1. 1 Fairview Health Services: A LEAN Case Study “Using Data to Make Decisions and Drive Quality and Results ” Institute for Quality in Laboratory Medicine April 29, 2005 presented by Rick Panning President, Laboratory Services Fairview Health Services Institute for Quality in Laboratory Medicine April 29, 2005 presented by Rick Panning President, Laboratory Services Fairview Health Services

2. 2 The building blocks of Performance Excellence Quality Improvement Methods (e.g., FOCUS- PDCA, LEAN, 7-Step, DMAIC, Rapid Cycle Improvement) Quality Improvement Methods (e.g., FOCUS- PDCA, LEAN, 7-Step, DMAIC, Rapid Cycle Improvement) Accelerated Change Accelerated Change Effective Results Effective Results Performance Excellence – Clinical and Financial x =

3. 3 Understanding the need for change How does your laboratory fit into the overall organization and provision of care? –How can the laboratory enable high quality, cost-effective care? How is the laboratory performing? How will LEAN help you improve these measures? –Productivity and Cost per test –Turnaround time compliance –Error rates (patient safety, quality) How does your laboratory fit into the overall organization and provision of care? –How can the laboratory enable high quality, cost-effective care? How is the laboratory performing? How will LEAN help you improve these measures? –Productivity and Cost per test –Turnaround time compliance –Error rates (patient safety, quality)

4. 4 Lean is: Waste Flow, Flow, Flow Applies to both Mfg. &Non-Mfg. Environments

5. 5 What is Lean? Relentless pursuit, identification and elimination of waste in all business processes in order to produce value for the customer.

6. 6 Make problems visible Mistake proofing Just in Time Right service Right amount Right time Pull System Continuous Flow People and Teamwork Waste Reduction Stable and Standardized Processes Visual Management Continuous Improvement Best Quality, Cost, Delivery, Safety and Morale From J.Liker, The Toyota Way

7. 7 Core Principles of Lean (“start with the customer”) One Piece Flow vs. Batch & Queue –Eliminates many forms of waste: waiting, inventory, overproduction. Batching inhibits flow. –Focus on 1 specimen/patient at a time First In/First Out –Best approach for the customer and best utilization of resources Mistake proofing –Prevent errors and defects

8. 8 Core Principles of Lean Unified Layout –Move from value added step to value added step Standard Work –Develop a standard based on the best known way to do the work, yields quality and reliability Visual Management Control –Tells at a glance what should be done, distinguishes normal from abnormal

9. 9 How does Lean impact customers? Shorter and more consistent cycle times Reduction of costs – lower prices Efficient use of resources – allow your professionals to “do the right stuff” Consistent quality of outcomes Establishes standard work “Without defined standards, there can be no improvement.” T. Ohno, Toyota

10. 10 Reasons for implementing LEAN @ Fairview Significant need to: –Improve patient care services –maximize efficiency / effectiveness of laboratory operations –simplify processes Significant need to: –Improve patient care services –maximize efficiency / effectiveness of laboratory operations –simplify processes

11. 11 Project Goals & Value Stream Product Flow Group Technology Operator Analysis Job Guidance Performance Measures Standardized Work Cell Layout Work Station

12. 12 RESULTS 2 Major changes Implementation of one automated work cell –Previously in 2 separate rooms –Previously in 6 separate workstations Implementation of one-piece flow phlebotomy process (24/7) –Baseline: Average phlebotomist was collecting 3-4 specimens per hour –Goal: 11-12 per hour (currently at 10.5) Implementation of one automated work cell –Previously in 2 separate rooms –Previously in 6 separate workstations Implementation of one-piece flow phlebotomy process (24/7) –Baseline: Average phlebotomist was collecting 3-4 specimens per hour –Goal: 11-12 per hour (currently at 10.5)

13. 13 Cycle Time Goal Goal: 95% of tests will be reported within 30 minutes from the time the patient is drawn. Previous standard: Results reported within 60 min from the time the sample is received in the lab. Goal: 95% of tests will be reported within 30 minutes from the time the patient is drawn. Previous standard: Results reported within 60 min from the time the sample is received in the lab.

14. 14

15. 15 Traffic Chemistry (blue) Specimen Processing (red)

16. 16 Core Work Area for the Clinical Lab Scientists who perform 90% of all Lab tests After LEAN One person walking 6 cycles in 30 min and operating 6 work stations After LEAN One person walking 6 cycles in 30 min and operating 6 work stations Proposed Layout

17. 17 Collection to Result (Compliance within 30 min.) Hemoglobin –Dec. 2002: 40% –Dec. 2004: 90% Potassium –Dec. 2002: 12% –Dec. 2004: 91% PTT –Dec. 2002: 5% –Dec. 2004: 89% Hemoglobin –Dec. 2002: 40% –Dec. 2004: 90% Potassium –Dec. 2002: 12% –Dec. 2004: 91% PTT –Dec. 2002: 5% –Dec. 2004: 89% (Dec. 2002 to Dec 2004)

