CEO SUMMARY: To date, only a handful of total laboratory automation (TLA) projects have been implemented in Great Britain. One of those first TLA projects is at the Royal Free Hospital, Hampstead, located in the northern suburbs of London. Design work started in 1998 and the first phase became operational in 2000. Despite Britain’s single-payer health system, most of the management themes and challenges were essentially the same as those encountered by early-adopter laboratories in Canada and the United States that were first to install total laboratory automation.
WHEN IT COMES TO LAB AUTOMATION, clinical laboratories in the United Kingdom (U.K.) have lagged behind their counterparts in Canada and the United States.
In North America, the earliest projects to implement total laboratory automation (TLA) became operational in the mid-1990s. In contrast, it was not until 2000 that the first major laboratory in the United Kingdom had an operational TLA installation.
The U.K.’s first TLA site was the laboratory at the Royal Free Hospital, Hampstead. Located in the northern suburbs of London, the Royal Free Hospital has 1,200 beds and is part of University College Medical School.
Tour Of The Royal Free Lab
During THE DARK REPORT’S visit to Great Britain last month to co-produce and speak at the first “Frontiers in Laboratory Medicine” program, it toured the Royal Free’s laboratory. Tour host was Dr. Michael Thomas, Clinical Head of Service, Pathology and Head of Department, Clinical Biochemistry.
Royal Free Hospital is both a tertiary care center and a teaching hospital. Annually it serves 94,500 inpatients, 311,000 outpatients, and 58,000 “accident and emergency” patients. Laboratory services are extensive. The lab gets 1,500 requisitions per day and each requisition averages 9 tests.
“The Royal Free handles sizeable numbers of liver, kidney and bone marrow transplants,” Thomas said. “We are also the largest treatment center for HIV in London and the U.K. Because of the large volume of potentially infectious samples handled here, we believed that laboratory automation in our biochemistry lab would improve both staff safety and the quality of our test results, all to the benefit of patients.
“Another goal was to consolidate a variety of testing technologies onto an automated line,” he explained. “There are several obvious efficiencies that result from such a step.”
However, the structure of laboratory services at the Royal Free made laboratory automation a daunting challenge. “Pathology comprises nine separate departments, ranging from biochemistry and haematology to virology and histopathology,” recalled Thomas. “Each department had its own test order form. This meant we had lots of primary sample tubes which generated lots of aliquots. In fact, we estimated we could save more than U.S.$80,000 per year just by adopting a single type of primary sample tube.
Other Automation Challenges
“Another challenge was logistics and accessioning,” he observed. “We have a complex method for picking up specimens in both the hospital and affiliated clinics, getting them into accessioning, and then distributing them out to the appropriate laboratory department. At the time we started this project, we also lacked a computerized order entry system. It wasn’t until lab specimens reached accessioning that information was entered into the computer.”
These challenges have a familiar ring to North American laboratorians. But the use of nine separate laboratory test requisitions within the Royal Free’s lab division certainly is a complex factor seldom encountered in North American laboratories. Because of this and other factors, the effort needed to gain support and develop consensus about the need for an automated biochemistry and immunoassay testing line at the Royal Free’s laboratory should not be underestimated.
Tangible planning for the laboratory automation project was launched in 1998. “This has been years in the planning and execution,” said Thomas. “It’s required us to remodel the laboratory, to replace our existing chemistry and immunoassay analyzers, implement a laboratory information management system, and reorganize staff responsibilities.”
Obtaining capital for a TLA project at the Royal Free Hospital laboratory was an essential first step. In contrast to capital budgets within most U.S. hospitals, in the United Kingdom, funding for capital improvements must come from a combination of the local health trust and the U.K.’s National Health Service (NHS). Like most the health programs of governments around the world, the NHS is strapped for cash.
