Clinical Chemistry 46: 784-791, 2000;
(Clinical Chemistry. 2000;46:784-791.)
© 2000 American Association for Clinical Chemistry, Inc.
Laboratory Automation and Optimization: The Role of Architecture
Alexander K. Wing1
1
Burt Hill Kosar Rittleman, 400 Morgan Center, Butler, PA 16001-5977
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Abstract
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The increasing automation of laboratory equipment has had far-reaching
impacts on the organizational structure and spatial requirements of
clinical laboratories. This report explores the changing role of the
laboratory in the healthcare environment and shows the architectural
impact of these changes, both inside and outside of the laboratory
space.
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Introduction
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A brief review of healthcare architecture shows a progression from
generalized, multifunctional spaces toward complex facilities designed
to accommodate a large number of specialized functions. A parallel
trend is evident in the evolution of clinical laboratories. Most
contemporary hospitals have several specialized laboratories, each with
its own organizational (and spatial) structure. Automation is changing
this, and along with it, the organizational, economic, and spatial
structure of diagnostic testing services.
The effects occur across organizational and architectural scales.
Broad-scale effects include the simultaneous proliferation of
point-of-care (POC) testing and total laboratory automation.
Reconciling the potential conflicts between these two approaches is one
of the first tasks in developing an integrated laboratory design
strategy, and it includes an analysis of both economic and technical
data. Perhaps the most critical issue to be addressed at this stage is
the effect of new sample collection, testing, and result distribution
methods on traditional laboratory organizational boundaries. Additional
issues to be addressed at this scale include the coordination of
transportation and information infrastructures with laboratory
services.
Similar changes occur at the scale of the laboratory itself. The
effects include the movement away from discipline-specific,
bench-intensive laboratories to consolidated core laboratories serving
multiple disciplines. Issues to be addressed at this scale include
internal workflow patterns and infrastructure flexibility.
The architectural design process, properly managed, offers laboratory
managers a comprehensive means of addressing these issues. Moving from
generalities to specifics, the process helps ensure that healthcare
systems address the technical and organizational challenges presented
by the new technologies. The opportunities for management of these
changes offered by this process include master planning (and associated
facility audits) and collaborative design efforts, both of which give
healthcare systems the opportunity to take stock of the impact of new
technologies on the way they work. These tools, combined with proper
administration of the schematic design, design development,
construction documentation, and construction administration processes,
help ensure successful projects. Other opportunities include the
extension of the process into a comprehensive and ongoing facilities
management effort. Ultimately, the architectural coordination of the
spatial needs of people with the infrastructure requirements of
automation is a valuable complement to any strategic planning effort,
and it offers an opportunity to reexamine the role of the laboratory in
the overall healthcare system.
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Hospitals: A Brief History
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Historical analysis of the evolution of hospitals reveals
parallel, conflicting trends. On the one hand, hospitals have demanded
increasing functional differentiation and specialization from spaces.
On the other hand, the technical requirements of these functions have
been in a constant state of flux, requiring greater flexibility from
the technical infrastructure of the buildings. This trend, in which
accelerated functional differentiation in served spaces demands less
particularity from the associated "servant" spaces, is paralleled
in most building types. In the case of hospitals, it has recently given
rise to federal mandates regarding the use of highly flexible
"interstitial" floors dedicated entirely to technical
infrastructure in all new Veterans Affairs hospital facilities.
Until the 17th century, "hospitals" consisted primarily of large
halls, with support services supplied by adjacent religious or military
institutions. During the 17th century, various functional segments of
the hospital were differentiated into separate pavilions, an approach
that has persisted until the present day. Florence Nightingale improved
on this idea in the late 19th century by subdividing patients into
smaller wards, complete with beds, nursing staff, and adequate
ventilation. Her original models for the improvement of hospitals were
the farmhouses of the Crimea, where she observed lower mortality rates
among the soldiers she treated in the vacated buildings (1).
Ten years after Florence Nightingale’s revolutionary documentation of
the beneficial effects of ventilation and sanitation on human health,
Drs. Drysdale and Hayward of Liverpool began some of the first
scientific studies of integrated air control systems for buildings.
Their houses, which they documented in the pamphlet Health and
Comfort in House-Building in 1872, were said to include systems
that were the precursors to modern heating, ventilation, and air
conditioning (HVAC) systems (2). Indeed, until the
advent of modern air conditioning techniques in the 1950s, most
hospitals were designed like large houses, relying on vertical stair
shafts and cross-ventilation for comfort (Fig. 1
). The legacy of these buildings, which had little space devoted
to building systems, is all too visible in the lowering of ceilings in
older hospitals to accommodate modern air conditioning and fire
suppression systems (Fig. 2
).
