Workflow consulting for the histology lab, perspectives on safety and efficiency

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make better, more informed decisions, workflow consulting for the histology lab, perspectives on safety and efficiency, In this sixty minute lecture with an extended question and answer session you will learn from a leading exert in single piece flow and lean six sigma techniques, participants will learn how a lean practitioner views the histology laboratory workflow with valuable before and after comparisons, you will hear about no cost techniques that could improve the turn around time in your laboratory immediately, start improving the safety quality and efficiency of your histology laboratory today

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  • I want you and your team make better, more informed choices about how to save lives in the AP lab. That may seem a little lofty to you, so allow me to explain:  One lab error changes a patient’s life forever. That same error can erode the two things you feverishly protect: your bottom line and customer trust.
  • Great study by the New England Journal of Medicine: http://www.nejm.org/doi/full/10.1056/NEJMsa054479#t=articleBackground It provides some relevant statistics:Study looked at 1,452 closed claims73% of claims involving medical error received compensationThe average compensation received as a result of medical error was $521,560The average administrative costs for defending a case were$52,521 overall average$112,968 in cases that went to trial
  • For a moment, I’d like you to see the typical anatomic pathology lab I encounter every day.
  • For a moment, I’d like you to see the typical anatomic pathology lab I encounter every day.
  • Is this a case study?
  • For a moment, I’d like you to see the typical anatomic pathology lab I encounter every day.
  • First, there’s a lot of activity. People move constantly, going back and forth between various stations.
  • I see a accessioning processes where cases are handled and separated before being accessioned. Many same tissue types follow each other in reference labs. Stickers, Hand written notes and cassettes being matched to the specimens through visual verification only
  • I see a accessioning processes where cases are handled and separated before being accessioned. Many same tissue types follow each other in reference labs. Stickers, Hand written notes and cassettes being matched to the specimens through visual verification only
  • I see a lot of paper. White, yellow and pink paper notes attach to specimens in grossing, little paper notes tuck inside specimen blocks. And, batches like these - all are potential for mix-ups.
  • When I look more closely, I see handwritten slide labels and blocks with hard to read patient identifiers.
  • Handwriting can lead to mismatched specimens and cassettes.
  • Work with Debbie on how to show these benefitsAsk the best way to highlight value add
  • Bozeman Deaconess
  • Tandem microtomists work case to generate slidesDetailed description of BP – The microtomists sit in mirror image of each other and work a case (and the corresponding cassettes) together, cutting only one case at a time (single piece flow)Impact of BP on Lab Performance – This practice of working a case in tandem improves complete case throughput, as well as allows the microtomy pair to double check each other’s work and ensure the correct slide is matched to the correct caseApplicability of BP to Other Labs – This practice can be applied to labs that want to improve case-specific TAT, and have the techs willing to try a new practiceGeneral Lab Overview – Reference Laboratory with +250,000 H&E SPY and +65,000 IHCs
  • Best Practice Overview 5S example. Embedding and Microtomy work station accessories organization drawer. (all tools and supplies necessary for completing work).Detailed description of BP The drawer that is connected to an articulating arm mounted to the deck top at each embedding and microtomy workstation. The drawer is segmented and labeled so that each supply item is identified. Users can tell before they begin work if all supplies needed are present and in quantity necessary to begin without work stoppage to resupply or search for a missing item. Tech came up with the idea and love it. *Impact of BP on Lab Performance It saves time and reduces errors associated with stopping and starting work. It cleans up the work area and creates more bench space.Applicability of BP to Other Labs This is a low cost project where the items are easily acquired and installed. It is highly applicable in most cases where space, volume of work and TAT’s are an issues. The change in the lab will be very positive and should be implemented very easy.General Lab Overview This product could be used in any lab regardless of size or type.
