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Implementation Case Studies Creating Customer Delight – A Case Study in Diagnostic Clinics: Part 4 of 5

Creating Customer Delight – A Case Study in Diagnostic Clinics: Part 4 of 5

This now five-part case study focuses on improving customer satisfaction at two of a company’s diagnostic clinics – Centers A and B. In Part One, the company worked at Center A to reduce patient turnaround time, a defining component of patient satisfaction. In Part Two, the chain’s improvement story focuses on increasing patient delight at Center B. In Part Three, the story returned to improving the processes of the lab in Center A. In Part Four, turnaround time in a new centralized laboratory is improved. Check back next Monday for Part Five.

A chain of medical diagnostic clinics was developed from the ground up. After two years of hectic expansion marked by acquisitions and setting up greenfield clinics across a number of cities, it became clear that due to the different inherited processes across those acquisitions, the chain needed to focus more on improving and standardizing the quality of service offered, and improving its customer satisfaction rankings.


After successfully improving the processes in laboratory of Center A, the chain of medical dianostic clinics wanted to move forward with improving the turnaround time (TAT) in the newly established centralized laboratory servicing the 62 individual lab centers.

A cross-functional team was set up to undertake the project.

Define the Problem

The group brainstormed a list of 52 problems related to the laboratory (see Appendix 1). Discussions revealed that most of the problems listed were causes of problems rather than problems in and of themselves. There were only four “real” problems:

  1. Delay (i.e., TAT)
  2. Quality
  3. Safety
  4. Service

These were prioritized to select the “vital” problem using a weighted average table. Scores indicated that delay (i.e., TAT) was the vital problem. The next step was to measure the problem.

Turnaround problems can be resolved using just-in-time (JIT) techniques. Here, this involved deciding at the outset the start and end points of the process for which the TAT was to be reduced.

Complete TAT starts with the customer arriving at the Diagnostic Center and ends with the report being given to them. The overall desire of senior management was that customers visiting the Center in the morning should receive their reports the same day and customers visiting in the afternoon should receive their reports the next morning.

The 30,000-foot-level process steps were listed and are shown in Table 1. Also shown are the various start and end points of the project that could be followed.

Table 1: Process from Patient Arrival to Getting Test Report

Table 1: Process from Patient Arrival to Getting Test Report

To select which part of the chain should be addressed, data was required for where the maximum time was being spent. A format was prepared to collect data for each part of the chain by tracking 100 samples as shown in Table 2.

Table 2: Excerpt of TAT Data Collection from Customer Registration to Report Handover
Responsible DivisionDept.ItemCustomer 1Customer 2
DateJanuary 7, 2012January 7,  2012
Customer ID112608112614
Customer nameXY
Diagnostic centerFront desk adminRegistration time07:4208:15
Diagnostic centerLabSample collection time08:0308:37
LabSample ready for dispatch08:4508:45
Back-end adminLogisticsSample pickup time09:0009:00
Back-end adminLogisticsSample delivered timeVariesVaries
Central labReport upload time17:3915:17
Diagnostic centerFront desk adminReport printing time17:4715:42
Diagnostic centerLabReport dispatch to counter17:5515:55
 TAT (hours:minutes)10:1307:40

The concept of sigma was introduced to the team to measure variability in addition to the average. The average and sigma for the current state TAT was calculated as follows.

Average = 15.9 hours
Average + 3σ = 56 hours

The logistics time was found to be 2.5 hours to 3 hours within the 15.9 hours average. The team set an objective of reducing the average TAT by 50 percent – from 15.9 hours to 8 hours.

A control chart was developed to track the TAT. The initial chart is shown in the figure below.

Control Chart of Register to Report TAT

Control Chart of Register to Report TAT

Mapping the Current State

Another metric was also introduced – the percentage of reports completed/returned to patients in a 24-hour period of time. Existing data showed that this was at 76 percent.

