LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST

by Ron Wince
President and CEO, Guidon Performance Solutions

& LEAN LAB ASSESSMENT: CASE STUDY

by Joseph Campos, Ph.D.
Director, Microbiology Laboratory, Molecular Diagnostics Laboratory and Laboratory Informatics at Childrens National Medical Center, Washington, D.C.

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST

Lean: Driving Up Efficiency And Quality While Driving Down Waste And Cost
By: Ron Wince, President & CEO, Guidon Performance Solutions In an already weakened economy, hospital-based microbiology laboratories are under increased pressure to provide the highest quality patient test results. This pressure is due to several factors, including same day test results demanded by physicians, an increasing number of test samples (legislation requiring HAI screening, increasing organism resistance, etc), additional testing menus based on new technologies (molecular testing), and limited laboratory budgets. Unlike other laboratory departments such as chemistry and hematology, the microbiology laboratories still rely on manual and subjective procedures to perform many of their routine tests. An estimated 40 - 50 percent of a microbiologists current time is spent on administrative and other manual tasks where they use little if any of their technical expertise. The amount of time that laboratory technologists spend cycling paperwork, performing unnecessary tests, or walking from bench to bench can be costly in terms of waste and money, with inefficiency as one of the largest drivers of waste. Compounding the existing inefficiencies in microbiology laboratories is the strain on resources with respect to skilled technicians. The January 2008 issue of Medical Laboratory Observer cites that for every seven clinical laboratory scientists that retire, only two new scientists are entering the field of laboratory technology. According to the U.S. Bureau of Labor Statistics, by 2014, approximately 81,000 technologists and technicians will be needed to fill spaces left by retirees, with another 68,000 technologists needed to fill new positions as a result of increased testing volume and menu. (ASCP, 2009) In the wake of increasing demands for patient care, the diminishing pool of well trained, experienced microbiologists is forcing many microbiology laboratories to reassess current processes to manage their workload. What is Lean? In 1989, the College of American Pathologists developed and implemented the first nationwide quality assurance program for pathology and laboratory medicine. Lean ensures that laboratories continue to meet strict regulatory issues without having to compromise quality control, turnaround times, or performance. Lean eliminates redundant procedures and motions by reorganizing the laboratory footprint so that lab personnel spend less time handling and processing specimens. It is not an endpoint; rather, it is a journey that relies on the ongoing relationship between management and the laboratory staff to reduce inefficiencies while striving for the highest possible patient outcomes. Lean helps laboratory workers and management find better ways to increase

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST
productivity and efficiency without driving up costs and impeding workflow. bioMrieux has joined forces with Guidon Performance Solutions, a leader in Lean Six Sigma performance management consulting, to help microbiology laboratory leadership identify waste and make recommendations for improving efficiencies, thus improving sample turn-around time. Waste is antithetical to efficiency. Waste interferes with thought processes, it creates workflow dams that interfere with laboratory personnel motion, it adds unnecessary time to procedures resulting in delayed turn-around times, it leads to higher error rates, and it reduces efficiency and quality control. Lean is a philosophy that considers all touches in the workflow path. It is about getting people to work together to reduce or eliminate waste. Lean, however, doesnt happen in a vacuum. It involves listening to administrators and managers as well as the individuals who process and handle specimens. Oftentimes, it is the lowest person on the totem pole who offers the greatest suggestions for removing waste. The Lean perspective and the seven forms of waste were originally defined by Toyota as part of their Toyota Production System (TPS) as an integrated socio-technical system that comprises its management philosophy and practices. In a book authored by James Womack and Daniel Jones, the name Tim Wood was coined by taking the first letter of each of the seven types of waste. This philosophy can also be applied to microbiology laboratories. 1. Transportation refers to the act of moving a patient specimen from one place to another. 2. Inventory refers to anything in the queue; it could be specimens that are waiting for processing or a surplus of supplies in inventory. 3. Motion refers to excessive movement caused by poor ergonomics such as workplace layout. 4. Waiting refers to delays caused by instrument availability, instrument downtime, or waiting on the sample to be processed. 5. Overproducing refers to performing work before it needs to be done, such as collecting samples that arent needed, preparing batches of preprocess forms, or preparing samples that are not ready to be processed by the next instrument. 6. Overprocessing refers to double checking work or waiting for approval from lab management. 7. Defects/Rework refers to time spent correcting mistakes.

