Practical Use of Lean in Cytology
Stephen S. Raab, M.D.
Department of Laboratory Medicine
Eastern Health and Memorial University of Newfoundland, St.
John’s, NL and University of Washington, Seattle, WA Norsk Forening for Klinisk Cytologi
February 3, 2012
Overview
Quality
Lean
Cytology
Summary
Quality
Quality is the product and or service that meets the
requirements of a wide number of individuals and or groups
Quality is what the customer wants
Quality is optimal patient care
US Institute of Medicine (IOM) Domains of Quality
Safety – avoiding injuries to patients
Timeliness – reducing waits and delays
Effectiveness – providing care based on scientific knowledge
Patient centeredness – providing care based on patient needs
Efficiency – decreasing waste
Equity – equal access
Lean
Lean is a system that incorporates
quality improvement at a fundamental level
The study of Lean documents the use of rules and principles that describe work components and philosophy
Lean practices often involve specific tools (A3, kanban cards)
Lean
Lean 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 Qual Health Care. 2009;21:341-347.
Lean (2001): Perfecting Healthcare
Each improvement allows the organization to move closer to providing Ideal
Healthcare.
Current State of Healthcare
Problem
Problem
Problem
Ideal Healthcare
Improvement Experiments
Toyota Way (14 Principles)
Philosophy as the Foundation
The Right Process Will Produce the Right Results
Add Value to the Organization by
Developing Your People and Partners
Continuously 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#
Activities
Connections
Pathways
Improvement
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 Work
Genchi Genbutsu (現地現物)
Principle 12, Go and See
Gemba attitude
Going to "the place" where the problem actually happens
Avoid the conference room, conference call, email, and board meeting
See and solve problems at the source
Areas of Improvement
Turn around time
Standardization of processes
Communication
Quality 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 Metrics
Monitor 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 time
ThinPrep tests that arrive on Friday afternoon are processed Monday morning and are not screened until Tues PM or Wed AM
Cytotechnologists off on procedures (fine needle aspiration) delays overall screening
Solutions
Drying oven
Auto cover slipping
Collect more data to better understand delays between receipt of specimen and specimen available for screening
Request 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 Days Monthly Volume of GYN Cases
April 2008-August 2010
Showing 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
Percent Completed
0 200 400 600 800 1000 1200 1400 1600
# of Cases
Percent Cases Completed Volume of Cases
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 achieved
KN- suggested this might continue to decrease with imager
Conclusions
Healthcare organizations use Lean principles and rules to implement change in many different ways
Lean principles and rules involve understanding work processes
Most healthcare organizations only partially (at best) practice a Lean system and consequently Implementation of change has variable levels of success
