3-2.Laboratory automation systems from a hospital management point of view

Due to marked advances in medical technology and the rapid progression of the aging of Japanese society, the contents and state of the Japanese medical system has been on the decline in recent years. Under these circumstances, and the nation's economic conditions, medical systems are under pressure to adapt to various changes.
During the period of Japan's rapid growth, the Japanese medical system was supported by the economic resources of the nation and each medical organization was guaranteed profitable operations, extension of facilities, and implementation of expensive medical equipment. As a result, medical standards increased rapidly, thus inadvertently contributing to the aging of society at a rate unprecedented in any other country. Nonetheless, supply created demand, which created large debts that have caused the current slow growth phase.
Recently, to differentiate functions and combine facilities, the Japanese government has been attempting to consolidate medical costs, expand the flat-rate system, integration of streamline institutions, and promote the sharing of expensive medical equipment. Furthermore, after the latest reforms of medical regulations, it appears that the Japanese government is attempting to bring the basic framework of medicine, such as specialized hospitals, local hospitals and social care insurance, under manageable control, and institutions that do not fit into this framework are managed at the discretion of each medical organization.
Thus, trends in the national medical system are markedly affected by the economic strength (or lack thereof) of the nation. In addition, it is also important to keep in mind that a change from a high growth economy to a low-growth economy does not simply represent quantitative changes, but also qualitative changes. If "management" means to change administrative strategies along with changes in the economy, then management ability is tested in this age of qualitative changes. Hence, it is necessary to clarify the nature of the change and to form effective strategies to tackle it.

There were no public medical organizations in Chikuho district at the end of the Meiji era, and people who required special medical care had to go by a buggy on a winding road over a mountain range to a university hospital in Fukuoka. The concept of public sanitation was not widespread at the time, and anti-infection measures were underdeveloped. Due to the emergence of modern industries, the number of tuberculosis patients had also increased alarmingly, which become a social problem.
Under these circumstances, the grandfather of the present president of Aso Cement Co., Ltd., Takichi Aso built a hospital (comparable to a country hospital) by himself so that people in the county could receive excellent medical care from good physicians.
Our present hospital has developed based on our founder's spirit and continued to serve the citizens of Iizuka city and Chikuho district.
At present, Iizuka hospital has 25 departments and 1,157 beds, and treats 2,300 outpatients a day. In addition, by an appointment from the prefecture of Fukuoka, this hospital also serves as the Chikuho Emergency Center. It is also important to mention that this hospital is one of the few companys, Aso Cement hospital built by a corporation.

Management consists of improving operations in accordance with changes in the operating environment, so concepts such as profitability and public utility are irrelevant. Therefore, even though medicine itself is a form of public welfare, the management technique used by private companies should also be effective in managing hospitals. As hospitals were basically not focused on making profits in the past, economically valid management systems were not widely implemented. In this age of qualitative change, however, hospitals need to begin implementing economically sound management techniques.
Since Iizuka hospital was run by a corporation, management techniques used by regular businesses have been used. In addition, in order to respond to economic changes, the implementation of Business Process Re-engineering (BPR) has also been considered.
BPR attempts to reduce costs markedly and to create new valuable production processes by drastically improving the efficiency of value creation. As a result, the subject of BPR includes not only laboratory services, but also overall hospital management and people who live near the hospital.
Quality assurance, satisfactory services and stable management are the common goals of all medical organizations regardless of their size and the characteristics of the area. Nonetheless, these goals often contradict each other in actual applications, making realization difficult. BPR is an important concept in the achievement of these goals, for which personnel and information systems that support BPR are also necessary.
The strategic plans of Iizuka hospital are total quality management (TQM) and computerization.
The decision as to whether or not to invest in a specimen transportation system and LAS was based on the strategic plans formed according to BPR principles.

To some degree, medicine is information processing, and clinical laboratories deliver information that is used to make diagnoses and treatment plans. Therefore, it is essential to invest money in laboratory computerization in order to obtain high quality information and ultimately to ensure high quality medical care, so the systematization of the entire laboratory, including specimen transportation system, is important. The following six points are essential to delivering high quality information services.
High Quality

1. Timeliness
2. Economically sound
3. Applicability
4. Convenience
5. Safety

When evaluating the role of a laboratory within medical services, rationalizing and improving laboratory operation leads to the systematization of medical information. The systematization of medical information is an important element in providing patient-oriented medical care. Since specimen transportation systems perform the basic role of clinical laboratories, specimen transportation systems will continue to play a large role in the systematization of laboratories from the viewpoint of hospital management. Therefore, it is important to invest from the viewpoint of BPR, as well as to improve the efficiency of current laboratory services.

