CEO SUMMARY: DSI Laboratories of Fort Myers, Florida became the nation’s first hospital laboratory to apply the “Lean” quality management system to a high volume core laboratory. In just 13 weeks, DSI’s Lean team created a work cell which performs 80% of the test volume in a 400-bed hospital and is staffed by just two medical technologists! Turnaround time in the lab fell 51%, to an average of 35 minutes. In conjunction with its “Lean” project, DSI was also able to double the productivity of its phlebotomy team, with corresponding improvements in quality and turnaround time from collection to receipt in the lab.
THERE’S AN EXCITING EXPERIMENT in clinical laboratory management unfolding at DSI Laboratories, Inc. in Fort Meyers, Florida.
Earlier this year, the decision was made to implement the quality management systems of Six Sigma and Lean. DSI Laboratories is a for-profit division of the not-for-profit NCH Healthcare System. It serves two hospitals, 400-bed Naples Community Hospital and 100-bed North Collier Hospital, and maintains a thriving outreach testing program.
As noted on the pages of THE DARK REPORT in recent years, a growing number of laboratories are introducing quality management systems such as ISO-9000, Six Sigma, and Lean into their lab operations. What sets DSI Laboratories apart from their peers is an important decision: lab administrators at DSI decided to apply Lean and Six Sigma methods in a comprehensive reconfiguration of the high volume portion of laboratory testing at Naples Community Hospital.
Most laboratories introducing Six Sigma and Lean select a first project which, by definition, won’t disrupt critical testing operations if things don’t go right. By contrast, Lab administration at DSI waded right in. Its first Lean project tackled the high-volume testing core laboratory of its 400-bed hospital. DSI lab administration made this decision confident that: 1) Lean methods would deliver significant improvements in a relatively short time; and 2) its lab staff could learn and implement its first Lean project without any detrimental impact on daily testing operations.
Both assumptions were validated by the project’s outcomes, although the planned eight-week project actually took 13 weeks to complete. The Lean team designed a primary work cell that performs 80% of the lab testing which passes through the hospital’s lab. Upon implementation, average time to result (from receipt in the lab) improved by 51%, to 35 minutes.
This work cell, covering chemistry, hematology, coagulation, and cardiac enzymes, among others, is comprised of nine instruments. Because of the efficiency of design, this primary work cell can be run by one medical technologist at peak hours. In fact, every med tech in the laboratory has been trained to run the primary work cell alone. For practical reasons, the cell is generally staffed with two med techs.
At the Executive War College on Lab and Pathology Management in May, attendees got an early peek at the first outcomes from this ground-breaking effort to “Lean” the laboratory at Naples Com- munity Hospital. Martha Sunyog, DSI’s Administrative Director, presented a case study about the project, the process of change, and its impact on the laboratory’s customers.
“Planning for this Lean project began in the summer of 2002,” said Sunyog. “It was designed to generate downstream improvements from a Six Sigma project that tackled specimen collection and transport within the hospital.
“Within DSI, there is an off-site core laboratory that does routine testing for the two hospitals. This central lab is located about 30 miles north of Naples, in Fort Meyers,” she explained. “We call the labs at the two hospitals ‘immediate response labs.’ Naples Community Hospital does lots of open heart surgery, oncology, orthopedics, and has a busy emergency department.
“We decided to tackle the central laboratory at Naples Community Hospital for a simple reason,” observed Sunyog. “Everyone was working hard, but there was this sense that we could achieve a higher level of efficiency. Our objective was to eliminate the root causes of daily problems found in every laboratory— those recurring issues which frustrate and stress the lab staff.
“We wanted tighter control over work processes, a better way to measure outcomes, and management tools that would allow us to continuously refine and streamline our lab operations,” she continued. “We were looking to break out of our status quo and boost our lab’s performance by a significant amount. Our Lean project was not about doing 5% or 10% better. It was about doing 30% and 50% better. Our goals were ambitious.”