The next step was mapping the current state process, by looking at:

  • Volume to be processed
  • Arrival pattern
  • Time to process the smallest unit at each stage of the process
  • Deployment pattern of people, equipment

From there, the future state process map would be developed while applying the following techniques to reduce work in process (i.e., waiting time) and, therefore, TAT:

  • Reducing non-value adding stages
  • Balancing the line (i.e., ensure capacity available can process arrivals at the required speed)

The volumes to be processed were based upon the Center’s past data and growth projections. The target volume to be processed was 50,000 tests per day. Since different tests require different equipment and times, it was necessary to ascertain the ratios of the tests required to be able to make all of them flow (Table 3) based on 25 working days per month.

Table 3: Volume Estimates for Central Lab
VolumePer Day
Patients300
Samples650-700
Tests1,200
DepartmentPer Day
Blood76%
Urine19%
Others5%

Arrival Patterns

Arrival patterns were studied by the hour for four days – for all samples, with blood and urine samples separately (the most common tests and the majority of tests ordered; see details in Appendix 2) – and are shown in Table 4. All patterns are based on 12-hour increments in time.

Table 4: Summary of Arrival Patterns of Samples
Per HourAll SamplesBloodUrine
Average65559
Peak13680-10033
Average Per Day500-600100-200

Testing Capacity

Next, it was time to look at testing capacity. A list of all equipment was prepared according to section (e.g., biochemistry, hematology, etc.). Against each test the information shown below was assessed:

  • Machine(s)
  • Batch (including batch size) or individual
  • Time
  • Units
  • Speed
  • Barcode logging of samples
  • Reports automatically generated
  • Printout of reports

Equipment Capacity

The results of an equipment capacity analysis helped explain the processes, the capacity, degree of automation/manual work involved and the batch/flow nature of the work.

  • Average time per test: A comprehensive list of tests was prepared and the average time per test was recorded. (See Appendix 3.)
  • Manpower deployment: When the arrival pattern of the load to be processed required deploying personnel to best match the incoming load patterns, manpower deployment was critical and also mapped.
  • Improving the TAT: Performed section by section.

Improved TAT Process

The following process was used to develop the improved TAT process:

  • Map key stages of process
  • Determine stations
  • Smallest unit though line at each station
  • Decide batch size
  • Time/unit at each station
  • Ensure flow capability at each station: capacity to process load-in time required
  • Instruct team
  • Run one batch without waiting
  • Record lead time/waiting time/non-value added times
  • Kill problems to smooth workflow
  • Try longer and longer runs at higher and higher loads

A green channel run, where the process is carried out without waiting between any stages of the process, was performed. TAT was obtained. Then, the team repeated the process for batch after batch to obtain the best possible TAT.

To determine a machine/section-wise load, the team needed to determine the number of tests expected per day in each section. This required estimations as follows:

  • Number of patients per day
  • Samples per patient
  • Tests per sample per machine or per station
  • Reports per patient

Biochemistry Example

Armed with this data, the green channel run was first piloted and then standardized in each section. For this article’s purposes, consider the example of biochemistry (a category of tests) with the maximum number of tests.

The process and the load – patients, samples per patients, tests per sample and the time per stage – are summarized in Table 5.

  • Samples per patient = 2
  • Tests per sample = 3
  • Tests per patient = 6
  • Time per test = 27 seconds
Table 5: Biochemistry Process and Stage Times
Process MapBiochemistryOp UnitTime (Seconds)Seconds/Sample
Accession (prepping a tray of samples to send to lab for processing – paperwork and arrangement)Smallest unit sample (1 sample test tube)16 samples900<56.25
Centrifuge16 samples16 samples90056.25
Biochemistry TestingTest16 tests/sample43227 (equivalent to 400 tests/hour)
ReportPatientUp to 16 samples/patient900<56.25
ApprovalPatientUp to 16 samples/patient900<56.25

The centrifuge was the bottleneck and was the pace setter for the biochemistry process. It holds only 16 samples at a time and this was, therefore, selected as the minimum batch size. Loading it with minimum interruption provided the maximum output and last TAT.

The process was run, timed and studied in several trial runs with improvements built in and tested in each run. The results of two trials are detailed here.

First Trial

  • Start: Load into centrifuge
  • Finish: Report approved
  • Samples: 17
  • Tests: 37

The results are summarized in Table 6.

