Application of Lean thinking to laboratory service improvement; 5S; seven wastes, working in cells, process mapping, single piece flow, reducing turnaround time

1. Our Lean Experience
Cellular Pathology, Royal Victoria Infirmary
Terry Coaker

2. Histology Operations Manager
One year secondment to:
North of England
Haematological Oncology Diagnostic Service
NEHODS

3. Cellular Pathology, Newcastle Hospitals
• Our history
• Why change?
• Most important lessons:-
– Lean Thinking
– Lean Tools
– Management
– Data

4. Cellular Pathology, Newcastle Hospitals
• 1981: RVI 9,700 requests per annum
• From 1995 to date: merger of NGH acute
services; NGH histology; Dental Hospital;
Freeman histology; Muscle & nerve; Cytology;
Neuropathology.
• Decant to prefabs for 3.5 years
• December 2006 - Bigger NOT Better ! - Lean
• May 2009: New PFI
• 2013-2014: 54,000 p.a.

5. Drivers for change
• Lord Carter 20% reduction
• Modernising Scientific Careers
• Private sector
• NHS England
• Regional rationalisation
• Trust CIP – 2012/13 = 4.0% = £328,280
• Trust ‘Transformation’ 2013/14
• Why would you NOT want to improve the service !

6. Drivers for change…
“Here is Edward Bear, coming downstairs now,
bump, bump, bump, on the back of his head, behind
Christopher Robin. It is, as far as he knows, the only
way of coming down-stairs, but sometimes he feels
that there really is another way, if only he could
stop bumping for a moment and think of it.”

7. November 2009, NHS Improvement

15. Unconscious incompetence
Conscious incompetence
Conscious competence
Unconscious competence

16. Continuous improvement ?
+ =

17. Continuous
improvement ?
+ =

18. Continuous improvement
Machines,
environment &
processes
WILL break
down over
time

19. Continuous improvement
People are the only
organisational asset that has
an infinite capacity
to appreciate in value

20. Continuous improvement
Reactance - if we try to make
people do something, they will
resist doing it…
…even if they agree with it !

21. NNoott iinnvveenntteedd hheerree……
‘‘TThhoossee ppeeooppllee aarreenn’’tt lliikkee uuss’’
Our situation is more complicated than
that’
‘Those ideas won’t work here’

22. ‘‘That’s the wwaayy II’’vvee aallwwaayyss ddoonnee iitt’’
‘We’ve tried that before…
and it didn’t work’
? Passive aggressive behaviour
– or worse!

24. Don’t let perfect get in the way of better
AAssssuummee nnootthhiinngg
Just do it
"She didn't know it couldn't be done, so she went ahead and did it"
CCoonnttiinnuuoouuss iimmpprroovveemmeenntt WWaallkk tthhee ggeemmbbaa
You get what you deserve
… you deserve
what you tolerate
It’s not people,
it’s processes
If you can’t measure it, you can’t
manage it
Every system is perfectly designed
to achieve exactly the results it gets

25. To improve the work is the work
RRiigghhtt ffiirrsstt ttiimmee
Quality at Source
NEVER Accept, Make or Pass a Defect
GGoo sseeee……,, aasskk wwhhyy??
rreessppeecctt tthhee iinnddiivviidduuaall

27. Lean Methods
Continuous Improvement Toolbox
Pull Systems
Work Cells Performance
TPM Measurement
Standardized Work POUS
Value Stream Mapping
5S System Layout
Setup
Reduction
Teams
Visual
Controls
Quality at
the Source Continuous Flow
Batch Size
Reduction
Lean Tools

28. Lean Tools - Seven forms of waste
1. Correction - re-embedding, deepers
2. Overproduction - inappropriate requesting
3. Transport - e.g. point of use p.wax
4. Movement - more steps than necessary /
double handling / stretching
5. Waiting …to do work
…work waiting to be done
6. Inventory - “batch and queue”/ unnecessary
supplies or equipment
7. Inappropriate - activities which do not add value
processing e.g. date and time of receipt
8. People waste - not using the knowledge skills and
abilities of the employee

