Trimming the fat from lab processes

May 2006
Feature Story

Karen Lusky

Henry David Thoreau cautioned that “our life is frittered away by detail,” suggesting that we “simplify, simplify.” And German artist and art teacher Hans Hoffman said simplifying means eliminating “the unnecessary so that the necessary may speak.”

Both statements describe what Lean teams in labs and hospitals do: Identify the superfluous steps in a process that squander productivity and profit. As a recognized national Lean expert, Mark Jamrog, president and CEO of SMG Group in Edwardsburg, Mich., simplifies it this way: In using Lean, “you scrape the nonsense off the top” so you can unearth the real problems.

And while Lean is mostly a science, there’s also an art to finding the simplest ways to drive out wasted time, motion, inventory, and space to give customers (ordering clinicians, patients, payers) what they want when they want it. “That is the whole idea of the concept of ‘creativity over capital’ where we take the time to develop a more innovative cost-effective solution that works better than an expensive solution,” says David Stowe, a Chicago-based partner in SMG Group.

Jamrog agrees. “In choosing a solution to a problem,” he says, the idea “is to make your costs go down—not to shift costs.” And “when you fix the simple things, oftentimes you find out that the complicated solution you first thought was needed isn’t needed anymore. Or then you can select appropriate new technology to further improve your process.”

Case in point: The Lean team at Saint Marys Hospital, a Mayo Clinic hospital in Rochester, Minn., came up with a simple but clever strategy to manage what had become a chaotic paper order system for lab work in its ICUs. The team executed a “bus route” schedule in which specialized phlebotomists on a vascular access team drop by patients’ rooms at designated times to collect blood for lab testing, including arterial blood gases. The technicians also perform point-of-care testing and place intravenous lines.

The vascular access team got its start a decade ago to consolidate specimen collection and IV placement in the units—a change that in and of itself boosted efficiency and patient care and satisfaction, says Twyla Rickard, laboratory operations manager for the Mayo Clinic.

Then last year, the Lean team decided to revamp the way in which the technicians were accessing and managing paper orders. At the time, the vascular access team, or VAT, technicians were receiving paper orders in multiple ways, creating opportunity for duplicate orders and other snafus. Some orders, Rickard says, “were hand delivered, some placed on [the VAT tech’s] working cart or desk or maybe hung on the patient’s door, or handed to the vascular access technician by the nurse or unit secretary.”

Further fueling the confusion, Mayo physicians make rounds in teams, and sometimes one team would order what another had already requested. As a result, for every hour the VAT tech spent entering orders, the person spent two hours reworking them, Rickard says. And a VAT tech’s pager was going off 30 or more times per shift for response to urgent requests.

The Lean planning team took a hard look at how it might fix the process. At the Lean planning meetings were VAT team members (representing all shifts), nurses, sometimes respiratory therapists, and, in the most recent project winding up in the sixth ICU, the physician assistant/extender group, says VAT supervisor Teresa Coughlin. She says the collaborative effort included “a lot of ‘what’s in it for me’ exploration to ensure the patient, nurses, physicians, etc. were all included.”

As a first step, the team mapped the current way things were done from “beginning to end” to determine the “bottlenecks and areas of waste,” Rickard says. Then they drew a “future state map that eliminated unnecessary process steps and waste... and focused on a single-piece flow process that would improve turnaround times, increase quality, and create value for the customer.”

The team decided it could reduce paperwork and eliminate disorganization by keeping physician orders for the VAT on the outside of the patient’s door. (To protect privacy, the orders are placed so that they face backward in a Plexiglas holder on the door.) The paper order in the holder provides a visual cue that a patient has an order for the VAT to manage. All of the physician teams use the same sheet to write orders. That way, Rickard says, they can see what another physician team has ordered so they don’t duplicate orders and can simply add on to a previous order rather than create another.

Before the Lean project, ICU nurse Tracy Mietzner says, “the physicians would all write separate orders in the chart and the VATs would have to differentiate what was a duplicate.”

