Case Study “LEAN in Healthcare: Seeing with NEW Eyes”...pneumatic tube system • Lack of...

Case Study “LEAN in Healthcare: Seeing with NEW Eyes”

Presented May 19, 20082008 APHL Annual Meeting“EquiLABration – Balancing Technology, Quality, & AdvocacyRick Panning, MBA, CLS(NCA)CEO, American Red Cross – North Central RegionASCLS President, 2007-2008

World-Class Performance

LEAN in Laboratory Operations

Objectives

• Understand LEAN principles• Why the Lean methodology was chosen for

Fairview laboratories• Review pilot implementation process at a

large, suburban hospital• Project results / lessons learned.



Performance Excellence – Clinical and FinancialPerformance Excellence – Clinical and Financial

The building blocks of Performance Excellence

Quality Improvement

Methods(e.g., FOCUS-PDCA,

LEAN, 7-Step, DMAIIC, Rapid Cycle Improvement)

Quality Improvement

Methods(e.g., FOCUS-PDCA,

LEAN, 7-Step, DMAIIC, Rapid Cycle Improvement)

Accelerated Change

Accelerated Change EffectiveEffectiveX =



Why? What are our challenges?

• Cost versus Quality• Increased awareness of medical errors• Difficult to correct problems in complex

health care delivery systems• Solutions involve redesign and

reorganization• Patients needs are unmet



Remedy• Recognize quality failings• Define and prioritize problems• Engage leadership, management and

research tools to recognize and measure appropriate inputs and outputs

• Analyze relationships between variables

• Implement and sustained solutions



The American health care system is “remarkable for its technological achievements,” but it is also “potentially dangerous – even lethal – in its execution.”



Lean Philosophy• Add value to a product with a minimum of

non-value-added activity or waste • Waste = unnecessary work, enforced idle time,

unnecessary resource use, high inventoryMuda is any human activity which absorbs resources but creates no value. ( T. Ohno, 1988)

Waste is anything, time, costs, work, that adds no value in the eyes of your customer. (M. George, 2003)

• Customer defines value



History of Lean Production

• Toyoda FamilySakichi Toyoda – late 1800s

Inventor – built weaving looms Developed automatic power loomsBegan the concept of “mistake proofing”

Kiichiro Toyoda – founder of Toyota Motor Company in the 1930s.

Philosophy of company based on two pillars: build in quality (mistake proof) and just-in- time (pull system)



What is Lean?

Relentless pursuit, identification and elimination of waste in all business processes in order to produce value for the customer.



8 Types of Waste

• Overproduction – the MOST fundamental

• Waiting (time on hand)• Unnecessary transport• Over processing • Excess inventory• Unnecessary movement• Defects and errors• Unused employee creativity



The Lean Challenge• Develop the ability:

To recognize and identify wasteTo have the courage to call it wasteTo have the desire to eliminate itTo eliminate wasteTo understand that waste

Raises costsProduces no valueThreatens jobs and employee satisfaction

Adapted from SMC Group



Core Principles of Lean

Start with the customer – what value does the customer want from the process?

• One Piece Flow versus Batch & Queue• First In/First Out• Mistake proofing• Unified Layout• Standard Work• Visual Management Control



Eliminating wasteful and meaningless work enhances the value of work for all employees and better serves our patients and community.

Case Study



Understanding the Need for Change

• How does your laboratory fit into the overall organization and provision of care?

How can the laboratory enable high quality, safe cost-effective care?

• How is the laboratory performing? How will LEAN help you improve these measures?

Productivity and Cost per testTurnaround time complianceError rates (patient safety, quality)



Reasons for implementing LEAN at Fairview Southdale

• Planning for automation• Planning for facility improvements /

expansion• Significant need to:

maximize efficiency simplify processes improve patient care service



The Benchmarking and Performance Profiling Service



Clinical Lab “LEAN” Team• Champions:

System Laboratory President Hospital Vice President Site Laboratory Director

• Consultant Project Leaders • Team members:

POCT SupervisorCLS (day/evening)CLS (evening/night)PhlebotomistManagerProcess Improvement Specialist



Product / Process Workflow• The equipment layout does not allow for test, specimen and

information to flow from one value-added step to another. • The highest volume analyzer was the farthest from the

pneumatic tube system• Lack of standardized work• Layout leads to batching.• Work stations were unorganized- cupboards and drawers

were filled with non-productive inventory• The current equipment layout produces many “isolated

islands” of work. inhibit the balanced distribution work poor utilization of equipment ineffective use of the technician time



