by Phlebotomists

Filled by Lab tech

BY ELIMINATING PAYMENT AT THE LAB, PATIENTS' TAT CAN BE IMPROVED BY APPROXIMATELY 50%

TOP 5 CLINICS WHO HAVE THE HIGHEST AMOUNT OF UNPAID PATIENTS

No. of PTs who made payment in the week 297 40 72 189 166 Total no. of Proportion of PTs seen in unpaid patients to the week total 421 58 109 370 360 71% 69% 66% 51% 46%

Analysis Summary:

With the assumption of sufficient phlebotomy rooms, removing the element of payment, TAT* of patients can be improved by: - (10.1/24.2)*100 = 42% on average - (22.9/40.8)*100 = 56% for 95th percentile

Clinics

M A B L K

Mon Average waiting time to make payment (min) 95th% percentile (min) Average TAT* for unpaid patients (min) 95th% percentile (min)

*TAT: Time of Arrival till Blood Test is completed Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

Tue 12.9 22.0 25.1 39.0

Wed 3.6 14.8 16.5 30.6

Thu 7.8 20.2 26.5 45.3

Fri 4.7 18.7 18.2 39.2

Average 10.1 22.9 24.2 40.8

21.5 39.0 34.6 50.1

APPROXIMATELY 10% OF ALL PATIENTS REMAIN AT SOC LAB FOR HARDCOPY RESULTS, MAINLY FROM `K' CLINIC

Clinics requesting for Hard Copies Analysis Summary:

-An average of 54 patients a day (approx. 10% of the total volume of patients) remain in SOC lab waiting area for average 35mins to wait for hard-copy results -The main bulk (71%) of these 54 patients comes from K Clinic

Mon # of patients waiting for hard copy results % of patients waiting for hard copy results # of patients who remained in waiting area for hardcopy % of patients remaining in waiting area to total no. of patients for the day 46 10.7 42 9.7

Tue 68 17.2 46 11.6

Wed 51 15.3 32 9.6

Thu 54 15.4 30 8.6

Fri 51 14.7 36 10.4

Average 54 14.7% 37 10.0%

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

OVERALL STATISTICS ­ PAYMENT

AVERAGE % of patients made payment at SOC Av time spent on payment / 95th percentile Av wait time for payment / 95th percentile

The bulk of patients who had to make payment originate from Clinics M, L and K. Clinics M L K B A

*others: consisting of Clinics D, E, F, G, J, CPD, NCC, NHC, DDR, Staff Clinic etc) Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

54.6% 2.0 min / 4.4 min 10.1 min / 22.9 min

No. of PTs who made payment in the week 297 189 166 72 40

Total no. of PTs seen in the week 421 370 166 72 40

PROPORTION 70.6 51.1 46.1 66.1 69.0

OVERALL STATISTICS ­ BLOOD-TAKING

AVERAGE Av time spent on blood taking / 95th percentile 2.4 min / 5 min

OVERALL STATISTICS ­ NEXT OF KIN (NOK)

AVERAGE % of patients with NOK Av time number of NOK per patient 36.3% 0.44

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

OVERALL STATISTICS ­ HARD COPIES

AVERAGE % of patients needed hard copy results % of these patients remained in waiting area No. of these patients remained in waiting area Total no. of people remained in waiting area (incl. NOK of 0.44) Clinics requiring Hard Copies

(consisting of Clinics A, B, G, H, J, M, CPD, NCC etc)

14.7% 66.0% 37 53

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

OVERALL STATISTICS ­ TURN AROUND TIME(TAT)

AVERAGE PAYING PATIENTS Av TAT* / 95th percentile NON-PAYING PATIENTS Av TAT* / 95th percentile 24.2 min / 40.8 min 14.3 min / 29.2 min

*TAT: Time of Arrival till Blood Test is completed

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

TOP CLINICS WITH UNPAID PATIENTS AND CLINICS REQUESTING FOR HARDCOPY RESULTS

TOP 5 CLINICS WHO HAVE THE HIGHEST AMOUNT OF UNPAID PATIENTS

No. of PTs Proportion of who made Total no. of unpaid payment at PTs seen in patients to SOC Lab in the week total no. the week 297 40 72 189 166 421 58 109 370 360 71% 69% 66% 51% 46%

CLINICS REQUESTING FOR HARD COPY RESULTS

Clinics

M A B L K

Source: Data collection at SOC labs for 1 week (8th ­ 12th Jun 09)

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