In South Africa’s National Health Laboratory Service, ad hoc mean turn-around time (TAT) reporting is an important indicator of performance. However, historic static TAT reporting did not assess very long or very short times. An interactive TAT dashboard was developed using the following TAT measures; (1) median, (2) 75th percentile and (3) percentage of within cut-off TAT to allow for improved differentiation of TAT performance.
The objective of our study was to demonstrate increased efficiency achieved by using an interactive TAT dashboard.
A retrospective descriptive study design was used. Creatinine TAT outcomes were reported over 122 weeks from a high-volume laboratory in Gauteng, South Africa. The percentage of within cut-off and 75th percentile TAT were analysed and reported using Microsoft Excel. A focus group session was used to populate a cause and effect diagram.
The percentage of within cut-off TAT increased from 10% in week 4 to 90% and higher from week 81. The 75th percentile decreased from 10 hours in week 4 to under 5 h from week 71. Component TAT analysis revealed that the 75th percentile testing was 5 h or longer for weeks 4, 5 and 48. The 75th percentile review TAT ranged from 1 h to 15 h. From week 41, the review TAT was under 1 h.
Our study demonstrated that the use of an interactive TAT dashboard coupled with good management can dramatically improve TAT and efficiency in a high-volume laboratory.
Turn-around time (TAT) is an important performance indicator of laboratory efficiency to deliver patient results.
Initially, the three measures described above were reported in Microsoft Excel (Redmond, Washington, United States) worksheet format from August 2016 to June 2017.
Within the dashboard, TAT can be viewed for a basket of tests including routine haematology full blood count with platelet and differential testing, international normalised ratio, activated prothrombin testing and D-dimers, chemical pathology testing including urea and electrolytes, liver function testing, glucose, cholesterol, among others, as well as microbiology testing for HIV (HIV viral load, HIV DNA polymerase chain reaction), tuberculosis (Xpert MTB/RIF [mycobacterium tuberculosis DNA/resistance to rifampicin) and syphilis (rapid plasma reagin and
Global TAT outcomes for each test are reported according to specifically stipulated, organisation-determined TAT APP at the national level and are described elsewhere.
Armed with the knowledge of TAT and which tests are identified as poor performers in the interactive dashboard, laboratory managers can identify and address areas of concern through review of the contributing causes.
The aim of this study was to report on the impact of an interactive dashboard that provides weekly information about TAT and enables laboratory and senior managers to monitor TAT and identify problematic areas for corrective action. The hypothesis was that an interactive TAT dashboard delivering week-by-week information about laboratory TAT provides the impetus for continuous service review and implementation of appropriate corrective action, where required, to ensure the timeliness of laboratory reporting. Data are presented from a single, busy, routine automated clinical pathology laboratory at a large regional hospital to reveal how the described TAT dashboard served to continually highlight ongoing TAT delays for urea and electrolyte (creatinine) result reporting and, ultimately, facilitated sustained corrective action.
Ethics clearance was obtained from the University of the Witwatersrand (study approval number: M1706108). No patient identifiers were extracted with data.
A retrospective descriptive study design was used to analyse laboratory data and highlight the impact of interventions by observing trends. Qualitative focus group sessions were used to unpack the root causes of poor performance. Convenience sampling was used. For the purpose of this study, the TAT performance for creatinine testing, which had poor TAT at the start of the study, was used to demonstrate how dashboard monitoring of TAT could highlight and impact the TAT. Creatinine testing outcomes were reported with an APP cut-off of 90% within 5 hours.
The data extract contained the following variables: (1) report week ending date, for example 23 October 2016 (Monday to Sunday), (2) laboratory name, (3) test method name, (4) TAT cut-off, (5) test volumes, (6) percentage of within cut-off TAT, (7) median TAT, (8) 75th percentile TAT, (9) inter-laboratory referral 75th percentile TAT, (10) testing 75th percentile TAT and (11) review 75th percentile TAT. All TAT 75th percentile values were reported in hours. Each week was numbered, that is, 1–122. TAT data refer to total TAT (i.e. time of first registration to time of result release after review) if not otherwise specified for TAT components. All data were prepared and analysed using Microsoft Excel (Redmond, Washington, United States).
The percentage of within cut-off TAT was calculated as the total number of samples meeting the organisation’s TAT cut-off criteria of 5 h for urea and electrolytes testing divided by the total number of tests performed, expressed as a percentage, per week. The results were reported as a line chart (indicating the week number and APP cut-off of 90%). Data were segmented into three phases: (1) baseline: week 1 to 44 (week ending 04 June 2017), (2) dashboard intervention: week 45 to 63 (week ending 15 October 2017) and (3) post-intervention from week 64 to 122 (week ending 02 December 2018). The dashboard intervention period indicates the switch from using an Excel worksheet to the interactive dashboard.
