Applying Lean to Outpatient Lab Services: How We Improved the … · 2017. 4. 2. · Eileen Seidel,...

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Eileen Seidel, Manager, Phlebotomy ServicesPam Carter, Director, Systems LaboratoriesLeslie Sprick, Owner & CEO, Sprick Group

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Applying Lean to Outpatient Lab Services:

How We Improved the Experience for 800 Patients per Day in our Patient Service Center, Plus Other Winning

Quality Outcomes

Lab Quality Confab, November 3, 2015

Session Objectives>Learn how to use readily available, inexpensive tools to improve the patient experience and create flow.>Understand why good facility design leads to increased productivity and higher customer satisfaction scores.>Gain insight on how to manage a Lean operation.>Discover how to get leadership committed to sustaining Lean advances.

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Marshfield Clinic

Largest private multi‐specialty medical practice in Wisconsin> 7000 employees > 780 physicians60 locations (including dental clinics)Non‐profit organization, physician led, professionally managed

Established 1916 by six local physicians, will have our 100 year anniversary in 2016!

Services and Service Area

• Northern ½ of WI and Upper MI

• Focused on Outpatient services with ASC in 4 locations

• Designing new model of ASC/Comfort and Recovery Suites…opening November,2015

Marshfield Labs Statistics • Routine Services for Marshfield Clinic, local

campus• Regional Lab Services referral work, human and

vet for outlying clinics• Reference Services for a variety of clients (human

and vet)• 3.8 million tests with gross revenues > $280

million• 425 FTEs including courier, support staff• 18 FTEs physician, 10 FTEs vet pathology• Couriers travel >10,000 mi per day

Intro of Phlebotomy Project

• Situation• How to ‘make the best of it’…

– Throughput– Streamlining of draw process– Efficient layout…we were going to be located on main floor, near main entrance and corridors..

• Highly Visible!

History of our Outpatient Phlebotomy

Lab F

Lab E

Lab D

Lab B

Lab A

Central Lab

Lab F

Problems with Current Setup

• Staffing requirements are higher and vary by station – Limits resource sharing– Extends training period

• Patients directed to numerous locations throughout the clinic

• Scheduling is complicated and time consuming• Space needs higher• Handicap accessibility is poor • “Special draws” can show up anywhere

So how did we do it?

Initial floor planning from within labEngaged PI to validate and test our plan…the workflows and facility layoutLooked for ideas outside of our industryUse of current tools applied differentlyFine tuned…Supply management Standardized workflows

Tracking Our Traffic: 75% of patients come in before Noon

Mfld Labs - 70th percentile data ( Cumulative Arrivals by hour)( 5/1/06 ~ 6/30/06 : All Phlebotomy Stations )

139.

8 258.

9

366 44

8.1 52

0.1

588.

1

645.

1

696.

1

737.

5

763.

5

773.

9

778.

6

782.

6

784.

6

785.

6

82%

94%

47%

33%

18%

89% 99%97%99% 100%

75%

66%

57%

0

100

200

300

400

500

600

700

800

900

1000

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Time

Num

ber o

f Pat

ient

s

15%

25%

35%

45%

55%

65%

75%

85%

95%

% o

f Tot

al

Number of Patients % of cumulative total

Marshfield Phlebotomy – Centralized Phlebotomy – Resource Routes

Time in Waiting Room ( Centralized Collection Point- 3 minute ) - Simulation Run with maximum 50 patients waiting

( 1 patient: 1 visitor )

0

20

40

60

80

100

120

0 31 55 80 105

128

155

181

206

236

311

374

471

Time ( 0= 7:00 am )

Num

ber i

n W

aitin

g Ro

om

Patients Total Persons

7:45 to 10 am

How we sized our waiting room

Establish GOALS Balance Supply & Demand Every Hour

1. Minimize wait times to 15 minutes at any waiting room

2. Limit waiting room size to 30 persons (incl. visitors) at peak time

3. Staff utilization and level loading4. Consistency in service5. Supply management and standardization

Further Challenges in Centralized Draw Station

• Locating patients in waiting room• Finding which station is available• High traffic intensity at doors & in waiting room

• Room call request frequency will increase

New Central Lab Station Design

Pharmacy

Reception

Waiting Room

Peds Waiting Room

Reception

Front Lobby – Single Check-in

Pager System (Look familiar?)

