Lean Pathology: Implementing The Problem Solving …gsblibrary.uct.ac.za/researchreports/2010/Chinyanga.pdf · IN A PATHOLOGY LAB. 9 o Data capture – patient information and the

Copyright UCT

LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 REPORT

IN A PATHOLOGY LAB

A RESEARCH REPORT

PRESENTED TO

THE GRADUATE SCHOOL OF BUSINESS

UNIVERSITY OF CAPE TOWN

IN PARTIAL FULFILMENT

OF THE REQUIREMENTS FOR THE

MASTERS OF BUSINESS ADMINISTRATION DEGREE

BY

THEONEVUS TINASHE CHINYANGA

10 DECEMBER 2010

SUPERVISOR: PROF NORMAN FAULL

UCT GSB

Embargo

Copyright UCT

LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB

2

ACKNOWLEDGEMENT

This report is confidential. This report may not be used or distributed without the consent

of the University Of Cape Town Graduate School Of Business.

I wish to thank Prof. Norman Faull for the valuable insights and guidance he has

provided during this research project. His knowledge of operations management and lean

principles is inspiring.

To the management at Cape Pathologists Ltd, I would like to extend my heartfelt

gratitude for the opportunity that you gave me by allowing me to experiment with your

organisation.

To the staff at Cape Pathologists Ltd, your involvement in this learning experience was

key and your support towards the completion of this report is greatly appreciated.

I certify that except as noted above, this report is my own work and all references used

are accurately reported.

Signed:

THEONEVUS TINASHE CHINYANGA

Copyright UCT


3

ABSTRACT

The private pathology service is an important component of the private health sector in

South Africa. Clinicians from private hospitals and practices refer specimens to

pathology services for testing, and expect to receive results in the shortest possible time

in order to make patient focused decisions. Failure to meet turnaround time is a major

source of clinicians’ dissatisfaction with pathology services (Hawkins, 2007) and might

lead to loss of business in this highly competitive marketplace. Cape Pathologists Ltd is a

private pathology practice in Cape Town that was failing to meet turnaround time on the

tests it performs.

The aim of this research was to reduce by 30% the proportion of urgent test results failing

to meet turnaround time of 2 hours at Cape Pathologists Ltd, as well as to generate theory

regarding implementation of the problem solving A3 report in a private pathology

environment. Action research methodology was found to be the most appropriate

research method to implement the problem solving A3 report in this environment.

The research only achieved a 13% reduction in samples exceeding 2 hours turnaround

time. However, the research found that the staff at Cape Pathologists Ltd believes that the

problem solving A3 report can be implemented in their environment. The study also

concluded that implementing the problem solving A3 report improved the problem

solving capabilities of the staff in the host organisation.

Key words: Healthcare, Pathology laboratory, A3 report, Lean

Copyright UCT


4

TABLE OF CONTENTS

LIST OF TABLES ................................................................................................ 6

LIST OF FIGURES .............................................................................................. 6

1. INTRODUCTION............................................................................................. 8

1.1 Background ............................................................................................................... 8

1.2 Problem definition and motivation for research ....................................................... 9

1.3 Research Objectives ................................................................................................ 10

1.4 Research Hypotheses .............................................................................................. 11

1.5 Research Assumptions and Ethics .......................................................................... 11

2. LITERATURE REVIEW .............................................................................. 13

2.1 Toyota Production System and Lean Principles ..................................................... 13

2.2 Lean Healthcare ...................................................................................................... 15

2.3 The A3 Report......................................................................................................... 17

2.4 Conclusion .............................................................................................................. 20

3. RESEARCH METHODOLOGY .................................................................. 22

3.1 Research Approach and Strategy ............................................................................ 22

3.2 Research design ...................................................................................................... 22

3.2.1 Background to action research ......................................................................... 22

3.2.2 Implementing action research .......................................................................... 24

3.2.3 Change management in action research ........................................................... 26

3.2.4 Applicability of AR methodology to current study ......................................... 27

3.3.5 Role of the researcher ...................................................................................... 27

3.2 Data collection methods and research instruments ................................................. 28

3.4 Sampling ................................................................................................................. 30

Copyright UCT


5

3.5 Data analysis methods............................................................................................. 31

4. RESEARCH FINDINGS, ANALYSIS AND DISCUSSION ...................... 32

4.1 The pre-step ............................................................................................................ 32

4.2 Organisational and environmental analysis ............................................................ 33

4.2.1 Phlebotomy service .......................................................................................... 34

4.2.2 Courier service ................................................................................................. 36

4.2.3 Pinelands Lab ................................................................................................... 37

4.2.4 The service value stream and nature of the problem ....................................... 38

4.2.5 Summary of environmental analysis ................................................................ 42

4.3 HYPOTHESIS TESTING ...................................................................................... 43

4.3.1 Hypothesis 1..................................................................................................... 43

4.3.1.1 Findings and observations............................................................................. 43

4.3.2 Hypothesis 2..................................................................................................... 51

4.3.3 Hypothesis 3..................................................................................................... 55

5. RESEARCH CONCLUSIONS ...................................................................... 59

6. FUTURE RESEARCH DIRECTIONS......................................................... 61

7. REFERENCES ................................................................................................ 62

8. APPENDICES ................................................................................................. 68

APPENDIX 1: Example of the A3 Report ................................................................... 68

APPENDIX 2: Likert Questionnaire 1 ......................................................................... 69

APPENDIX 3: Likert Questionnaire 2 ......................................................................... 69

APPENDIX 4: Example A3 report used in training ..................................................... 70

APPENDIX 5: First A3 Report..................................................................................... 72

APPENDIX 6: Second A3 Report ................................................................................ 76

Copyright UCT


6

APPENDIX 7: Research Log........................................................................................ 80

LIST OF TABLES

Table 1: Linking research question to methodology ......................................................... 21

Table 2: Summary of TAT on FBC and UEC .................................................................. 41

Table 3: Status A3 Report ................................................................................................. 47

LIST OF FIGURES

Figure 1: Taxonomy of lean healthcare literature ............................................................. 15

Figure 2: The action research spiral .................................................................................. 25

Figure 3: Cape Pathologists Ltd organisational chart ....................................................... 34

Figure 4: Sample arrival quantities over time (16/09/2010) ............................................. 39

Figure 5: Summary of tests performed at Pinelands lab (01/09/2010-07/09/2010) .......... 40

Figure 6: Responses to Questionnaire 1............................................................................ 52

Figure 7: Responses to Questionnaire 2............................................................................ 56

Copyright UCT


7

Glossary of Terms

Term Definition

JIT Just in time (JIT) is a philosophy based on the Japanese way of

manufacturing: only goods that the customer require are manufactured

as and when the customer needs such goods.

Jidoka A Japanese method of process improvement aimed at making

problems self-evident (Sugimori et al, 1977).

Lean Continuous improvement efforts characterised by elimination of steps

that do not add value for the customer (Womack et al, 1990).

TAT Turnaround Time – the interval between the times the test is requested

by the clinician to that when the result is reported back to the

clinician.

TPS Toyota Production System.

Pathology The study of the causes of diseases in human beings.

Copyright UCT


8

1. INTRODUCTION

1.1 Background

Cape Pathologists Limited (a pseudonym) was established more than twenty years ago

and offers professional pathology services to the private health sector in the Western

Cape area. The company has nursing staff who offer phlebotomy services to patients at

the company’s 30 depots within the city of Cape Town. In addition, independent medical

practitioners collect specimens (mainly blood, body fluids and body tissues) from patients

at the practitioners’ respective private practices. A courier service operated by the

company picks up specimens from the depots, physicians’ private practices, and private

hospitals mostly from within metropolitan Cape Town for processing at the main

laboratory in Pinelands (Pinelands lab). Pinelands lab is open for sample processing 24

hours a day, every day of the week throughout the year. On average more than 1000

specimens are processed at Pinelands lab everyday. After analysis of the specimens the

results are released to the respective clinicians via the company’s secure online system.

Dr Jonas (personal communication, May 28, 2010), the general manager of Cape

Pathologists Ltd stated that during the early days samples were processed by highly

specialized medical personnel (pathologists). Over the years automation of pathology

laboratories has allowed concurrent processing of multiple specimens (Buesa, 2009). In

order to take advantage of the resultant economies of scale brought about by automation,

management at Pinelands Lab invested in high tech equipment and hired medical

technologists to operate the machines that process samples and retained pathologists to

verify results (Dr Jonas, personal communication, May 28, 2010).

Pinelands Lab has two operational areas, the pre-analysis and the analysis areas. The pre-

analysis is manual and administrative in nature, consisting of the following sections;

o Receiving – samples delivered by courier are checked for adequacy and quality in

the presence of the delivering agent.

Copyright UCT


9

o Data capture – patient information and the requested tests are entered into the

laboratory IT system and stickers with bar codes identifying each sample are

generated.

o Toppling – bar coded stickers are applied to test-tubes and the samples are then

processed in a centrifuge machine.

Brooks (2005) posits that manual pre-processing of pathology specimens is a common

practice in laboratories within South Africa.

In the analysis section, test-tubes are manually loaded into machines (different machines

for different tests) which perform the required tests, and automatically match the results

with the patient. Medical technologists provisionally verify the results (final verification

is done by pathologists) before the results department dispatch these to clinicians as

appropriate.

This research study focused on the flow of specimens and information from the drawing

of such specimens by clinicians at depots, private practices and hospitals through to the

reporting of results back to clinicians via the online system.

1.2 Problem definition and motivation for research

With the growth of the middle class society and the expansion of the private health sector

in South Africa business has increased over the years for Cape Pathologists Ltd, and

Pinelands lab has to process an ever increasing number of specimens (Dr Jonas, personal

communication, May 28, 2010). Clinicians use laboratory results to make patient focused

decisions, and hence the speed with which samples are processed has a bearing on

patients’ duration of stay in hospital (and hence healthcare cost), and on patient outcomes

(Chigwedere, 2007). Urgent tests are mostly requested by clinicians to aid diagnosis and

treatment of critically ill patients.

Copyright UCT


10

Dr Jonas (personal communication, May 28, 2010) mentioned that Cape Pathologists Ltd

promises its clients a turnaround time (TAT – from sample drawing and test request to

reporting results) of 2 hours on urgent samples. Increasing sample volumes have created

congestion within the Pinelands Lab, and coupled with the intricacies of other business

operations (phlebotomy service and courier), meeting the promised timelines is becoming

increasingly difficult. Dr Jonas (personal communication, May 28, 2010) estimated that

around 25% of all results on urgent samples were being reported to clinicians after 2

hours. Failure to meet strict timelines promised to clinicians does not only lead to loss of

business to competition, but also to adverse patient outcomes (Dr Jonas, personal

communication, May 28, 2010).

The study therefore focused on exploring the foregoing problem by looking deeper into

the operations of the three divisions (phlebotomy service, courier and Pinelands lab) in

order to understand causes of the problem.

1.3 Research Objectives

The research study sought to explore the implementation of the problem solving A3

report in Cape Pathologists Ltd to reduce turnaround time on pathology results as well as

to improve the staff’s problem solving capabilities. The study sought to answer the

following questions:

o Can the problem solving A3 report be implemented at Cape Pathologists Ltd to

reduce by 30% the proportion of late urgent samples results?

o Does the staff at Cape Pathologists Ltd perceive the problem solving A3 report to

be adaptable to their work environment?

o Can the adoption of the problem solving A3 report at Cape Pathologists Ltd

improve the staff’s problem solving capabilities?

Copyright UCT


11

1.4 Research Hypotheses

The primary hypotheses of the study are as follows

o The problem solving A3 report can be implemented at Cape Pathologists Ltd to

reduce by 30% the proportion of urgent samples results exceeding TAT of 2hrs.

o The staff at Cape Pathologists Ltd perceives the problem solving A3 report to be

adaptable to their work environment.

o The adoption of the problem solving A3 report at Cape Pathologists Ltd can

improve the staff’s perceptions of their own problem solving capabilities.

1.5 Research Assumptions and Ethics

The study at Cape Pathologists was subject to the following assumptions:

o Issues contributing to lengthy turnaround time were limited to the three divisions

of Cape Pathologists directly involved with the pathology process (phlebotomy,

courier and Pinelands lab).

o The staff could assimilate the concepts of the problem solving A3 report in the

limited time period of the research project, and would be motivated to find

solutions to contribute towards improvement.

o The interpersonal dynamics within teams and staff attitudes resulting from the

change brought about by the A3 implementation would have no impact on the

outcomes.

o Delays in reporting results to clinicians affect the relationship between Cape

Pathologists and the clinicians, and might lead to loss of business to competitors.

o Timely reporting of results on urgent samples to clinicians positively affects

patient outcomes.

Copyright UCT


12

o The time allocated to the research project (three months) was enough to observe

the desired process improvement.

Throughout the study the researcher remained cognisant of ethical dimensions that could

have potentially impacted the research project. The researcher is not aware of any ethical

issues that arose and the following actions are hoped to have mitigated the development

of such ethical considerations:

o Access was sought from significant parties at all times.

o Participants’ consent and willingness to participate was confirmed on an ongoing

basis since the project followed an emergent process.

o Participants were continuously assured of confidentiality and information from

participants was kept in confidence and used for the sole purpose of the research.

