Process Improvement - 10 Essential Ingredients
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Identifies 10 essential ingredients for complex process improvement in the hospital laboratory.
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Process Improvement - 10 Essential Ingredients
- 1. Copyright© 1999-2010 Management Decision Systems, Inc. 1 Streamlining Process Improvement 10 Essential Ingredients Richard Ouellette, FACHE CLSSMBB MT(ASCP)H San Antonio, Texas November 2, 2010 Management Decision Systems, Inc.
- 2. PresentationPresentation OutlineOutline AvailableAvailable OnlineOnline Copyright© 1999-2010 Management Decision Systems, Inc. 2http://mandecsys.com/labconfab/SPI10Ingredients.pdf
- 3. Process Improvement JourneyProcess Improvement Journey Copyright© 1999-2010 Management Decision Systems, Inc. 3 1. Organization & Leadership 2. Understand The Customer 3. Rigorous Implementation Methodology 4. Understand Testing Demands 5. Design Space to Optimize Production 6. Instrumentation 7. Eliminate Process Bottlenecks 8. Establish Performance Metrics 9. Variation Reduction 10.Performance Visualization
- 4. A portion of this presentation based onâŠA portion of this presentation based on⊠ï Major Academic Pediatric Medical Center ï 1.5 Million tests annually ï STAT TAT - 4 to 11 Hrs. 20% <= 1 Hr. ï 60% of all testing ordered STAT ï High variability for routine TAT > 24 Hrs. ï Misplaced specimens ï High physician dissatisfaction ï Staffing vacancies (core lab ~ 35%) ï 70% testing drawn by nursing ï New Cerner Millennium install ï Major laboratory reorganization Copyright© 1999-2010 Management Decision Systems, Inc. 4 Referred to as⊠Pediatric LaboratoryReferred to as⊠Pediatric Laboratory
- 5. Fusion Management: Harnessing the Power of Six Sigma, Lean, ISO, 9001:2000, Malcom Baldrige, TQM, and Other Quality Breakthroughs of the Past Century by Stanley A. Marash 2004 Copyright© 1999-2010 Management Decision Systems, Inc. 5 #1 Organization & Leadership Chapter 1 Management by Fad (or Confusion Management) Majors Reasons For Failure: 1.Lack of Executive Leadership â âcommitment by deedsâ, âlead by mid-level managers with little if any involvement by executivesâ 2.Failure to Deploy â âmanagement fails to supportâ 3.Seeking Shortcuts â âmanagement adopts superficial aspects of a programâ 4.Inadequate Measurement â âmanagement does not measure success properlyâ, âmeasurements detached from business resultsâ
- 6. #1 Organization & Leadership ï No such thing as "Just A Lab Project" ï Silos & Matrix Management ï Money & Budget ï Executive Sponsorship ï Project Leadership ï Role of Lab Management & Staff ï Goal Congruency Copyright© 1999-2010 Management Decision Systems, Inc. 6 âUnderstand dynamics, priorities, urgency & politics!â
- 7. #1 Organization & Leadership Copyright© 1999-2010 Management Decision Systems, Inc. 7 âUnderstand dynamics, priorities, urgency & politics!â Executive Management Process Leader Staff Organization Participants Resources Managers
- 8. #1 Organization & Leadership Copyright© 1999-2010 Management Decision Systems, Inc. 8 âGoal Congruency, Communication & Coordinationâ Resources Staff Organization Participants Executive Management Managers Process Leader
- 9. Hospital Department SiloHospital Department Silo Copyright© 1999-2010 Management Decision Systems, Inc. 9
- 10. #2 Understand The Customer SIPOC ï Clarify High Level Process Structure ï Ties to Value Stream ï Understanding & Awareness Copyright© 1999-2010 Management Decision Systems, Inc. 10
- 11. #2 Understand The Customer House of Quality Copyright© 1999-2010 Management Decision Systems, Inc. 11 âMust understand customerâs needs & priorities!â