Next the team initiated and posted a standardized “bus route” for the VAT tech to stop by each room in the ICU to check for and implement new physician orders. The ICU has 12 rooms in an easily visible U-shaped area so all the patients can be seen from the center where the tech’s desk is located. The tech stops by the first three rooms from the top of the hour until a quarter after. So, for example, “if the physician writes the orders between 7:01 and 7:15 a.m,. the VAT [tech] will service that patient and the next two rooms from 7:01 to 7:15,” Rickard says. Then the tech goes to the next three rooms from 7:16 to 7:30 and so on.

To determine that a technician could service three rooms in a 15-minute time slot, the team relied on already available “workload recordings” that managers collected by following staff with stopwatches to determine how long it took to complete various procedures, says VAT supervisor Coughlin.

In the post-Lean ICUs, laminated maps of the VAT bus route are posted outside the patients’ doors so the doctors and nurses can see what time to expect the technician. Each time the phlebotomy tech comes by, he or she moves a large, colored paper clip to the next time someone from the VAT will arrive, which helps reduce stat orders. “If a physician is seeing a critical patient and wants a stat order,” Rickard explains, “he or she can see that it’s five minutes to 7 and the VAT will be there in five minutes—and can ask him/herself if the test can wait five minutes.” In fact, this method has all but silenced the roughly 30 priority pages the VAT received each shift. Post-Lean, Rickard says, the VAT receives on average one to two pages each month.

Cardiac arrests and other emergencies interrupt the VAT’s bus route. When that happens, the tech pages another tech known as a “flyer” who acts more like a “taxi” when he or she takes over the bus route so the VAT can manage the stat or emergency.

Nurse Mietzner has no doubt that the new system means better patient care. Not only are the patient interventions fewer, she says, “but before [the Lean project], if we had an hourly blood sugar and the technician was involved with a sick patient in another room, it might be two hours before the technician was available to do the blood sugar.” But now a backup person takes over the bus route.

Dick Sitta, a vascular access technician, says Lean has reduced and evened out the VAT’s workload. “Before we were bouncing back and forth from patients’ rooms...” Another perk: “Reducing stress on health care staff can make a huge difference in terms of improving job satisfaction and retention, which is important given the workforce shortage,” he says.

ProMedica Laboratories, the core lab for the ProMedica Health System and part of the flagship Toledo (Ohio) Hospital, used a number of Lean tools, including 5S events (where you sort, set in order, shine, standardize, and sustain), to free up space in its core lab and histology storerooms. Now people can find any item in the storeroom within 30 seconds. Moreover, the core lab storeroom has 17 percent more available space, and the histology lab 40 percent more storage space, says Mark Sattler, MBA, FHFMA, CHE, Toledo Hospital’s administrative director for diagnostic and therapeutic services.

To help people find any item in the storeroom within 30 seconds, the 5S teams posted an alphabetized list of supplies on the storeroom’s doorway. The stockrooms also have a “stock locator one-point lesson—a very visual instruction [explaining] how to quickly locate any supply item,” Sattler explains. The locator sheet details on which rack and shelf a supply item can be found. “The locations are clearly identified so that you can walk straight there and retrieve the desired items,” he says.

The labs also reduced stockroom inventory by limiting stock of items that didn’t turn over fast and by eliminating obsolete items, Sattler says. And they implemented a more just-in-time delivery system by receiving supplies from the in-system distribution center twice a week rather than weekly. “Additionally, we are working with our major clinical lab vendors to go to more frequent deliveries,” which will cut inventory significantly, he adds.

The anatomic pathology laboratory was able to free up an entire storeroom to convert to a room for cytology accessioning. To pull off that feat, the Lean team consolidated the reduced volume of histology supplies in one storeroom, which had 40 percent more room thanks to the 5S project. Then they moved the cytology supplies that had been in the second storeroom to unused space under the counter in the cytology preparation area. “We brought in some rolling pallets that fit under the counters and are now able to store inventory in that awkward space,” Sattler says. With the rolling pallets, staff members don’t have to bend over and drag a heavy item. And the items are now stored closer to the point of use—another time- and motion-saving Lean concept.