Table 6: Trial of Biochemistry Flow Run
StepActual Time (Minutes)Ideal Time (Minutes)
Centrifuge in12:1312:13
Centrifuge out12:2312:23
Into machine12:2312:23
Processing (37 tests at 9 secs/test)12:29
Report check start12:30
Report approve start12:31
Report check finished12:36
Report approve finished13:3212:37
TAT7924
Expected30

Against the ideal time of 24 minutes and expected time of 30 minutes, the actual time achieved was 79 minutes.

Avoidable reasons for the long actual time were:

  • Manual barcoding took 12 minutes. (Look for details on addressing this issue in the final part of this article next week.)
  • Waiting to be loaded into the analyzer that was avoidable in full flow took 10 minutes.

The achievable cycle time was 57 minutes.

Second Trial

  • Start: From sample repeat trial
  • Finish: Biochemistry report approved
  • Start time: 8:40 am
  • End time: Peak sample repeat trial time over by 12:30 p.m.

The results are summarized in Table 7.

Table 7: Second Trial of Biochemistry Flow Run
Step NumberCenter NumberIn TimeSamplesTo BiochemistryNumber of Samples
11,208:404208:5542
209:053009:1030
33,410:1519010:2016
10:3566
10:4753
10:5851
11:0112
11:061
11:081
4510:326511:0155
11:0610
5611:105712:0057
67,811:324211:4242
77,812:252212:3322

The run was completed by 1:30 p.m. With the peak time load processed early, the rest of the tests running in the afternoon were easy to manage.

Several improvements were implemented that had significant results.

  • Pre-trial process in accession: The first 42 samples were loaded into trays of 16 samples per tray. When one tray was loaded, the second tray was started. The process was to pass on the trays to biochemistry when all samples were loaded.
  • A small but significant change in work practice was made with one loaded tray being promptly passed on so that the centrifuge could start as the next tray was loaded. The bottleneck was able to begin running as soon as possible and then it was kept running.
  • There was a break between 9:10 a.m. and 10:15 a.m. due to a slipup from the Center related to transferring the samples. This break was removed and the centrifuge machine was able to keep running.

Third Trial

  • Number of samples = 16
  • Number of tests = 97

The results are shown in Table 8.

Table 8: Third Trial of Biochemistry Flow Run
Trial Run for 16 TubesStart TimeTime Lost (Minutes)Comments
Sample ready for centrifuge10:334· 15 red caps and 1 yellow cap (identifiers for types of sample tubes), which is taller and cannot balance in the centrifuge

· Yellow cap changed for red cap

Centrifuge start10:37
Centrifuge end10:476· Worklist not available and had to be retrieved from the accession

· Reference was required to determine tests that cannot be completed by the machine

· 1 tube needed electrolyte (potassium)

Loaded in the machine10:53
Barcode reading and ready for test10:58
Test started in machine11:03
First tube ready11:06
Test completed (for all 16 tubes)11:40
Report review start11:4024
Status changed to completed11:50Decimal values were added to whole number results (e.g., 14.00 instead of 14)
Approval completed by doctor12:0020
Total time taken1:27

When it came to the time lost in various tasks in the process, there were a couple of areas of concern that were quickly addressed.

  • A yellow cap, which was a different height than the others and thus did not balance in the centrifuge, was changed to a red cap so that it could go with the other tests at the same time.
  • The delays due to report review and completion were addressed by explaining to the doctors how they needed to fit into the overall process flow.

Addressing of these types of problems continued over several cycles. Two other examples were:

  • Tubes of different sizes in one batch or partial batches were sent to the centrifuge. To keep tests moving, balancing dummy tubes were kept at the centrifuge to fill the extra slots as needed.
  • The trays from accession to centrifuge could carry 20 tubes, which meant that 16 were loaded while 4 (then 8 and 12) had to wait for the next batch. New trays holding 16 tubes per tray rather than 20 were bought and then to maintain the even flow of tubes.

The above trials and improvements were spread over three days. A summary of the results follows.

  • Day 1: No work in process (WIP). Work was finished at 5:30 p.m., unlike before the project when some samples had to be processed overnight (maximum TAT = 4 hours).
  • Day 2: No WIP at 5:30 p.m.

The head of the laboratory shared a great compliment: “I used to chase biochemistry; now I have to chase other departments!”