Copyright UCT


13

2. LITERATURE REVIEW

2.1 Toyota Production System and Lean Principles

Sugimori et al (1977) summarised the Toyota Production System (TPS) as developed by

then Toyota’s chief engineer Taiichi Ohno over the preceding two decades. According to

Sugimori et al (1977), the cornerstones of TPS are;

o just-in-time production, where only the right quality and quantity of product is

made when the customer wants the product, any excess from this being viewed as

waste; and

o Respecting and empowering employees so that they make any production

problems instantly self evident (jidoka).

The publication of TPS by Sugimori et al (1977) attracted research interest from scholars

and academics (e.g. Schonberger, 1982a; cf. Hall, 1983a; Monden, 1983). However,

dissemination of the Japanese production system came to the fore much later; around

1991, after the publication of ‘The Machine That Changed The World’ by Womack,

Jones and Ross in 1990 (Holweg, 2007). ‘Lean production’ is a term that was coined by

the International Motor Vehicle Program (IMVP) after a comprehensive study of the

world’s automobile industry (Womack et al, 1990). According to Womack et al (1990),

Japanese car manufacturers utilised methods that were in stark contrast to the mass

production system prevalent in the West because they were short on resources after the

Second World War. Lean production took root in the Japanese industries from around

1950, and by the 1960s, the key features of a lean production system were fully

developed (Womack et al, 1990). During the period of the IMVP study TPS was the best-

known example of lean production (Holweg, 2006).

Lean production is a method that seeks to continuously improve the process by removal

of waste from the flow of material during production (Womack et al, 1990). According to

Copyright UCT


14

Sugimori et al (1977), Taichi Ohno identified the following as sources of waste in the

automobile production industry:

o Transportation – unnecessary movement of parts during production.

o Inventory – stock of material waiting production or finished goods not yet shipped

to customers.

o Motion – unwarranted movement of shop floor staff working on products.

o Waiting – unnecessary waiting by employees on the production line to begin the

next step.

o Over-Processing goods with steps that do not add value for the customer.

o Over-Production of products not needed by the end customer.

o Defects in the product resulting in rework.

Other scholars have included additional types of waste, e.g. goods and services that do

not meet the customer’s needs (Womack and Jones, 2003); underutilisation of people

(Liker and Meier, 2005).

Womack et al (1990) argued that the lean philosophy can be transferred to most settings

including outside the manufacturing industry. Womack and Jones (2003) posit that ‘lean

thinking’ is the best way of getting rid of waste and can be achieved in any organisation

by following five Lean Principles;

o Specify value from the perspective of the end customer.

o Identify activities/processes that add value and eliminate waste.

o Establish flow in the value creating steps.

o Let the customer determine production (make to order)

o Continuously improve the process by seeking better ways of satisfying the

customer

Copyright UCT


15

Lean is based on the tenets of achieving greater customer satisfaction with fewer

resources (Liker and Meier, 2005).

2.2 Lean Healthcare

Figure 1: Taxonomy of lean healthcare literature

Lean principles were first applied to healthcare settings around the turn of the 21st

century. In a study of lean healthcare literature, De Souza (2009) noted a yearly increase

on the subject from 2002, probably indicating enhanced interest in implementing lean to

the health sector. De Souza (2009) divides the literature into theoretical and case studies

depending on the approach that the researchers have taken:

o Theoretical literature relates to attempts in translating manufacturing principles

into the health sector without experimentation (speculative), or provides guidance

as regards the steps practitioners have to follow in order to transform to lean

(methodological).

o Case studies mainly consist of attempts that have been made by scholars and

practitioners to bring lean into hospital departments that deal with patients

Copyright UCT


16

(patient flow studies – e.g. Jimmerson, 2007; Friderichs, 2009; Boysen, 2007),

and other departments characterized by flow of materials such as pathology,

radiology and pharmacy (manufacturing-like).

The latter literature type is of particular importance to the current study.

Some scholars such as De Souza (2009) and Liu (2006) contend that lean principles can

provide an effective way to harness the runaway cost of healthcare prevalent in the world.

Healthcare organisations that have adopted lean thinking and concepts have benefited

through reduced crowding, improved service quality and efficiencies (Dickson et al,

2009; Buesa, 2009). De Souza (2009) envisages the next revolution in health services to

be the integration of the whole supply chain, as has happened in the auto industry, in

order to recoup the benefits associated with lean systems thereby harnessing the runaway

cost of healthcare.

Pathology laboratories are a crucial part of the healthcare system, aiding with the

diagnosis of disease. Samples from patients (blood, urine, stool etc.) are processed using

large volume automated machines to determine clinical markers of disease. Simple

administrative work such as data entry into systems is done manually in most cases. Liu

(2006) posits that traditional workflow techniques should be used to improve efficiencies

in laboratory administrative tasks since automation has greatly increased the number of

samples that can be processed simultaneously. Similar sentiments appear in De Souza

(2009) who argues that the flow of material in a pathology laboratory is akin to that of

material in a manufacturing environment, and hence lean principles can be applied to

these environments with minimal modification. Automation has also standardised not

only the cost of processing, but also quality across pathology laboratories, and hence

more emphasis is being placed on lead times (Smeds, 1994). Increased efficiencies

resulting from lean transformation in pathology settings have been reported (e.g. Brooks,

2005; Chigwedere 2007; Buesa, 2009).

Increased efficiencies in pathology entail improving the turnaround time that pathology

services offer on test requests from clinicians. In medical laboratory testing literature

Copyright UCT


17

there are variations in the definition of turnaround time (TAT). Lundberg (1981) defined

the ‘brain to brain’ turnaround time as the interval between the time that the clinician

orders the test to time that action (treatment decision) is taken by the clinician after

receiving the result for the test. Other definitions of TAT restrict the time period to intra-

laboratory throughput time arguing that steps such as specimen collection, specimen

transport, result interpretation and clinical action are outside the control of the laboratory

(Hawkins, 2007). However, some researchers (e.g. Manor, 1999) posit that extra-

laboratory activities contribute greater than 96% of TAT and conclude that application of

lean principles to the laboratories only will not yield the envisaged turnaround time

improvements.

2.3 The A3 Report

Jackson (2006) states that Toyota utilises a wide variety of the commonly known A3

report, and use this report to succinctly communicate the story of continuous

improvement in a visual and standardised format so that all parties see the story from the

same perspective. Two of these reports are briefly described below:

a) The problem solving A3 report

As part of its management process in lean production, Toyota developed the A3 report: a

report meant to capture problems that an organisation encounters on a single sheet of

paper, and to foster greater problem solving capabilities among staff members (Shook,

2008). The report is usually prepared on paper size A3 (roughly 11 X 17 inches). See

Appendix 1 for an example of the A3 report. A wide range of literature contain

completed examples of the A3 report, e.g. Jackson (2006), Chakravoty (2009), Shook

(2008), and Sobek and Smalley (2008).

The 11" x 17" paper is symmetrically divided into two right and left portions, and each

portion has a set of headings. The names of the headings can be changed to fit the

Copyright UCT


18

organisational context for which the A3 is intended (Jackson, 2006). The A3 report has

roughly nine key elements critical for implementation (Jackson, 2006; Shook, 2008).

o The title/theme names the problem that is to be addressed in a single sentence

(Shook, 2008).

o The owner/date identifies the person who ‘owns’ the issue and the date that the

A3 was last modified (Shook, 2008).

The foregoing two elements are important components to foster accountability and the

ease with which the problem is conceptualized by all concerned parties (Shook, 2008).

The following headings typically appear on the left hand portion of the A3 report.

o Background – “contains a description of all pertinent information needed to

understand the scope of the problem at hand” (Chakravorty, 2009 p. 8). Sobek and

Smalley (2008) posit that the author of the A3 report should be aware of the

requirements of the audience, and should tie the background to organisational

goals so that the use of resources to solve the problem is inherently justified.

o Current condition – depicts the information known about the problem in graphs,

charts, and tables for the audience to easily comprehend what is currently

happening (Sobek and Smalley, 2008). Storm bursts and notes can be used to

highlight the problems on the current process, especially when a value stream

map is used (Rother and Shook, 1998). Sobek and Smalley (2008) argue that the

current situation should be quantified by inserting information such as takt time,

percentage of defects etc, in order to present a fact-based perspective of the

problem.

o Goals/targets – clearly identifies the envisioned outcome. “A quantifiable

standard against which one can compare results is important to determine whether

a change has resulted in improvement” (Sobek and Smalley, 2008, p. 39).

o Analysis – the root cause of the current problem is determined using various

techniques. The 5 Why’s method (asking probing questions five times or more)

Copyright UCT


19

and the Ishikawa/fishbone diagram are examples of such tools (Sobek and

Jimmerson, 2004; Womack and Jones, 2003). According to Sobek and Smalley

(2008), most problems have multiple causes, and experimentation may be

required at this stage to establish cause-and-effect relationships.

The right hand portion of the A3 report often includes variants of the following headings;

o Target condition – Proposes some corrective action (countermeasures) to close

the gap between the current condition and the desired outcome until a better

alternative is found (Sobek and Jimmersom, 2004). Jimmerson (2007) stresses the

need for diagrammatic and/or quantitative representation of the target condition

so that the difference from the current condition presented on the left side is easy

to understand.

o Implementation plan - records the necessary steps to be taken, assigns

responsibility to the action plan, prescribes a timeline by which the improvement

process is to be carried out and identifies expected outcomes (Chakravorty,

2009).

o Follow up – “Creates a follow up review/learning process and anticipates

remaining issues” (Shook, 2008, p. 7). Accountability is reinforced at this stage

by clearly identifying who will do the follow-up, when the follow up will be done

and what test will be done to assess the progress of the improvement process.

b) The status A3 report

Sobek and Smalley (2008) describe another variant of the A3 report: the status A3 report.

The status A3 report focuses mainly on the Check and Act phases of the PDCA cycle,

and is used to report the progress of an improvement initiative. In addition to the theme

that addresses the content to the audience, the status A3 report has got the following

components (Sobek and Smalley, 2008):

o Background – contains a summary of the information pertinent to the project.

Copyright UCT


20

o The current condition – describes the changes that have taken place over the

preceding course of the project. Under ideal conditions, this current state should

mirror the future state envisioned at the beginning of the improvement process. A

comparison of the before and after states may help the audience to conceptualize

the difference.

o Results – objectively communicates the impact of the project in a quantitative

format. A baseline measurement should be available for comparison in order to

judge the effectiveness of the improvement.

o Unresolved issues – identifies actions that need to be completed and assigns

responsibility to such action items. Actions may include responding to

divergences between the planned outcome and the actual state achieved.

2.4 Conclusion

The transfer of lean manufacturing principles into healthcare has gathered momentum

over the past decade (De Souza, 2009). The lean movement has offered organisations

solutions to real problems that they encounter in practice (Shook, 2008). Organisational

members continue to provide valuable insights on how the transformation towards lean

can be achieved. However, most of the literature that is sprouting regarding lean

healthcare is in the form of case studies, many of them from the developed world.

Although experimentation with lean in the South African context is on the rise (e.g.

Brooks, 2005; Booysen, 2006), more cases are needed to form an opinion about the effect

of this process improvement principle due to the wide and varied nature of healthcare in

South Africa (Leon and Mabope, 2005).

The pathology sub-section of healthcare is considered similar to a manufacturing

environment, and therefore much more apt to realise the benefits of lean manufacturing

principles (De Souza, 2009). However, several authors have bemoaned the impact of

extra-laboratory activities as a stumbling block for lean implementation within the

Copyright UCT


21

laboratory (Brooks, 2005; Chigwedere, 2007). Smellie, Galloway and Johnston (1995)

posit that laboratories that are in control of most of the extra-laboratory activities,

especially the courier service, can realise greater improvement in turnaround time since

they can optimise operations by experimenting with lean through the entire value chain.

The implementation of the A3 report within organisations in South Africa is still in the

early stages. Friederichs (2009) reported successfully implementing such a tool in a

community health centre. The current study sought to add to the foregoing literature by

experimenting with the A3 report in a pathology service environment.

Table 1: Linking research question to methodology

RESEARCH QUESTION RESEARCH DESIGN

Can the problem solving A3 report be implemented

at Cape Pathologists Ltd to reduce by 30% the

proportion of urgent sample results exceeding TAT

of 2 hours?

Action research methodology and

quantitative assessment of results

achieved.

Does the staff at Cape Pathologists Ltd perceive the

problem solving A3 report to be adaptable to their

work environment?

Triangulation between field notes

and Likert Questionnaire 1.

Can adoption of the problem solving A3 report at

Cape Pathologists improve the staff’s problem

solving capabilities?

Triangulation between field notes

and Likert Questionnaire 2.

Copyright UCT


22

3. RESEARCH METHODOLOGY

3.1 Research Approach and Strategy

The researcher followed an Action Research (AR) methodology. The researcher began

with premises that were initially taken to be true (Leedy and Ormrod, 2010), collected

data from ongoing research and developed theory by deduction (Saunders, Lewis and

Thornhill, 2003), regarding A3 implementation in pathology labs. Leedy and Ormrod

(2010) posit that deductive logic is extremely useful in evaluating and testing hypothesis

and theories.

