DOI: 10.7860/JCDR/2014/7269.

4255
Original Article

Root Cause Analysis (RCA) of

Pathology Section

Prolonged Laboratory Turnaround

Time in a Tertiary Care Set up
Kalyan Khan

ABSTRACT within a 95% confidence interval of the difference. The maximum

Introduction: Among the multitude of daily administrative time which was needed in the control group was within the interval
problems which are faced by the modern hospitals today, pro­ between the prescription of the investigation by the doctor and
longed Turnaround Time (TAT) of laboratory investigations is a writing of the requisition by the Out-patient Department (OPD)
crucial one, which affects patient care as well as patient satis­ staff. For the study population, it was the interval between the
faction adversely. writing of the requisition by the OPD staff and the reaching of the
patient at the central Laboratory. The standard deviation (27.665)
Aims and Objectives: The specific objectives were to observe
and range (102) were also exceptionally high for this interval in
the TAT of common laboratory investigations, to identify cause
the study group.
of increased turnaround time and to formulate action plans to
rectify increased TAT. Conclusion: This study revealed that easy to implement admin­
istrative steps would help in reducing the TAT significantly and
Methodology: An observational, RCA study was performed on
in improving the quality of services of the central laboratory.
100 randomly selected patients. A separate group of 50 patients
These include the setting up of sample collection counters at
were assisted to get their investigations done and to reduce the
the outpatient department (OPD) and inpatient department
time intervals without actively interfering with the steps. The
(IPD), employment of minor methods like printing the directions
results which were obtained were accepted as standards. Root
for reaching the laboratory on the OPD ticket, the start of a
cause analysis of the delays which were detected in TAT was
single prick policy, declaring central laboratory as a separate
done. Time intervals of TAT in the two groups were compared by
department and integration of the administrative control under
2 tailed t-tests done for equality of means.
one authority.
Result and Analysis: All time intervals were high in the study
group and they were found to be statistically significant (p<0.05)

Keywords: Laboratory Turnaround Time, Root Cause Analysis, Pathology Investigations

Introduction be readily learned by managers as well as frontline personnel. It can

Among the multitude of daily administrative problems which are faced be conducted at several levels of depth and complexity [8, 9].
by the modern hospitals today, prolonged Turnaround Time (TAT) of Root Cause Analysis (RCA) is defined as “an objective, thorough
laboratory investigations is a crucial one, which affects patient care and detailed methodology which is employed to determine the
as well as patient satisfaction adversely and substantially. Health most probable underlying causes of problems, complaints and
care processes are difficult to define, because of their complexity undesired events which occur within an organization, with the aim of
[1]. Assessing time definitions in clinical processes can help in formulating and agreeing with corrective actions, to at least mitigate,
analyzing workflows in hospital information systems (HIS) and in if not eliminate those causes and to so produce a significant, long
identifying weak points [2]. Due to increasing costs of health care, it term performance improvement” [10].
is important to improve the efficiency of clinical workflows. The objectives of the present study were to observe the TAT of
When process times are analyzed, it is important to be aware of common laboratory investigations at the central Laboratory of a
the different definitions which are used for time intervals. One of tertiary care, state government medical college and hospital, to
the most common measures of laboratory or pathological services identify the cause of increased TAT, and to formulate action plans to
is the turnaround time (TAT), which has been frequently used since rectify the increased TAT, if any was detected.
1980, to quantify the time taken for doing laboratory tests in an
objective manner [3]. The first reference dates back to 1971 and it Methodology
has described TAT as the time interval between electrocardiogram The present study was a descriptive, cross-sectional study which
printing and placement of the printout in the patient chart [4]. In the was conducted on patients who attended the Medicine and
laboratory workflow, TAT is an important indicator of performance Surgery OPD and on those who were admitted to the Medicine
[5] and it is even seen as a “necessary condition for trust between and Surgery In-patient Department (IPD), of a tertiary care, state
patient and physician” [6]. Turnaround time in Pathology comprises government medical college and hospital. One hundred patients (25
of a fixed component, which is assay dependent (that is, the each from the Medicine and Surgery OPD and IPD) were selected
time which is required for analyzing a specimen), and a variable by using a simple random sampling technique. Only those patients
component (the time which is taken to receive the specimen and were included, who were advised Complete Blood Count (CBC)
order, and to post the result) [7]. and/or Urine Routine examinations, who were unrelated to any
Root cause analysis (RCA) is a method of problem solving, that tries staff member of the hospital, whose test order was not marked as
to identify the root causes of faults or problems that cause operating ‘urgent’ or ‘emergency’ and whose tests were performed free of
events. Root cause analysis is a valuable management tool that can cost i.e. there was no need to go to the cash counter for paying
Journal of Clinical and Diagnostic Research. 2014 Apr, Vol-8(4): FC05-FC08 5
 Kalyan Khan, Root Cause Analysis of Laboratory Turnaround Time www.jcdr.net

