Lean and mean

As the drive towards ever more efficient, cost effective pathology services gathers speed in the wake of the Carter Review, Barry Hill examines how the latest quality management tools are being implemented to make the UK’s laboratories faster and fitter

‘There is a need to improve the efficiency of pathology services to provide better, more convenient and speedier services for patients.’ These were the words of Lord Warner, Minister of State for NHS Reform speaking at the press launch of Lord Carter of Coles ‘Review of NHS Pathology Services in England’ earlier this year. The report itself highlighted the fact that substantial efficiency gains could be achieved by incorporating new ways of working in re-designed and streamlined laboratories. In particular the report specified how the introduction of process management techniques developed overseas such as ‘lean’ and ‘six sigma’ could be used to benefit pathology services, improve patient safety and help change clinical practice. It went on to add that these techniques are focussed on determining the essential processes and functions within the laboratory, the flows and interconnections between them, and on the activities and movement of staff so that what is deemed as not essential or unnecessary is stripped away in order to maximise the productive use of time and energy. All this sounds good on paper but how will it actually be achieved in practice?
   The concepts of ‘lean’ and ‘six sigma’ are nothing new. Lean manufacturing was first developed by motor firm Toyota in Japan during the 1970’s to streamline their production plants, thereby getting the most out of equipment, time and people to produce superior performance. The basic goal of lean is to get more done with less by first identifying and then systematically removing all the non-value added activities and waste, followed by a process of continuous improvement. Similarly, six sigma was developed by Motorola in the 1980s to improve the quality of their manufacturing processes and eliminate errors by changing the focus of quality measurement from the existing standards of ‘parts per hundred’ to the unheard of ‘parts per million’. Motorola pointed out that modern technology was so complex that old ideas about acceptable quality levels were no longer valid. Very much a measure of variability, six sigma therefore aims to make a process as close to perfect as it possible can be. Although both concepts were developed for industry however, lean thinking and six sigma can be applied just as successfully across all organisations in every walk of life. In terms of the health sector however, the key questions lean raises

Some labs could certainly do with a spot of streamlining

are ‘what are the added and non-value added areas in terms of the patient’, ‘can risks be reduced and patient safety improved through lean thinking’ and ‘could patients be diagnosed more quickly’. As for six sigma, the key questions here are, ‘what do patients need from the processes’ and ‘what improvements do patients want from the processes’.

One man who certainly believes he has the answer to re-engineering the laboratory environment to improve performance is Brian Jackson, managing director of argent Global Services, an operations improvement firm based in the US. Jackson, who is responsible for the Argent Healthcare Division, is a six sigma ‘black belt’ and also certified in ‘lean manufacturing’, and believes that by applying quality management concepts to diagnostics it is possibly to ‘turbo-charge’ the laboratory as he outlines. ‘Lean and six sigma principals can be easily applied in most pathology laboratories to get the best out of resources such as equipment, inventory and staff to produce superior performances. By transforming laboratories and treating them more as a production facility to make simple changes in the pre-analytical, analytical and post-analytical phases, it is possible to improve result turnaround times and reduce errors. But you must first identify your pain points by benchmarking your current situation. For example by using “sneaker trails”  to reveal wasted travel and unnecessary movement of staff, product and materials it is possible to re-design the laboratory environment to eliminate waste and improve specimen and people workflow rates’. Jackson considers therefore that both lean and six sigma are quality and process improvement techniques with significant applications in diagnostic laboratories, however to take advantage of them laboratory managers need to first take a step back to re-evaluate how these concepts can dramatically streamline their own pathology services.
   Argent Global Services recently undertook a re-design project which involved applying lean principles in a high capacity UK laboratory for Path Links, a single managed pathology service in Lincolnshire. Following a strategic review of their services, the Path Links team worked closely with Argent to introduce lean practices and designs extensively across their organisation. Pathlinks had been facing escalating workloads, increasing costs and had a very overstretched workforce, and were in need of an urgent a solution to their problems.  Following a fact finding US trip by Path Links representatives to see an American laboratory recently leaned by Argent, the Path Links ‘Lean Team’ got to work and, completely re-engineered their old laboratory layout using lean principles. Today the Pathlinks core laboratory at their Grimsby site features a central reception area incorporating a single analytical workflow, an open plan layout, modular furniture and crucially, two identical ‘mirror image’ analytical work cells rather than the discreet analyser systems used previously. Although it is relatively early days, Path Links assistant general manager Mick Chomyn speaking at the ‘Frontiers in Laboratory Medicine’ conference in Birmingham this year claimed he and his colleagues were already seeing significant productivity gains and improvements from their lean project. ‘By re-designing our workflow and processes we have removed the paper chases and bottlenecks in the system to greatly improve our turnaround times’.

Another UK laboratory that has recently undergone a lean transformation is the Blood Sciences Department based at Bolton Hospitals NHS Trust. David Slater, a former Clinical Chemistry and Pathology Computer Operational  Manager, but now a self employed consultant in Pathology IT, Pathology Management and Lean Working worked extensively on the Bolton project. As he explains, the history and geography of the old Bolton laboratory had lead to an urgent review of the pathology workflow.
 “Originally, the Pathology Department was split between two hospital sites but then amalgamated onto one site in 1995, but housed in two separate buildings, on separate floors. Over time, analysers were replaced and some sited where there was space available rather than in the most appropriate positions, so the system became inefficient in terms of batching samples and travelling distances, all resulting in delays in processing investigations. The configuration of analysers in the Haematology and Clinical Chemistry departments in particular was incorrect and needed reconfiguring, therefore going lean gave the opportunity to redesign the service into a Blood Sciences laboratory based  around the sample instead of the  department.”
 Although the Bolton project is still ongoing, the pathology department is already reaping benefits, which Slater considers has more than justified the decision to go lean. “The Blood Sciences Lean Project commenced in October 2005 with a Rapid Improvement week. During that week, a team consisting of three members of the pathology management, four staff from Blood Sciences, two from the Trust Service Improvement team, the division quality manager, plus a user of the pathology service (in this case an A&E nurse), worked together under the direction of a consultant from the Lean Consultancy Company, “Simpler”. A value stream map of the current state was produced, followed by the ideal state and finishing with the future state for three different sample types. Following consultation with laboratory staff, a new Blood Sciences laboratory layout was eventually designed and a project plan produced. Building work was completed by March 2006 and the new Blood Sciences lean laboratory became operational in May 2006. The total time taken was 8 months but without lean methodology it would have taken considerably longer. Amongst the main benefits have been that all serum samples are analysed in the same laboratory, floor space has been reduced by forty per cent with the resulting reduction of travelling distance of samples by up to 80% and most importantly, a reduced turnaround time for some assays of up to 80%. Furthermore, going lean has given management the opportunity to utilise the skill mix of staff in new ways.”
    Despite these benefits, Slater agrees that introducing lean working has been a difficult experience for the laboratory due to the enormous changes that had to be made. “We had to merge two existing departments into one, introduce new equipment, plus totally alter the working practices from “batch” analysis into processing samples “in flow” using lean techniques. This all took place over a 12 month roller-coaster period, and whilst some staff embraced lean working very well, others found the concept difficult to grasp. On the whole however, it is a great credit to all the staff and their managers that the project progressed so far, so quickly and with great success.”

By Barry Hill
Barry has worked within pathology for over 30 years and specialises in the discipline of blood transfusion & haematology. A former member of the IBMS Blood Transfusion Special Advisory Panel, he is also a freelance writer of short medical articles.