While the first hypothesis for the study lent itself to quantitative evaluation, the ensuing

sub-questions required a qualitative analysis. Therefore the researcher utilised a mixed

methods strategy. Coghlan and Brannick (2005) contend that action research has the

potential to achieve greater validity and reliability when mixed methods are used than

when a single method strategy (either quantitative or qualitative) is used in isolation.

3.2 Research design

3.2.1 Background to action research

The following concise definition of action research was put forward by Shani and

Pasmore (1989, p. 439): “Action research may be defined as an emergent inquiry process

in which applied behavioral science knowledge is integrated with existing organisational

knowledge and applied to solve real organisational problems. It is simultaneously

concerned with bringing about change in organisations, in developing self-help

competencies in organisational members and adding to scientific knowledge. Finally, it is

an evolving process that is undertaken in a spirit of collaboration and co-inquiry”

Action research developed largely from the work of Kurt Lewin (Coghlan and Brannick,

2005). Lewin (1946) proposed a cyclical approach to solving problems consisting of a

pre-step (naming the problem) and three core steps;

Copyright UCT


23

o Planning – conceiving an overall plan regarding what action to take as the first

step.

o Action – taking the first step, and

o Fact finding – assessing the first step, learning from the initial step and

formulating the basis for the next step.

Building up on Lewin’s work, Argyris, Putman and Smith (1985, p. 8-9) summarised the

main principles of action research as follows:

a. “Action research involves providing assistance to client systems by generating

solutions through change experiments.

b. Involves a continuous spiral of steps from identifying a problem, planning action,

taking action and evaluating the results of action.

c. Re-education of participants through evidence generated from the research so that

the participants exercise free choice to engage in new kinds of desired action.

d. Challenging the status quo from a participation lens; this also adds to effective re-

education.

e. Simultaneous contribution to the problem at hand and to basic knowledge in

social science.”

In the context of this research project, the specific change experiments involved

improving the process at Cape Pathologists Ltd in order to meet promised sample results

turnaround timelines.

Copyright UCT


24

3.2.2 Implementing action research

Brooks (2005) successfully transferred lean principles (waste elimination, value stream

mapping etc) into a pathology laboratory at a central hospital setting, but did not utilise

the A3 report as the process improvement tool. A successful implementation of the A3

report in a healthcare setting was recorded by Friderichs (2009), who advocates for

building interdepartmental small teams to focus on each problem to be solved using the

report. The research drew insights from implementation of the A3 report in a

manufacturing environment (Chakravorty, 2009) because in both environments, service

agents interact with non-human components of a process to create value.

Davidson, Martinsons and Kock (2004) identify five stages of robust action research:

researcher-client agreement, cyclical process model (CPM), theory, change through

action, and learning through reflection.

o Researcher-client agreement (RCA) - the RCA manages the relationship of the

researcher and the organisation. Chakravosky (2009) contends that the RCA is

vital for establishing internal validity of the findings, and must give the

researcher the right to access all data and people relevant to successfully

complete the study. Davidson et al (2004) posit that the RCA indicates the degree

of commitment of the organisation to the change initiative. As an initial step, the

researcher sought a viable RCA with the relevant stakeholders. Stakeholders in

this research included the management and staff close to the flow of specimens

and results at Cape Pathologists Ltd.

o Cyclical process model - There are many variants of the cyclical model of action

research, and different authors include varying numbers of steps in a cycle (cf

Coughlan and Coghlan, 2002; cf Susman and Evered, 1978). Susman and Evered

(1978) proposed a model consisting of five stages: diagnosis, planning,

intervention, evaluation and reflection. Kemmis and McTaggart (1988) modified

the cycle into a spiral, with each successive evaluation leading to revision of the

initial idea, and the beginning of another improvement cycle towards perfection.

Copyright UCT


25

Brainstorming and reflection sessions to conceive ideas for process improvement

are an important starting point for the change initiative (Chakravorty, 2009).

According to Sobek and Smalley (2008) the problem solving A3 report coincides

with the planning stage of the action research spiral. The current study therefore

started with a problem and followed a structured approach to problem solving

enforced by the A3 report.

While other researchers argue that “a masters core AR project need only progress through

one planning, acting, observing and reflecting cycle of management practice to

demonstrate mastery of the research methodology” (Perry and Zuber-Skerritt, 1991, p.

77), Grundy and Kemmis (cited in French, 2009) contend that a single cycle is the tip of

an iceberg and hardly constitute action research. The researcher aimed to progress

through two AR cycles as suggested by Saunders et al (2003), but time constraints

prevented successful completion of the second cycle.

Figure 2: The action research spiral

o Theory - McKay and Marshall (2001) posit change initiatives that are completed

without a thorough grounding in theory do not qualify as action research.

Davidson et al (2004) also proposed that problem diagnosis and alternative

Copyright UCT


26

solutions should have a strong theoretical backing. This research project was

undertaken with thorough reference to theoretical tools and models (e.g. A3

report, fish bone diagram). Participants were mentored on how to use these tools

effectively before implementation commenced.

o Change through action- Action research is not only about forming a world view,

but also to take action so as to arrive at the desired outcome (Coughlan and

Brannick, 2001). “Changes may operate at both personal and organisational

levels. Individuals in the organisation may experience changes in roles and

responsibilities, and be required to develop news kills” (Davidson et al, 2004).

When the A3 report is implemented in an organisation, the processes as well as

individuals are transformed (Charkravorty, 2009).

o Learning through reflection- Learning is an important aspect and is specific to

action research (Lau, 1997 as cited in Davidson et al, 2004). The researcher

should make sure that learning is taking place within the organisation, and should

communicate such learning through e-mails, learning logs and bulletin boards

(Davidson et al, 2004). Cady and Caster (2000) suggest that during the learning

phase, judgements and facts should be kept separate so that readers can make

their own assessments and interpretations. The researcher spent a significant

amount of time with the participants reflecting on ongoing activities. The learning

process was captured in the research log and was fed back to participants on an

ongoing basis.

3.2.3 Change management in action research

Action research involves challenging the status quo and changing the way people within

a system normally perform their duties. Biazzo and Panizzolo (2000) posit that the

transformation towards lean operations changes the culture within an organisation as

manifested by worker-worker and worker-management relationship changes. These

changes often go unnoticed as researchers concentrate on measurement of metrics such as

cycle time; capacity and throughput (Biazzo and Panizzolo, 2000). Managing change

Copyright UCT


27

starts with a strategic vision and intent by management but the ‘bottom-up’ approach

innovation and learning should be promoted (Smeds, 2010). McHugh (1997) suggests

that inclusion of organisational members in change planning and implementation is vital

to the success of change initiatives because neglecting the needs of workers will lead to

increased stress which can manifest in costly ways that derail change initiatives.

3.2.4 Applicability of AR methodology to current study

According to Coughlan and Coghlan (2002), action research is applicable when the

research question obligates the researcher to describe events concerning solving an issue

in an organisation over a period of time, including the development of ideas and the

learning that results from the action taken on those ideas. Furthermore, O’Brien (1998)

states that action research is the methodology of choice when the research requires people

to participate in solving real problems, especially when a change has to occur quickly or

holistically.

Cape Pathologists Ltd was experiencing issues of concern around long lead times and

congestion within the laboratory. The study sought to solve these problems, and entailed

the participation of frontline people in developing and championing the solutions. As

suggested by Smeds (2010), the strategic intent had been created by management and the

shop floor staff given the mandate to change things with the researcher facilitating the

said change. Within the context of the foregoing literature review, the researcher argues

that Cape Pathologists Ltd provided an ideal environment for action research and the

implementation of the A3 report as a problem solving tool.

3.3.5 Role of the researcher

O’Brien (1998) outlines some of the roles that an action researcher assumes during the

action research process. These roles include facilitator, teacher, catalyser, listener,

observer, reporter and synthesiser. The main role of the researcher is to facilitate

dialogue, reflection and action, and to nurture organisational participants to the point

where they are in a position to take responsibility for the process and are able to

Copyright UCT


28

continuously replicate the action research spiral when the researcher leaves (Coughlan

and Coghlan, 2002; O’Brien, 1998). Nurturing participants requires the researcher to

create a learning environment in which participants are able to develop insights in

themselves and the environment (Burnes, 2004).In action research, the researcher has to

balance two objectives: the creation of knowledge as well as positive contribution

towards company goals (Westbrook, 1995). The researcher’s background and experience

has the ability to impact success since these variables can assist the researcher to grasp

the complexities of the environment under study and to infer knowledge from it (Argyris,

1983).

The researcher contends that his medical background and experience contributed

positively towards understanding the business. Throughout the project the researcher

strove to mentor participants to exercise their own initiative in discovering superior

solutions to problems by encouraging open discussion, inquiry and reflection on actions

taken.

3.2 Data collection methods and research instruments

Action research exposes the study to both qualitative and quantitative data collection.

Collection of multiple data types can lead to better understanding of the study through the

process of triangulation (Leedy and Ormrod, 2010). Coghlan and Brannick (2005)

contend that in action research methodology, data is not merely collected but generated as

well through the continued interaction of the researcher-participants in action research

cycles.

Primary data generation was driven by the A3 problem solving report modeled on a

PDCA cycle. Two problem solving A3 reports were prepared during the course of the

research. The first A3 report focused on reducing the throughput time of specimens at

Pinelands lab while the second A3 report focused on reducing courier time for urgent

specimens. During the preparation of the A3 reports, secondary data sources were also

Copyright UCT


29

utilised. In order to place reliance on secondary data sources, the researcher ought to

understand the reason why such data was collected (Coghlan and Brannick, 2005). The

main sources of secondary data were the Disalab® IT system and textual work

instructions. The Disalab® IT system is meant to provide a store of information for tests

performed at Pinelands lab as well as an audit trail of specimens through the various

departments delivering the pathology service. These data sources landed themselves for

analysis pursuant to the current study since data contained therein is objectively recorded

as mandated by rules and regulations (Dhatt and Peters, 2001).

Nadler (1997, as cited in Coughlan and Brannick, 2005) argues that survey instruments

used within action research generate data by eliciting observable behavioural

phenomenon in participants: data that the researcher can record during the reflection

phase to corroborate findings. In the current study two Likert type questionnaires were

used (Appendices 2 and 3). The questionnaires were simplified to a five-point response

scale since some of the participants lacked autonomy by working under strict standard

operating procedures and therefore may have diminished decision making ability to

complete an eight-point scale questionnaire (Bernal, Woody and Schensul, 1997, as cited

in Friderichs, 2009). The first questionnaire was developed to measure the perceptions of

the staff regarding the usefulness of the problem solving A3 report in Cape Pathologists

Ltd. The questionnaire was distributed to participants at the end of formal and informal

meetings, as well as after one-on-one coaching and mentoring. The second questionnaire

was given out to participants at the end of the research project and was designed to

measure the staff’s own perceptions of growth in problem solving capability after

participating in A3 problem solving over the course of the project.

Documenting reflections in a research journal is of utmost importance in action research,

and is conveniently done by the researcher in private soon after engagement with other

participants (Coghlan and Brannick, 2005). Together with meeting transcripts and notes,

these data sources form the core of field notes in action research (Coughlan and

Brannick, 2005). Over the course of the project, the researcher kept such a journal

Copyright UCT


30

(Appendix 8), and data from it was used to triangulate findings from questionnaires.

3.4 Sampling

According to Leedy and Ormrod (2010) sampling in action research relates to both types

of data gathered during the research cycles. The study under review utilised both

quantitative as well as qualitative methods. Sampling therefore involved selecting

participants to complete the Likert questionnaires and selecting data to analyse for

quantitative measures.

Cape Pathologists Ltd has a staff complement of around 200, approximately 130 of them

(mainly nurses, clerks, data capturers, topplers, transport coordinators, drivers and

technologists) involved directly with the handling of specimens and results. Staff from

the pre-analysis and the analysis areas totaling 20 participated in the A3 report concerned

with reducing throughput time at Pinelands lab while 5 coordinators participated in the

A3 report aimed at streamlining the transport system. Purposive sampling was the most

appropriate sampling technique in this setting and hence questionnaires were distributed

to the staff that participated in A3 problem solving since they were deemed to have the

requisite knowledge to form an opinion on the matter. 100 copies of the first

questionnaire were distributed repeatedly to 25 participants and 85 responses were

received while 25 copies of the second questionnaire were distributed, eliciting an 80%

response rate. The foregoing response rates are generally higher for surveys especially in

a hierarchical environment where participants might have felt obliged to take part in the

study.

For the purposes of primary quantitative data generation, urgent FBC and UEC tests

formed the population from which convenience sampling of the specimens was

undertaken on certain days to indicate either the current condition or the achieved

outcome of the problem solving A3 report. Simple random sampling of secondary data

from a population of urgent FBC and UEC tests was also done to corroborate primary

data generation.

Copyright UCT


31

3.5 Data analysis methods

The first research question lends itself to quantitative data analysis since it points towards

a quantitative reduction (30%) in the proportion of sample results that are reported late to

the clinicians. Simple descriptive statistics were used to analyse the available data to

answer the first research question.