Visual Management Tool for Patient Management

Start

End

Simple Patient Pattern

Phlebotomy Workflow

Waiting Room

Restroom

Draw BoothExit

Drawing Booths

Phlebotomy Handhelds

• Clinic and Hospital settings

• Positive identification– Clinic– Hospital

• Communication– Technical sections– Provider– Phlebotomist

Pediatric Suite

Private rooms for line draws  

Staff Work Galley

Bathrooms• Standardization• Workplace drug collections

Stock Room

Wait Times Exceed Expectations

Outcomes GaloreMeasure Before After % Improve

# of draw sites 5 2 60% decrease# of collections 700 855 22% increase# of Phlebotomist

13 Full Time11 Part TimeTotal: 24 

9 Full Time12 Part TimeTotal: 21

40% increase in productivity

Wait time (minutes)

20 – 60 2 ‐ 10 80% decrease

Total square footage (Sq Ft)

3150 2200 30% less space

Errors per Week

4 – 5 0 Sustained over 7 years

‘Glimpses’ of 2015 Initiatives

• System care delivery model changing– Cost effective, innovative solutions– Standardizedmodels, rapid deployment

• Partnerships key to being successful– Enhance vendor relationships– Sought credible external expertise for ‘momentum’…

– Engaged physician leadership early on … ‘physician led organization….professionally managed’

Distributed Blood Delivery

• Goal of Service:a) Provide RBC units on site at ASC b) Provide O Neg, emergency‐released RBC 

units on site 

• Partnered with our Tx vendor to apply solution in a non‐traditional setting

• Engaged Txpathologist….external….credibility and ideas!!

Refrigerator with blood located near patient care area

Patient seen for PreOp

Eval

Marshfield Center

Clinic + Ambulatory Surgery Center

Decision made to have blood on hold for surgery; T&S sent  (up to 30 days prior to surgery date)

Testing done several days prior to OR date, blood sent to ASC

Blood units sent via Courier

Blood arrives at Clinic/Lab

Blood placed in limited access 

refrigerator

Proposed Workflow to have RBC units at ASC

Refrigerator at ASCRemote Monitoring at Marshfield Center

Transfusion Service Staff at Marshfield Labs –How to Manage Inventory

Regional Lab Staff support local ASC

Notification of RBC shipment and/or need for returning units

Focused External Expertise

• Pace of change – Incrementally challenged– Needed to be fast and focused to ensure viability and sustainability

• Embarked on Lean engagement ‐ Esoteric focus…‘work around the edges’‐ High cost, high skill areas

• Found our ‘aha’ moment for sustainabilityLean management 

The Missing Link in Lean: The Management System

• Most Lean organizations are missing a critical ingredient: a Lean management system to sustain it

• Lean organizations are mostly focused on finding waste and eliminating them using Lean “tools”

• However, to sustain Lean practices, we need a Lean management system

• Lean cultures grow from robust Lean management systems

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Four Key Elements of the Lean Management System

4.LeadershipDiscipline

“You have to manage a system. The system doesn’t manage itself.”~ W. Edwards Deming

Lean Elements Need to Work Together

Engine:Leader Standard Work

Gas Pedal & Steering Wheel: Daily Accountability ProcessDaily Accountability Process

Transmission:Visual Controls

Fuel:Discipline

It is important to improve the stability of a process first before implementing the Lean management elements

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Lean Culture is a Result of its Management System

Work Systems& Processes

Behavior

Attitude

Culture

The way we act

The way we think

Waste elimination

Contact information:• Eileen Seidel

– Manager, Phlebotomy Services, Marshfield Labs

– Phone: 715-221-6696– Email:

seidel.eileen@marshfieldclinic.org

• Pam Carter– Director, Systems Laboratories,

Marshfield Labs– Phone: 715-221-6307– Email:

carter.pam@marshfieldclinic.org

• Leslie Sprick– Owner & CEO, Sprick Group– Phone: 704-596-1861– Email: leslie.sprick@sprickgroup.com

Acknowledgements

• We would like to thank other members of our team who were involved along the way:• Bob Kult, Operations Manager• Alex Nelson, Senior Programming Analyst• Christopher Devadas, Process Engineer• Dr. Kathy Puca, Transfusion Services• Jan Weyhmiller, Transfusion Manager• Clint Borek, Transfusion Compliance Specialist/Assistant 

Manager• Marshfield Clinic Phlebotomy Department• Marshfield Clinic Building Services• Marshfield Labs Transfusion Services 

Thank You!