Continuous Flow and Anatomic Pathology Theory vs Reality

Transcription

1 Continuous Flow and Anatomic Pathology Theory vs Reality Kenneth Batts, M.D. Hospital Pathology Associates Allina Laboratories Minneapolis, MN Notice of Faculty Disclosure In accordance with ACCME guidelines, any individual in a position to influence and/or control the content of this ASCP CME activity has disclosed all relevant financial relationships within the past 12 months with commercial interests that provide products and/or services related to the content of this CME activity. The individual below has responded that he/she has no relevant financial relationship(s) with commercial interest(s) to disclose: [Kenneth Batts] 1

2 My Experience/Backdrop 9 years on staff Mayo Rochester Exposure to Lean Staffed the frozen section lab 14 years Hospital Pathology Associates 36 pathologist private practice group Cover large hospital system (Allina) Multiple hospitals and numerous clinics We designed histology, cytology, pathology areas 2 year s experience with it Cover busy physician s office laboratories We designed a GI office histopathology lab 7 year s experience with it Lean fixes things by eliminating waste. What are you interested in fixing? Worker productivity? Turnaround time? Productivity use worker s perspective TAT use specimen s perspective s Worker 2

3 Theory: Continuous Flow Reflects a -focused LEAN Approach LEAN Continuous Flow We will discuss this. What is Continuous Flow? Continuous-flow manufacturing (CFM) is a manufacturing strategy that produces a part via a just-in-time and kanban production approach.. calls for an ongoing examination and improvement efforts which ultimately requires integration of all elements of the production system. The goal is an optimally balanced production line with little waste, the lowest possible cost, on-time and defect-free production. Wikipedia 3

4 A Pretty Good Continuous Flow System VA Value Added Step Non-Value Added Wait A necessary manipulation of the product that improves it The buyer is willing to pay for it Something that does not add value The buyer is not willing to pay for it (it is your problem, not theirs) There still may be some waste within Entirely waste Examples: Examples: Queues ( Muda ) ing Awaiting something ing Deeper levels Interpretation Reprocessing 4

5 A Tiny Queue A Modest Queue A Big Queue A Modest Queue A Big Queue 5

6 A Pretty Good Continuous Flow System Single units (no batch) No queues due to proximities Each step adds value (closer to fire) Focused effort (no wasted energy) No defects Ok, I m interested in hearing more but I want less theory and more practicality. 6

7 Case Study: Practical Application of Continuous Flow in our Labs Attempted to get as close to continuous flow as possible: Eliminate queues whenever possible Create physical proximities; coordinate schedules Eliminate unnecessary steps when able Applied it to a GI office practice and a hospital system practice Step 1 Find a champion, and give them resources and authority. 7

8 Step 2 Understand your system (work flow analysis) Some understanding is critical Use your judgment to balance depth of data gathering with practicality consultants will usually want more data Accession VA Clinician Your AP work flow probably looks a lot like ours. Wait 8

9 Accession Getting data on actual times will create your lab s fingerprint and allow you to prioritize (look for the most bang for the buck ). Step 3 Attack queues first Wait total waste usually largest sources of delay The empowered champion can do a lot fixes often don t involve perturbing an individual worker s style (more easily sold ) smart physical layout can make a MAJOR impact; if you have a chance to design a new lab space don t blow the opportunity 9

10 No waiting - The Holy Grail of TAT An unattainable goal but worthy target Accession VA VA Physical Proximities Proximities - Physician Office Lab ing Acc. Path3 Path 1 Path 2 Emb. Ass.. 10

11 Histology Collation One flat at a time Delivery is 4 steps One flat at a time 1-3 pathologists Accession This largely This largely eliminated eliminated numerous numerous queues batches 11

12 Dual processors; one hour cycle for GI Biopsies Coordinate with ing 12:30PM-1:30 PM 5:30 PM-6:30 PM Coordinate with ing 1:30PM-2:30 PM 6:30 PM-8:30 PM (bigs) Accession Minimized the queue (1 hour max) and shortened fix time 12

13 Accession Waiting for courier We limited queue with mid-day pickups, but still a major source of delay Accession Waiting for accessioning Largely eliminated this with coordinated staffing/dropoffs 13

14 Accession We eliminated We eliminated these these with with electronic electronic (drop (drop down) down) documentation documentation Accession Await Clinician EMR > FAX > Mail Aim for before 5 PM or before their arrival in AM Prelim notes in EMR? 14

15 Outcome in GI Lab AM Samples Couriers 11:30-12:45 out 3:30-5:30 - Special stains 8 AM Results to clinician queue via EMR Accession Clinicians Pleased - write letters sooner - call pts. sooner - remember the case - tidy up pre-vacation Our Continuous Flow Sweet Spot - 3:30-5 One automated stainer with histotech assembler Three immediately adjacent pathologists 15

16 Results in GI Lab PM Samples Accession Couriers 4:30-6:00 PM out 8:00-11:00 AM - Special stains in PM Results to clinician queue via EMR Clinicians Happy Cyt. ASS. Histo ASS. Hospital System Lab (Centralized) COURIER AIDES PATHOLOGY 16

17 Cyt. ASS. Histo ASS. Hospital System Lab (Centralized) COURIER AIDES -Prioritize -Distribute (minimal queues) PATHOLOGY COURIER AIDES 5A 7A 7A G U GI BR BR AV H CP CP ADM DI C Y G MO L Y M RES D 17

18 Relative Priorities 1 Hospitalized patients with biopsies, and masses/possible cancer biopsies 2 Regular biopsies 3 Resections for significant diseases 4 Back burners (tonsils, appendices, etc) System used by histology, path. aides, pathologists, and transcription Cyt. AIDES Histo Optimized for Key Biopsies til 10 PM Overnight Histology Shortest poss. processor 4:30 AM Path Aide 5 AM On site (4-6 hour) special stains On site expert reviews 5A 7A 7A G U GI BR BR AV H CP CP ADM DI C Y G MO L Y M RES D 18

19 Accession What about eliminating waste at these steps? VA Step 4 Attacking The Value Added Steps Usually fairly unimportant from continuous flow perspective (where specimen is the focus) 2 min. vs 4 min. to do task saves 2 minutes Can be very important from a productivity and staffing perspective (where person is focus) 2 min. vs 4 min. to do task doubles productivity 19

20 Miscellaneous Points Residents are generally a queue be innovative (good luck) Wait A defect in the system interrupts continuous flow ( always move forward ) Try to fix the root cause of the defect so it doesn t happen again X Summary Don t let the obligate batch steps preclude you from attacking the rest of the steps Eliminating/minimizing queues (our red boxes) will have best yield; go for the biggies first Leaning the value added steps (green boxes) makes only a small impact on TAT, and more likely to irritate workers, but can have considerable impact on staffing (that would be a different lecture) Setting up case prioritization system can at least focus TAT on the cases that need it the most YOU WILL NEVER REACH PERFECTION (AND THAT S OK) 20