The cytology lab now stores patients’ liquid-based (ThinPrep) vials in the accessioning area. The vials are organized by date and accession number so staff can easily retrieve them for HPV reflex testing. In the pre-Lean days when requisitions came back for the reflex testing, “it took a long time to retrieve [the vials],” Sattler says. Now it’s easy for the accessioning staff person to pull the vials and hand them off to the people who will prepare the specimen to go to a reference lab for reflex testing.

Much of what the Lean teams did was “common sense,” Sattler says, which he compares to how he sets his keys and wallet in the same place in his home so as not to waste time hunting for them. “Using Lean you put the supplies you use most frequently where they are easiest to get to—and put the things that you use infrequently farther away,” he says. But he’s quick to add that this can’t be done unless managers “talk to folks who work at the workstations.”

In fact, says Maria Foster, worldwide director of Ortho-Clinical Diagnostics’ Valumetrix Services and Idexx, “the number of ideas for improvement coming from lab staff is a good metric in and of itself” to show how engaged the lab is in the Lean process.

To streamline the management of outreach lab specimens, ProMedica listened to the suggestions of employees working in the processing area where staff prepares samples to go to the technical bench for analysis. The result: A 25 percent reduction in “wait time,” Sattler says, defined as the period from when the courier drops off test samples at the window to when they reach the bench for technical analysis.

Pre-Lean, the couriers dropped off the outreach specimens in large bags placed into a first-in-first-out bin. “And each staff member would make a trip over to the bin to obtain work they would do for the next period of time,” Sattler explains. Because no one wants to get up every 15 minutes for more work, the staff would retrieve a large amount of specimens so they could work uninterrupted for longer periods. But in so doing, “they were creating a large batch,” Sattler says. That meant none of those tests in the batch made it to the technical bench for some time.

Each staff person also had to carry his or her completed work to its destination, which translated into 12 to 15 people crossing paths. What’s more, having to get up periodically also interrupted the staff’s concentration in performing a number of tasks that require close attention, such as making sure they have the right specimens in the right tube types and labeling the tubes.

So staff suggested they take turns serving as “runners” to transport the specimens from the bins to the staff for preparation and to the benches for analysis. The designated runner gives each person enough work to last 15 to 20 minutes which “isn’t quite single-piece flow,” as Lean espouses, “but we certainly reduced batch size,” Sattler says.

Medical Center Laboratory, an affiliate of West Tennessee Healthcare, Jackson, Tenn., used Lean last summer to streamline and error-proof its patient registration process. The lab decided to make the change before implementing PaperWise, a documenting imaging system for its requisitions, says Vickie Mayo, MT(ASCP), process excellence manager of the lab. That tack follows a key Lean principle: Don’t impose new technology on a broken process.

Pre-Lean, customer service representatives performed a simple patient registration when the specimen arrived, keying in the patient’s name and doctor and assigning the person an account number. Then the requisition went to the billing department after the lab testing where it would pass from “person to person to person,” Mayo says, which constituted wasted time and motion. “We did it that way pre-Lean just because we’d always done it that way,” she says.

The outreach lab was also having trouble pre-Lean with patients being assigned more than one medical record number, requiring staff to merge accounts when they discovered the problem. The Lean project reduced duplicate medical record numbers by 93 percent. In the week before implementing Lean, outreach patient registration had 180 duplicate medical record numbers assigned compared with 11 in one week after the lab made the Lean changes. “From April 1 to April 13, 2006, we had three,” Mayo says.

The Lean project also reined in data entry registration errors by 83 percent, including duplicate account numbers for the date of service, which can create cash flow problems when billing Medicare. “If a Medicare patient had duplicate account numbers for the same day of service [that were] billed separately,” Mayo explains, “Medicare would deny the claim and we’d have to merge those account numbers” before submitting the bill. Other errors were incorrect doctors’ names and incorrect financial codes, the latter resulting in claims being billed to the wrong payer (the client as opposed to the patient) if not caught before billing.

To avoid passing problems down the line from registration to billing, the Lean team took a lot of the data entry part of the billing process that had been occurring on the back end and moved it to the front end, Mayo says. They also had some of the billing clerks who worked upstairs in the billing department move downstairs to take over the revamped outreach patient registration. The reassignment made sense given that the billing staff had a “wealth of knowledge,” Mayo says, about the different types of insurance and other information needed to complete the registration.