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Figure 1. Narrow upper floors of a modern hospital building show
reliance of early 20th century hospitals on cross-ventilation for
climate control.
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Figure 2. Renovated lower floors of the building in Fig. 1
show the
impact of modern air conditioning on hospital plans.
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Modern Trends
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The increasing complexity of the architectural program, and the
corresponding complexity of the engineering infrastructure, has
rendered most older hospital buildings extremely resistant to new
technology. Dedicated diagnostic and treatment areas, intensive care
units, and outpatient departments are all relatively recent additions
to the basic hospital program. The introduction of numerous additional
diagnosis/treatment areas resulting from recent trends in healthcare
economics has not helped the situation. Hospitals are fast running out
of room to accommodate new engineering systems (1).
A similar trend has taken place within the clinical laboratory itself.
Modern laboratory design had its beginnings in the late 19th century,
and is characterized by a modular arrangement of benches, cabinets, and
fume hoods (Fig. 3
). Primary laboratory planning texts go to great lengths to
describe the use of human ergonomics to derive the ideal laboratory
planning module (~10.5–11.5 feet2). This
module allows two laboratory workers to work back to back at benches,
with space for a third to pass between them. The primary assumption of
this system is that most laboratory activities involve the manipulation
of materials and apparatus at the bench. The system is ideally suited
to laboratories with large quantities of fixed casework and relatively
small apparatuses built from easily handled components. All laboratory
utilities (e.g., water, gas, vacuum, electricity, and waste)
are coordinated with the module, usually by integration into fixed
casework systems. Originally, a hospital would have several of these
types of laboratories, each devoted to a specific diagnostic
discipline. Over time, many clinical laboratories have abandoned the
rigid ergometric module in favor of open plan settings more conducive
to the use of large analyzers (Fig. 4
). Although this has allowed for a more flexible
arrangement, it has generally been at the expense of the rational
coordination of laboratory utilities.
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Figure 3. Classic laboratory planning practice is based on an
ergonomic module designed to optimize the movement of people.
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Figure 4. Automated laboratories often sacrifice the ergonomic
module in favor of plans designed to optimize the performance of
automated materials systems.
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Simultaneously, as the rational planning module has lost importance, so
too have many of the traditional boundaries between disciplines.
Previously distinct groups are under increasing pressure to pool
resources and share equipment and space. The result, if not carefully
controlled, often is clinical laboratories whose ad hoc planning
mirrors that of many of the older hospitals we all love to hate. In
addition, to further complicate matters, it appears that, in today’s
economic climate, the optimal distribution of laboratory services will
consist of a complex combination of centralized and decentralized
functions. The coordinated coexistence of POC testing, central
laboratory services, and large-scale commercial laboratories, along
with advances in automated diagnostic technology, promises to improve
both the profitability and quality of care in many healthcare systems.
However, it has also brought along with it architectural challenges
that must be carefully managed to achieve the full benefit of these
technologies.
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The Architectural Design Process
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The architectural design process offers an opportunity to
simultaneously address the spatial, technical, and organizational
implications of increasing automation. When coupled with strategic
planning efforts, it can help facilitate organizational reorganization.
Conversely, strategic planning efforts can help facilitate
architectural reorganization by identifying critical trends in space
utilization.
Generally, architectural design progresses from large-scale to
small-scale issues, although a good designer will continually validate
most decisions across a range of scales. As defined in the American
Institute of Architecture manual of practice, the process
consists of a series of specific steps. These steps, listed below, have
implications for the successful implementation of automation
strategies.
The steps in the architectural design process include the following:
- Predesign
- Site analysis
- Building design
- Construction documentation
- Bidding and negotiation
- Construction administration
- Postconstruction services
- Supplemental services
predesign
Predesign, generally the first step in a design sequence, includes
the following primary tasks: (a) facilities planning and
programming; (b) financing and financial feasibility; and
(c) project scheduling and budgeting.
site analysis
Like predesign, site analysis deals with large-scale issues such
as site selection and programming. Perhaps the most important issue to
be dealt with for a clinical laboratory system at this scale is the
current and projected demand for service. The matching of service
demands with a delivery system has important implications for
architectural (and organizational) planning purposes. Automation has
brought with it economies of scale that are driving clinical testing
practices toward the creation of consolidated laboratories serving
multiple hospitals. However, it has also brought along with it the
potential for remote operation and validation of POC devices with large
testing menus, shifting demand for testing back to the bedside.
