LEAN in the Haematology Laboratory
The Hospital for Sick Children is Canada's most research-intensive hospital and the largest centre dedicated to improving children's health in the country.
By: SickKids and
Department of Paediatric Laboratory Medicine (DPLM)
November 2006
Lean in The Haematology Laboratory
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. A valuable and integral component of SickKids is the DPLM, which provides timely specialized diagnostic services, and generates original research. In addition, it is a complementary laboratory service that provides paediatric expertise to the Toronto hospitals and other laboratory providers across the province of Ontario.
Haematology Laboratory at SickKids
The General Haematology Laboratory, in addition to its role in leukemia diagnosis, provides a 24-hour/seven days a week essential service for the performance of CBCs, blood film examination, PT, PTT and fibrinogen. These tests are necessary in the management of critically ill patients, as well as in the routine assessment of most other patients.
What Is LEAN?
The LEAN concept or "LEAN" was first introduced in the 1960's by Toyota (known as the Toyota Manufacturing Process) as a systematic means of identifying and eliminating waste from processes. Waste can be defined as any activities within a process that the customer would not willingly pay for; that is, they do not add value to the service provided.
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 and faster service while improving their cost-effectiveness.
LEAN requires one to methodically map and understand the entire process (end-to-end system) rather than just individual components, allowing one 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, one speeds 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).
- Standardization Process - By reducing variation, one reduces the chance of mistakes and people are more 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 one has 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
Lean Journey
Objectives:
- To streamline work processes
- Eliminate waste
- To gain improved productivity, lower cost, and maintain or improve on the existing high quality
- Reduce CBC TAT to 30min or less
- Reduce Differential TAT to 60 min or less
- Reduce STAT requests
- Increase overall customer satisfaction
- Free up staff for other activities
LEAN Journey
During a six-day workshop, a Haematology focus group was introduced to Lean Principles (See Figure 1) and underwent intense sessions focused on analyzing and mapping the current processes. The first three days of the workshop consisted of practical exercises combined with discussions to clearly reinforce the LEAN concepts. The last three days were dedicated to Enterprise Value Stream Mapping ™, which included the development of the Current State Maps and Future State Maps of the Haematology Laboratory ("Laboratory").
The workshop was rounded off by the development of the LEAN Implementation Plan, followed by a communication campaign. Information and poster sessions were held, which provided opportunity for information-sharing and receiving feedback from staff. The focus group participants were on hand to present their "lean findings/observations" and looked for input from the rest of the staff. The sections below will provide more information on the Value Stream mapping experience and the LEAN implementation of the Laboratory.
Enterprise Value Stream Mapping ™
Enterprise Value Stream Mapping ™ provided the Laboratory means to illustrate all the value added and non-value added activities from beginning to end of the value stream, and means to apply the LEAN Principles. They were able to eliminate the non-value added activities from the value stream based on the expressed needs of the customer, which resulted in streamlined laboratory process and improved flow and efficiency. The flow of value from beginning to end became transparent during the value stream mapping exercise.
From a practical standpoint, value stream mapping created a visual representation of the process from the receipt of samples to the release of valid results including information flow as well as sample/specimen flows. It allowed the focus group to gain a birds-eye view and third party perspective of their process, and from this perspective they were able to properly question and analyze all the steps within our process.
Figure 1: Lean Principles
- Define value from the perspective of the end customer
- Identify the value streams and highlight waste
- Understand what drives waste
- Eliminate all the waste that one can by developing a proper Implementation Plan
- Make the remaining value steps flow
Source: Lean Advisors Inc. (LEAD®)
Our Experience Current State Mapping
The group's initial steps in Value Stream exercise was to create a Current State Map. As mentioned, Enterprise Value Stream Mapping ™ follows a product or service from beginning to end (including Information flows), and constructs a visual representation of every step in the process. Accordingly, the Laboratory built a Value Stream Map that included all the value-added and non-value-added steps in which Process Flow, Information Flow, and Timelines were incorporated. This tool took the complexity of the laboratory's staff work, and provided them with a simple and complete illustration of their process, including the value added and non value added activities.
