Achieving Small Batch Work Flow in AP to Achieve Faster ......Flow in AP to Achieve Faster TAT and Better Quality Results Pathology and Laboratory Medicine ... Service Line of Integrated

12/11/2012

1

Vancouver, March 19, 2012

Achieving Small Batch Work Flow in AP to Achieve Faster

TAT and Better Quality Results

Pathology and Laboratory Medicine

Richard J. Zarbo, MD

Lab Quality Confab VI, Nov. 6, 2012

© Henry Ford Health System

Disclosure

No conflicts of interest

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“We know from the changes that have already been brought about that far greater changes are to come, and that therefore we are not performing a single operation as well as it ought to be performed.”

– Henry Ford

Continuous Improvementin Anatomic Pathology


Medical Center

Medical Center & ER

Community Hospital & ER

Core Lab‐Academic Hospital & ER

HENRY FORD HEALTH SYSTEMPathology & Laboratory MedicineService Line of Integrated Labs

Core Lab Operations

80,000 surgical cases85,000 cytology cases12.5 million clinical tests50 courier runs/day4 acute care hospitals32 medical centers9 emergency rooms

Hub & Spoke Delivery Model

Pathology and Laboratory Medicine© Henry Ford Health System

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The Vision & Means & Goals

•All specimens from any Operating Room within

the Henry Ford Health System are transported,

grossed and processed within the day of surgery

at Core AP Lab

•Continuous flow processing for Biopsies & Large

Specimens using Lean processes with short

cycle times

•80% of all Biopsy reports within 2 days & all

Large specimens reports in 3 daysPathology and Laboratory Medicine

© Henry Ford Health SystemPathology and Laboratory Medicine© Henry Ford Health System

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Production that is Defect Free (goal is zero, meets customer expectation)

On demand (supplied when you want it, in right version)

Immediate (now, no waiting)

One at a time (single piece flow, batch size of 1)

Continuous flow (no batches, queues)

Minimal waste (materials, labor, energy, other resources)

Safely for every employeePhysical, emotional, professional

Strive for the IDEAL ConditionDelivery of products & services should pursue the Ideal


“It is not easy to get away from tradition. That is why all our new operations are directed by men who have had no

previous knowledge of the subject and therefore have not had a chance to get on really familiar terms with the impossible.”

– Henry Ford

Tradition vs Impossible


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CommHosp 1

CommHosp 2

CommHosp 3

TertiaryHosp

Courier

Courier

Courier

Walk

AccessionCore

Gross 2

Gross 3

Gross 4

Gross 5

Gross 1

Gross 6

HistologyCore

CommPath 1

CommPath 2

CommPath 3

Core Path

Outreach Courier

Courier

Courier

Courier

Walk

Walk

LIS

RegionalClinics

30Courier

EMR

Anatomic Pathology VSMCORE LAB


The Challenge

Key Problems– Core AP Lab operations

• Specimen accession, gross exam, histology, IHC, molecular studies

• Serving 4 hospitals up to 30 miles away• Specimen delivery efficiency• Production efficiency• Timeliness of slide production & return delivery

– Large specimen resections triaged to Tumor Board presentations at 4 hospitals


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Lean Operational Efficiency


• Continuous flow goal– Centralized production for Accession, Gross, Histology, all Stains and

Slide disbursement

• Operational challengesLoad leveling– Original condition- 1 histology shift– Challenge- Match courier with specimen availability and workers with

volumes of work around the clock

Batch size reduction– Original condition- overnight large specimen batch processors,

same-day rapid cycle processing of small biopsies only since 2004– Challenge- rapid cycle processing of large specimens & biopsies

Work simplification and mistake-proofing– Original condition- Barcoded operation with transcription-less &

paper-less gross, histology and signout– Challenge- same-day metrics of successful production and defect

resolution between hospitals

“Every well thought-out process is simple. We can at least save the waste of human labour

in handling and transportation.”– Henry Ford

Lean PrincipleStart with Work Simplification


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GrossAccessionLabel

cassettes Cut

Sign paper report

Return paper edits

Transcription

Pencil label slides

Stain + coverslip

Batch Tissue

Match paper labels

AssembleDistribute

MicroDictate

Return report + lab tags

GrossLabel

cassettes Cut

Edit + signE- report

Embed

Computerized Database

Pre label slides

Stain + coverslip

Tissueq 15 min.