charges for the test. The TAT of Pathology investigations in the events (i.e., six time intervals, D1 to D6 [Table/Fig-1] and overall
selected patients was observed and the RCA of the delays which TAT.
were detected in TAT was done. Salient recommendations were The existing process and time which was required for final delivery
formulated on the basis of the findings. of the report to the ward in case of indoor/admitted patients and
A flow chart was created to identify key steps in the laboratory also, receipt of the report by the OPD patients were also studied.
process [Table/Fig-1]. This allowed the measurement of seven Ten groups of five patients from different departments and wards
were accompanied by volunteers who helped the patients to get
their investigations done. The volunteers tried to reduce the time
intervals as far as possible, without actively interfering with the steps.
The results which were obtained were accepted as standards or
controls [Table/Fig-2].
The 100 cases which were studied and their samples were traced
passively by using a time motion study. The patients, their accom­
panying persons and concerned administrative key persons were
interviewed directly for obtaining necessary information. The results
which were obtained for these 100 cases were compared with the
standard or control time intervals [Table/Fig-3 and 4].
The data was collected in an MS Excel sheet and it was analyzed
by frequency distribution and descriptive statistics, along with other
parametric and non-parametric tests accordingly, by using Epi-info
7 and SPSS, version 14.Chikago.inc.

[Table/Fig-1]: Key steps in the laboratory process [Table/Fig-3]: The time intervals studied in the 100 cases

Minimum Maximum Standard Standard

Time Time Time Mean Error of Deviation
Interval (Minutes) (Minutes) Range (Minutes) Mean of Mean
D1a 12 65 53 38.28 1.580 15.799 n=100
D1b 20 91 71 51.32 2.021 20.206
95%
D2a 5 29 24 13.74 0.636 6.364 Confidence Interval
D2b 45 147 102 91.16 2.766 27.665 and Confidence
Limit
D3a 21 55 34 35.55 0.993 9.925
D3b 11 26 15 18.71 0.393 3.927
D4a 16 23 7 19.57 0.201 2.011
D4b 16 23 7 18.95 0.189 1.893
D5 10 58 48 29.53 1.333 13.325
D6 15 45 30 27.32 1.065 10.652
[Table/Fig-2]: Descriptive statistics of the 100 cases

t-test for Equality of Means 95% Confidence Interval of the Difference

Time Degree of Significance Mean Standard Error
Interval t- value Freedom (2-tailed) Difference Of Difference Lower Upper

D1a 17.755 102.209 0.003 28.280 1.593 25.121 31.439

D1b 12.835 104.837 0.002 26.320 2.051 22.254 30.386

D2a 13.518 105.268 0.012 8.740 0.647 7.458 10.022
D2b 27.456 100.053 0.001 76.160 2.774 70.657 81.663
D3a 20.289 107.002 0.002 20.550 1.013 18.542 22.558
D3b 19.723 138.711 0.010 8.710 0.442 7.837 9.583
D4a 26.554 130.713 0.011 7.570 0.285 7.006 8.134
D4b 32.327 125.085 0.009 8.950 0.277 8.402 9.498
D5 14.491 103.493 0.002 19.530 1.348 16.857 22.203
D6 11.363 105.973 0.008 12.320 1.084 10.170 14.470

[Table/Fig-4]: Comparison of the six time intervals between the case and control groups

