Automated Urinalysis White Paper

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 Paper

Patient Care, Financial & Workflow Benefitsof Automated Urinalysis & a LEAN-LAB Approach

Urinalysis is an important diagnostic tool, performed by U.S. hospital laboratories 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

Urine screening processes traditionally involve tedious manual steps, which are time-consuming and open to errors, including: Specimen deterioration & bacterial overgrowth. Prolonged standing at room temperature may compromise the accuracy of urinalysis results due to specimen deterioration and bacterial overgrowth. To avoid these problems, the Clinical and Laboratory Standards Institute and College of American 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 locations 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

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 laboratory 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 Memorial 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.

Leaks. Collection of urine specimens typically is done in broad-opening collection 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 collected from outpatients were contaminated.8 Contamination can occur during 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

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.”

False positives. If urine chemistry test strip and/or microscopic examination 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 unnecessary urine cultures and the concomitant costs in time, labor, and patient care delays.

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.

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As one of the oldest of all laboratory tests, urinalysis is deeply rooted in patient care, but its manual processes are time-consuming, can lead to inaccurate 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.

CASCADE EFFECT

Timely, accurate urinalysis becomes even more important in light of the growing concern about hospitalacquired infections.

AUTOMATED URINALYSIS—TECHNICAL INNOVATIONS

“By using a closed collection system, we’re improving the quality of specimens 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.”

The patient care and financial impact of these issues is felt far beyond the laboratory. 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 conditions, 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

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 accuracy, speed throughput, reduce staff time, save costs, and ultimately improve patient satisfaction.2, 10

Timely, accurate urinalysis becomes even more important in light of the growing concern about hospital-acquired infections. The Centers for Medicare 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 calculating 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 urinary 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 payment rules, treatment for false-positives, including medications, nursing time, and extended hospital stays, may not be reimbursed—placing an unnecessary financial burden on hospitals.

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 contamination.

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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 transported or awaits analysis. Closed urine collection kits may be customized from site to site to best accommodate factors such as distance to the lab, potential delays in processing, and technician preference.

Lean and Six Sigma principles go hand-in-hand in improving efficiency in healthcare facilities. Derived from Japanese manufacturing processes including those at Toyota, Lean aims to cut the waste that adds to production time and costs. By streamlining processes within the hospital, Lean practices speed throughput, reduce costs, and enhance productivity.17

Automation transforms urinalysis into a process that may be performed by just one technician. Among the systems available today is the Iris iQ®200ELITE™ Automated Urinalysis System (Iris Diagnostics, Chatsworth, California), which provides fully integrated chemical and microscopic analysis. When barcoded specimen tubes are placed in the racks, the system automatically mixes, samples, and analyzes. Nine chemistries are performed simultaneously, in addition to assessments of specific gravity, color, and clarity.

Six Sigma, a business management strategy originated at Motorola, Inc., uses quality management tools to reduce defects and errors. What sets Six Sigma apart from other quality improvement strategies is its emphasis on measurable financial returns. Statistically, the term Six Sigma refers to a process that produces 3.4 (or fewer) defects per one million opportunities. 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– 500,000 per million,18 leaving significant room for identifying the underlying causes and finding process and technology solutions.

A unique transfer system and embedded customized software manage all specimens for microscopic analyses as needed. The iQ200 patented autoclassification software (APR™) analyzes 500 digital images for each specimen and auto-classifies elements by size, shape, contrast, and texture. One hospital found that this feature alone—replacing an older, time-consuming manual microscopy process with automated digital photos—saved a minimum of 10–15 minutes of staff time for each sample requiring microscopic analysis.10 Abnormal samples may be verified on the screen, with less than 5% of samples needing additional manual review.

Six Sigma methodology encompasses five steps, summarized as DMAIC:   Define process improvement goals that are consistent with customer demands and the enterprise strategy.   Measure key aspects of the current process and collect relevant data.   A nalyze the data to verify cause-and-effect relationships. Determine what the relationships are, and attempt to ensure that all factors have been considered.   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 before they result in defects.

