Productivity Improvement in Pathology Laboratories Using Motion and Time Study Techniques
Canan CINAR, Afsun Ezel ESATOGLU
Department of Healthcare Management, Ankara University, Faculty of Health Sciences, ANKARA, TURKIYE
Keywords: Quality, Pathology laboratory, Productivity
This study aimed to determine the standard time required for the performed job and to examine the standard job critically for
productivity improvement in the pathology laboratory.
Material and Methods: In this study that was conducted at a tertiary teaching hospital, observation, fishbone diagram, and flow charts were
used to collect the information about the job process. All employees were observed from September 2017 to June 2018. The observations were
recorded by video camera in order to overcome the Hawthorne effect. Nine basic procedure steps were followed for productivity improvement.
Results: Within the scope of the study, the jobs of trimming tissue blocks and sectioning of tissue blocks was selected. The standard time
required was 0.19 minutes for trimming tissue blocks and 0.34 minutes for sectioning of tissue blocks. The procedure steps, named Removal
of tissue block and Fixing the block to the device, were removed from the flow chart to define the improved method. The implementation of
the improved method brought in a gain of 11.28 work days per year.
Conclusion: It is obvious that the pathology laboratory needs to take certain measures to improve working conditions and increase efficiency.
Our results demonstrate applying the study techniques could reduce the workload and processing time. This study also shows that the study
techniques can be applied in the hospital laboratory. Incorporation of all pathology technicians in the change or innovation process will be
important in maintaining the achievements.
Issues such as the structural change of population, developments
in science and technology, increased consumption
and needs, limited resources, and efficient use of existing
resources have caused significant changes in all areas
of life (1,2). Recently, there has been growing interest in
improving business processes and assessing performance
for building sustainability. In this context, the techniques
for productivity improvement should be adopted to contribute
to the development of employee and business performances
A number of work study techniques such as time study
and motion study are used to increase productivity and
efficiency (5). Time study and motion study have become
integrated into a widely accepted method in scientific
management. The time study technique is defined as full
observation of workers by using a stopwatch to specify the time required to perform certain tasks. The motion study
technique seeks out to make processes more efficient by
reducing the involved motions (6). The time and motion
study techniques, which improve working conditions and
offer benefits to improve productivity, are implemented
successfully in various industrial and service institutions
including healthcare institutions (2,7-9). Application of
these techniques in healthcare institutions adds efficiency
and quality to service delivery (2,9,10). Reducing errors
in healthcare and removing non-value adding activities in
processes depend on using these techniques (11). So, these
techniques can play a vital role in addressing the issue of
planning, employing, and educating the human resources
needed in the future to provide effective, efficient, and
The most important factor that causes labor force problems
is the change in the demographic structure of the population. A shortage of labor is nothing new in pathology
(12). There has been significant pressure on the service
time because of increasing workload and the employment
of inadequate pathologists (13). Improvements in the
pathology employees skills can provide cost reduction and
high-quality service (14). Quality means increasing the
likelihood of getting the right result in services provided
to the patient in healthcare institutions and organizations
(15). As in classical industry, patient-related quality control
and optimization of working conditions are required
in pathology (16).
To ensure quality, the standardization and continuity of
the work processes in the pathology laboratory will be possible
through time and motion study techniques defining
all the work processes. Despite the importance of productivity
improvement in pathology, no previous study has
employed work study techniques in this field. The purpose
of this study was to examine the standard job for productivity
improvement in the pathology laboratory through
time and motion study techniques. It was thought that this
research will guide the application of these techniques for
healthcare professionals and researchers in future.
The study was conducted in a pathology laboratory that
processes more than 30000 cases (about 20000 surgical
and 9000 cytology cases) annually, including more than
1200 frozen sections. The laboratory was at a tertiary care
teaching hospital in Ankara, Turkey with over 2000 beds,
and it was consisted of four separate laboratories: routine
histopathology, cytology, immunohistochemistry, and
molecular pathology laboratory. About 25 biologists and
technicians worked in these laboratories at the time of the
study. The laboratory served a normal working day of 09.00
to 17.00 hours Monday to Friday (17). This study has been
approved by the Ethics Committee of Ankara University
Two instruments were used to capture work activity:
direct observation by researcher using a time and motion
approach during working hours, and nonstructured observation
used to facilitate collection of detailed information.
Each employee was observed from September 2017 to June
2018 and on different days between 08:00 a.m. and 17.00
p.m. The observations were recorded by video camera in
order to overcome the Hawthorne effect that is known as
behavior change in staff to improve performance (18). The results of the observation were recorded by the researcher
as descriptive notes. All staff had the right to decline to
be observed, and no staff identifiers were used. The video
images were deciphered by the researcher according to the
time study method.