The second and third research questions are qualitative in nature, and analysis of the data

was achieved by simply counting the frequency of responses to each question. An

arithmetic average was then calculated for each question to give a single response to the

said question. The author acknowledges loss of meaning that happens when qualitative

data is numerically coded (Leedy and Ormrod, 2010), but argues that triangulation of

field notes and Likert questionnaires in each of the two sub questions added to the

substance of the research. The open ended questions in the two questionnaires were

interpreted by the researcher.

Copyright UCT


32

4. RESEARCH FINDINGS, ANALYSIS AND DISCUSSION

This section has been organised in the following sub-sections: 1) the pre–step highlights

activities that were carried out before the actual A3 implementation. 2) The

organisational and environmental analysis gives an overview of the operations of the

organisation Cape Pathologists Ltd that were under study. 3) The hypothesis testing sub-

section details the findings that relate to each respective hypothesis before analysing and

discussing those findings and gives an opinion on the hypothesis.

4.1 The pre-step

Several steps were necessary before implementing the problem solving A3 report at Cape

Pathologists Ltd. To begin with, Dr Jonas and Mavis (pseudonym -operations manager)

and the researcher mapped out the objectives and scope of the project in a researcher-

client agreement (RCA). Some of the details included in the RCA were that:

o the client was committed to TAT improvement and would grant the researcher

unlimited access to the business operations and premises, the employees and all

pertinent company information and data;

o the researcher would provide process improvement coaching and training in

informal and formal meetings to employees;

o the researcher would document all process improvement efforts in a research log

and provide feedback regularly to management and employees; and

o All employees would be available at their respective work stations during off-

peak periods (10h00 to 12h00 and 15h00 to 16h00) to provide feedback to the

researcher on the improvement efforts.

Copyright UCT


33

Since the research was exploring the implementation of the problem solving A3 report,

the A3 reports became the default tool to document and communicate the improvement

initiatives. The process improvement leaders (Dr Jonas and Mavis) suggested the use of

simple process improvement tools in order to increase the participation of shop floor

workers who did not have the necessary skills to understand sophisticated tools. In the

laboratory part of the operation, technologists use sophisticated quality tools such as

statistical process control. However, these tools have been introduced to measure quality

of results in relation to an established benchmark (precision and accuracy) and have

never been applied to the measurement of TAT.

The organisation has been exposed to process improvement initiatives in the past. Lean

manufacturing principles were presented to the organisation by a pathologist who has

since left the company. No changes were initiated after the presentation, and the

enthusiasm left the organisation with the said pathologist who attempted to implement

lean principles. As a result, organisational members had rudimentary knowledge of

process improvement. The researcher had to take an active role in designing the contents

of the training program. The main elements of the training program revolved around

using the A3 report in solving process problems that the organisation experienced on a

daily basis. Instead of viewing the A3 as a record, the researcher emphasised the

structured approach that this tool brings to problem solving. Tools incorporated in the A3

report included value stream mapping, the concept of waste in healthcare, 5 Why method,

fish bone diagrams and process flow diagrams.

4.2 Organisational and environmental analysis

The following findings are based on observations by the researcher and information from

meetings (formal and informal) held by the researcher and organisational members

during the course of the research project. The organisational chart below shows the

hierarchy of various departments within the organisation.

Copyright UCT


34

Figure 3: Cape Pathologists Ltd organisational chart

In light of the foregoing literature, the definition of TAT has been modified to suit Cape

Pathologists Ltd. Since the company operates a phlebotomy service and a courier service,

the company is therefore in control of the extra-laboratory activities offered by these

departments. For Cape Pathologists Ltd TAT is the interval from the time that the

clinician orders a test to the time that the result is reported back to the clinician. The

research project therefore focused on three departments involved in the process of

handling specimens and results (phlebotomy service, courier service and Pinelands lab).

A brief description of the activities carried out in these departments is as outlined below

4.2.1 Phlebotomy service

The phlebotomy service is offered by the nursing department. Cape Pathologists has 30

depots dotted within metropolitan Cape Town and these depots are staffed by a mixture

of nurses and clerks, nurses forming up to 75% of the 80 staff complement. 15 depots

have permanently stationed clerks while the other 15 are serviced by three clerks on a

Copyright UCT


35

rotational basis. About 20% of the nurses are locum employees (part-time) who are called

upon as and when they are required. 17 depots are located within private hospitals while

the remaining 13 are stand-alone sites. Nursing staff at hospital depots participate in ward

rounds with the doctors, typically around 07h00, and collect samples for tests as ordered

by the doctors. During the rest of the day, they wait in the depot either for ward staff to

call them for specimen collection when required, or for walk-in patients referred from the

outpatients departments. For the depots that are not in close proximity to hospitals, the

nursing staff waits for walk-in patients either referred by independent medical

practitioners from their practices, or self referred.

When the patient presents at the depot, s/he is given a laboratory test request form to fill

in the details, if s/he does not have one already from the referring clinician. When

available the clerk will highlight the requested tests for improved visibility further down

the value stream. The nurse will then collect the type of specimen that has been

requested. The main type of specimen collected at the depots is blood, normally

transported in 5 milliliter test tubes. The number of patients attended to at each depot is

variable depending on the size and site of the depot, generally ranging from 5 to 80

patients per day. The amount of specimens collected per patient is very variable and

depends on the nature of the tests that have been requested. After phlebotomy, the nurse

notifies the courier service at Pinelands Lab and communicates the urgency of the test

required (urgent versus routine).

According to the nursing manager, the staff turnover rate within the department is low

(approximately 5% to 10% per year). However, the following challenges were noted:

o Limited communication from the nurses to the nursing office at Pinelands lab

regarding leave days, leading to short-term staff shortages.

o Low rates of utilisation of the available resources such as the internet and

company database.

o Failure to check completeness of patient information on forms when sending

specimens to Pinelands lab.

Copyright UCT


36

4.2.2 Courier service

The transport manager oversees the courier service, and the office is stationed at

Pinelands lab. The courier service utilises small vans and motorbikes as the forms of

specimen transport from different sites to Pinelands lab. The staff complement is made up

of transport coordinators and drivers. The coordinators receive telephonic notification of

specimens for collection from depots, hospitals or medical practices and dispatch a driver

to the requesting site. The workload is divided into three categories depending on the

priority demanded by the clinicians as follows:

1) Stat specimens are those samples on which clinicians require results immediately.

When coordinators receive requests for stat specimens, a driver is immediately

dispatched to the requesting site from the pool of stat drivers waiting at Pinelands

lab for such requests.

2) Urgent specimens are samples from all the private hospitals that the laboratory is

serving. Specimens are collected by a pool of drivers allocated to various hospital

routes at 2 hourly intervals from 07h00 to 19h00 and normally 5 to 6 rounds are

completed in a day.

3) Routine specimens are those that come from independent medical practices and

such specimens are collected by a third pool of drivers. Drivers normally present

at the lab from the 2 rounds around 13h00 and 17h00.

The following challenges were noted in the courier department:

o Nursing staff at depots call in with vague information regarding the urgency of

tests requested thereby hindering coordinators from making the best decisions.

o Staff at hospitals has a tendency of marking samples as stat with the hope of

getting the results sooner than usual. However, this practice leads to coordinators

dispatching stat drivers unnecessarily to collect samples that might otherwise

have been collected by the hospital drivers on their usual rounds.

Copyright UCT


37

o Traffic jams during the morning and evening rush hours prevents smooth flow of

the courier service.

o The distance from Pinelands lab to depots is variable and therefore presents a

difficulty in standardising the time needed to perform the service.

o Drivers often call in sick causing service delivery failures.

4.2.3 Pinelands Lab

Pinelands lab performs the actual tests that are requested by clinicians. The lab operates

24 hours a day, seven days a week throughout the year, and the staff therefore operates on

a shift basis. The morning shift commences at 05h00 and ends at 14h00 when the

afternoon shift starts. The afternoon shift ends at 22h00 and a skeleton night staff

oversees the laboratory until the beginning of the morning shift of the next day. The lab is

divided into pre-analysis and analysis areas.

The staff in the pre-analysis section does either of two roles, data capturing and checking

or toppling:

1) Data capturing involves entering patient information and tests requested into the

Disalab® IT system used by the lab while data checking is a control step to verify

if all information from the form has been entered as well as linking the

information to the relevant billing system. On any given shift on average 4 people

capture data while 2 people check the quality of the data entered.

2) Toppling involves labeling the specimens with bar codes and centrifuging

specimens as needed depending on specimen type, as well as physically taking

the specimen to the relevant department in the analysis section. 1 or 2 people are

usually allocated to this work station. The station utilises 4 centrifuge machines

with a combined capacity to run 130 specimens concurrently. However a single

specimen can be processed in any of the centrifuges.

Copyright UCT


38

The analysis area comprises 4 departments: histology, microbiology, chemistry and

hematology. On a given shift each department is normally manned by 1 or 2 qualified

technologists with the support of a laboratory technician. The actual analysis of

specimens is done by automated machines after the specimens have been loaded into

such machines. The machines can typically process over 100 specimens at the same time

and more specimens can be loaded continuously while analysis is continuing on other

specimens already loaded. Each of the 4 departments has two machines that can perform

the same tests; the one machine serving as back up while the other is being used.

The following challenges were noted at Pinelands lab:

o High staff turnover, especially in the pre-analysis area, of around 30% - 40% per

annum (Dr Jonas, personal communication, May 28, 2010).

o Calls from outside the laboratory to the pre-analysis area disrupt service delivery

and the flow of samples.

o Incompletely or erroneously filled forms result in trouble shooting by data

capturers leading to further delay of sample processing.

o The protocol for urgent specimens was not being followed as it is documented in

the work instructions.

4.2.4 The service value stream and nature of the problem

In order to understand the nature of the problem at hand (failure to meet TAT of 2hrs or

less) the researcher and the management at Cape Pathologists Ltd decided to map out the

operation with a high level value stream map. The foregoing description in 4.1.1 details

the set up of the departments in isolation but these departments interact continuously to

deliver value for the customer. The service was therefore conceptualised to be composed

of 3 phases, all contributing to the TAT. Phase 1 is the phlebotomy service, whereby

nurses from the organisation’s 30 depots collect samples (blood, body fluids and body

tissues) from patients at the depots or in the hospital where such depots are located. In the

Copyright UCT


39

same phase, independent medical practitioners at their practices also collect samples from

patients for analysis. In phase 2, a driver is dispatched from Pinelands (after notification

either by a nurse at the depot or by the doctor at his practice) to collect the sample and

bring it to the lab in Pinelands for analysis. In phase 3, the specimen progresses through

the stations at the lab culminating in the analysis of the specimen and the subsequent

release of the results to the requesting clinician.

Since all specimens end up at Pinelands lab, this location provided a station where data

could be collected to quantify the problem at hand. At the receiving bay, specimens are

physically counted and recorded, noting the priority of the tests requested. Sample arrival

volumes for 16 September 2010 were analysed and revealed the nature of the demand as

depicted below in Figure 1. For ease of modelling demand the arrival time of samples

was rounded off to the nearest hour, e.g. samples arriving between 14h30 and 15h30 were

taken to have arrived at 15h00.

Figure 4: Sample arrival quantities over time (16/09/2010)

Copyright UCT


40

On that particular day, a total of 1075 specimens were received at Pinelands lab, almost

30% marked as urgent. About 60% of the samples were received from the 17 hospitals

that are serviced by the company while the remaining 40% of the samples were received

from independent medical practices and stand alone depots.

A random sample of secondary data was extracted from the Disalab® IT system (from

01/09/2010 to 07/09/2010 inclusive) and Figure 2 below shows the main characteristics

of the tests. The laboratory performs numerous tests, with actual analysis of some tests

such as liver function and cardiac enzyme tests lasting more than 90 minutes. Achieving

a 2 hour turnaround on tests that take long to analyse is therefore unlikely. The run time

for the tests Full Blood Count (FBC) and Urea Electrolytes & Creatinine (UEC) is at

most 10 minutes: therefore, these tests were chosen as a proxy for all urgent tests that

should be able to meet the TAT of 2 hours.

Figure 5: Summary of tests performed at Pinelands lab (01/09/2010-07/09/2010)

Copyright UCT


41

A total of 14600 tests were performed over the week and 40% of all the tests were urgent.

FBC and UEC (routine and urgent) formed 14% of the total. One fifth of the tests did not

have the time of specimen drawing from the patient recorded/noted and these tests were

excluded from further analysis. Just under half of the tests that had the time of sample

collection recorded had been labeled as urgent (45%), urgent FBC and UEC making up

9% of the total.

The abovementioned urgent FBC and UEC were further explored to quantify the problem

of failure to meet TAT of 2 hours. The time from sample drawing to registration was

used as a proxy for the time taken by the courier service to deliver the sample, while the

time from registration of the sample on the Disalab® IT system to the time that the result

got recorded on the same system was used as an indicator of the throughput time of

samples at Pinelands lab. The table below summarises the important insights gained from

the analysis of the 1517 FBC and UEC tests used.