Automation eliminates the time-consuming work of manually preparing specimens, interpreting them, and performing confirmatory tests. Results are reported quantitatively and may be edited, archived, exported, and formatted into custom reports. INCORPORATING LEAN SIX SIGMA

“Lean principles focus on eliminating waste or unnecessary motion that compromises efficiency. If you automate a bad process, you are just going to get bad results faster”

DMAIC is considered a valuable tool in identifying opportunities for improvement. Armed with this information, hospitals are better equipped to make purchasing decisions intended to improve both efficiency and quality control.

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

Automation has been shown to help laboratories both increase their capacity 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-

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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.

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.

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 practitioners.12 It therefore behooves laboratories to increase the productivity of the technicians they do have. Lean and automation aim to do just that.

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.

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 productivity and quality.

As part of its efforts to improve lab processes and guided by BD’s Lean Daily 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 improvement methodologies were incorporated into daily operations as well.

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 laboratory 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

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.

With Lean Six Sigma strategies in place and automated urinalysis online, hospitals can realize measurable improvements, as the following case study demonstrates.

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:  O perational—reduce turnaround time, improve productivity for faster and better patient care, and demonstrate merit from integrating the technology into the overall process value stream  C linical 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

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.”

Pre-pilot observations and videotaping were performed at seven highvolume 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 outpatient 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.

Lary Koval, Director, Laboratory and Courier Services, Conemaugh Health System

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A key finding in the benchmarking assessments was CMMC’s slow turnaround time for urinalysis. Compared with a peer group selected for comparable test volumes and lab type, CMMC ranked in the 9th percentile. The average 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 anticipated that the combination of Lean process improvements and automation could produce at least a 17-minute improvement in the average turnaround time, which would place the hospital in the top quartile in its peer group.

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Figure 1. Turnaround Time (Collect to Verify) 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. Percentage

Greater process improvement benefits of automated urinalysis were realized with a change in the urine collection process. The previous process involved collecting, bagging, and sending cups of urine to the main lab in batches. Urinalysis microscopy was previously performed with the Kova® System, using tubes, pipettes, slides, and stain.

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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 requirement 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 laboratory 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.

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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.

Figure 2. Outliers (Receive to Verify) Outliers from the Emergency Department and inpatient areas (7A, 8A) were dramatically reduced. 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).

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: 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)

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Improved Specimen Quality. With the closed collection system, the number of mixed-growth cultures dropped by 28%. (See Figure 3) This was attributed to two aspects of the new system. First, the aliquot process occurs without opening the specimen cup, thereby reducing the chance for contamination of the specimen after collection. Second, the preservative in the collection tube helps prevent overgrowth without causing toxicity to existing pathogens, maintaining 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. 12

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Figure 4. Outliers/Defects

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Emergency Department outliers, based on a 30-minute turnaround time, were reduced by 45%. Leaking specimens were eliminated.

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Increased Productivity & Labor Savings. The average time required for a technician to process a urinalysis specimen was reduced by 51%, from 143 seconds to 70 seconds. Furthermore, the faster and more predictable turnaround reduced the number of inquiries regarding specimen status. Overall, 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.

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Figure 3. Urine Culture: Proportion of Mixed-Growth Results

Specimen contamination, as measured by the proportion of mixed-growth results, was substantially reduced in all pilot areas. Mixed-growth specimens typically are considered false positive results, and contamination also may obscure detection of pathogens. Therefore, a reduction of mixed-growth results can lead to fewer false-positive results and improved diagnoses. 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).

Increased Capacity. The number of urinalyses a single technician can perform in one hour increased by 119%, from 13.5 to 29.5, including a proportion with microscopic exams. This increased capacity was particularly valuable when spikes in test volume occurred. During the pilot, 14 or more specimens were received within a one-hour period 9% of the time. This would have exceeded capacity in the pre-pilot system. With the automated system, a single operator could sustain the process even during these peak periods. (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)

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of $2,013 per month is attributed to faster turnaround time, reduced specimen contamination, and reduced operating time. The total savings also can be viewed as the sum of the product savings, process savings, and instrument savings.