The Ultimate Test – Saturday

Saturday mornings always presented peak load challenges as this tended to be the day of the week with the greatest number of patients. The first Saturday using the new process flow system produced the results shown in Table 9.

Table 9: Saturday Biochemistry Processing in Flow
Batch Starting at Minute
Batch 130
Batch 245
Batch 360
Batch 475
Batch 590
Batch 6105
Batch 7120
Batch 8135
Batch 9150
Batch 10165

The efficiency of processing was more than 90 percent.

  • Tubes = 160
  • Reports = 154
  • Start: 9:40 a.m.
  • Finish: 12:30 p.m.
  • Time to completion: 182 minutes
  • Ideal time: 165 minutes

By 1:00 p.m. the peak load had been processed and the worst was over.

Conclusion

The key objective – having 100 percent of the samples received in the morning getting their reports by the end of the same day – was achieved. Approximately 70 percent of the afternoon samples (fewer in number than what was received mornings) were completed by 7 p.m. The reports for those samples were ready to be given to patients by late evening.

Additionally, the revised process made the work easier, easily absorbing peak loads while dramatically reducing the overtime of staff and releasing capacity during the afternoons for additional samples to be processed.

The control chart was found to not be required and was, therefore, discontinued.


 

Appendix 1: List of Brainstormed Problems
Problem Number Problems Result 1Result 2
1Timing of reportDelay
2Not working as per systemDelay
3Passing the buckDelay
4Errors in reportsQuality
5Confusion for customerServiceDelay
6Communication to customersDelayService
7Early billingDelay
8Wrong testQuality
9Standard operating proceduresQualityDelay
10Delay in samples and, therefore, reportDelay
11Wrong committed time of report deliveryDelay
12Delay in critical samplesDelay
13Tracking of long test reportsDelay
14Wrong delivery commitment to outstation customersDelay
15Committed delivery to outstation customer not knownDelay
16GHKQuality
17SafetySafety
18Stock outsDelay
19ManpowerDelay
20Reagent temperature monitoringQuality
21IP reports delayDelay
22No logbook for GHK
23Micropipettes left on floorQuality
24Delay in sample transportationDelay
25Punctuality – leave inform sanctionDelay
26Low awareness of problemQuality
27Error In reportsQuality
28Maintenance of equipment/utilitiesQualityDelay
29Medical immunization/emergency of lab personnelSafety
30Sample handling gloves, personal protective equipmentSafety
31Internal quality control not maintained regularlyQuality
32Participation in external quality programsQuality
33Education in techniquesQuality
34Lab coats not worn by phlebotomistQualitySafety
35Handling/preservation and storage of reagentsQualityCost
36IT-related issuesDelay
37Annual maintenance of machinesQualityDelay
38Incoming quality inspectionQuality
39Evaluation of performance of kit before useQuality
40FIFOQualityCost
41Stock managementDelayCost
42Logbook of complaints from customers not availableQualityDelay
43Staff lockers
44Washing area for tubes inadequateQuality
45Medical waste disposal
46Door hitting people while opening
47PestsQuality
48Lab chairsFacility
49PantryFacility
50Laundry arrangement for lab coats, etc.Quality
51Separate cabin for clinical pathologyQuality
52Team workDelayQuality

 

Appendix 2.1: Arrival Pattern of Samples for Testing
Blood + Urine
February 10February 11February 12February 13
7:00 a.m.1031526
8:00 a.m.854024
9:00 a.m.74383353
10:00 a.m.681179075
11:00 a.m.85645875
12:00 p.m.13611150110
1:00 p.m.1306020100
2:00 p.m.48955551
3:00 p.m.20671049
4:00 p.m.2416244
5:00 p.m.2817219
6:00 p.m.3320539
7:00 p.m.2521013
8:00 p.m.85123
9:00 p.m.67010
10:00 p.m.155012
11:00 p.m.20013
12:00 a.m.3032
1:00 a.m.0003
2:00 a.m.0020
3:00 a.m.0000
4:00 a.m.0000
5:00 a.m.4800
6:00 a.m.115019
Total728674386760
Average30281632

 