Table 2: Summary of TAT on FBC and UEC

ITEM PARAMETER VALUE

Delivery time Average 66 minutes

Delivery time Standard deviation 43 minutes

Delivery time Median 60 minutes

Pinelands lab throughput time Average 39 minutes

Pinelands lab throughput time Standard deviation 26 minutes

Pinelands lab throughput time Median 30 minutes

Total TAT Average 105 minutes

Total TAT Standard deviation 62 minutes

Samples processed within 2 hours Percentage 69%

Samples processed after 2 hours percentage 31%

Copyright UCT


42

The analysis revealed that 470 specimens failed to meet the TAT of 2 hours or less. The

company has no standard time within which specimens are suppose to be delivered by the

courier to Pinelands lab and there is also no standard throughput time at Pinelands lab.

However, roughly 17% of the specimens that did not meet the TAT of 2 hours were

delivered already late (after 2 hours). 8% of the specimens that did not meet the

prescribed TAT were in the lab for over 2 hours.

4.2.5 Summary of environmental analysis

Cape Pathologists has been failing to meet the TAT promised by the company to

customers. Approximately 31% of all urgent specimens are delivered later then the

promised TAT of 2hours. The three departments involved in the handling of specimens

are the phlebotomy service, the courier service and the Pinelands lab: all of them

contribute to the lengthy TAT observed in analysed data from the Disalab® IT system.

The following problems were conceptualised to be causing a delay in the progression of

specimens and results through the value chain and hence a longer TAT than planned.

o Incorrect or missing information on forms

o Extra specimens send to Pinelands lab by the phlebotomy service as well as by

independent medical practitioners.

o Calls directed to the pre-analysis area from depots do not only add to the

workload of staff in that department, but also interrupt normal workflow, further

delaying processing.

o The phlebotomy service provides insufficient information regarding urgency

status of tests requested.

o The courier does not have standard intervals and routes for delivering specimens

from the sites that the company is serving, and delivers specimens later than 2

hours.

o The protocol for urgent specimens is hardly followed at Pinelands lab.

Copyright UCT


43

4.3 HYPOTHESIS TESTING

4.3.1 Hypothesis 1

Ho: The problem solving A3 report can be implemented at Cape Pathologists Ltd to

reduce the proportion of urgent samples results exceeding TAT of 2hrs by 30%.

Method of Verification Source Material

Quantitative & Qualitative – Action

research cycles undertaken at Pinelands lab

Data generated during research, secondary

data from the Disalab® IT system and field

notes.

4.3.1.1 Findings and observations

4.3.1.2 Action research cycles

The list of challenges identified under the summary of organisational and environmental

analysis (section 4.2.5 above) formed the problems to be solved using the A3 report. An

initial attempt was made to draw a single A3 report with the theme “reduction of the

proportion of urgent specimen results exceeding 2 hours TAT”. However, the problems

identified above tended to be department specific e.g. the nursing staff had no knowledge

of the protocol at Pinelands lab. A decision was then made to disaggregate the problem

into its components as outlined above, each department identifying problems that were

specific to it. This gave people close to the process an opportunity to apply their

knowledge and experience of work to structured problem solving. The planning part of

the action research cycle coincided with the drawing of the A3 report and was followed

by the implementation of the plan, checking the follow up plan and responding to

divergences from planned outcomes to complete the cyclical process model of AR.

Copyright UCT


44

4.3.1.3 First AR Cycle: reduction of throughput time at Pinelands lab

Over the period beginning early September 2010 to late October 2010, the staff in three

departments (phlebotomy, courier and Pinelands lab) was involved in A3 report

simulations exercises, informal discussions, and one-on-one coaching. In addition, the

environmental analysis was done over the same period, culminating in a thorough

understanding of the problems that needed attention. On the 26th of October 2010, the

first non-simulation problem solving A3 report was started by the staff at Pinelands lab.

The morning shift staff started the process and the late shift staff continued contributing

insights in the afternoon. Over the entire week iterations were made to several sections,

especially the implementation plan and the countermeasures sections. On 01 November

all the 20 members of the pre-analysis and the analysis sections met to finalize the A3

report and agree on the implementation plan. The final A3 report drawn is as shown in

Appendix 5.

The planned changes started taking effect on the 2nd of November 2010. Most of the

proposed changes were procedural in nature and required participants to follow the

protocol. The researcher observed the protocol implementation on the first 2 days and

entrusted participants to continue with the practice. Over the 2 days that the researcher

observed the process, the following steps were adhered to as planned.

o On arrival of specimens labeled urgent, the data capturers’ team leader distributed

these equally to the 4 team members available. Data capturers would then

complete capturing current forms before immediately turning to the urgent

specimens.

o After capturing, data capturers placed specimens in a red bucket that was centrally

located from all of them.

o The team leader notified the toppling desk about the urgent specimens by

shouting “urgent!!”

Copyright UCT


45

o The toppling bench had 2 people working at all times. On every shift, one person

from toppling was responsible for collecting urgent specimens from the red

bucket and processing these when available. The ‘urgent’ person would help with

routine work after processing urgent specimens.

o The ‘urgent’ person would take the specimens to the appropriate station in the

analysis area and notify the technologist at that station.

The lab supervisor and the researcher followed up by observing the system on the 10th of

November 2010. Moreover, a random sample of urgent test results was extracted from

the Disalab® IT system to validate findings. Although the protocol was observed to be

working as planned, 20% of urgent test results had exceeded the envisioned throughput

time of 29 minutes. Technologists blamed the ‘urgent’ people for not delivering

specimens on time, who in turn blamed data capturer team leaders for not shouting

“urgent!”

In response to the foregoing challenges, participants reconvened and agreed that the

protocol was sound. Proposals were put forward for a bucket that would make the

presence of the urgent specimens visually obvious from the toppling desk. An alarm

system was originally suggested as well but the idea was discarded because it was

thought to be disruptive and irritating due to the high volume of urgent specimens per

day. The technologists proposed an electronic time stamp on all samples between the

toppling desk and the analysis section. Two meetings were later held to discuss the time

stamp, which will be implemented early next year.

4.3.1.4 The second AR cycle: reducing courier delivery time.

The participants from the courier department started working on the problem solving A3

report around the 5th of November 2010. Coordination of efforts was much easier since

the team was smaller than for Pinelands lab. One major setback was that drivers were not

able to attend the A3 meetings and informal sessions since their availability tended to be

unreliable. The resultant A3 that was drawn therefore presupposed that drivers would buy

Copyright UCT


46

into the proposed action plans. Execution of action items started on the 15th of November

and therefore only took effect for 15 days. Appendix 6 shows the final A3 report that the

participants put forward for implementation.

Copyright UCT


47

4.3.1.5 Status A3 Report

Table 3: Status A3 Report

Theme: Reduction (by 30%) of the proportion of urgent test results exceeding TAT of 2

hours

Background

Three departments (phlebotomy, courier and Pinelands lab) at Cape Pathologists responsible

for TAT on specimens. Approximately 30% of urgent tests result reported late to clinicians,

resulting in poor relations and possible loss of business

Current Condition

Throughput time at Pinelands lab observed to have been reduced to 29.1 minutes on

30/11/2010. Current value stream map is as below:

X3-4

DATA ENTRY

X2

TOPPLING

X2-3

ANALYSIS

X1

RECEIVING

X2

REPORTING

1.2-5

1.9

1.4-3

2.2

5.5-6.3

5.7

2.1-4.1

2.55.0-10.0

7.7

1.3-3.4

2.6

1.3-3.0

1.9

1.2-2.4

2.0

2.1-3.2

2.6

WASTE 10.1Min

TOTAL 29.1Min

C/T: 5.5 minC/O: 0.5min

C/T: 1.5-5 minC/O: 0.5min

C/T: 1-5 minC/O: 0.5min C/T: 1-2 min

C/O: 0.4minC/T: 5-10 minC/O: 0min

KEY Inventory

C/TCycle Time

C/OChange over time

Proportion of samples exceeding 2 hours in lab= 3%

Data entry for urgent specimens done by all capturers on a shift. One toppler

dedicated to processing urgent samples on every shift.

Transport –specimens delivered after 2hrs = 6%

New drivers are getting training from old drivers.

Web system tracking urgent specimens and transport on pilot phase since 18/11/2010.

Copyright UCT


48

Results

Parameter Before After (observed) After (IT system)

Pinelands

throughput time

39 minutes 29.1 minutes 38 minutes

Specimens in

lab>2hrs

8% Not measurable 3%

Delivered after 2hrs 17% 6%

Average delivery

time

66 minutes 68minutes

Proportion of

specimens with

TAT> 2hrs

31% 27%

Percentage reduction achieved =13%

Other results:

Protocol for urgent specimens in place at Pinelands lab.

Coordinators learning the new web based specimen and vehicle tracking system.

Remaining issues

Activity Status Responsibility

Time stamp between pre-analysis

and analysis at Pinelands

In progress

(implementation

01/2011)

IT department

Training of drivers To start 07/12 Coordinators

Conversion to web-based transport

tracking ( do away with pen & paper)

To start 15/12/2010 Coordinators

Errors on forms, extra specimens A3 TBD Nursing department

Training of lab staff TBD Lab supervisor

Copyright UCT


49

4.3.1.6 Analysis and Discussion

At first glance, testing the above hypothesis seems to involve a quantitative evaluation of

the proportion of urgent test results that went beyond two hours after the implementation

of the problem solving A3 report. However, such an approach does not recognise the

piecemeal nature in which the problem solving A3 report was implemented. Under the

current hypothesis, implementing the problem solving A3 report in each of the

departments identified (phlebotomy, courier and Pinelands lab) should lead to the

reduction of the proportion of urgent test results exceeding the TAT promised to

clinicians. Since the implementation was not completed in all three departments as

planned, each A3 report outcomes ought to be evaluated to measure the contribution that

was made towards realizing the hypothesis.

a) Evaluating the first A3 report outcomes

The outcomes of the first A3 report are as outlined in the status A3 report above (Table

2). The aim was to improve the throughput time at Pinelands lab by eliminating waste by

50%. The envisioned throughput time was therefore 28.5 minutes. A random sample of

15 urgent specimens was observed as it progressed through the lab. The average

throughput time was 29.1 minutes, just 30 seconds beyond the expected time. However,

when such a finding was checked against data that was available on the system, the

average throughput time was 38minutes, a minute’s reduction from the average noted

prior to the improvement process. Although the implementation of the A3 did not reduce

throughput time significantly, the proportion of samples that exceeds 2 hours within the

laboratory dropped from 8% to 3%.

The random sample of 15 urgent specimens was probably too small to yield

representative results for the workload of all urgent samples processed at Pinelands lab.

Convenience sampling was used to generate data for analysis and hence results obtained

were subjective. Coghlan and Brannick (2005) posit that participants may increase the

Copyright UCT


50

pace of working when they are being watched resulting in signs of throughput

improvement (the Hawthorne effect). The secondary data from the Disalab® IT system is

much more representative of the workload at Pinelands lab. A total of 1075 urgent FBC

and UEC tests were extracted from the Disalab® IT system and used in the analysis. The

researcher therefore argues that the Hawthorne effect explains the paradox between the

data obtained from the Disalab® IT system (indicating minimal improvement) and that

observed by the lab supervisor and the researcher (showing considerable improvement).

b) Evaluating the second A3 report outcomes

The action items on the second A3 report were executed over a 15 day period. The web

based transport monitoring system was implemented to generate standard courier time by

region (distance from Pinelands lab). At the end of the research period, data was still

being generated to inform coordinators of possible average courier time per route. The

average delivery time did not improve from the baseline. However, the proportion of

samples delivered to Pinelands lab after 2 hours significantly dropped from 17% to 6%.

Observing delivery times on urgent specimens is difficult and would consume a lot of

resources. The researcher therefore posits that although the data used in this evaluation

was secondary data, the results are credible since the data is objectively recorded as

mandated by law.

Conclusion

As presented in the status A3 report, the project achieved a 13% reduction in the

proportion of specimens exceeding TAT by 2 hours.

Reject Ho: The problem solving A3 report can be implemented at Cape Pathologists Ltd

to reduce by 30% the proportion of urgent samples results exceeding TAT of 2hrs.

Copyright UCT


51

4.3.2 Hypothesis 2

Ho: The staff at Cape Pathologists Ltd perceives the problem solving A3 report to be

adaptable to their work environment.


Qualitative – Feedback was sought from

participants over the 15 week period of the

project.

Likert Questionnaire 1 and field notes

Likert Questionnaire 1 was distributed repeatedly to participants over the 15 week

period of the study. Responses to the each of the five scored questions were aggregated

respectively every week to arrive at an average that was taken to represent the

perceptions of the overall group of participants. An open ended question 6 sought more

clarification about why participants perceived the A3 report as being adaptable or

otherwise to their work environment.

Copyright UCT


52


Figure 6: Responses to Questionnaire 1

The perceptions of participants were compiled over the course of the project. The line

graph above shows the various responses to the five questions that were scored from 1

(strongly disagree) through to 5 (strongly agree). The trends observed in the responses to

Likert Questionnaire 1 (Figure 6) can be summarised as follows.

1) The participants generally found the discussions and one-on-one coaching

sessions useful as indicated by a score greater than 4 over the course of the

project.

2) In most cases, the facilitation skills of the researcher were held to be of a high

standard.

3) Most participants initially had difficulties in understanding lean principles

covered in discussions, but from the fourth week onwards, comprehension was

above average.

Copyright UCT


53

4) In the initial stages of the study, the majority of participants did not feel confident

to articulate A3 concepts to someone, while the reverse held true at the end of the

study.

