Blood Bank Professionals’ Perspective on Lean Culture and ......some projects. The organizations...
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Blood Bank Professionals’ Perspective on Lean Culture and Efficiency ___________________ A Research Study Presented To the Faculty of Simmons College __________________ In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy In Health Professions Education ___________________ Hassan El-Alami Summer 2016 Committee: Ludmila Epshteyn, MD Daren Graves, Professor Arlene Lowenstein, Professor © 2016, Hassan El-Alami
Transcript of Blood Bank Professionals’ Perspective on Lean Culture and ......some projects. The organizations...
Blood Bank Professionals’ Perspective on Lean Culture and Efficiency
___________________
A Research Study
Presented
To the Faculty of Simmons College
__________________
In Partial Fulfillment of the Requirements for the Degree
Doctor of Philosophy
In Health Professions Education
___________________
Hassan El-Alami
Summer 2016
Committee:
Ludmila Epshteyn, MD
Daren Graves, Professor
Arlene Lowenstein, Professor
© 2016, Hassan El-Alami
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Table of contents
Table of Contents
Table of contents........................................................................................................................2Chapter One – Introduction....................................................................................................4
Purpose of The Study.........................................................................................................................4Significance of the Problem..............................................................................................................5Conceptual Framework.....................................................................................................................7Research Question............................................................................................................................14
Chapter Two – Literature Review......................................................................................16Lean in Healthcare Organizations................................................................................................16
Efficiency and continuous improvement:..............................................................................................16Lean transformation in healthcare organization:.................................................................................20Blood bank in healthcare organizations:................................................................................................24Impact on healthcare:....................................................................................................................................24Efficiency and continuous improvement:..............................................................................................27Lean transformation examples in the blood bank:..............................................................................28
Change Theory and Dynamics.......................................................................................................30Dynamics of change:....................................................................................................................................30Change theory:................................................................................................................................................34
Intrinsic Factors that Motivate People to Change.....................................................................39Healthcare professionals in the blood bank:.........................................................................................42
Chapter Three – Methodology.............................................................................................44Qualitative Research........................................................................................................................44Healthcare Professional in The Blood Bank...............................................................................44Study Participants............................................................................................................................46Participant protection......................................................................................................................48
Risks:..................................................................................................................................................................48Protection Against Risks:............................................................................................................................48Benefits:............................................................................................................................................................48
Blood Bank Observations................................................................................................................49Interviews...........................................................................................................................................50Methodology of Data Analysis.......................................................................................................51Validity................................................................................................................................................56
Descriptive validity:......................................................................................................................................56Interpretive validity:......................................................................................................................................57Theoretical validity:......................................................................................................................................57
Researcher Identity..........................................................................................................................58Multiple selves:...............................................................................................................................................58
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Othering:...........................................................................................................................................................59Chapter four – Results..........................................................................................................60
Lean principles, waste and process...............................................................................................61Lean principles:..............................................................................................................................................61Eliminating waste:.........................................................................................................................................61Lean Processes:...............................................................................................................................................63
Change theory, fundamental causes, and reaction:..................................................................66Change theory:................................................................................................................................................66Fundamental causes of change:.................................................................................................................68Reaction to change:.......................................................................................................................................70
Motivation:.........................................................................................................................................72Keller’s ARCS model of motivation:......................................................................................................72Self-Determination Theory (SDT) according to Pink:......................................................................75
Chapter five – Discussion......................................................................................................77Lean principles, waste elimination, and processes:...................................................................77
Lean principles and waste elimination. (Koenigsaecker, 2013, p.11)..........................................77Lean processes (Jones 2013):.....................................................................................................................79
Change theory, fundamental causes, and reaction:..................................................................79Change theory: Trans Theoretical Model (TTM) of Change. Prochaska (1977).....................79Fundamental causes of change:.................................................................................................................80Reaction to change:.......................................................................................................................................81
Motivation by Intrinsic values to facilitate change:..................................................................82Kellers ARCS model of motivation:.......................................................................................................82Pink’s SDT values:........................................................................................................................................84
Chapter six – Conclusion......................................................................................................86Lean and efficient processes characteristics:..............................................................................86Change characteristics:...................................................................................................................88Intrinsic values characteristics:.....................................................................................................89Future work:......................................................................................................................................90Concluding Remarks:......................................................................................................................92
Glossary....................................................................................................................................93Definitions...........................................................................................................................................93
References................................................................................................................................99Appendix.................................................................................................................................104
Observation - Suggested ideas.....................................................................................................104A. Issuing blood Work flow................................................................................................................104B. No typenex...........................................................................................................................................105
Observation - Sought after ideas................................................................................................108Filing instrument quality control and error reports...........................................................................108
Interviews........................................................................................................................................109Tables containing elements and corresponsing themes from the responses.....................126
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Chapter One – Introduction
Purpose of The Study
The rising cost of health care has led hospitals to think about ways to do things
differently. The objective is to deliver the best care in the most efficient way, basically
cutting the waste from the process, otherwise called lean processes (Spear, 2005).
The question that comes next is how to institute a lean culture? How can people
start thinking differently to institute more efficient work practices? How can people
perform their work in a lean way? How can they change what they do to become more
efficient? And the hardest question of all, how can people who have been doing
something for tens of years change to do it differently?
These questions become difficult in the blood bank. The blood bank is a highly
regulated department in the hospital. Different government and non-government
organizations have put standards of work practices in the blood bank. The Food and Drug
Administration (FDA), American Association of Blood Banks (AABB), College of
American Pathologists (CAP), and The Joint Commission for Accreditation and
Certification of Health Care Organization are some of these organizations that regulate,
provide standards and inspect blood banks. For any blood bank to succeed, it must follow
these standards. The standards go under review and get changed semi-annually, annually,
bi-annually or less often, depending on the organization. The change process is slow and
cosmetic in many instances. Moreover, it instills in the blood bank worker a sense of
rigidity and resistance to change. These factors make change a harder process in the
blood bank. Nevertheless, the blood bank has to adopt more efficient practices along with
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the hospital to decrease cost, and improve healthcare. It has to become a leaner
department like the rest of the hospital.
The fundamental idea behind lean thinking is that everything is a process. Stream
lining the process and eliminating waste from it makes it a lean process. Although this
sounds simple, the key issue is change. A conceptual and behavioral change that will lead
to process change. In the case of the blood bank, it is important for the blood bank to
change its processes and at the same time comply with the regulation and standard culture
expected of it. This has to happen through the healthcare professionals who operate the
blood bank and execute its processes. They need to adopt this change and make the
processes leaner and more efficient.
Significance of the Problem
Adopting lean culture in healthcare organizations leads to improved healthcare, higher
employee morale, reduced cost, identification of change factors and improved
educational processes.
Improved Healthcare: There are numerous examples of how applying lean principles
have resulted in improving healthcare for patients. One such example is Pittsburgh
Regional Healthcare. Within 3 years it was able to reduce central line associated blood
stream infections by 50% (Spear, 2005). Wellman, Hagan and Jefferies (2011)
demonstrated how adopting lean in healthcare can “reduce cost and improve patient care
at the same time” (p.2). They demonstrated success examples in numerous healthcare
organizations like Seattle Children’s Hospital, Evert Clinic in Washington, Memorial
Care Health System in California, Children’s Hospital and Clinics in Minnesota, and
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Jefferson Health System in Washington. These organizations vary in size, structure and
healthcare delivery. Wellman, Hagan and Jefferies (2011) demonstrated that after
adopting lean principles, these organizations experienced “Improved quality, cost,
delivery, safety, and staff and physician engagement” (p. 3). �
Higher Employee Moral: Lean principles as designed and implemented in Toyota
manufacturing are built on respect for the employee. Reduction in time wasted is a tool to
show respect for the employee time. This has translated in boosting employee morale and
increased satisfaction at work. Bertholey, Bourniquel, Rivery, Coudurier, and Follea
(2009) reported increased staff satisfaction at blood transfusion establishments in Pays de
la Loire, France, when lean manufacturing techniques were introduced.
Seattle Children’s Intensive Care Unit (ICU) went through culture change to lean
processes to increase comfort care for critically ill patients. The staff was surveyed after
the change. It was found to be more satisfied with care measures than before the change.