  • AlphabetizedColor codedClearly labeledQuick inventoryReference Lab doing 350K IHC SPYComplex lab needed a streamlined way to pull controls for IHC cases sent in from around the countryLab Staff worked together to devise and implement solutionConsolidated extensive control menu into an easy to find and pull mechanismReduced case set-up and preparation by @ 2 hrs/day Can be applied to any lab utilizing moderate to large control menus
  • Best Practice Overview Visual Management Tool for slide storage. The yellow marker insert shows where a slide or group of slides where removed. Detailed description of BP The Yellow slide marker insert shows where, when and by whom a slide was removed from the slide achieving drawer. This marker serves 2 purposes; 1. It shows that a slide was removed. 2. It show where to put the slide when replacing it into storage. Impact of BP on Lab Performance It saves time figuring out where a slide is. It saves time figuring out where to place the slide upon replacement and reduces the risk of loosing a slide..Applicability of BP to Other Labs This is a very low cost project where the items are easily acquired and installed. It is highly applicable in all labs. The change in the lab will be very positive and should be implemented very easy.General Lab Overview This product could be used in any lab regardless of size or type.
  • Lab specimen flowDetailed description of BP – Created a histology work cell to promote linear physical workflow of histology cases. Impact of BP on Lab Performance – Layout improved ergonomics and non-value added motion activities in the lab thus improving ability at meeting TAT goalsApplicability of BP to Other Labs – Highly applicable to other labs as the concept of linear work cells can be implemented at every labGeneral Lab Overview – Medical center lab with 100,000 H&Es and 20,000 IHCs SPY
  • Water Spider or Lab RunnerWater Spider Walks 356 ft per Case or 38% of Total Distance TraveledDetailed description of BP – The water spider was responsible for distributing work and establishing a continuous flow for the labImpact of BP on Lab Performance – By establishing a continuous flow for the lab, the water spider cut down on potential bottlenecks and increased work-in-progress queues. Also, it decreased disruption for histotechs needing to get up to deliver slides for staining. As a result, the lab was able to meet their TAT goals more consistently than before.Applicability of BP to Other Labs – Medium applicability as this practice is best suited for higher volume labs (>75,000 H&E SPY)General Lab Overview – Reference lab with 300,000 H&E and 80,000 IHC SPY
  • OU
  • Workflow consulting for the histology lab, perspectives on safety and efficiency

    1. 1. 1Make Better, More Informed DecisionsOne lab can change a patient’s life foreverJ. Hylton Surrett, MBA, MHA, LSSMBBWorkflow Consulting SolutionsVentana Medical Systems, Inc.
    2. 2. 2ObjectivesWorkshop objectives:1. Review some of the ever evolving challenges in Histologyoperations and safety2. Review several examples of typical operational issues asseen through a lean perspective3. Review a few basic tools and how they impact patientsafety, chain of custody and case integrity2
    3. 3. 3Agenda• AP industry challenges• See the AP lab through the eyes of a lean practitioner• What can you start focusing on today• Closing remarks• Open Q&A discussion3
    4. 4. 4Key challenges for AP labs• Histology is still a very manualprocess and therefore hard toscale without adding staff• Productive plateaus will existthroughout the process sincehuman ability will set both thepace for production but also arethe error prevention safety net• Reducing the number of manualsteps and interventions in thehistology process is critical togreater efficiency and safety• Determining the balance betweenthe aspects of histology that areand should be “art” and whatshould be “automated”
    5. 5. 5The AP lab is challengingOne data point from a 2-week study in histology 1– Close to 30% of cases had manual rework totaling159 hours or 1.3 FTEs– 89% of defects were made in the analytic phase– Approx. 1.5% misidentification rate, 67% of those inslide labeling– All misidentifications would have been addressed byan integrated identification systemTypical savings found in service businesses 2– 30–60% reductions in cost (over time)– Cycle time improvements of up to 50%– Capacity recapture of 20% (with no additional staff)1Am J Clin Pathol 2007; 128 p4232George Group results, Lean Six Sigma for Service5
    6. 6. 6NEJM Study shows cost of medical error is greater than$500,000– 1,452 closed claims– 73% that involved medical error received compensation– Average compensation: $521,560– Administrative costs: $52,521-$112,968Source: New England Journal of Medicine:http://www.nejm.org/doi/full/10.1056/NEJMsa054479#t=articleBackgroundA medical error averages >$500,0006
    7. 7. 7Why are lean approachesnecessary?
