Lean in a Moose Jaw Hospital

Auto industry process revs up efficiency

No, not a hospital for moose -- a hospital in Moose Jaw, Saskatchewan, Canada.

The Five Hills Health Region is revving up speed in providing mental health services and lab tests for patients -- by applying principles used in auto manufacturing.

The hospital used value stream mapping to identify waste in the process:

Lab staff tacked sticky notes on to large sheets of newsprint to create maps to identify how to cut in half the time a patient waited to have their blood taken.

They also recognize the lean concept that the people doing the work are best positioned to actually improve the process:

As a result, outpatients getting bloodwork done wait about 15 minutes instead of half an hour. Besides decreasing wait times for patients, the team approach has boosted staff morale, said Barb Flowers, the region's director of laboratory services.

"All levels identify waste, but staff are the ones who can see that if I moved this over here, I'd save myself so many steps," Flowers said. "It's teamwork in that it is a bottom-up and top-down approach and management is moving toward more of a mentoring role to make sure that we meet standards and regulations."

Whether it's for mental health services or traditional hospital settings, Lean methods work... if you're willing to work at it and allow your employees to have some control over their process. The description of Lean being "bottom-up and top-down" reminds me of hearing John Shook talk about Toyota management being neither of those things (or being both of them). Lean leadership is definitely not the traditional dictatorial "top-down" method. Nor is it the "empowerment" model of just letting employees do whatever they want as long as they get the results you want. Lean leaders work WITH their people to define goals and standards, figuring out together how to meet those objectives.

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A Lean Lab Example

A tour of a LEAN-inspired clinical laboratory | DailyKaizen

Here's a nice story by Dr. Ted Eytan about a lab that a colleague of mine worked with in their Lean efforts. It is actually a lab that is mentioned briefly in my upcoming book on Lean Hospitals.

I'm glad that Ted had a positive impression of the lab. He writes (and posted a lot of pictures) about what he saw that was surprising to a non-lab person:

First, there is a work room right off of the lab floor. It seems out of place relative to the other conference rooms on another floor, but it is there by design. Staff can problem solve in a safe area that’s close to the work. Visual systems are used to alrt the team to important metrics.

The two formerly separated machines are now in the same room. One performs chemistry evaluations, the other hematology. Why is this important, I asked, if the types of tests are totally different? The answer is that the lab is cross training staff to operate both machines, which allows for leveling of the load.

Ted is right. A traditionally laid out hospital lab has sub-departmental silos. This is not unlike a traditional functional factory layout. There are historical reasons for the silos in factories (machines used to be run off of drive belts, so similar machines had to be grouped together, regardless of the overall flow) as there are in laboratories (chemistry and hematology were separate academic fields, so it was natural that they occupied different rooms).

As lab testing has become more automated, the testing areas are often still kept pretty separate... until Lean process flow analysis helps the lab identify that a cross-functional automated testing area, or "cell," can be created, an area that now houses instruments that used to be in their separate sub-departments. Modern medical technologists are typically cross-trained or at least have the skills and education to run multiple types of testing machines. The main "value add" of the technologists is in reviewing and interpreting the results of the testing (loading the tube into the machine isn't particularly skilled work).

When labs move to the cellular layout, the department typically moves from a "one person, one machine" staffing model to one where a technologist (or two, depending on workloads) can walk a standardized work pattern, loading and unloading different instruments and reviewing results as they come out. Manual testing work is typically isolated into an area that is staffed separately during a day (technologists are still cross-trained and able to work in either area). The advantage of this new standardized work is that the routine flow of specimens and testing in the automated cell is no longer interrupted by manual work or specimens/results that require more detailed interpretation.

The general approach might seem familiar to those of you from manufacturing settings... but it is certainly implemented in a way that's keeping with the mission and setting of a hospital. One key difference between a manufacturing "cell" and a lab "cell" is that lab specimens tend to only go through one test instrument, unlike a factory cell where a product would be machined or assembled in all (or almost all operations).

There are many examples that Ted cites where the process was improved to reduce walking and specimen travel distances -- also very classic benefits of a "lean lab." I'm glad that it also felt like a "lean" place in terms of environment and the focus on the customer/patient.

