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Application of Lean thinking to laboratory service improvement; 5S; seven wastes, working in cells, process mapping, single piece flow, reducing turnaround time
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Our Lean Experience
Cellular Pathology, Royal Victoria InfirmaryTerry Coaker
Histology Operations ManagerOne year secondment to:
North of England
Haematological Oncology Diagnostic ServiceNEHODS
• Our history• Why change?• Most important lessons:-
– Lean Thinking– Lean Tools– Management– Data
Cellular Pathology, Newcastle Hospitals
Cellular Pathology, Newcastle Hospitals• 1981: RVI 9,700 requests per annum • From 1995 to date: merger of NGH acute
services; NGH histology; Dental Hospital; Freeman histology; Muscle & nerve; Cytology; Neuropathology.
• Decant to prefabs for 3.5 years• December 2006 - Bigger NOT Better ! - Lean• May 2009: New PFI • 2013-2014: 54,000 p.a.
Drivers for change• Lord Carter 20% reduction• Modernising Scientific Careers• Private sector• NHS England• Regional rationalisation• Trust CIP – 2012/13 = 4.0% = £328,280• Trust ‘Transformation’ 2013/14• Why would you NOT want to improve the service !
“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming down-stairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it.”
Drivers for change…
November 2009, NHS Improvement
Unconscious incompetence
Conscious incompetence
Conscious competence
Unconscious competence
+ =
Continuous improvement ?
+ =
Continuous improvement ?
Machines, environment & processes
WILL break down over time
Continuous improvement
People are the only organisational asset that has
an infinite capacity to appreciate in value
Continuous improvement
Reactance - if we try to make people do something, they will resist doing it…
…even if they agree with it !
Continuous improvement
Not invented here…Not invented here…
‘‘Those people aren’t like us’Those people aren’t like us’
Our situation is more complicated than that’
‘Those ideas won’t work here’
‘‘That’s the way I’ve always done it’That’s the way I’ve always done it’
‘We’ve tried that before… and it didn’t work’
? Passive aggressive behaviour – or worse!
Don’t let perfect get in the way of better
Assume nothingAssume nothing
Just do it"She didn't know it couldn't be done, so she went ahead and did it"
Continuous improvementContinuous improvement Walk the gembaWalk the gemba
You get what you deserve … you deserve what you tolerate
It’s not people,it’s processes
I f you can’t measure it , you can’t manage it
Every system is perfectly designed to achieve exactly the results it gets
To improve the work is the work
Quality at Source
Go see…, ask why? Go see…, ask why? respect the individualrespect the individual
NEVER Accept, Make or Pass a Defect
Right first timeRight first time
Lean MethodsContinuous Improvement Toolbox
Value Stream Mapping
Pull Systems
5S System Layout
Setup Reduction
Teams
Visual Controls
POUSStandardized Work
Quality at the Source
Continuous Flow
Work CellsPerformance Measurement
TPM
Batch Size Reduction
Le
an T
oo
ls
Lean Tools - Seven forms of waste1. Correction - re-embedding, deepers2. Overproduction - inappropriate requesting3. Transport - e.g. point of use p.wax4. Movement - more steps than necessary /
double handling / stretching5. Waiting …to do work
…work waiting to be done6. Inventory - “batch and queue”/ unnecessary
supplies or equipment7. Inappropriate - activities which do not add value
processing e.g. date and time of receipt8. People waste - not using the knowledge skills and
abilities of the employee
Batch logic v Flow Logic
SPF
Ba
tch
1
2
3
3
2
1
Assumptions:
• 3 Operators
• 3 processes
• 1 min per process
• 0 min Move Time
• 10 specimens
10m 20m 30m
Batch
21”
30”
SPF
3”
12”
First result
Last result
Spaghetti diagramsBand 2 embedding
Spaghetti diagramsBand 6 microtomy
Cells• Cells – Danaher, Leica, Pathlinks • Integrate all functions in close proximity• Problem solving easier• Smaller batches, continuous throughput• Teamwork, ownership & accountability• Faster response• Reduced turnaround times
Spaghetti diagramsCells
Visual Display
Visual Display
Visual Display
Visual Display
Visual Display
Visual Display
Visual Display
Visual Display
Visual Display
Re-organisation of meetings
Weekly Huddle Review
Histology Performance
Spec Rec ICC General
Office
Cytology Slide
Production
Medical specialty team meetings
Benefits
• Daily ! Addresses issues immediately• Clarifies duties• Encourages feedback• Staff know more about their role• Ownership• Motivating and enjoyable!
Staffing
Healthcare Science Assistants Embedding
Healthcare Science Associates Microtomy, ICC, EM prep, Supervision
BMS Team Leaders Supervision / Management
BMS Advanced Practitioners Histological dissection Reporting pilot
Improve safety
Histology Complete Request Forms 2012
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan-
12
Feb-12
Mar
-12
Apr-1
2
May
-12
Jun-
12
Jul-1
2
Aug-1
2
Sep-1
2
Oct-12
Nov-1
2
Dec-1
2
Jan-
13
Feb-13
Mar
-13
Detailed Team TAT
587th November 2012
New Technology - IT
• Order communications, Electronic Patient Record
• Bar coding• Slide writers• Tracking Radio Frequency Identification RFID’s
• Digital imaging– Macro e.g. Macropath, Nikon– Micro e.g. Coolscope, Aperio, virtual slides
• Voice recognition
Automation
• Embedding• Motorised microtomes• ICC to include antigen retrieval, DCM• Special staining
Tissue Processing• Microwave – now automated• Continuous access• 1- 40 cassettes every hour• Formaldehyde and xylene free• UMFIX Universal Molecular Fixative• Danaher / Leica / Vision Biosystems Peloris XFP• Milestone Pathos• Siemens / Bayer / Sakura Finetech Histoexpress
Tissue Processing Azorides R.Morales
University of Miami / Jackson Memorial Medical Centre
Requests Reported on
day of surgery
1996 23349 27
2003 30124 1717317173
Reporting
‘DGH’Trim
Process
Report
Ideal ?Trim
Process
Report
Trainee
‘Teaching’Trim BMS /Trainee
Process
Report Trainee
Deepers / specials/ ICC
Trainee
Report Consultant
Cultural Enablers Lead with humilityRespect every individual
Continuous Process Improvement
Focus on processFocus on process
Embrace scientific thinkingEmbrace scientific thinking
Flow and pull valueFlow and pull value
Assure quality at sourceAssure quality at source
Seek perfectionSeek perfection
Enterprise Alignment
Create constancy of purposeCreate constancy of purpose
Think systematicallyThink systematicallyResults Create value for the customerCreate value for the customer
The Shingo Prize for Operational Excellence
Kegan and Lahey
20 30 30 20Resistant to change
Range of attitudes “Wait and see” “Show me”
Ready for change
“Lets get started!”
Dogs Horses Sheep Goats
‘The Lean Champion is a Farmer’
18th June 2007
Lemmings Hyenas
Innovators
Early adopters
Early Majority
Late Majority
Laggards
Rogers diffusion curve
Theory of constraints ?