- 12. #2 Understand The Customer House of Quality â Critical To Quality Copyright© 1999-2010 Management Decision Systems, Inc. 12 CTQ â Typically in Define or Measure phase of DMAIC project ïIdentify customer ïIdentify customer's need ïIdentify initial set of basic customer requirements ïProgress further with more levels as required ïValidate requirements with customers
- 13. #2 Understand The Customer House of Quality â Critical To Quality Copyright© 1999-2010 Management Decision Systems, Inc. 13 CTQ Issues leading to failure âą Not understanding the customer requirements âą Not having infrastructure to support the process âą Not having qualified human resources âą Absence of following established standards âIf your customer simply wants to go from point A to Point B donât give them a Mercedes when all they really need is a Hyundai .â
- 14. #3 Rigorous Implementation Methodology Copyright© 1999-2010 Management Decision Systems, Inc. 14 âUnfortunately control & sustain are often forgottenâ DMAIC (Six Sigma) ï Define ï Measure ï Analyze ï Improve ï Control PCDA (Deming) ï Plan ï Check ï Do ï Act
- 15. #3 Rigorous Implementation Methodology Copyright© 1999-2010 Management Decision Systems, Inc. 15 âProject managementâ Process improvement requires project management. It is very important to track majors phases, tasks, responsibilities, dates and deliverables, i.e. the details. Suggested Resources: âąPMBOK â A Guide to the Project Management Body of Knowledge, 3rd Edition by Project Management Institute âąMicrosoft Office Project
- 16. #4 Understand Testing Demand ï 3 Years of Trend ï Test Flows - Inpatient, Outpatient, Outreach ï Priority - Note if STAT > 25% = Service Issues ï 30 Days Billable Test Detail ï Day of Week (DOW) ï Hour of Day (HOD) ï Priority, Times, Location, Who ï Pareto - 40 of 700 = 85% Total Test Volume Copyright© 1999-2010 Management Decision Systems, Inc. 16 âCritical to have LIS support and that the data is validated!â
- 17. #4 Understand Testing Demand Copyright© 1999-2010 Management Decision Systems, Inc. 17 âCritical to have LIS support and that the data is validated!â
- 18. #5 Design Space to Optimize Production ï Core Concept ï Benefits ï 2nd , 3rd & Weekend Shifts ï Outreach Testing ï Efficiency ï Costs ï Cross Training ï Job Enrichment ï Ratio - Flexibility vs. Training & Competencies Copyright© 1999-2010 Management Decision Systems, Inc. 18 âCan have significant cost ramificationsâŠâ
- 19. #5 Design Space to Optimize Production continued ï Pareto - 40 of 700 = 85% Total Testing Volume ï Queuing - Grocery Store ï Bar Coding ï Cashier ï Waiting Lines ï 5S - Sort, Straighten, Sweep, Standardize, and Sustain Copyright© 1999-2010 Management Decision Systems, Inc. 19 âCan have significant cost ramificationsâŠâ
- 20. Grocery Store Vs. LaboratoryGrocery Store Vs. Laboratory Copyright© 1999-2010 Management Decision Systems, Inc. 20 #5 Design Space to Optimize Production continued
- 21. ï Proximity ï Specimen Type ï Instrument Location ï LIS â Printers & Terminals ï Staff Travel â Pre & Analytic ï Automation Lines ï Specimen Drop Off â Visible ï STAT Monitors - Visible Copyright© 1999-2010 Management Decision Systems, Inc. 21 âCan have significant cost ramificationsâŠâ #5 Design Space to Optimize Production continued
- 22. Pediatric Laboratory - Initial DesignPediatric Laboratory - Initial Design Copyright© 1999-2010 Management Decision Systems, Inc. 22 SpecimenProcessing Chemistry Chemistry Chemistry Special Chemistry Hematology Coagulation Urine Tube System & Drop Off
- 23. Pediatric Laboratory - SpaghettiPediatric Laboratory - Spaghetti DiagramsDiagrams 2.25 miles per shift 4.14 miles per shift Copyright© 1999-2010 Management Decision Systems, Inc. 23
- 24. Copyright© 1999-2010 Management Decision Systems, Inc. 24 SpecimenProcessing Chemistry Chemistry Chemistry Special Chemistry Hematology Coagulation Urine Tube System & Drop Off Pediatric Laboratory â Focus AreaPediatric Laboratory â Focus Area