Updated: Here is a book review, by Dr. Ted Eytan, of Getting the Right Things Done: A Leader's Guide to Planning and Execution.

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Another Pathology Mishap

L.I. Hospital Scrutinized After Deaths of Patients - New York Times

It wasn't the same laboratory this time, but it's more than likely a similar root cause. I wrote before about pathology specimen labeling errors, how they're preventable human error. Labs need to get away from batching multiple specimens (working with multiple patient specimens at the same time) and they need to stop blaming individuals when errors happen. We have to look at the system. We have to be proactive. We have to try to prevent errors from occurring.

You might recall an incident from last year, where a private NY pathology lab mixed up two patient specimens ("This Will Happen Again, Unless...")

In this most recent case (at a hospital):

"Last spring, doctors at Mercy Medical Center on Long Island gave a patient the news she had feared: Cancer had been detected in her left breast. She was only in her 30s, but she decided to act swiftly because breast cancer ran in her family. On May 25, she had a double mastectomy. The next day, she died of complications from the surgery. As it turned out, the woman did not have cancer. According to the State Department of Health, the pathology report from the woman’s surgery had found no tumors in her breasts. The hospital’s lab had mixed up her test with another woman’s."

Why the woman died after the surgery is a altogether different story and there aren't many details about that. The lab error was more clearly preventable.

Every pathology lab should be using Lean methods to identify "standardized work" methods that allow work to be done in a single-piece flow manner, reducing the opportunity for error. This should be done pro-actively, before an error occurs in your lab. I heard a lab manager say once, after being asked about error proofing that process, "But my people are careful." I'm sure they were generally "careful" in Long Island also, but being careful is not enough.

How many times does something like this need to occur? For all of the truly complicated things in a hospital, this is NOT one of them. These processes are all pretty manual -- put the right patient specimen onto the correct, properly labeled "cassette" or slide. These errors can be prevented.

In this article, a doctor who is speaking out very publicly about the problems at the hospital says:

"That mix-up was a simple procedure," Dr. Anthony Colantonio said. "The simple thing of placing a label on a specimen container. That sort of mistake should not happen."

Thinking about this more, I might not be completely accurate in calling it a "pathology error." It *is* possible that the specimen container was improperly labeled in the operating room, before it ever got to the lab.

Update: Here' s an overview of the anatomic pathology and "histology" process steps, including a photo of the cassettes and slides that get labeled.

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This Will Happen Again, Unless...

Medical mix-up, unnecessary mastectomy - Health - MSNBC.com

This will happen again, unless the process is fixed. Lean can help. Please read on...

I heard about this story this morning, this horrible tragedy where a 35-year old woman, Darrie Eason (pictured), from New York was told she had cancer and had a double mastectomy done on her, only to find out she really didn't have cancer. The lab had switched two patient specimens. So the woman who really had cancer didn't find out right away. The results were read properly by the pathologists, but they were mixed up due to what amounts to an administrative error.

Incidents like this are rare, but it happens regularly enough where I've heard about and read about cases like this before. I've been in about a dozen anatomic pathology labs where work exactly like what is described in that article takes place. I've seen "the gemba" -- not the exact lab where the mistake was made, but others.

I've thought about this a lot today... gotten angry... calmed down... gotten frustrated... went to the gym... thought about it some more. I thought about how and what to blog about this. There are probably 20 different things I could write, as there are many "Lean" aspects we could consider. I'm trying to be careful because I could share many more details, I will try to keep the story general based on what's standard industry practice. Other than the lab in this incident, I'm not referring to any specific laboratories.

First, the MSNBC story here was basically the same content that was on the Today Show (check out the video on the MSNBC site), from what I was told. I was struck how the discussion wasn't full of individual blame, there were comments about systemic problems.

The one victim's attorney probably has it right when he says:

“It may be one person, but personally I doubt it. One of the things we may learn is ‘Was there a system failure, and if so, what can be done to improve the system?’ Personally, I doubt this is a one-time event by someone who was careless for one time in his or her life,” he said.

