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LEAN deploys at Centrex Clinical Labs.

Do more with less. Many laboratories across the country--under pressure to produce high-quality patient results in the face of difficult challenges--have adopted this mantra. In New York State, Centrex Clinical Laboratories (Centrex) confronted similar challenges. Reimbursements are declining. The pool of technical staff is dwindling due to recent state licensure of technologists and technicians. Area physicians constantly demand improvement of turnaround time (TAT). The lab's in-house test menu grows longer, but there is no space to expand. Demand for the lab's services is overwhelming at certain periods throughout the day; and, at other times, some lab staff members are idle. While Centrex strives for standardization across five laboratory locations and 19 patient-service centers, there is always some variation in process. Pressure to turn a profit has never been greater. Centrex lab professionals' "burning platform" to change blazed hotter and hotter, but which way were they to turn?

Centrex' Chief Executive Officer (CEO) John Finn had called in consultants periodically over the last several years to look at lab processes and to assess what needed to be done to improve the lab's operations. Consultants came in for a week, presented their proposals, and left the lab staff to its own devices. Each time, many hours were spent gathering and analyzing lab data, however, bits and pieces of what was offered--never the whole package--were adopted by the lab.

During this same timeframe, Centrex representatives attended several LEAN/Six Sigma conferences around the country to learn about other healthcare organizations that had implemented this process-improvement strategy. LEAN thinking is all about 1) removing waste and variation that does not contribute to the customer's definition of value, 2) standardizing work processes, and 3) keeping work flowing though the system. Although initially associated with automotive manufacturing, LEAN thinking has since been adapted to fields ranging from government, defense, banking, retailing, and healthcare.

At each conference, amazing stories presented by healthcare professionals gave examples of the improvements they had achieved, using LEAN and Six Sigma principles. Dramatically improving turnaround time, weathering the technical-staff-shortage storm, avoiding overall FTE-replacement, and, of course, reaping financial rewards were a few of the benefits. One constant theme came through from each organization with which the company reps talked regarding LEAN: If a lab does not have 100% support of its CEO, its board of directors, and all of senior management, its plan to use LEAN is doomed to fail. At Centrex, the lab discovered that it definitely had upper level support.

Starting the LEAN process

In 2006, CEO Finn visited a hospital laboratory in South Dakota that was two years into its LEAN journey. Impressed with the results at this site, he commissioned the implementation organization used there to start Centrex on its own journey. In January 2007, he met with all core lab staff to discuss future plans and encouraged everybody to keep an open mind. He cautioned that "going LEAN" would not be easy, acknowledging that change is difficult for most people. He also emphasized that no layoffs would occur as a result of implementing new principles. A project kick-off date was set for February 2007, and with the implementation specialist on his way, a "LEAN team" had to be chosen.

Team members would be relieved from their current positions to serve. Being a LEAN team member also would be a full-time job; there would be no part-time members. Members were selected from professionals with successful track records in their current positions. Heading up the team was the director of regulatory affairs; members were the technologist in charge of molecular diagnostics, the supervisor of the courier staff, and a Human Resource Department trainer. Their aggressive timeline allowed 13 weeks for the first Centrex project--with a wide scope and based at the core laboratory--was to include inpatient phlebotomy central processing, and the chemistry/hematology departments. After an intense week of LEAN training and exercises from the LEAN implementation organization, the hospital's team was ready to begin.

To study a process from start to finish and find where it contained waste, the team had to become skilled at videography. Each step of the particular process was documented; the time the process took was recorded, as was how far the staff walked to complete the process. Each step was classified either as "value added" (e.g., something that changes the fit, form, or function of the product), or as other non-value-added (e.g., pure waste or material handling). After the videotaping, the team studied the films and broke down the process by removing all the nonvalue-added steps from the process. The remainder of the process was then referred to as the lab's standard work package. At this point, the team could then determine how many lab staff members were required to complete a known demand of work in a known time frame.

Eliminating wastes associated with batching through the implementation of single-piece flow was one goal. Unlike batching--where work is processed in groups--work in single-piece-flow systems is handled one piece at a time. Rather than having to wait while all the other work elements in a batch are processed, a work element in single-piece flow is immediately sent on to the next step once it is completed.

Prior to LEAN, phlebotomists were given batches of orders to draw at a time. The phlebotomists would then draw all the orders before returning to the lab, where those orders would all be received into the laboratory information system (LIS). Once entered into the LIS, they would be sorted by type and delivered to the appropriate functional area of the lab. Once there, specimens would often wait in another batch until the technologist was able to run them.

