Lean in the Lab: A Process Improvement Journey

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Kenneth Daniel
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Lean in the Lab: A Process Improvement Journey Disclosure I am receiving an honorarium from Sysmex for today s presentation 2 Who we are Positioned in picturesque New England, the Dartmouth-Hitchcock

1 Lean in the Lab: A Process Improvement Journey Disclosure I am receiving an honorarium from Sysmex for today s presentation 2 Who we are Positioned in picturesque New England, the Dartmouth-Hitchcock academic health center in Lebanon, NH serves a patient population of 1.9 million. Dartmouth-Hitchcock functions as the only level one trauma center in New Hampshire, home of a full service children s hospital, CHAD and includes the comprehensive Norris Cotton Cancer Center. D-H provides access to more than 1,000 primary care and specialty providers through more than 30 different outpatient clinic locations. The Dartmouth campus also serves as a clinical teaching facility in partnership with the Geisel School of Medicine; training nearly 400 residents and fellows annually and performing world class research. 1

The D-H Hematology Lab With Dartmouth-Hitchcock increasing volumes from regional affiliates, maximizing efficiency, while utilizing staff appropriately, is a priority.

0 came at a time when workflows within the laboratory were constantly being evaluated as part of an ongoing lean initiative within the facility.

2 The D-H Hematology Lab With Dartmouth-Hitchcock increasing volumes from regional affiliates, maximizing efficiency, while utilizing staff appropriately, is a priority. The hematology laboratory recently completed a major renovation to improve the usage of workspace and specimen handling. The upgrade from WAM v3.0 to WAM v5.0 came at a time when workflows within the laboratory were constantly being evaluated as part of an ongoing lean initiative within the facility. Our HST WAM line has been live with auto-validation since The upgrade process from WAM 3.0 to WAM 5.0 began in July, 2015 with the system going live in the facility on November 10 th, Sysmex HST 302 with WAM 3.0 The first step in our Lean journey was to implement automation in Hematology in preparation for bringing in additional work. Partnership with The DH Community Group Practices in 2010 Dartmouth Hitchcock CGP Manchester Dartmouth Hitchcock CGP Nashua 2

Our First Project Laboratory Pre-Analytic Pilot began in July 2009

3 Labeling Education Using automation meant educating specimen collectors throughout the network on properly labeled specimens. Our First Project Laboratory Pre-Analytic Pilot began in July 2009 Three month pilot Phlebotomy Inpatient & Outpatient Clinical Pathology Specimen Receiving 3

Improvements in Specimen Receiving Cart added for specimen delivery Route walked every 6 minutes Single piece flow Each specimen, patient is handled one at a time.

4 Improvements in Specimen Receiving Cart added for specimen delivery Route walked every 6 minutes Single piece flow Each specimen, patient is handled one at a time. Tasks rotated among staff by hour No one is left on the computer or cart for the entire shift Phlebotomy Improvements Pre-Analytic Pilot Result Summary Patient Wait Time from 22 min. to 6.5 min. today Highest Press-Ganey Patient Satisfaction Scores Decreased Cost per venipuncture Project Number Lean Project Demands Forcing Change Increasing Demand for TAT Improvement Financial Pressures to Do More with Less Bring in-house more testing Healthcare Reform Demand for Continuous Quality Improvement 4

5 2012 Lean Project Studied analytic sections of the laboratory Reviewed test systems accounting for 80% of total volume in laboratory Observations on all 3 shifts, various jobs and activities 20 week engagement Elements focused on Bench layout and design Turnaround time improvement Staffing variance improvement The DMAIC Process Project Schedule and Tools Used Define Measure Analyze Improve Control Define / Measure Team training- December 2011 Develop Problem Statement and Event Charter- Jan 2012 Collect baseline performance data- Jan/Feb 2012 Measure/Analyze Collect videos to establish current state- Jan/Feb 2012 Analyze videos- Feb/Mar 2012 Group Technology- Mar 2012 Layout development- Mar/April 2012 Improve/Control Develop and execute pilots- Mar/April 2012 Job Standardization packages- Mar/April 2012 Leadership training- April/May 2012 Metrics Report- May 2012 Summarize tools and results- May Development How do we maintain and improve on the gains after a large difficult LEAN implementation? Lean Book Club: Intended to educate ourselves on how to manage in a Lean environment that will sustain the new culture created. Early morning, weekly supervisor book club meetings for 2 months. Chapter questions, modified to our lab environment, sent before each chapter reading 5