The Research Procedure
There was a set procedure that was followed to achieve success
in the time and motion study investigation. No motion
and time study techniques had previously been performed
in this pathology laboratory. Therefore, the time study
method was first conducted and the motion study method
was then applied to determine the disruptions that
occurred. Nine basic steps were identified in this research
(3). The following steps were employed in the pathology
laboratory (Figure 1).
Step 1: The first step in this research procedure was to
obtain and record all information about the job. The Fishbone
Diagram, which is a visualization tool used for a
cause-and-effect analysis for a certain problem/event (19),
was used to explore possible causes for a problem in the
Step 2: After defining the problems, the job was selected to
evaluate improvement points.
Step 3: Following step 2, the job was separated into elements
to record a complete description of the jobs.
Step 4: In order to identify the sample size for each element,
the statistical method was applied to present a predetermined
confidence level in this study. For the statistical
method, a total of ten preliminary readings were first taken.
Then, the following equation was applied for the 95% confidence
level and a margin of error of 5% (3).
*n= sample size we wish to determine; n1= number of
readings taken in the preliminary study; Σ=sum of values;
x=values of readings
Step 5: For the purpose of this step, the observed time for
each selected job element was calculated by using the flyback
timing method with a stopwatch. In flyback timing,
the hands of the stopwatch are returned to zero at the end
of each element and are allowed to start immediately, the
time for each element being obtained directly. The calculated
observed time for job element was gathered from two
qualified technicians who have acquired the skill, knowl edge and other attributes to carry out the work in hand to
satisfactory standards of quantity, quality and safety (3).
At the same time, the researcher (C.C.) rated the selected
technicians operating speed through observation. Rating
is the assessment of workers rate of working relative
to observers concept of the rate corresponding to standard
pace. The British Standard Scale (0-100 scale) was used in
this step to compare between the observed rate of working
and the standard rate. In this scale, 0 represents zero
activity and 100 the normal rate of working of the standard
rate (3). Each element of the job was rated while the technicians
performed the relevant job. At the end of step 5, the
observed times were adjusted by using the following equation
applied to obtain the basic time for each job element.
Step 6: In this step, relaxation allowances were calculated
to allow the pathology technicians to recover from fatigue,
personal needs, contingencies. Since the issues of fatigue
or other issues could slow down the rate of working (3),
relaxation allowances for fatigue were added to the basic
times for each job. The aim of adding relaxation allowances
to the basic time is that standard time consists of basic time + relaxation allowance + any allowance for additional job
elements (3). To calculate relaxation allowances to compensate,
Tables of Comparative Strains were taken as reference
to allocate a standard time for each element by using
the following equation:
Step 7: For determining the standard time of a job, the
researchers calculated the total time that is needed to complete
the selected job.
Step 8: Critical examination was conducted to apply more
Step 9: The final step was to define an improved/new method.
In this step, it was aimed making the standard job more
effective and explain the improved method to the pathology
laboratory professionals and management.
Times for each job element were calculated with a stopwatch
and recorded. The sums of the times of all the elements
and activities were transferred into study summary
|Step 1. Collecting All Information about the Job
A fishbone diagram was used to identify the possible causes
of a problem and to collect all information about the job
in the laboratory. The causes of the problems that led to a
heavy workload were identified through observations and
brainstorming with technicians. The factors leading to a
heavy workload were determined as not checking records,
lack of technical knowledge, complexity of the process,
and lack of education about the machine in the laboratory.
The fishbone diagram revealed that the technicians caused
many of the problems in the laboratory (Figure 2
Step 2. Selecting the Job
Selecting the job to be studied is the common step in both
time and motion study. The standard times are required
to analyze efficiency of the original method (3). Therefore,
the jobs of trimming tissue blocks and sectioning of tissue
blocks were selected to determine the standard time and
examine the job critically.
Step 3. Breaking Down the Job into Elements
After all the information about the job was recorded, the
next step was breaking the job down into elements (3). The selected job named trimming tissue blocks consisted of
repeating three stages as: A-Fixing the block to the device,
B-Trimming tissue block and C-Removal of tissue block
while the other job named sectioning of tissue blocks
was separated into six phases as: D-Fixing the block to
the device, E-Sectioning tissue block, F-Floating the sections
on surface of the water, G-Removal of tissue block,
H-Taking the section on a microscope slide and I-Cleaning
surface of the water. A total of nine job elements were
observed within the study (Figure 3).