(Wellman, Hagan and Jefferies 2011)
Reduced Cost: Lean culture in healthcare organizations has been described as the new
revolution in the healthcare (D’Andreamatteo et al., 2015). Many hospitals have adopted
it and experienced improvement in patient experiences, reduction in wasted time, and
hence financial savings (Caton-Hughes and Bradt, 2007). The blood bank at Johns
Hopkins applied lean principles in reducing waste in blood products. Johns Hopkins
Hospital managed to reduce Red Blood Cell (RBC) product waste from 4.4% to less than
2%. Heitmiller et al., (2010) found “this reduction decreased the number of RBC units
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wasted by approximately 4300 per year, savings approximately $800,000 over the 4-year
period of the study” (p. 1887).
Identify Change Factors: The most successful lean implementations are the ones
involving a culture change. Many organizations attempted to implement lean techniques
and ideas. Resistance to change increased in the organization. The success was limited to
some projects. The organizations that instituted lean as part of a culture change were
successful. Caton-Hughes and Bradt (2007) assert that workforce engagement is an
essential element in the “successful application of lean” (p.1) in the National Health
Service (NHS) in the United Kingdom (UK). Identifying these change factors will help
enable other changes needed in any organization.
Improve Educational Process: Education is at the core of any change. For any change
to happen, people need to learn the new ways. This learning is essential. To adopt lean
principles, people need to learn about lean, its significance, and how it improves their life
as they do their daily jobs, and the lives of the patients they are taking care of. People’s
reception and acceptance to this learning will be as diverse as people are. Learning
methodologies that need to be used to deliver the message will vary as well. Knowing
what drives people to adopt a change is significant to adopting lean culture and gaining
its benefits. Moreover, it’s beneficial to know how to adopt any change, a key element for
success in an ever changing world.
Conceptual Framework
This research will move through the principles of lean, healthcare organizations,
blood bank departments, healthcare professionals working in the blood bank and change
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theory. Lean principles increase value and cut waste. Healthcare organizations are using
them as a continuous improvement tool. The blood bank department is an essential part
of the healthcare organization. It is highly regulated and needs to adopt this tool.
Healthcare professionals who work in these departments are the elements in adopting this
tool. This change is explored through change theory. The change in them to adopt
continuous improvement tools, lean principles, is the focus of this study. The following
diagram, Figure 1, represents the conceptual framework of this dissertation, and the
following articles support this model.
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Figure 1. Dissertation conceptual framework
Lean thinking is not a new idea. It is actually a Japanese idea that is attributed to
Toyota manufacturing. Koenigsaecker (2013) identifies the principles of lean thinking as:
• “The concept and practice of continuous improvement.
• The power of respect for people.” (p.10)
He tells us the 7 key wastes in any process:
1. Overproduction (making more than what you need or before you need it)
HealthCareProfessionalAdapttoLeanCulture
BloodBank
HealthcareOrganization
LeanCulture
ChangeTheory
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2. Producing defects
3. Movement or transportation (this does not actually make the material closer to
what a customer of the process would value)
4. Inventory (the storage of overproduction)
5. Over-processing (the classic inefficiency that we might usually look for)
6. Waiting time
7. Unnecessary motion. (p.11)
Some industries in the United States began using lean concepts and now the same
ideas are making their way to health care. Healthcare can benefit from principles that will
reduce waste and increase value. The rising cost of healthcare coupled with reduced
reimbursements puts healthcare organizations on a path for loss. Healthcare is full of
processes that need to be revisited to see how much value they add to the patient and how
much waste can be eliminated from them. Many hospitals are embracing this way of
thinking. Spear (2005) cites many examples of hospitals that implemented lean thinking
and had good results, in saving money and providing better health care. Campbell (2009)
describes lean relating to healthcare as “Lean thinking is an efficient use of staff
resources and technology to provide the highest level of service possible to the ultimate
healthcare customer: the patient” (p. 40).
Numerous healthcare organizations have tried to apply lean principles. Success
depended on how much lean principles were engrained in the culture of the organization.
The more the organization adopted lean as a culture change, the more it benefitted.
Caton-Hughes and Bradt (2007) wrote a white paper on lean implementation and
emphasized people engagement as an element of success. Dortz and Poksinska (2014)
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studied lean implementation in healthcare and concluded that the manager role changes
from managing tasks to coaching people. The kind of leadership needed is
transformational or service leadership. Stone et al., was cited by Poksinska, Swartling,
and Drotz (2013), “Both transformational leadership and servant leadership emphasize
the consideration and appreciation of individuals, the importance of teaching, coaching,
developing, and empowering followers.” (p.889). This focus on coaching and developing
people is the subject of this dissertation as it relates to the healthcare professionals who
work in the blood bank.
The blood bank department is an integral part of any hospital. The purpose of the
department is to supply blood to the patients who need it. Trauma, premature deliveries,
surgery, and other medical conditions require blood transfusions. That is why a blood
bank department at a hospital is sometimes called transfusion service. Blood transfusion
is the most commonly performed procedure in the United States (Tolich, et la., 2013).
The budget of this department is usually in millions of dollars depending on how many
transfusions are done each year in the hospital. The cost of transfusing a unit of blood
varies between $522 and $1,183 (Tolich, et la., 2013). Applying lean principles to the
operation of the blood bank will lead to substantial savings. Assuring the efficiency of the
operation of the blood bank will result in improved health care and cost reduction. Johns
Hopkinton Hospital saved more than $800,000 by reducing blood wastage at the hospital
(Heitmiller et la., 2010). The transfusion service at Naples Community Hospital in
Florida saved $250,000 when they implemented lean principles. (Sunyog 2004).
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Cost saving is just one benefit of lean culture adoption. Overutilization of blood has
been recognized as a problem by the Department of Public Health. This led to the
introduction of Patient Blood Management (PBM). Tolich, et la., (2013) stated: “Blood
management is defined as a patient centered standard of care in which strategies and
techniques are used to reduce, eliminate, or optimize the blood transfusions to improve
patient outcomes” (p.41). These are the same strategies used in lean. In practice, PBM is
an implementation of lean principles, or meets with it in reducing unneeded blood
transfusions.
The heart in adopting lean principles in the blood bank is the healthcare
professionals who conduct the processes leading to the transfusion. These are medical
laboratory scientists who prepare the blood to be transfused, nurses who transfuse the
blood, and physicians who initiate the previous two processes to treat the patient. The
processes involved in the preparation are complex, regulated by FDA, and overseen by
The Joint Commission. AABB, and CAP provide standards that comply with the
regulation and provide inspection services to make sure that organizations are in
compliance. The medical laboratory scientist who works in the blood bank must have a
minimum of a 2-year associate degree or its equivalent according to the Clinical
Laboratory Improvement Amendment (CLIA) of the Centers for Medicare and Medicaid
Services (CMS) of the US government. As healthcare is transforming to lean culture, the
medical laboratory scientist must adopt lean principles and be part of this culture change.
Leaders in the laboratory should also change from task mangers to coaches. Yet what
needs to be understood is how does the behavior of the healthcare professional change?
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Changing the culture of healthcare organizations stems from changing the
conceptual understanding and behavior of its workers. Al-Twfiq and Pittet (2013)
evaluated the application of different change theories in motivating healthcare
professionals to comply with better hand hygiene techniques. The study concluded:
Transtheoretical Model (TTM) of health behavior change helps to tailor
interventions to predict and motivate individual movement across the pathway to
change. A program could be based on this theory with multiple interactions with
John Keller’s (ARCS) Model of motivational design and Theory of Planned
Behavior (TPB). Linking attitude and behavior to promote hand hygiene could
strengthen such a program. The program could utilize different strategies such as
organization cultural change that may increase the attention as well as fostering
the movement in the ARCS stages (Al-Twfiq and Pittet, 201, p.374).
These change theories can be used to facilitate the change to lean culture in the hospital.
The change needs to build on qualities within the healthcare profession workers.
Grant and Hofmann (2011) studied what would motivate healthcare workers to
comply better with hand hygiene techniques to prevent infection at a US hospital. The
study found that hand hygiene of health care professionals increased significantly when
they were reminded of the implications for patients but not when they were reminded of
the implications for themselves.