He must inadvertently be a "Lean thinker" because that is the exact Toyota Way thought process -- what failed in the system? That's the same thought process Deming would have brought to this situation.

The MSNBC article mentioned the practice of "batching" specimens:

The state report said “the most likely source of the error” was the technician engaging in a practice called “batching,” which involves handling more than one specimen at a time.

Now, if you're a manufacturing person, you recognize the term "batching." It happens all the time in factories. When you implement Lean, you try to reduce your batch sizes to help improve flow. Batching interferes with flow. Batching also harms quality, in a number of ways.

Unfortunately, the same is true in a medical laboratory. "Batching" is the "conventional wisdom" method in EVERY anatomic pathology lab I have ever been in. That's how they do it -- at least that's how they do it before implementing Lean.

Let's assume you were on the table in an O.R. and had a biopsy specimen take out of you. Your specimen, that little piece of you they took out is special, right? Here's what typically happens. Draw a value stream map if the urge hits you.

• Your specimen is put in a container, in a preservative solution, and it waits for other specimens to accumulate. A batch. It's not "efficient" (in a traditional sense) to take one specimen to the lab.
  
  
• Your specimen is "grossed," often by a pathologist. It is examined and cut into small pieces and is placed into a plastic cassette. This cassette might be labeled as they go, or the casettes may have been labeled in advance -- batched -- either done manually or by a piece of automation. There is a risk, here, that the specimen is put into the wrong specimen. The pathologist usually does "one at a time," reducing the risk somewhat.
  
  
• As the cassettes are made, they usually accumulate in a tray, another batch.
  
  
• The batch is moved and loaded into a "tissue processor." Now this is inherently a batch process. Think of loading dishes into a dishwasher. Not a perfect analogy, but you don't load one dish and hit "start." Not if the dishwasher runs for 12 hours overnight.

Now let's stop and think about this for a minute. We see the exact same mentality in manufacturing. If you have a factory process that is batch oriented, we tend to use that same mindset and batch everywhere. With Lean in a factory, we move toward flowing up to the batch process and flowing after the batch process -- for quality purposes and other reasons. The same thing can be done in a lab.

• The tissue then goes through a few more operations. None of which is a batch process. It's a lot of manual work. But, batching is still the primary mindset. We do a lot of work and let specimens accumulate in a tray until we move them, as a batch, to the next step.

In the New York case, the slides were mislabeled or switched. Ideally, you should be handling and working with one patient specimen at a time. But, you have a batch of specimens ("work in process" in manufacturing terms") that you are working from. You cut a thin slice of specimen and you put it on a slide. Sometimes, the slide gets labeled (by hand) by the technologist right before the specimen slice is put on there. That's probably the least risky way to do it.

Sometimes, though, the technologist will "batch up" and hand label a whole batch of slides because it's "more efficient" to keep doing the same thing over and over. At least it seems that way if you're not a Lean Thinker.

Sometimes, the slides are all made, as a batch, the night before by automation.

So here's the risk. If you have ONE patient specimen and a whole BATCH of labeled slides, we are depending on the individual to "be careful." If you're a Lean thinker, that should set off fireworks and red flags. We're human, we make errors. Being careful isn't good enough, whether you're in a Toyota factory or a hospital. If you grab the wrong pre-labeled slide... you're going to have a mismatch. And that leads to often tragic results.

Again, batching is the "normal" non-Lean process. That's why this type of error happens again and again in different hospitals. It happens so rarely that we might think, "that shouldn't happen... that doesn't happen normally.... who screwed up?"

So we blame.

Stories other than the MSNBC story started to place blame.

This article said:

A state health department report said Eason's tissue sample was mislabeled at the CBLPath lab in Rye Brook because a technician "cut corners."

The laboratory management also blamed the employee in some articles.

Another article spelled out the "corner cutting" in two ways. First by batching and secondly by not double checking their work.

A CBLPath technician who handled Eason's test admitted to his supervisors that he "occasionally cut corners by batching," or handling more than one tissue specimen at a time, and did not always verify patients' initials when labeling them, according to a state Health Department report issued last August.