Testing LEAN waters

As they analyzed this process, LEAN team members noticed that hospital orders and specimens spent upwards of 99% of the time waiting. "By batching, the first order was paying a significant time penalty by waiting while all the other specimens were drawn," says LEAN team member Todd Failing. Additional penalties were incurred while the orders where entered in the LIS and, again, while in the testing area. Multiple opportunities existed for errors to occur. Because work was handled in bulk, accidental mix-ups were easy. Additional re-work time was required once the specimens were received into the lab.

To solve this problem, the team redesigned the collection- and pre-analytical-work processes. Instead of batching orders, order labels are now sent to phlebotomists via the hospital's pneumatic-tube network. A phlebotomist then draws a single patient and tubes that individual collection down to the lab where the order is entered and tested in single-piece-flow fashion.

The team found this process worked well on floors where the hospital has tubes. The team realized, however, that this method was not practical to perform on floors without a tube station. Therefore, it established standard work-in-process quantities and run-rules that helped the phlebotomy team keep the batch sizes to a minimum. The goal was to complete 30% of morning-round work by 6:00 a.m., 60% by 7:00 a.m., and 100% by 8:00 a.m. The 6:00 a.m. goal was met in April 2007, the first month of the new process. During the pilot, the team and staff knew they were on the right track when a hospital physician "complained" that he was getting results called too early in the morning. The LEAN team is monitoring improvements currently being made to the hospital that will allow them to overcome this constraint and bring them closer to achieving single-piece flow on all floors.

Pre-LEAN, the phlebotomists congregated and waited for orders in the lab's central area after morning rounds, spending considerable idle time between blood draws. While inpatients waited in their hospital beds, the phlebotomists waited in an adjoining building to be called to duty. Each time a phlebotomist was dispatched, he would wheel his cart to a patient's room; this involved much walking and elevator time. If a floor did not have its orders organized, phlebotomists would often get back to the lab after a draw only to be called right back to the same unit.

Thus, the hospital was divided into two zones, in addition to the emergency department (ED), with each zone including several nursing units. One phlebotomist was then stationed at each zone and at the ED instead of the lab. With the new pre-analytical work process, the phlebotomist draws the patient and tubes the sample down, significantly cutting the time from order to draw, and from draw to its receipt in the laboratory, freeing up 2.5 phlebotomy FTEs.

Pre-LEAN phlebotomy, batching; post-LEAN processing "pipe"

On the outpatient side, the team made the conclusions that batching was causing unnecessary delay and providing multiple opportunities for errors. After arriving from patient service centers and client offices via courier, specimens would be sorted and racked by type (room temperature, frozen, refrigerated), and then placed in temporary storage. Individual central processing staff would walk to this location, take a rack or two filled with specimens, and return to their workstations where the racks would be entered into the LIS. Once all the specimens had been entered, they would be sorted by functional area and taken to the lab.

The LEAN team solved the batching problem by creating two LEAN cells or "pipes," each configured so that orders would flow down the line in single-piece fashion. Work passed down the pipe was broken down in the order as it was received, entered into the LIS, and spun down (as required). A lab aide then walked the specimen directly from processing to the lab cell where they place it on the analyzer for analysis.

Initially, the LEAN team spent time understanding the flow of various types of work, since not all specimens require the same amount of work. About 60% of orders received from clients on paper requisitions needed complete order entry into the LIS. The other 40% of the work was already entered at one of the patient service centers and, therefore, only needed to be received. Additionally, the team observed that the volume of each type of work varied throughout the day. By working to smooth out the variations in demand and by designing "baton zones" to help smooth out the flow, the staff is able to process multiple types of work down the same line. In addition, the LEAN team and area managers developed a staffing model to help determine how many staff members were needed at each hour of the day. Depending on the hour of the day, each pipe may be staffed with up to four members. When asked what she thought of the "after" condition of the process, Char Benhoff, a senior processor states, "Getting used to the single-piece flow was a challenge at first; but after working with our new process, none of us would ever want to go back to the old way of handling specimens."

Jack S. Zito BS MT(ASCP) BB, is the director of regulatory affairs/LEAN team manager at Centrex Clinical Laboratories Inc. in New Hartford, NY. Contact him at jackz@centrexlabs.com. David A. Stewart, MSIE, is an implementation specialist with OpEx Inc. of Medford, OR.

By Jack S. Zito, MT(ASCP) BB, and David A. Stewart, MSIE
COPYRIGHT 2008 Nelson Publishing
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Title Annotation:CLINICAL ISSUES
Author:Zito, Jack S.
Publication:Medical Laboratory Observer
Geographic Code:1U2NY
Date:Mar 1, 2008
Words:1873
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