Ng et la., (2012) determined that Self Determination Theory (SDT) as cited by
Deci & Ryan (2000), is applicable in the healthcare setting. SDT postulates that people
are motivated by intrinsic motives. Pink (2009) used this theory to deduce that people are
driven by autonomy, mastery and purpose. Autonomy is self-direction. Mastery is
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becoming better at something that matters. Purpose is a cause greater and more enduring
than themselves. How can these qualities be tapped on to enable change to a new culture?
Do autonomy, mastery and purpose influence medical laboratory scientists? How can
medical lab scientists adopt a lean culture in the blood bank?
Research Question
Healthcare professionals who are involved in the blood bank processes are
medical laboratory scientists, nurses and physicians. The medical laboratory scientists are
responsible for the operations in the blood bank that revolve around preparing blood
products to be transfused to the patients. Nurses are responsible for transfusing the blood.
The physicians order the blood bank to prepare the blood for the patients and for the
nurses to transfuse it in them. The whole process is governed by standards established by
FDA, AABB, CAP and The Joint Commission. These standards are put to assure the
potency of the blood products given during transfusion and the safety of the patient
receiving them. They govern the processes that start with the blood donation and end
with the patient receiving the blood. Medical laboratory scientists, nurses and physicians
who are part of the blood bank processes are educated and trained to follow the standards
and regulations. It puts them in a frame of mind to follow specific orders.
Now, the healthcare organizations are expected to adopt a new culture; a culture
of efficiency that cuts waste and streamlines the processes towards what adds value to the
patient. By definition, this means changing the current processes towards new ones. The
blood bank is a critical part of any hospital and must be part of this change. The
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healthcare professionals who were educated and trained to follow standards are now
expected to adopt a new culture, a culture of lean and efficiency. The aim of this study is
to answer the question: how do blood bank healthcare professionals describe
adapting to lean culture and efficiency in blood bank operations?
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Chapter Two – Literature Review
Answering the question, how do blood bank healthcare professionals describe
adapting to lean culture and efficiency in blood bank operations, means answering
three questions:
1. What is lean as it relates to healthcare organizations?
2. What are the theories and dynamics of change?
3. What are the intrinsic factors that motivate people to change?
The literature review that answers the first question, what is lean as it relates to
healthcare organizations? will define lean, explore healthcare organizations’ experience
with lean and what is needed to transform a healthcare organization to lean. The lean
experience as it relates to the clinical laboratory and blood bank will also be included.
This will be followed by the literature review that answers the second question, what are
the theories and dynamics of change? In this section, how people change, what causes a
fundamental change in an organization, and how people react to change, will be explored
and defined. The last section of the literature review will touch upon the theories that
relate to motivating people to change.
Lean in Healthcare Organizations
Efficiency and continuous improvement:
No one person will live his or her live without getting sick and needing medical help.
Numerous healthcare organizations are established to care for the sick. As the population
ages and increases in number, it becomes more dependent on healthcare organizations.
Currently these organizations are facing 2 main problems: high cost and low quality.
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Faced with these problems, many health organizations looked for solutions tried in
different sectors of the economy. The automobile industry has adopted lean processes
established by Toyota manufacturing to increase efficiency and improve quality. Will
lean processes work in healthcare organizations?
Lean thinking is a Japanese idea that is attributed to Toyota manufacturing.
Koenigsaecker (2013) found that lean thinking is built on:
• “The concept and practice of continuous improvement.
• The power of respect for people.” (p. 10)
The following pillars will solve most of the problems in healthcare identified above. Lean
thinking is best looked at as a cycle of five steps:
1. Identify the value from the customer’s perspective
2. Map the stream of processes to deliver value to the customer
3. Create a flow of the processes that will eliminate waste
4. Fulfil customer’s pull from the organization
5. Refine, improve and add to the processes to reach perfection
Jones (2013) depicted this cycle in the following diagram, figure 2:
http://bhmpc.com/2013/11/lean_thinking_for_healthcare/
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Figure 2. Lean processes cycle.
Lean thinking is keen on eliminating waste from processes. There can be 7 key
wastes in a process (Koenigsaecker 2013):
1. “Overproduction: making more than what you need or before you need it
2. Production defects: Using defective material that affect the process or making
mistakes during the process
3. Movement or transportation: Not making the material closer to what a
customer benefiting from the process would value
4. Inventory: Storage or overproduction that would need unnecessary space
5. Over-processing. The classic inefficiency that is usually found in duplicating
work and redundancy
6. Waiting time
7. Unnecessary motion.” (p. 11)
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Researchers studied the Toyota Production System (TPS), isolated the principles
behind it, and evaluated if these principles can be applied in a field other than cars. They
found that these principles can be applied to any field, process or system (Liker, 2007).
Although the example cited in this article was for tile manufacturing, researchers found
that these principles are far reaching and can benefit any system. Lander and Liker (2007)
concluded that “TPS is a philosophy that can be better described as a set of general
principles of organizing and managing an enterprise which can help any organization get
on a path of positive learning and improvement” (p.3681). Many hospitals and health
care organizations adopted these principles to improve the quality and practice of health
care. Wellman, Hagan and Jefferies (2011) demonstrated how adopting lean in healthcare
can “reduce cost and improve patient care at the same time” (p.2). They demonstrated
success examples in numerous healthcare organizations like Seattle Children’s Hospital,
Evert Clinic in Washington, Memorial Care Health System in California, Children’s
Hospitals and Clinics in Minnesota, and Jefferson Health System in Washington. These
organizations vary in size, structure and healthcare delivery. Wellman, Hagan and
Jefferies (2011) demonstrated that these organizations, after adopting lean principles,
experienced “Improved quality, cost, delivery, safety, and staff and physician
engagement” (p. 3).
Numerous healthcare organizations believed that lean processes would solve their
problems. D’Andreamatteo, Lanni, Lega and Sargiacomo (2015) did a comprehensive
literature review of 15 years ending in September 2013. The authors analyzed 243 articles
in which lean was mostly adopted in hospitals and surgery departments. They found
positive results in improving productivity. They focused on barriers, challenges, and
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success factors in implementing lean. They cautioned against drawing a final conclusion
about the positive impact of lean on healthcare because of the lack of “sustainability,
framework for measurement and critical appraisal” (p.1). They found that “Evaluations of
system wide approach are low in number” (p.1). The authors found this particularly
important to point out because implementation of lean processes requires the engagement
of the whole organization. It is this final fact that intrigues the investigator. How does a
hospital change its culture? Does change theory and culture change mechanisms that
work in other areas work in healthcare?
This question was in the mind of Reijula, Nevala, Lahtinen, Ruohomaki and
Reijula (2014) who conducted a literature review of 100 research articles about lean and
healthcare design. They concluded, “Lean has shown great promise in enhancing work
process efficiency in health-care implementation projects but has not yet been validated
as a health-care facility design philosophy” (p.180). Although the focus of the study was
mainly on the design of the hospital and how it should be structured in a model that
enhances efficiency of services and decreases waste, it also listed the fundamentals of
lean as they apply to healthcare. The next section will explore this in more detail.
The literature review by Rejula et al., (2014) has also found that lean has to be
implemented as a culture change in the organization for it to be successful. It involves a
transformation and requires the tools of change management.
Lean transformation in healthcare organization:
So far it is concluded that successful implementation of lean processes involves a
transformation of the organization. The next question is to find the style of leadership that
best suits this transformation. Figuring out this style was the focus of the research by
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Poksinska, Swartling, and Dortz (2013). The group explored 5 case studies to better
understand the characteristics of lean leadership. They found a shift in focus in leadership
“from managing processes to developing and coaching people” (p.886). This is consistent
with the original leadership model founded in Toyota manufacturing. According to them
leadership consists of 4 stages:
1. “Be committed to self-development
2. Coach and develop others
3. Support daily Kaizen
4. Create vision and align goals” (p. 887-888)
The closest leadership theories or styles that resemble this type of leadership are
transformational leadership, servant leadership and leadership in self-managed teams.
