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 < 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 < 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 < 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