Bracketed by these two testing venues, automation promises to greatly
increase the efficiency of hospital-specific core laboratories by
allowing the processing of standardized test panels simultaneously with
the performance of more esoteric tests.
What is clear is that, given the rapid advances in automation
technologies, the volume of testing services to be performed in each of
these venues will be in a state of flux well into the future. Combine
this with shifting demographic and medical demands, and the only
certainty is that to protect investments, clinical laboratory systems
should be designed for maximum flexibility, allowing for a continual,
dynamic adjustment of the location of testing services. Implications
for site design include (a) an assessment of the
relationship of specimen transport networks to the laboratory site;
(b) an assessment of staffing needs for parking,
transportation, and other services; and (c) an
assessment of the impact of future expansion/contraction on the
laboratory facility. Where possible, a site should be selected that
will allow for easy expansion and future remodeling. Examples include
spaces with adjacent outdoor open areas, or floor areas bounded by
"generic" space, such as offices or storerooms. Additional concerns
that should be assessed at this time include site security and the
ability to shield sensitive equipment from unwanted environmental
influences, including vibrations, climatic variation, and
electromagnetic interference.
The dynamic nature of laboratory demand also influences the products of
predesign. The facilities planning and programming exercises that
generally occur during predesign must not only document current demand,
but must also define likely scenarios for expansion and/or contraction
of laboratory facilities. To achieve the best product, it is important
to involve multidisciplinary teams in the production of programming
documents. Decisions made at this stage may have unexpected impacts
later in the project; so it is important to develop "buy in" among
all players at this point. Unfortunately, consensus among building
owner/user groups does not always ensure good decisions. Common
mistakes result from the tendency to overcompensate for shortcomings in
existing facilities. A good program optimizes facilities use, fully
accommodating user needs without being wasteful. A well-orchestrated
design effort can help achieve this by clearly separating brainstorming
and planning tasks.
Other important products of the predesign phase may include schematic
flow diagrams, which document critical spatial and organizational
relationships. Automation, because of its ability to accommodate the
needs of previously distinct diagnostic specialties at a single device,
effects the structure of these diagrams. Laboratory
consolidation/reorganization clearly affects departmental relationships
throughout the hospital. Predesign is the appropriate time to map out
new relationships, including detailed work-flow and process analysis
(Fig. 5
). It is also important to analyze potential future
scenarios for departmental relationships at this point. This will
ensure that an appropriate level of flexibility is designed into any
new office and laboratory support spaces. Studies should assess the
impact of changes on specimen and materials volumes on all departments.
Finally, it is important to generate accurate facilities surveys at
this point.
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Figure 5. Preliminary analysis of existing materials flow and
general building organization is a critical part of the predesign
process.
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These surveys, or facilities audits, allow designers to assess the
carrying capacity of the building infrastructure. Depending on the
condition of the buildings in question, these surveys should generally
precede programming, thus allowing the program to be adjusted to the
reality of available facilities. Perhaps the most important issue to be
addressed at this point is the ability of the existing structure to
accommodate the creation of large open areas without disrupting the
overall organization of the building. This is particularly challenging
in older hospitals, where narrow wings with central corridors make it
very difficult to create the large open floor plates required by
automated laboratories. Additional issues that must be addressed at
this time include the ability to move materials, and the ability of
building mechanical, electrical, and plumbing (MEP) systems to
accommodate reconfiguration. In addition, an assessment of the
condition of the electromagnetic environment is wise at this time,
including an evaluation of primary sources of interference. In cases
where wireless networking is being considered, a full spectrum analysis
will help identify appropriate frequencies for network transmission and
will help network designers to identify appropriate technologies.
By pinpointing critical limitations, this type of comprehensive survey
can help identify an appropriate path toward the integration of
automated testing technologies. Finally, project schedules and budgets
are set during the predesign phase, after an assessment of finance
sources and financial feasibility studies. The goal of all of these
efforts is to achieve a thorough understanding of the limitations and
opportunities inherent in the existing conditions of the laboratory
site.
building design
This portion of the project encompasses schematic and design
development phases. It is during this period that specific spatial
configurations are evaluated and developed (Fig. 6
). As noted above, automation appears to be moving
diagnostic testing toward a dynamic balance between three primary
venues. This "distributed laboratory" system balances the need for
rapid turnaround (with associated reductions in hospitalization
periods) with the economies of scale associated with large centralized
laboratories (3).