    8. 8. 8Patient case integrityOne study showed that the average AP lab helps 93 patients per dayIf One patient becomes 8 Artifacts…thats 744 discrete itemsevery day and 186,000 A YEAR!How do we ensure every case’s integrity?– How many times is each item handled by the lab staff?– How do we know where all the items are?– How do we know who did the work and when?– How do you know when something is lost?Plan A market research study2,100 lab study, average of 24,000 cases per year, 152M to 330M H&E peryear8
    9. 9. 9Labs battle human error because of theconsequences for patients9
    10. 10. 10Who are we as leanpractitioners?
    11. 11. 11Lean workflow• Quality– Error Reduction– Consistent results– Continuous improvement• Productivity– Faster turnaround times– Higher testing capacity– Streamlined workflow• Cost Reduction– Reduce wasteful activities– Balance workload demands– Integration and adoption of technology• Lab Design/Redesign– Integrate Lean workflow principles– Increase efficiency by design– Automate good workflow practices11
    12. 12. 12Ventana workflow locationsNorth AmericaWell over +250 different engagement types ranging from FullLaboratory Workflow assessments to Targeted Solutions12
    13. 13. 13Increase efficiencySeamless alignment of automated solutions improves safety andreduces costs.
    14. 14. 14See the lab through the eyes ofaLean practitioner…
    15. 15. 15What a lean practitioner sees…..Many people moving work along in non-linear patterns
    16. 16. 16What a lean practitioner sees...Batch Accessioning where errors may not be caught…
    17. 17. 17What a lean practitioner sees...Batch Cassette Marking and Verification where sametissue types follow each other
    18. 18. 18What a lean practitioner sees...Batching results with potential for mix-ups
    19. 19. 1919What a lean practitioner sees...Manual documentation reduces efficiency
    20. 20. 20What a lean practitioner sees...Illegible Identifiers …Smudged cassettes
    21. 21. 21What a lean practitioner sees...Excessive & Illegible handwriting
    22. 22. 22What a lean practitioner sees...Mismatched specimen and cassettes
    23. 23. 2323What a lean practitioner sees...Mislabeled slides lead to errors and rework
    24. 24. 2424What a lean practitioner sees...Interruptions may cause mismatching
    25. 25. 2525Sorting Through MaterialsWhat a lean practitioner sees...Slides labeled up to 3 times prior to reaching the MD
    26. 26. 26So what can I focus on today to address theseissues in our lab?
