Continuous Flow and Anatomic Pathology –

Theory vs Reality

Kenneth Batts, M.D.Hospital Pathology Associates

Allina LaboratoriesMinneapolis, MN

Notice of Faculty Disclosure

In accordance with ACCME guidelines, any individual in a position to influence and/or control the content of this ASCP CME activity has disclosed all relevant financial relationships within the past 12 months with commercial interests that provide products and/or services related to the content of this CME activity.

The individual below has responded that he/she has no relevant financial relationship(s) with commercial interest(s) to disclose:

[Kenneth Batts]

1

My Experience/Backdrop

• 9 years on staff Mayo Rochester– Exposure to Lean– Staffed the frozen section lab

• 14 years Hospital Pathology Associates– 36 pathologist private practice group– Cover large hospital system (Allina)

• Multiple hospitals and numerous clinics• We designed histology, cytology, pathology areas

– 2 year’s experience with it

– Cover busy physician’s office laboratories• We designed a GI office histopathology lab

– 7 year’s experience with it

“Lean” fixes things by eliminating waste. What are you interested in fixing?

Worker productivity?

Turnaround time?

Wor

ker

Productivity –use worker’sperspective

TAT – use specimen’sperspective

Spec

imen

s

2

Theory: Continuous Flow Reflects a Specimen-focused LEAN Approach

LEAN

ContinuousFlow

We will discuss

this.

What is “Continuous Flow”?

• Continuous-flow manufacturing (CFM) is a manufacturing strategy that produces a part via a just-in-time and kanban production approach

• . . calls for an ongoing examination and improvement efforts which ultimately requires integration of all elements of the production system.

• The goal is an optimally balanced production line with little waste, the lowest possible cost, on-time and defect-free production.

‐Wikipedia

3

A Pretty Good Continuous Flow System

Value Added Step

A necessary manipulation of the product that improves it

The buyer is willing to pay for it

There still may be some waste within

Examples: Grossing

Fixing

Interpretation

Transcription

Something that does notadd value

The buyer is not willing to pay for it (it is yourproblem, not theirs)

Entirely waste

Examples: Queues (“Muda”)

Awaiting something

Deeper levels

Reprocessing

Non-Value AddedVA Wait

4

A Tiny Queue A Big QueueA Modest Queue

A Big QueueA Modest Queue

5

A Pretty Good Continuous Flow System

Single units (no

batch)

No queues due to

proximitiesNo

defects

Each step Each step adds value

(closer to fire)

Focused effort (no

wasted energy)

“Ok, I’m interested in hearingmore but I want

less theory and more practicality.”

6

Case Study: Practical Application of Continuous Flow in our Labs

Attempted to get as close to continuous flow as possible: Eliminate queues whenever possible

Create physical proximities; coordinate schedules

Eliminate unnecessary steps when able

Applied it to a GI office practice and a hospital system practice

Step 1 – Find a champion, and give them resources and

authority.

7

Step 2 – Understand your system(work flow analysis)

Some understanding is critical

Use your judgment to balance depth of data gathering with practicality

consultants will usually want more data

ClinicianSpecimen

Wait

VA

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

Your AP work flowprobably looksa lot like ours.

8

Clinician/Specimen

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

Getting data on actual times

will create your lab’s “fingerprint” and

allow youto prioritize (look for the most “bang for

the buck”).

Step 3 – Attack queues first

total waste

usually largest sources of delay

The empowered champion can do a lot fixes often don’t involve perturbing an individual

worker’s “style” (more easily “sold”)

smart physical layout can make a MAJORimpact; if you have a chance to design anew lab space don’t blow the opportunity

Wait

9

Clinician/Specimen

VA

VA

Transport

Accession GrossFix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

No waiting - The Holy Grail of TATAn unattainable goal but worthy target

Physical Proximities

Proximities - Physician Office Lab

Acc.Grossing

Fix

Emb.

Cut

Stain

Ass..