Average Daily Demand By Area Weekdays

0

5

10

15

20

25

30

35

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Hour of the Day

Num

ber o

f Spe

cim

ens

V950 CD4000 Stago Centaur Manual Clinitek IL-Syn All Remaining

• 20 tests of 121 represent 80% of total volume

• 4 analyzers perform 88% of total testing

Group Technology & Demand Data



Project Goals & Value StreamProject Goals & Value Stream

Product FlowProduct Flow

Group TechnologyGroup Technology

Operator AnalysisOperator Analysis

Job GuidanceJob Guidance

Performance MeasuresPerformance Measures

Standardized WorkStandardized Work

Cell LayoutCell Layout Work StationWork Station



RESULTS - 2 Major changes• Implementation of one automated work cell

Previously in 2 separate roomsPreviously in 6 separate workstations

• Implementation of one-piece flow phlebotomy process and testing (24/7)

Patients drawn and sent one at a timeTesting processed individually or in very small batches



PRE-Lean Standard: Results reported within 60 min from the time the sample was received in the lab

POST-Lean Goal: 95% of tests will be reported within 30 minutes from the time the patient is drawn

Cycle Time Goal



So what did we do?



Getting Started

EXPOSE THE CLUTTER• Remove cabinet/cupboard doors• Empty drawers and discontinue using them• Move all non-productive inventory to

temporary holding area



Phlebotomy Tray StandardizationNo Standard Work Lack of Organization



Visual Management Control /Tool Presentation



Determining the Layout

Product Process Flow1. Videotape the product moving through the

process from start to finish2. View steps and measure timeframes

• ORDER LABEL SPECIMEN RESULT




Product Process Flow2. Break down the activity of the product into

distance traveled and time spent in:StorageTransportation InspectionValue added processingNon-value added processing



Morning Pick-up Distribution of Total Time



Distribution of Total Time STATDraw for Vitros product Flow



wall24 sq ft

LIVING AREA7952 sq ft

SPECIMENPROCESSING

94 sq ft

MICROBIOLOGY666 sq ft

CHEMISTRY1080 sq ft

CLOSET15 sq ft

BATH32 sq ft

MR6

CLERICAL AREA382 sq ft

Dr. Carlson'sOffice

75 sq ft

HEME/COAGSEROLOGY

552 sq ft

T

TubeSystem

CellDyne4000

Determining the LayoutProduct Process Flow3. Draw a point to point diagram showing the route the

product has traveled




Group TechnologyDefinition: The grouping of similar and recurring tasks so that the products can be produced on multi-purpose lines

1. Look at annual product (test) volumes and demand data by the day and by the hour

2. Establish patterns in process steps



Determining the LayoutCell Layout• Design a layout giving prime location to highest volume

analyzers• Set up flow for 80% of high volume tests and low volume

critical tests• Design layout in a cellular formation to achieve efficient

walk patterns and flexibility in number of operatorsPriorities in order of importance:1. The activity of the product2. The activity of the operator3. The flexibility of the operation4. The method of measuring performance



Determining Standard Work

• Operator Analysis• Videotape the activity of the operator to

determine:Which tools and supplies are needed at the work stationWhat is the order of job stepsHow many seconds does each job step take

• Break down the activity of the operator into time spent into pre-determined categories



Determining Standard Work Job Guidance1. Document suggestions to eliminate or

decrease required waste2. Determine what the order of job steps

should be 3. Estimate how long the job step should

take based on video tape analysis



Determining Standard Work Work Station1. Design a proposed work station with the tools and

supplies needed for one day’s work2. Arrange the tools and supplies in order of use

corresponding with the job guidance steps of that work station

3. Determine operator walk patternSetting Up the Work Station

• We shadowed and labeled the permanent location of each tool and supply

• We set up a two-bin supply replenishment system• We color coded tube racks to clarify the status of our

specimens



Standard Work Package

Cell Layout Work StationJob Guidance



Performance Measurement

• Monitor vital statistics - are we achieving our goal? (95% of tests will be reported within 30 minutes from the time the patient is drawn)

• Identify reasons for not achieving goal -downtime tracking

• Resolve highest frequency issues



06/30/05 Coulter (HGB) Vitros (K) Stago (INR) Clinitek (UMAC)

Centaur (TROP)

Total Tests 184 172 94 35 Total Tests 42Tests <25 Min 168 165 88 34 Tests <40 Min 39Tests >=25 Min 16 7 6 1 Tests >=40 Min 3% Tests <Threshold 91.3% 95.9% 93.6% 97.1% 92.9%% Tests >Threshold 8.7% 4.1% 6.4% 2.9% 7.1%

Coulter (HGB) TATs

91%

9%

Tests <25 Min

Tests >=25 Min

Vitros (K) TATs

96%

4%

Tests <25 Min

Tests >=25 Min

Stago (INR) TATs

94%

6%

Tests <25 Min

Tests >=25 Min

Centaur (TROP) TATs

93%

7%

Tests <40 Min

Tests >=40 Min

Clinitek (UMAC) TATs

97%

3%

Tests <25 Min

Tests >=25 Min



Diff &

Kit Testing

Bio Haz Cap

sSample V950Label

MisysMonitor La

bel

MisysMonitor

MisysMonitor

Labe

lMisysMonitor

Core Work Area for the Clinical Lab Scientists whoperform 90% of all Lab tests

After LEANOne person walking 6 cycles in 30 min and operating 6 work stations

Proposed Layout



Post-project Productivity

(actual daily staffing (actual daily staffing deduction of 35%)deduction of 35%)(target (target –– 58)58)