5) During the early weeks of the research, most participants could not form an

opinion on whether the A3 report was adaptable to their work environment.

However, at the end of the project overwhelming responses pointed out that the

A3 report was adaptable to Cape Pathologists Ltd.

Responses to question 6 were variable. During the first week, responses such as “This is

my first time seeing this report and I cannot comment about it” and “My point of view

regarding any tools does not matter in this organisation” were not uncommon. As the

project progressed and participants got used to the tools, more positive themes started to

surface. A certain participant commented that “The A3 does not require a high level of

education to be used, I can also use it with my matric level”, while another responded that

“the A3 method makes problem solving easier by proposing a structure that allows

exploration of the problem before jumping to conclusions and solutions.” Most

participants who stated that the A3 report was not adaptable to their work environment

bemoaned the presence of exacting work instructions as a stumbling block hindering their

active participation in process improvement. Participants also highlighted the increased

responsibility that the tool brought to their work, and wondered if management would

entrust them to make improvement decisions in the absence of the researcher.

The researcher observed that the participants were skeptical about the motive of the

project during the early days. Some participants thought that management was out to get

them while others believed the researcher was a disguised employee of the organisation.

Questionnaires were therefore made anonymous to address the participants’ concerns.

Copyright UCT


54

4.3.2.2Analysis and discussion

The trends observed in responses to question 5 reveal that during the early days of the

study, most participants did not regard the A3 report to be transferrable to their

environment. However, as the research progressed, participants overwhelmingly

contended that the A3 report was indeed adaptable to Cape Pathologists Ltd. The

researcher argues that participants had no previous experience in lean principles and tools

to immediately comprehend what the tools entailed. Therefore, the participants could not

form a sound and informed opinion regarding the A3 report. Over the life of the study

participants got more knowledge and were able to give a better assessment of the A3

report. The reasoning above is corroborated by the trend observed in question 3, which

shows that the understanding of the A3 report and lean principles was below average in

the first three weeks, steadily rising over the course of the project to an aggregate score

above 4 at the end of the study. The field notes gathered by the researcher also point

towards a similar interpretation.

The researcher used purposive sampling to elicit responses to the questionnaire. While a

representative sample of workers at Cape Pathologist Ltd would have been more

appropriate to deduce externally valid conclusions, the researcher argues that other

organisational members had no knowledge of the A3 method and lean principles, and

could not have given informed opinions on the subject matter. Visich and Wicks (2010)

posit that employees need basic knowledge of lean and the A3 method in order to

comment on the merits of the A3 report.

The researcher acknowledges the subjective nature of the interpretations. One way of

adding credibility to the interpretations would have been to ask participants to validate

the researcher’s assertions. However the respondents had given anonymous feedback and

hence it was not possible to identify individual participants. Discussing the findings in

meetings would also have raised ethical issues regarding confidentiality of responses. The

researcher could not involve an external researcher to validate the findings because the

environment under study was not open to outside observers. However, the researcher

Copyright UCT


55

believes that triangulation between the field notes and the questionnaire findings increase

the validity of the findings.

Conclusion:

Cannot reject Ho: The staff at Cape Pathologists Ltd perceives the problem solving A3

report to be adaptable to their work environment.

4.3.3 Hypothesis 3

Ho: The adoption of the problem solving A3 report at Cape Pathologists Ltd can improve

the staff’s perceptions of their own problem solving capabilities.


Qualitative – Feedback was sought from

participants at the end of the research

project.

Likert Questionnaire 2 and field notes

Likert Questionnaire 2 was distributed to participants at the end of the study. Responses

from the three scored questions were respectively aggregated to give an average view of

the said participants. All participants who responded willingly identified themselves in

the questionnaires that they answered.

Copyright UCT


56


The findings from the three scored questions are depicted in the bar chart below.

Figure 7: Responses to Questionnaire 2

The findings from the scored questions can be summarised as follows:

1) Most participants found the research project useful.

2) The staff would want to continue using the skills that they learnt over the course

of the project.

3) The respondents thought that the project improved their problem solving

capabilities.

Findings from the open ended question eliciting an explanation to scored question 3

yielded varied answers. One respondent commented that “I have never received training

in problem solving before, so I am much better at problem solving” while another

participant said that “If I know the problem, I will categorise the causes before thinking

Copyright UCT


57

of the solutions.” A few common themes that emerged and were validated by respondents

include:

o Participants regarded highly the structured approach to problem solving that the

A3 report brought to their daily work and lives in general.

o Respondents believed that they no longer had to wait for the supervisor to provide

all the solutions but could also make suggestions.

o Respondents felt more confident to give advice to others in difficult situations.

The researcher also spent a significant amount of time with the participants over the

course of the project. The researcher observed that participants started engaging each

other more often, and would collaborate is solving small problems that they were

encountering during the course of their work. The preparation phase involved participant

involvement in A3 report simulations and participants were mentored on drawing up the

A3 report. When the actual A3 reports were drawn, participants showed more confidence,

enthusiasm and an above average comprehension of the problems that were being solved.

Suggestions for root causes and countermeasures were easier to elicit from participants

than in the A3 simulation phase.

4.3.3.2 Analysis and discussion

The findings from the questionnaire articulated above were verified by respondents and

hence the assertions are valid. Taken together with the observations that the author made

while he was in the field, these findings seem to point towards improved problem solving

capabilities among the participating staff.

The author acknowledges the shortcomings of using a sample that did not represent the

composition of Cape Pathologists Ltd. However, the question sought to elicit responses

from those who would have participated in the project. The results could have been more

robust if there was a pre-test and a post-test to objectively assess the problem solving

capabilities of the staff. The researcher argues that since he had no knowledge of the

Copyright UCT


58

participants’ background, he could not have provided a fair test of problem solving ability

because such abilities depend on one’s educational background and experience (Liu,

2006).

Conclusion

Cannot reject Ho: The adoption of the problem solving A3 report at Cape Pathologists

Ltd can improve the staff’s perceptions of their own problem solving capabilities.

Copyright UCT


59

5. RESEARCH CONCLUSIONS

Action research in an organisation ought to satisfy two goals: contribution to theory as

well as towards finding solutions for real organisational problems (Coghlan and

Brannick, 2005). The aim of the research was to address the issue of turnaround time on

urgent tests at Cape Pathologists Ltd while exploring the implementation of the problem

solving A3report in an organisation operating in private pathology services. The major

problem was broken down to department level and the problem solving A3 report was

implemented in Pinelands lab and the courier departments, two of the three departments

contributing to long lead times on results. The researcher also sought to explore the

perceptions of the participants regarding A3 report implementation in the environment

under study. Prior to implementing the problem solving A3 report, participants

underwent training on lean principles and the A3 report. A high level value stream map

was then developed in order to conceptualise the problem and identify departmental

activities that needed improvement. Thereafter teams were set up in each department to

implement the A3 report, under the guidance of the facilitator-researcher, to address the

identified process failures.

Notwithstanding the constrains of time on the project and failure to fully implement the

A3 report in all three departments, the researcher concluded from hypothesis 1 that the

problem solving A3 report could not reduce, by 30%, the proportion of urgent test results

going over 2 hours TAT. Even though the study fell short of meeting the improvements

set forth in the hypothesis, valuable insights were gained from the research.

Organisational members at Cape Pathologists Ltd were able to view their service delivery

value stream, and to understand how failures in other departments can negatively impact

the performance of departments down the value chain.

The researcher also concluded that the staff at Cape Pathologists perceived the A3

problem solving report to be useful and adaptable to their environment. The problem

solving A3 report was also shown to improve the staff’s problem solving capabilities.

Copyright UCT


60

However, apart from accepting the A3 report as a tool for process improvement, several

other conditions have to hold true for improvement initiatives to be successful. Although

participants merely believed the A3 report to be useful, turning that belief into action did

not follow since improvement only happened when the participants were actively

observed.

Several researchers posit that the actions of management in organisations can go a long

way towards sustaining change initiatives (Biazzo and Panizzolo, 2000; Smeds, 1994;

McHugh, 1997). The management at Cape Pathologists Ltd has initiated the

transformation towards lean using the A3 problem solving report. Working through the

remaining issues and sustaining the gains already realised will therefore depend on how

management chooses to act going forward in the absence of the researcher.

Copyright UCT


61

6. FUTURE RESEARCH DIRECTIONS

There implications for future research emanating from this A3 implementation

experiment in a pathology lab are twofold. First and foremost, tools for problem

identification and prioritisation need further investigation. The current research utilised a

high level value stream map to identify the source of problems in an organisation that

delivers a service across three intertwined departments, all of them potentially

contributing towards a major observable problem. In the scenario investigated, the major

challenge faced was how to conceptualise the problem: whether the problem ought to be

broken down into component parts and delegated to the respective departments for

solutions, or whether to set up a single team that spans across departments to drive

change. Chakravorty (2009) also reported experiencing challenges in finding and

prioritising problems for process improvement. Zimmerman and Weiss (2005, cited in

Chakravorty, 2009) argue that most improvement initiatives fall apart because the

problems have been incorrectly identified and prioritised. Tools already under

investigation in literature include Six Sigma, lean and theory of constraints (Chakravorty,

2009).

Secondly, participant management in improvement initiatives calls for further

exploration. Several authors posit that the human side is a critical success factor in

change and improvement endeavors (Chakravorty, 2009; French, 2009; Dickson, 2009).

Womack et al (1990) contend that the foundation of lean principles is respect for and

empowerment of people involved in processes, but these foundational aspects are hardly

recorded on improvement documents as change agents concentrate on tools under the

presupposition that participants are inherently motivated to be involved in the envisaged

change. More research is needed to provide insights on how to successfully manage

participants so that they become proactive in improvement initiatives. Chakravorty

(2009) recommends in-depth analysis of how team composition and incentives contribute

towards success or failure in improvement initiatives.

Copyright UCT


62

7. REFERENCES

1. Argyris, C. (1983). Action science and intervention. The Journal of Applied

Behavioural Science, 19(2), 115 – 140.

2. Argyris, C., Putman, R., & Smith, D. (1985). Action Science. San Francisco, CA:

Jossey-Bass.

3. Biazzo, S., & Panizzolo, R. (2000). The assessment of work organisation in lean

production: the relevance of the worker's perspective. Integrated Manufacturing

Systems, 11(1), 6 – 15.

4. Brooks, S. (2005). A lean services environment experiment: Introducing TPS and

lean principles to a pathology laboratory. Unpublished MBA research report,

University of Cape Town Graduate School of Business, Cape Town.

5. Booysen, T. (2006). Lean in Healthcare: Applying value stream mapping and lean

in the accident and emergency unit at G. F. Jooste Hospital. Unpublished MBA

research report, University of Cape Town Graduate School of Business, Cape Town.

6. Buesa, R. J. (2009). Adapting lean to histology laboratories. Annals of Diagnostic

Pathology, 13, 322 – 333

7. Cady, S.H., & Caster, M.A. (2000). A diet for action research: an integrated problem

& appreciative focused approach to organisational development. Organisation

Development Journal, 18, 79 – 92.

8. Chakravorty, S. S. (2009). Process Improvement: Using Toyota’s A3 Reports. Quality

Management Journal, 16(4), 7 – 26.

9. Chigwedere, R. (2007). Application of TPS and Lean principles to healthcare:

Process improvement in a HIV laboratory. Unpublished MBA research report,

University of Cape Town Graduate School of Business, Cape Town.

Copyright UCT


63

10. Coghlan, D., & Brannick, T. (2001). Doing Action Research in Your Own

Organisation. London: Sage.

11. Coghlan, D., & Brannick, T. (2005). Doing Action Research in Your Own

Organisation. London, Sage Publications Inc.

12. Coughlan, P., & Coghlan, D. (2002). Action research for operations management.

International Journal of Operations & Production Management, 22(2), 220 – 240

13. Davidson, R., Martinsons, M., & Kock, N. (2004). Principles of canonical action

research. Information Systems Journal, 14(1), 65-86.

14. De Souza, L. B. (2009). Trends and approaches in lean healthcare. Leadership in

Health Services, 22(2), 121 – 139.

15. Dhatt, G. S., & Peters, S. (2001). Accreditation of medical laboratories in South

Africa. Accreditation and Quality Assurance: Journal for Quality, Comparability and

Reliability in Chemical Measurement, 7(7), 290 – 292.

16. Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, A., & Singh, S. (2009). Use of

lean in the emergency department: A case series of 4 hospitals. Annals of Emergency

Medicine, 54(4), 504 – 510.

17. French, S. (2009). Action research for practicing managers. Journal of Management

Development, 28(3), 187 – 204.

18. Friderichs, C. (2009). An experiment in a lean services environment: An A3 approach

in a community health centre. Unpublished MBA research report, University of Cape

Town Graduate School of Business, Cape Town.

19. Hawkins, R. S. (2007). Laboratory turnaround time. The Clinical Biochemist Reviews,

29(4), 179 – 194.

20. Holweg, M. (2007). The genealogy of lean production. Journal of Operations

Management, 25, 420–437.