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST

Changing the Way Microbiology Laboratories Conduct Business At least 50 percent of what happens in microbiology laboratories is waste. This includes unnecessary breaks in workflow from receipt of patient sample to administrative follow-up. Activities that are deemed essential, or value-added, must meet all of the following three criteria: The activity must be done right the first time. The activity must transform the request, i.e., moving the samples to transform into a result that is provided to the physician. The activity must conform to the original request only, i.e., perform only those activities that were requested. Lean helps microbiology laboratory personnel increase efficiency without having to work faster or harder. Lean is about learning ways to improve efficiency by working in a different way. It takes an end-to-end approach for identifying problems in the value stream or value chain that lead to breakdowns in efficiency doing the right thing and effectiveness doing things right. Lean teaches laboratory managers how to identify areas that negatively affect workflow by helping them recognize waste. Guidons unique partnership with bioMrieux helps microbiology laboratories identify breakdown points or waste that result in non-value-added activities, such as samples sitting in queue, barricades to traffic flow, or time wasted waiting on instrument availability. By identifying where waste occurs, laboratory managers can work toward eliminating waste, thereby increasing efficiency and effectiveness anywhere from 10-40 percent, and can reduce defects as much as 80 - 90 percent. Out With the Old, In With the New Many hospital-based microbiology laboratories do not have the budget to replace old equipment or manual procedures, regardless of their inefficiency or high cost. Other laboratories adopt the if its not broke dont fix it philosophy. All too often, laboratories follow antiquated routines just because they work, despite the inefficiencies, increasing cost, and potential risk of errors. This mindset reminds me of a story I was told about the mother who cuts off the ends of a ham before placing it in the oven. One day, her daughter asks her, Why do you cut off the ends of the ham? Her mother responds, because that is how my mother did it when I was a young girl. Not to be deterred, the young girl asks her

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST

grandmother, Why do you cut off the ends of the ham before placing it in the oven? Her grandmother responded the same way, because my mother did it that way. Further and further back she goes, peeling back generation after generation, until she finally gets the answer she sought: the ends were cut off so the ham would fit into smaller ovens of the past. This do it as its always been done mentality is still prevalent in a number of microbiology laboratories even today. Many microbiology lab managers continue to use the same manual procedures that were used decades earlier, despite the availability of faster, more efficient, and less costly (in the long run) automated instrumentation. They continue to use processes and procedures that are time and labor intensive and that carry a risk for errors. Lean helps laboratory managers use their staff and equipment more wisely, often leading to unfound money that can be used to purchase state-of-the-art automated equipment. Laboratory managers face the day-to-day challenge of balancing the need for new equipment with the limitation of budgets. Historically, healthcare administrators have been slow to adopt Lean strategies and processes because of the change to the status quo it requires. Lean, however, is ideally suited to data-driven, process-oriented departments such as clinical and microbiology laboratories. Is There an Enemy Within? The Lean assessment process begins with an assessment of task management given the specific laboratorys sample volume, test menu, staff, and physical layout. The goal of the assessment is to identify sources of waste or other activities that impede workflow, delaying sample report time. The assessment typically takes between two to three days to complete for a small laboratory, and up to six days to complete for a large microbiology or reference laboratory. During this phase, Guidon and bioMrieux assign a workflow analysis team who physically follows patient samples from receipt in the laboratory to the release of test results. The process is inclusive of lab personnel, without being disruptive to their daily workload. During the Lean process, the team quantifies movement patterns, determines the duration of each step, evaluates cycle times, and observes how lab personnel process patient samples. When this step is complete, the workflow team utilizes many tools, such as spaghetti diagrams, to communicate the findings (see

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST
Figure 1). The Guidon/bioMrieux team meets with laboratory managers and staff

to discuss their findings and identify waste most importantly they determine what steps to take to eliminate or reduce it. Figure 1: Spaghetti Diagram

The Lean Lab Design phase starts with a kick-off meeting with the key laboratory stakeholders. During this meeting, laboratory management discusses current workflow processes, division of labor, and key areas on which to focus the evaluation. After observing the laboratory at different times of the day, and across different shifts, the Guidon/bioMrieux team analyzes the findings and develops a final report for the laboratory. This report includes analysis of motion studies, cycle time data, administrative workflow, existing information systems, quality issues, and specimen flow patterns. This analysis concludes with a roadmap outlining how the lab can improve efficiencies and sample turn-around times. This roadmap includes actions that can be taken, their impact, and next steps for implementing the actions. These recommendations are typically categorized into one of three areas: laboratory layout, sample volume/staff optimization, or areas where automation will increase efficiencies.

