CEO Summary: Pathologists at Ottawa Hospital not only must handle a large volume of specimens regularly, but are experiencing a 14% per year growth in the number of specimens. Last year, when the average turnaround time for a case was nine days, the pathology department embarked on a series of Lean and process improvement projects. In a matter of months, changes in both histology and in scheduling of the anatomic pathologists contributed to a 50% reduction in average turnaround time. In turn, the faster TAT has improved patient care.
FACED WITH A GROWING BACKLOG of specimens and a nine-day average turnaround time (TAT) anatomic pathologists at one of Canada’s largest hospitals turned to Lean and process improvement methods to achieve a reduction in TAT of more than 50%.
The anatomic pathology (AP) department at Ottawa Hospital in Ontario, is holding average turnaround time to four days, compared with an average TAT of nine days that it ran at the end of 2012.
This is an important accomplishment, because it shortens the time to diagnosis for patients with cancer and other diseases, thus contributing to better patient safety and improved patient outcomes. Moreover, the lab team at Ottawa Hospital was able to accomplish these goals in a matter of months.
The Ottawa Hospital, a 1,149-bed academic health sciences center, serves 1.2 million residents of Eastern Ontario. It operates three facilities and handles almost 48,000 annual admissions. Staff numbers 11,813, including 1,300 physicians. The anatomic pathology lab has 27 pathologists and a staff of 100.
This story starts in November 2012. That is when Dr. Diponkar Banerjee, MBChB, FRCPC, Ph.D., assumed the position as head of the Division of Anatomical Pathology in the Eastern Ontario Regional Laboratory Association at the Ottawa Hospital. He is also a Professor of Pathology and Laboratory Medicine at the University of Ottawa.
“At that time, I concluded that our pathology laboratory had adequate resources for our specimen volume,” stated Banerjee. “Recent recruitment and the creation of new positions meant that we had close to the right mix of subspecialist pathologists. The lab facility had been renovated in recent years and an LIS upgrade had also been done. A barcode system was in place and some training in Lean had been completed.
“Still, the lab was under stress because of the continual increase in pathology specimens,” he noted. “Our volume growth is averaging 14% per year, primarily due to the cancer incidence in an aging population.”
Upon his arrival, Banerjee and William Parks, the newly appointed Operations Director, quickly identified one major cause of long turnaround times. “Like most pathology labs, we were organized around large batch processing,” he said. “But with an unbalanced specimen flow in the laboratory, the staff was struggling to prioritize work.”
That workload is substantial. Last year, the AP lab handled 71,000 cases involving 109,000 specimens and 419,000 slides for interpretation, including cytopathology. “That’s roughly 400 anatomic pathology specimens or 2,500 slides per day,” observed Banerjee. “For Canada, that’s a fairly high volume. We are one of the highest-volume AP laboratories in Canada. Also, being an academic health sciences center, we are engaged in teaching and research.”
In addition to high volume, the pathology lab had suboptimal workflow. “Workflow was unbalanced because we were trying to second guess the urgency that was required for each specimen,” recalled Banerjee. “Staff tried to anticipate which specimens needed to be processed first.
“That was a problem,” he said. “For example, if a specimen that was not processed early turned out to be cancerous, then the wait time for that patient’s report might have been nine days or more.
“To resolve this logjam, we decided to apply the Lean principles we had used in other process improvement projects in the lab,” stated Banerjee. “Our goal was to do workflow balancing throughout the whole process—receipt of specimens through delivery of the pathology reports.
“We wanted to balance the flow of incoming specimens with the flow of outgoing reports—as close to first-in/first-out as possible,” he explained. “However, applying the first-in/first-out rule to all specimens is a challenge because of the complexity in the range of the cases we see.
“Our process improvement project started with a review of existing rules,” Banerjee said. “These rules addressed the need to handle some specimens with urgency, but were complex, imprecise, and subject to individual variation.
“Some cases considered to be nonurgent would sit around for too long untouched,” he said. “Once pathologists got to these nonurgent cases, they might find something of clinical significance that would require urgent action by the oncologists.
“Of course, each time that a malignant specimen was at the end of the queue because of these workflow rules, that was a problem for patients and the clinical staff,” noted Banerjee. “After all, for cancer or other serious illnesses, time to diagnosis is a critical factor in whether a treatment will be successful or not.
“Another problem with the existing processing rules is that they created a big pile of unprocessed specimens in the histology laboratory at the end of each day,” he added. “That situation needed fixing.
“We did a value stream map and our analysis showed us that, if the specimens that came in first were processed first, we could move away from large batch processing,” noted Banerjee. “And that’s what we did. Starting early this year, we began running smaller batches multiple times throughout the day.
“For example, our histology lab moved to first-in/first-out specimen processing,” he added. “The exception involved certain small and large specimens because of the time involved for grossing and fixation.
“It was quickly recognized that smaller biopsies couldn’t be held up just because staff was working on a large resection,” said Banerjee. “For that reason, we did fine-tuning of histology workflow to correct and improve this situation.
