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ARUP's Decades-Long Effort to Prevent Lost Specimens Achieves Six Sigma Levels

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NEW YORK (360Dx) – Through a more than two-decades-long journey of high-tech automation and low-tech process improvement, ARUP Laboratories has achieved Six Sigma level quality in reducing lost specimens, a metric that is equivalent to 3.4 lost specimen per million.

The focus on reducing lost specimens, which began in the 1990s, has combined automation to eliminate the risk of human error when possible, with process improvements aimed at redesigning work to reduce the opportunities for accidental blunders, ARUP executives said.

"People are trying to do a good job with some pretty astonishing constraints," said Bonnie Messinger, process improvement manager for ARUP.

Interruptions and distractions, for example, are a part of everyone's work day, but they increase the chance that something will be misplaced or forgotten, she said.

"I think it's kind of a shared approach to behavior management," Messinger said. "Eliminate the human touch wherever you can, and where you don't automate, change the expectation of the way the work is done, recognizing that a human will be performing the work and we have limitations."

In fact, some of the non-technical improvements made in the lab have had surprisingly significant results in reducing lost specimen, according to David Rogers, assistant vice president and group manager support services for ARUP.

"Specimens come in round tubes and when they are laid down, if there is any gravity force, any tilt on the desk, or even if you just stand up and push on your desk, you are going to cause a little downward slant and those specimens love to roll off," Rogers said. "One of my favorite things to discuss is that on the desk at every processing area that we have, there is a now a raised edge."

Similarly, garbage cans, in most workspaces, are traditionally right alongside the edge of a desk, he noted.

"I don't like that because if specimens roll off, they can roll off easily into the trash. So, one thing I did was I removed the trash cans so you have to purposely reach to throw something away," Rogers said.

In addition to moving trash cans farther away, the cans were all fitted with lids with slits, so that the cardboard shipping racks used to transport specimens would not fit into them.

"The biggest improvements do come when you automate a process, but not all clients can go out and afford automation. So you have to look at what you do to improve when you are waiting for automation to be implemented," said Rogers.

ARUP does not share the volume of specimens it processes. In achieving theSix Sigma quality level, which is 3.4 defects per million opportunities, it defined a defect as an irretrievably lost specimen, and an opportunity as a specimen, resulting in a metric that measures the number of lost specimens per million, Messinger said. While lost specimen numbers may vary from month to month, the University of Utah Hospital lab, which is a division of ARUP, did not lose a single specimen in the first three months of this year, she said.

Other low-tech improvements that have helped reduce specimen losses include covers around the bottom of all refrigerators so that nothing can roll underneath, said Messinger.

Rogers also had wires under all work areas tucked into canals that were covered, so that if you look under desks there is a clean line of sight without wires that specimen could hide behind, he said.

Rogers overseas the processing group within ARUP, which is the first point of contact when specimens arrive at the lab, and is responsible for ensuring that samples are sent to the appropriate testing area and are stored at the appropriate temperature. As such, the group he overseas touches ever sample that comes to the lab.

"A lot of the work that we have done occurred after [someone] lost a specimen," he said. "It's a lot of hindsight. We would say, what could we have done to improve."

For example, anyone sending glass slides or paraffin blocks containing tissue sample to ARUP uses a transport kit that is essentially a large Styrofoam box with cutouts for the blocks and slides. There is one transport kit per patient. This transport kit was devised after a paraffin block once went missing, Rogers said.

Paraffin blocks are small, about an inch by an inch. Before the creation of the transport kit, if a block went missing, it was impossible to tell whether it was accidentally discarded at the bottom of a bag, misplaced in the lab, or whether it never made it into the mail bag to begin with. The large transport kit that was created as a result is impossible to overlook, Rogers said. In addition, the kit stays intact until it reaches its testing location.

"When it gets to ARUP, my group does not remove the contents from that kit. We do not remove the blocks or slides. We put our label over the client's label on the kit as if the kit is the specimen. Then we send it to the lab for testing. It reduces the chance of me losing a specimen in the processing area," he said.

A high-tech focus on lost specimens

Low-tech changes were coupled with technology improvements that began in the late 1990s with a conveyor belt track system from a Canadian company called MDS, according to Charles Hawker, who recently retired as a scientific director for automation and special projects at ARUP. ARUP deliberately did not purchase a system from one of the major lab equipment manufacturers because most systems were connected to analyzers rather than the types of reference lab equipment that ARUP uses.

The track system is designed to query the laboratory information system when bar codes are read, to get instructions on where to route specimens. In cases where multiple tests are run on the same specimen, the bar codes identify which test should be conducted first. When a specimen is returned to the track after its first test, it is routed to its next destination, and ultimately routed to the storage sorter when testing was completed, Hawker said.

