White

Paper

Patient Care, Financial &

Workflow Benefits
of Automated Urinalysis
& a LEAN-LAB Approach

Lary Koval, Director, Laboratory and Courier Services, Conemaugh Health System
and Maryann Ciampa, Director Global Product Development System
and MST Leader Consulting Services, Becton, Dickinson and Company
White Patient Care, Financial & Workflow
Benefitsof Automated Urinalysis &
Paper a LEAN-LAB Approach
Urinalysis is an important diagnostic tool, performed by U.S. hospital labo-
ratories an average of 120 times a day.1 In this era of automation and Lean
Six Sigma processes, such an ubiquitous test ought to be highly streamlined.
Yet urinalysis in many hospitals remains a decidedly low-tech, inefficient,
and frequently inaccurate process.2, 3
Change, however, is on the horizon. Technology advances now allow
hospitals to switch from manual to fully automated urinalysis to improve
accuracy, streamline workflow, enhance productivity, and reduce overall
costs.4 Combined with Lean Six Sigma principles, longstanding labora-
tory practices for urinalysis are being revised with significant benefits to
hospitals in quality, turnaround time, cost savings, and improved physician
and patient satisfaction.2
These benefits recently were experienced firsthand by Conemaugh Memo-
rial Medical Center (CMMC), a large healthcare provider in Pennsylvania,
when it adopted a closed urine collection system, automated urinalysis and,
through applying Lean Six Sigma principles, changed workflow patterns
with impressive results.
MANUAL URINALYSIS
“Urinalysis is one of the most
commonly ordered tests.
Unfortunately, as a manual
test, it takes a significant
amount of time to complete.”
Jim Barkley, Regional Sales Manager
Iris Diagnostics
Routine, yet labor-intensive, slow, and inefficient, are terms commonly
used to describe manual urinalysis. Hospitals process hundreds of millions
of urine samples annually in the United States,5 yielding results that range
from unremarkable to life saving. But the journey from sample collection
to processing to analysis to results is fraught with inefficiency. Manual
urinalysis is also more subjective than most other laboratory tests.4
Inaccurate results may lead to unnecessary urine cultures—wasting resources
and further delaying results.4 Consequently, the cost of urinalysis—measured
in time, labor, materials, and accuracy—soars far higher than it should, and
patient satisfaction suffers as well.
1
Urine screening processes traditionally involve tedious manual steps, which
are time-consuming and open to errors, including:
Specimen deterioration & bacterial overgrowth. Prolonged stand-
ing at room temperature may compromise the accuracy of urinalysis results
due to specimen deterioration and bacterial overgrowth. To avoid these prob-
lems, the Clinical and Laboratory Standards Institute and College of Ameri-
can Pathologists require that urine specimens should be processed within 1 to
2 hours of collection or refrigerated.3, 5, 6, 7 Yet transport from a variety of lo-
cations both within the hospital and from outside facilities such as physician
offices, as well as laboratory delays, often cause samples to remain at room
temperature for longer periods of time. A study of nearly 50,000 urinalysis
specimens in 346 hospitals found that of those that were never refrigerated,
11.2% exceeded the two-hour time standard before analysis.5
Leaks. Collection of urine specimens typically is done in broad-opening col-
lection containers with screw tops. In transport or when being transferred for
chemistry analysis, specimens collected in these containers often leak, which
may render them unusable and require new samples to be collected.
Contamination. Contamination, whether during collection or processing,
is also common. One study of 906 institutions ranging in size from 50 beds
to more than 600 beds reported that 18.1% of urine culture specimens col-
lected from outpatients were contaminated.8 Contamination can occur dur-
ing collection or when the specimen cup is opened for aliquotting, and again
for culture plating which can occur hours later. Consequently, initial dipstick
chemistry analysis may result in a high number of both false negative and
false positive results.1
False positives. If urine chemistry test strip and/or microscopic examina-
tion suggest that bacteria are present, specimens are cultured. This process
requires additional costs and technician time, and may delay final results
for 24–48 hours.2 A disproportionately high number of urine cultures—as
many as 70%—reflect false positive chemistry results and yield no clinically
relevant information.2, 3 There clearly is a need to reduce the number of un-
necessary urine cultures and the concomitant costs in time, labor, and patient
care delays.
CASCADE EFFECT
Timely, accurate urinalysis becomes
even more important in light of the
growing concern about hospital-
acquired infections.
The patient care and financial impact of these issues is felt far beyond the lab-
oratory. Inefficient use of labor—one of the largest expenses in healthcare—
represents significant hidden costs for hospitals. For example, when samples
are delayed or contaminated, additional nursing, staff, and physician time
is required to follow up on results, determine that repeat tests are needed,
communicate and document the problem, recall patients to collect additional
specimens, and reprocess and report results. Not only is needed care delayed
for some patients, but treatment also may be started for non-existent condi-
tions, for example if infections are falsely reported. Inaccurate results and
delays in reporting lab results to areas of the hospital such as the Emergency