AssembleDistribute

E-synopticreport

Accession

Embed

Match lab tag+ paper gross

GrossDictate

Process eliminated

Process modified

2004-5

2006-7

Transition to Paperless Barcoded Workflow in AP

16 => 11 steps, 31% reduction

Requisition

Requisition


Key Changes 2004-2008

Work simplification & standardization reinforced by LIS design and barcode technology

Elimination of dictation 100% cases (-3 FTE transcription)

Gross & Diagnostic templates tied to LIS part types

Bar code specified work processes- accession to signout (2006)

Barcode design integrated with LIS (partner General Data)

Elimination internal mis-IDs (- 1.3 FTE rework)

Adopt chemical resistant slide labels (StainerShield DT)

Eliminate pencil writing glass slides (-0.37 FTE histotech)

Eliminate slide label matching post stain (-1.0 FTE histotech)


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GrossAccession

Pencil write tissue type

& cut directions on side cassette

Cut each cassette to protocol log sheetor penned cassette

directions

Edit paper report

Deliver cassettes in batches

to Processor

Match & stick paper labels

to pencil labeled slides

Verify w/ gross & lab tags, assemble on trays & distribute

to pathologists

Verify & dictate Pat. Info from lab tag & gross

Return report & lab tags

to transcription

Histology

Reassemble slide cases by matching lab tag & dictated

paper gross

Dictate gross description

Load Processors at end shift

Deliver tapes & lab tags

to Transcription

Embedlarge batches

Dictate clinical information

Match master list& assemble cases

Pencil write all slides w/ SP#& part & level

Retype SP# & part into standalone

label printer

Stain & coverslip

Pathology

Dictate DX & microscopic

Deliver tape to transcription

Return edits to transcription

Sign paper report

Dictate billing codes

Transcription

Transcribe corrections

Transcribe microscopic

dictation

Transcribe gross dictation

Accession

Pencil write SP # on container & lab tag

Place manyLab Tags & containers

in baggies in bucket for Gross pick up

Retype SP# & part into standalonecassette printer

Obtain SP # from LIS Delivergross dictation

to Histology

Delivermicro dictation

to Pathology

Enter Snomed codes

Finalize signed reports

Verify patient ID, info

5 6 7

9

= number of steps

8

35

Process Map 2004-5


GrossAccession

Open Case in LIS by lab tag barcode

Cut each cassette to slide label

directions

Deliver cassettes in q 15 min. to Processor

Verify in LIS, assemble labeled

slides on trays & distribute

to pathologists

Open case in LIS by slide barcode

Histology

Embedsmall batches

Enter gross-2 numbers-

into LIS templateStain & coverslip

Pathology

Use LIS synoptic or Quiktext or type DX

ElectronicSign-out

TranscriptionAccession

Assign part type to ea. container tied

to cut protocol & bill code

Place barcodedlab tag, containers,

cassettes in work tray

Obtain SP # from LIS

Enter all clinical information

Print & afixbarcode lab tag label

Print & afixbarcode container label

Collate barcode etched cassettes w/ container

Verify patient ID, info

Verify cassette ID

Image barcoded lab tag into LIS

Print Stainershield labels for ea.

cassette by barcode

View imaged Requisition &

verify ID & info

94 0

6 4

= number of steps24

29% reduction overall steps

33%

50%

100%

33%

80%

Process Map 2009

Match master list& assemble cases

31% reduction overall


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Simplified Activities


All work is highly specified and front-loaded


Key Changes 2004-2008 Laboratory structural redesign, work cell design & standardization

•Linear flow•U-shapedindividualworkcells


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Key Changes 2004-2008 Organized workflow, visual standard work, priority specimen streams