“All areas of medicine are competing for capital for improvement projects,” noted Thomas. “We considered ourselves fortunate that our funding requests were accepted. The NHS, centrally through its Modernisation Programme, provided the funding necessary to acquire the automated equipment and purchase a pre-analytical software system. whilst a lease agreement was reached between the hospital and the vendor for other components of the TLA system (analzyers, reagents, and consumables.)”
TLA Project Went To Bid
In 1998, the laboratory at Royal Free Hospital placed a “European Tender Bid” for its automation project. The tender was shortlisted down to three diagnostic vendors, each of which provided a detailed bid.
“The three bids involved Bayer Diagnostics, Roche Diagnostics, and a consortium of Olympus, Diagnostic Products Company (DPC), and Labotix,” stated Thomas. “For a variety of reasons, we selected the Roche bid. Based on the products it could offer us in 1998, we believed they had the best solution for our laboratory’s needs.”
THE DARK REPORT also reminds readers that diagnostic instrument systems and test menus vary from country to country. This happens because there are differences in medical practices and differences in how national regulators review and approve diagnostic technology. That is why there would be notable differences in the mix of instrument and test menu choices offered to Royal Free’s lab in 1998 (and other European laboratories) than what would be offered by these same vendors to labs in the United States.
Royal Free Lab Serves Nearby Doc’s Offices
GREAT BRITAIN’S single-payer health system uses regional health trusts to fund and manage healthcare services.
Because administration and payment is handled by a regional trust, there is more operational and clinical integration between hospitals and physician’s offices than typically found in the United States. In the example of the Royal Free Hospital, its laboratory provides almost all the daily testing needed to support affiliated physician clinics in the neighborhoods near the hospital.
In contrast to the United States, the Royal Free Hospital laboratory picks up lab specimens from these physicians’ offices and feeds these specimens into the lab throughout the day. Thus, by days’ end, almost all routine testing has been done and the results reported to the referring clinic. Very little testing is done in the laboratory during the evening and night shifts.
This same-day turnaround time is unmatched by most labs in the United States, which pick up specimens from physicians’ offices at the end of the working day, perform the tests during the night, and report most routine results by 8 a.m. the following morning.
“Having selected Roche, it was decided to implement our automation project in three phases,” Thomas said. “Phase one, started in 2000, was installation of the automated chemistry line. This included the analytical modules for chemistry tests. We selected an instrument configuration with a throughput of 800 colorimeteric tests per hour per module (2,400 tests per hour overall), plus 1,800 ise tests per hour.
“Phase two came six months later,” he continued. “This involved connecting pre-analytical functions to the automated testing line, including the capabilities of centerfugation, cap and decap, and on-line and off-line aliquoting. The laboratory information system (LIS) we use is WinPath (William Woodward Associates), which is not available in the United States.
“Phase three saw the addition of immunoassay analyzers to the automated line. This was completed in early 2002. We have 42 assays on the auto- mated chemistry and 26 assays on the immunoassay lines,” added Thomas.
Thomas and his colleagues consider the automation project to be successful. “Our major goal was to maintain laboratory costs, post-project, at the level of 1998, before the automation project was launched,” he noted. “We’ve done that even as we’ve gained additional test capacity and improved several important measures of laboratory performance.
Reduction in Average TAT
“For example, sample preparation times went from averages of 45 to 90 minutes down to averages of 17 to 27 minutes. There’s been no change in average analytical times of 10 to 20 minutes. Overall averages before were between 60 and 120 minutes. Post-automation, our average is under 60 minutes,” observed Thomas.
This accomplishment is all the more impressive because it not only includes the hospital’s inpatient and outpatient work, but also specimens from nearby physicians’ offices. Throughout the day, couriers pick up from the physicians’ offices hourly. As a result, when the laboratory’s day shift ends in the late afternoon, virtually all automated chemistry and immunoassay testing has been completed and reported to referring physicians. Office-based testing is about 15% of the total testing volume at Royal Free’s laboratory.
Thomas claims the implementation went relatively smoothly. “Of course we had our share of glitches and unpleasant surprises,” he conceded, “but the overall project went forward steadily, without major setbacks. We didn’t experience major disruptions.”