Department increase costs, prevent patients from being efficiently moved
through the system, increase wait times for patients, and negatively impact
patient satisfaction.8
Timely, accurate urinalysis becomes even more important in light of the
growing concern about hospital-acquired infections. The Centers for Medi-
care and Medicaid Services (CMS) no longer pays hospitals for the increased
cost of care associated with twelve categories of secondary conditions that
it sees as preventable complications of medical care. These conditions, if
not present on admission, will no longer be taken into account in calculat-
ing payments to hospitals after October 1, 2008. One of these conditions is
catheter-associated urinary tract infections. The Centers for Disease Control
and Prevention reports that there are 561,667 catheter-associated urinary tract
infections per year in the United States.9 Approximately 40% of Medicare
beneficiaries have a urinary catheter during hospitalization.9 Nosocomial uri-
nary tract infections necessitate one extra hospital day per patient and add an
average of $676 to a hospital bill.1, 8 As a result of the new government pay-
ment rules, treatment for false-positives, including medications, nursing time,
and extended hospital stays, may not be reimbursed—placing an unnecessary
financial burden on hospitals.
2
As one of the oldest of all laboratory tests, urinalysis is deeply rooted in pa-
tient care, but its manual processes are time-consuming, can lead to inaccu-
rate results, and negatively impact hospitals far beyond the lab itself. Today, a
combination of enhanced urine collection technology, automation, and Lean
Six Sigma initiatives present an opportunity for urinalysis to take a dramatic
leap forward and contribute to hospitals’ overall cost and revenue objectives.
AUTOMATED URINALYSIS—TECHNICAL INNOVATIONS
“By using a closed collection system,
we’re improving the quality of spec-
imens submitted to the laboratory,
and this will reduce the number of
phone calls back to the floors and
outpatient collection centers saying
the urine is unacceptable.”
Lary Koval, Director,
Laboratory and Courier Services,
Conemaugh Health System
Today, fully automated urinalysis, including chemistry and microscopy, may
be performed in a single, integrated system. In conjunction with a closed
urine collection system, automated urinalysis has been shown to improve ac-
curacy, speed throughput, reduce staff time, save costs, and ultimately im-
prove patient satisfaction.2, 10
A closed urine collection system, such as the BD Vacutainer® System from
BD (Becton, Dickinson and Company, Franklin Lakes, New Jersey), reduces
the potential for specimen contamination and leakage to nearly zero. Instead
of collecting urine in cups, affixing a lid, bagging the cups, and sending them
to the lab, urine is collected in a cup with an integrated transfer device. The
sample is transferred to evacuated tubes that are leak-proof and compatible
with pneumatic systems. The tubes are placed directly on the automated
urinalysis system upon arrival in the lab, eliminating the need to manually
transfer the sample from the collection cup and the associated risk of con-
tamination.
LEAN SIX SIGMA Contamination rates are further reduced by using collection tubes that contain
a preservative to prevent organisms from multiplying while the specimen is
Lean and Six Sigma principles go hand-in-hand in improving
transported or awaits analysis. Closed urine collection kits may be custom-
efficiency in healthcare facilities. Derived from Japanese manufactur-
ized from site to site to best accommodate factors such as distance to the lab,
ing processes including those at Toyota, Lean aims to cut the waste that
potential delays in processing, and technician preference.
adds to production time and costs. By streamlining processes within the
hospital, Lean practices speed throughput, reduce costs, and enhance
Automation transforms urinalysis into a process that may be performed
productivity.17
by just one technician. Among the systems available today is the
Iris iQ®200ELITE™ Automated Urinalysis System (Iris Diagnostics,
Six Sigma, a business management strategy originated at Motorola, Inc.,
Chatsworth, California), which provides fully integrated chemical and micro-
uses quality management tools to reduce defects and errors. What sets Six
scopic analysis. When barcoded specimen tubes are placed in the racks, the
Sigma apart from other quality improvement strategies is its emphasis on
system automatically mixes, samples, and analyzes. Nine chemistries are
measurable financial returns. Statistically, the term Six Sigma refers to a
performed simultaneously, in addition to assessments of specific gravity,
process that produces 3.4 (or fewer) defects per one million opportunities.
color, and clarity.
This translates to 99.9997% efficiency. In contrast, quality problems in
healthcare have been shown to occur at rates of 20–50%, or 200,000–
A unique transfer system and embedded customized software manage all
500,000 per million,18 leaving significant room for identifying the under-
specimens for microscopic analyses as needed. The iQ200 patented auto-
lying causes and finding process and technology solutions.
classification software (APR™) analyzes 500 digital images for each specimen
and auto-classifies elements by size, shape, contrast, and texture. One hospi-
Six Sigma methodology encompasses five steps, summarized as
tal found that this feature alone—replacing an older, time-consuming manual
DMAIC:
microscopy process with automated digital photos—saved a minimum of
10–15 minutes of staff time for each sample requiring microscopic analy-
Define process improvement goals that are consistent with customer
 