Lean Management has four basic elements 1) Leadership Standard Work 2) Visual

6 Book Club What We Learned from the Book Club Success in creating a new production environment (TPS) requires a new way that supervisors and managers do their work: Lean Management has four basic elements 1) Leadership Standard Work 2) Visual Controls 3) Daily Accountability Process 4) Discipline Hematology Supervisor Rounding 6

7 Supervisors Daily Rounds at Start of Shift Chemistry Performed by: Frank Polito date: time: 07:30 Check Call ins-adjust Labor Plan Check AM setup board-adjust Resources Have daily rounds been performed and follow-up performed as needed? Is the Workstation organized according to the Material Location Plan? 10am Are supplies restocked at the beginning of the shift with the appropriate levels? Are visual queues in place and being used as designed? Are established TATs being appropriately monitored and met? Is the Workstation organized according to the Material Location Plan? Are supplies restocked at the beginning of the shift with the appropriate levels? Are visual queues in place and being used as designed? Are established TATs being appropriately monitored and met? Is the Workstation organized according to the Material Location Plan? Are supplies restocked at the beginning of the shift with the appropriate levels? Are visual queues in place and being used as designed? Are established TATs being appropriately monitored and met? Is the Workstation organized according to the Material Location Plan? Are supplies restocked at the beginning of the shift with the appropriate levels? Are visual queues in place and being used as designed? Are established TATs being appropriately monitored and met? Is the Workstation organized according to the Material Location Plan? Are supplies restocked at the beginning of the shift with the appropriate levels? Are visual queues in place and being used as designed? Are established TATs being appropriately monitored and met? Are there any instrument or Technical matters that require additional follow-up? Are there any suggestions on the board or improvements suggested from rounds/meetings? Daily Rounds Cobas 8000 Cobas CEE Cobas 6000 (CCE) Manuals/Blood Gas/IDs/Vitros PEPs Additional Follow-Up YES NO Comments/Actions Taken Daily Standard Work Examples Director Standard Work - Gross Room Assessment Performed By: Mike Harhen Date: Process Focus: Yes No If No, Action(s) Taken Process Improvement: Yes No If No, Action(s) Taken Visual daily task assignment process is in use and current Standard Work: Yes No If No, Action(s) Taken Other Observations: Lean Management Leadership Standard Work- Checklists that are focused on the process of doing the work. Checklists apply to: team leaders, supervisors, managers and director. Visual Controls- Charts and other visual tools to monitor, by hour, actual vs. expected performance Accountability Process- brief, on your feet, structured tiered meetings held in the production area Discipline- Leaders need to do it! Leadership Commitment How do you sustain the control? Make sure your leaders are committed to keeping up the process. 7

8 Define: Project Charter Problem Statement With continued pressure to reduce cost, optimize labor, and enhance the level of service and quality, the Department of Pathology is seeking new approaches to address the many challenges of today and the near future. A Lean tools approach will serve as the precursor to the laboratory s ongoing financial and performance success and complement any future improvement initiatives, accreditation requirements, and space redesign in the Department of Pathology. Project Scope Core Laboratory testing including: Chemistry and Immunoassay testing, Hematology, Coagulation, Urinalysis, Manual Testing (may be limited to bench layout and design) Specimen Processing & Receiving Anatomical Pathology department to include: Surgical Pathology, Anatomical Pathology Accessioning, Histology including routine and specials, Immunohistochemistry Ortho-Clinical Diagnostics, Inc Lean Project Studied analytic sections of the laboratory Reviewed test systems accounting for 80% of total volume in laboratory Observations on all 3 shifts, various jobs and activities 20 week engagement Elements focused on Bench layout and design Turnaround time improvement Staffing variance improvement Define: Project Charter Turnaround Time (TAT) Goals Test Baseline Goal Hemoglobin 22 min 20 min Manual Differential 61 min 60 min Urinalysis 4 hr 6 min 30 min PT 2 hr 30 min 35 min HA1C 5 hr 30 min 90 min Potassium 61 min 40 min BUN 65 min 40 min TSH 4 hr 13 min 60 min Breast Needle TAT 24.8 hours 24 hours Derm TAT 28.3 hours 26 hours GI biopsies TAT 42.9 hours 48 hours 24 8