6 Journal of Clinical and Diagnostic Research. 2014 Apr, Vol-8(4): FC05-FC08

www.jcdr.net Kalyan Khan, Root Cause Analysis of Laboratory Turnaround Time

Minimum Maximum Standard Standard

Time Time Time Mean Error of Deviation
Interval (Minutes) (Minutes) Range (Minutes) Mean of Mean
D1a 8 12 4 10.00 0.202 1.429 n=50
D1b 21 29 8 25.00 0.350 2.474
95%
D2a 4 6 2 5.00 0.114 0.808 Confidence Interval
D2b 13 17 4 15.00 0.202 1.429 and Confidence
Limit
D3a 13 17 4 15.00 0.202 1.429
D3b 8 12 4 10.00 0.203 1.429
D4a 10 14 4 12.00 0.201 1.429
D4b 8 12 4 10.00 0.202 1.429
D5 8 12 4 10.00 0.201 1.429
D6 13 17 4 15.00 0.202 1.429
[Table/Fig-5]: Descriptive statistics of the 50 controls

The above [Table/Fig-5] shows that all the time intervals, both in
Results and Analysis case of the OPD and IPD cases, were high in the study group
The age of the study population ranged from 19 to 85 years, with a in comparison to the control group and they were found to be
mean of 41.7 years. Male and female patients accounted for 52% statistically highly significant (p<0.05) within a 95% confidence
and 48% of the study population respectively. Complete Blood Count interval of the difference.
(CBC) and Urine Routine examinations, the two most commonly
The time motion study and direct interviews revealed the
advised pathological tests, were studied for their turnaround times
following: The manning and control of Pathology subunit was
(TATs).
undertaken by the office of the Medical Superintendant cum
CBC was advised in 89% of the study population and 46% were Vice Principal (MSVP); whereas those of the Microbiology and
advised Urine Routine Examination. Eighty eight percent of the Biochemistry subunits were undertaken by the respective
patients were also advised some other investigations which were departments of the Medical College.
mostly biochemical tests. [Table/Fig-2] shows the descriptive
In the same complex of central Laboratory, in three separate rooms,
statistics of the 100 cases. Maximum time which was needed
a single patient was pricked thrice if he/she needed tests for hae­
in almost all of the cases was between the preparation of test
matology (say, blood RE), microbiology (say, malaria antigen) and
requisition and the reaching of the patient at the central laboratory.
biochemistry (say, blood sugar, urea or creatinine).
[Table/Fig-2] shows the time intervals studied in the 100 cases.
These three reports were to be collected by the patients from three
[Table/Fig-5] shows the descriptive statistics of the 50 control or
different tables and may be at variable time intervals [Table/Fig-7
intervention cases.
and 8].
[Table/Fig-6] shows the parameters studied and their values along
The following were the mean differences in time intervals of TAT
with the control values for each. Please refer to [Table/Fig-1] for
between the study group and the control group and the causes,
further clarifications about the parameters.
along with their suggested solutions.
Time Time interval Range (in minutes) Mean Control The extent to which improvements in laboratory turnaround time
Intervals between (Minutes) (Minutes) enhance patient outcomes is still unclear [11].  A critical issue is
Minimum Maximum
clinicians’ capacities in responding to, and making clinical use of
D1a T2a and T1a 12 65 38.2 10
faster results. The limited data which are available to date are not
D1b T2b and T1b 27 91 51.3 25 encouraging. A UK study which investigated the impact of ward
D2a T3a and T2a 05 29 13.7 05 computers which allowed access to laboratory results, found that
D2b T3b and T2b 40 147 91.6 15 45% of urgent requests for biochemistry tests from accident and
D3a T4a and T3a 21 55 35.5 15
emergency wards, and 29% from inpatient wards, were never
accessed. Of the results which were never read, 3% were assessed
D3b T4b and T3b 11 26 18.7 10
as necessitating an immediate change in patient management.
D4a T5 and T4a 16 23 19.5 12 [12]. Clinicians report dissatisfaction with current tracking and follow
D4b T5 and T4b 14 20 18.9 10 up of test results [13]. So, unless clinicians’ behaviours change, for
D5 T6 and T5 10 58 29.5 10 utilizing faster results, we face the risk of over optimizing a single
D6 T7 and T6 15 45 27.3 15 system. Additional system features such as e-mail inboxes which
post important results to clinicians directly, or computer alerts
Total 171 559 344.2 127
which highlight urgent results, may help in supporting a better test
[Table/Fig-6]: Parameters studied and their values along with the control values
for each
management [14].

