CEO SUMMARY: Long-standing work flow traditions in anatomic pathology provide fertile ground for improvement with Lean and similar process improvement methods. That was the case at Henry Ford Health System, where empowered teams in the pathology laboratory employed the principles of single-piece/small batch work flow, “pull”, and standard work. The outcomes were reduced defects, improved productivity, and a reduction in average turnaround time in specimen processing of up to 50%!
INNOVATIVE LABORATORIES are using Lean methods and new automated systems to transform workflow. The goal is to dramatically reduce defects and inefficiencies, while improving quality and saving considerable amounts of money.
Henry Ford Health System in Detroit, Michigan, operates one of the nation’s largest health system laboratories. It is using Lean and similar process improvement methods in pathology to unlock remarkable gains in productivity and quality, including a 50% reduction in average turnaround time.
“It was 2005 when laboratory managers introduced The Henry Ford Production System,” stated Rita D’Angelo, the Pathology Department’s Quality Improvement Specialist. “This quality improvement process is modeled on the Toyota Production System, which inspired the Lean methods that are widely used today.
“As a result of this system, we now perform hundreds of process improvement efforts every year,” D’Angelo said. “Our strategy is for pathology lab staff to work in integrated teams and to encourage multiple teams to work together to achieve mutual goals.”
Since 2005, the pathology department has applied process improvement to a wide variety of routine processes. These cover every aspect of specimen processing, including workload smoothing, accessioning, and sample identification. “At the time this effort was launched, Henry Ford Health System did not invest in outside consulting services,” noted D’Angelo. “Instead, laboratory administration asked our laboratory staff to develop ideas for process improvement and take the lead in implementing these ideas.
Implement Process Redesign
“However, before we could implement process redesign, we needed to change the existing culture in our laboratory,” explained D’Angelo. “Micro-management was common, as was an atmosphere of persistent blame. People were afraid to talk and team members were reluctant to share their ideas. Micro-management had to stop and staff needed to feel empowered to contribute ideas and to implement improvements to the system.
“A major first step in our redesign of work flow was to identify and implement standard ways of performing our work,” she said. “As Lean practitioners know, it is essential that employees who perform this work are the ones who evaluate and develop the standardized work. This needs to be a ‘bottom up’ effort, not a ‘top down’ directive.
“The cornerstone of our histology lab’s efficiency is continuous flow, designed to pull specimens through the lab using the single piece/small batch method,” she stated. “With this system, we pull small batches through the system rather than doing work in large boluses that can overwhelm a work station and add delays.
Creating Continuous Flow
“Before Lean, our anatomic pathology processing laboratory was like many others,” she noted. “Most specimens arrived in the morning and that is when the majority of staff worked. Now, specimens flow in throughout the day and our staffing stretches out to accommodate that work.
“In the beginning, we quickly learned how much we didn’t know about our histology lab,” added D’Angelo. “For example, we had no clue about how many specimens came through the system at any given time during the day. We did not know how many specimens were in the gross station or how many specimens were in each processor.
“It was the same for the activities of our histotechnologists,” continued D’Angelo. “Without knowing how many blocks and slides each histotech handled, we lacked the criteria for evaluating workload. Lean changed all of that. We now constantly collect data on all of these activities and make improvements as we go. The improvements and benefits are often quite impressive.
“For example, one of our most significant improvements involves how we process prostate specimens,” D’Angelo said. “Standard work was the tool we used to eliminate variation. We determined that our existing method for handling prostate specimens required that about a third of them be resubmitted for processing because they were improperly fixed.
Implementing A New Protocol
“To prepare a prostate sample for analysis, our new protocol is to inject every prostate sample that comes in with formalin to improve fixation time,” she said. “Prior to this process improvement project, it was common for our lab to reject about 31% of samples due to unfixed tissue blocks and poorly-cut slides. Each rejected sample had to be resubmitted because it couldn’t be processed as is.
“Following our improvement process, the reject rate was lowered by one-third, to 21%. This was an important benefit. The reduction of 10 percentage points allowed us to shorten an average four-day processing time to three days! The key improvement was a simple revision to the prostate injection process, along with standardizing workflow.
“Another significant improvement involved batch size reduction,” she said. “In 2005, we would accession specimens in one large batch. Specimens would be crammed into huge pink buckets—in no order whatsoever.
“Also, in anatomic pathology we handled each specimen at least five times involving about six steps. Accept it in the lab, take it out of the baggy, identify it, record it, put it back into the baggy, and replace it in the bucket,” recalled D’Angelo. “Post-Lean, our histotechs take a specimen out once and put it into a workcell tray that includes specimen container, the requisition, and the cassette. This is accomplished in four steps.
“As a result, accessioning time was cut by 50%!” she stated. “It was a simple solution, reducing the number of steps from six to four. As part of this project, we instituted a different color tray for each type of tissue work stream or priority.”
Batch Size Reduction
Henry Ford Health’s anatomic pathology laboratory applied the single piece/small batch method to other areas of work flow, with similarly impressive results. One big opportunity was to apply Lean to the common practice of batching and processing all of the day’s specimens overnight.