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST
Automation oftentimes can reduce the overall footprint of the laboratory, thereby reducing the laboratorys overhead cost. It can help reduce bottlenecks in workflow, thereby increasing productivity, reducing turn-around times, and freeing up time for more experienced laboratory staff to perform value-added activities (see Figure 2). Something as simple as reorganizing workflow can have dramatic effects on time and motion analysis. Figure 2: Automation Reduces Variability and Increases Quality of Test Results

Overproduction Standardize Processes Maximize Automation Reduce Errors Improve TAT

Reduce unnecessary process steps, tests and duplication

Identify variability in processes from Tech to Tech, Shift to Shift

Identify unnecessary process steps, tests and duplication

Identify variability, error prone steps and manual transcription in the process

Identify bottle necks and delays in the process

Winston Churchill said, There is nothing wrong with change, if it is in the right direction. Lean strategies and tools help laboratories move in the right direction. The best way to effect change is to include all laboratory personnel from management to bench technicians in the assessment process. Not only does this alleviate stress among the laboratory workers, but it also helps the workflow analysis team quickly discover where the skeletons are hidden.

LEAN: DRIVING UP EFFICIENCY AND QUALITY WHILE DRIVING DOWN WASTE AND COST
We dont have to wait to discover the things that drive technologists and administrators crazy. Because of the involvement of the multi-disciplinary group, they already know their points of pain. The assessment can piggyback on what the lab staff already knows and take it to the next level. Another advantage of this all-inclusive approach is the success in changing the attitude of the most vocal opponents of Lean, the so-called CAVE dwellers (citizens against virtually everything) into some of the most outspoken advocates of Lean. The group becomes Lean-thinkers by the very nature of the discussion. We typically find that laboratories that adopt Lean see a five-time return on investment. Lean laboratories consistently deliver high quality results with faster turnaround times and lower costs to the physician and patient. That means physicians can start treatments earlier so that patients can vacate hospital beds and go home sooner. Conclusion In the current healthcare environment, the microbiology laboratory is faced with unprecedented challenges. The need to address mounting pressures due to multidrug resistant organisms and a growing list of superbugs in the face of a dwindling population of skilled microbiologists places further burden on the laboratory workload. In order to answer to physicians requests for rapid, reliable results, laboratories and their staff are turning to lean alternatives to reduce waste, speed the time of results to physicians, and enhance the quality of the information they provide. With the potential for increasing efficiency and effectiveness anywhere from 10 - 40 percent, coupled with a reduction of defects as much as 80 - 90 percent, can your laboratory afford not to be Lean?
References Amirahmadi, Fazi, Al Dalbello, Dan Gronseth, and Jean McCarthy. Innovations in the Clinical Laboratory: An Overview of Lean Principles in the Laboratory. (2007): 2. Mayo Medical Laboratories. Aug. 2007. Web. 28 Oct. 2009. Critical Values: News for the Entire Laboratory Team. American Society of Clinical Pathology. 2008: 1(4). Deckard GJ, Borkowski N, Diaz D, Sanchez C, Boisette SA. Improving timeliness and efficiency in the referral process for safety net providers: application of the Lean Six Sigma methodology. J Ambul Care Manage. 2010.;33(2):124-30. Wince, R. Personal Communication. Lean Assessments in Healthcare Systems. April 6, 2010. Available at: http://www. guidonps.com/industry-expertise/ideas-and-resources/multimedia/lean-six-sigma-podcasts.

LEAN LAB ASSESSMENT: CASE STUDY

Lean Lab Assessment: Case Study

By: Joseph Campos, Ph.D., Director, Microbiology Laboratory, Molecular Diagnostics Laboratory and Laboratory Informatics, Childrens National Medical Center, Washington, D.C. In the same way a community depends on its hospital, the hospital depends on the clinical laboratory. The lab is the lynchpin for nearly every treatment decision within the hospital. Each step along the continuum of care patient admission, diagnosis, treatment, patient discharge requires data provided by the clinical lab. Therefore, the speed and accuracy with which results are provided is critically important to the wellbeing of our patients. As director of the Microbiology and Molecular Diagnostics laboratories and Laboratory Informatics at Childrens National, my role is to ensure our laboratory delivers efficient and accurate results that are cost effective. In addition, we also strive to adopt new tests that provide better clinical information. All must be done, at a time when there is a shortage of skilled clinical laboratory scientists. I am very proud of our microbiology laboratory and staff and feel that we have proven to be a critical member of the patient care team. Nonetheless, as highly regarded as a laboratory might be, we are always looking for ways to improve. Operational efficiency can always be enhanced and the clinical utility of test results can always be made better. In addition, our expanding workload has been outstripping the size of our laboratory staff. Over the years, Ive witnessed Lean process improvement efforts that were conducted in other laboratories. I have heard some state that Lean principles are better suited for automated chemistry and hematology laboratories than they are for microbiology laboratories. I knew that Lean had helped many organizations extract waste from their processes, improving speed, efficiency and quality. Contrary to what others might have thought, I was confident it could do the same for our microbiology laboratory. In many ways, a microbiology laboratory is similar to any other enterprise that works on the in/out principle (e.g., the post office, global shipping companies, automobile manufacturers and supermarkets). For the lab, specimens come in one end, test results go out the other end and elimination of waste in between leads to more time being spent on value-added activities.