Unless the lab had implemented Lean methods (and it's a small percentage that actually have), batching was the normal process. It's not "cutting corners" if you are following the same normal process that everyone else is using. The normal process that sets people up to make errors. Not often, but it will happen. It's a perverse lottery where you have a 1 in 47 million chance of losing. Losing big time. The worker and the patient both.

The step of verifying initials -- that's an inspection step. To a Lean thinker, the fact that you NEED inspection is a sign that your process is prone to errors. To say someone forgot to do the inspection once, it's conceivable. We're human. We need to design a BETTER PROCESS where inspection isn't necessary. The lawyer had it right, for pete's sake.

Now, don't get me wrong -- the patient has suffered immensely, I don't mean to forget about her for a second.

But, the employee who was involved in the error. Don't you think they are suffering? I've read other stories about nurses who were involved in a medical error (a systemic series of errors they were a part of) and they feel horrible. Many leave the profession. Some get convicted, for crying out loud. Not is not helpful for preventing future errors. That does not help create a construction "blame-free environment" as some hospitals are doing. Not blaming doesn't mean we aren't holding people accountable. But we have to look and see if the error or problem was systemic or if it was likely to happen, given the design of the system. In this case, I think it clearly was.

The other stories highlighted that the employee who made the error is gone. Under what circumstances, we don't know.

"[The CEO] said the technician responsible for the mixup also no longer works there."

What does that do, other than making sure that same person won't make that same mistake. What about all of the other people working in that lab? What about all of the other labs around the world that work using similar processes? This same error pops up all over:

Back in 2003, CBS News reported that Linda McDougal, 46, learned that the lab had mixed up specimens. Unfortunately, she had undergone a mastectomy only days before based on the inaccurate lab report. In 2005, Molly Akers had her right breast removed only to discover -- thanks to a biopsy -- that she didn't have cancer, according to UPI, which says the 33-year-old filed a lawsuit alleging that the lab mislabeled specimens.

Another similar case via Newsday.

Are you convinced yet that this is a systemic problem?

The NY State Board of Health isn't helping. I don't think they get it at all.

Claire Pospisil, a spokeswoman for the state health department, said mistakes like Eason's are "very rare" in New York. She said the state's investigation ended with its report.

"Very rare?" One mistake is one too many. Having identified "batching" as a risk factor and a failure mode, why aren't they looking for batching in other labs? You'll find it. Do we all need to call our local hospital to ask the CEO, "Are you batching anatomic pathology specimens in your lab?" Unless they have implemented Lean and/or "single piece flow," chances are they do. And it's potentially putting people in your community at risk.

The state also claimed

The state health department determined that CBLPath’s error was isolated and found “no systemic problems and no deficiencies” at the lab.

Sigh. Let's just blame the person. Problem solved. Go back to trusting your health system.

There is some good news out there: many laboratories are making systemic improvements using methods from Lean Manufacturing and the Toyota Production System. They are reducing the use of batching, improving the flow of patient specimens, while using “error proofing” methods to prevent errors, rather than relying on people to “be careful.” Again, It’s called “human error” for a reason – we are human and we make mistakes. Smart system design recognizes that and makes it harder for errors to occur. A company like Toyota, unfortunately, has better methods in place to prevent the wrong steering wheel from being installed in the wrong vehicle than a typical laboratory has in place to make sure the wrong patient specimen doesn’t get on the wrong patient slide.

If you read the whole thing, thanks for hanging in there. I'm going to relax, watching my Thursday night NBC shows, including my favorite bad bosses -- Michael Scott (The Office) and Jack Donaghey (30 Rock). Watch the 30 Rock clip in this blog post if you need a laugh. I sure do.

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LAME: Lean is Not Automation

Here's another example of what you might call "L.A.M.E" ("Lean" As Misguidedly Executed) instead of "Lean."

I received a disturbing report in my email inbox two weeks ago, a report that tries to co-opt Lean and the Toyota Production System to support what might be some very non-Lean ideas. The report, published by a healthcare industry group called the “The Advisory Board Company,” puts its agenda right in the title of the report, at least:

“Automating the Lab”

I work with a lot of hospital labs, helping them implement Lean. Many hospital labs are seduced by the promises of automation, a “siren song” if you will. This should sound familiar to the manufacturing folks reading this. Whether it’s robotics or software, a lot of money is wasted each year on technology and automation that fails to deliver on its cost savings promises.

