Grand River Hospital and St Mary’s General Hospital

lean healthcare, lean hospital

Grand River Hospital and St Mary’s General Hospital Increases Throughput, Cuts Costs using Lean.

In healthcare today, having to do more with less goes with the territory. Volumes are increasing five to ten percent every year, regulatory and administrative burdens are becoming more restrictive, and wait times are rising. Already stretched providers struggle to keep up, even as healthcare consumes a growing chunk of the provinces’ budgets.

These symptoms had been all too familiar at the pathology department of Grand River Hospital. For years, they faced complaints over long wait times, backlogs of work, and frustrated staff. “All in all it was a pretty chaotic environment, and highly stressful,” says Vince D’Mello, Integrated Laboratory Administrative Director at Grand River and St Mary’s General Hospital. “We never seemed to be getting out of the circle of events.”

“It was very difficult to pinpoint what the real issues were,” says Dr. Dimitrios Divaris, Chief Pathologist at the Kitchener-based hospital. “We were always doing quick fixes, so the problems kept recurring. It just wasn’t sustainable.”

The lab was under-staffed, but D’Mello, who had prior experience with lean, knew that the root of their troubles lay deeper than that. Their department was trapped in a siloed environment where departments – the pathology lab, nursing, technical support, etc. – were self-contained and independent from one another. This caused several critical problems; work cells were blaming each other when something went wrong; departments were competing for resources; and staff efforts were conflicting with one another.

A fundamentally different approach was needed – one that could break down these barriers and get everybody working together with the patients’ interests in mind. D’Mello got approval to introduce lean to the department, and through a competitive process opted to bring in Lean Advisors as consultants.

Getting up to Speed

All lean journeys begin with education. Front-line workers – the primary change agents – need to understand not only how lean will help them make a difference, but also why it is important to do so. Without this source of motivation, their efforts can become little more than lip service.

D’Mello began by getting representatives from all departments in the same room. Working with Lean Advisors’ Vice President of Client Services, Mike Boucher, he created a cross-functional team that would provide the spark for a lean transformation. Among the nine team members was a pathologist, Grand River’s medical director, their department manager, senior technologists, and technologists from the non-pathology lab sections.

Boucher outlined the lean view of the pathology department for the group, showing how the traditional silo approach encourages departments to focus only on their internal needs. Lean, he explained, would break down barriers and create a system where every staff member’s activities were linked to the needs of the patient. “Mike acted as a mediator more than anything,” says Kerry Lackie, transfusion medicine technologist at the lab. “He steered the committee with questions, but he never gave specific answers on what to do. Those came from the people on the committee themselves.”

Next, Boucher introduced the team to value stream mapping (VSM), a lean technique that maps the flow of all information, materials, and activities leading to the desired outcome for the customer or patient. The “journey” of a blood sample through the lab – from receipt by the pathology department to the presentation of lab results to the patient’s physician – is a good example. In the mapping process, team members draw up two representations similar to flowcharts – one of the present, pre-lean state, and the other of the future state, whereby waste has been eliminated wherever possible.

In healthcare, waste includes walking by staff, waiting, paperwork, or any activity or outlay that doesn’t improve the wellness of the patient. Reducing this in every way possible is an ongoing mission for lean organizations.

VSM also teaches staff how the various parts of the organization interact. A secretary, for example, can better understand how patient information is used by technologists/technicians, doctors, and other staff. This transparency makes waste visible to everybody in the organization.

Finding the Cure

The first priority for the Grand River lean team was the pathology department’s growing backlog. In a telling example of staff frustrations, one technologist had said to D’Mello, “Vince it’s like this: I come to work on a Monday morning, and I have a backlog in front of me. I leave at five o’clock on a Friday, and I still have a backlog. Something has got to give.”

In the current state, samples were divided into three groups: biopsies, routine samples, and large cases. The process had three phases:

    • Pre-analytical, where a technologist and/or technical assistant sorted samples and matched them with relevant medical data.
    • Analytical, where samples were prepared for analysis.
    • Post-analytical, where the slides were delivered to the pathologist, who would make the diagnosis, write up the report, and send it to the physician who had ordered the test.

The problem was that there was no integration between the three stages. Technologists would deliver samples to the pathologists based on pre-assignment regardless of how busy the doctors were, and the samples would pile up on their desks for days, or even weeks. The congestion would eventually work its way back down the line, forcing technologists to constantly re-prioritize their work. “There was no visibility whatsoever,” says D’Mello. “Ultimately, it concluded with unhappy clients, and reports not being generated in a timely manner. We weren’t meeting the needs of the patient.”

The lean team responded by creating a future state map that eliminated the barriers between these phases, and outlined a smooth flow of work and information between them. “We adopted a vision that we needed to go forward with,” says D’Mello, “and that’s when the rubber hit the road.”

