College of American Pathologists
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Waste watchers learning the lean routine in clinical laboratories

Lean for labs

August 2003
Karen Lusky

When Ben Franklin coined the adage “Waste not, want not,” he may have unwittingly inspired Henry Ford to envision the lean production principles that Toyota fine-tuned more than half a century later to catapult the motor company to world-class status. And Toyota probably never foresaw that the Lean Management system, as it’s come to be known, would one day make its way into clinical labs.

With its rigorous emphasis on eliminating waste to improve productivity, Lean Management has risen to the fore as a way for labs to compete on cost and quality under fixed or dwindling reimbursement systems. The CAP ’03 annual meeting in San Diego next month will host a session on the Lean quality management system, which a growing number of labs are adopting or at least eyeing as a solution, albeit one that turns traditional thinking on its head.

“The easiest of all waste, and the hardest to correct, is the waste of time, because wasted time doesn’t litter the floor like wasted material, and once you lose it, you can’t get it back,” said Mark Jamrog, president and CEO of the consulting firm SMC Group LLC, Edwardsburg, Mich.

In laboratories, he said, waste takes many forms: transportation, overproduction, defective products, human potential, and information. “But the king of all waste is the waste of time,” emphasized Jamrog, who led a presentation on Lean Management last May at the Executive War College sponsored by The Dark Report.

The key to Lean Management in any industry is to keep the product in motion. In labs, that product is “a tube of life—blood,” said Jamrog, who has applied Lean production principles to everything from fighter aircraft to draperies and now to clinical lab specimens. “It doesn’t matter what the product is, the fundamentals and principles are the same,” he told War College attendees.

Laboratories that implement Lean strive to minimize “storage time,” or the time that a specimen sits around waiting for something to happen to it, which in Lean-speak constitutes “non-value-added time.”

“That’s waste, and when you eliminate the waste, you speed up the process,” says Leo Serrano, FACHE, CLSup (NCA), executive director of laboratory services for West Tennessee Healthcare, Jackson, Tenn. Serrano and his colleagues implemented Lean Management in January, and they’ve seen a 77 percent reduction in the time between when a specimen is collected and when it’s received in the lab. “And that went a long, long way toward improving our performance and customer satisfaction,” Serrano told CAP TODAY.

Going with single-piece flow

A Lean lab processes specimens in the order they are received by creating a standardized production line akin in principle to how Subway sandwich shops move their products down a line of operators toward the cash register. The more standardized the process, the better and more consistent the product’s quality and turnaround time—and the faster the cash flow.

To standardize protocols for lab testing functions, laboratories implementing Lean Management videotape their work and compare how they work to standard operating procedures. “They then establish very specific work instructions that everyone has to follow,” Jamrog says. For example, all phlebotomists perform their work in the same way, follow standardized routes, and use standardized carts or trays.

Phlebotomists and operators in a Lean environment work on one specimen at a time, unless it is necessary to batch specimens—for example, when growing microbiology cultures or processing tissues in histology. “But even then, you single-piece flow around areas that you have to batch, which works well,” Serrano says.

On the front end, the phlebotomists retrieve one specimen label at a time, identify the patient, draw the specimen, label it, and send it by pneumatic tube from the nursing station to the lab. Then they get the next label without returning to the lab.

While it might seem phlebotomists would chalk up more miles than usual with all those trips to and from the pneumatic tube, the opposite is true, Jamrog insists. “The walk time is actually reduced because the phlebotomist is not repeatedly walking from the lab to various assigned floors throughout the day,” he says. “Rather, they are walking from the nurses’ station to the patient’s room and back.”

The phlebotomists’ standardized carts are restocked at regular intervals from the back so the oldest inventory is pushed forward and used before it expires. Jamrog likens the process to restocking a pantry: “If someone’s pantry is disorganized, the person doesn’t really know what to go buy. But if they clean and organize it, it’s easy to see that there’s an oversupply of chicken soup and many items that have passed their expiration date.”