    27. 27. 27• Single Piece Flow• Reducing Touches• 5s & Visual Controls• Poka yoke• BarcodingAP lab improvement via basic leanprinciples & enabling technologiesEliminate Waste– Errors– Overproduction– Wait Time– Transportation– Rework– Inventory– Motion– Unrealized Talents27
    28. 28. Single piece flow error rate prevention &technologyAn integratedsoftwaresolution canhelp to prevent& help eliminatethese errors.Single Piece FlowAccessioningreduced slidelabeling errors by<75%QP094 – Mislabeling Rate of Specimens, Blocks, and Slides in Surgical Pathology 28
    29. 29. 29Single piece flowConfidence at each step means free to move forward faster• Improve throughput and turn over time- 10 to 30% increase• Create capacity to grow the business by uncovering moreproductivity• Less need for scheduled or unexpected over-time29
    30. 30. 30VANTAGE rework reductionProcess safeguards reduce mistakes and any rework theycreateTotal annual savings of $298,195$174,613Data capturesavings26%Turnaroundtime$51,090Overtimesavings$63,492Bar codingsavingsWorkflow Consulting Case Study = Reference Lab30
    31. 31. 31Primary staining without automationPlace basketinto ovenLoad basketoncoverslipper& startUnloadbasket fromcoverslipperMoveslides toarchivedrawerRetrieve& labelslideUnloadbasket fromstainerConfidential and Proprietary InformationMove slideto warmerPlace slideinto basketTravel toovenRemovebasket fromovenLoad basketon stainer &startSlide is stainedSlide dryingMove slidesfrom basketto folderTravel tobenchTravel toovenTravel tostainerTravel tobenchTravel tostainerTravel tocoverslipperTravel tobenchSlide iscoverslippedTravel tocoverslipperTravel toslide sortingareaMount tissueon slideDryIs loadpositionoccupied?NoPlace basketnext tostainerTravel tobenchYesIs basketin unloadposition?Travel tobenchContinueother workContinueother workNoStainType ofcoverslippingAutomatedManual Travel tomanualstationWait forcover-slipper tocompleterunIs coverslipperrun complete?YesNoRemove slidefrom basketApplycoverslipPlace slide inbasketPlace labelon slideSlide is reviewedby pathologistFolderdelivered topathologistOrder recut?YesNoFolder isreturned tolabRecoverslipnecessary?NoYesRetrieve slidefolderMove slidesfrom folder totrayTravel toovenPlace tray inovenSlides dryovernightTravel tobenchTravel toovenRemove trayfrom ovenYesCoverslipReview &Archive
    32. 32. 3232Automated primary stainingIncreased Consistency & Throughput
    33. 33. 330Mislabeledslides sincego-live140Eliminatedmanual stepsper dayIncreasedproductivityReduce error, improve productivityCase study: community hospital& eliminated handwriting while reducingdependency on paper
    34. 34. 34The 5s system/process• to separate the needed items from theun-needed itemsSort• to arrange in a way for how theremaining items will be usedSet In Order• to maintain the work area in a clean andorderly fashion supporting the sortedand set-in-order itemsShine• to replicate and ensure consistencyacross all usersStandardize• to maintain and improveSustainMake errors difficult to create, easy to detectand eliminate the non-value added activities
    35. 35. 3535Examples of 5s (before)
    36. 36. 3636Example of 5s (after)
    37. 37. 37LabelerWater BathLampBlocksSlide HolderSlides TrayScannerIceMaterials:Blades,Cotton, etc.MicrotomeTrayMicrotomeVantage5s improves throughput at the cuttingstation
    38. 38. 385s improves throughput atcase assembly
    39. 39. Identification & tracking via barcodingBarcodes give you a connection to each sample, cassette andslide• Real – time visibility at keypoints in your process• Provides historical audit trailfor every block, slide, andsample• Supports process reportingfor CAP, JCAHO or otheragency goals39
    40. 40. The Case for VANTAGEHistology Challenges Manual & paper processes
    41. 41. The Case for VANTAGEHistology Challenges Manual & paper processes Limited or no process data
    42. 42. The Case for VANTAGEHistology Challenges Manual & paper processes Limited or no process data Limited or no system integration
    43. 43.  Manual & paper processes Limited or no process data Limited or no system integration Opportunity for errorThe Case for VANTAGEHistology Challenges