sis.10 Abnormal samples may be verified on the screen, with less than 5% of
demands and the enterprise strategy.
samples needing additional manual review.
Measure key aspects of the current process and collect relevant
 
data.
Automation eliminates the time-consuming work of manually preparing
A nalyze the data to verify cause-and-effect relationships. Determine

specimens, interpreting them, and performing confirmatory tests. Results are
what the relationships are, and attempt to ensure that all factors have been
reported quantitatively and may be edited, archived, exported, and formatted
considered.
into custom reports.
Improve or optimize the process based upon data analysis using

techniques like Design of Experiments.
Control to ensure that any deviations from target are corrected be-
  INCORPORATING LEAN SIX SIGMA
fore they result in defects.

DMAIC is considered a valuable tool in identifying opportunities for “Lean principles focus on eliminating
improvement. Armed with this information, hospitals are better equipped waste or unnecessary motion that
to make purchasing decisions intended to improve both efficiency and compromises efficiency. If you
quality control. automate a bad process, you are
just going to get bad results faster”

Maryann Ciampa,
Director of Global Product
Development and
Laboratory Services, BD

Automation has been shown to help laboratories both increase their capac-
ity and improve the quality of their results.2, 10, 11 These outcomes fit neatly
with the tenets of Lean and Six Sigma initiatives being widely adopted by
healthcare institutions to improve efficiency and quality (see Lean Six Sig-

