College of American Pathologists
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Automation site visits: making the trek to the trenches

November 2002
Anita Slomski

Like everything else in life, you’ll get out of a laboratory site visit what you put into it.

Some visitors who want to see lab automation at work come with savvy questions and color-coded charts comparing various vendors’ systems. Others "stand there wide-eyed with their mouths open," says Ronald W. McLawhon, MD, PhD, director of regional laboratory services and medical director of hospitals laboratories for the University of Chicago Hospitals and Health System. "They are so awed they don’t ask any questions except, ’When can I get one of these?’"

Then there are visitors who come to laboratory tours against their will and retaliate by loudly announcing the flaws in the host’s automation system. Mercifully, many more visitors engage in a constructive give-and-take with their hosts. "Every site visit leaves us with a little pearl that our technical staff, administrators, or pathologists can use here," says Leo Serrano, executive director of laboratory services at Jackson Madison County General Hospital in Jackson, Tenn.

Of course, since people and machines are unpredictable, there are also plenty of opportunities for mishaps on site visits. Like the visitors who stick their hands in the machinery and press switches to see how it works—while the line is moving. "Would you do this in your own lab?" asks Dr. McLawhon. "If you’re a guest in someone’s laboratory, please don’t play with their ’toys’ unless you have been given the host’s permission to do so under direct supervision." Dr. McLawhon restricted the size of lab tours when someone in a group of 20 overseas visitors dropped a bag containing several bottles of duty-free liquor on the lab floor. "While both the visitor and vendor were apologetic, it flowed all over and was a horrendous mess for us to contain and clean up in such a busy and crowded work area," he says.

And the first time the machinery acts up during a site visit can be a bit unnerving for everyone. "It was quite embarrassing when we invited a group of lab managers and directors from Toronto to see our state-of-the-art process and the machine was throwing tubes all over the floor while it was being installed," admits Robert Fox, director of diagnostic laboratories at St. Michael’s Hospital in Toronto, Ontario.

Of course, if you have your eye on lab automation and want to learn from those who’ve taken the plunge, showing up prepared is a simple courtesy. "For people who expect us to spoon-feed them information on our system or lab automation in general, we only give them a brief overview but don’t go into very much depth, because we prefer to take a more interactive approach and respond to thoughtful and well-reasoned questions," Dr. McLawhon says. "They simply aren’t serious or educated consumers and haven’t done their homework, so we clearly aren’t going to expend valuable time trying to fill in the gaps."

At the very least, visitors need to understand what automation can do and know how they plan to use the system in their own labs. Kathy Crouch, laboratory director at Lakeland Regional Health System in St. Joseph, Mich., marvels that one group of visitors hadn’t yet begun using bar-code labels in their lab. "They were light years away from automation," Crouch says. "We had to explain that they couldn’t automate without bar-code labels, which was a surprise to them."

Other hosts shrug off the naïve questions, but they do mind visitors who come merely for a free meal. "If you aren’t seriously interested in the equipment, don’t do a site visit just to get a vendor off your back," Serrano says. "It’s clearly evident to the people you’re visiting. And there is a lot of effort that goes into a site visit."

Preparing for a site visit

Many labs hosting site visits today had to choose their automation systems with a prayer and a leap of faith.

"When we started this process in 1995, there weren’t a lot of good examples to visit," says Dr. McLawhon. "We had questions about how the system performed in a real-life setting, but all we got was the same sales pitch we’d been hearing from vendors. One prestigious facility we visited had parts from aliquoters, centrifuges, and specimen transport racks lying on the floor, and staff pointed to where the equipment would go. They were continually sending bits and pieces back to the manufacturer because they couldn’t get the centrifuges to work properly, and the aliquoters weren’t robust enough to handle their volume. They were true believers in automation, but they never did install that particular system." It was two years before Dr. McLawhon and his colleagues were able to see a fully functional automated facility in routine clinical operation.

Today, however, laboratory professionals have the tremendous advantage of learning from those who pioneered automated labs and have had time to work out the bugs. Also, laboratorians are choosing improved second-generation automation systems and have a wider selection of options than they did a few years ago. But they still need to do a careful analysis to determine what and if they should automate.