Many hospital labs see a choice between automation and Lean (as factories do). That’s a false choice, but it’s especially painful to see hospitals spending money to automate a bad process. For example, if a hospital lab layout is poorly designed, instruments might be put in locations where space was available, rather than considering the flow of test specimens and employees. If a high-volume test instrument is located a long distance from the receiving area, many companies would be happy to sell you automation to carry the specimens instead of having a person carry them. The Lean solution would consider changing the layout so that the “waste of transportation” is eliminated or minimized, rather than just automating it.

So the “Automating the Lab” article starts with this header on the first page:

“Re-creating the Laboratory in the Image of Toyota.”

Ok, this is interesting, I thought. I thought this was an article about automation, but they’re immediately invoking Toyota. But Toyota’s success isn’t due to automation. Toyota’s success is arguably the result of its people… its culture of respecting people, investing in their growth, and encouraging (or demanding!) continuous improvement. Pushing "automation" as Lean might more accurately be described as "LAME" ("Lean As Misguidedly Executed").

The article takes a horribly wrong direction on this first page when it states:

"However, as health care professionals increasingly turn to other industries such as auto manufacturing for ideas on process improvement, the lab has emerged as the perfect assembly line model to revolutionize using LEAN Toyota principles and Six-Sigma concepts. Taking the concept of streamlining workflow one step further, many hospital leaders are embracing (and investing significant capital in) the totally automated, human-free laboratory system."

Whoa, whoa, whoa! Since when was Toyota’s goal a “totally automated, human-free” factory??? That was GM CEO Roger Smith’s goal in the 1980’s, the “lights out factory” (that didn’t pan out, did it??).

The article continues to talk about automation that ties together the receiving area and test instruments. The header of a diagram (click for larger view) says:

“Tracking Eliminates Need for Transport.”

WRONG. An automated track (like a conveyor) only automates the waste. This is a false efficiency gain, especially when the lab automation can cost hundreds of thousands of dollars (or even over a million dollars!). Lean is very inexpensive to implement, even if you include the cost of an initial consultant (Yes, I’m a consultant – if you want to write an “anti-consultant” piece on your own blog, go right ahead, I’ll even link to it).

The article does point out a lean notion, that you shouldn’t immediately cut employees, that you should allow them “scale back their staff levels gradually through attrition.” But if the goal of automation is cutting headcount, how many hospital administrators are going to get that message? Sure, Lean can reduce your headcount requirements, but Lean also leads to improvements in areas other than labor cost – safety, quality, and lead time, to name a few.

So why aren’t lab employees going bonkers for automation? One reason for “staff resistance” is stated as:

“… staff may perceive automation as the hospital’s attempt to replace staff with robotic equipment.”

Do ya think? When the stated goal on page one is “a human-free laboratory,” the staff is only “perceiving” that the hospital doesn’t value them? Where would they get that idea?

Who, in a “human-free laboratory” would maintain the equipment? Are the instruments going to load themselves with test reagents? Are the machines going to call doctors or nurses to discuss test results? Of course not. If I were trying to sell lab automation, I certainly wouldn’t talk about a “human-free” workplace. I know I wouldn’t talk about a “human-free workplace” when selling lean.

It is true that there is a shortage of Medical Technologists in the lab world. Automating might be a strategy for coping with shortages of skilled people. But putting it that way is completely different than saying you have a goal of a "nearly human-free lab." That makes it sound like you WANT to get rid of people, rather than coping with a shortage of them.

I’m not opposed to automation. But, as the Toyota Way states, you want to use technology to “support your people” (to reduce safety or ergonomic risks, or to improve quality) rather than replacing them. Use automation to relieve people of mundate, thoughtless, or routine tasks, maybe, so they can focus on higher-level value-added activities that support the patients and medical staff. Realizing that employees are valuable, because they learn new skills and drive continuous improvement is lean. It’s not lean to look to automation as a way to driving out your “costs,” viewing people as a cost instead of as an asset.

