Lean Tools

Lean Tools

Principles to Improve Lab Performance

By Thomas G. Zidel and Robert SanLuis

Interest in Lean is receiving more attention in medical laboratories as a means to reduce costs and improve efficiencies. Lean, however, is not a new craze in process improvement. In fact, Lean, a term coined to describe the Toyota Production System, has been evolving for almost 60 years.

The first application of Lean in the United States was undertaken at Danaher Corp. in 1987. By the early 1990s, Lean was demonstrating its ability to improve quality, decrease costs, enhance revenue and increase customer satisfaction in companies such as Wiremold, United Technologies, Johnson & Johnson and many others. Shortly thereafter, American manufacturing became a hot bed of Lean activity.

Lean principles are also pertinent to the medical environment. Healthcare organizations have processes; work in process inventory comes in the form of patients, test results, reports and medical records. And, many healthcare organizations employ computers to schedule, register and track patients. Dealing with life and death situations invokes an even greater need to provide consistent, safe, quality care.

Lean tools can be effectively adopted rather than adapted by the lab. As with manufacturing, the opportunities to implement Lean tools in laboratory services are inexhaustible, can reduce costs, increase efficiencies, diminish or eliminate errors, improve patient and physician satisfaction and increase productivity.

Key Elements in a Lean Transformation

Lean focuses on the elimination of non-value added activities or waste. To accomplish this, three elements should be applied:

1. standard work,

2. user friendliness and

3. unobstructed throughput.

Standard work is necessary to make problems obvious. When there is no standard process, staff members conduct their work the way they feel is best. When problems arise in that environment, they are remedied on an individual basis, failing to institute a procedural change that will prevent reoccurrence. The practice of making problems obvious and providing immediate problem resolution is a fundamental concept in Lean.

The second element is user friendliness, or providing what is needed, for the patient and staff, when it is needed, in the quantity it is needed, on time, every time, 24 hours a day, seven days a week, 365 days a year. Standard work cannot be accomplished if supplies are not readily available, if clarifications of instructions are required, if equipment is not in working order, or if processes are not clearly defined. User friendliness incorporates tools such as 5S (sort, straighten, scrub, standardize and sustain), Kanban (a method used to trigger the movement of materials or patients to or through a process) and visual controls (using visual methods to share information).

The final element, unobstructed throughput, can be associated with the Japanese word Heijunka, meaning sequencing products or services to provide an even distribution, or more simply defined as level loading to create flow.

Where to Begin?

It is recommended to conduct "pilot" events to demonstrate Lean's potential and provide a solid foundation from which to launch a successful Lean transformation. The laboratory is an excellent proving ground for Lean, not only because of its manufacturing-like environment, but also because of the laboratory's high visibility within the organization.

A key contributor to the success of the pilot event is the support supplied by senior administration. By providing the resources necessary to conduct Lean events, training staff to use Lean tools and demonstrating their support of the Lean initiative, laboratory administrators will greatly increase the likelihood of their organization's success implementing these quality principles.

As with any new initiative, there are challenges. First and foremost will be cultural resistance. Lack of familiarity with the tools and concepts of Lean, which are often counterintuitive, will undoubtedly manifest itself as doubt and rejection in the minds of staff members. Lean will, however, prove its value in a relatively short period of time (usually after the first event) and staff will be more accepting as they see positive results.

Lean in Action

St. Agnes Hospital in Baltimore, MD, is in the third year of its Lean transformation. St. Agnes has performed over 100 Lean events; many of these have been conducted in the laboratory. In March, a Lean event was initiated to improve the flow of specimens received in the lab's Microbiology/Immunology section to streamline the process and reduce turnaround time by 50 percent.

The Microbiology/Immunology section is comprised of six separate work stations. Each workstation had one full-time equivalent (FTE). Specimens were being batched with the misconception that this was the most efficient method of processing specimens. By batching the cultures, 57 percent of results were completed by noon each day. Sustaining this processing method throughout the day meant that results could be reported at a fairly consistent rate and by 2:30 p.m., 90 percent of the cultures were complete (Fig. 1a).

Technologists were working to maintain this completion rate and felt they were providing the best service possible for their customersÉand they were, with the processing method they were employing. However, the physicians were demanding results earlier in the day. To define value from the standpoint of the physicians, discussions were held with the physicians in the critical care area. It was determined that to make the greatest impact to patient care and throughput, the physicians needed results by 9:30 a.m. The Lean event team developed a stretch goal, hoping to deliver 90 percent of patient results by noon.

The first step was to create a current state value stream map to provide a common understanding of the existing process, expose areas of waste and highlight constraints or bottlenecks in the process. There was a total of 96 process steps. Three technologists were assigned to the process, two reading cultures and one reading blood cultures. Most of the volume was outreach.

With the current state map complete, the team needed to define how the process should function. To accomplish this, the team mapped out the ideal process flow for Microbiology/Immunology, which is the future state value stream map. This would require that the team stop batching, eliminate non-value added process steps, level load the process based on customer demand, establish new work cells and establish new standard work.

Ready for Change

Using standard work forms, the team documented task times for each step in the process, identifying unnecessary motion, delays, interruptions, redundant or needless operations, and other non-value added tasks. Existing process cycle times were established from this data and were compared to the takt time–the rate of customer demand. For a process to meet customer demand, cycle times must be less than or equal to takt time. Armed with this information, the team could now go about changing the process to reflect the future state.

The team began by implementing 5S. This phase provided more work space, a cleaner/neater environment and visual controls and kanbans for replenishing supplies and materials. Reading benches were arranged to optimize process flow and an additional station was established with a designated technologist that set-up the cultures for reading, eliminating this task from the reader's cycle time.

Cultures were prioritized based on customer demand and the process was level loaded (sequencing cultures in a cyclical order to provide an even distribution of results) to accommodate all customers. The entire focus of the department was shifted to meet customer demand.

Since the completion of this Lean event and the establishment of the new standard work in May 2007, 90 percent of new cultures (less than or equal to 24 hours of growth, read on day one) are reported by 8:30 a.m.; 80 percent of old cultures (less than or equal to 48 hours of growth, read on day two) are reported by 9:30 a.m.; and 95 percent of all results are reported by 10:30 a.m. (Fig. 1b).

Thomas G. Zidel is president, Lean Hospitals, LLC and faculty for the American Society for Quality. Robert SanLuis is laboratory technical and quality manager, St. Agnes Hospital.