First, lean leadership is related to transformational leadership. To develop
employees and encourage cooperation and responsibility, the managers use a
coaching leadership style, which shows many similarities with transformational
leadership. This style of management implies helping employees discover their
own talents and skills and facilitating the problem-solving and improvement
processes. Second, lean leadership shares underlying principles with servant
leadership. In traditional companies, the management hierarchy may be drawn as
a pyramid, similar to an organization chart, with the CEO at the top, and the
operators at the base. The principle is that directions are given from the top, in a
command and control manner. This study shows that the hierarchy pyramid in
Lean organizations becomes inverted with managers at the base and employees at
the top. Managers pay much attention to employees’ needs and their development
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and the managerial work is focused on creating a learning and facilitative work
environment. Third, Lean leadership has a connection with leadership in self-
managed teams. As the Lean implementation matures, the teams become more
self-managed and the managerial tasks start to be shared between the first-line
manager and the internal team leader. Internal leaders together with teams are
responsible for managing daily activities and first-line managers only become
responsible for providing direction and support to teams. (Poksinska, Swartling,
and Dortz, 2013, p.896)
Transitioning from leadership to employees. Dortz and Pokinska (2014) studied
lean implementation from the employees’ perspective. They looked at three healthcare
organizations that successfully adopted lean culture. They interviewed, observed and
studied healthcare professionals’ reaction and interaction with lean culture
implementation. They found a change in skills and tasks. Healthcare professionals used to
be annoyed by problems and perceived them as interruption to their work. Even when
treating the patient, the focus is comfort and safety. As good as this sounds, by
implementing lean the focus changed to problem solving and continuous improvement.
Healthcare professionals took more ownership for solving the problems and formed
teams within and across departments to solve the problems and improve the quality of
care.
The focus has shifted from healthcare professionals, where clinical autonomy and
professional skills have been the guarding principles of patient care, to process
improvement and teamwork. Different job characteristics may make it difficult to
implement certain Lean practices in healthcare. Teamwork and decentralization of
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authority are examples of lean practices that could be considered countercultural
because of the strong professional culture and uneven power distribution, with
doctors as the dominant decision makers. (Dortz, and Pokinska, 2014 p.177)
The conceptual and behavioral changes needed on the leadership and employees’ role
should not be taken lightly.
National Health Services (NHS) oversees healthcare organizations in England.
Many healthcare organizations in the NHS system recognized the importance of
continuous improvement and adoption of lean culture. Experts in organizational
development studied the experiences of these organizations and came up with a strategic
framework for the development of programs of quality improvement and lean culture
adoption (Canton-Hughes, and Bradt, 2007). They showed the importance of these
programs in benefiting healthcare in the short and long term. They also cautioned against
forgetting the human factor when implementing such programs. They found that
forgetting this contributed to the failure of such programs. People will go through shock,
anger, resistance and acceptance as change occurs in the organization. Good leadership
mitigates bad feelings through engagement. They cited the ten considerations that help
achieve engagement:
1. Consider all my needs
2. Give me a voice
3. Tell everyone the same story
4. Lead & see me differently
5. Make me part of the solution
6. Keep me informed
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7. Reward my effort as well as my success
8. Be honest with me
9. Plan for unintended consequences
10. Follow through. (Canton-Hughes, and Bradt, 2007, p.8).
Successful adoption of lean culture in a healthcare organization will transform the culture
of the organization. The dynamics of this change is the focus of the next section of this
chapter.
Blood bank in healthcare organizations:
Impact on healthcare:
The Department of Health and Human Services contracted the American
Association of Blood Banks to conduct a survey on blood collection and utilization in the
United States. The most recent survey was in 2011. The 2011 National Blood Collection
and Utilization Survey Report estimated that “a total of 15,721,000 Whole Blood (WB)
and Red Blood Cell (RBC) units were collected, a significant decline of 9.1% (p<0.001)”
(p.2). The survey also found that “the estimated total number of WB/RBCs transfused in
2011 was 13,785,000 units, 8.2% fewer units trans-fused than in 2008 (p<0.001).” (p.3)
The trend in less transfusions is attributed to the patient blood management programs.
These programs share some of the same values and principles of lean, efficiency and
continuous improvement. The decline in blood collection and utilization has both positive
and negative connotations. It is positive in the sense that only people who need blood will
get it. It is negative given the increase in the population as a whole and the increase in the
number of older patients in particular, who will more likely need it.
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Blood transfusion is the most commonly performed procedure in the United
States, (Tolich, et la., 2013). Blood is needed to treat newborn babies, trauma, cancer,
transplant, surgery and other patients with hematologic disease. The number of donors
giving blood is also declining. The 2011 National Blood Collection and Utilization
Survey Report indicated “only 4.5% of the US population aged 16 to 64 donated in 2011,
a drop from the 5.4% of the total age eligible US population reported to have donated in
2008” (p.3). The cost of obtaining blood is also increasing.
It might seem strange to address the cost of blood. After all, blood comes from
donors who freely give it without taking any monetary reimbursement for it. The cost of
blood starts adding up when the safety and regulation processes that goes into it are
calculated. Blood is considered a drug and the establishments the process it are regulated
by the FDA. As a drug, blood must be safe to get and safe to give. It has to be also potent
to produce the intended result of transfusing it. The donors have to be screened to make
sure they are not carrying any diseases and do not live a life that might make them prone
to disease. For example, a person who traveled to a malaria endemic region cannot donate
for a year after coming back, even if he or she does not have any symptoms. It is an
assurance that their blood does not have the potential to get the person receiving it sick.
The same goes for people who had a tattoo with an unsterile needle. Once blood is
obtained it had to be tested against many infectious diseases that might be transmitted by
blood. This includes, HIV, hepatitis B & C and other diseases. Every time a test is added,
the cost of blood increases, and the regulation gets more stringent.
26
The Medicare Payment Advisory committee studied the impact of blood safety
requirements on the operational costs of hospitals. The study was done upon the request
of the congress and published in the December 2000 report: “Blood safety in hospitals
and Medicare Inpatient Payment” as sited by Carden (2004) p.32. The report indicated
that between 1986 and 1999 the operating cost per discharge has increased by 3.5%.
However, the blood related cost per discharge has increased by 4.1%. Since the report
was published more tests have been added for additional viruses, and more to come.
The budget of a transfusion service department in a hospital is in millions of
dollars depending on how many transfusions are done each year in the hospital. The cost
of transfusing a unit of blood varies between $522 and $1,183 (Tolich, et la., 2013). This
cost includes testing, storage and transfusion. The process of giving blood starts when a
physician or a licensed provider orders the blood to be prepared on a patient and to be
transfused. The order to prepare the blood is handled by a transfusion service in the
hospital. The order to transfuse the blood is handled by the nurses who care for the
patient.
The transfusion service performs a lot of tasks to prepare the blood products for
the patient. It starts with obtaining blood from donor centers like the American Red
Cross. It arrives in boxes, gets unpacked, tested and stored. Some products are
refrigerated, frozen or kept at room temperature depending on the type of product. All are
kept in storage units with temperature monitors to make sure that storage conditions are
never compromised. Once an order is placed to prepare blood for a patient, a sample from
the patient is drawn and sent to the transfusion service. The patient blood is tested and
27
matched with the appropriate blood product. Once the appropriate blood is found and
matched to the patient, it is sent to the nurse to administer it to the patient. All these tasks
and processes are regulated by standards and guidelines from the FDA, AABB, CAP and
other regulatory agencies.
As healthcare organizations adopt efficiency and lean culture, the transfusion
service has to change and adopt them as well. Operations and tasks need to combine
compliance with standards along with finding the best value stream for the patient. The
transfusion service operations have to be remapped to cut waste, increase efficiency and
continuously improve.
Efficiency and continuous improvement:
Laboratory and transfusion services are expected to adopt efficiency and lean
culture in a health organization. Graban and Padgett (2008) report about the experience of
the Reverside Medical Center in Kanakakee, IL. “Lab costs were skyrocketing, supply
chain costs were increasing, performance was degrading in terms of turnaround times,
and the emergency department was complaining” (p. 645). The hospital reduced the
number of staff to curb the cost, but that did not help. The emergency department was
worried about not getting the results fast enough and were about to start doing one of the
tests on their own.
An initiative to implement lean principles was started in the laboratory. The flow
process was analyzed and a new process was discovered that saved time and space.