The 75th percentile was calculated for total TAT per week, as well as for TAT components, that is, testing and review. As tests were local hospital-based and not referred from surrounding laboratories, the pre-analytical TAT component was not applicable. When samples are referred, the pre-analytical TAT measures the interval (time taken to transport the sample between laboratories) from registration at the source (the laboratory where the sample was received) to the testing laboratory. Results from this analysis were plotted as 75th percentile, per testing week, for both total and component TAT.
The root cause analysis diagram was used to identify potential factors causing poor TAT performance.
This laboratory performed 326 081 tests for the financial period 2016/2017, 341 760 tests for 2017/2018 and 399 538 tests for 2018/2019. Assuming 24/7 operations, this equates to between 894 and 1095 tests per day (Booplal N 2019, personal communication). Prior to the implementation of the interactive dashboard, weekly TAT data were extracted from the corporate data warehouse that houses laboratory information system data within the National Health Laboratory Service. Weekly Microsoft Excel worksheets were prepared manually and distributed via email prior to the implementation of the interactive dashboard at week 45.
For the baseline phase, the percentage of TAT within the cut-off fluctuated (range: 10% to 79%) (
The percentage of within cut-off turn-around times for creatinine testing at a high-volume laboratory across 122 weeks after implementation of a weekly dashboard, Gauteng, South Africa, 2017.
During the baseline phase, the total TAT 75th percentile ranged from 4 h to 20 h, changing to 2–10 h for the intervention phase (
75th percentile total turn-around time for creatinine testing at a high-volume laboratory across 122 weeks after implementation of an interactive weekly dashboard, Gauteng, South Africa, 2017.
Four major clusters of contributing causes were identified in the root cause analysis including: equipment and supplies, environmental causes, rules, policies and procedural causes and, lastly, staff and personnel factors (
Root cause analysis diagram developed in conjunction with the laboratory manager at a high-volume laboratory, Gauteng, South Africa, 2017.
In this study, it was hypothesised that the application of appropriate corrective action guided by an interactive TAT dashboard indicating the proportion of samples within stipulated TAT cut-offs and tail size (outliers) would result in improved performance.
All laboratories typically adhere to a quality management system (QMS) that is used to assess laboratory quality from the pre-analytic phase through the testing and reviewing processes. A QMS is defined as a set of coordinated activities that direct and control a laboratory with regard to quality.
In this study, we reveal how the introduction of a TAT dashboard enabled senior management of the laboratory in question to assess TAT performance for a particular battery of tests that had not met the stipulated TAT cut-off (greater than 65% of results were outside of the stipulated TAT cut-off). Upon introduction of the dashboard, several areas of concern were immediately identified including pre-analytical, analytical and post-analytical factors. With respect to component TAT, assessing specifically the timeframes of registration to testing and testing to release of the report, TAT delays were attributable to delays of review during weeks 1 to 41, with further delays caused by testing (instrument) interruptions during weeks 4 and 48. The root cause analysis revealed several contributing factors categorised as equipment and supplies, rules, policies and procedures, environmental and personnel or staffing issues. Specifically, the introduction of an auto-review rule process played an important role in improving TAT cut-off. A similarly placed high-volume core laboratory in Canada also reported that the implementation of a series of lean approaches in their busy laboratory, including automation and auto-review rules, were effective to more efficiently manage substantial volumes of samples while meeting TAT cut-offs.
Several important lessons learned and documented by the study laboratory could serve as a template for outreach training to help other public sector laboratories achieve similar TAT performance improvements and establish the practices adopted at this site. Key learning outcomes emerged: Firstly, the importance of the need to collate and actively review real-time information about TAT, including components of TAT, in ensuring overall timely reporting in laboratories was understood and confirmed. Secondly, the value of vertical audits was demonstrated. Vertical audits assisted in understanding what contributed to delayed TAT, and specific focus on outlier samples and vertical audits directed subsequent meaningful corrective action. In line with the requirement of ongoing improvement of service delivery, a weekly ‘results for action’ statement was developed and found to be useful to deliver specific information at the sample or episode level. Such reports, while getting the attention of senior management, could be directed to relevant managers to highlight specific problematic areas and guide the focus of managers’ attention to the investigation of true TAT outliers or exceptions. Such investigation (with solutions) of specifically identified problem areas could yield practical and advantageous outcomes, not only solving the issues at hand but more widely having a positive impact on overall service delivery improvement. The final lesson learned revolved around the importance of documenting and following through on corrective actions as part of the QMS. This ensures that corrective actions taken have consequences and are sustained. In the services review presented here, the week-by-week reminders of outlying TAT were a constant cue that solutions implemented had not been effective. Re-evaluation and re-assessment allowed for streamlined processes to be considered when initial corrective actions had failed. Also highlighted was the importance of conducting a root cause analysis, as cause and effect diagrams, to tease out and understand all aspects of errors and any contributing factors that may lead to delays in TAT. It is also important to point out that although a corrective action may be resolved with a single intervention, more frequently corrective action is a multi-step process to identify possible solutions and alternatives. Once implemented, these corrective steps require consistent monitoring and evaluation for sustained impact. Here, the information provided by the dashboard offered objective evidence of identified issues that could be documented and presented to senior managers month to month and at the annual management meeting; that, in due course, enabled corrective action planning and the facilitated, necessary, mandates to effect better service.
