CEO SUMMARY: Like many labs today, the gynecologic cytology laboratory at the University of Iowa Hospitals and Clinics had a pre- and post-analytical work flow with many complex steps. This work flow—heavily influenced by a legacy of previous information systems—was inefficient, contained unnecessary redundancies, and lacked systematic measures for preventing errors. That all changed when the Department of Pathology did its first Lean project, greatly improving work flow and staff productivity.
IN RECENT YEARS, LAB MANAGEMENT at the University of Iowa Hospitals and Clinics in Iowa City, Iowa, became suspicious that work processes within the cytology laboratory were less than optimally efficient. Management had confidence in the competence and capabilities of the entire laboratory staff, but discussions about the pre-analytical and post-analytical phases of the workflow always seemed to lack a solid, consensus understanding.
Efforts to modify workflow proved frustrating because the myriad of steps were not well understood. Management wanted to understand why seemingly simple changes could not be implemented easily. Frontline staff wanted management to see and understand the full picture. The lack of a consensus understanding was creating tensions, and, despite the best intentions to improve processes, the same pre-analytical and post-analytical processes remained in place. However, that all changed this spring when, for the first time, staff in the Department of Pathology applied Lean methods to stream-line, simplify, and improve each step from specimen receipt to billing.
“The results were remarkable!” noted Kent Becker, MT, CLS, Anatomic Pathology Coordinator, who led the Lean team on this process improvement project. “We were able to slash the number of decisions required in pre-accessioning and technical and professional billing by 37%, from 49 to 31. At the same time, we eliminated 41% of the work flow steps required in these areas. We reduced the total number of process steps from 138 down to 82.”
Steps to Improvement
These achievements were so impressive that, when the University of Iowa Department of Pathology presented its Lean strategy as a poster at the Lab Quality Confab in Atlanta last month, judges awarded it First Place in the anatomic pathology category. Along with this recognition came an award check of $2,000.
“This was our first Lean project,” recalled Becker. “We studied work processes involved in gynecologic specimen receipt and accessioning. We transformed the process from a batch-and-queue workflow to single piece flow. We also eliminated process constraints and put in a systematic way to reduce labeling errors. Following implementation of the new work processes, staff has flexibility in managing the workflow—rather than having to wait almost two hours for the flow of specimens to reach their workstations.”
The team also identified and eliminated inefficiencies in billing processes. Today, the previously complex processes are well understood and well documented, allowing the 18,000 cytopathology specimens the lab processes each year to move through smoothly and efficiently.
The story is particularly useful for any lab manager who may have inherited complex processes that have been resistant to improvement. These are legacy processes that commonly are rationalized by the phrase, “that’s just the way we’ve always done it.” In addition to Becker, the Lean team included Operations Manager Jeanne Myers, Financial Officer Rose Meyer, Cytotechnologist Chad Hoffman, Clerk Typist Cheryl Lown, and Laboratory Technician Tanika Moreland.
The problem for this team was that, prior to the Lean project, no one person in the cytopathology lab at the 680-bed UI Hospitals and Clinics, an academic medical center in Iowa City, could fully explain the rationale for the existing pre- and post-analytical processes.
“We didn’t completely understand why we had all these steps from pre-accessioning through billing,” Becker explained. “After so many years of doing these steps, staff accepted this situation as ‘the way we’ve always done it.’ There was no documentation from the people who created these work steps to explain their purpose. Over the years, people had moved on, but the work processes they established remained. Existing lab staff followed those same processes simply because they always had.
“It was needlessly cumbersome and frustrating,” he said. “At times, even talking about it was frustrating because the staff that performed it everyday couldn’t always explain it sufficiently. In the past, we had managers who tried to understand it but could never grasp the full scope of the process to make good decisions about how to fix it.
“When the Lean team was formed, we decided that the way to start was to do a full-blown process analysis,” continued Becker. “So, the team developed detailed process maps to identify all the steps in the processes and to assess for deviations from Lean principles, sources of waste, and process steps that created defects.