Copyright UCT


64

21. Jackson, T. L. (2006). Hoshin Kanri For The Lean Enterprise. Productivity Press,

New York

22. Jimmerson, C. (2007). A3 Problem Solving for Healthcare: A Practical Method of

Eliminating Waste. Productivity Press, New York.

23. Kemmis, S., & McTaggart, R. (1988a). The Action Research Planner. Deakin

University, Melbourne.

24. Leedy, P. D., & Ormrod, J. E. (2010). Practical Research: Planning and design.

Pearson Education, Inc, New Jersey.

25. Leon, N., & Mabope, R. (2005) Chapter 3, South African Health Review, Health

systems Trust, Available at: http://www.hst.org.za/uploads/files/sahr05_chapter3.pdf

26. Liker, J., & Meier, D. (2005). The Toyota Way Fieldbook: A Practical Guide for

Implementing Toyota’s 4P’s. New York: Mc Graw-Hill.

27. Liu, W. (2006). Clinical research the six sigma way. Journal of the Association for

Laboratory Automation, 11(1), 42 – 49.

28. Lundberg, G. D. (1981). Acting on significant laboratory results. Journal of the

American Medical Association, 245, 1762 – 1763.

29. Manor, P. G. (1999). Turnaround times in the laboratory: a review of the literature.

Clinical Laboratory Science, 12, 85 – 9. McHugh, M. (1997). The stress factor:

another item for the change management agenda? Journal of Organisational Change

Management, 10(4), 345 – 362.

30. McHugh, M. (1997). The stress factor: another item for the change management

agenda? Journal of Organisational Change Management, 10(4), 345 – 362.

31. McKay, J., & Marshall, P. (2001). The dual imperatives of action research.

Information Technology and People, 14, 46–59.

Copyright UCT


65

32. McKellar, L., Pincombe, J., & Henderson, A. (2009). Encountering the culture of

midwifery practice on the postnatal ward during Action Research: An impediment to

change. Women and Birth, 22, 112—118.

33. Nutt, P. (2002). Why Decisions Fail: Avoiding The Blunders and Traps that Lead to

Debacles. San Francisco: Berrett-Koehler Publishers, Inc.

34. O'Brien, R. (2001). An Overview of the Methodological Approach of Action

Research. In Roberto Richardson (Ed.), Theory and Practice of Action Research. João

Pessoa, Brazil: Universidade Federal da Paraíba.

35. Oliver, N., Schab, L., & Holweg, M. (2007). Lean principles and premium brands:

conflict or complement? International Journal of Production Research, 45(16) 2007,

3723–3739

36. Peck J, et al. Axiomatic approach for efficient healthcare system design and

optimization. CIRP Annals - Manufacturing Technology (2010),

doi:10.1016/j.cirp.2010.03.033

37. Perry, C., & Zuber-Skerritt, O. (1991). Action research in graduate management

research programs. The First World Congress on Action Research & Process

Management, 1(6), 67 – 79.

38. Rother, M., and Shook, J. (1998). Learning to see. The Lean Enterprise Institute, Inc.

Brookline, MA.

39. Saunders, M., Lewis, P., & Thornhill, A. (2003). Research Methods for Business

Students. Harlow, England: Pearson Education.

40. Shani, A. B., & Passmore, W. A. (1985). Organisational inquiry: Towards a new

model of the action research process, in D. D Warrick (ed.), Contemporary

Organisation Development: Current Thinking and Applications. Glenview, IL: Scott,

Foresman, 438 -448.

Copyright UCT


66

41. Shook, J. (2008). Managing to learn: Using the A3 management process to solve

problems, gain agreement, mentor, and lead. Cambridge, Massachusetts: The Lean

Enterprise Institute, Inc.

42. Smeds, R. (1994). Managing change towards lean enterprises. International Journal

of Operations & Production Management, 14(3), 66 – 82.

43. Smellie, W. S., Galloway, P. J., Johnston, J. I. (1995). Laboratory turnround time:

closing the loop. Journal of Clinical Pathology, 48, 372 – 375.

44. Sobek II, D. K., & Jimmerson, C. (2004). A3 Reports: A tool for process

improvement and organisational transformation. In Proceedings of the Industrial

Engineering Research Conference,Houston, Texas.

45. Sobek, D. K., & Smalley, A. (2008). Understanding A3 thinking: A critical

component of Toyota’s PDCA management system. Taylor & Francis Group: Boca

Rotan.

46. Sørensen, E. W., & Haugbølle, L. S. (2008). Using an action research process in

pharmacy practice research – A cooperative project between university and internship

pharmacies. Research in Social and Administrative Pharmacy, 4, 384–401.

47. Sugimori, Y. , Kusunoki, K. , Cho, F. & Uchikawa, S. (1977). Toyota production

system and Kanban system Materialization of just-in-time and respect-for-human

system. International Journal of Production Research, 15(6), 553 – 564.

48. Susman, G., & Evered, R. (1978). An assessment of the scientific merits of action

research. Administrative Sciences Quarterly, 23, 582 – 603.

49. Visich, J. K., & Wicks, A. M. (2010). Practitioner’s perceptions of the A3 method for

process improvement in healthcare. Decision Sciences Journal of Innovative

Education, 8(1), 191 – 213.

Copyright UCT


67

50. Westbrook, R. (1985). Action research: a new paradigm for research in production

and operations management. International Journal of Operations and Production

Management, 15(12), 6 – 20.

51. Womack, J. P., & Jones, D. T. (2003). Lean thinking. New York, Free Press.

52. Womack, J.P., Jones D.T., & Roos, D. (1990). The Machine that Changed the World:

The Story of Lean Production. Toronto: Harper Perennial.

Copyright UCT


68

8. APPENDICES

APPENDIX 1: Example of the A3 Report

Adapted from Shook (2008), p. 145.

Copyright UCT


69

APPENDIX 2: Likert Questionnaire 1

6. Can you please explain your answer to question 5 above

………………………………………………………………………………………………

……………………………………………………………………………………………..

APPENDIX 3: Likert Questionnaire 2

QUESTION 1.Strongly

disagree

2.Disagree 3.Neutral 4.Agree 5.Strongly

agree

1. Did you find the research

project useful?

2. Do you wish to continue

utilising the skills that you

have learnt?

3. Do you think the project

improved your problem

solving capabilities?

4. Can you please explain your answer to question 3 above

………………………………………………………………………………………………

………………………………………………………………………………………………

……………………………………………………………………………….

QUESTION 1.Strongly

disagree

2.Disagree 3.Neutral 4.Agree 5.Strongly

agree

1. Did you find the session

useful?

2. Did the facilitator clearly

articulate what you were

expected to do?

3. Did you understand the

lean principles covered in the

discussion?

4. Would you be able to

explain the A3 problem

solving report to someone?

5. Do you think A3 problem

solving can be adapted to

Cape Pathologists to solve

problems?

Copyright UCT


70

APPENDIX 4: Example A3 report used in training

Title: Reduction of time spent following up results for specimens referred to other

laboratories

Process Owner: S. Williams Date: 28 September 2010

Background

Some of the specimens received at Viking are referred to other labs – specialized

tests/cost effectiveness

• Referral labs include Lancet, MDS, Pathcare, Tygerberg, Red Cross, WPBT.

• On average 50 – 70 specimens/day

• Results are often delayed and have to be followed up

• Following up takes time

• Doctors become disgruntled – damaged relationships

Current Condition

• Call referred from one department to the other

• Typical call progresses as depicted below:

• Average calling time 7 – 15 Min

• Follow up list averages 80 tests per day, therefore 560min (7minx80 >8hrs)

needed.

• Work piles up over time and other results remain outstanding for over 1 week.

Goals

• Calls directed straight to the responsible department

• Reduce calling time to under 5 minutes

Root cause analysis

Using the 5 Why method

Tests are done in different departments

Other specimens are further referred e.g. from Lancet to NHLS Johannesburg.

No record to indicate what tests are done in what lab and in which department

No record of telephone numbers of different departments

Call switchboard Transfer to histology Transfer to virology

Transfer to genetics and get results

Copyright UCT


71

Proposed countermeasures

Compile an alphabetical list of tests with respective telephone numbers and departments

responsible for those tests. The list should be in the following format:

TEST TAT DEPT TEL CONTACT

PERSON

TB Culture 1 Week UNISTEL-TB 021432156 Mark

Implementation Plan

Williams will compile the list of numbers in the above format in an A4 book

already provided.

All tests that are performed at referral laboratories will be compiled in

alphabetical order in the first column by Friday 08 October 2010.

Other details will be filled in on an ongoing basis as results are followed up from

different labs.

Every Friday a S. Williams will draw a Gantt chart to show the progression

towards completion, and submit it to laboratory supervisor.

Follow up

Lab supervisor will follow up and monitor progress as informed by the Gantt

charts every Friday.

If progress is deemed slow, lab supervisor will authorize calls to find out the

information without following specific results.

Copyright UCT


72

APPENDIX 5: First A3 Report

Title: Reduction of throughput time in the lab from receipt of specimens to dispatch

of results to clinicians.

Facilitator: Tinashe Chinyanga

Process Owners: Team Leaders

Participants: Topplers and Data capturers

CURRENT CONDITION Current layout and value stream map for urgent samples at Pinelands Lab is as below:

X1

DATA ENTRY

X1-2

TOPPLING

X2-3

ANALYSIS

X1

RECEIVING

X2

REPORTING

1.5-5

2

1-17

7

5.5

5-15

75-10

6.5

1-5

2

1-2

2

1-8

3

1-5

3

WASTE 19Min

TOTAL 38Min

C/T: 5.5 minC/O: 0.5min

C/T: 1.5-5 minC/O: 0.5min

C/T: 1-5 minC/O: 0.5min C/T: 1-2 min

C/O: 0.4minC/T: 5-10 minC/O: 0min

KEY Inventory

C/TCycle Time

C/OChange over time

Whose task?

1 capturer?

specimen: where?

Waste accounts for half of throughput time

Standard deviation = 26minutes)

8% of urgent specimens last >2hrs in lab.

33% of urgent specimens last > 40 minute

BACKGROUND Specimen volumes are increasing at Pinelands lab averaging 1100 daily, with over 40%

requiring urgent processing within 2 hours. Over the years the standard operating

practices have remained unchanged and workarounds divergent from the protocol are

common. Urgent tests are often delayed leading to sour relationships with referring

clinicians. Failure to meet timelines imposed by clinicians might lead to loss of business.

All data capturers

shout ‘urgent!’

No one has clear

responsibility of

taking samples to

toppling desk –

data capturers &

toppling staff

move around.

Copyright UCT


73

APPENDIX 5 (CONTINUED)

GOALS

Reduce throughput WASTE by 50% from current state level.

Envisioned throughput time < 30 minutes.

Establish a protocol for urgent specimens that all participants can relate to.

CAUSE ANALYSIS

Using the fish bone diagram:

Waste =½ of

throughput time

Machine

Materials

Methods

People

Protocol for urgents is unclear

Machines are down 3% of the time

Errors on forms delay data entry

Missing information of forms

Extra specimens add to work load

Topplers batch samples

Topplers do not prioritise work

Team leaders assign

Urgents to 1 capturer

1 toppler absent most of the time

Data capturers do not shout “urgent”Routine specimens labelled as urgent

Strain the system

Urgent specimens out of sight

of topplers

New toppler recently started work

No standard time for performing tasks

Missed tests add to rework

Poor station communication

Other queries directed at toppling

Specimen cannot be traced once in lab

Copyright UCT


74


TARGET CONDITION

The envisioned layout is as shown below.

PROPOSED COUNTERMEASURES

Reduce waste in

throughput time

by 50%

People

Methods

Materials

Machine

Establish electronic time

between analysis and toppling

Clarify protocol for urgents

& paste a visual map

Establish 1 visible point to place

urgents after data capture

Generate time for tasks

for inclusion in protocols

Direct all queries to help desk

Follow protocol for servicing machines

At least 2 people to countersign

for servicing a machine

All forms with missing information/errors

to help desk for follow up

Nursing department to tackle errors

and form labelling

Train people on urgents protocol

Assign 1 toppler for urgent specimens

Prioritise urgent specimensTeam leader is responsible for

notifyingtopplers about urgents

Distribute urgents equaly to

available data capturers

Protocol for urgent

1) Only team leader

shouts ‘urgent!’

2) All data capturers

place urgent

samples in a red

bucket centrally

located – no

movement required.

3) Toppling staff

collect urgent

samples from red

bucket.

Copyright UCT


75


IMPLEMENTATION PLAN

WHAT WHO WHEN WHERE

Protocol training Team leaders 02/11/2010 Pinelands lab

Toppling desk roaster (with

2 people/shift)

Toppling staff 02/11/2010 Pre-analysis area

Paste 2 visual copies of

protocol in lab

S. Williams 02/11/2010 Pinelands Lab

Lean coaching T. Chinyanga Ongoing Pinelands lab

Implement protocol for

urgent specimens

All participants 04/11/2010

and thereafter

Pinelands lab

FOLLOW UP

Lab supervisor and T. Chinyanga to observe a random sample of urgent

specimens go through the protocol on 11/11/2010 and on 30/11/2010.

Lab supervisor to extract data from the Disalab® IT system on 30/11/2010 to

track progress in achieving throughput time.

All participants to reconvene on 01/12/2010 to discuss progress.