Over the years there have been multiple approaches to monitoring TAT reporting with the aim of improving TAT and, in turn, patient care. Approaches range from identifying outliers to implementing Lean Sigma Six to process mapping.
Many laboratories have implemented Lean Six Sigma approaches to improve TAT performance.
Another approach to improve TAT reported by Barakauskas et al. involved using LIS time stamps, direct observations and discussions with staff to construct various value stream and process maps for immunosuppressant drug level testing.
Ultimately, the aim of any of the approaches described above is to improve TAT performance and, thus, patient care. Although TAT is especially important for emergency tests that have very short TAT cut-offs, it is equally important to set cut-offs for other, less urgent tests to ensure that respective test results are received by attending physicians in a timely fashion to effect appropriate patient care, an important factor in assuring both the quality of care and the cost-effective use of hospital services.
Integration of laboratory information system specimen-level turnaround time data from multiple laboratories into a single, aggregated structured query language database for development of an interactive dashboard, Gauteng, South Africa, 2017.
Cross country collaboration and sharing of resources could play an important role in securing already developed dashboard tools for other African countries. A multi-country approach could reduce overall costs and effort. For example, a single TAT dashboard could be developed for the Southern African Development Community to ensure accessibility and provide scalability. To secure the system and provide confidentiality, each country could have access to their own data using data access privileges. The benefit of this approach is that after the methods, systems and dashboards are developed, it is easy to extend these developments to other countries with minimal additional cost. The only additional effort required at the country level would be to collate and share the data extracts with the umbrella organisers.
Only LIS data were used for our study. Without a laboratory specimen tracking system, it is not possible to report end-to-end TAT. The implementation of an end-to-end tracking system from the time of venesection to delivery into a laboratory, additionally integrated into a TAT dashboard, could provide valuable supplementary date and time values to allow for an extended TAT efficiency review.
In summary, this study demonstrated that an interactive TAT dashboard, reporting appropriate TAT parameters, applied in the context of a QMS, coupled with proactive and diligent management, can accurately identify outliers and lead to appropriate corrective action and sustained timely laboratory reporting.
Lessons learned
A weekly interactive TAT dashboard enables reporting of appropriate TAT parameters and respective outcomes by confirming ongoing quality and timely reporting, as well as identifying outlying TAT that may require appropriate corrective action.
TAT data can be collected at the laboratory, local network or national level. A dashboard that includes aggregated and local level data, with a data drilling function, allows hierarchical review of the data, so that both higher-level managers and laboratory managers are able to view the same data, but at different levels appropriate for their respective level of responsibility.
Continuously collating and analysing the data and presenting TAT information in a user-friendly, visual dashboard format allows for immediate attention to be focused on outlying sites and areas.
Visibility and transparency of TAT data and outcomes to all levels of management provides an incentive (with repeated peer or organisation pressure, if consistently outside of TAT) to act on poor performance.
A quality management system requires active input, monitoring and appropriate action where needed. The presentation of information does not necessarily confer good performance or the meeting of TAT cut-offs. A dashboard, such as that presented here, is merely a tool. Proactive, consistent and diligent review of TAT data presented in a dashboard is required to facilitate meaningful improvement and corrective action. An auto-review rule implemented for a specific test or battery of tests on the laboratory information system has the potential to reduce TAT by acting to reduce the workload for senior staff through automatic review of predominantly normal results. With the auto-review implemented, senior staff effectively use their time and reserve the resultant review only for samples that fail to meet the auto-review rule, for example delta check failures.
The authors thank area, business and laboratory managers in Gauteng for their participation and input.
The authors declare no conflict of interest. The authors further declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
D.K.G. supervised the study by providing leadership and oversight as the project leader. N.C., M.E.E.T. and L.M.C. designed the study, developed the methodology and conducted the research. M.E.E.T. extracted the data. N.C. conducted the data analysis. L.P. provided content for the cause and effect diagram and provided details on the interventions implemented. D.K.G. provided editorial comments and technical input. All authors reviewed the results and contributed to the manuscript development.
We are not able to share the data.
The authors declare that the views expressed in the submitted article are their own and not the official position of any institution or funder.