One issue that proved a surprise was evaporation from sample tubes. “In our laboratory layout, during the time it took for the on-line aliquot tubes to get through pre-analytical to the analyzer itself, there was enough evaporation to affect test results,” recalled Thomas. “Our solution was to install an additional air conditioning unit. The reduced laboratory temperature solved the evaporation problem.”
Attention was also devoted to solving such problems as getting tests added or deleted while the specimen was on the automated line, centrifuge spin time, and false rack information alarms. “In hindsight, our selection of a primary tube was not the best because they can’t be auto-recapped,” said Thomas. “However, at the time this decision was made, nine different laboratory departments needed to agree on a primary tube. This illustrates the challenges we faced moving from our existing operational structure to the fully-automated chemistry and immunoassay line.”
Staff Productivity Goes Up
Thomas described several other benefits from the automation project. “From a staffing perspective, we do more work with a reduced staff. There was measurable improvement in sick time, which dropped from 10% to 5%. Staff turnover rates have also declined,” he added.
“Improvements to our work processes are significant,” continued Thomas. “Post-automation, error rates dropped. Not only were turnaround times reduced, but variability in turnaround times declined as well. Our lab can handle increased workloads and we utilize floor space more effectively.”
As one of the first efforts to implement TLA in Great Britain, the Royal Free Hospital’s laboratory seems to have avoided some of the serious operational issues which plagued the earliest automation attempts in North America. “I think one reason why that’s true is because our automation equipment represents several generations of improvements,” observed Thomas. “Throughout the multi-year process of bidding and planning, we saw our equipment options change as vendors introduced new features and capabilities. Some of the automation systems we finally installed in 2000 were not available during the bid process in 1998.”
Another interesting difference in laboratory management in the United Kingdom versus the United States is the relative lack of intense focus on cost inputs, such as labor, supplies, and capital expenditures. Most lab directors and pathologists in the U.S. are keenly aware of productivity measures such as average cost per test, average med tech FTE productivity, and similar measures.
That is not the case in the United Kingdom. THE DARK REPORT observed that, during conversations between British lab administrators and pathologists and their North American counterparts, the North Americans invariably know specific numbers about their lab’s costs, productivity, and related performance measures.
In contrast, most of their British peers did not have similar command and recall about their laboratory’s performance in these areas. There seems to be an interesting explanation why this difference exists between each side of the Atlantic Ocean. During the 1990s, laboratories in both Canada and the United States saw significant year-to-year reduction in laboratory funding.
With less money available to reimbursement for laboratory testing, economic survival in Canada and the U.S. required laboratory administrators to look diligently for ways to eliminate unnecessary costs and improve productivity—even as they maintained or improved the laboratory testing services they provided to physicians in their community. In North America, survival required a more intense management of laboratory assets and resources.
Meanwhile, during the same decade in Britain, funding for laboratory services was not reduced in a comparably dramatic manner. Pathologists and lab directors could maintain a focus on clinical services. They did not have to cope with the extreme reimbursement pressure faced by so many of their North American counterparts during most of the 1990s.
Capital Funding Strategies
Capital funding is another reason why North American lab directors give so much attention to laboratory operations relative to their British col- leagues. In the United States, hospital administration is much more likely to provide capital for laboratory improvements if the laboratory executive team can demonstrate the rate of return that will result from that capital investment.
In simplest terms, North American hospital lab directors recognize the fastest way to get the money they need to improve their laboratory is to demonstrate how such money will be deployed to reduce laboratory costs, improve productivity, and create a better cash flow that returns capital back to the hospital.
Much of this will change for laboratories in the United Kingdom, however. The National Health Service is pushing for “pathology modernisation” which requires the nation’s laboratories to consolidate lab testing services across several facilities and develop regionalized lab service organizations. For this reason, there will be lots of changes in the laboratory system which supports healthcare
in the United Kingdom.