CEO SUMMARY: To improve the quality of lab services it provides to more than 300 skilled nursing facilities (SNF) while reducing costs, MuirLab of Concord, California, has created a “mobile specimen processing” solution. It operates a fleet of courier cars with centrifuges and refrigerated storage. Now specimens transported by these cars arrive at the core lab already labeled and processed so they can go directly onto the automated line. This is just one part of an effort to advance patient care by integrating wireless informatics solutions with mobile processing.
TO TRANSFORM THE PERFORMANCE AND PROUCTIVITY of its laboratory couriers, MuirLab of Concord, California, has gone high tech. It operates its courier cars as mobile accessioning units, so that when specimens reach the laboratory, they immediately go onto the automated line for testing!
“This accomplishes two things,” observed Michael Tarwater, Executive Director at MuirLab. “First, mobile processing protects specimen integrity during transport. That leads to a higher-quality lab test result that improves patient care.
“Second, it reduces the overall cost of specimen collection, delivery, and specimen segments of the laboratory testing marketplace, such as skilled nursing facilities (SNF) and nursing homes.”
These innovations have paid big dividends. “The improvement in specimen integrity during transport has been significant,” declared Tarwater. “MuirLab decreased recollects by 48% from 2007 to 2010, even as total requisitions serviced increased by 45% during this same time.”
In many ways, it’s a “brave new world” for MuirLab’s couriers and phlebotomists. Their daily routine involves use of Lean workflow and wireless real-time integrated informatics as they drive courier cars equipped with centrifuges and refrigerated storage.
THE DARK REPORT believes MuirLab is unique in the United States in its innovative approach. By adding the functions of specimen accessioning and specimen preparation to the collection and transport of specimens before they are delivered to the laboratory, MuirLab has demonstrated another way that clinical laboratories can improve quality while eliminating unnecessary costs.
In fact, it was the need to develop a cost-effective way to serve 300 SNF and nursing home clients that originally motivated MuirLab to apply Lean methods and technology to the specimen collection, transport, and pre-analytical functions.
“It is phlebotomists who drive to these client facilities,” stated Tarwater. “They already do double duty, since they collect the specimen, then hop into a car and drive it to the laboratory or to one of our courier/logistics hubs.
“Now we support their workflow in an intelligent manner,” he continued. “At a client’s site, the phlebotomist first uses wireless laptops to verify patient information before collecting specimens. A wireless printer produces labels at the patient’s side. This system also, via wireless, registers the patient requisitions with our laboratory information system (LIS).
“Each courier car is equipped with centrifuges and refrigeration units,” said Tarwater. “Specimen processing and preparation can start at the client’s location. The refrigeration units in each courier car are monitored wirelessly so that staff at the core lab will know instantly if a sample is compromised.
Laboratory Outreach Growth
“MuirLab has a fast-growing lab outreach program,” he said. “Each day, we process about 3,800 requisitions, representing 8,400 tests. About half our outreach volume originates at about 300 SNFs. These facilities are located as much as 100 miles from our central lab.
“It is no mystery to most pathologists and clinical lab managers that skilled nursing facility clients are notoriously low-margin operations for the lab that services them,” explained Tarwater. “That is why we continously do everything possible to drive more efficiency into this part of our laboratory operation.”
MuirLab’s outreach program has 300 full-time staff members. This includes 35 phlebotomists and 12 staff members in the information technology department. On any given day, MuirLab visits about one third of its SNF clients and collects around 1,800 samples.
“From my standpoint, the overall story in many labs is about how we face continuing pressure of lower reimbursement per test, particularly from Medicare,” declared Tarwater. “Where Medicare goes, the other payers tend to also go.
“That continued pressure on reimbursement means that the laboratory has to figure out ways to get more efficient,” he noted. “SNFs have a high proportion of Medicare patients. It is expensive for the laboratory to send out phlebotomists to the nursing homes to collect the specimens and bring them back to the laboratory. Thus, shrinking reimbursement adds to the lab’s challenge of breaking even while meeting the service needs of nursing home clients.”
Starting Point of the Story
This is the starting point in MuirLab’s story of the multi-tasking phlebotomists and centrifuge-equipped courier cars. There was an immediate need to significantly reduce the costs associated with serving its 300 nursing home clients—along with the urgency to do it quickly, since reimbursement associated with nursing home testing is generally below the cost to service that client.
“We didn’t immediately attack the costs of servicing SNF clients,” recalled Tarwater. “In recent years, MuirLab was focused on designing, building, and bringing into operation a state-of-the-art automated central laboratory.
“Our priority was getting automation in place in the core lab, then fine-tuning it in support of all our testing activities,” he said. “Once we did that, it was time to address ways to improve the pre-analytical and the post-analytical steps in the process.
Reduce Unnecessary Costs
“What quickly hit our radar screen was the need to address the costs involved in specimen collection, specimen transport, and specimen preparation involving samples from nursing home clients,” added Tarwater. “These are steps in the pre-analytical stage. Improvements in workflow and individual work processes upstream of the automated laboratory would also directly benefit our analytical stage performance.”