The new layout reduced the distance that specimens traveled through the
laboratory by more than 50% and also freed up 228 square feet that would be used
28
in the future for needed expansion of the microbiology department. Turnaround
times decreased across the board, including the troponin test that was so important
for the ED, which decreased from an average of 54 minutes to 34 minutes, an
improvement of 37%.” (Graban and Padgett (2008) p. 645).
A team from laboratory healthcare professionals carried out this change.
Another team of laboratory professionals led the redesign of the Laboratory
Alliance of Center New York in the greater Syracuse area, Stallcup (2015). The driver for
this change was the anticipated decrease in insurance reimbursement and the number of
qualified laboratory professionals to do the work. The team redesigned the work flow and
work stations to decrease wasted steps and times. The key conclusion in the article stated:
Just as laboratorians strive to control processes to provide the best patient care,
planning for the implementation of a lean laboratory is no different. By
developing teams, empowering staff and using readily available relatively
inexpensive software, the facility was able to keep the project under control and
on budget” (Stallcup 2015, p.11).
Staff empowerment was a key factor in the success of the project. How to do that is part
of the question we want answered.
Lean transformation examples in the blood bank:
Some transfusion services also have adopted lean practices. DSI laboratories in
Naples, Florida had a transfusion service that needed to adopt lean culture to serve
patients better. Patients waited a long time for their blood transfusion due to lack of
29
standard work, poor layout and uneven distribution of work in the transfusion service.
(Sunyog 2004) The lab director found that there was wasted time waiting for the
instrument to finish work and wasted motion in the way the work flowed in the
transfusion service. There ware also no defined responsibilities for the different tasks.
“By establishing a more efficient workflow process within the laboratory, a
single technologist could quickly move between stations and perform those tests
that made up 80% of the work volume. New inventory management techniques
reduced both excess inventory and the risk of shortages. Cost savings for the first
year were: Reduced overtime spending by 60% ($78,000), Reassigned six
phlebotomists for an annual savings of $160,000, 4.5 fewer technologist positions
for a savings of $250,000” (Sunyog 2004, p. 255).
More importantly, patient wait time to get transfused was decreased, and employee
morale increased.
The impact of adopting lean culture was also felt at Johns Hopkins Hospital in
Baltimore, Maryland, (Heitmiller et al., 2010). The team focused on using lean principles
to reduce the number of Red Blood Cell (RBC) units wasted each year. The article cited a
reported waste range of 0% to 6.7% by the CAP quality probe. At Johns Hopkins
Hospital, before the study was conducted, the rate was 4.4% from 2003 - 2004. The waste
included in-dated and outdated units. The waste of in-dated units was mainly due to not
maintaining the blood at an appropriate temperature when it leaves the transfusion service
in a cooler, or returned not used after more than 30 units. A time limit was established to
comply with the AABB standards. The team applied lean principles to reduce RBC
waste. They studied the flow of blood in and out of the coolers, found problems and
30
solved them. This resulted in a decrease in the percentage of units wasted to 2%.
Heitmiller et al., (2010) indicated: “This reduction decreased the number of RBC units
wasted by approximately 4300 per year, savings approximately $800,000 over the 4-year
period of the study” (p.1887). The other significance of the study is the number of
donations utilized that could have been wasted. It also showed that lean culture can be
adopted along with complying with the AABB standards. The authors accomplished this
through educating the providers about the importance of keeping the blood in the
required environment, and teaching them about the standards. They were also held
responsible when they were asked to explain the reason the blood got wasted every time
it happened. The participants of this study were the providers who ordered the blood for
surgery and not the healthcare professionals who prepared the blood in the coolers.
Change Theory and Dynamics
Dynamics of change:
Transformation in an organization needs a culture change. Langley et al., (2009)
outlined the dynamics of change. The process starts with “profound knowledge” (p.79)
combined with subject matter knowledge. In profound knowledge the authors meant:
1. Appreciation of a system: Knowing all the parts of the organization, how they
play together to achieve the objectives and enhance their interdependence
2. Understanding variation: Observing how things vary, and knowing the right cause
of it.
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3. Building knowledge: Enhance learning through observation, experimentation,
estimation and deduction.
4. Human Side of change: Understanding people’s perception and reaction to the
desired improvement and engaging them in it.
These four elements interact together and must be understood in any system to be
changed. There are two types of change, reactive change and fundamental change.
Reactive change solves a temporary problem. Fundamental change is a system wide
change like culture change. The authors describe five approaches for developing
fundamental change:
1. Logical thinking about the current system. Create a flow diagram of how the
current system works and look for ways to improve it.
2. Benchmarking or learning from others. Look for how others dealt with the same
problem.
3. Using technology. Use scientific tools like computers and new instruments.
4. Creative thinking. Innovation through “provoking new thought patterns” (p.129).
5. Using Change concepts. Use one or more of the 72 change concepts identified by
the authors.
Langley et al., (2009) identified the following 28 change concepts used in lean
culture changes:
1. Eliminate things that are not used
2. Eliminate multiple entry
3. Reduce or eliminate overkill
4. Reduce control on the system
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5. Recycle or reuse
6. Use substitution
7. Reduce classifications
8. Remove intermediaries
9. Match the amount to the need
10. Use sampling
11. Change targets of set points
12. Synchronize
13. Schedule into multiple processes
14. Minimize handoffs
15. Move steps in the process close together
16. Find and remove bottlenecks
17. Use automation
18. Smooth workflow
19. Do tasks in parallel
20. Consider people as in the same system
21. Use multiple processing units
22. Adjust to peak demand
23. Match inventory to predicted demand
24. Use pull system
25. Reduce choice of features
26. Reduce multiple brands of the same item
27. Give people access to information
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28. Change the order of process steps. (Langley et al., 2009 p.132)
An important consideration in implementing a change is the human side. Langley et al.,
(2009) identified the following behaviors to look for while implementing and adopting a
change:
• Resistance: responding with emotions or behaviors meant to impede change that
is perceived as threatening.
• Apathy: feeling or showing little or no interest in change.
• Compliance: publicly acting in accord while privately disagreeing with the
change.
• Conformance: changing behavior as a result of real or imagined group pressure.
• Commitment: becoming bound emotionally or intellectually to the change.
(Langley et al., 2009 p.186).
A commitment to change can be achieved easier if it is linked to the values of the
organization. A healthcare organization that wants to adopt a lean culture would link the
outcome of lean culture to the values of the organization. For example, an organization
that has respect as a value, would advocate adopting lean culture since it leads to
respecting employees’ time from being wasted in unnecessary steps. Langley et al.,
(2009) offer other guidelines that management can use to get employees commitment to
change:
• Create the will in the organization to adapt the change
• Provide information on why the change is being implemented
• Offer specific information on how the change will affect people
34
• Get consensus on solutions, resources and other necessary support to implement
the change
• Publicize the change” (Langley et al., 2009 p.189-190).
These guidelines usually help mitigate the resistance. Otherwise, management
needs to confront the resistance and provide clear expectations and consequences if
certain behaviors are not met. (Langley et al., 2009)
Change theory:
These dynamics of change are built on theories of change like Transtheoretical
Model (TTM), Theory of Planned Behavior (TPB), and Attention, Relevance,
Confidence, and Satisfaction (ARCS) model of motivation. Al-Twfiq and Pittet (2013)
evaluated the application of these change theories in motivating healthcare professionals
to comply with better hand hygiene practices. The study concluded:
Transtheoretical Model (TTM) of health behavior change helps to tailor
interventions to predict and motivate individual movement across the pathway to
change. A program could be based on this theory with multiple interactions with
John Keller’s (ARCS) model of motivational design and Theory of Planned
Behavior (TPB). Such a program could be strengthened by linking attitude and
behavior to promote hand hygiene. The program could utilize different strategies
such as organization cultural change that may increase the attention as well as
fostering the movement in the ARCS stages” (Al-Twfiq, and Pittet, 2013, p.374)
According to TTM theory, Prochasca (2005), the change is a process that starts
with pre-contemplation, then proceeds through contemplation, preparation, action and
ends with maintenance. Glanz, Rimer and Viswanath (2008) evaluated the use of TTM in
35
behavior change. They found a lot of literature applying this theory to smoking cessation
and other practices like correcting alcohol abuse, organ donation and condom use. They
found success in its use in adults but not in children and adolescents. A culture change in
a healthcare organization deals with adults and the tools of TTM can be used in adopting
lean culture in healthcare organizations. Lenio (2006)
http://www2.uwstout.edu/content/rs/2006/14Lenio.pdf summarized how an individual
behaves in each of the 5 stages. The author collected these behaviors based on a person
engaged in a bad behavior like smoking. If a person were to go through the stages of
change in TTM, that person would act as follow:
The first stage of the TTM is the pre-contemplation stage, where people have no
intention of taking action in the foreseeable future, usually measured as the next
six months (Prochaska et al., 1992; Prochaska & Velicer, 1997; Scholl, 2002).