Appendix 2.2: Arrival Pattern of Samples for Testing
Blood Samples
February 10February 11February 12February 13
7:00 a.m.821120
8:00 a.m.643018
9:00 a.m.56292540
10:00 a.m.52896857
11:00 a.m.65494457
12:00 p.m.103843884
1:00 p.m.99461576
2:00 p.m.36724239
3:00 p.m.1551837
4:00 p.m.1812233
5:00 p.m.2113214
6:00 p.m.2515430
7:00 p.m.1916010
8:00 p.m.64117
9:00 p.m.5508
10:00 p.m.11409
11:00 p.m.20010
12:00 a.m.2022
1:00 a.m.0002
2:00 a.m.0020
3:00 a.m.0000
4:00 a.m.0000
5:00 a.m.3600
6:00 a.m.111014
Total553512293578
Ave23211224

 

Appendix 2.3: Arrival Pattern of Samples for Testing
Urine Samples
February 10February 11February 12February 13
7:00 a.m.2146
8:00 a.m.21106
9:00 a.m.189813
10:00 a.m.16282218
11:00 a.m.20151418
12:00 p.m.33271226
1:00 p.m.3114524
2:00 p.m.12231312
3:00 p.m.516212
4:00 p.m.64011
5:00 p.m.7405
6:00 p.m.8519
7:00 p.m.6503
8:00 p.m.2106
9:00 p.m.1202
10:00 p.m.4103
11:00 p.m.0003
12:00 a.m.1010
1:00 a.m.0001
2:00 a.m.0000
3:00 a.m.0000
4:00 a.m.0000
5:00 a.m.1200
6:00 a.m.0405
Total17516293182

 

