"These machines used to be in two different States (Virginia and Maryland)" – A tour of a LEAN-inspired clinical laboratory
As part of my journey to understand LEAN in different environments for the purpose of growing it everywhere, I was invited to tour the Regional Laboratory at Kaiser Permanente Mid-Atlantic, one of the regions of our national affiliate, Kaiser Permanente.
As I posted previously, I have been observing the leaders and staff of this organization begin to embrace LEAN, and have been looking for more examples of LEAN practices in our nation’s capital. Luckily, I am finding them now, and this was a terrific example.
I know many of the readers here have worked in lab medicine in LEAN transformations, so I am going to start by admitting a very naive perception that I have had of lab services as a family practice physician:
Whenever I have walked by a clinical lab, I have assumed that all of the big machines meant that everything was standardized and automated. The sample goes in the machine. The machine reports it. The patient and I use the data. Compared to primary care, what could be non-standard about laboratory processes?
(end naive perception)
Outside of the big machines there are huge potentials for variation and waste, and the impact is incredible. We started our tour with the story as told by the lab’s leaders. A decision was made to regionalize lab services, and the new facility came with a templated version of lab layout, which included walls, pillars, and separation of staff and machinery. The team knew they needed LEAN (more on that later) and started on a journey to build an operation that incorporated LEAN philosophy throughout.
For a service organization that performs about 5 million reportable tests a year, the impact is significant. The case study lays this out well, so I will focus on what I saw.
Pictures, click on any to see in gallery format
First, there is a work room right off of the lab floor. It seems out of place relative to the other conference rooms on another floor, but it is there by design. Staff can problem solve in a safe area that’s close to the work. Visual systems are used to alrt the team to important metrics.
The two formerly separated machines are now in the same room. One performs chemistry evaluations, the other hematology. Why is this important, I asked, if the types of tests are totally different? The answer is that the lab is cross training staff to operate both machines, which allows for leveling of the load.
The building has been set up to be as open as possible. I was told that the design team worked to have as many columns and walls removed as possible. The bulk of testing (80%) happens as close to specimen processing as possible. More specialized areas are located farther away.
I was next taken to inventory, which is made up of several Remstar storage units, which extend 22 feet up into the building and dramatically save space. Inventory is rotated and kept to a minimum. There is one individual managing $6 million of inventory here.
Specimen Processing, the heartbeat
I was next taken to specimen processing. This is where the heartbeat of the organization is, I was told. In the design, which involved a labor-management partnership, the team elected to replace a million-dollar conveyer belt system with a $200 dollar cart to move specimens to the work area. Ideas have been incorporated on the fly as well, such as a slight tilt to the short set of rollers that bring specimen loads into processing. A little gravity is harnessed to move specimens closer to the work.
The urinalysis area has been transformed to a continuous flow model. Formerly, technicians could walk 4.3 miles in a day to complete urine sample evaluation. Now, the most commonly evaluations are located closest to specimen processing, and further required testing is arranged sequentially. Specimens that require the most specialized evaluations are located at the end of the line.
We spent some time talking about water. It was discovered that an unreliable water supply can disrupt operations, and was responsible for reduced efficiency. When I was shown the highly managed water system, I asked, “How did LEAN impact this?” I was told that lab leadership brought their supplier to the table, the water company, and developed plans to ensure a high quality water supply. A visual cue is placed next to the door to let people know how to get help if there are problems.
There were examples of keeping things orderly and easy to find throughout, as you can see from the images.
How does it feel, though?
The individual pieces are very important to support the best result – a patient who has the information they need to make decisions.
When I meet a group like this, I want to find out how it feels, and how they got here. Why did they decide to do LEAN in the first place? The lab director told me that he has an industrial engineering background and he had an experience where he worked in a lab for the Navy when he was younger, and then came back to run that same lab. He noticed that the processes and workflow hadn’t changed, and as a result what had been an efficient work environment had become less functional. He noticed the impact after being away for some time.
I liken this to an analogy about chronic illness. As physicians, we have to think about patients as more than a point in time. A patient who says today that their hip hurts could come back in a year using a cane, and the next, in a wheelchair, because they may not see a very slow decline. The same is true for processes, in places where people work day to day.
I was also told that in a competitive industry such as laboratory medicine, LEAN is a necessity. The way that these improvements are being funded is by bringing in more of the testing in house, where it can be done more economically and in a more integrated fashion with the delivery of care in the system. This means a net economic benefit to Kaiser Permanente’s members, and a loss to laboratories that were formerly contracted to do the work. The commercial labs, in turn, embrace LEAN, to make their services more competitive to the entire community. Health care then, is made more affordable for everyone.
What I also noticed was a feeling of comfort on the part of the leadership. The lab director told me he had been at one of the medical center labs taking pictures to understand the situation better, and it did not seem like a big deal. This reminded me of the quote from one of our VP’s about this (see: “Not in Trouble“). The operations manager spoke with a confidence that came from having results she could demonstrate. As it says in the case study, the difference between receiving a critical lab value at 5:00 pm on the same day the specimen is drawn instead of 3:00 in the morning the next day is significant. Imagine the feelings on the part of the patient and their care team that would come with that situation.
As usual, I saw many correlates here to the patient care that happens in an ambulatory medical center. I am being careful to include the laboratory as a provider of patient care because what I see isn’t test tubes with specimens in them – there is a human being behind every one that has uncertainty about their health.
Impact of the Gemba Tour Itself
Finally, I want to comment on the process of doing this walk through. I did it with one of my counterparts here, Mark Snyder, MD, who also happens to be an infectious disease specialist. This means that he orders many of the tests that the staff here run. What I saw during the visit were several individuals meeting Dr. Snyder for the first time or connecting with him from past work. One of the tests that Dr. Snyder orders on several of his patients is among the more difficult to run, and I saw the impact of Mark talking about this with one of the technologists, in recognition of the service this provides for the member. I imagine that both individuals will take this experience back to their work with greater understanding of their role in supporting members. I really enjoyed watching these interactions.
I close with great thanks to the Regional Lab at Kaiser Permanente for sharing their story with me, and by extension, all of you, and with the knowledge that LEAN is alive and growing in our nation’s capital. Who’s next?
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