9 Analyze: Themes from Operator and Product Analysis Physical layout often a barrier to operator and specimen flow 30% of operators time in specimen receiving areas dedicated to changes from the new EMR workflows Multiple touch points and hand-offs Improve: Approach to Pilots 11 pilots were conducted on multiple shifts and peak workload times of day in each area (some pilots were concurrent) 4 in Gross Room 3 in Histology 1 Frozen Section Pilot 3 in Central Preparation Area (CPA) 3 in Hematology 2 in Chemistry Used analysis data, eliminated waste, developed processes that incorporated single patient flow, first in first out (FIFO), developed work in progress visual controls Summary of Pilot Results Turnaround Time (TAT) Goals Test Baseline Goal Pilots Hemoglobin 22 min 20 min 18 min Manual Differential 61 min 60 min 54 min Urinalysis 4 hr 6 min 30 min 31 min PT 2 hr 30 min 35 min 28 min HA1C 5 hr 30 min 90 min 40 min Potassium 61 min 40 min 41 min BUN 65 min 40 min 46 min TSH 4 hr 13 min 60 min 59 min Breast Needle TAT 24.8 hours 24 hours 21.7 hours Derm TAT 31 hours 26 hours 27 hours GI biopsies TAT 42.9 hours 48 hours 14.5 hours 27 9

Workcell 2. 3. 1. 1. Diffs 2. Sysmex 3. Float Diffs (1.) and Sysmex (2.) rotate positions at breaks.

10 Hematology Workcell Previously staffed with 4 technologists- 2 to run Sysmex, 2 to perform Differentials Hematology Workcell Diffs 2. Sysmex 3. Float Diffs (1.) and Sysmex (2.) rotate positions at breaks. Float (3.) remains float for entire shift, covering (1.) or (2.) as needed. Breaks are taken one position at a time. Move scopes closer to Sysmex for better workflow & communication 10

Path East Blocks in numerical order from the Gross Room Smaller embedding, cutting, and staining batches in Histology Hematology Sysmex/Diff

11 Added visual controls at diffs to indicate when to trigger the float into action 4 slide rule to remain within TAT Added a supply basket to each scope station containing oil, wipes and cleaning supplies Changes in Place Implementation of Changes in Place PAP/Triage work station in Path East Blocks in numerical order from the Gross Room Smaller embedding, cutting, and staining batches in Histology Hematology Sysmex/Diff work bench Manual Chemistry workcell Leadership standard work Front line supervisor checklists Process metrics Ortho-Clinical Diagnostics, Inc. 11

12 Hematology results Diffs (1:00) Sysmex (0:20) FTE's assigned Pre-Implementation Post-Implementation Improvement TAT % Within Target TAT % Within Target 1:02 64% 0:19 70% 1:00 68% 0:19 70% 2 min 4% Same Same 1 FTE 4 3 Control: Leadership Standard Work Metrics reports have been developed to capture representative tests to be monitored These metrics, paired with rounding and checklist activities, are the basis for leadership standard work Improve hand off communication between shifts Face time with leadership daily rounding Tools One of the most important outcomes of this project was the set of tools created that are now routinely used to manage our lab. Data collection Communication Alerts Customized to the lab sections and activities 12

13 Control: Interval Report Can be used same day in 2-4 hour intervals in order to follow up on TAT outliers. Report is customized to include patient info on request Performance Metrics Reports Auto-print every 2 hours & are reviewed by staff for outliers If the metrics are ALL listed as GREEN: Initial to indicate that you reviewed the printout and place it in the designated bin. NO further action is required. If any of the metrics are listed as RED: Initial and write a BRIEF note explaining why. If it is not your bench that is in the red, take to it the bench that is. Performance Metrics Report Cumulative Roll-up 12/13/2012 start end DIFF Hgb PT UA PTT BF CSF Auto CSF Man Stainer problems - Pos BC - tech reset in micro Not 23:00 0:59 TAT = 65 min No TAT Issue TAT = 48 min No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 0:00 2:59 Not Performed No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 3:00 4:59 No TAT Issue No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 5:00 6:59 No TAT Issue No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 7:00 8:59 No TAT Issue No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 9:00 10:59 No TAT Issue No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Stainer problems - reset Not 11:00 12:59 TAT = 67 min No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 13:00 14:59 Not Performed No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed No note from tech Not 15:00 16:59 Not Performed No TAT Issue No TAT Issue TAT = 40 min No TAT Issue Not Performed Not Performed Performed Not 17:00 18:59 Not Performed No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 19:00 20:59 Not Performed No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed Not 21:00 22:59 Not Performed No TAT Issue No TAT Issue No TAT Issue No TAT Issue Not Performed Not Performed Performed 13

