Testing a newborn's blood for disease is a process that must operate like clockwork.
Within 24 hours after a baby is born, the child's heel must be pricked and pressed against a little sheet of filter paper.
That little paper must be packaged and shipped quickly enough to arrive at a lab in Nashville within two days, state rules say. There it will be tested for two dozen conditions, including genetic diseases such as cystic fibrosis and sickle-cell anemia. Without such tests - and without quick turnaround times for results - some swift-acting disorders can cause disability or even death within the infant's first few weeks.
But only a quarter of Tennessee hospitals' samples are actually meeting the state's deadline, and nearly half are delayed as long as four to nine days, according to new data compiled and released by the Tennessee Department of Health.
In August - the most recent data analyzed - 27 percent of all hospitals got the newborns' tests to labs within the state's target time of under two days; 26 percent made it in two to three days and 46 percent arrived in the four- to nine-day window.
"The number is certainly much higher than what we want," said Dr. Michael Warren, director of maternal and child health for the Tennessee Department of Health.
In Georgia, where the tests' transit times have been made public, about 4.7 percent of the samples took six or more days to reach the lab, 2012 data showed.
It is unclear whether the delays in Tennessee are from hospitals failing to ship the samples quickly enough, or because of the shipping methods they use.
The new data, said Warren, allow officials to "see where there is a breakdown, and where are the opportunities for improvement."
It is unclear how individual hospitals, like Chattanooga's birthing hospitals Erlanger Health System and Parkridge Health System, perform on transit times.
Warren said the state is giving hospitals six months to review performance data and implement changes before results for individual hospitals are made public.
But both Chattanooga hospitals have said they have logging and tracking systems in place to prevent delays.
The state health department already has begun taking measures to reduce delays. Starting in January, the state will begin contracting with a courier service that will shuttle newborns' blood samples from hospitals across the state to the Nashville lab seven days a week.
The state lab's hours will also be extended, from five to six days a week, to prevent backlogs.
State officials say the courier service will be quicker and more secure than the U.S. Postal Service or FedEx, which Erlanger and Parkridge, respectively, have used to send their tests.
"The sooner you can identify an infant might have a condition, the better the outcome," said Warren. "That is what is driving this."
The conditions that hospitals test for affect one in 800 babies.
The new services will be funded by raising the fee for the newborn screening lab tests, Warren said.
State officials recently decided to publicly start tracking the transit times after the Milwaukee Journal-Sentinel newspaper brought attention to the need for better oversight in an extensive investigation.
That series revealed serious delays in many hospitals' newborn screening procedures. It found that Tennessee was one of 14 states at the time that did not release information about the number of days it takes samples to reach the lab.
Tennessee also had no clear standard for how the specimens should be transported, and did not have its lab open on weekends.
In Georgia, samples must be sent by courier, overnight delivery, or express mail. Georgia's state lab pays for one UPS shipment each day from each hospital.
That Journal-Sentinel report, plus a growing emphasis on quality improvement for maternal and newborn health, spurred the state to bring more scrutiny and support to the process of newborn screenings, Warren said.
The Tennessee report for August showed approximately 92 percent of babies' samples were tested within 24-48 hours, while 6.7 percent were tested within 48 to 72 hours.
Contact staff writer Kate Harrison Belz at firstname.lastname@example.org or 423-757-6673.