Work Simplification Redesign


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CommHosp 1

CommHosp 2

CommHosp 3

TertiaryHosp

Courier

Courier

Courier

Walk

AccessionCore

Gross 2

Gross 3

Gross 4

Gross 5

Gross 1

Gross 6

HistologyCore

CommPath 1

CommPath 2

CommPath 3

Core Path

Outreach Courier

Courier

Courier

Courier

Walk

Walk

LIS

RegionalClinics

30Courier

EMR

AP Bottlenecks & Challenges



Accession Core


• Resolving the bottlenecks– 2 shifts (16 hours) (7AM-11PM)

– Standard work, QC checked, barcode production

– Small batches, continuously pulled

– Dictation-less

– Front-loaded entry all clinical data, billing codes

– Specimen tracking & delivery metrics

– Case batch creation for internal tracking

– Daily maintenance kaizen

• Lean aligned technology

•Laser etched cassette 2D barcodes•Scanned, LIS attached requisitions

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Gross Core


• Resolving the bottlenecks– 2 shifts (17.5 hours) (6AM-11:30PM)

– Standard work, barcode driven, LIS integrated

– Small batches, continuously pulled

– Dictation-less


• Lean aligned technology, case embedded•LIS gross templates, quick text, synoptics•Digital gross images•Digital specimen radiography

“Our own attitude is that we are charged with discovering the best way of doing everything, and that we must regard every

process employed in manufacturing as experimental.“– Henry Ford

Accession & GrossCore Redesign


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Current Gross Lab Process MapJan 2006