The single-piece flow also lessens the opportunity for error, reducing it to virtually nil in some cases. “In a batch environment, the phlebotomist has multiple orders on the cart at the same time,” Jamrog says, “so the possibility and probability of getting someone’s blood mixed up with another person’s is higher than it needs to be.”

Tackling the workforce shortage
By reducing and balancing lab operators’ workload, Lean might prove to be at least a partial antidote to the laboratory workforce shortage. For example, Fairview Health Services, Minneapolis, which is putting finishing touches on a Lean pilot project at its suburban Fairview Southdale Hospital lab, is confident the new system will improve productivity by 30 percent. And that will mean a reduction in the need for full-time staff for automated testing, says Rick Panning, MBA, CLS(NCA), president of laboratory services for the health system.

“Fortunately, we have been anticipating the staffing reduction and held many technical positions open until the end of the project. We’ll also be considering other opportunities for redeployment of staff,” said Panning, in sharing his lab’s experience with Lean in a case study presentation at the War College.

Serrano also found that Lean reduced staffing needs, which made it possible for management to reallocate staff to expand the lab’s test menu and support its educational mission.

Lean also requires all employees to pull their own weight by performing defined standard work and hitting defined standard times. This approach allows workers and managers to see points where the product isn’t flowing, either because someone isn’t keeping pace or a machine is down. “In some systems, you don’t readily see the slow person who consistently does not handle a fair share of workload,” Jamrog says. “We all experience that when we get in a line at the grocery store or bank. If the line is too slow, people move to another line, so it’s hard to visually see the person is handling far fewer customers than average.”

Supervisors in a Lean environment visually inspect for bottlenecks and monitor output hourly and daily to determine if the lab is hitting its performance benchmarks, which are based statistically on workers who know how to do the job and represent the work ethic the system espouses. The hourly monitoring is critical, Jamrog says, because it helps supervisors “respond to misses in planned output. If you fall behind in the first hour of the day, but don’t detect the problem until the eighth hour of the day, you have created a situation where you have zero time to respond to the problem.”

The Lean system also addresses the need for automation, Jamrog told War College participants. “For example, once you lay out the lab properly so that a person can easily include transportation of the material in the walk pattern, then management can see it doesn’t make sense to invest in automation to move the specimen from machine to machine.”

In other words, automation is not always the answer to improving productivity, or at least not the answer of first resort. The answer lies in creatively developing low-cost “commonsense and practical mechanical and industrial engineering solutions,” Jamrog said. “Then you strategically and tactically place automation, if it turns out to be necessary.”

‘Leaning out’ the lab
The effort to “lean out” a lab is a methodical one that gets to the nitty-gritty of how the specimen flows through the system and how the employees do their work.

It starts with a “Lean team,” which at Fairview Southdale Hospital is composed of six people pulled from their jobs for 14 weeks. The team includes management, a lead person from phlebotomy, a couple of clinical lab scientists, and a representative of the performance excellence program in the corporate division to lend an unbiased eye to the project. Lab management pared a list of several employees interested in volunteering for the team to six, selecting staff members known to be informal leaders.

At the outset, management observed that the equipment layout did not allow for a smooth workflow and that testing was batched in many islands of work, Panning said.

The Lean team videotaped workers to document their processes, walking patterns, and workflow, capturing the details of every task. The group concentrated on testing in the clinical lab (hematology, chemistry, immunochemistry, coagulation, and urinalysis). Based on methodical analysis and graphing of the videotaped data of workers’ activities and the specimen flow, the team designed one work cell, rather than separate departments, for all of these areas of testing. This work cell accounts for more than 90 percent of the testing performed in the clinical laboratory. The Lean team is also standardizing the specimen collection and processing part of the lab.

“The work cell is one space that includes the instruments and tasks assigned to that cell,” Panning explains. “We hope to assign two to three people to work in that environment as one cell ... and will do one-piece flow where the technical staff focus on one specimen at a time. These same areas were formerly staffed by five to six people on the day shift.”