Appendix 3: Time Required for Each Test
Test NumberLab WorkingCentrifugeTestMachine
I: Hematology
1Hemoglobinx5Sysmax and Abx
2PcvX5Sysmax and Abx
3RbcX5Sysmax and Abx
4WBC countx5Sysmax and Abx
5Platelet countx5Sysmax and Abx
6Differential countX20Sysmax
7Malarial parasitex15Manual
8MicrofilarialX15Manual
9P. smear studyX30Manual
10Reticulocyte countX30Manual
11Blood groupX15Manual
12Prothrombin time (PT)2030Stago
13PTT2030Stago
14La1 and La22030Stago
15Fibrinogen2030Stago
16EsrX30Vesmatic and manual
II: Biochemistry
1Glucose1010CS 300 and CS 400
2Urea105CS 300 and CS 400
3Creatinine105CS 300 and CS 400
4Uric acid1010CS 300 and CS 400
5Total cholesterol1010CS 300 and CS 400
6HDL cholesterol1015CS 300 and CS 400
7Triglycerides1010CS 300 and CS 400
8Bilirubin total1010CS 300 and CS 400
9Bilirubin direct1010CS 300 and CS 400
10SGOT1010CS 300 and CS 400
11SGPT1010CS 300 and CS 400
12Alkaline phosphatase1010CS 300 and CS 400
13Gamma Gt1010CS 300 and CS 400
14Total protein1010CS 300 and CS 400
15Albumin105CS 300 and CS 400
16CPK total1010CS 300 and CS 400
17CPK MB1010CS 300 and CS 400
18LDH1010CS 300 and CS 400
19Micro albumin1010CS 300 and CS 400
20GTT1010CS 300 and CS 400
21Calcium1010CS 300 and CS 400
22Phosphorus1010CS 300 and CS 400
23Iron1015CS 300 and CS 400
24Tibc1015CS 300 and CS 400
25Magnesium1010CS 300 and CS 400
26Amylase1010CS 300 and CS 400
27Lipase1010CS 300 and CS 400
28Ra factor1010CS 300 and CS 400
29Aso1010CS 300 and CS 400
30Crp1010CS 300 and CS 400
31Urine protein1010CS 300 and CS 400
32Urine creatinine1010CS 300 and CS 400
33Ferritin1015Centaur
34Electrolytes1010IRIS
35Trop I1010Manual
36pHX10Symmons
37pO2X10Symmons
38pCO2X10Symmons
III: Clinical Pathology
1Urine complete1015Strip reader
2Urine ketoneX15Strip reader and manual
3Urine glucoseX10Strip reader and manual
4Bile saltX20Manual
5Bile pigment1020Manual
6Stool completeX25Manual
7Stool occult bloodX20Manual
8Stool reducing substancesX15Manual
9Semen analysisX30Manual
10Pregnancy testX20Manual
11CFS cell count and type1030Manual
IV: Microbiology
1Routine culture and sensitivityX48 hoursManual
2Gram stainX30Manual
3Smear for AFBX60Manual
4Blood cultureX5 daysManual
5Smear for fungusX30Manual
6Fungal cultureX10 daysManual
7Hanging dropX30Manual
8AFB cultureX7 weeksManual
9Stool cultureX5 daysManual
V: Immunserology
1T31020Centaur
2T41020Centaur
3TSH1020Centaur
4Free T31020Centaur
5Free T41020Centaur
6FSH1020Centaur
7LH1020Centaur
8Prolactin1020Centaur
9Insulin1020Centaur
10Beta hcg1020Centaur
11IGE1020Centaur
12E21070Centaur
13AFP1020Centaur
14CEA1020Centaur
15PSA1020Centaur
16Anti-thyroid antibodies1020Centaur
17Vitamin B121020Centaur
18Vitamin D1020Centaur
19Testosterone1020Centaur
20CA–1251045Centaur
21CA–19.91050Centaur
22CA–15.31060Centaur
23Cortisol1020Centaur
24Progesterone1020Centaur
25Folic acid1020Centaur
26C–Peptide1020Centaur
27Phenytoin1020Centaur
28Valproic acid1020Centaur
29PTH1020Centaur
30Phenobarbitone1020Centaur
31Homocystine1020Centaur
VI: Serology 
1HIV103 hoursElisa Reader
2HbsAg103 hoursElisa Reader
3HCV103 hoursElisa Reader
4ANA103 hoursElisa Reader
5Anti-ds DNA103 hoursElisa Reader
6Anti-cardiolipin – IgG103 hoursElisa Reader
7Anti-cardiolipin – IgM103 hoursElisa Reader
8Anti-phospholipid – IgG103 hoursElisa Reader
9Anti-phospholipid – IgM103 hoursElisa Reader
10Anti-TB IgA103 hoursElisa Reader
11Anti-TB IgG103 hoursElisa Reader
12Anti-TB IgM103 hoursElisa Reader
13Torch profile–IgG
14Toxoplasma antibody1060 minutesMini Vidas
15Rubella antibody1060 minutesMini Vidas
16Cytomegalovirus antibody1060 minutesMini Vidas
17HSV I–IgG103 hoursElisa Reader
18HSV II–IgG103 hoursElisa Reader
19Torch profile–IgM
20Toxoplasma antibody1060 minutesMini Vidas
21Rubella antibody1060 minutesMini Vidas
22Cytomegalovirus antibody1060 minutesMini Vidas
23HSV I–IgM103 hoursElisa Reader
24HSV Il–IgM103 hoursElisa Reader
25Dengue–IgG1030 minutesManual
26Dengue–IgM1030 minutesManual
27Leptospira–IgG1030 minutesManual
28Leptospira–IgM1030 minutesManual
29Anti HEV–IgM103 hoursElisa Reader
30Anti-Hbe1090 minutesMini Vidas
31Anti-HAV1090 minutesMini Vidas
32Anti-Hbc–IgM10120 minutesMini Vidas
33Anti-HBC–Total10120 minutesMini Vidas
34Western blot104 hoursManual
35Brucella melitensis1030 minutesManual
36Brucella abortus1030 minutesManual
37Mono spot (infectious mono nucleosis)1030 minutesManual
38Widal1030 minutesManual
39Widal tube1012 hoursManual
40D–Dimer1030 minutesManual
41HIV–Tridot1030 minutesManual
42HbsAg spot1030 minutesManual
43Anti-HCV spot1030 minutesManual
44Leptospira–IgG102 hoursElisa Reader
45leptospira–IgM102 hoursElisa Reader
46Leptospira (MAT)1030 minutesManual
47Dengue–IgG102 hoursElisa Reader
48Dengue–IgM102 hoursElisa Reader

 

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