PC PC

PCPC

CassettePrinter

Scanner

Table

1

2 3

4

Microscope

Buckets

Problem Specimens

PCPC

PCCassettePrinter

To Histology

Sto

rage

Storage

Transcription

1 4

2 3

Storage

Cutting Station 2

Computers

Specimen Buckets

Cassette Printers

Cutting Station 4

Delays

Cutting Station 3

Cutting Station 1To Gross Lab

To Gross Lab

Tags

Cutting Stations

Tag Entry

Accession

SMART

Gross Lab Process Map- January 2006

INITIAL STATE

Bottlenecks

Baseline

Transcription

Volume 45,000




PC PC

PCPC

CassettePrinter

Scanner

Table

1

2 3

4

Microscope

Buckets

Problem Specimens

PCPC

PCCassettePrinter

To Histology

Sto

rage

Storage

Transcription

1 4

2 3

Storage

Cutting Station 2

Computers

Specimen BucketsCassette Printers

Cutting Station 4

Delays

Cutting Station 3


To Gross Lab

Tags

Cutting Stations

Tag Entry

Accession

SMART

Gross Lab Process Map- March 2006

Countermeasure STATE #1

2 months

Transcription

Volume 45,000


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PC PC

PCPC

CassettePrinter

Scanner

Table

1

2 3

4

Microscope

Buckets

Problem Specimens

PCPC

PCCassettePrinter

To Histology

Sto

rage

Storage

Transcription

1 4

2 3

StorageCutting Station 2

Computers


Cutting Station 4

Delays

Cutting Station 3


To Gross Lab

Tags

Cutting Stations

Tag Entry

Accession

SMART

Gross Lab Process Map- January 2007

Scanner

Accession #1

Scanner CassettePrinter

CassettePrinter

Accession #2

Specimen Rehab

Specimen Tracking

Cutting StationsSort Station

Color CodedBuckets

Histology

Storage

1 year

Transcription

Volume 45,000





PC PC

PCPC

CassettePrinter

Scanner

Table

1

2 3

4

Microscope

Buckets

Problem Specimens

PCPC

PCCassettePrinter

To Histology

Sto

rage

Storage

Transcription

1 4

2 3


Computers


Cutting Station 4

Delays

Cutting Station 3


To Gross Lab

Tags

Cutting Stations

Tag Entry

Accession

SMART

Gross Lab Process Map- June 2011

Scanner ScannerCassettePrinter

Specimen Rehab

Specimen Tracking


Color CodedBuckets

Histology

6 years

Quality SystemsDivision

Accession #2

3

2

1

5

4

Storage

Accession #1

Volume 65,000




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PC PC

PCPC

CassettePrinter

Scanner

Table

1

2 3

4

Microscope

Buckets

Problem Specimens

PCPC

PCCassettePrinter

To Histology

Sto

rage

Storage

Transcription

1 4

2 3


Computers


Cutting Station 4

Delays

Cutting Station 3


To Gross Lab

Tags

Cutting Stations

Tag Entry

Accession

SMART

Gross Lab Process Map- October 2012

Scanner ScannerCassettePrinter

Specimen Rehab

Specimen Tracking


Color CodedBuckets

Histology

7 years

Quality SystemsDivision

Accession #1

Accession #2

Accession #3

Accession #4

3

2

1

6

5

4

Storage

Volume 80,000




CommHosp 1

CommHosp 2

CommHosp 3

TertiaryHosp

Courier

Courier

Courier

Walk

AccessionCore

Gross 2

Gross 3

Gross 4

Gross 5

Gross 1

Gross 6

HistologyCore

CommPath 1

CommPath 2

CommPath 3

Core Path

Outreach Courier

Courier

Courier

Courier

Walk

Walk

LIS

RegionalClinics

30Courier

EMR

AP Bottlenecks & Challenges


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Histology Core

• Resolving the bottlenecks– 2.5 shifts (20 hours) (5AM-1AM)

– Standard work, barcode driven, LIS integrated

– Small batches, pull


• Lean aligned technology


•Rapid cycle times•Adapted to small batches•Continuous Flow Production•Closer to ideal flow one at a time


In Search of a Batch


“All this waste adds up quickly. Here’s where

your bonus went!”

Whiteboard in Histology

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7 AM AP Core Lab- Accession & Gross


To be accessionedsame day arrival

Accessionedprevious evening

Gross from previous evening


7 AM AP Core Lab- HistologyTo be embedded Cutting, 3 of 15 stations

Blocks to be cut Slides to be stained Pathology and Laboratory Medicine

12

3

Cases delivered


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4 PM AP Core Lab- Level Load, Pull

3 of 6 stations working


courier “pull” sort

Case triage station Outbound hospital slides

accession


Continuous Flow Promoted by Technology

Accession Gross ExamEmbed

CutStain

Deliver Slides

Report Signout

Gross Exam

Gross Exam

Rapid Cycle, MicrowaveProcessors

Courier Deliveries


Small Batches, Rapid Cycle Times Promote Flow


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MoTown Motion- Continuous Flow

Woodward Avenue

Bergamo Boulevard



Processor

Finish

Time

Convntnal

Overnight

Medium

Convntnal Overnight

Large 1

Convntnal Overnight Large 2

Convntnal Overnight

Breast

Convntnal Overnight

Prostate

Convntnal Midday

Medium

Microwave

Biopsy

4am

5

6

7

8

9

10

11

12pm

1

2

3

4

5

6

7

8

9

10

11

12am

1

2

3

Cycle

Time

1.5 hrs

Cycle Time

10-12 hrs

ConventionalOvernight processing

Large & Medium & Derm

MicrowaveSame Day processing

Biopsies from previous day

and early same day Biopsies

in mornings except Prostate and Breast

Histology Processing

Flow


Cycle

Time

4 hrs

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Processor

Finish

Time

Convntnal

Overnight

Cell Block

Convntnal Overnight

Large 1

Convntnal Overnight

Breast

Convntnal Overnight

Large 2

Convntnal Midday

Large

Microwave

Large 1

Microwave

Large 2

Microwave

MacroblockProstate 1

Microwave

MacroblockProstate 2

Microwave

Biopsy 1 Biopsy 2

4am

5

6

7

8

9

10

11

12pm

1

2

3

4

5

6

7

8

9

10

11

12am

1

2

3

Histology Processing Flow

Cycle Time

10 hrs

Cycle Time

5 hrsCycle Time

7 hrs

Cycle

Time

1.5 hrs


“Time waste differs from material waste in that there can be no salvage. The easiest of all wastes, and the hardest

to correct, is the waste of time, because wasted time does not litter the floor like wasted material.”