“Another change we made in the histology laboratory that improved workflow was to run small batches of specimens in the processors throughout the day,” recalled Banerjee. “Another improvement was to organize tissue blocks into small batches of the same specimen types.
Color-Coding Different Cases
“These small batches remain organized right up to when cases are routed to the pathologists,” he noted. “We also instituted color-coding of specimen cassettes for the same types of cases to improve organization of work.
“These visual cues help staff recognize the different types of specimens at all stages in the workflow,” said Banerjee. “Also, the color organization ensures workload balance in histology so that all pathologists receive a flow of work throughout the day.
“Grossing saw its own share of improvements,” explained Banerjee. “Smaller and moderate-sized specimens are grossed during the first 1.5 hours of the shift, thus ensuring these tissues can be processed the same day.
“We did this to take advantage of the fact that staff are far more efficient at the beginning of their shift,” he noted. “Thus, the output of small specimens is much higher than it is at the end of a shift. We also used predefined text and templates to reduce the time staff spends on specimens.”
These changes in grossing and tissue processing, by themselves, did not produce a sufficient reduction in average turnaround time. Therefore, the lab decided to change how and when specimens arrived in the participating labs.
“We turned to the clinics within the hospital and worked with them to have surgical pathology specimens delivered throughout the day,” Banerjee stated. “This was consistent with our goal of moving to small batches and continuous flow. It stopped the practice of these clinics sending all the day’s specimens to us at 3 p.m. each day.
“In histology, the day shift is now organized around shorter processing schedules throughout the day, both for biopsies and for smaller or moderate- sized tissue samples,” he added. “Next, the afternoon-evening shift in histology can prepare larger and remaining specimens so they are ready for the pathologists to review in the morning of the next day.
“All these workflow improvements required changes in the staffing schedule,” explained Banerjee. “For example, an evening shift was implemented in the histology laboratory to make better use of the microtomes. This change specifically supported the flow of work first thing every morning to the pathologists.
“A weekend shift on Saturdays was instituted in the gross room to deal with the work received on Fridays,” he stated. “That contributes to improved turnaround times for Friday biopsies.
“One Lean principle we used was standard work,” continued Banerjee. “This made it easier to have staff rotate through embedding and microtomy to keep the batch size smaller and allow for more variation in their ergonomics to reduce repetitive strain injuries.”
The other opportunity to improve workflow and move away from batch processing involved how surgical pathologists were scheduled to read cases. This change made an equally important contribution to the reduction in average TAT.
“Like other subspecialty pathology practices, we have complex areas that may have low case volume.” said Banerjee. “Existing pathologist scheduling arrangements often resulted in underutilized time and underused pathologists. At the same time, we had pathologists who were overloaded.
“The existing policy scheduled pathologists in a manner that was more like a specialized practice,” he continued. “A pathologist would cover renal pathology one day. The next day, he or she would work in a different specialty area. For example, someone might cover gynecological pathology on Monday, then urology on Tuesday, and breast pathology on Wednesday.
“The flaw in this arrangement was that it was impossible to anticipate how much work each pathologist in each subspecialty would get each day,” stated Banerjee. “This arrangement was the source of regular backlogs. Cases not completed on Monday formed the backlog on Tuesday.
“Moreover, if they didn’t complete that work, they had a backlog on Wednesday,” he said. “Pathologists did have Thursdays and Fridays to reduce the backlog because on those days they did not receive new cases. Plus, they would try to catch up in the evenings or on weekends. But the backlog was continual. Every day compounded the problem.
“In March, this workflow was changed to specifically balance out each subspecialty workload,” explained Banerjee. “A schedule was established so the subspecialists work on just one specialty for the full week.
“The workload calculation is based on a simple slide count,” he noted. “We established the maximum number of slides each pathologist could safely report each day and adjusted that number for complexity.
“After implementing this method of scheduling the pathologists, the slide count was adjusted to a daily maximum,” recalled Banerjee. “This is when we realized that our original scheduling rules had underestimated the time required for pathologists to do their work each day for certain high-volume subspecialties.
“It was the right solution to have subspecialists operate on a weekly schedule,” recalled Banerjee. “If the workload fluctuations overwhelmed a pathologist on Monday, the backlog could get caught up by the end of the week—if the right number of pathologists were covering that subspecialty practice.
“In addition to scheduling the proper number of subspecialists for each area, it was necessary to account for vacation days, continuing medical education, and other reasons why a pathologist would be gone from the lab,” he noted. “Because there were a minimum number of subspecialists required each day, the need for scheduling vacation and CME time could create problems.
“Our solution was to have each subspecialty group of pathologists manage their own schedules for vacations, CME, and other time off,” explained Banerjee. “That was the final step in our process redesign.
“By having the staff do its own fine tuning, we allowed the solution to a problem to come from those who do the work,” said Banerjee. “When Lean is done properly, the solutions to problems usually come from the grassroots level.