At this scale, it is critical to assess the real impact of the
materials management and information management infrastructure demands
of automation. These systems, because of their large impact on result
turnaround times (and associated labor costs), are the primary
architectural determinants of the optimal distribution of laboratory
services.
Materials handling systems range from pneumatic tubes to track-based
systems, mobile robot systems, and human messengers. The selection of a
system has a large impact on the design of the building that will
accommodate it (the converse is also true). The ability of any system
to adapt to changing usage patterns should be addressed during the
schematic design phase, along with the ability of the system to serve
immediate needs (Fig. 7
). At a minimum, the system must be extremely reliable,
with an appropriate match between materials transport volume and speed
and the processing capabilities of the central laboratory. A primary
architectural consideration is the ability of the system to adapt, both
to changing needs of the laboratory and to changes in the configuration
of other spaces and systems adjacent to the transport mechanism.
Buildings with well-coordinated mechanical and equipment spaces are
likely to be well served over the years by intelligently designed tube
or track systems, whereas many older buildings may be better served by
mobile robots. Mobile robots, with their ability to adapt to changes in
building configurations via software, appear to offer the most flexible
solution for materials handling in large, complex facilities. However,
it is critical that their movement paths be planned to eliminate
potential interference with primary life safety routes and fire zoning.
This requires consideration of the ability of the robots to open doors
separating fire zones or to negotiate obstructions (such as
inadvertently closed doors) in their routes. Although these issues are
primarily the concern of the robot designers/manufacturers, a
well-designed building can help eliminate potential problems.
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Figure 7. Materials handling strategies should be coordinated with
basic laboratory layouts for each of the disciplines using the
automated laboratory.
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All of these materials handling systems should include a designated
"terminal", or receiving/handling area at either end of the
materials route. It is important that these points be strategically
located during schematic design. Locational considerations include the
separation of hazardous materials handling from public areas, and the
ability to accommodate future automated loading and unloading
mechanisms. At the very least, areas of the floor plan should be
designated for these functions, and ergonomic/mechanical studies should
be performed to determine the best possible interface between machines
and people in these locations.
Along with materials handling networks, information handling networks
form the backbone of the automated laboratory system. These networks
bring with them a host of architectural challenges, including the
provision of adequate expansion space and the control of
electromagnetic interference. Systems inside the core laboratory should
be designed to allow periodic revision of wiring without major spatial
disruption. However, the real challenge lies outside of the core
laboratory, in the link between the POC and the laboratory information
systems. Here, the coordination of cabling with other building systems
grows more difficult. This is complicated by the trend toward wireless
testing apparatus, making it necessary to design a solution that
minimizes the impact of electromagnetic interference. At the schematic
design phase, issues that must be addressed include the evaluation of
the practicality of wireless/wired networks. Depending on the extent of
wireless networking, it may be necessary to devise a means of
minimizing interference from other devices (especially pagers and cell
phones) by means of spatial zoning and shielding. Although a
specific discussion of wireless networking technologies is beyond the
scope of this report, the difficulty with these systems lies in the
tendency of different radio signals to mix, producing intermodulation
products across the radio spectrum. This process, called heterodyning,
is very difficult to predict in relatively noisy radio environments.
Although electronic filtering and error correction technologies promise
to help deal with the problem, any facility considering wide ranging
use of these systems should have a thorough evaluation of the
feasibility of the systems within their specific electromagnetic
environments. Any evaluation should consider, at a minimum, the
following potential sources of interference:
- radio transmitters (both inside and outside of the hospital);
- broadcast stations;
- radiofrequency interference from equipment (e.g., electro-static
units);
- hand-held radios;
- cellular telephones;
- digital PCS systems;
- poorly installed or unshielded computer network cables; and
- telemetry systems.
Other infrastructure requirements of automated systems that must
be addressed at the schematic design phase include the development of
flexible design strategies for MEP systems. Depending on the scale of
the project, this may include the division of the building into primary
served/servant zones, such as those found in the interstitial designs
mandated by the Veterans Administration.
