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Implementation of Lean in Laboratory Medicine Services

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Title: 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

2
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

3
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

5
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)

10
Results of Lab Productivity
11
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)

12
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

13
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

15
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
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