Application of Lean and work flow redesign methods helped the MuirLab team identify opportunities to improve the quality of work processes, reduce rates of errors and defects, and eliminate sources of waste and unnecessary cost. In the nursing home segment of the business, this can mean the difference between losing money and breaking even for the laboratory that provides testing to SNFs.
“In developing our new workflow solutions in specimen collection, specimen transport, and specimen preparation, we actively looked for ways that technology could support increased efficiency, accuracy, and quality,” said Tarwater. “That is a key to understanding why these new approaches have been successful in sustained use.”
MuirLab’s secret sauce in its innovative solution are the courier cars used by the phlebotomists who visit each SNF to collect specimens. “We operate these courier cars as mobile pre-processing units,” stated Tarwater. “The goal is simple. When the courier car arrives at our core laboratory, all the specimens it delivers can go directly onto our automation line. Every courier car used by a phlebotomist has centrifuges and a refrigerated unit.”
“Each phlebotomist goes out with a laptop, a wireless label printer, and a wireless internet connection,” he said. “At the patient’s side, the phlebotomist can look up the orders and print the labels as they collect the samples. This technology supports on-demand orders (non-standing or recurring orders.)
“Before leaving for the next location, the phlebotomist will put the samples in the centrifuge and spin them,” noted Tarwater. “Once prepped, the specimens are then refrigerated.
“Collectively, these steps save about five to six minutes per specimen” Tarwater added. “That is because, when they arrive at the lab, these specimens are ready to immediately be put on the automated line. They don’t need to go through processing to check the order, print the label, and they don’t have to be spun. Instead, they already have the barcode label from the wireless printer, were logged on via the wireless link at the client’s site, and go directly to the analyzers.”
California’s hot summer climate played a role in designing solutions for specimen handling and specimen transport. “A significant part of our service region is the high desert of California, where the temperature can get over 100 degrees in the summer,” he observed. “Also, some of our clients are located 100 miles away from our core laboratory. Maintaining specimen integrity with coolers and dry ice under these conditions is always a challenge.
“We did our first courier cars like this about four years ago,” added Tarwater. “For us, combining centrifuges and refrigerated units in the courier cars immediately paid big dividends. Spinning and refrigerating the specimens before transport stabilizes them and helps prevent them from being compromised in the heat.”
“Anytime a specimen is compromised, it means we would have to recollect that sample, and that could require at least another day,” he stated. “With this new work flow, there has been measurable reduction in the number of compromised specimens. Each of these steps contributes to improved patient care.”
Adding Costs, Cutting Staff
“Of course, we do have the cost of adding centrifuges and a refrigeration unit to our vehicles,” he stated. “We spend about $3,900 per car on this retrofitting. Our fleet includes such Toyota models as the Prius, Corolla, and Yaris.
“In each car, the passenger seat is removed to allow the installation of a two-centrifuge sub-assembly made to our specifications,” continued Tarwater. “Each centrifuge holds six to eight specimens and can run side by side in case one breaks down.
“The refrigeration unit goes in the backseat,” he said. “This unit is about the size of a large camping cooler and has a built-in compressor. A battery pack is installed in the trunk to power all that equipment.”
These courier cars have another feature. “We have sensors in the refrigerated units that relay the temperature back to our central laboratory wirelessly and continuously in each cooler in each car,” added Tarwater. “That way we know if a specimen has been compromised.”
Used for other Purposes
On hot days, MuirLab may also use the specially-equipped courier cars when serving a lab or client located some distance away. “Since the temperature can often top 100 degrees in the summer, we’ll use one of the cars with refrigeration to ensure that the specimens are stable,” Tarwater stated. “This is a great help because we cover a lot of geography. The core lab is in Concord and we go over 70 miles to the north, 80 miles to the east, and 100 miles to the south.
“There are about 180 cars in our fleet and 35 cars are retrofitted with this equipment,” added Tarwater. “Courier cars used to collect specimens from our patient service centers (PSC) do not have centrifuges because the PSC staff spins those samples on site.
“The additional cost of equipping 35 courier cars with these centrifuges and refrigeration units is more than offset by the resulting savings,” he noted. “For example, we have reduced the work associated with processing specimens as they arrive in the lab. Further, we reduced the need to send staff out to recollect specimens if any are compromised.
“Like many labs, we track our vehicles with GPS (global positioning satellite) so that our dispatchers know where each vehicle is at any given point,” Tarwater observed. “It also helps us check their average speed and their top speed. Not only do we want safe drivers, but these cars do prominently display the name of our laboratory.
“Now that we have improved the preanalytical processes that we use to service our SNFs and other clients, we are ready to go one step further this year,” commented Tarwater. “Since the bulk of orders from SNFs are standing orders and don’t change much from day to day, we are preparing to install an improved and robust application to handle these standing orders.