At a minimum, the need for future flexibility should impact the zoning
of the plan of any centralized core laboratory facilities. Radial
plans, centering around the sample entry point, have two drawbacks in
this respect: They make it difficult to insert new machinery without
displacing other equipment, and they spread floor and ceiling
penetrations across a large area, increasing the chance that revisions
to the space will impact areas above and below the laboratory. These
plans, however, do an excellent job at rationalizing the movement of
materials and workers from sample accessioning to analysis, and show
the impact of automation on the organization of laboratory workers
(4). Several possibilities for laboratory layout should be
explored at this stage, with close attention paid to the impact of
analyzer groupings on both human movement and efficiency, and the
ability to adapt to future changes in configuration. In addition, the
proposed distribution of laboratory tasks (e.g., POC vs core laboratory
vs consolidated laboratory) should be checked against the proposed
schematic design at this stage to ensure adequate capacity across the
entire system and the ability of components of the system to adapt to
changes in demand. This type of analysis helps confirm the assumptions
for the project at hand, regardless of its specific scope.
In addition to basic laboratory layout and infrastructure strategies,
it is also important to address the impact of laboratory consolidation
on associated office and support spaces at this time. Numerous
solutions should be studied, with an eye toward developing a flexible
solution capable of efficiently adapting to future needs. This may
include the consolidation of office areas or the creation of dedicated,
centralized monitoring areas for POC devices. Additional strategies
include the development of generic, team-oriented work spaces similar
to those found in corporate offices. These areas, combined with generic
workstations, allow rapidly changing organizations to balance the need
for constant communication and team orientation with needs for
individual privacy.
During design development, the basic relationships developed during the
schematic design are clarified. Materials and information handling
systems, typically selected at the end of schematics, are integrated
into a comprehensive design. Specific solutions are developed, tested,
and selected.
In terms of materials management, this should include flexible
solutions to the transport interfaces, currently one of the major
bottlenecks in any automated laboratory system. At a minimum, this
should include an efficiently designed unloading/specimen delivery
area, separated from public circulation. Depending on predicted
specimen load, it may be necessary to allocate adequate space and power
for future robotics. If they are not yet automated, in most cases,
adjacent specimen sorting and accessioning areas should include
adequate space and power for future automation because it appears that
this is one of the most likely sites for future automation. Depending
on the degree to which POC testing is implemented, additional zoning of
the materials handling system and accessioning areas may be required to
expedite the processing of priority (stat) testing services. This will
allow the parallel processing of stat and routine testing, increasing
laboratory efficiency without sacrificing the need for quick turnaround
on stat tests.
Specific solutions for data networks should also be addressed at this
stage. Dedicated wire management systems and local area network
closets may be required for the implementation of extensive POC
devices, and will almost certainly be required for centralized
laboratory services. A primary test of the design of these systems is
their ability to accommodate expansion and the extent to which they
obstruct the renovation of other building systems. To be effective,
wireless networking solutions will require a full-spectrum analysis,
along with a plan for mitigating known permanent interference sources.
This may include the adjustment of fenestration, along with shielding
and zoning of sensitive areas. Although wireless networks offer many
benefits, it is important to note that they are highly susceptible to
transient interference from other devices. Indeed, this transient
electromagnetic interference has been known to adversely effect
electronic medical devices, regardless of whether they utilize wireless
networking. With the proliferation of automated electronic devices at
the patient’s bedside, we may well be reaching a time when the use of
"portable electronic devices" is tightly controlled in certain
areas of hospital buildings. This, of course, will not be easy, given
the public nature of most hospital corridors.
Finally, during design development, the office and support spaces
mapped out during the schematic design phase will be finalized, and
associated furnishing systems will be selected. Final equipment
selections for both laboratory and support spaces should be made early
in the design development process to allow the development of room
equipment worksheets. These worksheets will allow engineers to finalize
the design of MEP systems during the later stages of design
development, and should document final equipment selections. It is
important that these worksheets also include expected future equipment
requirements. This will allow adequate engineering for potential
equipment expansion. It is also important to identify an equipment
"triage" plan in the event of power failure, so that back-up power
supplies can be adequately sized to serve the power needs of necessary
laboratory equipment.
construction documentation
The next phase of the project, construction documentation,
involves the final detailing of the building project in both drawing
and specification forms. It is critical at this point to adequately
document any special installation procedures required by automated
equipment. Issues such as responsibility for the delivery and handling
of large pieces of machinery and the prevention of disruption of
ongoing hospital services must be clearly specified in these documents.