“Using sticky notes and a dry-erase board, the team identified every step in the pre- and post-analytical processes,” he said. “Then, we converted the notes from the dry-erase board to formalized electronic process maps. The process mapping proved to be a key analysis tool because it facilitated a consensus understanding and a thorough assessment of the ‘as is’ process. This analysis unraveled and documented a complicated workflow, allowing us to see why the situation created frustration.
The Need to Ask Why
“Once we had the process written out on paper, we used the 5-Whys tool to ask ourselves this question over and over: ‘Why do we do it this way?’ Everything about our processes revolved around batching our specimens,” he explained. “We had to drill down into the reasoning. The 5-Whys tool requires that you keep asking ‘why?’ about every step until it becomes absurd to ask anymore. You can’t ask why only once. If you do, you get only a surface reasoning. You have to keep asking ‘why?’ until you get into the real rationale behind what you’re doing. It’s almost annoying for some. But when used appropriately, it’s helpful and revealing.
“You can’t begin to change a workflow before you fully understand its ‘why?’,” he said. “Without that understanding, potential changes could actually worsen the existing situation. It is imperative to know which work flow steps add value and which do not.
“Once we had that information, we could identify each process step as either adding value or simply waste,” he observed. “That meant we knew the value-added steps to keep while eliminating the ones that didn’t add value.
“Each part of the process analysis allowed us to see the peaks and valleys in production,” Becker continued. “We didn’t want anything waiting in queue or have any specimens set aside in batches. In Lean, batching is inefficient because it prevents a continuous flow in the system. It introduces spikes in production processes and your work backs up. Then, the next process inherits that pent-up supply. For the sake of the downstream processes, we aimed for a continuous flow.
“To eliminate spikes, we investigated and measured the specimens held in waiting,” he said. “We looked at time stamps on requisitions to know how long they were delayed from receipt until accessioning. We found that—even though we had staff ready to start work at 8 a.m.—each day staff had to wait for up to two hours before they were processing specimens.
“The process mapping showed that staff couldn’t do certain parts of their work until 9:20 a.m or 9:56 a.m. each morning,” stated Becker. “That meant that even though the area was staffed for eight hours of capacity each day, they were, in reality, constrained to about 5.5 hours of time they could devote to these processes. The staff was known to be productive in the meantime and the work was getting done, but the current process limited the lab’s ability to ‘flex’ its production across that full eight hours or to adapt whenever unexpected increases in volume occurred.
Challenging But Rewarding
“Once our Lean team identified all the places where we could eliminate waste, we redesigned the process on paper and then did feasibility trials to see how it would work through trial and error,” Becker continued. “The new processes came close to working right away. The diverse representation and talents of the team members were key because feasibility was essentially “baked-in”. We did make minor adjustments here and there, such as how and when we applied labels. Even though we made minor tweaks, there was no option to revert to the old way.
“From all of this, we learned that a process-focused, employee-involved approach to operational management can effectively identify and address problems and inefficiencies in lab workflows,” Becker concluded. “The application of Lean principles effectively reduced waste within the laboratory’s processes. It is proof that manufacturing-based quality improvement methods can be used to improve operational efficiency and effectiveness in a clinical lab.
“In addition, these process changes have yielded opportunities for improvements in related processes,” he said. “The team from this project has made recommendations for other process improvements in the laboratory, creating momentum for continuous improvements throughout the laboratory.
“Overall, this was a challenging but rewarding Lean project that showed the value of applying quality improvement methods from manufacturing to the lab,” he said. “Also, it helped us to close the gap between the frontline personnel and the operational management people.
“What was more rewarding than actually tweaking processes was proving that these things work,” added Becker. “Now we have a new management approach and a new set of operational tools that we can apply to other processes. As an institution, we are in our Lean infancy. But this project gave Lean credibility with our staff, and there is enthusiasm and interest for us to apply Lean in various other areas or our laboratory in the future.”