To eliminate distractions, the Lean team identified and moved interruptions “somewhere else for other people to handle,” Panning says. “That way the clinical laboratory technical staff can focus on what provides value, which is taking the specimen and producing the result.”

At CAPTODAY press time, people in the Fairview Southdale laboratory were being trained to do their work in standardized ways. That’s where Lean gets mean: “No longer can someone come in and redesign their workspace,” Panning says emphatically. To prevent that from happening, the Lean team used shadowing to outline where everything should go, down to the phones and staplers. Serrano’s laboratory used tape to do the same.

Panning reports that while some lab staff initially found the shadowing to be unnecessary for professionals, they now understand it helps them perform their jobs better. “Lack of standardization introduces so many chances for error and delay,” he says. “And we have situations where someone goes to lunch or on break and another person takes over for him or her, which is very difficult to do” when everyone has designed their own workspace.

Yet management stressed to its employees that the move to Lean was designed to improve human potential, not to penalize people, says Panning. “One of the major messages we had to convey to staff is that we didn’t start this project because they weren’t working hard,” he says. “We communicated that we know they work hard but their performance could only be as good as the old system allowed.”

Not exactly lean results
Fairview’s Lean project is producing other, unexpected results. “For one, we freed up so much space that we were able to create a new space for microbiology. They get to occupy what used to be our chemistry lab, and other space will be converted into a Lean storage space,” Panning says. But instead of moving into the new space and going about business as usual, the microbiology department laid out the space, including instruments and incubators, so that work flows logically. (The scope of the original Lean project was expanded to accomplish this.)

Lean will not only improve turnaround time in the lab, but also make the reporting of test results more consistent—so much so that Panning expects the system may question the raison d’être of the “stat” designation because everyone should consistently get test results when they expect them.

Lab managers are now speaking with physicians about what tests they need stat and why. “In the old days I might have blamed physicians for misusing the stat designation,” Panning admits. “But I think it was a defense mechanism on their part where they’d order a test stat just to get the results in a normal time frame.

“We’ll be educating physicians and clinical staff in the patient care units about the realities of how fast the system can work,” Panning adds. “We can now set reasonable turnaround targets which will meet the customer’s needs and are based on the new capabilities of the system. We shouldn’t try to aim for a 20-minute troponin if the capabilities of the system, at its best, can’t deliver.”

Fairview Health Services, in fact, did a form of what Panning calls “Lean Lite” in a project in the Fairview-University Medical Center. The project focused on stat orders, improving consistency, and reducing errors and turnaround time. The person who led the project, Cindy Hudson—a soon-to-be-certified black belt in Six Sigma—eliminated a lot of the clutter in the workspace and used the 5S system of workplace organization and standardization developed in Japan. “Every cupboard and drawer was reorganized and is now supplied so you can tell what’s needed,” Panning says. “The project didn’t involve the rigor of Lean, but it did reorganize the work area.”

Implement Lean and Six Sigma will come
How does Lean fit with statistical performance improvement systems like Six Sigma or ISO? “Like hand and glove or foot and shoe,” Jamrog says. Panning and Serrano agree, noting that when you “lean out” a lab by removing waste, the Six Sigma projects, which require root-cause analysis, readily emerge.

Maria Foster, business director of Johnson & Johnson’s Ortho-Clinical Diagnostics consulting group, cites three reasons why laboratories should consider streamlining their operations with Lean Management before reducing variation in their processes (thereby reducing error) with Six Sigma:

  • Lean can result in significant improvements that substantially change laboratory processes.
  • Lean may eliminate a process that was causing an error.
  • Once the lab fixes/leans out its processes, the focus shifts to other areas because the lab has fixed other known quality process problems by simplifying and standardizing. Or, in some cases, the lab may not see the real cause of a problem until it is leaned out.

Says Maureen Harte, a Six Sigma master black belt with Ortho: “Until Lean removes waste from the system, you can’t fully identify the variable processes that truly take a bite out of the bottom line.”

Karen Lusky is a writer in Brentwood, Tenn.