Practical Use of Lean in Cytology

Stephen S. Raab, M.D.

Department of Laboratory MedicineEastern Health and Memorial University of Newfoundland, St.

John’s, NL and University of Washington, Seattle, WA

Norsk Forening for Klinisk CytologiFebruary 3, 2012

Overview

Quality LeanCytologySummary

Quality Quality is the product and or service that meets the requirements of a wide number of individuals and or groupsQuality is what the customer wantsQuality is optimal patient care

US Institute of Medicine (IOM) Domains of Quality

Safety – avoiding injuries to patients Timeliness – reducing waits and delaysEffectiveness – providing care based on scientific knowledgePatient centeredness – providing care based on patient needsEfficiency – decreasing wasteEquity – equal access

LeanLean is a system that incorporates quality improvement at a fundamental levelThe study of Lean documents the use of rules and principles that describe work components and philosophyLean practices often involve specific tools (A3, kanban cards)

LeanLean is an integrated operational and sociotechnical approach of a value system, whose main objectives are to maximize value and thus eliminate waste by creating cumulative capabilities – Joosten et al. Int J QualHealth Care. 2009;21:341-347.

Lean (2001): Perfecting HealthcareEach improvement allows the organization

to move closer to providing Ideal Healthcare.

Current State of 

Healthcare

Problem

ProblemProblem

Ideal Healthcare

Improvement 

Experiments

Toyota Way (14 Principles)Philosophy as the FoundationThe Right Process Will Produce the Right ResultsAdd Value to the Organization by Developing Your People and PartnersContinuously Solving Root Problems Drives Organizational Learning

Toyota Production System

Stability is the Foundation

Heijunka – level the work load

Kaizen – Continuous improvement

Jidoka – Immediate and  continuous quality checks

Just‐in‐time – Continuous  flow

Liker, page 33

Toyota Production System (TPS) House

Rules In Use

Customers#ActivitiesConnectionsPathwaysImprovement

Principles of Work Design

Decoding the DNA of the Toyota

Production  System*

* Steven Spear and H. Kent Bowen, “Decoding the DNA of the Toyota Production System”, 

Harvard Business Review, Sept‐Oct 1999, p 96

# Not from Spear and Bowen

Visual Management

Close to WorkGenchi Genbutsu (現地現物)

Principle 12, Go and SeeGemba attitude

Going to "the place" where the problem actually happens

Avoid the conference room, conference call, email, and board meetingSee and solve problems at the source

Areas of Improvement

Turn around time Standardization of processesCommunicationQuality of diagnosis

Current Condition

Target Condition/Ideal State

Smooth sign out without delays.

All clinical history gathered before meeting with the attending.

Action Plan

Experiment includes MetricsMonitor sign out by pathologist for improvement

Date: 10/21/08

Improvement Opportunity

Title: Reduce resident delays in non-gyn

cases

Prepared by: Barb T –

driver -

Meredith

Problem/Improvement Opportunity

There is delay in non-gyn

cases by the resident.

Anatomical Path Area: Cytology

Action Responsibility Deadline

Print out extra tracking log for resident when slides are taken into screning room

Lab Techs 10/22/08

Modify tracking log to include pt name and MR #

Luann 10/22/08

If needed resident goes into lab and write down information on patients before getting the log.

Resident On going

5 Whys – Root Cause Analysis Why is there delay in the case by the resident?

Why ? Resident had to return to get additional pt histories.

Why? The resident was not prepared with all the information.

Why ? The resident didn’t have the time to gather all the information.

Why? Resident didn’t know patient cases until the cases were completed by cytotech.

Impact (circle): Activities, Connections, Pathways

resident Pt hist

+slides Attending

Review cases

resident

More pt info

Time delay to get more pt info

Root Cause Analysis

Large volume of manual cover slipping increases timeThinPrep tests that arrive on Friday afternoon are processed Monday morning and are not screened until Tues PM or Wed AMCytotechnologists off on procedures (fine needle aspiration) delays overall screening

Solutions

Drying ovenAuto cover slippingCollect more data to better understand delays between receipt of specimen and specimen available for screeningRequest slide delivery not in batches but throughout the day

Implementation (kaizen)

Change process flow (use drying oven) Change work activities (limit cytotechnologist time on procedures)Change process flow (use auto cover slipper)Change connections (one by one hand-off of Pap tests to cytotechnologists)

Percent GYN Cases Completed within 7 DaysMonthly Volume of GYN Cases

April 2008-August 2010Showing Threshold 70% within 7 Days

40.0%

45.0%

50.0%

55.0%

60.0%

65.0%

70.0%

75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

105.0%

Apr-08 May-08 Jun-08 Jul-08 Aug-08 Dec-08 Jan-09 Mar-09 Jul-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10

Perc

ent C

ompl

eted

0

200

400

600

800

1000

1200

1400

1600

# of

Cas

es

PercentCasesCompleted

Volume ofCases

Summary

Reviewed TAT graph that shows turn around time for receiving the specimen to completing cytotech screen has reduced from 5.5 days to 4 days.Target condition of TAT A3 achievedKN- suggested this might continue to decrease with imager

ConclusionsHealthcare organizations use Lean principles and rules to implement change in many different waysLean principles and rules involve understanding work processesMost healthcare organizations only partially (at best) practice a Lean system and consequently Implementation of change has variable levels of success

Practical Use of Lean in CytologyOverviewQuality US Institute of Medicine (IOM) Domains of QualityLeanLean Lean (2001): Perfecting HealthcareToyota Way (14 Principles)Toyota Production SystemRules In UseLysbildenummer 12Close to WorkAreas of ImprovementLysbildenummer 15Lysbildenummer 16Root Cause AnalysisSolutionsImplementation (kaizen)Lysbildenummer 20SummaryConclusions