Hospital - Cytogenetics Laboratory
There were no formal limits on slides produced. If analysis rate dropped, the number of slides awaiting analysis grew. Now there is a visual cue to show optimum number of slides available for analysis.
About SickKids
The Hospital for Sick Children (SickKids), affiliated with the University of Toronto, is Canada's most research-intensive hospital and the largest centre dedicated to improving children's health in the country. As innovators in child health, SickKids improves the health of children by integrating care, research and teaching.
With a staff that includes professionals from all disciplines of health care and research, SickKids provides the best in complex and specialized care by creating scientific and clinical advancements, sharing knowledge and expertise and championing the development of an accessible, comprehensive and sustainable child health system.
In 2003/2004 SickKids saw over 300,000 clinic, medical day care and diagnostic visits, nearly 50,000 emergency visits, and performed nearly 12,000 operating room cases.
What Is Lean?
The LEAN Management System was originally developed by Toyota and has been used extensively in industry to increase productivity through the elimination of waste. In recent years, this process-based solution has also been applied in numerous healthcare settings including laboratories to allow departments to maintain/improve quality while providing better, faster service while improving their cost-effectiveness. LEAN requires you to methodically map and understand the entire process (end to end system) rather than just individual components, allowing you to "unmask" areas of waste that negatively affect the process as a whole. This waste can take many forms (e.g. time, transport, overproduction, errors or resources) and by removing waste you speed up the process without compromising the essential steps and therefore quality.
Each activity carried out must create value from the perspective of the client/patient. In the case of the laboratory, the sample should flow through the laboratory rather than continuously sitting, waiting for the next step in the process
Key Ideas
- Reduce waste - Ensures activities being done are of value and maximum use of available resources is achieved. This can also help reduce turnaround times.
- One Piece Flow - Handling samples one at a time rather than in batches keeps the sample moving through the system, reducing "wait times". It can also reduce the chances of mix-ups and other errors. (Note - One piece flow is the ideal state and small batches may be necessary depending on the existing system).
- Standardisation - By reducing variation you reduce the chance of mistakes and people are more of Processes aware of the level of expectation. It is also easier for someone to "step-in" when necessary if workstations and processes are standardised.
- Set Realistic Targets - Productivity increases if you have a target/deadline to work to. However, these targets must be realistic or they are likely to be counterproductive.
- Use Visual Cues - Allows communication quickly and effectively in a non-verbal way. These can also quickly highlight any problems allowing them to be fixed rapidly rather than developing.
- Monitor Progress - Develop and use tools to assess progress and allow rapid detection of problems.
What is Cytogenetics?
- The study of the structure of human chromosomes with the aim of generating information regarding an individual's phenotype.
- Patient samples (e.g. blood, bone marrow, skin) are usually cultured and cells arrested at metaphase, allowing the chromosomes to be visualised.
- Some of the cells are transferred onto a glass slide and may then be enzyme treated and stained (G-banding) or used in molecular cytogenetic techniques such as FISH.
- Routine cytogenetic analysis is a whole-genome screen examining G-banded chromosomes band by band, looking for subtle changes that indicate chromosome abnormalities.
- FISH uses fluorescently-labelled DNA as a probe to detect the presence, absence or rearrangement of a DNA sequence of interest.
LEAN in Cytogenetics
- We undertook the LEAN process with the hope that it could make our laboratory more efficient and help to improve/prevent sample backlogs.
- We hope to maintain any changes implemented through LEAN by involving all staff members and by updating/creating relevant SOPs.
Understanding the Requirements
- A focus group was established and the demand on the laboratory (numbers and types of referral) was identified based on real sample data.
- We then mapped every activity that happens to a sample (both in the laboratory and administratively) from the moment it is received until the final report is issued (system not just points). Included in this were all the points at which a sample sits and waits for the next step in the process.
- We then incorporated timescales onto this basic framework to identify how long each step takes and how much time is "wasted" with the sample sitting between steps.
- Finally, we identified the number of people required to complete each step and also the number of samples waiting between steps, to help identify where any overproduction or sample backlogs occurred. All the steps carried out in the laboratory were represented in the "Current State Map"
- Based on our Current State Map, the focus group tried to identify areas of the process that could be changed to improve work flow and reduce waste.