20%20%51.2 FTE51.2 FTE62 FTE62 FTETotal LabTotal Lab

50%50%4 FTE4 FTE8 FTE8 FTECore Lab Core Lab (M(M--F, day shift)F, day shift)

50%50%5 FTE5 FTE10 FTE10 FTEPhlebotomy Phlebotomy (M(M--F, day shift)F, day shift)

% ImproveAfterBeforeArea



Collection to Result (Compliance within 30 min.)

(Improvements over 3.5 years))• Hemoglobin

Dec. 2002: 40%June 2005: 91%

• PotassiumDec. 2002: 12%June 2005: 96%

• PTTDec. 2002: 5%June 2005: 94%



Premier LabFocus: Cost per test

• Dec.2002: $9.00• July 2003: $8.00• Dec. 2003: $6.75• Mar. 2004: $6.45• Sept. 2004: 6.24 (31% improvement)• June 2005: $5.99 (45% improvement)



Premier LabFocus: Productivity (test/hour)• Dec. 2002: 4.75• July 2003: 5.50• Dec. 2003: 6.40• March 2004: 7.05 • September 2004: 7.40 (>50% improvement)• June 2005: 7.72 (62% improvement)

Ability to absorb increased test volume



June 2005 Benchmarking



Summary of Benefits• Testing thru-put (TAT) reduced by 50%• Productivity improvement >40%• Cost reduction at 28%• Space savings of >450 ft2• Standardized work practices• Reduction in Errors and Error Potential• Performance measurement• Elimination of excess unused inventory ($16,100) • Elimination of visual noise• 100% cross-training of staff



Additional Benefits• Development of a core team of people that has

implemented “Lean Manufacturing” and are therefore available to spread the benefitsorganizationally

• Standard Work and Standard performance measurement tools developed

• 2004 employee engagement score in clinical lab rose by 0.48 on a 5 point scale. 2005 improved add’l 0.25.

• Laboratory recognition from customers• Laboratory recognized as a pioneer within

organization



Key Learnings• Change is stressful • Constant and repeated communication• Coordination with IMS, facilities, vendors, other

depts.• High visibility of the LEAN team and manager

has increased trust and engagement.• The staff is able to see the Waste of previous

process.• Need to help staff understand their professional

contributions are valued and needed.



After the Project is “Finished”• Insure that day-to-day operational leadership

maintains the gain (supervisor)Compliance with standard work is the key

• Track down-time and evaluate reasons• Measure daily, weekly, monthly• Keep measures in front of staff• Share positive feedback and impact on patient care

with staffLaboratory professionals need to understand that the change made a difference.



Systemwide: 2003-2005• Cost per test improvement

Lakes: 10%Northland: 13%Red Wing: 12%Ridges: 15%Southdale: 33%Riverside: 13%Hibbing and University: cost has gone up by 5-10%. No Lean changes at this point

• Productivity Improvement

Lakes: 16%Northland: 30%Ridges: 43%Southdale: 53%Riverside: 28%



Another way

• Kaizen events – shorter, more targeted improvement

• Training• Assessment and observation• Multiple, shorter projects to try suggested

improvements and modify real-time• Used at the American Red Cross for

improvements in the collections/donor process



Introduction• Goal:

Reduce Health History Total Process Time from average of 25 minutes by 30% to 50% in the North Central Region by the end of April 2008

Reduce Process Time by eliminating Non Value Add (NVA) timeCreate Standard WorkMatch Cycle time to Takt/Customer Demand

• Results:Reduced Health History time at Over-Goal Drives from 34 minutes to 21 minutesNo increase in Staff / Increased Productivity by 39%



Improvement Idea - Flip CardBEFORE• Health historians can't see

if histories are occupied. • Staff walk the length of all

the histories looking for a vacant booth.

• Staff can’t tell when donors are done with SAHH and waiting.

• Donors had to stand and wait for staff to finish health histories

No way for staff to tell which booths are occupied.



Improvement IdeaAFTER• Create flip signs for

visual cues of HH Status. - Ready – Pink- In-Use – Orange- Re-check - Yellow- 2RBC – green

• Quality Improvement-Improved donorconfidentiality.

Improved donor confidentiality



Improvement Idea - Flip cards

-Before- -After-

Walking distance decreased from 257ft to 114 ft (approx 48 secs per staff per history)



Other changes in health history

• “Priming the pump” – match initial process to donor flow (takt time)

• Layout of health history table (presentation of tools)

• Layout of printer table (presentation of tools)

• Managing breaks – match process to donor flow (takt time)



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