LEAN LAB ASSESSMENT: CASE STUDY

About Childrens National Medical Center Childrens National Medical Center is the only exclusive provider of pediatric care in the metropolitan Washington, D.C. area. Nationally recognized as one of the best pediatric hospitals in America by U.S. News & World Report and the Leapfrog Group, Childrens National has been serving the nations children for more than 135 years and is a proven leader in the development and application of innovative new treatments for childhood illness and injury. The hospital cares for more than 360,000 patients each year who come from throughout the region, the nation and the world. Serving as an advocate for all youth, Childrens National is the largest non-governmental source of pediatric care in the District of Columbia, providing more than $50 million in uncompensated care each year. In addition, Childrens National serves as the regional referral center for pediatric emergency, trauma, cancer, cardiac and critical care as well as neonatology, orthopaedic surgery, neurology and neurosurgery. Putting Ourselves Under the Microscope Prior to beginning the actual Lean Lab design workflow optimization service, bioMrieux spent a day in our laboratory, gathering data for use in the workflow analysis. These data included sample volumes, time of day samples were received, turn around time for test results and staffing schedules. The bioMrieux/Guidon team prefers to be given a calendar years worth of laboratory data, which is sensible considering the seasonality of many infectious diseases. While a few weeks or months provide a snapshot of the workflow, 12 months are better because of the marked effect that the change of seasons has on the workload in our lab. Our workload ebbs and flows throughout the year due to weather fluctuations, school schedules, community outbreaks, etc. The bioMrieux/Guidon Lean Lab Design workflow optimization service commenced with a kick-off meeting attended by key laboratory personnel. During the introductory meeting, the Lean Lab team from bioMrieux/Guidon described their process so that lab personnel would know what to expect the rest of the week. Additionally, lab personnel identified key areas where they felt process improvements would have the greatest impact. Over the course of three and a half days, three Lean Lab assessment team members observed how samples were processed in the microbiology lab. This observation was done in a way that did not impede our workflow because it was conducted by individuals who understood microbiology testing. The team came to me or the

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LEAN LAB ASSESSMENT: CASE STUDY

laboratory supervisor periodically for validation of findings or to clarify observations. They also requested data from the recent past, regarding specimen arrival dates and times, culture result turn-around times, staffing patterns, etc. Specimen Drop-off: Efficiency Starts at Receiving During peak hours, specimen accessioning and processing at any large microbiology lab can seem like controlled chaos. But, there is a method to the madness. Specimens are dropped off, sorted, bar-code labeled, received into the laboratory information system (LIS) and processed. Processing can include centrifuging, pouring off supernatants, aliquotting, grinding tissue and other steps necessary for the preparation of smears and the inoculation of cultures. The Lean Lab assessment team recommended that we improve our process of specimen accessioning by creating a work cell dedicated to the complex and iterative process of handling specimens. At the time of the assessment, our labs accessioning area was a pass-through area located in the Core laboratory, away from the rest of the microbiology laboratory. People walked through it because it was an aisle in the laboratory that led to other work areas. The assessment team recommended that we relocate the accessioning area to a work cell in the main microbiology laboratory where specimens would be delivered to a dedicated accessioner to eliminate specimen backlogs and decongest this vital space and function. By making the accessioning area a dedicated work cell, we will increase efficiency by ensuring STAT specimens receive top priority, while other specimens will be processed in the order they are dropped off. Under the previous system, some microbiology specimens remained in the general laboratory accessioning area while STAT chemistry and hematology specimens were processed first. Tracking Samples Within a day of the observation period, the bioMrieux/Guidon team had prepared an assessment presentation and an evaluation. We all gathered to listen to their recommendations and to brainstorm solutions to help us improve our processes. From my perspective, this was one of the most positive parts of the experience. One of the most eye-opening parts of the presentation was the spaghetti diagram analysis, (See Figure 1) which tracked the movement of technologists and specimens within the laboratory over a brief period of time.