“This new application will allow us to pre-print by route all standing order labels and the companion draw sheet,” he explained. “When phlebotomists start their route, they can pick up a packet of the scheduled work for that day. The labels will be sorted by route, and by facility and that information will be in our LIS. When the phlebotomist arrives at a client facility, he or she will only need to enter that day’s on-demand orders on their laptops.”
Process Improvement’s Role
It is oft said that necessity is the mother of invention. Certainly the need for MuirLab to reduce the cost of servicing a money- losing group of clients was the motivation to develop these clever solutions.
However, an equally important part of this story is how Lean, process improvement, and similar quality management methods gave MuirLab team the tools needed to analyze existing workflow, and identify sources of waste. It gave them a roadmap for developing, testing, and implementing solutions that would have a high likelihood of success. This is important validation of workflow redesign methods.
The result is a highly innovative solution that is unique among clinical laboratories in the United States. MuirLab has developed the business model of the multi-tasking phlebotomist and the courier car as a mobile station for specimen preparation and specimen processing.
In doing this, MuirLab points the way forward for other hospital and health system laboratories that provide laboratory testing services to skilled nursing facilities. It is an innovation that, when deployed by other laboratories, can help them improve the lab testing services they deliver to SNFs while significantly reducing the costs associated with those clients.
Why Servicing 300 Skilled Nursing Facilities Is a Tough Financial and Service Challenge
“PATHOLOGISTS KNOW THAT THERE are very tight margins in servicing skilled nursing facilities (SNF) and nursing homes,” noted Michael Tarwater, Executive Director of Muir Labs in Concord, California.
“Anything we can do to identify and cut wasted time and eliminate non-value-added processes, the more efficient our laboratory will be,” added Tarwater. “To help us pare down the expense of providing laboratory testing services to SNFs, we wanted to rethink the pre-analytical phase. That includes specimen collection at the time when the phlebotomist visits the client SNF to obtain specimens; specimen transport; and the processing and preparation of the specimens.
“This is how we recognized the value of having a courier vehicle run parallel tasks instead of doing the serial tasks—or simply sitting idle while a phlebotomist collects the specimen,” he said. “Multi-tasking lets you take full advantage of that vehicle.
“This insight came as a direct result of the guiding management principle here at MuirLab, which is to continuously improve what we do every day and every hour,” he observed. “It is important to understand that what we’ve accomplished with our multi-tasking phlebotomy and courier workflow is rooted in several core management values.
“Reengineering is at the heart of how we view activities in our laboratory,” explained Tarwater. “Staff constantly looks for opportunities to improve processes and to eliminate non-value-added steps.
“Every clinical laboratory needs highly efficient processes that are scalable and repeatable. MuirLab is no exception,” he declared. “Scalable and repeatable processes allow you to predict your outcomes. In turn, that predictability is what drives the lab’s ability to regularly improve quality.”
If Tarwater sounds like he’s well- schooled in Lean and process improvement, it’s because two of his main responsibilities at MuirLab are laboratory information systems and quality management. Also, before coming into the laboratory testing business, he gained experience in other industries.
“In addition to my 13 years of clinical laboratory experience, I also have an extensive background in information technology (IT), transportation, and manufacturing distribution,” he says. “So, I brought all those skills to this laboratory.
“I view our core laboratory as a factory and our product is information,” he com- mented. “Our laboratory must render that information in multiple different formats while also ensuring the quality and integrity of that information.
“Like every medical laboratory, MuirLab takes data and turns it into information,” continued Tarwater. “Our laboratory must accomplish this using repeatable and scalable methods even as it continues to improve the quality of the information that it produces.
“Anything we can do to save time, steps, and non-value-added processes, the more efficient we will be in the pre-analytical stage. So if we have a vehicle running parallel tasks instead of doing tasks serially or sitting there idle while a phlebotomist does the drawing, then we are taking full advantage of that vehicle.”
Economics Are Tough When Labs Serve SNFs
IT’S NO SECRET THAT SKILLED NURSING FACILITIES (SNFS) place intense service demands on clinical laboratories, while offering meager reimbursement. This means most laboratories lose money from their nursing home business.
In fact, it was during the mid-1990s when all the nation’s biggest independent laboratory companies dropped nursing home clients, precisely because they were unprofitable to service. Into that vacuum stepped many hospital laboratories, often as a way to further the strategy of their parent hospitals or health systems to build strong clinical relationships with the SNFs in their community. The hospital benefits when the SNF refers it patients who need to be admitted for an inpatient stay.
For this reason, hospital administrators will absorb the operating losses incurred from the laboratory outreach testing services delivered to a client SNF, in exchange for access to the inpatient referrals from that SNF.
That is why the management team at MuirLab is working diligently to continuously develop and implement workflow solutions that reduce the cost to service a nursing home client, even as these same process improvement projects contribute to better quality, lower costs, and improved patient outcomes.