- The map was divided into several distinct areas or "loops" according to the nature of the processes within them.
- We came up with several basic ideas or "Kaizens" (meaning "change for the better") for improvements that could be made and recorded these on our "Future State Map".
- These Kaizens were then ranked so that the first to be developed was the one that we expected to have the greatest impact, ensuring that the biggest improvements would be made rapidly.
- Typically the first steps targeted were those towards the end of the whole process since improvements in earlier steps would fail to have any effect overall. This is because samples would still have to wait at the slower, less efficient, later steps.
Developing and Implementing Changes
- For each Kaizen (currently 12 identified), a working group was set up to develop a practical solution to the challenge. This group included people who worked in that particular area and overall every member of staff was involved in some way.
- This was coordinated using the "Implementation Plan" which also included a given timescale for each group. The overriding idea is that making small, immediate improvements is better than waiting until next year for the perfect solution!
Although the implementation of many of the ideas generated is still ongoing, there have already been several improvements within the laboratory as a result of LEAN.
Example 1: Visual Cue for Slide-making
Previously there were no formal limits on the number of slides produced, so if the analysis rate had dropped, the number of slides sitting awaiting analysis continued to grow.
Now there is a visual cue to show the optimum number of slides available for analysis and whether more slides need to be produced. This means that staff involved in slide-making can be reassigned to more immediately useful tasks, rather than just producing more slides that aren't needed yet.
In addition, this acts as a quick, visual audit to show whether we are meeting our demand or could also act as an indication that our demand has changed.
Example 2: Changes in Analysis Procedure"Old" Analysis Procedure
- File is handed to a second technologist and awaits karyotyping
- File is handed back to primary analyst and awaits print analysis
- File awaits data entry by second technologist
- File awaits review by senior technologist
- File awaits review by director
This method was used so each technologist could be more efficient in a single role rather than having to switch between multiple roles.
"New" Analysis Procedure
Steps 1-5 now performed by the same technologist so there is no time wasted with a case just sitting around between each step (i.e. wait times A, B and C eliminated)
Example 3: Standardisation of G-band analysis protocols
G-band analysis involves the comparison of both G+ve (dark) and G-ve (light) bands, looking for differences from the "normal" banding pattern. Analysis is subjective, not quantitative.
Standards were already in place regarding the quantity and quality of cells to analyse but individual approaches vary, even though the end result is the same.
The aim of this Kaizen is to reduce this variation and standardise the process:
- First, surveys were completed by all analysts on approaches to all aspects of analysis
- Surveys collated by the working group for the Kaizen and "best practice guidelines" developed.
- Currently guidelines are under review prior to SOP update and implementation.
Example 4: Visual cue showing analysis demand
The analysis demand chart shows everyone the amount of analysis expected based on our sample demand and indicates whether we are hitting our targets. This method encourages pride when targets are met and if they are not, we can assess why this may be the case.
Conclusions
The aim of this exercise was to improve laboratory efficiency where possible in order to help reduce/prevent sample backlogs. Following the mapping exercises, we identified that the laboratory already had a good level of sample flow but quickly noted several areas where changes could be made. Overall, it is the combination of several small changes which will reduce waste and improve flow, rather than any one big change.
Many of the Kaizens identified through this exercise are still being developed and implemented so it is not yet possible give a quantifiable summary on the way LEAN has impacted on the laboratory.
However, over the last couple of months we have seen our backlog of samples reduce and although only a few Kaizens have been developed and are having a practical effect at the moment, LEAN has had a large impact on the way we approach our work.
By setting targets that are realistic, we have been encouraged to improve productivity by thinking more about how we organise our work and also to take pride in meeting these targets.
In order for LEAN to succeed, we are keenly aware that all staff must be kept informed of progress and involved in the decision making processes. This is particularly true for those people who work on the section involved as it is they, not the supervisors/management team who need to make the system work on a daily basis.
Future Developments
- Continue to develop and implement Kaizens, driving the improvement of flow and the reduction of waste.
- Use other LEAN tools such as "5S" to standardise workstations and physically organise the laboratory in a way that helps to remove clutter and reduce time and transportation waste.
- Continue to assess laboratory processes to drive further improvement.
- Encourage staff participation in developing improvements.