With more and more labs turning to Lean manufacturing principles to shore
up the efficiency of their operations, the examples of Lean’s power to
transform grow in number by the year. But where and how to start can stall
even the most well intentioned.
Organizations should focus first on where 80 percent of the opportunity,
volume, costs, or revenue exist, says Rick Malik, managing principal of
ValuMetrix Services for Ortho-Clinical Diagnostics, which has guided multiple
labs in implementing Lean. "Focusing there," he says, "will provide a
meaningful project with a solid return on investment."
And going for the quick wins will help "carry your team through more
difficult times or complex processes," says Kevin Wiersma, chief financial
officer of MedTox Scientific, whose subsidiary MedTox Laboratories, a
workplace drugs of abuse and clinical laboratory in St. Paul, Minn., launched
its Lean project two years ago.
That’s because celebrating the small successes along the path to achieving
larger goals will drive home to employees that "the organization is going
to change and that change pays," says David Stowe, the Chicago-based partner
in Strategic Manufacturing Consulting Group, the firm that helped MedTox
with its Lean project. "Success breeds success, and success is what helps
overcome resistance," Stowe says.
Yes, a number of labs have learned that and more about Lean and how to
make it work. Take Miami’s Jackson Memorial Hospital, for example, which
began its Lean work one year ago. Since then, it has achieved more than
a 50 percent improvement in turnaround time for its core laboratory. "In
some areas, we’re up 72 percent," says Leyda Napoles, MT (ASCP), MBAHA,
administrator of pathology services.
Or Alegent Health, a large integrated health system in Omaha, Neb., which
is implementing Lean principles at seven of its metropolitan laboratories.
In the past two years Alegent decreased its overall turnaround times at
its consolidated reference lab by 64 percent for 80 percent of its volume
in the general laboratory area (which doesn’t include microbiology and
histology), says Sheryl Wilson, MHA, MT, DLM(ASCP), senior executive at
the Alegent Health laboratory. The consolidated laboratory also cut its
error rate from three percent to 1.2 percent, its inventory by $35,000,
and the general lab and storage room space by 50 percent, Wilson says.
And Fairview Health Services in Minneapolis, one of the Lean trailblazers,
has improved its turnaround time in the core laboratory by 50 percent,
productivity by more than 40 percent, and cost by 30 percent, says Rick
Panning, administrative director of laboratory services.
Says Stowe, "There is a growing realization by hospitals and laboratories
that they can use Lean to dramatically improve productivity and/or profitability."
Virginia Mason Medical Center, Seattle, a 336-bed hospital with nine
satellite clinics and 400 physicians, has been implementing Lean in its
laboratories and other settings since 2002. "You can start Lean in the
lab, but considering that 70 percent of all clinical decisions are based
on lab results, the lab interfaces with so many processes ... eventually
you want to spread Lean throughout the organization so that everyone is
on the same page," says Lee Darrow, MT(ASCP), SBB, administrative director
of the laboratory.
One of Virginia Mason’s recent Lean projects reduced by 50 percent the
lead time from when a patient in the emergency department enters an exam
room until the person’s lab test results are in the treating physician’s
hands, says Katherine Galagan, MD, chief of pathology and director of
the clinical laboratory.
"Before the Lean project, the nurse might have to try a couple of times
to draw a blood specimen, and if unsuccessful, call the phlebotomist who
had to be paged," says Dr. Galagan. The process-improvement team found
that if the nurse did the laboratory draw in the ED, the average lead
time as defined by the project was 70 minutes. But if the nurse had to
page the phlebotomist to help with a difficult draw, the lead time stretched
to 95 minutes.
So the team decided to station a phlebotomist in the ED to help the RN
with the initial venipuncture, which improves the RN’s success rate. "The
phlebotomist labels tubes, helps check the patient’s ID, and takes the
specimens and tubes them up to the lab," Dr. Galagan says. When the specimen
arrives in the lab, the central processor takes it to the stat centrifuge
and puts it on directly. The chemistry technologist takes it off as soon
as it’s spun down and puts it on the analyzer. "We cut a ton of time off
by following those steps ... and it’s single-piece flow, as they do one
specimen at a time," Dr. Galagan says.
When the Lean team mapped out the steps in the processes to identify
non-value-added work and waste, they found that the ED staff was spending
a lot of time walking to and from the computer to check for laboratory
results, which is waste, she says. "Then the ED staff would get frustrated
and might not check the lab information system for 30 to 45 minutes when
the lab results were actually there during that time period."
The remedy proved to be a simple one, as Lean solutions often do. "We
turned the lab printer back on, which someone had turned off because they
decided it was [using] too much paper," Dr. Galagan says. "Then we put
in a simple flag system for the unit secretary to use to alert the doctor
that the results were available." To save paper, the team decided to turn
off the pending reports function so the printer would print fewer reports
Virginia Mason has also leaned out its satellite clinics to reduce the
lead time from patient check-in at the front desk to discharge. To do
that, the process-improvement team decided to deploy a series of visual
signals to expedite communication among health care providers and maintain
supply inventory in a just-in-time manner.
