Vol. 24 • Issue 2 • Page 26
For years, lean principles have led to successful outcomes in the manufacturing industry, but only recently have they been applied in healthcare settings. Lean principles work by eliminating non-value added processes, ultimately leading to reduction in waste – cost, time and errors – thereby optimizing quality and patient safety. Many microbiology laboratories have successfully implemented lean practices over the past decade; however, the changing landscape of technology available to microbiologists has compelled laboratories to reexamine their processes to achieve maximum efficiency and quality.
There is much published to assist laboratories in utilizing lean tools such as 5S (Standardized Clean-up), Spaghetti Diagrams and Value Stream Mapping and the author encourages referencing the literature for basic information for application. This article provides a review of lean principles, focusing on how the recent advances in technology support a new look at workflow and processes in the microbiology laboratory.
Basic Lean Principles
Lean principles began in the manufacturing industry with the Toyota company and are based in the concept of Kaizen, or quick rapid improvement projects and a never ending quest for perfection. When Toyota leaders first employed these principles, their goals were to reduce variation and minimize waste (non-value added activities) to achieve a more efficient work stream. Management’s role was to respect the people involved and seek input from those doing the work as they best can, and to identify how to redesign processes to improve flow and reduce waste. In healthcare today, increasing costs and decreasing reimbursements, mandated reporting of hospital outcomes and the demand for decreased length of stay warrant increased scrutiny of hospital and laboratory process and systems.
In the laboratory, challenging factors also include a decreasing labor pool, aging technologist population, increasing test menus and changes in technology. Applying lean principles to achieve identified goals is now more timely than ever.
The cornerstone of Lean principles lies in identifying and removing non-value added activities or waste that occur during routine operations. This waste is known as “muda,” named by Toyota’s chief engineer, Taiicho Ohno, who identified two types of muda found throughout an organization’s processes.
• Type 1 Muda: practices that can be eliminated immediately. “That doesn’t work anymore. Let’s stop doing that.”
• Type 2 Muda: required for the way things are currently done and cannot be eliminated (e.g., inspection, regulatory).1
A systematic examination of all activities in a laboratory is crucial in identifying waste. One easy way to start your lean implementation is to use the examples below to identify muda or non-value added activities.
There is an 8th waste often described that relates to unclear expectations, ignoring employee ideas and untapped human potential. For a lean project to be successful, strong leadership is imperative for change management. Leadership must be open to suggestions, willing to accept failures along the way and celebrate successes. An effectively managed lean project results in employees who have job satisfaction, are engaged and will continue to contribute to future continuous improvement.
Lean Trends in Microbiology
Rapid and molecular identification methods in microbiology are geared toward generating actionable results faster than conventional and phenotypic methodologies. Most laboratories employ a combination of some of the following:
• peptide nucleic acid fluorescent in situ hybridization (PNA-FISH),
• microarray nucleic acid test (e.g., Nanosphere’s Verigene),
• DNA sequencing, and
• matrix-assisted laser desorption/ionization time of flight (MALDI-TOF).
With the advent of contained systems no longer needing multiple workspaces and the production of clinically useful rapid results, the testing milieu of the laboratory is changing. Workspaces, testing algorithms and staffing schedules need to be re-designed. New strategies and functional systems are needed for optimal functioning and efficiency in today’s laboratory.
Mayo Medical Laboratories in Rochester, MN recently published their experience with a two-year lean project to improve efficiency in their high-volume clinical molecular microbiology laboratory.2 Specimen routing, manual result entry in the laboratory information system and a secondary review of results prior to release were identified as processes requiring improvement. Their approach to problem solving involved the following actions important to any lean project:
1. Education – creating a culture focused on customer care and eliminating waste
2. Obtained input from laboratory staff; challenged current ways of working using web-based tools
3. Developed Kaizen team to conduct value stream mapping for rapid process improvements. One creative strategy was to use Lego blocks to simulate how one seemingly small change affects the whole.
4. Adopted small changes-pilot on a small scale.
Here are some of the changes implemented by the Mayo staff to help reach their goals.
• “First In First Out” specimen processing (no batching)
• Instrumentation relocation to reduce travel
• Consolidation of instrument platforms to minimize waste and maximize number of assays performed
• Use of electronic interfaces to reduce human errors
• Increased preventative maintenance on equipment enabling more uptime
• All work completed on day and evening shift (elimination of overnight and Sunday shifts)
• Work shift time changes to match new work processes
Following their lean implementation, they demonstrated a statistically significant reduction in turnaround time by decreasing batch size and keeping technologists focused on the work at hand, ultimately reducing errors. The success rates for four different assays ranged from 85.1 percent to 94.9 percent and were sustainable during a ðmonitoring period of seven months post-lean implementation. In addition, costs were reduced, testing capacity increased and level distribution of work across all shifts was achieved.
Another example comes from Children’s Medical Center, Dallas, where Microbiology Supervisor Shari Young states that re-leaning was important following the addition of new molecular platforms such as MALDI-TOF. “With the implementation of the MALDI-TOF and molecular techniques, we’ve reduced the number of additional kits and supplies needed for organism identifications. This reduction in additional testing has resulted in a cost savings in supplies and has decreased the workload for our staff. The staff now has additional time to assist other areas of the department that may need support, resulting in level loading of the work in all areas and better turnaround times. Another positive outcome has been staff satisfaction. Our team is very proud of the department, the work that they do, and all that they have accomplished,” Young stated.
Young’s observation properly summarizes the changes that occur with the introduction of rapid methods and how the lab needs to respond. It also emphasizes importance of staff involvement and its positive impact on staff satisfaction.
With current demands on the clinical microbiology laboratory, including the need to be fiscally sound, provide rapid actionable clinical test results in the presence of a qualified laboratory personnel shortage and the ongoing need for quality and patient safety, laboratories need to apply their efforts in a smart manner. Lean principles provide a systematic way to examine every process in the laboratory, identify ðopportunities for improvement and utilize lean tools to do more with less. For a lean project to be successful and sustained, strong leadership in change management is required. Lean must become an accepted, supported culture change of continuous improvement in the laboratory for laboratories to thrive in the future.
Deborah Blecker-Shelly is manager, Clinical Microbiology, The Children’s Hospital of Philadelphia.
1. Graban M. (2009). Lean Hospitals. New York: Taylor and Francis Group.
2. Mitchell PS, Mandrekar JN, Yao JD. Adoption of lean principles in a high-volume molecular diagnostic microbiology laboratory. J Clin Microbiol 2014; 52:2689-2693.
Sidebar: Common Lean Goals
• Reduced turn-around times
• Increased quality and patient safety
• Reduced cost
• Increased test capacity
• Improved employee retention and satisfaction