Abstract
Consolidation, reorganization, and physical design are common topics in today's clinical laboratory. As we prepare to meet the onslaught of managed care and capitation, the discussion begins to focus on spatial relationships, instrument and product standardization, robotics, and cost reduction. Staff cross-training, skill mix modification, and change become significant challenges. Individually these subjects require significant study; when combined they can become overwhelming. This article is the first of three that will describe how the Bristol Regional Medical Center Laboratory (Bristol, TN), part of the Wellmont Health System, is meeting the challenge.
During Diagnosis Related Groupings (DRG) implementation in the mid-1980's our laboratory experienced staff reductions of ten to fifteen percent, forcing minor modification to our outmoded and compartmentalized laboratory. Initial steps at developing “Chematology” were made with minor success. Although space for specimen processing and testing was shared, staff scheduling continued to follow classic compartmentalization, by department. Our long term objective was to refocus staffing from specialist to generalist through extensive cross-training in an effort to reduce labor costs and improve productivity. The need for cross-training became even more evident in 1990 when the hospital Board contracted with the Facility Design Division of Quorum Health Resources (Brentwood, TN) to development a 700,000 sq. ft. replacement hospital.
Once the Board approved the construction of the new facility, the laboratory management team began space and design meetings. The overall facility plan focused on a 130 acre medical complex required to last a minimum of 40 years. The teams' charge was to develop a laboratory design flexible enough to meet the demands of the next twenty years. Focusing on specimen processing, we developed an open laboratory with an emphasis on linear work flow and shared test areas (diagram 1). During our first meeting with Quorum, we presented justification for a 25,000 sq. ft. laboratory which was eventually reduced to 20,000 sq. ft. By industry standards, the new laboratory design was considered large for a 340 bed hospital with marginal outreach volume. However the team felt that the future for laboratory medicine would be found in regional core laboratories.
During the planning stage we found printed information related to clinical laboratory design to be limited and mostly outmoded. As managers we were fortunate to have full latitude in design and layout. We followed good laboratory practice, using our experience and a keen understanding of the future for guidance. Focusing on specimen processing, it was felt that a conveyor system from central processing to work center or work site would be most effective. However, conveyor systems found in manufacturing and food processing offered limited solutions. Because no automated laboratory systems were available nor were operational costs savings defined, the concept was dropped.
Most importantly, the linear deck flow and “extra” mechanical, electrical, and communication equipment remained in the plans, allowing for future automation. Additionally the laboratory was located adjacent to shell building space, making further expansion possible.
The general design focused on a musical concept, addressing the need to flex operations based on work volume, time of day, and day of week. The full production shift of day to mid-second shift was considered a full orchestra, while mid to late second shift was a twelve piece ensemble. Shifts with limited coverage were considered a quartet. Specimen processing, LIS daily operations, phlebotomy distribution, and the pneumatic tube stations were thought of as the conductor and placed at the center of work flow. Areas unrelated to direct testing were located on the periphery. Simplistic but effective, this design has simplified work flow, reduced costs, and improved quality as desired.
The physical layout placed STAT testing adjacent to specimen processing while space for high volume outreach and esoteric testing was located further from the core. Time was taken in the design of the case work and even the location of office doors became important. Movable case work was considered but not installed due to cost restraints. Other special features such as UPS, filtered, and emergency power, LIS connectivity, hand free phones and sinks, refrigeration and storage, salad bar, water systems, and even floor covering and wall paint became major topics.
Specimen and work flow followed the specimen matrix rather than departmental functions. This design enhanced the generalist concept resulting in departmental consolidation and cross-training once the new laboratory was occupied. The classic departments of Chemistry, Hematology, and Blood Bank are now consolidated into a true general laboratory. These planned design and staffing modifications have improved productivity and flexibility, reduced test turn-around time and cost, and improved overall quality as well as total laboratory operations.
The next article will detail the special design features included in the physical plant that we felt were required for improved work flow as well as future laboratory automation. We will also describe the more difficult and time consuming process of changing culture and environment through the much-abused word “re-engineering”.
In our last article we will describe how the design and paradigm shift resulted in cost reductions of over $900,000 (24%) in one year. We will also focus on how we continue to reduce cost while improving quality through an ongoing change in skill mix, introduction of the cGMP process lab wide as well as the use of a robotic delivery system (CCRI ROBOCART).