"One of the nifty Lean tools is use of visual signals that allows staff
to communicate [routine information] without having to talk," Dr. Galagan
explains. "And the clinic had these little plastic colored flags over
the doors that no one was using. So we used those flags to identify when
the doctor or nurse was in with the patient and who needed to go in next
so the health care providers could look up and down the hall and know
where to go."
The Lean team also put a file on a central desk where the physician could
put in a laboratory-related request without having to find a person—to
ask the nurse for a biopsy kit, for example. The nurses and medical assistants
retrieve the messages as they walk by the file.
The clinics also use what are known in the Toyota production system as
"kanban" or visual cue cards just short of a depleted inventory, saying,
for example, "We need 20 more Q-Tips." When the nurses or physicians reach
the red card (usually three or four items before the supply runs out),
they stick the card on the outside of the door. "The medical assistant
sees it and knows to restock that room. That way, you have less storage
and inventory and use a nonverbal system to keep things stocked and running
smoothly," Dr. Galagan says.
Avera McKennan Hospital and University Health Center, Sioux Falls, SD,
which has applied Lean to most of its laboratory operations, is extending
Lean now to non-laboratory settings, including the ED and the OR.
The Lean project in the 400-bed hospital’s ED, which is a certified trauma
center, aims to reduce the current two-hour, 12-minute lead time from
patient check-in to release or admittance to 1.5 hours—and ultimately
to one hour, says Leo Serrano, FACHE, CLSup(NCA), director of clinical
laboratories at Avera McKennan. To facilitate patient flow, ED patients
go directly to triage, where they are received, which generates an account
number and patient identification band. A complete registration is done
at bedside after care has begun. "The goal," Serrano says, "is to have
the patient seen by a physician within 20 minutes of arrival."
Rather than having dedicated rooms to provide certain types of care,
the ED is standardizing all of its rooms, which frees up room availability.
The ED staff brings standardized carts to the rooms for specific patient
problems, such as a suture cart, a gynecology cart, or cast cart, Serrano
The ED Lean project has triggered ideas for spinoff projects known in
the Lean Toyota process as a Kaizen event. For example, the Lean team
identified that the ED was having trouble admitting people to the hospital
because rooms weren’t available. So in July, Avera McKennan kicked off
a Lean project with housekeeping and nursing to look at the inpatient
discharge process from the time the physician writes the discharge order
until the hospital room is ready for a new admission.
But Serrano has a word of caution: "When you do something in one area,
it has a downstream effect that can be significant. So if you don’t coordinate
your Kaizen events sequentially, you can impact your functionality."
When MedTox Scientific decided to implement the "waste not, want not"
Lean manufacturing philosophy in 2003, it had a burning platform for abandoning
business as usual.
The laboratory was on a roller coaster of inconsistent annual earnings
performance. Its workplace drugs of abuse lab, which produced more than
60 percent of MedTox Laboratories’ revenues, had been negatively affected
by the post 9/11 recession, said Kevin Wiersma, the company’s chief financial
officer, who shared MedTox’s Lean experience at this year’s Executive
War College, sponsored by The Dark Report.
MedTox initially applied Lean principles espousing single-piece specimen
flow where possible and eliminating wasted time and other resources throughout
its workplace drugs of abuse lab, which has three areas: specimen receiving;
processing, which includes drug screening; and an extraction area for
confirmatory testing of positive screens.
The Lean project yielded impressive productivity gains. Output per employee
climbed by 22 percent, "and the lab made huge strides in confirmatory
testing turnaround time, improving the throughput in that area by 79 percent,"
Wiersma told War College attendees.
The lab’s test volume also skyrocketed, says Stowe of Strategic Manufacturing
Consulting Group. "The lab could take in more samples, process them more
efficiently, and meet market challenges," Stowe told CAP TODAY.
As part of its Lean overhaul, the workplace drugs of abuse lab created
best-practice standardized work based on accumulated knowledge so everyone
performs processes in the same way and knows how much time each step should
take. The Lean team also implemented first-in-and-first-out linear flow
of samples, reduced batch sizes, and implemented good visual management
In the new Lean environment, workflow occurs at a balanced rate through
all three areas of the lab. A gravity-feed-roller conveyor line moves
specimens from the processor to the next station, eliminating transportation
time, Wiersma said.
With newly designed processing benches, laboratory technicians can move
the work smoothly from the left to the right of the bench with no unnecessary
movements. A label under each bottle or item on the workbench tells the
lab technician exactly what needs to be there, including quantity and
optimal location. That way, the technicians can be sure they have everything
they need at the start of a shift. The Lean team color coded materials
in the extraction area to match the assay the technicians are working
on, which reduces errors, Wiersma said.