Individuals in this stage may be unaware or uninformed of the consequences of
their behavior (Prochaska et al., 1992; Scholl, 2002) or may have had a number of
failed attempts at change and are discouraged to try again (Prochaska & Velicer,
1997). Prochaska et la., (1992) suggest that the main trait of someone in the pre-
contemplation stage is in showing resistance to recognizing or modifying a
problem behavior. For an individual to move out of this stage, they must
experience cognitive dissonance, a negative affective state, and acknowledge the
problem (Scholl, 2002).
In the next stage, contemplation, individuals are intending on making a change
within the following six months (Patten et al., 2000; Prochaska et al., 1992; Prochaska &
36
Velicer, 1997; Velicer et al., 1998). People in this stage weigh the pros and cons of
making the change, which can cause them to remain in this stage for long periods of time
(Patten et al., 2000; Prochaska et al., 1992; Prochaska & Velicer, 1997; Velicer et al.,
1998). A person in this stage is deciding if he or she needs to correct the problem and
whether or not the pros and cons of making a change outweigh the pros and cons of
maintaining his or her present behavior (Scholl, 2002). Being stuck in this stage is known
as chronic contemplation or behavioral procrastination (Prochaska & Velicer, 1997).
During this stage the person still participates in the risky behavior but is aware that this
behavior causes a problem (Patten et al., 2000). The main trait of someone in the
contemplation stage is that the person is seriously considering resolving the problem
(Prochaska et al., 1992). An individual will move on to the next stage if he or she
perceives that the pros outweigh the cons and if the force of motivation is stronger for
change than it is for remaining stable (Scholl, 2002).
The next stage, preparation, is when the person is planning on making a behavior
change within the following month (Patten et al., 2000; Prochaska et al., 1992; Prochaska
& Velicer, 1997; Velicer et al., 1998). A person in this stage has often unsuccessfully
taken some sort of action to change the behavior within the previous year, but still
engages in the high-risk behavior (Patten et al., 2000; Prochaska et al., 1992; Prochaska
& Velicer, 1997; Velicer et al., 1998). An individual in this stage may not know how to
proceed to make a change and could be nervous about his or her ability to change (Scholl,
2002). A plan of action is made up for elimination or significant reduction of the problem
behavior in which the person can choose between alternative potential solutions
(Prochaska et al., 1992; Prochaska & Velicer, 1997; Velicer et al., 1998). Individuals will
37
move to the next stage when they select a plan of action they feel will work and if they
feel confident that they can follow through with the plan (Scholl, 2002).
In the action stage, individuals have made effort to modify their behaviors,
experiences, or environments within the last six months to overcome their problem
(Patten et al., 2000; Prochaska et al., 1992; Prochaska & Velicer, 1997; Velicer et al.,
1998). The action stage requires a significant commitment of time and energy and is the
stage where the individual gets the most recognition from others because of their visible
efforts (Patten et al., 2000; Prochaska et al., 1992). Research warns not to mistake this
visible action of trying to change with change itself, because the individual’s actual
change only occurs when a certain criterion has been reached, a criterion which scientists
and professionals agree is sufficient to reduce the problem behavior (Prochaska et al.,
1992; Prochaska & Velicer, 1997; Velicer et al., 1998). Prochaska, DiClemente, and
Norcross (1992) suggest that the main ways of recognizing that someone is in the action
stage is through their significant effort made to change and through modifying the
problem behavior to acceptable criterion levels. Movement into the final stage occurs
when an individual sees evidence of performance improvement, has a positive affective
state, and receives positive social and performance feedback (Scholl, 2002).
The final stage of the TTM is maintenance (Patten et al., 2000; Prochaska et al.,
1992; Prochaska & Velicer, 1997; Velicer et al., 1998). In this stage people work to
prevent relapse and secure their gains made during action (Patten et al., 2000; Prochaska
et al., 1992; Prochaska & Velicer, 1997; Velicer et al., 1998). Individuals in the
maintenance stage are less tempted to relapse and more confident that they will be able to
38
continue their changes (Prochaska & Velicer, 1997; Velicer et al., 1998). According to
Prochaska and colleagues (1992), the ability to remain free from the problem behavior
and the ability to participate in new incompatible behaviors for more than six months is
the criteria used to categorize someone into the maintenance stage. Research also
recognizes that maintenance is a continuation of change, not an absence of it (Patten et
al., 2000; Prochaska et al., 1992; Prochaska & Velicer, 1997; Velicer et al., 1998). (Lenio
(2006) p.73-75). In some literature, Prochaska and DiClemente (2005) add a
“Termination” stage: “No temptation to relapse and 100% confidence”, p.98.
Measuring which stage the person is in, is done by a 4 to 5 item algorithm of questions
asked. Johnson et al., (2006) used this algorithm in assessing the adherence of patients to
antihypertensive medication.
Another change theory is TPB. This theory is best illustrated in the following
diagram, figure 3: http://people.umass.edu/aizen/pdf/tpb.measurement.pdf
39
Figure 3. Theory of Planned Behavior (TPB)
Beliefs generate attitude which lead to intention that translate into behavior.
Applying this theory starts with creating or changing beliefs about the change,
accompanied with favorable norms to implement it. This will lead to the intention of
adopting change. In the presence of the appropriate environment, the intentions are
manifested into behavior change. Sniehotta, Presseau and Araújo-Soares (2014) argue for
retiring this theory due to lack of utility and validity.
Intrinsic Factors that Motivate People to Change
ARCS model of motivational design is another change theory. This theory is
based on four concepts, attention, relevance, confidence and satisfaction. These concepts
and the strategies used to use them are summarized in table 1 below (Francom and
Reeves, 2010, p. 56)
40
Table 1. ARCS model of motivation
Motivational Concept Motivational Strategies
Attention • Incongruity and conflict
• Concreteness
• Variability
• Humor
• Inquiry
• Participation
Relevance • Experience
• Present worth
• Future usefulness
• Need matching
• Modeling
• Choice
Confidence • Learning requirements
• Difficulty
• Expectations
• Attributions
• Self-confidence
Satisfaction • Natural consequences
• Unexpected rewards
• Positive outcomes
41
• Negative influence
• Scheduling
This model was used in developing educational materials and evaluate their
effectiveness in motivating the learner. Pittenger and Doering (2010) used the model to
evaluate the motivational effectiveness of self-Study in online pharmacy courses. The
model uses surveys to assess the ability of the educational material to motivate people to
change based on the four concepts (ARCS). This model seems to be good in developing
educational material and specific programs. It is not clear if it can be used to change a
culture. In the context of adopting lean culture, the material developed should grab the
attention of the healthcare professional, be relevant to the healthcare environment and
patient care, instill confidence by ease of understanding and use, and satisfy the need of
quality improvement and reducing cost.
ARCS model of motivational design assumes that there are basic qualities the
learner needs to satisfy to engage in change. This is the same assumption behind the self-
determination theory (SDT). It postulates that people are moved by intrinsic motives.
Other motives were identified by Pink (2009). They are autonomy, mastery and purpose.
Autonomy is self-direction. Mastery is becoming better at something that matters.
Purpose is a cause greater and more enduring than themselves. The work of Grant and
Hofmann (2011) confirmed that health work professionals are motivated by a cause that
is greater than themselves. They developed a study to find out what would motivate
healthcare professionals to comply with hand hygiene practices. The research described
the reaction of healthcare professionals to signs that describe the consequences of hand
42
hygiene:
In two field experiments in a hospital, we compared the effectiveness of signs
about hand hygiene that emphasized personal safety (“Hand hygiene prevents you
from catching diseases”) or patient safety (“Hand hygiene prevents patients from
catching diseases”). We assessed hand hygiene by measuring the amount of soap
and hand-sanitizing gel used from dispensers (Experiment 1) and conducting
covert, independent observations of health care professionals’ hand-hygiene
behaviors (Experiment 2). Results showed that changing a single word in
messages motivated meaningful changes in behavior: The hand hygiene of health
care professionals increased significantly when they were reminded of the
implications for patients, but not when they were reminded of the implications for
themselves. (Grant and Hofmann, 2011 p.1493).