To teach the principles of Six Sigma and Lean and guide the initial projects, DSI engaged the Process Excellence team from Ortho-Clinical Diagnostics, a division of Johnson & Johnson Company. “Their role was two-fold,” Sunyog explained. “First, they were to train our lab managers and staff in the philosophies, methods, and tools of Six Sigma and Lean. This training is designed to allow us to successfully design and complete Six Sigma and Lean projects on our own.
Why DSI Labs Chose To Plunge into “Lean”
“OUR MOTIVATION TO INTRODUCE Six Sigma and “Lean” techniques into our laboratory was rooted in the need to meet the needs of our clinicians throughout the hospital,” stated Paul Gotcher, CEO of DSI Laboratories.
“We recognized the contradictions. On one hand, our lab staff works at a relentless pace day after day to do the best they can,” continued Gotcher. “On the other hand, when we surveyed our customers—the emergency department, the ICU, and other areas of the hospital, we were told that turnaround times were inconsistent and their perception of the lab didn’t always reflect the hard work we put in on our side.
“We recognized that Six Sigma reduces variation and that, by removing variation, our lab’s quality would improve,” Gotcher explained. “Lean thinking is about removing waste, streamlining processes, and moving work through the system as fast as possible.
“Our first Six Sigma and Lean projects have delivered exactly these types of benefits. If our laboratory looks different, that’s because it was designed by people who come from non-laboratory environments. But these folks, and the techniques of Six Sigma and Lean, helped us create a lab that is much better at meeting the expectations of our customers,” declared Gotcher.
“These early projects have trans- formed the culture of our laboratory,” he observed. “We see everything from a new perspective. It’s exciting to implement changes which push us toward goals that we once could only envision—but now are within reach.”
Coaching And Training
“Second, they were to guide us through the first projects to insure that evaluation, planning, implementation, and measurement were carried out properly and in a timely fashion,” she said. “We wanted both pieces, because the strategic objective for our laboratory is to create a management knowledge base that allows us, without consultants, to continuously improve lab quality and productivity into the future.”
With Sunyog as “champion,” the Lean team included Sunyog, two candidates working on their Six Sigma black belt designation, two med techs, a histologist, and a lab assistant. These individuals were released from normal duties and assigned, full-time, to the Lean project until its completion.
“Without this full-time effort, we could not have accomplished what we did,” observed Sunyog. “For a lab our size, this was a considerable investment of human resources. But it allowed us to achieve a substantial management breakthrough in our laboratory.”
All the Six Sigma and Lean efforts in the laboratory were designed to improve how the laboratory supported critical care in the hospital. A Six Sigma effort had earlier tackled the challenge of reducing the time from test order to receipt of specimen in the laboratory. This effort involved phlebotomy and: 1) shortened the average time between order and receipt of specimen in the lab by 30%; while, 2) generating an even flow of specimens into the laboratory.
Value Map Of The Lab
The Lean project’s objective was to improve the lab’s performance in receiving the specimen and reporting the result. “Our first step was to diagram the existing work flow and map our existing value stream,” Sunyog noted. “In our lab, it was possible for tubes of blood to go in all sorts of directions. That increases the possibility for mishandling, misplaced tubes—all the types of mishaps we deal with daily.
“Along with mapping our existing work flows, our consultants came into the laboratory to take photographs and videotape work processes,” she said. “Talk about an eye-opener! The photographs and the videotape showed us why everyone was so stressed handling the daily workload. In viewing our lab through the perspective of Lean, we realized how unstructured our laboratory actually was.
“Boxes and supplies were stored in inappropriate places. Different med techs had different ways of handling the same work. The power of the photographs and the videotape is that you cannot deny the conclusions, because the film so graphically demonstrates the inefficiencies and waste that were part of our laboratory at that time,” observed Sunyog.
“Two guiding principles of Lean are eliminating waste and establishing standard work,” she added. “Photographs and video tape let you see precisely how the existing layout and work processes of your lab impede productivity and quality. More importantly, to be successful with Lean, one has to be willing to recognize waste, call it waste, and take steps to eliminate waste. That requires courage from lab managers, because it means they must literally acknowledge that much of the operational activity in their lab, for which they are responsible, needs corrective work.