“To support our first-in/first-out approach, it was not necessary to buy additional equipment or hire more staff in the histology lab,” he added. “This was because of the foresight of the previous laboratory leadership.
“For the past five years, the pathologists and laboratory managers had researched and purchased the newest technologies available,” Banerjee stated. “In recent years, the following technologies were purchased: multi-chambered processors that allow for short processing times, automated immunohistochemistry instruments, a barcode-driven laboratory information system, a dual linear stainer for H&E, and an automated single-slide stainer that is used exclusively for special stains.
“Productivity was also improved by introducing a voice recognition system that is used in the grossing of specimens and when pathologists produce their final pathology reports,” he said. “With this system, no transcriptionists are needed.
“At the moment, we don’t have digital pathology technology for use in diagnostic work,” added Banerjee. “But that technology is occasionally used for teaching rounds. Plans are to take a fresh look at digital pathology strategies next year.
“Looking back on all the improvement projects we completed, Lean methods played an essential role,” he observed. “At the same time, we always looked at the big picture and used common sense.
“Why not design the system so that every patient gets the same turnaround time?” asked Banerjee. “Not until the slide is reviewed will the disease state be known. A specimen could be cancerous and show significant lesions that the surgeons did not anticipate.
“After all this review and revision to workflow in our pathology laboratory, we cut the turnaround time for everything— including biopsies and resections—from nine days last November to just 4.5 days last summer,” he stated. ““Since that time, additional improvements to workflow have helped us to drive down turnaround time for biopsies to two days and our standard deviation is plus or minus two days. Most biopsies get turned around in a day or two days. Larger resections get done in about four days on average.
“Further, our test volume is going up by almost 14% per year because of the aging population and the incidence of cancer,” he added. “The workload is not decreasing. We have to make the system as efficient as possible without sacrificing quality or patient safety. That’s the challenge.
“In a pure fee-for-service system, there is less pressure for labs to become efficient,” concluded Banerjee. “But here in Canada, our system requires us to spend every dollar judiciously. We do not have volume-driven funding. That’s a significant point about how we work and may become important in the U.S. healthcare system in the coming years.”
AP Lab Staff Gains Time from Improved Workflow
FOR THE PATHOLOGISTS and staff in the anatomic pathology laboratory at the Ottawa Hospital, the biggest surprise from process improvement was fewer hours.
“The staff anticipated that they would need to work more hours and work faster once we made all these improvements,” said Dr. Diponkar Banerjee, the head of Anatomic Pathology for the Eastern Ontario Regional Laboratory Association and the Ottawa Hospital, one of the largest in Canada. “But in fact it has been the opposite. They get their work done at the end of the day. That leads to the question of whether our volume has gone down.
“Not at all. In fact, it’s the opposite. The volume has gone up,” he added. “We are a large academic medical center and it’s a high volume lab. The slightest glitch in specimen flow can lead to an immediate backlog. Our challenge is to keep the flow going without any hiccup.
“Now that we have a balanced workload throughout the week, the staff no longer needs to catch up on evenings or weekends. They feel less stressed out and can go home at the end of the day.
“We have even freed up enough time for individual pathologists to do research for which they have grants but previously couldn’t find time to do that work,” Banerjee explained. “Now, they get their abstracts submitted on time and their research is running ahead of time.”
Can Pathology Labs Use Hospital Info Systems To Help Plan for the Volumes of Incoming Cases?
IS IT POSSIBLE TO LINK a laboratory information system (LIS) to a hospital information system so that the LIS could know weeks or months in advance what kind of pathology specimens the lab could expect?
To answer this question, Dr. Diponkar Banerjee, head of the Division of Anatomical Pathology in the Eastern Ontario Regional Laboratory Association and at the Ottawa Hospital, has begun to take action.
“We want to work with the hospital’s IT team,” he said. “If we can interact with operating room schedules and with the schedules for first patient visits and follow-up visits, this information would allow us to anticipate what the pathology workload will be. Perhaps we can look ahead three months to know how many and what kind of specimens to anticipate.
“When you think about how patient visits are scheduled in a hospital, this should be possible,” Banerjee continued. “Most patients are scheduled weeks or months ahead.
“If we could connect that information into our information system automatically, it would give us a heads up about how busy we might be next week or next month,” he added. “It might tell us what months would be busiest.
“At most hospitals, the senior surgeons get their first priority for vacations,” noted Banerjee. “In their absence, the junior surgeons get more time in the operating room. When they get into the OR, surgical pathology gets different cases than when the senior surgeons are here.
“This knowledge has practical value,” he added. “If more than the usual number of prostate cases is coming through, we wouldn’t want the majority of our urology pathologists to be away. Similarly, if the hospital expects a large number of breast cancer patients, we would want an adequate number of breast cancer pathologists to be here on duty.
“Our pathology department wants to be more intelligent about planning and scheduling,” observed Banerjee. “We have a large volume of work that is increasing. This requires constant juggling. With the right information, we can better align our pathologist work, vacation, and CME schedules with the expected number and mix of specimens.”