# Presentation: 075707

## 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

## 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

## 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

## 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

## Scope of Lean Implementation

- Began implementation in August 2003
- Chose to use Perfecting Patient CareTM (PPC) as the Lean improvement method
- Education by the Pittsburgh Regional Healthcare Initiative
- Jewish Healthcare Foundation funding for a team leader
- Internal learning network

## 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)

## Implementation Methods

- Organizational commitment
- Physician champions
- Team leader
- Internal collaboration
- Front line workers
- Design depended on input from those involved in the process

## Lean Evaluation

- Metrics
- Efficiency of services
- Turn around time
- Productivity
- Quality
- Error reduction
- Resource utilization
- Satisfaction
- Costs
- Business case analysis

## 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)

## Results of Lab Productivity

## 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)

## 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

## 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

## 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

## 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