January 2012
Feature Story

Cynthia Seaver, CSSBB, CLE, BSMPH, BSC
Kimberly Collison, MSA, MT(ASCP)
Molly Catalina, BSBA

The Spectrum Health Hospitals flow cytometry department relocated in 2008 to a new cancer pavilion on the health system’s main campus in Grand Rapids, Mich. The staff members loved their spacious new laboratory on the top floor. However, after a year in the new location, they realized they needed to improve their workflow and efficiency to handle a steadily increasing workload. At the same time, budget constraints made it necessary to reduce supply expenses.

The Spectrum Health Hospitals flow cytometry department is a regional laboratory that serves the overall Spectrum Health system. The staff consists of three hematopathologists, a technical specialist, five full-time medical technologists, two secretaries, and a laboratory services representative. While it was important for all departmental staff to be involved in the change, the members decided to form a core work team of seven from each area of expertise. This team had one ground rule: Every person on the team and in the department must freely and honestly make suggestions and raise issues or concerns to create the synergy needed for success. They would build upon each other’s ideas.

5S process

To begin, the work team asked the Spectrum Health operational improvement department to provide an overview of the Toyota Production System¹ for the entire department. This included the system’s 5S process improvement model (sort, straighten, shine, standardize, sustain). Originating with Toyota in Japan, 5S is considered one of the basic building blocks for high-performance work teams and a necessary step for other continuous improvement efforts.

After initial training, the work team used the 5S process to reorganize the department’s workspace. Later, it identified several areas in which processes could be improved.

Sorting (seiri) was the first step in this 5S process. The team members opened every cabinet, box, and refrigerator in the work area and determined which items were needed to do the work. Many unused, outdated, and other items were discarded. When the work team members were unsure of the value of an item, it was given a red tag and placed on a table for review by their coworkers. Items not located near where they were used were moved to the appropriate workspace. The work team identified excessive inventory in several areas and corrected the locations of the existing stock.

Straightening (seiton) was step No. 2. As the work team identified the appropriate items for a work area, they organized and straightened that space, including optimizing inventory levels.

Shine (seiso) was next. Once its work in an area was completed, the work team defined a way to clean and inspect the area daily.

Step No. 4 was to standardize (seiketsiu)—establish ongoing practices for future changes. The team members defined a process for establishing appropriate space for new equipment and reconfiguring work areas as needed. They also developed a process for reviewing inventory and maintaining improvements in supply management.

Sustain (shitsuke) was the final step. The department’s staff members agreed to review and discuss organization and cleaning issues, including the overall feel of the workplace, at regularly scheduled meetings.

Process improvement

When the work team was in the final stages of 5S, it began viewing its ongoing work in a new light. Team members realized the incoming specimen process was full of redundancies and ambiguities. This caused process “waste,” as defined by the Toyota Production System. At this point, the 5S core work team pulled in people from different areas of the laboratory to help improve the specimen intake process. A facilitator and teacher from the operational improvement department offered guidance.

The expanded team used process mapping questions and procedures to examine the workflow (Table 1). It defined each step in the process as it related to what, why, who, and how the work was performed; studied detailed workflow patterns mapping the current state processes; and noted potential improvements by developing a future state process map.

To accomplish this, the facilitator taught this expanded team additional basic principles of the Toyota system, beginning with the four rules Spear and Bowen presented in their article, “Decoding the DNA of the Toyota Production System.”² Spear and Bowen explain the rules as follows:

1. All work shall be highly specified to content, sequence, timing, and outcome.
2. Every customer-supplier connection must be direct, and there must be an unambiguous yes-or-no way to send requests and receive responses.
3. The pathway for every product and service must be simple and direct.
4. Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at the lowest possible level in the organization.

These four rules require that activities, connections, and flow paths have built-in tests to signal automatically that problems exist. It is the continual response to problems that makes this seemingly rigid system so flexible and adaptable to changing circumstances.

Members of the cross-functional work team studied the existing specimen intake process. They created a process map depicting the specimen entry workflow. During this mapping process, the team was able to identify how the process wasn’t meeting the four rules.

For example, in relation to rule No. 1 (all work shall be specified to content, sequence, timing, and outcome), the team noted that staff members had different ways of recording the incoming specimens in various logs throughout the laboratory. There was no consistent, defined sequence of steps or clearly identified work standard for specimens transiting from the general laboratory area into the flow cytometry department. Lab representatives and technologists handled the specimen log-in process differently depending on how busy each area was at any given time.

The team also realized that rule No. 2 was not being followed; the connections between lab services and the analytical technologists were not well defined. A lot of rework was done as everyone tried to move specimens quickly into the analytical testing phase while the registration and accessioning process wasn’t complete. The paperwork moved back and forth erratically between the analytical area and the laboratory receiving area. As rule No. 3 says, the pathway from specimen arrival to final physician report needed to be simple and direct. But the process map showed that the existing registration process, designed to get specimens into the testing area quickly, created bottlenecks, interruptions, and errors, while also taking more time.