29. Batch logic v Flow Logic
SPF Batch
1
2
3
3
2
1
Assumptions:
• 3 Operators
• 3 processes
• 1 min per process
• 0 min Move Time
• 10 specimens
10m 20m 30m
Batch
21”
30”
SPF
3”
12”
First result
Last result

30. Spaghetti diagrams
Band 2 embedding

31. Spaghetti diagrams
Band 6 microtomy

32. Cells
• Cells – Danaher, Leica, Pathlinks
• Integrate all functions in close proximity
• Problem solving easier
• Smaller batches, continuous throughput
• Teamwork, ownership & accountability
• Faster response
• Reduced turnaround times

33. Spaghetti diagrams
Cells

34. Visual Display

35. Visual Display

36. Visual Display

37. Visual Display

38. Visual Display

39. Visual Display

40. Visual Display

41. Visual Display

42. Visual Display

43. Re-organisation of meetings
Spec Rec ICC General
Slide Cytology
Production
Office
Weekly Huddle Review
Histology Performance
Medical specialty team meetings

45. Benefits
• Daily ! Addresses issues immediately
• Clarifies duties
• Encourages feedback
• Staff know more about their role
• Ownership
• Motivating and enjoyable!

47. Staffing
Healthcare Science Assistants
 Embedding
Healthcare Science Associates
 Microtomy, ICC, EM prep, Supervision
BMS Team Leaders
 Supervision / Management
BMS Advanced Practitioners
 Histological dissection
 Reporting pilot

50. Improve safety
Histology Complete Request Forms 2012
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Mar-12
Jan-12
Feb-12
Apr-12
May-12
Jul-12
Aug-12
Jun-12
Oct-12
Nov-12
Sep-12
Jan-13
Feb-13
Dec-12
Mar-13

52. Detailed Team TAT

57. Thank you for listening
…any questions ?
terry.coaker@nuth.nhs.uk

58. 58
7th November 2012

63. New Technology - IT
• Order communications, Electronic Patient Record
• Bar coding
• Slide writers
• Tracking Radio Frequency Identification RFID’s
• Digital imaging
– Macro e.g. Macropath, Nikon
– Micro e.g. Coolscope, Aperio, virtual slides
• Voice recognition

64. Automation
• Embedding
• Motorised microtomes
• ICC to include antigen retrieval, DCM
• Special staining

65. Tissue Processing
• Microwave – now automated
• Continuous access
• 1- 40 cassettes every hour
• Formaldehyde and xylene free
• UMFIX Universal Molecular Fixative
• Danaher / Leica / Vision Biosystems Peloris XFP
• Milestone Pathos
• Siemens / Bayer / Sakura Finetech Histoexpress

66. Tissue Processing
Azorides R.Morales
University of Miami / Jackson Memorial Medical Centre
Requests Reported on
day of surgery
1996 23349 27
2003 30124 1177117733

67. Reporting
‘DGH’
Trim
Process
Report
Ideal ?
Trim
Process
Report
Trainee
‘Teaching’
Trim BMS /Trainee
Process
Report Trainee
Deepers / specials/ ICC
Trainee
Report Consultant

68. The Shingo Prize
for Operational Excellence
Cultural Enablers Lead with humility
Respect every individual
Continuous
Process
Improvement
FFooccuuss oonn pprroocceessss
EEmmbbrraaccee sscciieennttiiffiicc tthhiinnkkiinngg
FFllooww aanndd ppuullll vvaalluuee
AAssssuurree qquuaalliittyy aatt ssoouurrccee
SSeeeekk ppeerrffeeccttiioonn
Enterprise
Alignment
CCrreeaattee ccoonnssttaannccyy ooff ppuurrppoossee
TThhiinnkk ssyysstteemmaattiiccaallllyy
Results CCrreeaattee vvaalluuee ffoorr tthhee ccuussttoommeerr

70. ‘The Lean Champion is a Farmer’
Kegan and Lahey
Innovators
Early
Majority
Dogs Horses Sheep Goats
Lemmings Hyenas
20 30 30 20
Resistant to
change
Range of attitudes
“Wait and see”
“Show me”
Ready for change
“Lets get started!”
18th June 2007
Early
adopters
Late
Majority
Laggards
Rogers diffusion curve

72. Theory of constraints ?