Copyright UCT


76

APPENDIX 6: Second A3 Report

Title: Reduction of courier time for urgent specimens from receipt of phone call to

delivery of specimens to Pinelands lab

Facilitator: Tinashe Chinyanga

Process owners: Transport coordinators

Participants: Drivers

BACKGROUND

The courier service at Cape Pathologists is an integral part of the business, and is

responsible for the delivery of all specimens from depots and private hospitals/clinics.

The service delivers on average 1100 specimens daily and roughly 40% of these samples

need urgent transporting and processing. The courier must therefore provide an efficient

service for TAT to be met as promised to doctors.

CURRENT CONDITION

Analysis of a random sample gives the trends depicted below.

17% of urgent specimens are delivered well after the TAT promised to clinicians.

Current throughput time at Pinelands lab is 40 minutes: courier must deliver within 80

minutes – 30% of specimens are delivered after 80 minutes.

Drivers use different routes resulting in variable delivery time across depots.

Copyright UCT


77

APPENDIX 6 (Continued)

GOALS

Reduce (by 40%) proportion of urgent specimens delivered after 1 hour 30

minutes

Envisioned goal is to have at most 18% of urgent specimens exceeding 1 hour 30

minutes in the short term.

CAUSE ANALYSIS

30% URGENT

SAMPLES DELAYED

MACHINES

MATERIALS

METHODS

PEOPLE

Vehicles down 3% of the time

Maintenance carried

out during the week

Traffic congestion at peak times

Weather conditions affect traffic flow

Unclear communication

from phlebotomy

Protocol for dispatching

drivers not clear

No standard routes

No monitoring system to

inform improvements

Drivers dont know why the rush

Absenteeism of drivers

High turnover

among drivers

Newer drivers dont

know shorter routes

Coordinators dont match vehicle

type with time of day

Routine specimens labelled urgent

Sometimes coordinators delay to dispatch drivers!

Copyright UCT


78


COUNTERMEASURES

The proposed countermeasures are as depicted by the reverse fish bone diagram below:

REDUCE BY 40 % SAMPLES

DELIVERED >1HR20

MACHINESMETHODS

MATERIALSPEOPLE

Communication training for staff

Establish protocol for

dispatching drivers

Establish standard routes

Install monitoring system

with audit trail

Train drivers about

importance of pathology

Investigate cause of and

remedy absenteeism

Ongoing orientation of new drivers

Match vehicle type with time of day

When possible use

motorbikes at peak hours

Nursing department to label

specimens accurately

Schedule maintenance

on weekends

Adhere to vehicle service plan

Proposed web based transport and specimen tracking system will function as below:

Com

pute

r

Computer

Use

r

Use

r

Message Formats

Message Formats

1. Patient details & urgency of

requested test entered at depot:

time automatically recorded

2. Details pop up in coordinator’s

worklist

3. dispatch driver within 5 minutes: time

automatically recorded (screen turns red

after 5 min)

4.Drive

r re

turn

s with

in s

tipula

ted ti

me

for re

gion: s

cree

n turn

s re

d after

tim

e

for th

at reg

ion h

as e

lapse

d &

coord

inat

or fo

llows

up

Web based tracking system will generate data by region that will be used to create

standard time for courier along the routes.

Standard routes will also be created.

Copyright UCT


79


IMPLEMENTATION PLAN

ACTION ITEM RESPONSIBILITY TIMELINE LOCATION

Establish protocol

for vehicle

prioritisation &

dispatching drivers

Transport manager &

coordinators

15/11/2010 Courier office

Train coordinators

on new web-based

tracking system

IT Department 15/11/2010 to

22/11/2010

Courier office

Pilot web-based

tracking system

Coordinators 15/11/2010 to

30/11/2010

Courier office

Train nursing staff

on new web-based

tracking system

Nursing manager &

clerks

01/12/2010 to

15/12/2010

Depots/Pinelands

nursing office

Go live with web

based tracking

system

IT department,

coordinators and

nursing staff

16/12/2010

Train drivers on

pathology

Technologists Every Wednesday Pinelands Lab

Orientation and

training of new

drivers

Senior drivers Every Friday Courier routes

Weekend service

schedule for

vehicles

Senior driver and

transport manager

Monday of every

month

Courier office

FOLLOW UP

Monthly transport meetings to assess progress towards envisioned goals.

Transport manager to analyse data from the web-based tracking system weekly.

Transport department to establish standard time for routes within 4 months.

Copyright UCT


80

APPENDIX 7: Research Log

DATE PARTICIPANTS LOCATION TYPE OBJECTIVES OUTCOMES

28/05/2010 Dr Jonas Cape Grace

Hotel

Meeting Introduction to Cape

Pathologists Ltd

business environment

Dr Jonas explained

challenges faced in

terms of failing to meet

promised turnaround

time (TAT) on urgent

tests

Tinashe explained

probable research

opportunities that might

help the company

Dr Jonas agreed to host

Tinashe at Cape

Pathologists Ltd offices

23/06/2010 Dr Jonas, Mavis Pinelands

Lab

Company tour To find out more

about Pinelands lab

Specimens processed in

pre-analysis and

analysis areas

Pre-analysis area people

typically have matric

level education, analysis

area staffed by degreed

technologists

Specimens pass through

receiving, data capture,

toppling and analysis

Mood generally

welcoming

Copyright UCT


81

GSB Reflection Training needs to take into account the education level of

would be participants

Keep material simple and avoid MBA jargon when

talking to shop floor employees

Several visits are needed to understand the flow of work

at Pinelands lab

22/07/2010 Dr Jonas Pinelands

Lab

Meeting To discuss scope of

process improvement

project

Dr Jonas accepted to

host the project on

behalf of Cape

Pathologists

Agreed to have a RCA

outlining the scope of

the project by end of

August latest

Dr Jonas to set up

appointments with

heads of departments

GSB Reflection TAT as defined by Cape Pathologists need the

involvement of three departments in the project

The project needs to start early if results are to be

realised in all three departments to impact TAT

29/07/2010 Prof Norman

Faull

GSB Meeting To discuss research

project and

supervision possibility

Prof Norman Faull

happy to supervise

project but will need

formal proposal

Advised to keep

research journal to

reflect on what is

happening

02/08/2010 Transport Pinelands Meeting To get an overview of Overview of how the

Copyright UCT


82

manager Lab (courier

office)

the courier service department works

highlighted

Challenges include

absenteeism, traffic

jams and

communication

difficulties with depots

GSB Reflection Transport coordinators have matric level education; most

started as drivers and they know the routes well. Their

involvement in problem solving for the department is

important

Training needs to be tailored to what the department is

doing

11/08/2010 Nursing manager Pinelands

lab (nursing

office)

Meeting To understand how the

department works

Department has 80

staff, mainly nurses

Low turnover of staff

GSB Reflection Nursing manager is new to department and does not have

a nursing qualification. Avoid clinical jargon when

communicating with him

Deputy nursing manager has a nursing qualification and

has experience of working in phlebotomy department.

Her experience will be beneficial for the project

Getting all nursing staff at one venue would be difficult

and probably not fruitful; managers may need to identify

change champions to mentor others

17/08/2010 IT department Pinelands IT

office

Meeting Overview of databases

and data that can be

useful for analysis

IT department happy to

provide secondary data

for evaluation of

Copyright UCT


83

current state.

GSB Reflection Databases are a good source of secondary data, but how

objective is this data? Are there any legal requirements

for the data to be recorded objectively?

Will need to find out what the compliance requirements

are before depending on the data

25/08/2010 Senior

management

Pinelands

Boardroom

Meeting Discuss probable scope

of project

Introduce process

improvement concepts,

lean, TPS and A3 tools

Discuss researcher-

client agreement

(RCA)

Research project to

involve 3 departments

(phlebotomy, courier

and Pinelands lab)

Senior management

happy to host project

and believe there is

need to change

RCA drafted and to be

signed by GM and

researcher

GSB Reflection Strategic intent for change is evident amongst senior

managers and would count in favor of the project

RCA provides unlimited access to company data, staff

and premises: this will be very helpful for the project


Faull

GSB Meeting Discuss project

proposal

Proposal generally

good and advised to

start project

12/09/2010 Dr Jonas, Mavis

Laboratory staff,

courier staff and

nursing staff

Pinelands

Boardroom

Workshop Presentation of key

lean principles

Introduction to A3

problem solving

Lean principles

generally accepted and

understood

Participants indicated

Copyright UCT


84

Problem definition and

scope of project

they would need

coaching

GSB Reflection Group was probably too large to be involved

individually with researcher-facilitator

Follow up workshops with smaller groups important.

Operations of three departments seem to be distinct and

people in one department generally do not have enough

knowledge of other departments to suggest

improvements

Consider splitting tasks by departments

13/09/2010 Pre-analysis staff Pinelands

lab

One-on-one

coaching Mentor participants on

A3 problem solving

Progress in learning

generally slow

Regular follow up

sessions to be arranged

GSB Reflection Most participants jump to solutions when confronted

with a problem

Simulation exercises might be important so that

participants support each other

Participants a bit skeptical about the motive of the

project; some believe management is out to get them

14/09/2010 Depot staff Kuils River,

Bellville

Melomed

Depot Visits To understand

phlebotomy service

Depot staff believes

Pinelands lab needs to

improve

15/09/2010 Driver Hospital

route

Courier route

experience To walk the courier

‘gemba’

The visit went well.

Several vehicles

clashed at one depot

twice

21/09/2010 Courier staff,

phlebotomy staff

and Pinelands lab

Pinelands

lab

Meeting/workshop High level value stream

mapping and

identification of

Phlebotomy and

courier difficult to

conceptualise as

Copyright UCT


85

staff problems distinct steps/stations

for value stream map

VSM for Pinelands lab

drawn: process flow

diagrams for courier

and phlebotomy drawn

22/09/2010

to

24/09/2010

Pinelands lab

staff

Pinelands

lab

A3 simulation

workshops/one-

on-one coaching

Improve staff’s A3

skills before drawing

actual A3s

Staff’s perceptions of

the project improving

Enthusiasm is going up

and tendency to jump

to solutions is fading

04/10/2010 Courier staff

(transport

coordinators)

Pinelands

office

A3 simulation

workshops/one-

on-one coaching

Improve staff’s A3

skills before drawing

actual A3s

Staff motivated to find

solutions to problems

Low representation of

drivers worrying

06/10/2010 IT Department IT office Meeting Extract secondary data

from Disalab® IT

system

Data made available

for analysis

08/10/2010 Technologists Pinelands

lab

One-on-one

coaching Mentor participants on

A3 thinking

Progress of

technologists much

faster

Some offered to help

mentor pre-analysis

staff

11/10/2010 Pinelands lab

staff

Pinelands

lab

Data analysis and

observation of

current state

Objectively map the

current state of the lab

Generate data for

future reference

Participants

successfully generated

data for current state

12/10/2010

to

Pinelands lab

staff

Pinelands

lab

A3 simulation

discussions Skills transfer to

participants.

Participants more

confident in drawing

Copyright UCT


86

15/10/2010 A3s.

Some wonder if the

increased workload

will result in higher

incentives

Others highlight the

challenges they face in

suggesting

improvements when

there are hard and fast

work instructions and

protocols

18/10/2010 Courier staff Pinelands A3 discussions Mentoring of

participants

A3 simulations

Work instructions

viewed as stumbling

block to process

improvement

20/10/2010 Management,

Pinelands lab &

courier staff

Pinelands Meeting Report back about

current state findings

Prioritization of

problems identified

Improving throughput

time in laboratory and

courier delivery time

identified as problems

for immediate attention

Problems relating to

nursing and

phlebotomy to be

solved at a later stage

25/10/2010

to

29/10/2010

Pinelands lab

staff

Pinelands

lab

Discussion Drawing of A3 to

improve throughput in

lab

A3 successfully drawn

and approved by

management for

implementation

10/11/2010 Lab supervisor Pinelands Observation visit Observe the new Apparent improvement

Copyright UCT


87

lab protocol in action

Generate data on new

state

noted.

Secondary data

obtained from IT for

analysis

11/11/2010 Pathologists, IT

Department,

Technologists

Pinelands

Boardroom

Meeting Discussion of time

stamp between pre-

analysis and analysis

areas in lab

Participants believe the

suggestion is valuable.

Participants to propose

plans for a follow up

meeting on 18/11/2010

12/11/2010 Courier staff Pinelands

courier

office

Discussion Drawing of A3 for

transport system

A3 successfully

completed

IT department needs to

be involved

15/11/2010 Transport

manager, IT

department

IT office Meeting IT system for vehicle

and specimen tracking

Training to start

16/11/2010

Go live date to be

discussed after piloting

for 2 weeks


Faull

GSB Meeting Discussion of findings

and progress made

Advised to get a draft

out soon for review.

Prof satisfied with

progress

30/11/2010 Lab supervisor Pinelands

lab

Observation Observe and generate

current state data

New protocol observed

in action


Faull

GSB Draft report back Comment on draft

submitted

Several changes

suggested

Documents

Lean Pathology: Implementing The Problem Solving …gsblibrary.uct.ac.za/researchreports/2010/Chinyanga.pdf · IN A PATHOLOGY LAB. 9 o Data capture – patient information and the