The maximum time which was needed in the control group was Conclusion
in D1b i.e. the interval between prescription of the investigation by The present study arrived at the following conclusions: The
the doctor and the writing of the requisition by the OPD staff for the Turn-around Times of investigations which were performed at the
said investigation. But for the study population, the maximum time central Laboratory, especially the pre and post-analytical steps,
which was needed was in D2b i.e. the interval between writing of were prolonged and these were statistically significant.
the requisition by the OPD staff and the reaching of the patient at the In the observed TAT of the study population, maximum time needed
central Laboratory. The standard deviation (27.665) and range (102) was in the interval between writing of the requisition by the OPD
were also exceptionally high for this interval in the cases group. staff and the reaching of patient at the central Laboratory. Hence,
[Table/Fig-4] shows the comparison of the six time intervals between employment of minor methods, like printing the directions for
the case and control groups of 100 and 50 patients respectively. reaching the laboratory on the OPD ticket, would substantially bring
down the TAT and subsequently increase patient satisfaction.

Journal of Clinical and Diagnostic Research. 2014 Apr, Vol-8(4): FC05-FC08 7

 Kalyan Khan, Root Cause Analysis of Laboratory Turnaround Time www.jcdr.net

Standard
Deviation
Time Mean of Mean of Major Causes
Interval Difference study cases of delay Suggested Solutions
D1a 28.280 15.799 1. No separate/designated staff for test order entry. 1. Separate team of lab staffs may be posted at OPD
2. Paper-work involved. and IPD for sample collection at a counter in a prominent
D1b 26.320 20.206 1. Lack of clear instruction to patient about where requisition would position.
be made. 2. Clear instruction regarding requisition making at the point
2. Paper-work involved. (dedicated staff present) of advising tests.
3. Training of staff regarding importance of pre-analytical
D2a 8.740 6.364 1. No separate / designated staff for phlebotomy or sample collection. phase of tests.
2. Usually treated as low priority job in comparison to therapeutic 4. Electronic test order entry software with bar-coding of
management of patients in the wards. samples may be started in the future.
D2b 76.160 27.665 1. Lack of proper direction to reach the Central Laboratory which is far 1. Sample collection counter at OPD.
away from the OPD. Those who are conversant reach early; hence the 2. Direction to the Central Laboratory may be printed on the
Standard Deviation is more. OPD tickets.
2. Difficulty in identifying the Central Laboratory entrance. No sign- 3. Lab entrance should be made visible and more
boards in vernacular languages [Table/Fig-8]. identifiable. Sign-boards especially in vernacular languages
should be installed.
4. Existing social workers, volunteers and ‘May I help you’
desks should be utilized more efficiently.
D3a 20.550 9.925 1. Individual wards have separate staffs to transport the samples to 1. Single messenger can transport samples from a few
the Laboratory. Hence availability of staff is less. closely located wards thus increasing the availability of staff.
D3b 8.710 3.927 1. No designated staff for phlebotomy or sample collection. 1. Sample collection counter at OPD.
2. Senior technicians usually treat phlebotomy or sample collection as 2. Training of staff regarding importance of pre-analytical
low priority job in comparison to actual testing. phase of tests.
D4a 7.570 2.011 1. Laboratory staff accumulate samples and register them at a time. 1. Accumulation of samples should be discouraged.
2. Paper-work involved. 2. Training of staff regarding ill effects of sample
D4b 8.950 1.893 1. Laboratory staff accumulate samples and register them at a time. accumulation and importance of post-analytical phase of
2. Paper-work involved. testing.
3. Designated report delivery desk may be started with a
D5 19.530 13.325 1. Laboratory staff accumulate samples and test them at a time. separate staff.
Hence samples have variable waiting time which increased the 4. Electronic test result approval system may be started in
Standard Deviation. the hospital including the OPD within its domain.
D6 12.320 10.652 1. Laboratory staff accumulate the reports and dispatch them at intervals.
2. No designated staff is available for report delivery which is treated
as a low priority job.
[Table/Fig-7]: Mean differences in time intervals of TAT between the study group and the control group and the causes, along with their suggested solutions