Step 4. Determining the Sample Size
The required sample size for the trimming tissue blocks
job was at least 85 observations, and for each element of
sectioning of tissue blocks at least 67 observations were
required to ensure that the results are within ±5% accuracy.
Step 5. Measuring the Basic Time
After the elements were selected and recorded, measuring
the basic time step was started. The measurement of the
basic times for each element of trimming tissue blocks
based on 85 routine specimens were obtained from two
qualified technicians. The basic times for each element
of trimming tissue blocks were as follows: A-Fixing the
block to the device (0.01 min.), B-Trimming tissue block (0.05 min.) and C-Removal of tissue block (0.02 min). The
total basic time for trimming tissue blocks was 0.16 minutes.
The measurement of the basic times for each element
of sectioning of tissue blocks were based on 67 routine
specimens obtained from two qualified technicians. The
basic times for each element of sectioning of tissue blocks
were as follows: D-Fixing the block to the device (0.02
min.), E-Sectioning tissue block (0.08 min.), F-Floating
the sections on surface of the water (0.03 min), G-Removal
of tissue block (0.02 min.), H-Taking the section on a
microscope slide (0.06 min.) and I-Cleaning surface of the
water (0.02 min). It was found that the total basic time for
sectioning of tissue blocks was 0.28 minutes (Table I).
Step 6. Measuring the Relaxation Allowances
The derivation of the relaxation allowances was based on
the data produced from Tables of Comparative Strains. Allowance was calculated on the job elements. It can be seen
from Table I that the total relaxation allowance amounted
to 0.02 minutes for trimming tissue blocks and amounted
to 0.05 minutes for sectioning of tissue blocks.
Step 7. Determining the Standard Time
By gathering the basic time and relaxation allowance, the
standard time required for trimming tissue blocks was
0.19 minutes, and was 0.34 minutes for sectioning of tissue
blocks (Table I).
Step 8. Examining the Standard Jobs
There were fundamental problems in the job processes
while examining the standard job critically. When the job
processes were thoroughly examined, it was specified that
all technicians first trimmed all tissue blocks. In job process,
the job steps C and D were repeated by technicians each time. So, the tissue blocks contacted water approximately
30-60 minutes till the phase of sectioning of tissue
blocks. This issue caused problems in the diagnosis
of the disease during the microscopic examination due to
exposition to water for a long time. Also, in the sectioning
of tissue blocks step, the technician should compare
the block and microscope slide number to avoid confusion
and contribute to better quality results in the output. It was
observed that the technicians avoid performing the checking
the records process to reduce processing time.
Step 9. Defining Improved Method
The improved method is defined in Table I. To make
the standard job more effective, the steps C and D were
removed from the flow chart. It would be a gain of 0.05 minutes in the process time and 0.8 meters in the process
distance. This would reduce the workload of the technicians
and help the pathologist to make the diagnosis on time. So,
the checking the records was added in the sectioning of
tissue blocks step to improve the productivity (Table II).
The implementation of the improved method brought in a
gain of a total of 11.28 days (10.42%) in the number of days
worked per year (Table III).
This study evaluated the time and motion techniques performed
in a pathology laboratory. Although few published
studies have examined the productivity by work study techniques
in healthcare institutions and organizations, there is
no published study about these techniques in the literature of pathology. The aim of work study is to increase productivity
in order to enable the transformation of inputs into
outputs. The basic graphics and schemes used in work study
were communication tools (5). All the information about
the job, activities and times were recorded with workflow
chart, study summary sheets and time study form in this
study. These forms and diagrams were thought to offer a broad perspective to management to see how the process
works. Identifying duties and responsibilities of laboratory
physicians provides information for workload allocation
and workforce planning (20).
Taking measures for improving the quality of produced
job, developing standardization, early detection of problems,
and minimizing the errors have become a part of
everyday life (21). Standardization of the work done in
the pathology laboratory is an important consideration
for improved efficiency and productivity. With the help
of job study techniques, standardization can be achieved
by identifying the work done in the process and separating
the work into its elements (22). In this study, it was found
that many problems such as not checking records, lack of
technical knowledge, complexity of the process, and lack of education about the machine result as a heavy workload.
The previous studies have shown that problems with lack
of materials and devices, and problems with equipment
supply, cleaning and information are the causes of waste in
the pathology laboratory (23,24).
We determined that the jobs of trimming tissue blocks
and sectioning of tissue blocks consisted of nine workflow
steps. Within the application of the time study technique
in this study, the standard time taken to each job in a
pathology laboratory was determined. Our results showed
that the standard time of trimming tissue blocks was 0.19
minutes and sectioning of tissue blocks was 0.34 minutes.