3
ma Sidebar). For hospitals seeking to streamline processes and reduce errors,
automated urinalysis is a logical area to focus attention, but the surrounding
processes and workflow must be as efficient as possible in order to maximize
the benefits of automation.
In light of the high cost of labor for healthcare facilities, a key component of
Lean is improving staff efficiency, which is becoming all the more urgent in
the laboratory as the pool of qualified technicians shrinks.12 The average age
of laboratory technicians is rising, with fewer new professionals entering the
workforce. A California report about allied health personnel shortages found
that the greatest area of concern was for technologist-level laboratory practi-
tioners.12 It therefore behooves laboratories to increase the productivity of the
technicians they do have. Lean and automation aim to do just that.
Six Sigma brings the process full circle to ensure that efficiency and quality
go hand-in-hand. The Six Sigma DMAIC process (define, measure, analyze,
improve, and control) assesses a laboratory’s potential to increase both produc-
tivity and quality.
As use of Lean Six Sigma in hospital laboratories grows, facilities are
reporting surprising results. For example, the lab at the University of Michigan
Medical Center reported findings it described as “pretty typical for any labora-
tory environment that has implemented Lean,”13 including:
Reduction in throughput time for testing of 30–50%
Increased productivity of 30–40%
Reduction in space requirements for testing of 20–40%
Reduced supply inventory of 40–50%13
With Lean Six Sigma strategies in place and automated urinalysis online,
hospitals can realize measurable improvements, as the following case study
demonstrates.
A CASE IN POINT—
CONEMAUGH MEMORIAL MEDICAL CENTER
“The adoption of Lean Six Sigma
principles and automated urinalysis
with a closed collection system
provided critical patient care benefits
and cost savings for Conemaugh...
contaminated samples were reduced,
unnecessary processing steps were
eliminated, and turnaround time was
greatly improved.”
Lary Koval, Director,
Laboratory and Courier Services,
Conemaugh Health System
4
The largest healthcare provider in west central Pennsylvania, 616-bed
Conemaugh Memorial Medical Center (CMMC) is part of the three-hospital
Conemaugh Health System. With a staff of 166, the clinical lab at CMMC
performs nearly 2.4 million tests per year, more than 41,400 of which are
urinalyses (33% inpatient and 67% outpatient, including the Emergency
Department). On a daily basis, the laboratory performs an average of
145 chemistries and 74 microscopic analyses.
Already committed to Lean Six Sigma practices elsewhere in the hospital,
CMMC aimed to streamline its urinalysis process. Of particular concern
were the high rates of negative urine cultures and long turnaround times for
urinalysis results. In addition, the hospital wanted to reduce public perception
of long waits in the Emergency Department, which often were impacted by
delays in urinalysis and other results from the lab, as well as accommodate
increasing demand. The initiative also fit well with the hospital’s total quality
focus, and its participation in the Malcolm Baldrige National Quality Initiative,
focusing on Total Quality Management across the hospital system.
As part of its efforts to improve lab processes and guided by BD’s Lean Dai-
ly Management Program, CMMC performed a pilot study in which the BD
Vacutainer® closed urine collection system and Iris iQ200ELITE work cell
were integrated for automated urinalysis. Lean Six Sigma process improve-
ment methodologies were incorporated into daily operations as well.
Results of the study at CMMC were impressive and included a projected
overall cost savings of more than $24,000 per year, a 26% overall reduction in
urinalysis turnaround time, and improved specimen quality with significantly
fewer mixed-growth cultures. These positive results in quality improvement,
throughput, and cost savings also contributed to improved physician, patient,
and employee satisfaction.
CMMC PILOT STUDY
CMMC embarked on the study, sponsored by Iris Diagnostics and BD, to
quantify anticipated improvements from automated urinalysis and adoption of
Lean Six Sigma processes in the lab. To be considered successful, automation
would need to meet specific objectives:
 Operational—reduce turnaround time, improve productivity for faster and
better patient care, and demonstrate merit from integrating the technology
into the overall process value stream
 Clinical Outcomes—reduce false positives, culture overgrowth,
rejected samples due to leakage, and contamination
 Financial—reduce total cost of use
 Service—Improve customer satisfaction and enhance value for patients
and clinicians
Pre-pilot observations and videotaping were performed at seven high-
volume locations over a three-day period, December 18-20, 2007, in order to
establish baseline metrics. These sites included the Emergency Department, two
inpatient services (surgical/trauma step down and telemetry), and four out-
patient sites. In addition, data on quality, satisfaction, process, and financials
were collected and analyzed to establish a baseline for comparison in the study.
These data also were used to identify opportunities for improvement.
A key finding in the benchmarking assessments was CMMC’s slow turn-
around time for urinalysis. Compared with a peer group selected for compara- 100 -21% -33% -34% -26%

Minutes
ble test volumes and lab type, CMMC ranked in the 9th percentile. The average 50
Receive to Verify time at CMMC was 33 minutes, while the median for the
peer group was 24.3 minutes, and the 90th percentile was 10.6 minutes. CMMC 0
DEM 8A 7A DOP OX CR RCC AII
anticipated that the combination of Lean process improvements and automa-
tion could produce at least a 17-minute improvement in the average turnaround Patient Location
Pre-Pilot

time, which would place the hospital in the top quartile in its peer group. Pre-Pilot