“We certainly had to confront that dynamic. The Lean project proposal was to create two work cells. The primary work cell would handle 80% of the lab’s test volume. The secondary work cell would handle the remaining 20%. Histology was not involved and will be addressed in a separate Lean project.
“…to be successful with Lean, one has to be willing to recognize waste, call it waste, and take steps to eliminate waste.”
“Initially, it was a leap of faith to commit 80% of our lab’s testing into a single work cell,” she stated. “Everyone in the laboratory likes to see redundancy and we were going to change many of our long-standing work practices. But redundancy is an integral part of Lean. As we learned more about this management system we better appreciated how it boosted quality and productivity even while improving back-up capabilities.
“With limited space, I’d like to describe some of the key design elements that make our primary work cell successful,” said Sunyog. “First, all the instruments in the work cell are automated. So it doesn’t make sense a med tech to load the instrument, then stand by waiting for results.
“To resolve this, the work cell is laid out so that the med tech moves, in an orderly fashion, around a circuit, sequentially loading or unloading instruments,” she explained. “This means the med tech is moving continuously and results are generated continuously from all the instruments.
“The second concept is continuous flow of testing, not batch,” added Sunyog. “This is counter-intuitive to most lab managers. Batch is considered efficient. But in a hospital lab, faster turnaround time (TAT) for critical testing is the goal and TAT is better served by continuous flow. We changed several elements of our work processes to encourage continuous flow.
“In phlebotomy, the Six Sigma project taught phlebotomists to complete a draw, then use the pneumatic tube sys- tem to send that patient’s specimen directly to the lab. As each specimen reaches the lab, it doesn’t sit in accessioning, because we decentralized that function. As both lab assistants and phlebotomists walk through the lab, they pick up specimens just arrived in accessioning and carry them to color-coded racks at the primary work cell.
Continuous Test Flow
“The third concept is that everyone must take responsibility to maintain continuous flow of specimens through the lab,” offered Sunyog. “For example, anyone who walks by and sees a tube in a rack waiting to be loaded into a centerfuge will stop. They will unload/load the centerfuges.
“Not only does this accelerate a single tube’s journey through the lab, it avoids that familiar problem of accessioning spending 45 minutes loading 300 tubes into racks, then dumping them on the techs, who then rush to meet TAT deadlines,” explained Sunyog. “This is the type of stress I mentioned earlier. Under our old sys- tem, people worked hard to do a good job. But it was flaws in that old system which generated the stress.
“With Lean tools, we are reconfiguring our work flow in ways that reduce stress on the lab staff, while allowing them to do a better job meeting goals for quality and turnaround time. In turn, this improves patient care in our hospital.”
These details are just a sampling of the radical transformation that occurred in the laboratory at Naples Community Hospital. Not only did the principles of Lean management touch every aspect of laboratory operations, but the laboratory has made huge improvements in a variety of operational measures.
“In support of critical care for our patients, we’ve cut average turnaround time for tests by significant amounts,” Sunyog said. “Total TAT from request to result declined from 129 minutes to 66 minutes, a 49% reduction. TAT from receipt in lab to result declined 51%, from 70 minutes to 35 minutes. Because of speedier time from collection to test result, specimen quality is enhanced. We’ve reduced product travel of tubes by 92%. These changes boosted the quality of our test results.
“Overall, we reduced the number of medical technologists from 19 to 15.5,” stated Sunyog. “However, the real impact can be seen on different shifts. On our day shift, we had six to seven techs per day. We can now do it easily with four even during our busy season. Overall, our post-Lean lab operates with 7.6 fewer FTEs.”
As the results posted by DSI Laboratories demonstrate, effective application of the principles Lean can trigger substantial improvements in a wide variety of laboratory performance measures. Moreover, DSI Laboratories, because it invested in training, has established a knowledge base within its laboratory that can perpetuate these projects.
Lab Quality Measures
THE DARK REPORT will track subsequent Lean projects at DSI Laboratories, because the story is not in a spectacular one-time gain from a single project. DSI Labs is undergoing a management and operational transformation. It is learning—and mastering—a new perspective on laboratory operations, along with a new set of management tools to continuously harvest quality and productivity gains. Their success will be both the inspiration and the example for other laboratories to emulate.