Before making a site visit, do a flow map of the laboratory and consolidate workstations, suggests Frederick L. Kiechle, MD, PhD, chairman of clinical pathology and medical director of the reference laboratory at William Beaumont Hospital in Royal Oak, Mich. "We reduced the number of immunochemistry analyzers by 50 percent before we even made a decision about automation," says Dr. Kiechle. "If you don’t take this initial step, your staff will experience unbelievable culture shock when you automate." He recommends simulating automation by lining up workstations in the order work is done. "There won’t be a cost savings because you still need the same number of people to do the work, but you can get a handle on the concept," he says.

Dr. Kiechle also advises hiring a consultant to determine what areas and which tests the laboratory should automate. "In our case, we decided to automate those tests in hematology, chemistry, and coagulation that had turnaround times of more than two hours," he says. The consultant helped choose the site for the automated lab. And when you are ready to visit an automated laboratory, ask the host how accurately the vendor assessed the lab’s workflow and specimen-handling requirements in recommending an automation platform. And were there any surprises in the cost of configuring the lab to accommodate automation?

Enough creative thinkers to fit into a car

Who should go on a site visit? Most hosts prefer a cozy group of five or six visitors; groups that arrive in buses are hard to herd and disruptive to lab staff. The mix should include an administrator, the front-line staff who will use the equipment, a member of the medical staff, and an IT representative. "You need your visionary who leads the team at a site visit, but many hospitals send all managers," Serrano says. "The most successful site visits are those attended by both managers and nuts-and-bolts guys in critical areas. And the more creative-thinking they are, the better."

But the team doesn’t have to travel to site visits en masse. When St. Michael’s Hospital was looking for an automation vendor, various members of the decision-making team visited lab sites at different stages of the vetting process. "It’s beneficial to get away from group think and have a fresh set of eyes look at a system," Fox says. "If everyone in the group liked a system, we’d send our most critical member to look at it. Or, if no one liked it, we’d send our most optimistic person or an administrator to see where the hidden opportunities may be."

When choosing a site to visit, find a laboratory that is comparable to yours in size and volume and has similar goals for automation, counsels Drake Yip, information technology coordinator at St. Michael’s Hospital. "If you’re a teaching hospital, visit another teaching hospital. And try to find a host with the same LIS your lab uses. I visited a lab that was huge, and it was hard to visualize how the equipment would fit in our little lab."

Try to schedule your visit when the automated system is operating at peak volume. "When we’re running dialysis, it’s a steady flow of specimens and they are ugly specimens, so you get to see the system at its maximum as it’s reflexing, auto diluting, rerunning critical values automatically, and sorting specimens," says Roger Gregorski, coordinator of technical services at Lakeland Regional Health System. "That’s when I’d like to see the system in action, although some labs won’t want visitors in the way at that time."

No place for sales pitches

Vendors are welcome at the table when it’s time to pay the dinner bill, but most hosts and visitors would rather they disappear during a site visit. "I send the vendor away because people are more uncomfortable when they’re there," says Yip. "I want visitors to talk to our techs so they don’t feel they’re getting a sell job."

And visitors should be choosy about which technologists they talk to. "We tell visitors to talk to the most bitter-looking person on the line," Fox says. "You’ll get insight into the worst-case scenario—having your most disgruntled staffers working on the system. Visitors should get the full spectrum of opinions on the system because that is why they came." To thank staff for tolerating visitors standing over their shoulders and barraging them with questions, Fox awards the technologists and technicians with the hosting fee that his vendor pays the lab.

Jackson Madison County General Hospital, too, turns visitors over to its technologists to hear "the good, the bad, and the ugly" about lab automation, but also to give staff "the opportunity to show off what they have and what they know," Serrano says. "We are in rural west Tennessee, and it gives my staff a real sense of value to do site visits in addition to getting exposure to what other labs are doing. We are often honored at the site visitors we get from prestigious institutions. And when someone with a very well-run lab compliments ours, staff is very proud."