    44. 44. The Case for VANTAGEHistology ChallengesVANTAGE Workflow Solution
    45. 45. 45Case studies: Create asafer, effective, efficient labenvironment
    46. 46. 46• Tandem microtomists sit in mirror image of each other• Single case flow improves case-specific TAT, qualityImprove throughput
    47. 47. 47• Save time and reduce errors associated with stopping and starting workat Embedding and Microtomy workstationsOrganize Accessories
    48. 48. 48• Reduce case set-up and preparation by 2 hours per dayImprove visual controls
    49. 49. 49• Visual slide marker marks spot where slide was removed; facilitates faster,accurate slide replacementReduce lost slides in archiving
    50. 50. 50• Create linear histology workflow to increase TATSymphonySymphonyBuVisitImprove specimen flow
    51. 51. 51Improve reflex testing and consult flowAdvanced Staining Bench• Advanced Stain orders are printed• HT picks up the order(s) & pulls as required• Block(s)• Unstained slide(s)• Controls (if not TMA appropriate)• Consult cases• HT places in empty slide tray for case integrity• Order is QC’ed and any additional slidesrequired (negatives) are ordered and staged forpick-up by HTConsult CasesLIS Terminal (QC)Block &UnstainedSlideStagingControlPullStationPrinterConsultCasesTo MicrotomyAdvanced Stain Cases
    52. 52. 52• Lab runner, water spider establishes continuous flow• Reduces 356 ft/case or 38% of total distance traveledMicrotomyMicrotomyMicrotomyMicrotomyEmbeddingSpecialStainersGrossingGrossingGrossingTPTPTPTPTPTPTPMicrotomyCaseAssemblyH&EStainingRecutsandSpecialsXTXTXTXTXTULTRASSSSSSSSSSSSReduce bottlenecks, increase TAT
    53. 53. 53Open Q&A Discussion
    54. 54. 54Closing Remarks
    55. 55. 555555
    56. 56. 56I need to reduce errors and risk...I need to increase my quality tracking documentation…I need to increase my staff’s efficiency…What reason resonates with you?
    57. 57. 5799.7%Reduction inmislabeled slidessince VANTAGEgo-live&improved staining quality and consistency1,100Eliminatedmanual stepssaving 5hrs/day25%Reduction induplicate slidesresulting inreworkReduce errors, streamline operationsCase Study: Reference Lab
    58. 58. 58&annual savings of $298,195$174,613Data capturesavings26%Turnaroundtime$51,090Overtimesavings$63,492Bar codingsavingsReduce costs with VANTAGECase study: reference lab
    59. 59. 59
    60. 60. 60BusinessNon Value-Added 30%Non-ValueAdded 65%Value-Added 5%A typical workflow processBefore Leaning a process, most activities are NVA
    61. 61. 61Primary staining without automationTypical H & E Stainer SupportedProcessPlace basketinto ovenLoad basketoncoverslipper& startUnloadbasket fromcoverslipperMoveslides toarchivedrawerRetrieve& labelslideH&E Workflow with Symphony StepsUnloadbasket fromstainerConfidential and Proprietary InformationMove slideto warmerPlace slideinto basketTravel toovenRemovebasket fromovenLoad basketon stainer &startSlide is stainedSlide dryingMove slidesfrom basketto folderTravel tobenchTravel toovenTravel tostainerTravel tobenchTravel tostainerTravel tocoverslipperTravel tobenchSlide iscoverslippedTravel tocoverslipperTravel toslide sortingareaMount tissueon slideDryingIs loadpositionoccupied?NoPlace basketnext tostainerTravel tobenchYesIs basketin unloadposition?Travel tobenchContinueother workContinueother workNoStainingType ofcoverslippingAutomatedManual Travel tomanualstationWait forcover-slipper tocompleterunIs coverslipperrun complete?YesNoRemove slidefrom basketApplycoverslipPlace slide inbasketPlace labelon slideSlide is reviewedby pathologistFolderdelivered topathologistOrder recut?YesNoFolder isreturned tolabRecoverslipnecessary?NoYesRetrieve slidefolderMove slidesfrom folder totrayTravel toovenPlace tray inovenSlides dryovernightTravel tobenchTravel toovenRemove trayfrom ovenYesCoverslippingReview & Archiving
    62. 62. Hylton Surrett,MBA, MHA, MBBSenior Manager, Advanced WorkflowMobile: (520) 306 - 0589Fax: (520) 299 - 6819hylton.surrett@ventana.roche.comContact information

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