The lean team’s goal was to increase throughput to 150 samples a day – a 22% increase over the current state level. To achieve this, the accessioning of data was re-assigned to clerical staff, who’s superior typing skills helped eliminate the previous backlog of 20 cases per day. This change also gave technologists more time to better utilize their professional skills.

The pathology department also changed the system of case assignment. Previously, samples were pre-assigned to pathologists based on case type and severity, then hand delivered to the pathologists. This created imbalances – for example, there was a disproportionate share of biopsies chosen – and assignments had to be constantly readjusted to maintain a balanced distribution of case complexity between the available pathologists. Consequently, technologists were frequently wasting their valuable time running back and forth.

The lean team replaced the old system with a construct known as a lean supermarket, so-named after the food store equivalent where selections are presented to the consumer and continually re-stocked according to demand. At Grand River, the “consumers” are the pathologists who visit a central stocking area where samples are drawn out of slots. Each slot represents a day of the week, and is expected to be empty by the end of the day.

An important aspect of the new system was the replacement of the previous “pick and choose” approach with a first-in, first-out model. This ensured a smooth, consistent workflow, a lean goal that ensures maximum efficiency.

With the supermarket in place, samples were no longer being pushed through the system while pathologists scrambled to keep up. Now, the doctors – in response to patient demand – determined the pace of the work flow, and the rest of the system responded to those demands. In lean, this is known as a pull system.

“The biggest benefit of the supermarket was that it didn’t matter if you were a technician, or a pathologist, or a technical assistant,” says D’Mello, “you could see what was outstanding on a daily basis, or weekly basis in the supermarket. Everything became transparent.”

The results speak for themselves. Before implementing the supermarket model, Grand River had a backlog of roughly 14 days. Six weeks after implementing lean, it dropped to two days.

The pathology department’s costs have dropped, too. A $45,000 investment in lean initiatives is expected to save over $117,000 every year, thanks to the elimination of wasteful processes, and a significant reduction in overtime hours.

“It’s phenomenal,” says Lackie. “There’s no longer the underlying sense of drowning. There’s light at the end of the tunnel.” In a post-lean survey of hospital staff, 50% said that bottlenecks and backlogs had been reduced significantly, and 38% said they had been reduced marginally.

Keys to Success

Because lean relies on front-line workers to provide solutions, managing people’s fears and resistances is essential. D’Mello addressed this by emphasizing open dialogue. “We were very transparent with our communications and our strategies,” he says. “Communication is a two-way street.”

When pathologists were initially showing skepticism, Boucher met with them to discuss their concerns. “That was a turning point to get them on board,” says Boucher. “I have to give them credit when they supported the initiative, even though they were nervous about it. They really came through.” Dr. Divaris – who had wanted to implement lean for years – was, as chief pathologist, also instrumental in providing leadership on this front.

The enthusiasm of the lean team gave the project the energy and enthusiasm it needed to succeed. Members described their co-workers as hard working, open to new ideas, and respectful of each other’s opinions. “The sessions were fabulous,” say Lackie. “The first session said ‘check your egos, hats and qualifications at the door,’ and this committee took that to heart.”

Team chemistry like this is essential not only for launching a lean transformation, but also for sustaining it for months and years to come. The true spirit of lean is all about continuously improving, and understanding that a lean journey is never really over.

“I think it starts with effective leadership,” says D’Mello, “and with having an engaging vision that is evidence-based, and patient-focused. If we just embrace those strategies, if we put the interests of the patient first, and then start strategizing around that to engage leadership, and engage workers, we can find a solution.”

The team at Grand River succeeded because they discovered how to work together in a collaborative and respectful manner – rather than only for the good of their department – to better serve the patient. As Dr. Divaris says, “If the pathologists have a problem, the operational side has a problem, and vice versa. We are, after all, like partners in a three legged race. We can run together, we can stumble together, or we can fall together. One thing is for certain; we cannot go our separate ways.”

Microbiology Laboratory at Ottawa Hospital

lean healthcare, lean hospital, lean laboratory

The LEAN Experience of the Microbiology Laboratory of The Ottawa Hospital

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One of the ongoing issues in any laboratory is change. The Microbiology Laboratory of The Ottawa Hospital (TOH) is no exception. Throughout major changes of staffing, policies, procedures, and budgetary constraints, it is difficult to focus on the day-to-day procedural issues of processing specimens in the most efficient manner and addressing staff concerns.

In 2006, the Microbiology Laboratories for the three campuses at TOH were amalgamated into a newly constructed laboratory located at the General Campus.

In the existing labs, there had been ongoing changes in standardization of procedures, specimen receiving, transportation, work distribution and specimen flow. Many attempts had been made at improving the work areas; some were successful and some continued to be a concern. It remained evident that, although we now had a spacious new lab, we still had a number of issues that we were unable to resolve.