Additional communication tools White Boards: used mainly for patient related issues: Cold agglutinins, platelet clumpers, blasts/nrbcs that don t flag, factor assay patients scheduled for surgery,

14 Tools Data Collection Displaying data generated by LIS in real time What can you tell just by glancing at the report? Tools - Communication Shift to shifthandoffs Section to section Each tech in walks by this board to enter the department. Additional communication tools White Boards: used mainly for patient related issues: Cold agglutinins, platelet clumpers, blasts/nrbcs that don t flag, factor assay patients scheduled for surgery, high HCT having coag testing, special anticoagulants, exchange transfusions for electrophoresis, BM coming from south or other location, etc. Instrument Logs CAP requires us to keep records of QC failures, instrument errors, downtime, repairs, etc. Our compliance in this practice could use some improvement! Proper use of instrument logs and examples: QC/reagent failures and handling thereof Instrument errors and codes Service calls and troubleshooting End of Shift Logs: shift to shift communication hand-off 14

Tools - Alerts Pick up and drop off locations Indicates if an instrument is available Indicates types of specimens ready for next step Alerts - continued How to make LEAN part of

staffing and maintenance. Requires documentation when targets not met.

15 Tools - Alerts Pick up and drop off locations Indicates if an instrument is available Indicates types of specimens ready for next step Alerts - continued How to make LEAN part of your culture Make it part of daily set up, AM set up board posted that everyone passes as they enter Chemistry 2-Hour Turn-Around-Time log used to monitor operations such as staffing and maintenance. Requires documentation when targets not met. Shift to Shift Communication log- avoids post office effect, provides data in examining frequency of problem re-occurrence Daily rounds, staff and management team reviews operational status, problems/issues and can discuss suggestions Use standardized checklists, post these for other shifts 15

16 Creating a Lean Lab We lived through construction Moving and revalidating our analyzers 16

Renovations Created an Opportunity to Realign Workload And so yet another project. 49 Concord Community Group Practice June 2016 saw the addition of another Community Group Practice.

17 Renovations Created an Opportunity to Realign Workload And so yet another project. 49 Concord Community Group Practice June 2016 saw the addition of another Community Group Practice. Problem/Opportunity Statement Gradual changes have occurred in the hematology department s regular work processes (due to changes in instrumentation, methods, specimen volumes, etc.) while daily staff work block assignments have remained largely the same. Renovations throughout the department of pathology have begun and will further alter workflow patterns, making the existing work block assignment structure obsolete. 17

18 Business Case Ineffective deployment of staff impacts the department. Capacity exists and can be reallocated within the department to better align staffing to workload. This will allow more opportunities for cross training, reduce onbench idle time, provide structured off-bench time for mandatory continuing education for certified technical staff as well as regulatory compliance and section management, while also keeping to the departmental budget goal of zero overtime. Voice of the Customer Hematology staff were given a survey in which they could describe what they felt was wrong with the current work block structure. Responses were grouped into categories and charted: Baseline Performance 18

19 Target Areas or Key Issues Workload Balance Communication Bench Coverage Off Bench Time 55 Potential Causes: 5 Whys Poor communication between/within work blocks. Why? People don t realize when certain benches are busy. Why? People can t physically see other benches. Why? Lab layout. People aren t in the habit of checking other benches once they are slow. Why? Because there s no standard for cross coverage between benches. Why? There s no definition of what your priorities should be when your bench work is done. Potential Causes: 5 Whys Not enough off-bench time Bench staffing structure does not allow for offbench time. Why? We don t have a good definition of what we need for off bench time. Why? We ve never captured the data well. 19

20 Selected Solutions Reallocation of tasks among work blocks Creation of Floor Coordinator work block Structure for breaks/coverage Flexibility to respond to volatile incoming workload 58 Old Layout U C S F S C X D 59 New Layout C C S