When investing a large amount of money, such as the case with specimen transportation systems, cost reduction is discussed first, but it is also important to evaluate cost performance. Hence, the effectiveness of specimen transportation systems must be examined from many angles. The effect of LAS implementation on running costs is assessed using actual numbers. Based on our performance in 1996, it is predicted that 25 million yen (16.9%) will be saved in reagents (biochemistry, STAT, TDM, RI, EIA, serum coagulation and transfusion), and another 25 million yen (12.5%) in labor costs (reducing the workforce by five technologists). In particular, reagent costs can be lowered by about 20% to 30% by utilizing single multi-analyzers instead of super multi-analyzers, and the costs of consumable supplies such as aliquot tips can also be markedly reduced. Therefore, it is possible to save about 50 million yen by implementing a specimen transportation system, and since specimen transportation accounts for about 64% of laboratory operations, indirect effects can also be expected.
In particular, increases in the degree of flexibility of laboratories operation brought by the implementation of a specimen transportation system greatly affect laboratory operation (e.g., routinely processing night-time STAT tests, decreasing specimen exchange errors, and solving problems associated with the exposure of bio-hazardous materials to medical technologists). Furthermore, if a specimen transportation system can easily be customized for each laboratory, it is easy to improve the efficiency of laboratories. Nonetheless, the biggest advantage of implementing a specimen transportation system is that test results are promptly delivered to patients. Therefore, to further improve the efficiency of laboratory operations by BPR, reduce running costs, and deliver prompt and high quality medical information to patients, the efficiency of laboratories needs to be evaluated by quantifying all aspects of laboratory operation such as, time, workforce, materials. Even though specimen transportation systems can appear to be a considerable big investment, it is necessary to assess their objective and effect accurately.

Note from the editor: a specimen transportation system comprising two single multi-lines (biochemical, immunology, coagulation, fibrinolysis and urinalysis line, and blood line) is planned to begin operation in October 1997 (Figure 1).

Figure 1. Structural diagram of Iizuka hospital's system

The information system of clinical laboratories is roughly divided into two parts, specimen transportation systems and laboratory information systems. Both of these subsystems are deeply involved in laboratory operation, so it is important to evaluate them as an integrated information system. At Iizuka hospital, we are planning to construct an original medical information system that considers the compatibility of the ordering system and medical accounting system, rather than concentrating on specific labor savings. Furthermore, we are planning to store medical information in databases, and to facilitate the common usage of information by establishing local medical information networks.

This is our duty as the main local hospital, and at the same time, this will lead to the creation of new information routes. Furthermore, to guarantee the quality of medicine and respond to Diagnosis Related Groups (DRG), we are attempting to standardize medical care. The success of consolidated medicine is dependent on the construction of strategic medical information systems.
The third reform of Medical Service Regulations is expected soon. Local medical information networks are being constructed and the existence of hospital laboratories is being reexamined. Although outsourcing and branch laboratories are always being compared, when considering the societal position of primary local hospitals, outsourcing that achieves only cost reductions should be avoided. On considering STAT and urgent tests, it is detrimental to make clinical decisions based solely on economic considerations. The advantages of hospital laboratories should first be examined on the basis of BPR.
In any case, it is not possible to truly improve the efficiency of a clinical laboratory by simply improving the efficiency of laboratory operations. Rather, it is important to provide high quality tests to patients and contribute to patient-oriented medicine through BPR principles. Investment in the systematization and computerization of laboratories is a large step forward in ensuring quality, enriching patient services, and stabilizing hospital management.

Ever since the second reform of Medical Service Regulations in 1992, there has been a movement to clarify the assigned role of medicine. "Hospital-Clinic" / "Hospital-Hospital" cooperation. Nonetheless, this does not mean that all medical organizations fall under the category of an integrated public management system. In particular, private hospitals are forced to establish a system based on the ideology of their founders and the characteristics of the local area. Iizuka hospital's goal is to contribute to the establishment of a healthy, cultural city, and to function as a key hospital of the area. Iizuka hospital hopes to provide acute-phase and emergency medicine and clinical training, as well as to function as the core center of the local medical information network, so that we can truly serve patients in the area. Not only will this hospital provide specialized medicine, but also establish a unique comprehensive hospital management system, so to speak, Iizuka hospital method.