In the Laboratory's exercise, the specific data collected were:
- Inventory - Samples that were between processes, waiting for work to be performed
- Cycle time - Time between test results
- Process time - Total time it takes a sample to travel through a process
- Batch size - Number of samples that move from one process to next
- Uptime - % that he process or equipment is available to "work" when one requires it to work
- Changeover - Time it takes to convert a specific process or equipment from doing one type of work to doing the next type of work
- # of operators - Observed number of people working at that specific process at the specific moment in time
The specific types of waste that we were able to identify consisted of:
- Waiting - Waiting for work or performing unnecessary activity; for example, instruments ready but specimens waiting at accessioning
- Inventory - # of specimens waiting for the next step of the process; for example, specimens sitting to be smeared, analysed, and stored
- Transportation - Travel of samples from bench to bench
- Motion - Extra motions made when all the tools required are not within the work cell; for example, reaching for pipettes, etc
- Over Processing - Doing more than required or is needed within a process; for example, making slides on every CBC in case they are needed
- Variation - Not doing things in a standardized fashion; non-adherence to the SOP's result in different "ways of doing things".
- Re-Prioritization - Ever changing demands and interruptions cause stopping and starting.
See Figure 2 for the end product: the Current State Map - a snapshot of the Laboratory's path of workflow.
Future State Mapping
According to the first LEAN Principle, focus on creating value from the perspective of the client. With the Current State in front of them, the group began to construct the Future State Map. They began by identifying Product Families (grouping tests by common activities and utilize the same resources), and focused on the ones with the highest test volumes (CBC and DIFF). Focusing on the product families with the highest volumes allowed them to remove peripheral activities from the main flow and to introduce continuous balanced flow to the process. For example, the group focused on the CBC (high volume) and kept it simple: Receive, move it to stage of analysis, analyze, determine if slide is required then make smear or store, End. The lower volume activities such as sorting the CBC's for Sickle, G6PD, ESR were worked out of the main process.
Subsequently, the group proceeded to determine the Takt time. Takt time can be defined as the rate of customer demand and can be calculated by dividing production time by the quantity the customer demands at that time (volume). Knowing the Takt time helped to determine the resources required (capital and human) to meet the demand (the heartbeat of their system). Based on the current state, the focus group identified areas where they could introduce continuous flow. Controls such as smaller batches to be delivered by accessioning (3-5) and no more than 3 racks waiting to be analysed would be the cue to shift resources to meet demand. See Figure 3 for the Future State Map.
Developing and Implementing Changes
The "Implementation Plan" guided the change process, which consisted of eight identified Kaizens and associated timelines. (Kaizens are issues identified for improvements that are dealt with in continuous and incremental steps.) The general premise for how to achieve the Future State was to break the Future State into small manageable pieces (Kaizens). For each Kaizen, a Lead was assigned to work with a group consisting of front-line staff who were intimately familiar with the area of focus to develop and implement practical solutions. Some of the initiatives that occurred surrounding the Kaizens in order to achieve the future state were:
- Standardization of equipment - This was achieved by replacing existing non-identical analysers with new identical ones. The benefits of this allowed us to have one set of procedures and review criteria. It also allowed us to distribute the workload equally between analysers.
- Remove bottleneck between accessioning and analyzing - The practice of sending specimens to a set-up area to be smeared and checked created inventory and increased the time between accessioning and analysing. This non value added step was eliminated and specimens allowed to flow directly from accessioning to the analyzer.
- Revised criteria for smear review - With the introduction of new analyzers, the focus group took the opportunity to revise their smear review criteria to take advantage of newer technology. This important step allowed them to change their practice from making smears on all slides (which required staining and sorting whether they needed them or not) to making smears only when required for review. The end results were less time wasted on making, staining and sorting smears, and cost saving due to less required reagents.