While attending the 2008 AMMI-CACMID convention in Vancouver, I had my formal introduction to LEAN. I was travelling with one of the Microbiology Lab’s charge technologists and we were both very interested in what we heard at lectures and viewed on posters. We learned how LEAN had been successfully used in the laboratory environment to increase efficiency and save time and money in the process. A stop at Calgary Laboratory Services on our return home also showed us first-hand what a success LEAN could be in a microbiology laboratory.

It had now become quite evident to me that a LEAN process could be the answer to many of the issues in the TOH Microbiology Laboratory. Our most pressing concern was the Specimen Receiving Area (SRA). Specimens are received from all three campuses of TOH and from two area hospitals. Our existing system, coupled with the severe staff shortages, was creating excessive stress on the staff and resulting in increased sick leave and a significant number of errors. However, with all the cost cutting and budgetary concerns of the hospital, I felt it would be very difficult to obtain buy-in from those holding the purse strings.

Fortunately, our new EORLA (Eastern Ontario Regional Laboratory Association) manager was familiar with a successful LEAN process that had been carried out in Toronto. She was on board. Our administrative director was very open-minded, and the VP was quite agreeable to looking at anything that would improve the extreme concerns arising in the Micro Lab and potentially save the hospital money. The lab microbiologists were a little skeptical, but not restrictive in any way, as we moved forward in implementing the LEAN process.

With the assistance of the new EORLA Manager and our VP on board, LEAN Advisors Inc. was hired to come into the Microbiology Lab and assist us with our concerns.

A LEAN team was carefully chosen from the staff, consisting of a Charge Technologist, a Senior Technologist, a fairly recent MLT graduate and a Laboratory Technician. The Charge Technologist, although not working on the routine benches or in specimen receiving, is thoroughly knowledgeable on all aspects of the lab. The Senior Technologists are resource technologists for the rest of the staff and are required to answer questions and troubleshoot issues; they work both on and off the benches. The bench technologist has been trained on all the routine benches in the lab, including the SRA, and is very open minded to new ideas. The Laboratory Technician works solely in the SRA and is extremely knowledgeable in this area. I, as Laboratory Manager, was also on the team.

LEAN Advisors gave a one-day overview session on LEAN to the Micro staff, Microbiologists, Laboratory Directors and anyone else who might have an interest in, or be affected by, our LEAN initiative.
Our contract with LEAN Advisors Inc. provided the team with thorough training in the principles of LEAN and access to Change Management processes if required. Training, process review and implementation were all intertwined. Each session was a full day and days were scheduled in groups of two or three for maximum effectiveness. Our trainer was present at all sessions and was adept at drawing out new ideas from the team members and making them feel very comfortable in doing so. This interaction with team and trainer allowed for thorough review of the process in our SRA, sound recommendations and prompt implementation of changes.

The results were beyond our expectations. The four main work areas in our SRA were cleaned up, excess equipment moved, schedules reorganized, staffing and processing changed. All this ended with much improved TAT, a considerable increase in the number of specimens processed per shift, and a huge amount of stress being taken off the shoulders of the staff. These LEAN initiative results are documented in another article on this web page.

In most hospitals across the country, the time is right for implementation of a LEAN process in laboratories. We have been working far too long with old procedures and methods. A new look at processes that save time, energy and money, improve TAT, decrease stress levels on staff, and introduce usable and effective processes can only be of value in any institution.

The biggest hurdle for anyone thinking of getting started with LEAN may well be acquiring unanimous agreement from the powers that be and from the staff who will be resistant to the change. Our lab was in a staffing crisis due to multiple resignations and illness and therefore the staff was willing to try anything that might improve workflow and efficiency for them. I must commend them on their ideas, input and implementation. In the end, it is the staff that learns the process, implements many of their own ideas and is responsible for keeping the processes moving forward.

Undoubtedly there are always a few diehard holdouts that are reluctant to change, no matter what. A change management process can be put to good use in these situations.

Communication to the staff and to the department heads was essential. Everyone had to be continually kept aware of how things were progressing, why changes were being made, and how it was improving the process. Communicate, communicate, communicate. To be honest, this was one area where we fell a little short. In trying to keep the staff informed and updated, we were lacking in information flowing to the Microbiologists and General Manager. We had to address the challenge of communication and realize how important it was.

“LEANing” the SRA naturally impacted other areas and showed us where LEAN could be used throughout the Microbiology Laboratory. LEAN has now been implemented in the Level 3 Lab, the Mycology Lab, and the routine benches. It also led to reorganization of our fridges, freezers, and inventory control. Our LEAN team must continually improve the process, keep LEAN on track and address concerns from the staff as they arise. It will take a strong leader and a diligent team to fight this uphill battle, however, once LEAN has begun, it is quite evident that there are improvements in turnaround time, processing, efficiency and, certainly in our case, staff morale. This ultimately leads to our goal of providing the best possible patient care.

