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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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9/18/15 40
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:
• Pam Carter– Director, Systems Laboratories,
Marshfield Labs– Phone: 715-221-6307– Email:
• Leslie Sprick– Owner & CEO, Sprick Group– Phone: 704-596-1861– Email: [email protected]
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!