MedTox also spread out how it managed receipt of test samples, which
begin arriving in the lab’s receiving area at about 5:30 AM and continue
to arrive over the next three to four hours. In the lab’s pre-Lean days,
the morning influx of specimens created a backlog in specimen processing.
Now the lab staggers shift start times, so people who process the specimens
first start earlier to build up inventory for the next phase of testing.
"The staff for the third phase of testing, extraction and confirmation,
starts about two hours after receipt of the samples," Stowe says.
To maintain the gains from the Lean project, the lab posts hourly production
rates in real time on the floor, a change that staff resisted a bit at
first, Wiersma admitted. But they now like the feedback about how they’re
performing, said Wiersma, who has found that "people want to know the
standards and what’s expected." The hourly posting also gives supervisors
a tool to detect and troubleshoot problems in real time and to praise
technicians who are doing well—or coach those who need to pick up
Management also installed an idea board and asked employees to post their
input on how to improve the standards and make their jobs easier.
MedTox didn’t restrict its Lean feats to its workplace drugs of abuse
lab. The company is now tackling the lab sales area with a project aimed
at eliminating waste by synchronizing the information flow and standardizing
the sales process and performance metrics. "The objective is to reduce
the time between [sales] prospects and when we are receiving payments
for lab tests," Wiersma said.
To speed up sales, the laboratory sales department shifted some of what’s
known in Lean speak as non-value-added work to customer service. "If you
are a sales rep," Stowe says, "your value-added steps are talking to a
prospect, convincing the prospect that the company’s services are value-added
to their company—that is, something the prospect is willing to pay
for—and completing the sale, including filling out information and
the database." Yet the Lean team found that the MedTox sales force was
fielding calls daily from existing customers. "The Lean project clarified
how to resolve the hand-off issues to customer service, which is important
because no lab wants a dissatisfied customer," Stowe says.
In the Lean scheme, "the customer’s concern or call is like a vial of
blood sitting there" waiting for something to happen to it, Stowe adds.
"You want to move that information to the right person who is prepared
to process it quickly and accurately."
To produce an early, quick win, MedTox focused first on the receiving
area where samples sat for a long time waiting to be processed. After
an initial analysis of product flow and labor use, "the Lean team put
together a prototype workstation to simulate the flow of material across
the bench and throughout the receiving area," Stowe says. This prototype
area allowed other associates and supervisors to offer input into developing
a work area that is "physically easy to use and controls quality and productivity."
Eventually, the Lean team made physical changes and organized the flow
of samples to prove things were moving more efficiently—first with
one workstation, then one line, then the whole area. "We took baby steps
to get us to the bigger goals," Stowe says.
Laboratories with Lean experience have distilled key learning points
to help those considering or embarking on Lean projects to sidestep common
misperceptions and stumbling blocks.
1. Lean is not a quick fix. In fact, before you can fix anything with
Lean, you have to determine—in what can seem like excruciating
detail—exactly how it’s broken.
For example, in its Lean projects, Virginia Mason Medical Center uses
videotaping and other tools to map the workflow. The process improvement-team
members "use forms where they watch the specimen and write down all the
steps they see," says Dr. Galagan. "Then they use a stopwatch to time
the steps and waiting time where nothing happens to the product." Another
form helps the team track the flow of the specimen or the staff person.
"Initially you get a spaghetti diagram with lines going everywhere," Dr.
Galagan says. "Then you look for ways to decrease that disorder and lessen
staff walking and product travel distance."
By using the Lean tools, you spot the waste in the identified process,
she adds. "You take out seconds in some cases or minutes—or even
hours or days sometimes. And that wasted time adds up to considerable
gains in efficiency or shorter lead time;s."
2. Lean "lite" can make you back slide in efficiency. For example,
"if you just clean up and move or change equipment in a cellular layout
without doing the detailed analysis up front ... you won’t know what machines
need to be in that cellular layout or how to arrange them to have single-piece
flow and balance the work," says Malik of Ortho’s Valu Metrix Services.
"And you won’t know how many people should be in each work cell" to manage
Part of Lean requires you "to do a deep dive and peel away the layers
of a problem to get to the root cause," says Lee Darrow at Virginia Mason
Medical Center. "It’s sort of like wound debridement. The wound isn’t
going to heal until you get the dead tissue out."
3. Single-piece flow isn’t written in stone. The Lean principle of
promoting single-piece flow of a product (blood tube, tissue sample,
form, patient) through a process is important to maintain an evenly
paced workflow and output. But in a limited number of cases, "batching"
in a Lean environment may be required, though you must clearly justify
the need for it, says Mark Jamrog, president and CEO of Strategic Manufacturing
The goal of using single-piece flow is to shorten the lead time for a
defined process, Darrow says. "Sometimes getting down to one-piece flow
will work to shorten the lead time, and other times it may lengthen it."
Karen Lusky is a writer in Brentwood, Tenn.