It is my sincere hope that the LEAN process will move into the remaining laboratories in the Department of Pathology and Laboratory Medicine and throughout the entire hospital. With LEAN, patients will receive the quality of care and service that they expect and deserve, and the work environment will be improved by decreasing the stress and allowing the trained professionals and support staff to provide more value to their clients

Lean Implementation in the SLC Electronics Factory

lean manufacturing, lean management, lean principles, toyota roduction system, TPS

Lean Implementation in the SLC Electronics Factory

Lean implementation is a challenge in any area, but it was a special challenge in the electronics factory, where a large number of different products/models flow across the same shared resources and assembly lines.  The electronics factory today makes over 188 product models (122 types of SMT cards, 25 wave-style cards, 18 types of harnesses, and 23 types of chassis), not to mention over 200 different spares which do not follow a regular production schedule.  The challenge the electronics factory faced was to design a system that would flow a variety of products through the common value stream, each product having its own cycle time, different parts, and varied labor content—and each card at a different rate required by its specific rate of customer demand!

Before a Lean strategy was adopted in the electronics factory, the factory was plagued with the problems familiar to batch-type traditional production.  Circuit cards were scheduled for production in batches of one-months worth of customer demand.  The large batch sizes were chosen in order to avoid long machine downtime associated with changing over the machines to run a different type of card.  Large amounts of WIP were on the shop floor, and quality problems often were not detected until after a large amount of defective product had been run.  Another problem was the difficulty of seeing parts shortages arise in time to avoid the line shutting down.  The average lead-time of a circuit card was 57 days (time it took for a card to be produced from the work order dropping to sell-off).

Lean Implementation in the Electronics Factory began in Feb 2004 with a kick-off 1-week training of core factory members by our Lean consultant, Jim Myers.  Jim taught lean tools such as quick changeover, kanbans and supermarkets, and heijunka level-load scheduling that the team later used to design their lean system.  Dan Davis, electronics factory manager, and his team had to rely heavily on their own creativity and resourcefulness as they applied these tools to their factory, since they had no other factory to benchmark or model after.  The resulting mixed-model lean system is one-of-a-kind and a marvel to those who are familiar with its details.

In this lean system, production of all cards is paced by customer pull of finished goods, instead of push from an ERP schedule.  Each piece of hardware is represented by a visual plastic tag; when a card is pulled from finished goods, the associated tag is routed to the production scheduling board, where it signals to begin production of a replacement card.  Thus, the assembly lines are never ‘choked’ with excess WIP or raw inventory.

A major change in the way the automated machinery was utilized was necessary to achieve this production schedule.  Changeovers of the pick n’ place machine took about 4 hours.  This seriously limited the flexibility of the machine to handle the constant switching of product models down the value stream.  By acquiring dedicated reels and magazines and streamlining work elements, the factory team was able to reduce the changeover time to 10 minutes.  This allowed the variety of lots that run across pick n’ place to increase from 1.5 to 4.3 lots per day (while maintaining the same amount of labor.)

A heijunka board, or ‘level load’ board, is used after the cards flow through the automated machinery (pick n’ place and wave solder) and enter manual assembly.  The heijunka board is a tool that allows the ‘now smaller lots’ to continue the process as a one-piece flow.  Each card is assigned to a different ‘family’ based on its required manual labor content.  The heijunka board visually indicates (by another plastic tag) when during the day each card should begin assembly.  This way, cards with a labor content of only 30 minutes do not wait in a queue for production behind cards that take 200+ minutes to assemble.  Each family’s cards are flowed through the line at the rate that is required by their specific level of customer demand.

By using the lean tools and staying disciplined to the lean process, the electronics factory was able to decrease the lead-time of any card from the original 57 days to 27 days- a 52% reduction.  WIP inventory on the floor dropped from 4393 serialized assets to 2719—a 38% reduction.  Estimated direct labor savings due to streamlined efficiency of the process are in the area of 170 hours/month.

The SLC electronics factory has accomplished much to be proud of- and yet they are still not satisfied.  One of their next lean projects is focused on developing a material delivery system where the vendor makes just-in-time parts deliveries right to the point of consumption on the assembly line.  They will not stop until they have reduced batch size in their factory down to 1 day’s worth of customer demand; that means when a card enters production it will complete within it’s individual cycle time– typically less than 1 week. This continual pursuit of perfection is a trademark of lean thinking.  Kudos to the SLC electronic factory for setting a great example to the rest of the division as we all  “go lean”.