Figure 1. Turnaround Time (Collect to Verify)

Integrating Lean Process, Automation & Closed Collection
CMMC lab management, supervisory, and technical staff worked together to
develop Lean process improvements. Laboratory staff attended a workshop
on the tenets of Lean Six Sigma. The workflow and physical space used for
urinalysis underwent review and overhaul. A control plan was established to
optimize physical location and configuration of the urinalysis system as well
as the integration of improved workflow processes.
For automated urinalysis, CMMC selected the Iris iQ200ELITE System, in
part because it combines both urine chemistry and microscopy in a single,
fully automated system. The image- based technology minimized the require-
ment for manual results verification. The system was located and configured to
maximize its functionality and achieve efficiency improvements in areas such
as workflow processes. For example, locating the system close to the labo-
ratory entrance and within a few steps of the receiving area reduced wasted
steps. A “U” shape configuration, with the urinalysis system placed closest to
specimen entry and specimen storage at the far end of the cell, further reduced
staff movement.
Percentage
The overall median turnaround time (Collect to Verify) was reduced by 26%
(15 minutes) for all patient locations and 21% for Emergency Department
testing. Patient locations include the Emergency Department (DEM), two
inpatient services (Surgical/Trauma Step Down, 8A; and Telemetry, 7A), and
four outpatient sites (Outpatient DTC, DOP; Express Care Outpatient, OX;
Crichton Rehabilitation Center, CR; and Richland Care Center, RCC).
Furthermore, in-lab turnaround time (Receive to Verify) was reduced by
10 minutes for all locations (a 25% reduction) and by six minutes for the
Emergency Department (a 29% reduction). Outliers, which represent the
biggest disruption to workflow and negatively impact physician satisfaction
with the laboratory, were dramatically reduced. (See Figure 2) Also, during the
pilot, 52% of specimens were completed (Receive to Verify) in 15 minutes or
less. Prior to the pilot, only 29% were completed in a similar time frame.
30 -56.0% -9.8%

-26.7%
20 -100.0% -73.5%
Greater process improvement benefits of automated urinalysis were realized
with a change in the urine collection process. The previous process involved 10 -68.8%
collecting, bagging, and sending cups of urine to the main lab in batches. 0
Urinalysis microscopy was previously performed with the Kova® System, DEM 8A 7A DOP OX CR RCC AII
using tubes, pipettes, slides, and stain. Pre-Pilot
Patient Location
Pre-Pilot

The new urine collection system from BD includes a closed collection

container, along with either preservative or non-preservative tubes that may be
placed directly on the Iris iQ200ELITE as soon as they arrive in the laboratory.
The tubes, part of the BD Vacutainer® system, are available with preservative
for locations where specimen delays are common.
Pilot Study Results
Following inservice training and education, the pilot study was conducted for
one month, from April 14–May 13, 2008. The study period represented an
average month with no holidays or other special events that could influence the
data. The study documented significant improvements in all key areas:
Figure 2. Outliers (Receive to Verify)
Outliers from the Emergency Department and inpatient areas (7A, 8A) were
dramatically reduced. Patient locations include the Emergency Depart-
ment (DEM), two inpatient services (Surgical/Trauma Step Down, 8A; and
Telemetry, 7A), and four outpatient sites (Outpatient DTC, DOP; Express
Care Outpatient, OX; Crichton Rehabilitation Center, CR; and Richland Care
Center, RCC).

Reduced Turnaround Time. The overall median turnaround time

(Collect to Verify) was reduced by 15 minutes, or 26%, and turnaround time
for the Emergency Department was reduced by 6 minutes (a 21% reduction).
(See Figure 1)

5
 Improved Specimen Quality. With the closed collection system, the number of
mixed-growth cultures dropped by 28%. (See Figure 3) This was attributed to 2.5
Proportion of ED UAs
two aspects of the new system. First, the aliquot process occurs without open- with TAT greater
ing the specimen cup, thereby reducing the chance for contamination of the 2.0 than 60 min
specimen after collection. Second, the preservative in the collection tube helps
prevent overgrowth without causing toxicity to existing pathogens, maintain-