- 25. Copyright© 1999-2010 Management Decision Systems, Inc. 25 Chemistry Chemistry Hematology Coagulation Urine Pediatric Laboratory â Core FocusPediatric Laboratory â Core Focus
- 26. Pediatric Laboratory â Core FocusPediatric Laboratory â Core Focus Copyright© 1999-2010 Management Decision Systems, Inc. 26
- 27. A Black Belt Examines a SiloA Black Belt Examines a Silo Copyright© 1999-2010 Management Decision Systems, Inc. 27
- 28. #6 Instrumentation ï Throughput - Manufacturer Specification ï Staffing/Input Requirements ï Bar Coding ï Importance of LIS/HIS ï Location & Support Space Copyright© 1999-2010 Management Decision Systems, Inc. 28 âOptimal test throughput & required staffing is usually established by the manufacturerâ
- 29. #6 Instrumentation Copyright© 1999-2010 Management Decision Systems, Inc. 29 âOptimal test throughput & required staffing is usually established by the manufacturerâ
- 30. #7 Eliminate Process Bottlenecks Process Diagramming & Value Stream Mapping ïModeling - KISS ïTakt Time - Customer Demand ïProcess Breakdown - Pre-Analytic, Analytic ïWorkload Balancing ïStaff Involvement - Stakesmanship Copyright© 1999-2010 Management Decision Systems, Inc. 30 âNeed involvement of staff performing the workâ
- 31. Total Testing Process â 3 Phases/13 Steps Copyright© 1999-2010 Management Decision Systems, Inc. 31 Clinical Question Test Selection Test Order Patient Specimen Identification Specimen Collection Specimen Preparation Specimen Processin g Analysis Results Reporting Report Review Results Interpretation Action Transportation Post Analytic (Care Provider) Analytic (Laboratory) Pre Analytic (Care Provider) #7 Eliminate Process Bottlenecks Source: Adapted from Boone, J. Presentation at the 2007 Institute on Critical Issues in Health Laboratory Practice: Managing for Better Health, Atlanta, September 23 â 26, 2007
- 32. Copyright© 1999-2010 Management Decision Systems, Inc. 32Source: Adapted from Boone, J. Presentation at the 2007 Institute on Critical Issues in Health Laboratory Practice: Managing for Better Health, Atlanta, September 23 â 26, 2007 8 Key Steps #7 Eliminate Process Bottlenecks Total Testing Process â 3 Phases/13 Steps Clinical Question Test Selection Test Order Patient Specimen Identification Specimen Collection Specimen Preparation Specimen Processing Analysis Results Reporting Report Review Results Interpretation Action Transportatio n Post Analytic (Care Provider) Analytic (Laboratory) Pre Analytic (Care Provider)
- 33. #7 Eliminate Process Bottlenecks Copyright© 1999-2010 Management Decision Systems, Inc. 33 âSwim Lane Process Diagramingâ
- 34. Copyright© 1999-2010 Management Decision Systems, Inc. 34 âIshikawa Diagramâ #7 Eliminate Process Bottlenecks
- 35. #7 Eliminate Process Bottlenecks Copyright© 1999-2010 Management Decision Systems, Inc. 35 âValue Stream Mappingâ
- 36. #7 Eliminate Process Bottlenecks Copyright© 1999-2010 Management Decision Systems, Inc. 36 Lead Time = 122 Minutes VA/T = 11.2 Minutes Lead Time = 66 Minutes â of 46% VA/T = 9.3 Minutes â of 17%
- 37. #8 Establish Performance Metrics ï #7 Institute leadership ï #8 Drive out fear ï #9 Break down department barriers Copyright© 1999-2010 Management Decision Systems, Inc. 37 âDeming offered fourteen key principles for management for transforming business effectiveness; 3 key principles areâŠâ Being measured is not bad⊠it is good!
- 38. #8 Establish Performance Metrics ï Ownership - Lab's... Like it or not ï Communication - Customer & Staff ï Measurement ï Frequency ï Actual Performance - Sharing & Follow-up Copyright© 1999-2010 Management Decision Systems, Inc. 38 âMetrics provide focus & direction, otherwise you are a ship without a rudderâ
- 39. #8 Establish Performance Metrics Copyright© 1999-2010 Management Decision Systems, Inc. 39 Few have been bitten by an elephant⊠but almost everyone⊠has been bitten by a mosquito.