References
[1] Ammenwerth E, Ehlers F, Eichstädter R, Haux R, Pohl U, Resch F. Systems
analysis in health care: framework and example. Methods Inf Med. 2002;41:134–
40. 
[2] Lenz R, Buessecker F, Herlofsen H, Hinrichs F, Zeiler T, Kuhn KA. Demand driven
Evolution of IT Systems in Healthcare. Methods Inf Med. 2005;44:4–10. 
[3] Bloch DM. Computer-generated management tools for the clinical pathology
laboratory. II. Computer-generated graphic work flow. J Med Syst. 1982;6:305–
10. doi: 10.1007/BF00992807. 
[4] Tell R, Hoffman I. The elimination of turnaround time in routine ECG processing. J
Electrocardiol. 1971;4:279–81. doi: 10.1016/S0022-0736(71)800420. 
[5] Hawkins RC. Laboratory turnaround time. Clin Biochem Rev. 2007;28(4):179–94
[6] Braddock CH, Snyder L. The Doctor Will See You Shortly The Ethical Significance
of Time for the Patient-Physician Relationship. J Gen Intern Med. 2005;20:1057–
62. doi: 10.1111/j.1525-1497.2005.00217.x.
[7] Ash J S, Gorman P N, Lavelle M. Perceptions of physician order entry: results of
a cross site qualitative study. Methods Inf Med. 2003;42:313–23.
[Table/Fig-8]: The reception counter at the Central Laboratory is devoid of any sign [8] Patricia M. Williams. Techniques for root cause analysis. Proc (Bayl Univ Med
boards or directions in any vernacular languages Cent) 2001; 14: 154–7.
[9] Battles JB, Kaplan HS, van der Schaaf TW, Shea CE. The attributes of medical
This study also revealed that certain easy to implement adminis­ event-reporting systems: experience with a prototype medical event-reporting
system for transfusion medicine. Arch Pathol Lab Med. 1998;122:231–8. 
trative steps would also help in reducing the TAT significantly and [10] Vorley G, Tickle F. Quality Management – Principles and Techniques; Q M and T
simultaneously improve the quality of services of the central Lab­ Publishers: 2002.
oratory as a whole. These include the setting up of sample collection [11] Garg A, Adhikari N, McDonald H.  Effects of computerized clinical decision
counters at the OPD and IPD, the start of a single prick policy and support systems on practitioner performance and patient outcomes. A systematic
review. J Am Med Inform Assoc. 2005;29:1223–38.
declaring central Laboratory as a separate department. [12] Kilpatrick E S, Holding S. Use of computer terminals on wards to access
The TAT can be substantially reduced if minor assistance without emergency test results: a retrospective audit. BMJ. 2001; 32:101–3. 
[13] Poon E, Gandhi T, Sequist T. I wish I had seen this test result earlier!
active interference is provided to the patients. This was observed in Dissatisfaction with test result management systems in primary care. Arch Intern
the present study, among the control group of patients. Med. 2004; 16:223–8. 
[14] Rind D, Safran C, Phillips R. Effect of computer based alerts on the treatment and
outcomes of hospitalised patients. Arch Intern Med. 1994; 15:511–7. 

PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of Pathology, North Bengal Medical College, India.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Kalyan Khan,
Date of Submission: Aug 03, 2013
Assistant Professor, Flat no. 11, Bela Apartment, Netaji Subhas Road, Subhaspally, Siliguri -734001, India.
Phone: 9733347243, E-mail: kkhan2001@gmail.com Date of Peer Review: Jan 29, 2014
Date of Acceptance: Mar 12, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Publishing: Apr 15, 2014

8 Journal of Clinical and Diagnostic Research. 2014 Apr, Vol-8(4): FC05-FC08