Showing how change will improve the patient experience is a key factor in instituting any
culture change.
Healthcare professionals in the blood bank:
Engaging the healthcare professionals in adopting lean and efficiency is important
for the culture change necessary for success. This is not an easy task to accomplish.
Wellman, Hagan, and Jeffries (2011) describe the frustration of healthcare professionals
with this change. They are usually skeptical of the value of continuous improvement
programs. They do not believe that it will improve their work because of previous
initiatives by management that were not successful. The authors claim that the key to
changing their mind is participating in a process, outcome or a workshop. That will turn
43
them to full participants and advocates for culture change and increased lean and
efficiency.
Healthcare professionals in the blood bank are trained to follow standards of work
established by the FDA, AABB, CAP and TJC. Following standards is part of lean
culture. So for them they are already following lean. They will be very skeptical about
changing their work standards and will resist it. How do blood bank healthcare
professionals describe adapting to lean culture and efficiency in blood bank
operations? This is the question we are trying to answer and the next chapter outlines the
methods used to answer it.
44
Chapter Three – Methodology
Qualitative Research
This study aims to use qualitative research methodology to answer the Question:
How do blood bank healthcare professionals describe adapting to lean culture and
efficiency in blood bank operations? Qualitative research explores people’s experience
with a phenomenon. A phenomenological study looks at how people interact with an
experience. It provides a description of people’s behavior as they move through the
experience. It identifies their perspective and perception of the experience.
This study uses qualitative research to explore how health care professionals in
the blood bank experience the change associated with lean processes. It goes after how
they interact with initiatives to increase efficiency in their work. It describes their
behavior towards lean initiatives and ideas through observation of their work in the blood
bank. Interviews were used to identify the perspective and perception of health care
professionals who work in the blood bank.
Healthcare Professional in The Blood Bank
The first step in answering the question is to understand the healthcare
professional who works in the blood bank. Work in the blood bank is considered high
complexity testing by CLIA standards. Olea (2012) of the The Joint Commission sites
that CLIA mandates that such testing is performed by a person with:
Education AND training equivalent to an associate degree in laboratory science or
medical laboratory technology:
45
– Education - 60 semester hours including either 24 semester
hours of medical laboratory technology courses or 24 semester hours of
science courses (6 hours of chemistry; 6 hours of biology, and 12 hours of
chemistry, biology or medical laboratory technology, or any
combination).�
– Training – either completion of an approved/accredited clinical
laboratory training program, which may be included in the 60 semester
hours specified above or at least three months of documented laboratory
training in each specialty in which the individual performs high
complexity testing. (Olea (2012) p.20)
These are the minimum credentials acceptable for a blood banker. Most
laboratories would like to hire a person with an associate or a bachelor degree in the
Medical Laboratory Science with certification by American Society of Clinical Pathology
(ASCP). Some states like New York, Florida and California require a state license too.
The Joint Commission conducts regular inspections to make sure the requirements and
standards of work are adhered to in the laboratory. Other organizations that provide
standard work for the blood bank is CAP and AABB. They also inspect the blood bank
on regular basis. If the blood bank has a donor room, it must be registered and inspected
by the FDA. During inspections, the healthcare professionals much show knowledge,
competence and compliance with standard procedures of work that conform to the
standards set forth by these organizations. Failure to comply can lead to consequences as
severe as cessation of operation.
46
Another criterion for working in the blood bank is critical thinking. Automation is
relatively new in the blood bank and limited. There is much reliance on deductive work
to identify the correct antibody the patient has and the best blood compatible with her or
him. A mistake in identifying the correct type of blood to give to the patient can be fatal.
Working under stress is another must for the healthcare professional working in
the blood bank. Patients suffering from traumatic events like falls, wounds, and bleeding
will require blood fast. Compatible blood products have to be produced very fast with no
room for error.
Continuous improvement and problem solving are the two new characteristics of
lean that should be added to the above list of qualities. Finding the impact of adding these
qualities on the healthcare professionals who work in the blood bank and their reaction
will be measured by observation and interviews. Observation will look at their reaction to
changes in the environment as the healthcare organization adopts and institutes lean
measures. It will assess their progress in change as outlined in the TTM theory.
Interviews will measure their perception of efficiency and lean, the elements that will
help them adapt to it and the barriers that will stop them from embracing it.
Study Participants
A 384 bed hospital that is designated as a trauma II center by the College of
American Surgeons was the site of the study. The hospital started introducing and
implementing lean principles in 2012. A new department was created to facilitate lean
implementation throughout the hospital. Workshops to all leaders who supervise staff
47
were conducted. A one and a half hour lecture about the hospital’s objectives and lean
processes was given to all of the hospital staff which is more than four thousand people.
Implementation is celebrated by a monthly presentation by teams that implemented lean.
Presentations show how much waste was eliminated, time saved, and morale raised.
The blood bank at this hospital is staffed 24 hours a day, seven days a week.
Work is divided in 3 shifts: morning, evening and night. The morning shift is staffed with
5 people who mainly work in the blood bank. These staff members were the participants
of the study in addition to another part time member working in the blood bank who
works in the evening shift and does not rotate to other areas. Staff members who rotate to
other areas in the lab were not included in the study. The total number of participants in
the study was 6 participants.
Blood bank work is overseen by the blood bank supervisor who is the researcher
for this dissertation research project. Because the researcher is in a supervisory position,
the interviews were conducted by a person other than the researcher to relieve the
participants from any pressure and allow them to fully disclose their opinions. The
interviewer kept the names of the interviewees private from the researcher. The
supervisor/researcher does not and is not required to employ any punitive measures on
the staff for accepting or rejecting an idea. Opinions and behaviors are not judged. They
are observed and recorded. Discussions and participation by all members of the staff is
encouraged so that no single person’s dominating character causes to prevent others from
voicing their opinions.
48
Participant protection
Risks:
There is no physical, psychological and social well-being, legal or financial risks to
the participants. There are no punitive measures for not adopting lean. Adopting lean is
encouraged but not mandated. There is no deadline to adhere to. The researcher is the
supervisor of the participants. This might influence them to participate in the study.
Protection Against Risks:
The author cannot and will not cause any harm to the participants. There are no
punitive measures for not adopting lean. Adopting lean is encouraged but not mandated.
There is no deadline to adhere to. It is in the interest of the researcher/supervisor to
encourage volunteerism and not cause any harm, since for a true change to lean culture to
happen, it has to come from within the person who wants to adopt it.
The study was reviewed and approved by the Institutional Review Board (IRB) of the
hospital were the study was conducted and Simmons College. A consent form was obtained
from the participants; it explained the study and offered the option to withdraw from the
study without penalty or prejudice. The interview was conducted by a person other than the
researcher to relieve the participants from any pressure and allow them to fully disclose their
opinions.
Benefits:
The interview process has the potential to engage the employees in adopting lean and
benefiting from it. These benefits may be rewarding to the patients they serve, the work they
do, and in their personal lives. The interviewees may not agree that lean cuts waste, increases
49
efficiency and productivity. It's important that research questions are not leading. There are
no monetary benefits.
Blood Bank Observations
The hospital blood bank started implementing and introducing lean principles as
part of the hospital’s culture change adopting lean. The morning staff reaction and
interaction with the change were observed and recorded. Improvement ideas were
suggested in some instances and sought after in others.
Suggested ideas are presented in a huddle format. The idea is suggested to the
staff and their opinions are captured. The advantages and disadvantages are discussed.
The impact of change on the daily workflow is discussed. The benefit of the change to
the patient and staff is also discussed. A plan of change is devised and implemented.
Sought after ideas are captured on a bulletin board that was hung for the staff to
post ideas for lean. It was divided into four sections: ideas, to do, in progress and done.