- 40. ï Use tests on STAT list for major metrics ï Commit to a reasonable TATs Better to under commit and over deliver! âSTAT - 1 hour from order to report âRoutine - 4 hour from order to report âAM - Report by 6 AM/7 AM ï Send-Out â Published SO Labâs TAT ï Outreach â Sales, Customer Service Copyright© 1999-2010 Management Decision Systems, Inc. 40 #8 Establish Performance Metrics
- 41. #8 Establish Performance Metrics Copyright© 1999-2010 Management Decision Systems, Inc. 41
- 42. #8 Establish Performance Metrics Copyright© 1999-2010 Management Decision Systems, Inc. 42
- 43. #9 Reduce Error & Variation ï Accelerate Discovery ï Measurement - Metric & Frequency ï Daily Monitoring - Dashboard & Scorecards ï Drive Performance - With a passion! Copyright© 1999-2010 Management Decision Systems, Inc. 43
- 44. #9 Reduce Error & Variation Copyright© 1999-2010 Management Decision Systems, Inc. 44
- 45. #9 Reduce Error & Variation Copyright© 1999-2010 Management Decision Systems, Inc. 45 âDonât assume everyone knows how to interpretâ Pre-Analytic Analytic Expected TATs Exceptions
- 46. Copyright© 1999-2010 Management Decision Systems, Inc. 46 âCustomer demand vs. laboratory supplyâ 2 PM Customer Demand 2 PM Laboratory Supply #9 Reduce Error & Variation
- 47. #9 Reduce Error & Variation Copyright© 1999-2010 Management Decision Systems, Inc. 47 Cadence - balanced, rhythmic flow
- 48. Copyright© 1999-2010 Management Decision Systems, Inc. 48 #9 Reduce Error & Variation âPeople will do what you ask⊠if you watch what they do.â
- 49. #10 Performance Visualization Copyright© 1999-2010 Management Decision Systems, Inc. 49 âQuickening through visualizationâ
- 50. #10 Performance Visualization ï Leadership ⊠BIG picture & results ï Your staff want to succeed ï Train, train, train ï Communication... Feedback ï Share successes & failures with customers Copyright© 1999-2010 Management Decision Systems, Inc. 50 âQuickening through visualizationâ
- 51. #10 Performance Visualization Copyright© 1999-2010 Management Decision Systems, Inc. 51 âPediatric Laboratoryâ 1 Hr. 30 Min. Difference
- 52. #10 Performance Visualization Copyright© 1999-2010 Management Decision Systems, Inc. 52 âPediatric Laboratoryâ
- 53. #10 Performance Visualization Copyright© 1999-2010 Management Decision Systems, Inc. 53 âPediatric Laboratoryâ
- 54. Silo Process ImprovementSilo Process Improvement Copyright© 1999-2010 Management Decision Systems, Inc. 54 No such thing as "Just A Lab Project"
- 55. Process Improvement Journey SuccessProcess Improvement Journey Success Copyright© 1999-2010 Management Decision Systems, Inc. 55 1. Organization & Leadership 2. Understand The Customer 3. Rigorous Implementation Methodology 4. Understand Testing Demands 5. Design Space to Optimize Production 6. Instrumentation 7. Eliminate Process Bottlenecks 8. Establish Performance Metrics 9. Variation Reduction 10.Performance Visualization
- 56. Summary RemarksSummary Remarks ï Complex process improvement is dynamic, involves the entire organization and leadership ï Process improvement is a team effort ï Fair, or unfair you have full responsibility for a test from the time of ordered for until it is complete ï Improving costs & service is an ongoing effort ï The laboratory is a detailed oriented business Copyright© 1999-2010 Management Decision Systems, Inc. 56
- 57. Thank you!Thank you! Richard Ouellette, FACHE CLSSMBBRichard Ouellette, FACHE CLSSMBB Management Decision Systems, Inc.Management Decision Systems, Inc. 101 Main Street101 Main Street Holden, Massachusetts 01520Holden, Massachusetts 01520 Website:Website: http://www.mandecsys.comhttp://www.mandecsys.com Phone: 508-829-7813Phone: 508-829-7813 Email:Email: rouellette@mandecsys.comrouellette@mandecsys.com Copyright© 1999-2010 Management Decision Systems, Inc. 57
- 58. #8 Establish Performance Metrics Copyright© 1999-2010 Management Decision Systems, Inc. 58 Few have been bitten by an elephant⊠but almost everyone⊠has been bitten by a mosquito.