So the team went to work on defining standard work and creating a simpler, more efficient pathway for specimen intake. They determined that the most direct path was to wait for specimens to be registered and logged in to the laboratory computer tracking system by a lab services representative, who would then bring the specimens to the analytical testing area. This immediately reduced time spent hunting for the specimen as well as the potential for labeling errors. Although initially it seemed as though this way of working might delay the testing process, there was no delay, the team discovered. Testing is completed in batches and technologists are often waiting for specimens to arrive before starting a test.

With the specimens fully registered and logged in to the laboratory computer tracking system before they arrived in the flow cytometry department, there appeared to be no need to maintain a handwritten log in the department. The team then investigated whether they could drop the manual tracking process being used to help count and track the volume of specimens in the department. The technologists recognized this information was now available in the computer system. They worked with computer personnel to develop a report to pull applicable data from the system, thus eliminating the manual log-in process.

Outcomes

The work team completed its 5S work, which it had begun in October 2009, in about three months, working two to three hours per week with a facilitator from the operational improvement department. The early measurable outcomes were, in part, reduced time spent hunting for needed supplies (from an estimated 30 minutes per day to less than five minutes per day per technologist, for a total of 125 minutes saved per day) and freed up cabinet and countertop space needed to accommodate more testing platforms (22 square feet of cabinet space during the initial 5S process).

The culture of 5S has been embedded throughout the department, and as other issues come to light, the staff now has a process to resolve them. One example was the realization that a leased copy machine was no longer required. The work team recommended to management that the machine be removed, freeing up the space for testing equipment. The lease was not renewed, which saved the department $600 per year.

The work team continues to use the TPS 5S process to identify improvements in the flow cytometry department’s workspace organization and is especially aware of appropriate inventory management. By identifying the appropriate storage space and items needed, the team has reduced inventory levels and purchases only what is needed. The team also has combined efforts with two other laboratory departments to merge general laboratory supplies. The three departments standardized on two glove types, one type of laboratory wipes, office supplies, and several other items to reduce overall inventory. The estimated savings is $8,000 annually. The work team also created a process to monitor expenses for antibodies and reagents; they saved $13,000 in fiscal 2010 by improving their purchasing process.

Learning how to recognize outdated steps in a process and use appropriate technology was a major learning experience for the team members, and their process improvement efforts produced significant outcomes. For example, eliminating the manual log-in process freed up an estimated total of 75 minutes per day for five technologists.

The work team also identified technology solutions to reduce the steps being used to shuffle various papers around the office. They used software to track each specimen throughout the analytical process. They began to save reports as pdf files instead of generating paper printouts, and they created electronic folders for each patient instead of paper files. This reduced the workload for technologists and secretaries. The revised process also made reports immediately available to appropriate personnel and ultimately reduced the need for retyping when secretaries created final analytical reports for physicians. This reduced overall turnaround time for reporting results to ordering physicians and patients. (Fig. 1 shows materials cost savings captured by the initial reduction in paperwork.)

The pathologists and secretaries worked together to implement voice-activated transcription, which further reduced the flow of paper in the department. It also reduced the overall time spent by pathologists and secretaries on dictating and transcribing by about 50 minutes per day. (Fig. 2 shows the estimated total time savings owing to initial improvements in the department.)

Over a period of several months, the department’s staff members continued to identify areas where they could improve the flow of their processes (Table 2). Most of our work was completed by January 2010, with the project having confirmed that the Toyota Production System works in health care (Fig. 3).

Lessons learned

The work teams and department staff members learned several important lessons during this TPS journey.

First, it was critical that the staff own this project. They received full management support throughout the project and were empowered to make suggestions and implement changes they felt were necessary. Although the department manager established the goal for the project, she did not drive the improvements. Instead, staff commitment and enthusiasm led to a cultural transformation, which ultimately resulted in project success and sustainability.

Second, the process had to be ongoing and not just another flavor-of-the-month project. The initial mapping process provided the team with an eye-opening view of the waste and redundancies in its existing process. The workflow changes were simple to see and easy to correct. When the staff felt empowered to implement changes, they experienced immediate gratification, which made it easier to sustain the process over time. Work volume has increased by more than eight percent, yet there has been no need to increase staff or schedule overtime.

Third, this TPS process changed how the staff members work together as a team. Every new test and issue is examined with a critical eye to ascertain the best workflow and the best process. Staff, not management, leads this, and the result is an efficient and cost-effective flow cytometry laboratory.

Finally, the work team and department staff were able to identify a list of specific, immediate action items needed to maintain the high service level expected from a regional specialty laboratory. They were able to set and accomplish their initial goals for process improvement within several months, not years. And the flow cytometry department continues to identify and reduce waste in its processes. TPS techniques are now part of its culture.

References