- Elimination of paper requisition - The practice of having the requisition follow the specimen and having to reconcile it with instrument printout and slides was determined to be a non-value added activity, therefore was eliminated. This was replaced with using the instrument printout with patient demographics to be reconciled with slides for review.
- Increase the number of 2 ml collection tubes used for collection - Collaboration with the Phlebotomy Department was undertaken (and still ongoing) to increase the number of 2 ml collection tubes in order to enable the Laboratory to reduce the amount of specimen handling required, and to take advantage of instrument features to increase efficiency.
- Smaller batches and introduction of FIFO (First In-First Out lanes) - Batches of specimens delivered were reduced from accessioning to the analyzer by increasing the frequency of delivery. The smaller batches allowed the staff to analyze specimens on a FIFO basis. The racks provided a visual cue to let the staff know when more or less resources were needed to maintain continuous flow.
Consequently, there have been several improvements seen so far in the Haematology Laboratory as a result of LEAN.
LEAN Improvements
Turnaround Times
- All routine CBC turnaround times reduced to less than 20 mins. (See Figure 5)
- All differential times reduced to less than 40 mins. (See Figure 6)
- Number of smear reviews reduced to less than 40%.
Streamlined Process
See Developing and Implementing Changes
Fig. 4: Following full implementation of changes (March 22.06), dramatic decline in the number of smear reviews from an average of 80% to 40% are clearly seen.
Fewer Staff Required
The LEAN changes enabled the Laboratory to process the same volumes of work with fewer staff members. This has created the opportunity to cross-training staff in more labour intensive specialized areas (e.g. Flow Cytometry, Hemoglobinopathies).
Fewer Calls to Call Centre
Improved TAT has reduced the number of calls by 25% to the Call Centre with inquiries about results, allowing the call centre representatives to better manage the incoming calls and provide a more attentive service.
Reduction in Safety Report
Improved TAT has greatly reduced the number of Safety Reports (complaints and incident reports).
Customer and Employee Satisfaction
Improved service to the Laboratory's end users created increased customer satisfaction as indicated by the reduction in complaints. Streamlining and "flowing" the work to make it more manageable reduced stresses on staff and increased work satisfaction. Staff comments like "It doesn't feel like I am doing the same amount of work as before." and "I don't feel worn by the end of the day like I use to." are indicators of employee satisfaction.
Conclusions
Laboratories are under continual pressure to maintain service in the face of increase demands and shrinking resources. The Lean exercise provided the Haematology Laboratory with tools necessary to systematically eliminate waste and speed up the process, regardless of the form that it exists within their process, thus enabling the Laboratory to survive in an environment by "doing more with less". The results obtained such as reduced TAT and streamlined processes have permitted the Laboratory to further efficiently meet the demands and expectations of its customers.
Factors critical to the success of LEAN were strong leadership (the support from senior management and the commitment of the value stream leaders), communication and input from frontline staff, as well as constant and timely monitoring by managers to effectively address issues as they arose.
The Haematology Laboratory and DPLM take pride in the staff's commitment and success with LEAN. This was recognized by the OLA (Ontario Laboratory Accreditation) Team during this year's OLA audit by paying DPLM a compliment on its LEAN initiatives. The embracement of LEAN in the Laboratory and the department embodies the values of SickKids: Excellence, Collaboration, Integrity and Innovation. To this end, DPLM celebrated LEAN's First Anniversary last summer, and the Laboratory's staff's feelings were mixed with satisfaction about the successful process improvement and eagerness towards future developments.
Future Developments
The Haematology Laboratory will continue to build a LEAN Culture by continuously applying the LEAN Principles in order to gain further efficiencies and to improve process. Having experienced success, the Laboratory plans on applying the lessons they have learned to other areas of the DPLM, such as Coagulation, Biochemistry, TDM/Toxicology, Microbiology, Pathology, and Phlebotomy; as well as it endeavours to share their knowledge and experience with other laboratory and health providers.