Vendor representatives tend to get flustered when alarms ring and the automation malfunctions during a site visit. But from the host’s perspective, visitors are lucky to witness a mechanical failure. "One vendor was frantically trying to get a stuck tube out of the serum-level detector before the group got to that point in the tour," recalls Kevin Shively, assistant director of clinical laboratories at Ohio State University Medical Center in Columbus. "I told him to leave the equipment alone. It’s more beneficial for visitors to see that someone had put masking tape on the tube, which caused the problem. The vendor wants everything to run perfectly, but that’s not reality." An automation breakdown allows hosts to show visitors how easily the problem can be repaired, either by lab staff or by calling a hotline and having the vendor fix it over the phone.

Reps who insist on hanging around during a site visit can be pressed into service, however. "They can be helpful in suggesting new modifications to the system, since visitors are looking at two-year-old equipment in our case," Lakeland Regional’s Gregorski says.

Check your bad attitude at the door

They don’t have to say a word; their crossed arms and pursed lips telegraph their anger at being forced into a site visit. As far as they’re concerned, the trip is a waste of time, either because they’re dead set against automation or because they’ve already settled on a different vendor. As long as these visitors engage in the silent treatment, hosts don’t seem to mind the glares. "I’m not out to change anyone’s mind," says Fox of St. Michael’s. "It’s just a shorter visit when visitors aren’t open to discussion."

It’s the vocal ones who are disruptive. "They try to poke holes in your process and badger you like you’re on trial," says Beaumont’s Dr. Kiechle. "You’re being sacrificed while they’re making a point. Of course, these people walk away with the same opinion they came with."

One physician visitor to St. Michael’s Hospital was so aggressive that he upset the laboratory staff, so Fox showed him the door. "He challenged everything to the point of calling our processes ’dumb.’ Other visitors also challenge us, but constructively. They’ll say, ’We notice you do this. Have you thought of that?’ That’s the type of interaction we’re looking for," Fox says.

Then there are those visitors who simply can’t conceive reengineering their work processes, which means they won’t benefit much from automation. "They aren’t willing to give up practices that they feel are sacred, and they expect to work the way they always have," Serrano says. "One group was aliquoting almost everything, including their immunoassay tests, simply because the instrumentation lent itself to that practice. The amount of work they devoted to aliquoting, freezing, and labeling was amazing." That group will surely run into trouble with automation because it isn’t flexible in its thinking, Serrano says. "If you automate a bad process, you haven’t improved anything. The real value of site visits is to see other ways of doing things."

And that’s true for hosts as well. "We gain as much from a site visit as we give," Serrano continues. "When visitors critique what we do, we take it to heart, since an outside pair of eyes can see things we’re blind to." For example, a visitor from Stanford Medical Center suggested that Serrano consider moving a bar-code reader and terminal closer to the processing area, which solved the problem of staffers getting in each other’s way. Visitors to St. Michael’s Hospital have offered valuable advice on noise, lighting, and instrument problems, and one group of visitors even shamed the lab into upgrading its information system.

"We think of ourselves as a leading-edge technology group, but because of our limited information system, we were still sending out results manually," Fox explains. "It was quite embarrassing when this group walked by the room and said, ’What are they doing?’ It gave us a wakeup call that we really needed to get our hospital information system fixed."

Don’t be afraid to talk money

Justifying a $2 million automation system to hospital administrators and boards requires detailed and confident return-on-investment projections. Yet many people don’t pump site-visit hosts for their ROI data, perhaps because they believe the vendor prohibits hosts from discussing what they paid for the automation system. But hosts are generally willing to talk about labor savings, efficiency, and turnaround time without doing all the math for visitors.

"I explain the rationale behind our automation decision and then share the numbers line by line so people can see our costs and how we’re benefiting," Fox says. "I don’t give them all the numbers, but they get an idea of how much we invested in the product."

"Ask hosts for their real data instead of the numbers they’ve modeled and built their business case on," Dr. McLawhon advises. "I talk about the actual savings we’ve realized with the disclaimer that I can’t assure that the automation system alone is totally responsible. Changes in upstream and downstream workflow, growth in test volume, or other equipment may also have contributed to our reduced costs."

The ROI question often put to Kathy Crouch is whether Lakeland Regional Health System has justified the cost of automation by eliminating full-time equivalents—a question that continues to amaze her. "We say, ’No way, José. We didn’t even pretend to claim we would lose FTEs through automation.’" Adds Gregorski: "We’ve accepted that we will never be fully staffed in today’s environment of scarce lab techs. So it makes no sense to us when people ask how many staff we cut when we can’t even fill our open positions."