Notas do Editor
- Hello my name is Richard Ouellette and I will be talking today on process improvement. In this presentation I have identified 10 key ingredients that are required in order to be successful in a âcomplexâ process improvement undertaking. What sort of circumstances warrant this approach toward process improvement: A combination of several of the following Complex improvement that may exceed any one individualâs capabilities A crisis may exist High level Analytical & group dynamic & project management skills required Need to draw upon multi-disciplinary expertise from several departments A requirement to obtain resources that may not be budgeted The need for an executive sponsor that can garner consensus among disparate interest The process improvement approach that I will be discussing does not replace ongoing process improvement s that managers make on a daily basis, it simply provides a recommended methodology for complex problem solving and implementation within a complex organization.
- This presentation outline is available on line at the address found at the bottom of this slide.
- Think of each of the 10 ingredients as individual climbers. Similar to the climbers in these pictures each âingredientâ is tied to one another. Success is for all climbers to start at the mountain base together and to successfully reach the summit together, as a team.
- A portion of this presentation is based on a case study. Specific highlights are in red: Pediatric hospital 70% of the testing drawn by nursing Significant service related issues
- The 1st ingredient is Organization and Leadership 1st point to be stressed is there is no such thing as a âJust a lab projectâ. If you want to move an instrument it involved engineering, solving a supply storage problem involves purchasing, introduce a new collection tube requires nursing, implement a new test involves finance⊠and the list goes on. Healthcare, especially in a hospital is a collection of disciplines operating in silos of expertise. In order to benefit patients these silos must work together and barriers must be bridged. Improvements are generally implemented through project teams. This means that the âImproved departmentâ may need to implement the improvements and they most certainly will have to own and sustain them as well. Very early into the process the âProject Leaderâ must explain, where we are currently, where we want to be in the future, what & how & when we will get there. People need to see the âBig Picture
- There are a number of key roles with any process improvement effort. Staff, the individuals that do the work need to be involved, managers need to be committed, resources need to be allocated, support needs to be provided by organization leaders and there needs to be a process leader to coordinate implementation and communication.
- As with all complex undertaking there is a need to align these dynamic entities so that there is good communication, coordination and goal congruency as depicted by the overlapping circle entities.
- I think humor is an important tool in opening up dialog. How often does a lab employee have direct contact with a patient, a nursing unit or a physician. How many nurses or physicians have actually visited the laboratory. The nature of our work puts us in silos but we must fight the negative impact this can have on patient care.
- Understanding the customer is ingredient #2 There are 2 six sigma tools that may be helpful, SIPOC & House of Quality It is important that everyone understand the big picture and the relationships of how things fit together to meet the needs of the customer. SIPOC shows a High-level picture of how the given process is servicing the customer. It promotes understanding and awareness.
- The House of Quality tool is used for defining the relationship between customer desires and the laboratoryâs capabilities. It is a part of the quality function deployment (QFD) and it utilizes a planning matrix to relate what the customer wants to how the laboratory is going to meet those wants. This tool provides a rigorous approach to getting at what the customer wants and how you are going to make that happen.
- What are critical components to quality? Identify who is the customer, e.g., doctor, physician, nurse, family etc. What does the customer need What are their requirements And⊠how do you validate requirements with the customer?
- What are some of the issues that can lead to failure in meeting customer need? 4 are identified on this slide⊠but the most prevalent is not understanding the customers requirements.
- Important Ingredient # 3 is Rigorous implementation Methodology Deming started us off with Plan Check Do & Act and the six sigma folks are developed the DMAIC approach (Define, Measure, Improve, Control). Regardless of which one you use, similar to a recipe either serves as an ordered & structured approach that can be cycled depending on the complexity of the improvements involved.