“This is a situation common to most hospital-based histology laboratories,” noted D’Angelo. “Typically, all the day’s specimens are in the lab by 8:00 p.m., but there is no staff in the laboratory in the evening to handle that work.
“To handle that large volume of specimens at Henry Ford, we started our accessioning staff at 5:00 a.m.,” she explained. “Not only did that mean our histology specimens sat for nine hours untouched in the lab overnight, but it also required us to staff a sizeable number of people in the early morning to process that large volume of specimens.
“By implementing a work flow based on single piece/small batch in a continuous flow, we could schedule techs throughout the day to avoid that ‘big batch rush’ at 5 a.m. each morning. Staffing is now balanced across all working hours. We implemented a second shift to support single piece/small batch work flow throughout the day.
“We identified another opportunity to level the workload and support ‘pull’ in the work flow,” explained D’Angelo. “We instituted a standard of 20 slides per pathologist per tray.
“This simple solution supports ‘pull’ because each histotech only produces what is needed to pass work forward to the next step in production,” she said. “The standard of 20 slides per pathologist per tray eliminated a source of individual bottlenecks because we removed inventory stores between each work cell.”
Deployment of the Henry Ford Production System and use of its Lean methods has paid big dividends for the anatomic pathology laboratory. These encompass multiple benefits. “Collectively, these process improvement projects have slashed average turnaround time from one day to 12 hours in anatomic pathology,” said D’Angelo. “That’s a 50% improvement and directly contributes to improved patient care.”
Successes From Use of Lean
Use of Lean and the Henry Ford Production System by this pathology laboratory demonstrates the power of these quality management methods to unlock major gains, often in improvement projects that deliver results in just a few weeks. Wider adoption of Lean and similar quality management approaches will trigger fundamental changes in basic operational practices in histology and pathology labs across the country.
The Department of Pathology at Henry Ford Health System has been recognized for its effective use Lean methods. At both the 2007 and 2008 Lab Quality Confab conferences, Lean Six Sigma poster presentations given by D’Angelo and her colleagues won national awards, accompanied by cash prizes.
THE DARK REPORT observes that the experience of the pathology department at Henry Ford Health provides an example of how long-standing operational practices and work flow arrangements in the profession are giving way in the face of new management approaches and new automation solutions. Often, pathologists overlook the fact that when Lean management methods are combined with automated histology systems, a totally unorthodox work flow often results.
However, this unorthodox work flow generally produces higher quality pathology services, at a lower cost and with fewer errors. These are all important benefits at a time when the pathology profession is undergoing transformation by molecular technologies and digital pathology systems.
Recognition of these trends is one reason why growing numbers of histology laboratories and pathology groups are introducing Lean methods into their organizations. It also shows why the competitive bar is being raised in the anotomic pathology marketplace.
Lab Staff Finds a Way to Mistake-Proof Handling of Anatomic Pathology Specimens at Accessioning
ONE FERTILE OPPORTUNITY for mistake-proofing involves selecting an accurate body part type at accessioning. Existing work practices at many histology laboratories allow an unacceptable rate of defects to occur at this step in specimen processing.
At Henry Ford Health System, Quality Improvement Specialist Rita D’Angelo shared how the pathology department used the methods of the Henry Ford Production System to attack and fix this problem. “When a biopsy is collected in a doctor’s office, office staff put the biopsy and the requisition into a bag and send it to the laboratory,” she said.
“But, often, that specimen arrives in pathology without a correct body-part type,’ explained D’Angelo. “This presents a problem for accessioners, who must identify the body-part type. Accessioners will add the information they have into the database and then estimate the body-part type from a drop-down menu box provided by the computer system.
“Many times, accessioners pick the incorrect part type,” D’Angelo said. “Our process improvement team identified this as a high-payoff opportunity.
“A first step was to collect data to determine the rate of body-part type identification errors,” she continued. “To accomplish this, a white poster board was hung in the histology gross room and other poster boards were placed in the pathologists’ work areas. Each time a body-part type error was identified, that individual was asked to record the event on the poster board.
“This data collection effort generated interesting numbers,” observed D’Angelo. “We tallied 123 problems from a population of 1,690 specimens. That’s an error rate of about 7.3 %, which is significant. Further, each mistake is frustrating for the pathologists at the end of the line. When a pathologist working with such a specimen detects an error, he or she must take additional time to correct all the information required to produce an accurate report.
“Informed by this data, we recognized that this problem encompassed several departments,” she said. “We next evaluated the 2,000 body-part types listed in our laboratory information system (LIS). Pathologists reviewed the list to make sure each item was accurate and up-to-date.
“This corrected list was used within the lab for training,” continued D’Angelo. “We now also inservice the clinicians and their staffs who originate and label these specimens. This entire improvement project took about eight months, from validating the database list to staff training and clinician education.
“It was well worth the effort,” noted D’Angelo. “Our lab saw the number of errors tied to body-part type fall from 123 to just one! By any measure, that is a significant success in mistake-proofing.”