Five years ago, eliminating FTEs was a realistic goal of automation—and one that vendors still tout erroneously, Dr. Kiechle says. But today, automation has become a survival tool. "I couldn’t possibly do 6.5 million tests a year without automation," he says. "In the current labor environment, you have to sell the concept of automation to hospital administrators with a cost-avoidance strategy of not hiring more people or buying more equipment as the volume increases."

Talk to hosts about how long it took to train staff on the system and how much training support the vendor provided. Ask whether staff was sufficiently trained to hit their marks at least 80 percent of the time when the system went live, Dr. McLawhon suggests.

"We asked about staff training, but not at the level we probably should have," he says. "For example, how do you train staff to troubleshoot problems? Our staff was trained separately on the preanalytical and analytical components of our automation system. But when these components were linked together and fully integrated, staff had no systematic approach for solving a problem upstream or downstream. They would try random things here or there, which introduced more problems not only on the system itself, but also on workflow elsewhere in the laboratory. We wished we had done another four to six weeks of training on the combined platform and made changes in our internal operating procedures to support the system before going live."

Other staff questions to ask: Is the system robust enough to ward off mechanical problems introduced by staff? Can a technologist or technician be trained to do maintenance on the system, or do you need a biomedical engineer?

How automation-ready is your lab?

Don’t be so enamored with the machinery that you neglect to examine how well the automation system will interface with your laboratory information system. Do you have the information technology support staff to maintain 20 interfaces to your LIS? Or does the vendor offer a single interface connection?

"Like most health care providers, our IT resources are sparse because we’re competing with the higher-paying banking industry and Fortune 500 companies for skilled computer personnel," Dr. McLawhon says. "So any level of complexity in connectivity between our automation system and our LIS would create a lot of staffing demands and require expertise we frankly don’t have."

Naturally, you’ll want to ask how many downtimes the system has and how good the vendor service response has been. "But," Dr. McLawhon says, "also ask whether you can recover during downtimes and continue to produce clinical test results. That was critical for us because we’re a 24/7 shop and we provide stat testing services to support the diverse clinical needs of an academic medical center environment, as well as process a large share of our outreach work during off-peak hours."

It’s also a good idea to talk to your information system vendor about the automation company you’re considering, advises St. Michael’s Yip. And think ahead to how you might expand the automation in five years. "You don’t want an automation line that is limited to that vendor’s equipment," Yip notes.

Ask whether the equipment and instruments the manufacturer proposes are automation-ready, suggests Serrano. "Automation companies will tell you they can interface to anything, which is true if you’re willing to throw enough bucks at it. Our manufacturer said it had an automation solution for one of our key analyzers that we wanted to put on the track. But the solution didn’t work. The vendor is working hard at solving the problem, but it has hurt us significantly."

You expect automation to do what?

There may be no such thing as a stupid question during a site visit, but there are plenty of naïve assumptions. Take, for example, the notion that everything in the laboratory should be automated.

"We’ve had visitors determined to put an aliquoter on their automated line," Serrano says. "But then we ask them how many tubes they aliquot and whether they even need to aliquot. Automate only your high-volume functions. We have parallel processing lines here because we didn’t want to connect our hematology automation to our chemistry, immunochemistry, and coagulation automation line. There’s no point in connecting hematology that doesn’t need to be centrifuged and delaying the function of the track."

During one of the best site visits Serrano has hosted, he suggested that one group not automate at all. "By simply organizing their processes, they were able to significantly improve their functions. Clustering instruments to enable one individual to do multiple tasks saved this group millions on automation they didn’t need," he says.

But the biggest myth is that automation is the ultimate solution. "I think people come to our lab thinking they’ll find a panacea to some of the problems in the processing area," Gregorski says. "But there are no easy answers to getting things out of the front end of the lab, especially if you have a large outreach business. You still have to register patients, compile insurance billing information, and get ABNs. And there are no easy answers for the high turnover of lab assistants. Automation won’t fix that, at least for now."

Adds Serrano: "Automation is merely having a machine do what your people used to do. And if what your people were doing wasn’t working, automation isn’t the remedy."

Anita Slomski is a writer in Evanston, Ill.