A study conducted by Eriguc (25) aimed to find the time
spent on the glove preparation in the sterilization section
by using the time study method and they reported that the
total time spent on glove preparation as 86.11 seconds.
Another study performed in a private hospital based on the
time study technique aimed to determine the number of
daily scrub and nurses needed for performed operations.
The authors have found that the duration of the operation
was 2 hours and 53 minutes and the number of operations
was an average of 16.4 a day. According to these results, a
total of 29 nurses were needed to perform operations (26).
In a time study, Sahin et al. (27) investigated a study about
workload in terms of nursing activities and the number
of nurses required. This study demonstrated that 7 additional
nurses were needed in the internal medicine department
of a training hospital. In another study conducted by
Ozkan and Uydaci (28), work study techniques were used
to determine the need for radiology technicians working in
hospitals. The study reported that the average examination
time for conventional X-rays was 5 minutes, and the current
number of radiology technicians should be increased
by 17% to meet the standards set.
Time is one of the valuable resources for hospitals. How
health care workers spend their time is important for quality
and efficiency. Work study helps to classify activities in
the delivery of health services (2,11). Removing non-value
adding activities in the pathology laboratory contributes to
the effective usage of natural resources and staff resource
planning (29). Considering the total number of sectioned
tissue blocks in 2015 (n=194.800), the time spent on sectioning
of tissue blocks was 120 days. A study conducted
by Melgar et al. (9) used time and method study techniques
to determine the time spent on clinical activities by physicians.
The study revealed that physicians spent less than
half of their time in the clinic with medical assistants. The
results of another study revealed that nurses allocated a significant
part of their time to service work and personal
The most obvious finding to emerge from this research is
that redescribing the job processes in the pathology laboratory
though the motion study technique provided process
time and distance improvements. The processes and procedures
were examined with the motion study technique in
this study. Within the motion study method, it is easier to
find out the areas of improvement if the process is examined
thoroughly. This study determined that there would
be a gain of 0.05 minutes in the process time and 0.8 meters
in the process distance with the proposed improved method
instead of the original method. Another important finding
was that the implementation of the improved method
in the pathology process with the motion study technique
led to a saving of approximately 12 days a year. This result
represents important time savings considering that pathology
technicians work with small biopsy specimens. In the
study conducted by Bircan and Iskender (30), the time
study technique was used to evaluate the productivity of
the endoscopy procedure in the department of general
surgery at a research hospital. This study revealed that the
standard time of the endoscopy procedure for the patients
where a biopsy was taken to be 15 minutes. However, if the
new method was applied in accordance with the proposed
methods, the processing time would be reduced. Thus,
the number of endoscopies performed in a day could be
increased from 9 to 15. Another study conducted by Durur
and Akbulut (23) was carried out in a pathology laboratory
at a public hospital in Turkey and the authors have claimed
that rate of waiting time would be reduced from 73.6% to
69% through eliminating the causes of waste in the pathology
The current study focused on the productivity improvement
in a part of the pathology laboratory. It is obvious that
the pathology laboratory needs to take certain measures to
improve working conditions and increase efficiency. In
order to ensure quality and standardization, it would be
possible to define all the job processes that take place in the
pathology laboratory, and to determine the rules and principles.
In the creation of the pathology report (15), which
is the product of the pathology laboratory, the knowledge
and skills of the pathologists are equally important as the
laboratory conditions in which the material is prepared
(31). For the complete, accurate and timely preparation of
the pathology report, the steps during the period until the
report reaches the clinical physician must be performed
under standard conditions (32). In pathology laboratory
studies, the role of technicians is very important in all
processes. For this reason, no other laboratory specialty is
technician-dependent as much as pathology. If the number
and quality of technical elements are not sufficient, the risk of erroneous results is quite high (33). Also, our study
demonstrates an improved method to access productivity
improvement in a pathology laboratory. Further studies
should focus on the whole process (including the pre-analytical
and post-analytical stage) to present a comprehensive
evaluation for problems in pathology. Incorporation
of all pathology technicians in the change or innovation
process will be important in the continuity of the achievements.
Conflict of Interest
All authors confirm that there are no conflicts of interest.
We thank Prof. Dr. Aylin Okcu Heper, Prof. Dr. Isinsu Kuzu, and all
pathology department staff for their contributions.
This study was supported by the Ankara University Scientific
Research Projects Coordinatorship.
Concept: CC, AEE, Design: CC, AEE, Data collection or processing:
CC, Analysis or Interpretation: CC, AEE, Literature search: CC,
Writing: CC, Approval: CC, AEE.
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