- I have never been involved with a process improvement effort where âproject managementâ skills were not required. There is a tremendous amount of information and detail with tracking project phases, tasks, due dates and deliverable. They say the devil is in the detail so here are 2 recommended resources. PMBOK Microsoft Project
- Important Ingredient #4 is Understand Testing Demand Given that the laboratory is the largest producer of clinical information in healthcare it is important that you understand the demand flows and ordering priorities on an inpatient, outpatient and outreach basis. I will typically look at 3 or more years of testing trends as well as 30 days worth of billed test detail analyzing DOW, HOD testing patterns. Iâll also take a close look at roughly the 40 top tests (out of 700) that tend to generate 85% of the total testing volume. I will go into more detail on this later in the presentation.
- This slide shows some of the day of week and within day testing pattern analysis.
- Ingredient #5 is Design Space to Optimize Production⊠we are at the half way point An entire presentation can be done on this subject alone so let me touch on the key points quickly. The core concept is based on the Pareto concept that I touch upon in Ingredient #4 Under Testing Demand; roughly 40 of you 700 orderable tests constitute 85% of you testing volume. Given this, focus this high volume testing in a centralized, well designed area with unidirectional testing flows that are in close proximity to the specimen receipt area. Design the space to minimize travel. Lay out the equipment so that single operators can operate multiple instruments. Configure your LIS to expedite testing, i.e., bar coding, delta checking, auto verification and STAT monitors. Cross train you technical staff to work in multiple departments. The result is greater efficiencies, quicker testing throughput, enhanced workflows on 2nd, 3rd & weekend shifts and generally⊠a much more satisfied technical staff.
- Cleanliness is next to godliness and unfortunately some laboratories do not understand this concept and the end result is a fraternity house environment. If you walk into the managers or supervisors office and the you find that it is disorganized and messy as well, you need to rethink your 5S implementation⊠perhaps with a root cause analysis. Lets talk about grocery storesâŠ
- A grocery store with itâs check outs, waiting lines (queues) , bar coding, supply chain management and customer frustration & anxiety serves as a great way to explain how a laboratory functions to a non-labatorian. I would go so far to say that queuing in particular is not given enough emphasis in lean/six sigma methodology⊠it does however play a more predominate role in TOC Theory of constraints. Take a look at these picture and please retain the image especially the bar code reader upper right and the queue that is held up on the lower left picture by the customer that decided to write her check only after all her groceries were wrung up and bagged⊠and then she forgot her pin and needed to make a call. I always seem to be behind these individuals⊠see thatâs me.
- I have already touched upon many of these items on this slide⊠key take aways are proximity and unrestricted flow.
- This is a diagram of the pediatric medical centerâs core laboratory. It is not ideal space but it does have potential. Remember one of the 1st slides in the presentation with the table full of specimens. That table is here and you should be aware that it was quickly determined that specimen processing space was inadequate and had congested traffic flow.
- Spaghetti diagramming was done and it was determined that an day shift laboratory assistant traveled 2 Πmiles within this space per day and the evening shift assistant traveled a little over 4 miles. This travel is a great way to keep the staff lean, but it is not what Taiichi Ohno at Toyota had in mind.
- The focus of the improvements was in this area: Locating high production equipment in close proximity to support specimen share and reduced travel distance Breaking down a non-load bearing wall and turning the new space into automated chemistry. Eliminating a non-load bearing wall that created a blind alley bottleneck. Completely re-designing specimen processing work area and standardizing work activities
- Here is the new space⊠actual construction costs were $45,000 Note the new processing space and automated chemistry and the workflow pattern indicated by the green arrows. This space is also configured for outreach should this client wish to venture into this
- Here are some pictures of the improvements STAT monitors that provide real-time performance feedback, also referred to later in this presentation as âperformance visualizationâ. Upper left slide â expanded work space as opposed to the slide shown earlier in this presentation. Processing area has been centralized with defined workstations in individual responsibilities assigned, aka âwork standardizationâ Petition wall removed for better workflow in chemistry area
- Once again⊠looking into a healthcare silo can be difficult as this picture indicates. Stanley Marash author of Fusion Management may have used this slide as an example of leadership in some organizations and why process improvement did not work.