18. 18 Potassium Turn Around Times Collection to Receipt plus Receipt to Result Time In minutes Time period (Dec 2003 - Feb 2004) Project initiatedBaseline Dark Blue = Collection to receipt Light Blue = Receipt to result 160 140 120 100 80 60 40 20 0

19. 19 Potassium Lab Collection vs. Nurse Collection Time in minutes (0 – 50 minutes) Weeks: Dec. 28 – Feb 14 Blue = Lab Pink = Nursing 50 45 40 35 30 25 20 15 10 5 0 14 42 11 47 11 45 9 40 11 37 11 36 13 37

20. 20 Troponin: Its own challenges (goal is 95% within 45 minutes) Dec. 2002: 10% Feb. 2004: 55% SIGNIFICANT IMPROVEMENT BUT STILL NOT GOOD ENOUGH?!?!?!?!?! Consistency improved greatly Current (Dec 2004): consistently within 45 minutes Dec. 2002: 10% Feb. 2004: 55% SIGNIFICANT IMPROVEMENT BUT STILL NOT GOOD ENOUGH?!?!?!?!?! Consistency improved greatly Current (Dec 2004): consistently within 45 minutes

21. 21 Troponin - …but what does the customer need? Jan. 2005: Lab / ED piloting new POCT method on the I-Stat for the initial Troponin. –Ultimately ED physicians decided not to implement because the “laboratories turnaround time was consistently exceptional” Jan. 2005: Lab / ED piloting new POCT method on the I-Stat for the initial Troponin. –Ultimately ED physicians decided not to implement because the “laboratories turnaround time was consistently exceptional”

22. 22 Summary of Benefits Testing thru-put (TAT) reduced by 50% Productivity improvement >40% Cost reduction at 28% Space savings of >450 ft2 Standardized work practices Reduction in Errors and Error Potential –Specimen and patient ID errors reduced Performance measurement Elimination of excess unused inventory ($16,100) 100% cross-training of staff Testing thru-put (TAT) reduced by 50% Productivity improvement >40% Cost reduction at 28% Space savings of >450 ft2 Standardized work practices Reduction in Errors and Error Potential –Specimen and patient ID errors reduced Performance measurement Elimination of excess unused inventory ($16,100) 100% cross-training of staff

23. 23 Additional Benefits Development of a core team of people that has implemented “Lean Manufacturing” and are therefore available to spread the benefits organizationally Standard Work and Standard performance measurement tools developed 2004 employee engagement score in clinical lab rose by 0.48 on a 5 point scale Laboratory recognition from customers Development of a core team of people that has implemented “Lean Manufacturing” and are therefore available to spread the benefits organizationally Standard Work and Standard performance measurement tools developed 2004 employee engagement score in clinical lab rose by 0.48 on a 5 point scale Laboratory recognition from customers

24. 24 Cycle Time Improvements Project #2 – Fairview Ridges

25. 25 Example of daily reporting to staff (next step: drill down into “defects”)

26. 26 Quote from FRH physician “I ordered a set of stat and comprehensive labs last Friday morning and I was astounded by the short turnaround time for all testing. The level of efficiency (15 minutes for a Basic Metabolic Panel) resulted in a much earlier treatment for a critical issue for this patient. Please extend my thanks to the staff for this excellent level of service” (Physician came directly to laboratory to provide feedback and sent letter.) “I ordered a set of stat and comprehensive labs last Friday morning and I was astounded by the short turnaround time for all testing. The level of efficiency (15 minutes for a Basic Metabolic Panel) resulted in a much earlier treatment for a critical issue for this patient. Please extend my thanks to the staff for this excellent level of service” (Physician came directly to laboratory to provide feedback and sent letter.)

27. 27 Eliminating wasteful and meaningless work enhances the value of work for all employees and better serves our patients and community.

28. 28 After the project is “finished” Insure that day-to-day operational leadership maintains the gain (supervisor) –Compliance with standard work is the key Track down-time and evaluate reasons Measure daily, weekly, monthly Keep measures in front of staff Share positive feedback and impact on patient care with staff –Laboratory professionals need to understand that the change made a difference. Insure that day-to-day operational leadership maintains the gain (supervisor) –Compliance with standard work is the key Track down-time and evaluate reasons Measure daily, weekly, monthly Keep measures in front of staff Share positive feedback and impact on patient care with staff –Laboratory professionals need to understand that the change made a difference.

29. 29 What have we found? If we use the tools and apply them as intended, the positive changes WILL occur If we try to “fiddle” with the model, it does not perform. Follow your rules! Don’t waiver! LEAN ultimately is not “rocket science”. It is basic, logical and data driven. If we use the tools and apply them as intended, the positive changes WILL occur If we try to “fiddle” with the model, it does not perform. Follow your rules! Don’t waiver! LEAN ultimately is not “rocket science”. It is basic, logical and data driven.

30. 30 Lean Balance (behind every result is a properly educated and trained laboratory professional)