Percentage
1.5
ing the urine sample for up to 72 hours at room temperature. The delay from
collection to plating may be several hours, especially for outpatient specimens.
1.0

12 Leaking Specimens
0.5
10 -28.8% -27.1%
-18.4%
8 -38.5% -28.0% 0.0
-19.0%
Percentage

-39.5% Pre-Pilot Pilot Pre-Pilot Pilot

6
Figure 4. Outliers/Defects
4 -5.7% Emergency Department outliers, based on a 30-minute turnaround time, were
2 reduced by 45%. Leaking specimens were eliminated.

0 Increased Productivity & Labor Savings. The average time required

DEM 8A 7A DOP OX CR RCC AII
Pilot for a technician to process a urinalysis specimen was reduced by 51%, from
Patient Location Areas 143 seconds to 70 seconds. Furthermore, the faster and more predictable turn-
Pre-Pilot
Pre-Pilot around reduced the number of inquiries regarding specimen status. Overall,
Figure 3. Urine Culture: Proportion of Mixed-Growth Results the time savings from the automated urinalysis system totaled about 0.5 full
time equivalents (FTE). By reducing time spent on urinalysis, staff members
were redeployed to perform other tests, such as whole blood chemistry, thereby
improving lab performance beyond urinalysis processing.
Specimen contamination, as measured by the proportion of mixed-growth
results, was substantially reduced in all pilot areas. Mixed-growth Increased Capacity. The number of urinalyses a single technician can
specimens typically are considered false positive results, and contamination also perform in one hour increased by 119%, from 13.5 to 29.5, including a
may obscure detection of pathogens. Therefore, a reduction of mixed-growth proportion with microscopic exams. This increased capacity was particularly
results can lead to fewer false-positive results and improved diagnoses. Patient valuable when spikes in test volume occurred. During the pilot, 14 or more
locations include the Emergency Department (DEM), two inpatient services specimens were received within a one-hour period 9% of the time. This would
(Surgical/Trauma Step Down, 8A; and Telemetry, 7A), and four outpatient have exceeded capacity in the pre-pilot system. With the automated system,
sites (Outpatient DTC, DOP; Express Care Outpatient, OX; Crichton Reha- a single operator could sustain the process even during these peak periods.
bilitation Center, CR; and Richland Care Center, RCC). (See Figure 5)

Reduction of Outliers and Defects. For urinalysis, defects can be

measured in terms of missed turnaround time targets (outliers), especially
when the time to report a test result does not meet customer requirements, as
well as leaking specimens. The number of Emergency Department outliers
was reduced by 47%, and the problem of leaking specimens was eliminated.
(See Figure 4) The elimination of leaking specimens improved the Sigma
rating from 4.45 to greater than 6 Sigma. (See Lean Six Sigma Sidebar)

6
 35.0 of $2,013 per month is attributed to faster turnaround time, reduced speci-
30.0 men contamination, and reduced operating time. The total savings also can
Specimens per Hour

be viewed as the sum of the product savings, process savings, and instrument
25.0
savings.
20.0
15.0 Table 1: Projected Savings
10.0
Projected Savings (monthly)
5.0
Total Savings $ (2, 013.00)
0.0
26% TAT improvement $ (503.25)
Pre-Pilot Pilot
28% Reduction in Contaminated Specimens $ (543.51)
Figure 5. Operator/Process Capacity
50% Reduction Operating Time $ (966.24)
Product Savings Allocation $ (543.51)
In the pre-pilot system, a single technologist could perform 13.5 urinalysis
procedures per hour. Following implementation of Lean, automated urinaly-
Process Savings Allocation $ (865.59)
sis, and a closed collection system, a technologist now can perform 29.5 pro- Instrument Savings Allocation $ (603.90)
cedures per hour, a 119% increase in capacity.
Projected savings of $2,013.00 per month is attributed to turnaround time
Reduced Staff Movement. The automated system, coupled with a Lean labora-
improvement, reduction in contaminated and poor-quality specimens, and re-
tory layout, reduced by 61% the amount of walking required for one cycle of
duction in operator time to produce reports. Each component of the solution
the urinalysis procedure. (See Figure 6)
implemented—product changes, process change, and instrument change—
contributes to these improvements and savings.
Pre-Pilot Pilot In addition to these savings, there are other savings that are less easily
accounted for. For example, since urinalysis results are received approxi-
mately 21% faster in the Emergency Department, wait times may be reduced,
8 7 3 4
Atlas Atlas making it less likely that patients will leave without being seen or against
2
medical advice. Faster results mean faster patient discharge or admittance to
the hospital from the Emergency Department, freeing up beds for new patients
10
6
9 5
1
from the waiting area. Data supports that if patients are seen within 45 minutes
iQ200 2 1
of arrival to the Emergency Department, the likelihood that they will leave
3
before being seen is near zero. This improves the bottom line for Emergency
SERUM 4 SERUM
PROCESSING PROCESSING departments by the average amount of a patient stay. Using very conserva-
B228 B228
tive numbers, lost revenue from patients leaving the Emergency Department
without being seen ranges from $7,665 to $15,330.