Although construction sequencing is not generally described in these
documents, they should specify the performance requirements for all
contractors, enabling them to sequence work in an appropriate manner.
bidding and negotiation
After completion of documentation, the project enters the bidding
and negotiation phase. In large projects, where proper sequencing and
coordination of the various building systems may have a major impact on
the duration (and thus cost) of construction, it may be helpful to hold
a pre-bid meeting in which any special coordination issues are
identified. Although it is not generally a part of basic
architectural/engineering services, particularly complex systems may
warrant the construction of physical mock-ups or computerized models
for presentation at a pre-bid meeting. These devices, although
relatively expensive, can help bidders develop more accurate
assessments of construction sequencing (5). In cases where
the systems and coordination strategies are unfamiliar to the bidders,
the payoff of this strategy can come in more competitive bids. This is
particularly true in new buildings using interstitial service floors,
where great savings in construction time can be achieved by careful
systems coordination. The strategy was used successfully at the Keck
Science Building at Stanford. Here, a mockup o f the building MEP
systems helped contractors cut time from the overall construction
schedule, saving the owner money.
Another way to achieve the same end is by prequalification of bidders.
Such strategies are becoming increasingly important in controlling the
construction costs of the flexible building infrastructure demanded by
automated laboratories. They are also helpful in allowing contractors
to accurately assess the impact of unfamiliar technologies, such as
radiofrequency shielding or materials handling equipment, on the
constructability of the project.
construction administration
During the construction administration phase of the project, the
architect monitors progress of the construction. Automation has little
specific impact on this phase. However, it is important to note that,
during the early part of this phase, the contractor should be required
to submit detailed construction schedules and coordination drawings.
These help ensure the accurate and timely installation of building
systems as designed. They allow the contractor to more precisely define
the installation procedures that will be used during construction. As
noted above, it is important to be watchful of the impact of these
procedures on future systems flexibility.
postconstruction services
For many projects, the completion of construction marks the
beginning of a series of postconstruction services. These may include
commissioning, the production of record documents, and the integration
of project data into an integrated facilities management database.
Automation generally will benefit from all of these services.
Commissioning, in which all elements of the building are systematically
tested and brought on line before occupancy, helps ensure a smooth
transition. It gives personnel a chance to become familiar with new
systems and helps locate and solve any problems in the systems. The
production of record documents, although not critical, will undoubtedly
expedite any future modifications to the laboratory area. Finally, the
input of laboratory data into a graphically oriented facilities
management database will help ensure the disciplined monitoring of the
status and location of automated equipment, and will greatly assist in
maintaining and revising the system. Although these systems generally
are used to document basic building infrastructure, it is also quite
possible to use them to map the materials and data management networks
that come along with automation. The systems also help to document
future expansion methods, indicating preferred locations for new or
relocated equipment and helping to match unanticipated equipment
changes to system capacity. Ultimately, it may be possible to integrate
the locational data provided by these systems with dynamic performance
statistics, providing a comprehensive look at system performance.
Information such as this will be invaluable in adjusting automated
systems to changes in demand and distribution of testing services.
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Conclusion
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Clearly, what is at the core of any automation strategy is the
desire to optimize the testing process. Architects, by coordinating all
of the various building systems required to support this optimization,
are an integral part of this process. In addition, because their
efforts involve the synthesis of the requirements of many user groups,
they have the ability to assist clinical laboratory systems in the
creation and maintenance of new paradigms for laboratory organization.
Although much more technically demanding, this process parallels the
recent transformations of corporate offices brought about by business
automation. What one finds in both cases is that, properly managed, the
architectural design process can help build consensus about the need
for organizational change brought about by new systems. Well-planned
laboratories thus can satisfy both technical and human needs and can
provide a platform for the inevitable changes to come in both areas.
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Acknowledgments
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An expanded version of this article, with additional figures, is
available on the Clinical Chemistry Online Web site at
http://www/clinchem.org/content/vol46/issue5.
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Footnotes
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Fax 724-285-6815.
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References
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Banham R. The architecture of the well tempered environment 1969:29-34 University of Chicago Press Chicago. .
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Felder R. The distributed laboratory—point of care testing with core laboratory management. Price CP 1999 AACC Hicks J. Point-of-care testing. Washington. .
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Moore R, Luczyk K, Wu AHB. Workstation optimization: need and steps for implementation. Kost GJ Wells J eds. Handbook of clinical automation 1996:506 John Wiley & Sons robotics, and optimization. New York. .
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Kelley FJ, Borthwick JAS. Integrated building systems, a case study. Cost Eng 1986;28(11).
Top
Abstract
Introduction
