There is so much talk of Lean as it relates to the lab industry in the literature and at conferences these days that one may wonder what’s so magical and wonderful about Lean that so many profess to practice it in one form or another. Our lab had two unique opportunities to design a Lean lab. First, the clinical laboratory moved from its cramped, compartmentalized quarters into a new space with state-of-the-art analyzers and an updated floor plan. The second opportunity came when the hospital decided that after a decade of sending out pathology specimens that it would once again house a full service pathology department. The thought process and decisions for floor plans and equipment were vastly different than that of the clinical laboratory. There was no template to follow since it had been so long since a pathology department existed at Catholic Medical Center (CMC). This article is the first in a series that will explore how decisions were made concerning floor plan, equipment choices, pathology laboratory information system choices and morgue space design and equipment. Ultimately, and perhaps most importantly, we want to share our results: What has been the result of over a year of planning and implementation to achieve a fully functioning Lean Pathology Department? How did Lean work for us?
About Catholic Medical Center
CMC is a 330-bed, full-service healthcare facility located in New Hampshire’s largest city, Manchester. It is host to 25 subspecialties, the largest of which is the New England Heart Institute, one of the premier cardiac treatment facilities in New England. The hospital has an estimated 110,000 patients per year and the Obstetrics facility, aptly named The Mom’s Place, averages over 900 births per year. The Emergency Department has about 37,000 visits in a year’s time. The cardiac surgeons perform approximately 450 cardiac surgeries per year. There are 11 primary care physician practices and an affiliation with the Norris Cotton Cancer Center, a full service oncology practice. CMC is a thriving, mid-sized community hospital.
The implementation team at CMC.
Prior to May 2007, CMC did not have a hospital-run laboratory. The laboratory was managed by a commercial vendor, maintaining only a stat lab and a blood bank on site; everything else was sent to the main vendor laboratory for testing about 40 minutes away. Pathology testing was completely outsourced. May 2007 was the starting point to bring full service laboratory services back to CMC. In less than two years after the laboratory implementation, the facility moved into a new lab on a different floor and, as of FY 2010 the lab’s 84 FTEs have processed over 736,000 billable tests. The laboratory is also responsible for 7 Patient Service Centers (PSC) including an Oncology service. The PSC’s alone saw 58,869 patients in FY2010.
Pathology Project Defined
Based on the typical volumes of pathology testing that were being sent out, a decision was made to explore the possibility of bringing a Pathology service back to CMC. Part of the plan involved moving the Clinical Lab from its existing space to a new location on a different floor of the hospital. The plan required the space allocated for Pathology to be completely gutted and rebuilt to specifications that could accommodate a full service Pathology laboratory. The administration at CMC was completely committed to the project and it was placed on a high priority list of projects for funding. A budget was established as well as a business plan that involved projections based on current pathology send outs, staffing estimates, budgets for construction and equipment procurement.
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It was during this preliminary stage of planning that the decision was made to involve strict Lean planning into the construction design, equipment choices and staffing decisions. Basic team members were defined to incorporate facility planning, informatics, equipment choices, staffing and specimen flow. Core team members consisted of the medical director, laboratory director, laboratory manager, pathology supervisor and laboratory information system analysts. Additional team members included the CMC architect (who accompanied the core team on site visits to other labs), CMC’s owners rep and equipment and supply vendors. A key factor early in the planning was to incorporate the vendors we would be purchasing the majority of our equipment and supplies from as partners in the project. The importance of this will be explained in follow-up articles when the Lean in action is detailed.
The core team members met weekly and discussed an ongoing agenda consisting of large functional categories including facility, equipment, staffing, informatics and outreach.
Keeping to the same basic agenda, assigning action items and tracking key phases in the project proved an essential element to the overall success of the project. Also key was the incorporation of a shareholders committee made up of representatives from OR, endoscopy, IT, patient transport, security, facilities management and nursing. Many of the processes these departments were accustomed to would change and including them in the planning helped to give everyone a sense of ownership in the project.
While the planning of the various committees proceeded, the pathology supervisor began meeting weekly with our major equipment vendor’s Lean Six Sigma specialist. Preliminary workflows and work schedules were formulated as were review of the physical layout and projected equipment placement. As we began to track the types of specimens that were being sent out, preliminary processing schedules were formulated based on expected processing times and the benchmarked times recorded by other institutions for the other tasks associated with a fully functioning pathology lab. Completion of the project was a full six to eight months away but a preliminary workflow and staffing projection based on workload and workflow began to take shape. The committees continued to meet and interact with the workflow specialist as equipment choices were finalized and consumables were identified. The next step was interviewing staff and including the concept of Lean staffing and workflow up front in the process. A large part of staff selection would be their reaction and acceptance of a new way of practicing pathology: As a lab without a third shift or weekend work that was capable of producing as much or more than traditional pathology labs.
Next in the series will be how we incorporated Lean into each section of Pathology:
(2) Accessioning and Gross Using Bar coding and Voice Recognition Software, Histology and IHC: Bar Coding, Specimen Tracking and Software Interfaces are Key to Lean, (3) Cytology Processing and Screening, (4) Pathologist workflow and sign-out: Voice Recognition Software and Middle Ware to Reduce the Need for Traditional Transcription and Reduced Turn Around Times, (5) How is Lean working for us after being operational for 6 months, and (6) Lessons learned from initial planning to where we are now and future plans to maintain our gains.
Roberta Provencal is laboratory director and Stephen A. Feher is pathology supervisor at Catholic Medical Center in Manchester, NH.