21 New Layout Old Layout 62 New Layout 21

22 Old Layout 64 New Layout Results: Volumes CBC UA COAG FOBI FLUIDS SLIDES HOUR OF DAY :00 00: :00 01: :00 02: :00 03: :00 04: :00 05: :00 06: :00 07: :00 08: :00 09: :00 10: :00 11: :00 12: :00 13: :00 14: :00 15: :00 16: :00 17: :00 18: :00 19: :00 20: :00 21: :00 22: :00 23: TOTAL % increase 4.8% increase 2.1% increase 39.3% increase 0.3% increase 14.0% increase 22

Results: TATs CBC COAG UA FLUIDS SLIDES WEEKDAYS 2014 2015 Change 2014 2015 Change 2014 2015 Change 2014 2015 Change 2014 2015 Change 00:00 00:59 0:36 0:24 0:12 0:24 0:25 0:01 0:30 0:44 0:13 0:29

23 Results: TATs CBC COAG UA FLUIDS SLIDES WEEKDAYS Change Change Change Change Change 00:00 00:59 0:36 0:24 0:12 0:24 0:25 0:01 0:30 0:44 0:13 0:29 1:14 1:05 0:08 01:00 01:59 0:16 0:13 0:02 0:27 0:27 0:00 0:25 0:32 0:06 3:02 1:44 1:18 1:02 0:55 0:07 02:00 02:59 0:13 0:12 0:01 0:24 0:28 0:03 0:20 0:20 0:00 0:55 1:25 0:29 0:56 0:49 0:07 03:00 03:59 0:12 0:11 0:00 0:26 0:27 0:00 0:20 0:18 0:02 0:23 1:03 0:40 0:49 0:52 0:02 04:00 04:59 0:11 0:11 0:00 0:21 0:26 0:04 0:22 0:15 0:06 1:09 1:09 0:51 0:55 0:03 05:00 05:59 0:15 0:13 0:01 0:24 0:27 0:03 0:22 0:16 0:05 8:29 8:29 0:58 1:02 0:04 06:00 06:59 0:14 0:15 0:00 0:21 0:22 0:01 0:18 0:19 0:01 5:20 1:02 1:20 0:18 07:00 07:59 0:10 0:11 0:00 0:20 0:20 0:00 0:17 0:17 0:00 1:32 1:00 0:53 0:07 08:00 08:59 0:10 0:13 0:02 0:25 0:23 0:02 0:17 0:25 0:07 2:31 1:24 1:06 0:44 0:49 0:04 09:00 09:59 0:11 0:12 0:00 0:26 0:23 0:02 0:16 0:18 0:02 0:45 1:02 0:17 0:44 0:46 0:02 10:00 10:59 0:13 0:13 0:00 0:22 0:23 0:01 0:27 0:16 0:10 0:56 1:04 0:07 0:45 1:12 0:26 11:00 11:59 0:11 0:15 0:03 0:22 0:23 0:00 0:35 0:20 0:14 1:00 2:23 1:23 0:49 0:59 0:10 12:00 12:59 0:11 0:16 0:04 0:22 0:27 0:05 0:18 0:20 0:02 1:14 1:05 0:09 0:55 0:55 0:00 13:00 13:59 0:15 0:25 0:10 0:22 0:26 0:03 0:19 0:23 0:04 1:02 1:09 0:07 0:46 0:58 0:12 14:00 14:59 0:54 0:31 0:23 0:30 0:29 0:01 0:30 0:28 0:02 1:18 1:16 0:01 0:59 0:58 0:00 15:00 15:59 0:42 0:32 0:10 0:31 0:26 0:04 0:24 0:32 0:08 1:18 1:08 0:10 1:03 1:52 0:49 16:00 16:59 0:17 0:19 0:01 0:28 0:24 0:03 0:18 0:25 0:07 1:05 1:03 0:02 1:16 1:06 0:10 17:00 17:59 0:15 0:15 0:00 0:30 0:28 0:02 0:18 0:18 0:00 1:13 1:03 0:10 0:55 1:08 0:12 18:00 18:59 0:25 0:19 0:05 0:31 0:28 0:03 0:22 0:25 0:02 1:25 1:23 0:02 0:55 1:07 0:11 19:00 19:59 0:56 0:36 0:19 0:50 0:25 0:25 0:38 0:40 0:01 1:32 1:09 0:23 1:03 1:01 0:01 20:00 20:59 0:44 0:47 0:03 0:40 0:28 0:11 0:38 0:45 0:06 1:30 0:49 0:40 1:17 1:17 0:00 21:00 21:59 0:28 0:29 0:00 0:27 0:27 0:00 0:29 0:23 0:05 2:24 0:43 1:41 1:05 1:21 0:16 22:00 22:59 0:15 0:12 0:02 0:32 0:37 0:04 0:19 0:18 0:01 0:56 0:56 0:00 1:00 0:53 0:07 23:00 23:59 0:50 0:33 0:17 0:24 0:26 0:01 0:39 0:30 0:09 1:04 0:49 0:50 0:00 Day Average 0:24 0:21 0:02 0:26 0:26 0:00 0:27 0:28 0:01 1:18 1:13 0:05 0:57 1:06 0:08 Results: Workload Balance Control Plan: The Floor Coordinator 23

