Implementation of Lean in Laboratory Medicine Services

1
Implementation of Lean in Laboratory Medicine
Services

• Stephen S. Raab, M.D.
• Department of Pathology, University of
  Pittsburgh, Pittsburgh, PA
• Reducing Waste and Enhancing Value in Health Care
  Delivery
• September 27, 2007

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Purpose of Lean Implementation

• Initially, we needed a quality improvement method
  for our AHRQ RO1 Improving Patient Safety by
  Examining Pathology Errors 1992-1997
• Measure current state of error in laboratory
  medicine (data 30 of specimens are defective)
• Perform root cause analysis and design error
  reduction initiatives (data errors related to
  breakdown in various testing phases)
• Implement error reduction and quality initiatives
  and measure effectiveness

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Purpose of Lean Implementation

• Lab expenditure represents 5 of total healthcare
  expenditure
• 70 of clinical decisions are based on lab
  information
• Lab medicine testing failures have major
  downstream implications
• Pre-pre-analytic phase choice of the test
• Pre-analytic phase performance of the test
• Analytic phase processing and analysis of the
  specimen
• Post-analytic phase reporting of the test
  result
• Post-post-analytic phase use of the test result
  in patient care

4
Scope of Lean Implementation

• Institutions University of Pittsburgh Medical
  Center, Henry Ford Health System, Western
  Pennsylvania Hospital, University of Iowa
• UPMC Shadyside
• Tertiary 486 bed urban hospital
• Medical staff includes more than 600 primary care
  physicians and specialists
• Provides cancer care to 30,000 patients annually
  (Hillman Cancer Center)
• 2.11 million laboratory tests, 67 FTEs
• Surgical pathology 20,000 specimens, 14 FTEs

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Scope of Lean Implementation

• Began implementation in August 2003
• Chose to use Perfecting Patient Care (PPC) as
  the Lean improvement method
• Education by the Pittsburgh Regional Healthcare
  Initiative
• Jewish Healthcare Foundation funding for a team
  leader
• Internal learning network

6
Implementation Methods

• Implemented PPC in different ways
• Use of a team leader
• Histology section of anatomic pathology lab
• Use of PPC principles
• Cervical cancer prevention
• Pap test procurement (pre-analytic)
• Laboratory screening (analytic)
• Invasive radiologic services
• Breast cancer care
• Specific lab phases (i.e., accessioning, gross
  examination, interpretation)
• Reporting (post-analytic)

7
Implementation Methods

• Organizational commitment
• Physician champions
• Team leader
• Internal collaboration
• Front line workers
• Design depended on input from those involved in
  the process

8
Lean Evaluation

• Metrics
• Efficiency of services
• Turn around time
• Productivity
• Quality
• Error reduction
• Resource utilization
• Satisfaction
• Costs
• Business case analysis

9
Results of Interventional Radiology Implementation

• Studied thyroid gland fine needle aspiration
  (FNA) services
• Sensitivity Pre-intervention 70.2 post
  intervention 92.3 (P lt 0.001)
• False negative rate Pre-intervention 41.8
  post-intervention 18.2 (P 0.006)
• Repeat FNA rate Pre-intervention 12.7 post
  intervention (with immediate interpretation)
  3.7 (P 0.001)
• Cost savings 167,000 per 100 patients (501
  million annually)

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Results of Lab Productivity
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Results of Lab Productivity

• The number of UPMC Shadyside FTEs/day in 2003 and
  2006 was 4.5 and 5.1, respectively and the
  productivity ratio was 3,439 and 4,074 work
  units/FTE, respectively (P lt 0.001)
• A second histology section produced 23,972 mean
  monthly work units with 15.0 FTEs/day and had a
  productivity ratio of 1,598 work units/FTE (P lt
  0.001)

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Hurdles

• Lack of organizational commitment
• Turf issues
• Training
• Long term evaluation is problematic
• Disruptive physicians
• Middle management not engaged
• Up-front costs
• Cultural model (top down versus bottom up)
• Punitive history difficult to eradicate
• Disincentives for improvement
• Difficulties in linking improvement with outcome

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Lessons Learned

• Metrics of quality, efficiency, and costs can be
  improved simultaneously
• The more the front line is involved, the greater
  the improvement
• An organizational leadership that is not engaged,
  fearful, and disruptive derails the process
• Beware the drive for efficiency!
• Workers need constant feedback and metrics with
  meaning
• Difficulties with sustainability
• True learning lines difficult to implement

14
Knowledge Transfer

• Publications, work-shops, lectures
• Shop floor walk through
• On the job training
• Disseminate principles to other labs
• Development of a national lab medicine learning
  network

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Next Steps

• Experiment with implementing a true leaning line
• Continue developing a national lab medicine Lean
  learning network
• Develop models in different lab medicine settings
• Learn how current disincentives may be reversed
• Study how Lean may be implemented in different
  cultural models