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Figure 5. Operator/Process Capacity

50% Reduction Operating Time Product Savings Allocation

In the pre-pilot system, a single technologist could perform 13.5 urinalysis procedures per hour. Following implementation of Lean, automated urinalysis, and a closed collection system, a technologist now can perform 29.5 procedures per hour, a 119% increase in capacity.

Process Savings Allocation Instrument Savings Allocation

Projected savings of $2,013.00 per month is attributed to turnaround time improvement, reduction in contaminated and poor-quality specimens, and reduction in operator time to produce reports. Each component of the solution implemented—product changes, process change, and instrument change— contributes to these improvements and savings. In addition to these savings, there are other savings that are less easily accounted for. For example, since urinalysis results are received approximately 21% faster in the Emergency Department, wait times may be reduced, making it less likely that patients will leave without being seen or against medical advice. Faster results mean faster patient discharge or admittance to the hospital from the Emergency Department, freeing up beds for new patients from the waiting area. Data supports that if patients are seen within 45 minutes of arrival to the Emergency Department, the likelihood that they will leave before being seen is near zero. This improves the bottom line for Emergency departments by the average amount of a patient stay. Using very conservative numbers, lost revenue from patients leaving the Emergency Department without being seen ranges from $7,665 to $15,330.

Reduced Staff Movement. The automated system, coupled with a Lean laboratory layout, reduced by 61% the amount of walking required for one cycle of the urinalysis procedure. (See Figure 6) Pre-Pilot

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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 tract infection ranges from $112–172.14

Figure 6. Route for One Urinalysis Cycle 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 Sigma processes. An increase in the cost of equipment and supplies is offset by reduced overall costs of collecting and reporting results. The projected savings

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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, automated 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% improvement 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.

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REFERENCES 1. Crowe D. CEO voicing caution despite Iris’s urinalysis breakthrough. Los Angeles Business Journal. September 12, 2005.

10. Amacher K. Advanced urinalysis technology and Lean management help a hospital lab improve productivity. MLO Med Lab Obs. December 2006;38:33–34.

2. Cronin M. Automated urinalysis technology improves efficiency and patient care. MLO Med Lab Obs. October 2008.

11. Kibak P. Tools for benchmarking performance. Clinical Laboratory News. 2008;34(4).

3. Simmerville J, Maxted W, Pahira J. Urinalysis: a comprehensive review. Am Fam Physician. 2005;71:1153–1162.

12. Hillborne L. The other big workforce shortage. Mod Healthc. June 2008;38:23.

4. Paxton A. Automation nudges urinalysis into spotlight. CAP Today. July 2007.

13. Brewing a high-octane laboratory, step by step. CAP Today. August 2007:86.

5. Howanitz P, Saladino A, Dale J. Timeliness of urinalysis. Arch Pathol Lab Med. 1997;121:667–672.

14. Rosenberg M. Pharmacoeconomics of treating uncomplicated urinary tract infections. Int J Antimicrob Agents. 1999;11:247–251.

6. Urinalysis and Collection, Transportation, and Preservation of Urine Specimens; Approved Guideline, 2nd Edition. Vol 21: Clinical and Laboratory Standards Institute; 2001.

15. Atwell J. Automation alert: Upgrading with automated urinalysis. Advance for Administrators of the Laboratory. May 2007;16:22. 16. Check W. Urinalysis finally catches up. CAP Today. September 2002:1.

7. College of American Pathologists. Laboratory Accreditation Manual 2007. 17. de Koning H, Verver J, van den Heuvel J, Bisgaard S, Does R. Lean Six Sigma in healthcare. J Healthc Qual. 2006;28(2):4–11.

8. Valenstein P. Urine culture contamination: A College of American Pathologists Q-Probes study of contaminated urine cultures in 906 institutions. Arch Pathol Lab Med. 1998;122:123–129.

18. Chassin M. Is healthcare ready for Six Sigma quality? The Milbank Quarterly. 1998;76(4):565–591.

9. Federal Register, Vol. 72, No. 162. Washington, D.C.: Office of the Federal Register; 2007.

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