24 Lessons Learned Floor coordinator issues Measuring off bench time Change overload is hard on staff Change Management Force Field Analysis Driving Forces (+) Restraining Forces ( ) Renovations Instrument/method changes Sponsor committed to change Engaged team Economic drive to do more with less Specimen volumes Several individuals are pro change This is the way we ve always done it. Desire for personalization of physical space Change overload Fear that the data doesn t describe reality Fear for job loss Fear of being forced to change shifts/hours LSR concerns about impact of heme changes Lack of understanding of future layout plan Actions: Use data to demonstrate the need for change Use sponsor whenever needed Use enthusiastic peers when possible Actions: Change builds a better future for the lab. Communicate layout changes with staff Listen and learn, be sympathetic Dorothy to speak to concerns about job changes How We Are Using Performance Metrics & Rounding Stainer Issue: noted on Performance Metrics or at Supervisory Noted on rounding Performance Metrics Noted at Rounds 27- Nov 28- Nov 29- Nov 30- Nov 30- Nov 4- Dec 12- Dec 13- Dec 19- Dec 20- Dec 26- Dec 27- Dec 28- Dec 3- Jan 4- Jan 5- Jan 5- Jan 7- Jan 9-Jan 9- Jan In Nov & Dec we were experiencing problems with our automated stainer, however our staff was fixing the issues and not contacting service. The issues were impacting TATs, causing delays in testing, significant amounts of work for our team troubleshooting and remaking slides. We were able to address this before the system failed. 24

25 Goal/Measures Maintain TATs Maintain or decrease department overtime Decrease on-bench idle time Provide structured off-bench opportunities How to start? Everyone has a role 24/7 Operational Change, not just day shift Bottom to Top expectations, inverted pyramid Not a pilot but an operational change Emphasize that it s the start of an on-going, permanent process Determine frequency: 2 hour TAT logs Daily Rounds Shift-to shift hand off communication logs Benefits We do good work Showing attention to process by all leadership shows staff that the process and the improvement efforts are important David Mann, take care of your process, and your process will take care of you and produce the results you expect. 25

26 What s working? Using data & information to impact change and improve processes Leadership rounding Standard work Performance metrics Documenting communication handoffs What s not working Sections originally out of scope are harder to bring into the fold Meaningful metrics (misses/delays) Change is hard and not everyone wants to change How to keep it going? Discipline: make it happen Must be done consistently Incorporate into daily routine Lead by example, talk is cheap Now expected not suggested Just do it! Use metrics to monitor operations Metrics need to have value (pertinent and timely, don t measure stuff just because you can) Visuals important, post data (TAT) to show improvements Must change and adapt as operations change 26

Summary Developed by the process leaders Checklists and rounding, like all improvement, has been continuously changed to incorporate new work and suggestions Metrics

from eves to days Better allocation of workload Maximizing Benefits Changes Automation with autovalidation Hematology Urinalysis Leadership Standard Work Lab Assistants

27 Summary Developed by the process leaders Checklists and rounding, like all improvement, has been continuously changed to incorporate new work and suggestions Metrics have been in use and updated as operation changes Future Steps Sysmex replacement and new location Will require further adjustments to work block structure FOBI moving from eves to days Better allocation of workload Maximizing Benefits Changes Automation with autovalidation Hematology Urinalysis Leadership Standard Work Lab Assistants loading analyzers 6 minute cart runs Renovation of Laboratory Cross-training Next Steps Sysmex XN9000 Autovalidation in Coagulation MINIMUM IMPACT TRANSFORMATIONAL CHANGE 27

28 Questions? 82 28

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