- Important ingredient #6 is instrumentation Every manufacturer of testing equipment will provide you with itâs throughput capabilities as well of, operational instructions and expected staffing. So for example, if you have a hematology instrument that can produce 60 tests per hour and you have certain hours of the day that exceed this throughput, e.g., 80 test/hour 7 â 10 AM, you know you have a bottleneck that you can resolve in 1 of 3 ways Buy an additional analyze to double throughput Divert testing demand⊠start the morning earlier Do nothing
- With todays instrumentation automation, testing bottle necks are not typically occurring in the analytical phase of testing. Iâll touch upon this when discussing the next key ingredient.
- We are in the home stretch. Ingredient #7 is Eliminate Process bottlenecks When looking at any complex process it is important to break it down to itâs individual pieces and study them in detail. There are several tools that can be used to accomplish this including process, swim-lane and value stream mapping. It is OK for the process leader to develop initial drafts of these maps but it is important that the project team actively participate and reach consensus on the final documents. Customer demand could be accessions/day or accessions/1st shift or tests/day or hematology tests/day. Takt time takes the minutes of work /unit produced, e.g., if there were 200 CBCs on 1 shift (assume 8 X 60 = 480 Minutes) the Takt time would be 480/200 = 4.8 minutes per CBC to keep up within 1st shift demand. The mix and coordination of resources (phlebotomy, transportation, information systems & instrumentation) constituents the âsupplies you will allocate to meet this âdemandâ. Some key points⊠You may not have perfect data to apply to these mapping tools; it can run the gamut from obtain near perfect real time information from the list to time studies and counting test tubes and accession arrivals. It is important to understand the limitations of the data you are using and that it ties out to you measures ,e.g., physician expectations are tied to completed tests, phlebotomy & speciment receipt is tied to accessions⊠2 very different denominators These are powerful tools and they can be as complex or simple as you want them to be⊠keep it simple. 3 relatively simple value stream maps may be more effective than 1 complex one that no one can understand other than the black belt that put it together. These are visual tools. If any member of you process improvement teams does not understand their output they offer little to no value to your improvement effort.
- This diagram depicts the Pre-analytic, Analytic & post-analytic phases of producing a laboratory result and the individual steps involved in the process. Results reporting â quality aspect of this step that we are looking at related to delta checking and auto-verification
- The laboratory is responsible for 8 of these steps in both the Pre-analytic and analytic phases. When examining the testing continuum it is important to look in detail at each for these steps and carefully examine the resource you are deploying. Let me stress, it is important that the laboratory take responsibility for all 8 steps identified in this diagram, even, for example, if they are not be collecting the specimen. Iâll talk more about this in establishing performance metrics.
- This is a swim lane process diagram and it is useful in showing process steps by area of responsibility.
- This is a swim lane process diagram and it is useful in showing process steps by area of responsibility.
- This is a value stream map and it can be closely tied to the SIPOC diagram that I mentioned earlier. Each box on the bottom depicts a process step going from left to right. The yellow triangles typically represent inventory, however they can also be used to reflect patients or tests in a queue between process steps. The objective in using value stream mapping is to optimize the supplied resources to closely match customer demand; supply vs. demand.
- OK lets look at the pediatric core laboratory and the issues identified in this simplified value stream map looking at the various steps of draw, transport receive, process test verify and report. The tube system was not trusted and we also leaned that there were tube container shortages Nursing was manually tracking test orders and collections; the lab was printing collection floor lists at defined times. As a result, add-on orders created multiple accessions on the same specimen and there were a number of instances of inadequate specimen. This was a problem for nursing and it was a big problem for the lab when these specimens were received and needed to be reconciled. Poor & inadequate space in specimen receipt & processing Delta checking & auto-verification were not being used There were significant backups of specimens throughout each step creating a significant lead-time of roughly 2 hours Future State Tube system was validated and new transport containers purchased Epic EMR installation delayed in order to give nursing ability to pull own collection list Processing area reengineered LIS functionality was expanded to include delta checking, auto-verification, specimen tracking and STAT monitors Lead-time was cut roughly in half and value added time was reduced by roughly 2 minutes
- Fair or unfair, like it or not, the lab is held responsible to all 8 of the pre-analytic and analytic steps, even if they do not directly control all of the steps, e.g., in the pediatric medical center 70% of the tests were collected by nursing, not the laboratory. You must establish performance goals as a department and for implementing process improvements. Otherwise, how do you, your customers and your executive sponsor know you are performing at acceptable levels. Your performance goals need to be measurable, timely and made available to your staff and customers
- There is an old saying that I heard early in my laboratory careerâŠ. Few have been bitten by an elephant but almost everyone has been bitten by a mosquito. Basically what this means is that it is the most frequently ordered tests that will bite you if they are delayed, not the big expensive esoteric send-outs.
