What Does ARUP's Automation Mean for ARUP's Clients?
- Improved quality
- Improved turnaround time
- Improved productivity
ARUP first introduced an automation transport and sorting system in 1998. Many additions to this automation were implemented in succeeding years, such as expansions to the track system, a 2.3 million specimen freezer automated storage and retrieval system (AS/RS), thawing and mixing work cells, the 4000 specimen per hour automated storage sorter, and the sort-to-light system that automates the sorting of specimens that cannot use the Automated Transport and Sorting System. For more than twenty years ARUP has made extensive use of a Continuous Quality Improvement program to implement numerous process improvements in every facet of our business, including operations that utilize and benefit from our automation. ARUP’s automation and accompanying process improvements are world-class and widely recognized through publications, lecture invitations at prestigious conferences, and awards.
The multiple expansions of our automation combined with continuous process improvements have enabled ARUP to stay ahead of increasing volumes of work as well as achieve significant improvements in quality, turnaround time, and productivity.
The automation and process improvements have collectively enabled ARUP to become the first clinical laboratory in the U.S. to achieve Six Sigma quality in any metric, whether analytic or non-analytic. Six-Sigma quality is defined as having fewer than 3.4 defects per million opportunities (DPMO). At ARUP, we have reduced our incidence of lost specimens by 100-fold since 1991 and have had nine individual months in the most recent six years in which the incidence of lost specimens has been equal to or less than 3.4 per million billed units (0.34 per 100,000). The following figure shows a 22 year history of ARUP’s incidence of lost specimens.
In this figure, the scale of the ordinate (lost specimens per 100,000 specimens received) is logarithmic. From 1991-1996 only annual incidences are plotted. Starting in 1997, each point in the chart is the monthly incidence. During the time covered by this chart, the incidence of lost specimens per 100,000 total specimens received decreased by 100 fold from 65 in 1991 to 0.65 or lower in the years since 2010. This chart also shows three months (green dots) in which the incidence was less than 0.34 per 100,000, which is the Six Sigma cut-off level.
However, as noted above, the definition of quality on the Sigma scale is based on defects per million opportunities (DPMO), where “opportunities” may represent handling steps or other activities when a defect could occur. In the case of the lost specimen metric, each step in which a specimen is handled by an employee is an opportunity to lose the specimen. ARUP’s automation and process improvement are believed to have reduced the number of handling steps for each specimen by more than half, and clearly this has resulted in the significant reduction of lost specimens.
It is difficult to accurately determine exactly how many times an individual specimen is handled or even to estimate an average number of handling steps per specimen. However, because ARUP performs an average of 1.6 tests per specimen, it is reasonable to use the number of tests ARUP performs as the number of “opportunities,” even though the real number of handling steps is probably much higher. Billed units were therefore used as a measure of “opportunities” in the chart below, a plot of lost specimens per 100,000 billed units since 1997. Data prior to 1997 cannot be plotted because the Medicare definition of a billed unit changed that year.
This chart shows the exact same data as in the previous chart, but using billed units instead of specimens as the denominator. One can immediately see that nine months (instead of only three) over the past six years have values (green dots) at or below 0.34 lost specimens per 100,000 billed units (3.4 DPMO), and that most of the lost specimen values during that period are below a level of 1 per 100,000. It is also evident that if an accurate estimate of handling steps could be made and were used in this chart, that there would many more monthly points below the line depicting Six Sigma quality.
Of course, there are other measures of quality that have also improved as a result of ARUP’s automation. The metric of lost specimens was selected to illustrate this improvement because it is a long-standing measure at ARUP with more than twenty years of data.
Improved Turnaround Time
The impacts of ARUP’s automation and process improvements on the turnaround time of our test are illustrated by the data in the figure below.
In this chart the turnaround time is shown in hours on the abscissa and the percentage of all tests performed by ARUP within the stated years at each hour of turnaround time is shown on the ordinate. Any of the percentiles can be used to illustrate how to interpret the chart. For example, at the 50th percentile (median), at the point at which a colored line intersects the percentile line, exactly 50% of all turnaround times were less than the hours at the point of intersection and 50% were greater than that number of hours. Similar logic applies to any other percentile. The important conclusion is that, compared to the baseline year of 1997-98 (pink dashed line), which was prior to the implementation of any automation, all of the lines for succeeding years are to the left of the baseline year, indicating that fewer hours, on average, were required to report that percentage of ARUP’s total number of tests. The improvement is evident at all percentiles, but is easier to see at the 50th, 60th, 70th, 80th, 90th, and 95th percentiles. Using the 90th percentile to further illustrate the improvement due to automation and process improvement, 90% of all tests in 1997-98 required up to 92 hours to complete and report, whereas 90% of all tests in 2010 and 2014 required only up to 68 hours to complete and report. This is an improvement of a full 24 hours.
The elimination of the many redundant sorting and handling steps as a result of ESP and the Automated Transport and Sorting System has greatly improved ARUP's productivity. The rate at which ARUP has historically hired new employees to keep up with testing volume has slowed significantly, simply by eliminating repetitive, unnecessary handling steps.
This chart shows (line with solid blue squares) total billed units per FTE for the 25 different laboratory sections that receive most of their specimens via the Automated Transport and Sorting System. Also shown (dashed red line) is a prediction of the billed units per FTE that these 25 laboratory sections might now have without automation. This estimate was determined by regression analysis based on the rate of productivity improvement for two years prior to automation. Despite a continuing increase in workload, the rate of hiring of new staff was significantly lowered as a result of ARUP's automation initiative. This chart estimates that ARUP has saved approximately 115 FTEs that we have not had to hire because of automation. Since automation was implemented in 1998, productivity of these 25 lab sections has improved by much more than the annual 5% improvement predicted by the regression line. The overall productivity improvement was 98.5% or nearly double.