It makes me really angry to see people saying it’s “lean” to automate away your people. That's "LAME". I assume it would make Toyota mad as well to see their name used that way.

Lean, Batch Sizes, and Equipment Selection

This has always been a problem in the manufacturing world -- companies selecting equipment that is "biggest, fastest, and cheapest" (or at least "cheapest" in terms of unit cost). To be cheapest, the machine usually has a giant batch size, so the expensive machine's cost is spread out across a large batch. The temptation is there to run the machine to spread out costs across many batches, even if demand isn't there. That's the non-lean manufacturing world, the mass production world.

Lean teaches us to right size our batches. Smaller batches means shorter cycle times, whether in a factory or in a hospital laboratory. Hospital labs, pre-lean, usually have large centrifuges that run giant batches (up to 80 tubes, in some cases). These centrifuges take up a lot of space and there is a strong temptation to let a batch accumulate before pressing the "start" button.

At the left, we see a typical large batch centrifuge. A centrifuge that holds 24 tubes currently costs about $1600.

Even with 24 tubes per batch, the centrifuge isn't fully utilized. Tubes wait either for a batch to accumulate, or they wait because a batch is already going (which takes 6 minutes).



To the left is a "StatSpin" centrifuge that holds only 8 tubes. It costs more ($2100), I suppose because the smaller motor is more expensive. I wish I had photos of them side by side, the StatSpin is much smaller. Not only is the smaller one more expensive, but you need two of them. On a purely cost-driven basis, this would be a dumb decision.

But, with lean thinking, you consider the whole picture. The two small centrifuges take up less space than one big one, and hospital real estate is valuable. You can also run smaller batches, which means faster cycle times and faster test results. The smaller centrifuge also runs faster (don't ask me to explain the physics of it), in about 3 minutes. Oh, of course, the quality of the "spin" is just as good (it would be or we wouldn't have been able to consider them).

Lean labs are moving overwhelmingly to the smaller centrifuges. Centrifuge makers are adapting and offering more small batch options. You're moving in the direction of one piece flow, at least, even if you're not completely there. Don't ask for a true "single piece" centrifuge, as it would be out of balance!

I wanted to share this for the factory folks -- people in healthcare struggle with many of the same decisions you do. Looking at tradeoffs of cost and cycle time, you have to make the decision that's right for the whole big picture, not just the limited view of unit cost.

The Need for Lean Laboratories

Hospitals move to cut dangerous lab errors

Here is a free version of a WSJ article from last week. I know I've been posting about "lean healthcare" a lot this week, I hope that is of interest to the manufacturing folks who are reading. Lean is lean, to some extent, so I hope you'll keep reading.

After transitioning into healthcare, I've seen many hospital labs. The opportunities for errors are all over the place, pre-lean, mainly due to bad processes and batch thinking. Because of batching, it is far too easy to mis-label slides or to put the wrong label on a test tube, which is going to lead to false positives or false negatives.

I don't think I've seen error rates this high:

"...studies show that 3 percent to 5 percent of the billions of specimens taken each year are defective, be it a biopsy that doesn't extract the tumor cells, blood that isn't drawn correctly or a mix-up with another patient's sample."

The results can be disasterous, as this article highlights.

"Tests fail because things can go wrong at every step of the process, and there are no checks and balances in place in pathology to catch these errors," says Stephen Raab, director of the center for pathology quality and health-care research at the University of Pittsburgh Medical Center, who is leading the lab-safety collaborative.

While only about 1 percent of errors lead to serious harm or delays in treatment, he says, "You wouldn't want to have 1 percent of all airlines crashing."

From a lean perspective, I don't think the solution is more "checks and balances" -- you can't inspect your way to quality results. We need lean methods and single-piece flow -- methods that work in labs and pathology areas, methods that help PREVENT errors or mix-ups from occurring.

Lean really works in laboratory settings. Lean reduces errors and improves cycle time for getting test results back (known as "turnaround time" in the lab world). Lean works, we just need more of it.

If you have questions about lean in laboratories, email me. I have done a lot of work in hospital and reference laboratories over the past year, it is the focus of my employer. I would love to help you out if you have interest in lean.