Antibiotic usage also is decreased as a result of reducing the number of false

positive urinalysis results. False positive results yield false positive culture
results, causing unnecessary treatments with antibiotics. Excluding any factors
for legal ramifications, the average cost for antibiotic treatment for a urinary
Figure 6. Route for One Urinalysis Cycle tract infection ranges from $112–172.14
The before (left) and after (right) routes of the operator demonstrate a
reduction of 61% in the amount of walking required to complete one
urinalysis.

Projected Savings. Table 1 illustrates the projected savings at CMMC with

automated urinalysis and closed urine collection, incorporating Lean Six Sig-
ma processes. An increase in the cost of equipment and supplies is offset by
reduced overall costs of collecting and reporting results. The projected savings

7
SUMMARY
In short, CMMC exceeded its expectations with automated urinalysis. With
better specimen quality and fewer outliers, turnaround time became faster
and more predictable. The amount of labor required to process a single urine
sample was reduced, and overall laboratory capacity increased. With the
shrinking pool of skilled laboratory technicians, increased productivity in the
lab and throughout the hospital is a key benefit. Less time also was wasted on
false positive cultures and on recalling patients, and hard costs were saved on
the media required for additional testing. Faster turnaround time provides the
opportunity for faster management of patients, producing higher satisfaction
among both physicians and patients. The improved quality, in particular, was
important to the hospital as part of its overall quality improvement initiatives
and as it prepares to compete for the Malcolm Baldrige Quality Award.

The calculated savings potential with automated urinalysis is based on

integration of all components of the solution—closed urine collection, auto-
mated urinalysis, and Lean Six Sigma processes. As with any new technology,
adoption of automated urinalysis requires changes in thinking and habits. At a
time when hospitals are seeking to enhance efficiency and cost effectiveness,
the Conemaugh experience illustrates that automated urinalysis and closed
collection systems, in conjunction with Lean processes, can produce
significant, measurable savings while improving quality. While every
acility is unique, there are numerous common issues with urinalysis that may be
effectively addressed by this comprehensive, individualized approach.

CMMC’s experience mirrors that of other facilities, which have experienced

similar benefits in turnaround time, staff and workflow efficiency, and
overall return on investment by combining automated urinalysis with Lean
practices.4, 15 Providence Alaska Medical Center in Anchorage is achieving
its urinalysis turnaround time target of under 45 minutes more than 90% of
the time, versus its previous rate of 73%.15 Enhanced efficiency has positively
impacted other lab processes as well. Another facility that implemented fully
automated urinalysis found that it was able to speed the reporting of other
commonly ordered lab tests, experiencing, for example, up to a 30% improve-
ment in turnaround time for CBC (complete blood count) results.4 Providence
Alaska Medical Center cut its CBC time in half.15

Urinalysis is one of the most frequently performed laboratory tests, and one
of the few areas of laboratory medicine that is still done manually in many
hospitals.16 The ability to quickly and accurately turnaround urinalysis results
impacts the entire hospital. For a procedure that is mired in a long history of
inefficiency, the time is right for urinalysis to take an overdue leap into the era
of automation.

8
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