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LEAN LAB ASSESSMENT: CASE STUDY

Figure 1: Spaghetti Diagram of Current Workflow

You just dont realize how extensively people move around a laboratory in the course of a regular work day and how much time they spend getting from point A to point B. Our spaghetti diagrams showed that we had an opportunity to decrease wasted time through a more efficient organization of the lab. One trip here that takes 30 seconds and another trip there that takes 45 seconds, adds up quickly to a significant sum. In the final analysis, we learned our technologists were actually walking great distances for long periods of time. Another tool used by the laboratory assessment team was a Pareto diagram, which showed the time of day specimens arrive in the laboratory versus the staffing level (See Figure 2). It actually surprised me to learn how many of our specimens arrived during the third shift, between 11:30 p.m. and 7:30 a.m. Approximately 20-25 percent of our workload was collected during this shift from patients in the emergency department and in the in-patient units. As the figure shows, this was at a time when the laboratory

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LEAN LAB ASSESSMENT: CASE STUDY

had limited staff to process specimens other than CSF and STAT antigen detection requests. Figure 2: Analysis of Staffing and Specimen Volume

Current State I suspect that the workflow and staffing patterns described above are similar to those in many other microbiology labs across the U.S. The day shift arrives and gathers the culture plates that have incubated overnight and begins the reading process. Theres either growth or no growth and further work is performed accordingly. Culture plates showing no growth on the first reading are re-incubated and read again the following morning. However, a culture that is inoculated in the evening lets say at 10 p.m. and then examined at 8 a.m. has incubated for only 10 hours. In most laboratories such cultures would be re-incubated for 24 hours before the next examination. Many clinically significant organisms cannot form visible colonies in just 10 hours; whereas, they likely will form visible colonies in 16-18 hours. This single morning plate reading

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LEAN LAB ASSESSMENT: CASE STUDY

per day has a major delaying impact on the overall turn around time for specimen results to our physicians (See Figure 3) Figure 3: Positive Culture Turnaround Time Future State
80% 70% 60% 50% 40% 30% 20% 10% 0% Blood Urine Misc Resp Positive TAT (Days)

Blood

Urine

Misc

Resp

2 8% 72 % 43% 16 %

3 47 % 23 % 34 % 26 %

4+ 45% 6% 23 % 57 %

10

Because the Pareto analysis showed that the number of people available to handle our workload was out of synch with the arrival time of our specimens, we have decided to adjust our staffing patterns in an appropriate fashion. Presently, the microbiology laboratory is staffed for the first and second shifts, but not the third shift. Specimens other than CSF and STAT antigen detection requests that arrive during the third shift are refrigerated until the following morning. Thus, there is an inherent, 1-8 hour lag in the processing and culturing of those specimens simply because they arrive during the third shift. Planning to eliminate this delay required a careful examination of our staffing patterns. We are planning to allocate two technologists each to the second and third shifts, leaving our remaining seven technologists for first shift responsibilities and filling vacancies due to sickness, vacations and time off for weekend/holiday work. New

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LEAN LAB ASSESSMENT: CASE STUDY

cultures will be inoculated as specimens arrive and will be placed in the incubators according to the time of inoculation. All newly inoculated cultures will be examined for the first time after 16-18 hours of incubation and identification/antimicrobial susceptibility tests set up as appropriate. Setting up and reading cultures around the clock will shorten the turnaround time for most cultures in dramatic fashion. These changes will also ensure that specimen integrity is maintained, since delays in specimen processing will be kept to a minimum. Processing better specimens up front will mean a higher quality of test results will be delivered. Conclusion Laboratory scientists are, by nature, observational and analytical they watch and analyze. So, there was some irony when we put ourselves under the bioMrieux/Guidon microscope for three and a half days. Additionally, theres an understandable tendency for people at the workplace to be fearful and suspicious when a group of strangers comes into a laboratory with pencils and clipboards. One of my responsibilities was to reassure the staff that our goal was to improve the quality of our laboratory service not eliminate positions. As our lab staff became accustomed to the presence of the Lab Assessment team, they became involved in the process, and soon realized that this Lean lab assessment wasnt something to be worried about, but rather it was something to be welcomed. Im fortunate that our laboratory staff and I share one common goal that steers us all in the same direction: the well-being of our patients. What we saw during and after the assessment was an evolution of thought among the technologists because they were part of the process and part of the desire to provide better service to our physicians and to our patients. We have the tools we need to initiate change and with the assistance of bioMrieux and Guidon, we believe that we will continue to make our laboratory better and more efficientfor us and for the patients we serve.

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