- Here is a recommended approach that I have successfully used for a number of years. âŠ. Read from slide You also need to be very specific on your metric, e.g., 1 hour from ordered for to report result. I have not run into a medical staff that opposed this approach, most were estotic especially when the laboratory started delivering on the TATs.
- Here is an example of what I mean by Pareto. I took a months worth of performed tests and ordered them in ascending order. The top 15 tests constitutes 54% of the test volume and all of these tests are in this clients STAT test list.
- Therefore including the high volume STAT tests list in your metric will include 57% of all of your tests, 48% of all of your routine tests and 76% of all of your STAT tests
- Reduce Error and variation is item # 9. Once you understand you testing demands, have identified your bottlenecks and established targeted performance metrics, you are now ready to roll up your sleeves and make improvements. The goal is to move performance from what is shown on the left to the graph shown on the right. Note that the red line id the performance goal.
- Daily dashboards with individual drill down exception reports for each metric is an effective âvisualâ tool in accelerating change especially when you share it daily with your staff, nursing and key physicians. Regardless of stumbles, everyone knows you are committed to these improvements.
- Important point
- Important point⊠do not assume that everyone knows how to read and interpret a dashboard or drill down report. Go over them in detail at staff meetings and do one-on-ones with key nurses and physicians.
- Reduce Error and variation is item # 9. Once you understand you testing demands, have identified your bottlenecks and established targeted performance metrics, you are now ready to roll up your sleeves and make improvements. The goal is to move performance from what is shown on the left to the graph shown on the right. Note that the red line id the performance goal.
- Important point⊠do not assume that everyone knows how to read and interpret a dashboard or drill down report. Go over them in detail at staff meetings and do one-on-ones with key nurses and physicians.
- The last important ingredient is Performance Visualization. Keep in mind that we want to make significant improvements, so you need to understand human nature. As this graph shows people retain visual information to a much greater degree than what they hear or see. We have all heard that a picture is worth a 1,000 words. And let me add I am not talking just about graphs and dashboards. You gain significant credibility in you process improvement efforts when you meet in person with 2nd shift staff during the evening, 3rd shift in the early AM or the weekend crew on Saturday. Having executive management, physicians and your pathologist visibly present, engaged and participating in process improvement efforts is very important.
- Did you ever wonder why religions plays such a big role in many of our lives? Here is my take⊠religion shows you the big picture from start to finish, what you need to do right and what you should not be doing. Furthermore, if you do everything right it tells you how you will be rewarded. So, if my assessment is correct, most people due to their upbringing have a predisposition for wanting to see the big picture, do what is right and participate in the rewards. NEED TO REMOVE TIE TO RELIGION
- We are at the end with a few wrap up slidesâŠ. This compares March vs Julyâs cumulative testing completed. Note that in July 6 AM work was completed whereas the same work in march was being completed at 7:30 AM.
- This slide shows the 3 major performance metric trend with major initiatives depicted below on the March â June time table. The implementation cycle was rigorous and the improvements were as well.
- This was the ERâs laboratory performance graph with improvements starting in March - August
- This brings this presentation to a close
- Think of each of the 10 ingredients as individual climbers. Similar to the climbers in these pictures each âingredientâ is tied to one another. Success is for all climbers to start at the mountain base together and to successfully reach the summit together, as a team.
- Let me leave you with a few summary thoughts. I would like to thank you for your time and interest.
- There is an old saying that I heard early in my laboratory careerâŠ. Few have been bitten by an elephant but almost everyone has been bitten by a mosquito. Basically what this means is that it is the most frequently ordered tests that will bite you if they are delayed, not the big expensive esoteric send-outs.