Path1

Path2

Path3

10

Histology CollationOne flat at a timeDelivery is 4 steps

PathologistOne flat at a time1-3 pathologists

Clinician/Specimen

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

This largely eliminated numerous batches

This largely eliminated numerous batches

This largely eliminated

numerous queues

This largely eliminated numerous batches

This largely eliminated numerous batches

This largely eliminated

numerous queues

11

Coordinate with Grossing

12:30PM-1:30 PM5:30 PM-6:30 PM

Coordinate with Grossing

1:30PM-2:30 PM6:30 PM-8:30 PM

(bigs)

Dual processors; one hour cycle for GI Biopsies

Clinician/Specimen

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

Minimized the queue (1 hour

max) and shortened fix

time

Minimized the queue (1 hour

max) and shortened fix

time

12

Clinician/Specimen

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

Waiting for courierWe limited queue

with mid-day pickups, but still a

major source of delay

Clinician/Specimen

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

Waiting for accessioning

Largely eliminated this with

coordinated staffing/dropoffs

13

Clinician/Specimen

Transport

AccessionGross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

TranscriptionWe eliminated these

with electronic (drop down)

documentation

TranscriptionWe eliminated these

with electronic (drop down)

documentation

TranscriptionWe eliminated

these with electronic (drop

down) documentation

Clinician/Specimen

Transport

Accession Gross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

Await ClinicianEMR > FAX > Mail

Aim for before 5 PM or before their

arrival in AMPrelim notes in

EMR?

14

Clinician/Specimen

Transport

Accession

Gross

Fix

EmbedCutStain

Assemble

Pathologist

Sign

Outcome in GI Lab – AM Samples

Couriers 11:30-12:45Signout 3:30-5:30

- Special stains 8 AMResults to clinician

queue via EMR

Clinicians Pleased- write letters sooner- call pts. sooner- remember the case- tidy up pre-Vacation

One automated stainer with histotechassembler

Three immediately

adjacentpathologists

Our Continuous Flow “Sweet Spot”- 3:30-5

15

Clinician/Specimen

Transport

Accession GrossFix

EmbedCutStainAssemble

Pathologist

Sign

Results in GI Lab – PM Samples

Couriers 4:30-6:00 PMSignout 8:00-11:00 AM

- Special stains in PMResults to clinician

queue via EMR

Clinicians Happy

PATHOLOGY

Cyt. Histo

AIDES

COURIERASS. ASS.ASS. ASS.

Hospital System Lab(Centralized)

16

PATHOLOGY

Cyt. Histo

AIDES

COURIERASS. ASS.ASS. ASS.

Hospital System Lab(Centralized)

-Prioritize-Distribute(minimal queues)

DIMO

L

BR

5A 7A 7AGU

GI

D

HBRBR AV

CY

GY

M RESDI

CP

CP

AIDES

COURIER

ADM

17

Relative Priorities

1 – Hospitalized patients with biopsies, and

masses/possible cancer biopsies

2 – Regular biopsies

3 – Resections for significant diseases

4 – “Back burners” (tonsils, appendices, etc)

System used by histology, path. aides,pathologists, and transcription

Cyt. Histo

DIMO

L

BR

5A 7A 7AGU

GI

D

HBRBR AV

CY

GY

M RESDI

CP

CP

AIDES ADM

Optimized for Key BiopsiesGross ‘til 10 PMOvernight HistologyShortest poss. processor4:30 AM Path Aide5 AM PathologistOn site (4-6 hour) special stainsOn site expert reviews

18

Clinician/Specimen

Transport

Accession Gross

Fix

Embed

Cut

Stain

Assemble

PathologistTranscription

Sign

What about eliminating waste

at these steps?

Step 4 – Attacking The “Value Added” Steps

Usually fairly unimportant from continuous flow perspective (where specimen is the focus) 2 min. vs 4 min. to do task – saves 2 minutes

Can be very important from a productivity and staffing perspective (where person is focus) 2 min. vs 4 min. to do task – doubles productivity

VA

19

Miscellaneous Points

Residents are generally a queue be innovative (good luck)

A defect in the system interrupts continuous flow (“always move forward”) Try to fix the root cause of the defect so it

doesn’t happen again

Wait

X

Summary Don’t let the obligate “batch” steps preclude you

from attacking the rest of the steps

Eliminating/minimizing queues (our red boxes) will have best yield; go for the “biggies” first

“Leaning” the value added steps (green boxes) makes only a small impact on TAT, and more likely to irritate workers, but can have considerable impact on staffing (that would be a different lecture)

Setting up case prioritization system can at least focus TAT on the cases that need it the most

YOU WILL NEVER REACH PERFECTION(AND THAT’S OK)

20