"My favorite example is we do a lead profile that includes a blood lead and a zinc protoporphyrin test, and the lead always has to be done first because that tube has to be opened in a metal-free environment," Hawker said. "So that is a good example of how routing is supposed to work. You can set up all the priorities in the computer system so that all it does is read the bar code on the tube."

That track system was used until it was replaced with a MagneMotion intelligent conveyor belt system in 2014. The MagneMotion system uses magnetized linear synchronous motors, which cause less friction and wear and tear than traditional conveyor belt systems, Hawker said.

Approximately 15 percent of specimens are not put on the track system at all, because either they aren't in tubes, such as fecal specimens or urine specimen cups, or they are critical frozen molecular testing. Those specimens are sorted through a system that ARUP calls Sort-to-Light, according to Hawker. Lab staff using the Sort-to-Light system each pick up a barcode reader with a color assigned to it. There are LED displays over different sorting locations, some of which may be frozen specimen bins, refrigerated bins, or room temperature bins. The LED displays for each bin are able to light up to the color of whichever barcode reader the lab staffer is using.

"Every time someone reads a tube using a violet barcode reader, the LED array of where the tube is supposed to go will illuminate in violet. You can actually have multiple employees working at the same time storing and retrieving specimens," Hawker said. "Sort-to-Light was really key to hitting the Six Sigma quality level."

Another area where the lab implemented automation, was in thawing and mixing of specimens, Hawker said. Many tests that are transported frozen need to be thawed for testing to be conducted, and every specimen in the laboratory must be mixed before it is sampled, he noted.

'We built these robots that would take the specimens off the track and blow a jet of room temperature air on them," Hawker said. "When thawed, the robot would pick them up and rock them gently back and forth in a precise pattern to mix them," he said.

Specimens thaw in 23 or 24 minutes, with some lower-volume tests thawing in as little as five to six minutes, he said. Initially, there were two robots, but recently a third was added. Each robot can thaw and mix up to 1,000 specimens an hour.

The lab's two-story, 60-foot-long and 30-foot-wide fully automated freezer is designed to ensure that no employee ever has to enter the freezer to retrieve a specimen, Hawker said. It can store more than 2.3 million specimens.

The freezer puts specimens on trays that might be stored for two weeks or up to a year, depending on the type of specimen. Each tray has an expiration date based on when the last sample is added, so if a tray used for 90-day storage takes two days to fill, the 90-day storage period begins on that second day. Lab personnel who need to retrieve a stored test for retesting or other purposes, can enter their retrieval request in the lab's computer system, and pick it up at a retrieval window. Each day, before the sun rises, lab personnel pull up the discard list and the freezer system retrieves all tests ready to be discarded.

Transforming work culture

A major technology shift used technology not to eliminate human intervention, but to change how people work.

"My favorite thing that we have done, and we are constantly proving it, involves big data," Rogers said.

The intelligent track system that runs through the lab, and the more manual sort-to-light system track specimens at multiple touchpoints.

"If you process a specimen, and it does not get checked into the Sort-to-Light or it does not get put on the track, I can run a report that shows that," Rogers said.

Reports run every 10 minutes to check the flow of specimens in the lab, and if a specimen does not arrive at its next destination within two hours, the last person who touched it will get an email alert to look for it. The alert comes with an embedded flow chart indicating where the missing specimens might most likely be. The flow chart has been created based on the lab's experience with misplaced specimens, and is continually reviewed and updated when staff find other recommendations to add, according to Rogers.

"We are used to reports that we can use reactively, such as show me how many times this came up in the last five months," Rogers said. "But the thought of looking for situations in near real time, and having reports notify you every 10 or 15 minutes when situations occur was revolutionary when I put it in, and I started to train other groups on how to use it."

The flow charts that accompany alerts were critical for finding lost specimens, not only because they are built on best practices, but because they create a structure to searching for lost specimens, Messinger said.

"Sometimes, people would be so sure that a specimen was lost in their lab that they would never say a word to specimen processing," she said. "Dave [Rogers] and his team initiated a group of individuals to look at the way the rest of the organization worked with specimen processing, and they began to align their procedures to come up with ways of doing things that has a chance of succeeding across the organization rather than in silos."

Intraday alerts are now used across almost all of ARUP, according to Rogers, and have made a drastic shift in the lab's response time to potential errors, he said.

"A lot of times when something would be lost before, we wouldn't know until the client came looking for results," Rogers said. "It could be a day or several weeks later, and if we said we didn't receive the specimen, that makes for a really upset phone call."

In addition to prompting quicker reaction times, intraday alerts have increased accountability of the front-line processing group, according to Rogers.

"It used to be that our processing front-end staff really wouldn't get involved when specimens were missing because everyone assumed they didn't displace it, it was someone else's fault. That's what humans do," Rogers said. "No one likes to get a report like that, but the nice thing is they actually own it. It has changed our culture where people understand how important this is and they start the search much sooner now."