Here’s how the “leaned out” registration now works:

• The outreach lab’s courier delivers requisitions and specimens to the “FIFO” (first-in-first-out) rack. The couriers flip over a sign on the FIFO to let the registrars know work is waiting.
• The registrar registers the outreach patients one at a time in the lab information system. The person assigns the patient a medical record number (if he or she doesn’t already have one) and enters patient demographic and insurance information in the LIS, as well as the client, ordering physician, and client-requested specific information such as fasting.
• The registrar prints a bar-coded label that contains the patient’s name, account number, client, and financial code, and places the bar code on the requisition. The person then places a smaller label with the same information minus the bar code on the demographics sheet or copy of the insurance card.
• The registrar scans the requisitions and other papers into the PaperWise imaging system, which allows the billing department to view them on its computers.

After that, the registrar takes the requisitions back to the FIFO rack and turns the sign over to let the client service representatives know they have work to do. The representatives retrieve the requisitions and samples and verify that the name on the requisition and specimen match.

The client service representative scans the bar-coded label using a handheld scanner that pulls up the patient information in the order entry screen in the LIS. “If the requisition the CSR scans says ‘Susan Smith, yellow top tube,’ the CSR pulls the tube identified as Susan Smith to the front of the rack,” Mayo says. The CSRs verify they have the blood sample before ordering the test. The CSRs thus do single-piece flow so they will finish all of Susan Smith’s tests before moving to the next patient.

The service representative orders the tests, labels the blood specimens, and places the specimens in the “ready for delivery” rack. A runner picks up the specimens and delivers them to the testing area in the lab. When the customer service rep is finished ordering the lab work, he or she takes the requisitions to the registration cubicle where they are filed. The paper requisitions are bundled by date and stored in billing.

Thanks to Lean, billing is now paperless. The billers have dual screens where they can pull up the PaperWise system on one screen and the billing system on the other. Then they verify that all the necessary information has been keyed into the system. They also enter the doctor’s universal provider identification number, or UPIN, and the ICD-9 codes if the client provided them. The billing system has a program built in that verifies medical necessity.

If the billing information is complete, the clerk sends the requisition electronically to the “awaiting remittance” queue that indicates it’s ready to send to the payer electronically or by mail.

If a narrative diagnosis needs to be translated into an ICD-9 code—or if the code fails to meet medical necessity requirements—the clerk sends the requisition electronically to the “coding queue” where a coder opens the queue and then translates the verbiage into a code or contacts the physician for a proper diagnosis.

When a requisition is missing pertinent billing information, the clerk sends it to the “error callback” queue, Mayo explains. The billing clerk who is working the error callback queue will open that queue, view the requisition, call the client, and get the missing information. If there are several requisitions from one client, the billing clerk prints the requisitions and sends them to the client via the lab’s couriers.

Some of the people from the billing department initially had concerns because though they’d heard about Lean, they had yet to be affected by the Lean changes, Mayo says. But once the billing clerks learned the process, “they loved it,” she adds. Before Lean, “we had a batch mentality where hundreds” of orders were batched in a hurry-up-and-wait mode, she says. “Now we send the samples to the lab as they come in.” They’ve had positive responses from the technologists in the core lab who have noticed that the specimens are arriving in the testing area earlier and at a more constant rate, Mayo says.

Donna Threadgill, client service manager at Medical Center Laboratory, says job satisfaction among the client service reps is up. “Staff is no longer stressed with the pressure of getting everything registered and ordered on time.” In fact, the registrars and the CSRs are getting the work done earlier and have been cross-trained to work in other client service areas.

All three labs did as Lean expert Jamrog says: They knocked out the nonsense. And like Stowe says, they chose creativity over capital. Saint Marys Hospital didn’t put an electronic physician order entry system in place to solve its problem in the ICUs, and ProMedica didn’t tear down walls to add another room to its cytology preparation area.

“There are many people in a company, including senior level executives, who feel that buying a new machine is the key to success—and maybe there are silver bullets in the marketplace,” Stowe says. “But creativity can go a long way.”