– Henry Ford

Lean PrincipleTime Waste


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When Does the Clock Start?

Shift 1 Shift 2 Shift 3

Same day processSame day &

Overnite processSame day &

Overnite process

gross

accession

8AM 4PM 12PM 8AM

1.5 Work Shifts

accession

gross

histologyOvernite process

histology histology histology

2-3 Work Shifts4PM-8AM = 16 hr grace period in accession & gross

8 hr accession

clockbottleneck

Perception of better TAT from time of

Accession but not time

of collection

histology

16 hr accession

clock



TAT Outcomes


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Work Flow, Pull & Smoothing OpportunitiesStructure and management

Horizontal management across work stations, divisionsDefined workcells, team leaders, teams along path of work, partnerships

Workplace physical redesignU or linear workstations to reduce motionInventory relocated to workstations

Work redesign for continuous flow and pullSensitization to time waste and in-process defectsReduction cycle timesFront loading work in the path of workflowElimination of loops, forksReduction of stepsMaintenance of sequence of partsLoad leveling across shifts and hoursBatch size reductionVisual workplace to surface defects daily for correction by teamsStandardized activities, connections, pathways

Kanban system Production kanbans to promote pull production & communicationInventory kanbans for JIT, recovery of stock room space

Metrics to monitor and target variationDaily metrics to monitor performance variationWhiteboards to identify in-process defects and outliersFeedback loops to inform defect repair in real-time by empowered teams



Now that we have a functional System of Work

• What’s next?

Defect Free On demand Immediate One at a time Continuous flowMinimal waste

Safely for every employee


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What does KielbasaEmployee safety and pre-analytic specimen

quality have in common?colectomy



Formalin


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Vacuum Seal

Nephrectomy for cancer



Formalin Avoided


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Vacuum Sealed, RefrigeratedBioSpecimen Transport System*

TissueSAFE Trials 2012

• 1, 2 & 3 days tissue storage, under vacuum at 4°C, compared to paired formalin fixed tissues

• Specimen transport 25 miles from Community hospital to Core Lab, 1-2 days before fixation

• Specimen transport from ORs of Main hospital to Core Lab, 1-10 hrs before fixation

*TissueSAFE, Milestone Medical, Kalamazoo, MI

Vacuum sealed tissues held at 4°C are preserved for histologic assessment when held in that state up to 48 hours

Promising new technology to eliminate formalin from ORs and dramatically reduce Lab use of formalin and disposal costs


A centralized lab can be just as efficient as a small ‘boutique’ lab but provide higher levels of specialization & quality with lower $$

Involve those that do the work in its redesign

Educate your workforce so that they:

1. Know the goals and reasons for change2. Know what good work redesign looks like

3. Are accountable for quality on a daily basis

Select appropriate technology to meet the goal

“Your methods are formed by what you are trying to do; they do not determine your purpose. To my mind it is starting wrong

to put methods ahead of purpose.”-Henry Ford

Lessons Learned- Must DOs


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Set the goal from above, but don’t solve the minutiae

Don’t rush it, this is a team that learns together

Don’t fail to delegate

Don’t fail to meet, regularly

Don’t avoid transparency, visible measures and accountability

Don’t forget to recognize contributions

Don’t take the credit

“It is amazing what you can accomplish if you do not care who gets the credit.”

-Harry Truman

Lessons Learned- Must AVOIDs


“I cannot discover that anyone knows enough to say definitely what is and what is not possible.”

“Nothing is particularly hard if you divide it into small jobs.”– Henry Ford

Conclusion


Documents

Achieving Small Batch Work Flow in AP to Achieve Faster ......Flow in AP to Achieve Faster TAT and Better Quality Results Pathology and Laboratory Medicine ... Service Line of Integrated