Any staff member can suggest an idea, write it on a post-it note and stick it in the “ideas”
section. Ideas are discussed. If the idea is feasible and relevant, the post-it note is moved
to the “to do” section. Then a plan of implementation is discussed and developed. The
post-it note is moved from the idea section to the “in progress” section. At the time of
implementation, the idea is moved to the “done” section.
The staff’s reaction and interaction with the ideas were recorded. Their perception
of change and the way it affects the workflow was captured. Their resistance, acceptance,
approval, or embracement of the change was observed and recorded.
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Interviews
The 6 participants work in the morning and evening shift in the blood bank. They
do not rotate to other departments of the laboratory. Some work full time, 40 hrs/week,
others work part time. They have varying education degrees, 4 year Medical Technology,
2 year Medical Technician, and 4 year Bachelor of Science degree in Biology. They are
all certified by ASCP to work in different areas of the lab. All participants have the same
job duties. They are all trained and competent in all duties of the blood bank. They were
interviewed by a person other than the author since the author is their supervisor. The
interviewer does not oversee the staff’s work and has no bearing on their performance
evaluation, nor can she cause any harm to them. The author has no bearing on the
interviewer’s performance evaluation. The interviewer was trained by the author to probe
for deeper answers and ask the interviewees to elaborate more and give examples.
Approval of laboratory management was obtained.
The interviewees signed a consent form to answer the questions with an option to
stop at any time. The interview was recorded. Their anonymity was assured. The
following questions guided the interview:
1. How long have you been working in the blood bank?
2. How did you become a blood banker?
3. What do you like about blood banking?
4. How do you define efficiency and lean operations?
5. How can you do your work more efficiently?
6. Tell me about the tools that help you do your work more efficiently? What are
they? Do you use them? And how often?
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7. Tell me about the barriers that make it harder for you to do your work more
efficiently?
8. How do you change a process to a more efficient one? List steps.
9. If you are used to doing something for a long time, what will make you think
about doing it in a more efficient way?
The first three questions were designed to ease the interviewee and understand
how the participant relates to working in the blood bank. The next three questions were
designed to understand how the participant understands efficiency and lean principles and
processes. The last three were designed to understand how the participant relates to
change towards lean principles and process.
Methodology of Data Analysis
Field-notes on the observations and transcripts of the interviews constitute the
data gathered for this research. The data was analyzed by looking for lean, change and
motivation themes. Koenigsaecker (2013) identified the lean themes as the pillars of lean,
and the 7 wastes. Jones (2013) identified the lean process themes. The lean pillars and 7
wastes are:
• “The concept and practice of continuous improvement:
• The power of respect for people.”
1. Overproduction (making more than what you need or before you need it)
2. Producing defects
3. Movement or transportation (this does not actually make the material closer to
what a customer of the process would value)
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4. Inventory (the storage of overproduction)
5. Over-processing (the classic inefficiency that we might usually look for)
6. Waiting time
7. Unnecessary motion
The change themes are the Prochasca (2005) TTM stages of change. If a person
were to go through the stages of change in TTM as it applies to lean, it might look like
this:
• Pre-contemplation: The individual does not intend to implement lean principles in
the near future, at lease 6 months. The individual is not aware of the effects of lean
culture on individual, organization and patient outcome. The individual might have
had negative experience with change before. To move to the next stage, the individual
needs to acknowledge the harms of not implementing lean culture and the benefits it
will bring on the individual, organization and patient.
• Contemplation: The individual intends to implement lean principles in the next 6
months. At this stage the individual weighs the pros and cons of applying lean
principles and evaluates the change on their behavior and environment. The
individual will move out of this stage when he or she perceives that the pros
outweighs the cons and there is a bigger motivation for change than staying in the
same state.
• Preparation: An individual in this stage is planning to change within a month. She or
he is not sure how to adopt lean culture and if he or she will be successful in it. A
plan of action will help moving to the next stage. It should be accompanied by a
feeling of confidence that the plan will succeed.
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• Action: An individual at this stage has made effort to implement lean principles
within the last six months. The individual needs a lot of recognition and positive
feedback at this stage. The individual’s engagement with lean culture is a sign of
moving in the right direction. Moving to the final stage requires that the individual
recognize self-improvement and receive positive and social performance feedback.
• Maintenance: The individual at this stage has implemented a lot of lean principles and
established a process to stop falling back. The individual would look for more ways
to conform other processes to lean culture. The person continues to do this for more
than six months.
• Termination: The individual at this stage will actively change all processes to more
efficient and lean processes.
Ideas for change conform to Langley et al., (2009) description of fundamental
change and change concepts:
Cause of fundamental change:
1. Logical thinking about the current system. Create a flow diagram of how the
current system works and look for ways to improve it.
2. Benchmarking or learning from others. Look for how others dealt with the
same problem.
3. Using technology. Use scientific tools like computers and new instruments.
4. Creative thinking. Innovation through “provoking new thought patterns”
(p.129).
5. Using Change concepts. Use one or more of the 72 change concepts
identified by the authors.
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Change concepts used in lean culture changes:
• Eliminate things that are not used
• Eliminate multiple entry
• Reduce or eliminate overkill
• Reduce control on the system
• Recycle or reuse
• Use substitution
• Reduce classifications
• Remove intermediaries
• Match the amount to the need.
• Use sampling
• Change targets of set points
• Synchronize
• Schedule into multiple processes
• Minimize handoffs
• Move steps in the process close together
• Find and remove bottlenecks
• Use automation
• Smooth workflow
• Do tasks in parallel
• Consider people as in the same system.
• Use multiple processing units
• Adjust to peak demand
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• Match inventory to predicted demand
• Use pull system
• Reduce choice of features
• Reduce multiple brands of the same item
• Give people access to information
• Change the order of process steps. (Langley et al., (2009) p.132)
The following themes describe the reaction to change:
• Resistance: responding with emotions or behaviors meant to impede change that
is perceived as threatening.
• Apathy: feeling or showing little or no interest in change.
• Compliance: publicly acting in accord while privately disagreeing with the
change.
• Conformance: changing behavior as a result of real or imagined group pressure.
• Commitment: becoming bound emotionally or intellectually to the change.
(Langley et al., (2009) p186).
The intrinsic values the change speaks to are Kellers ARCS model of motivation,
and Pink’s SDT values.
ARCS: Attention, Relevance, Confidence and Satisfaction
SDT: autonomy, mastery and purpose
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Validity
Descriptive validity:
Descriptive validity of the observations was assured by recording the actions and
comments of the participants in their natural environment. The first was in the blood bank
after showing and distributing the workflow diagram, figure 1. In this observation the
participants were presented with a diagram of the workflow. Langley et al., (2009) calls
for creating a flow diagram of how the current system works and look for ways to
improve it. The diagram of the current status was presented to the participants and they
were asked to comment on the impact of the change on them. This example speaks to the
descriptive and theoretical validity of the data.
The second was capturing responses to a suggested idea by one of the
participants. The idea was changing the way error reports were filed. Participants’
actions, questions, observations, analysis, reflections and comments on their experience
with the workflow and filing were a reflection of their own perception of efficiency.
Descriptive validity of the interviews was assured by transcribing what the participants
said. The responses to the questions were typed directly in the computer. The participants
described in steps how they would change a process to a more efficient one. Two
participants mentioned identifying the pros and cons. This describes a person in the
“contemplation” phase according to TTM theory. Three of the six participants listed
testing the new process as a step in moving towards a new efficient one. This describes a
person in the “preparation” phase of the same theory.
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Interpretive validity:
Participants interacted with the interview questions as they relate to efficiency and
change. When asked how they define efficiency, one participant said, “Getting a
particular task done in the least amount of time, steps but still maintaining accuracy”. The
participant interpreted efficiency as saving time and steps. Time and over processing are
2 waste items that lean processes tackle.
Another participant portrayed feeling about change by saying, “Letting go of the
old is probably the hardest”. The participant understood that efficiency and lean
processes involve change and this change could mean letting go of old ways and
processes. This speaks to the resistance as a response behavior to change mentioned by
Langley et al., (2009). This behavior was seen also in the workflow observation as a
reaction to changing the printer location, “We have always done it this way.”
Three participants requested testing a change before implementing it. This speaks
to the need to build “confidence” which is mentioned in Kellers ARCS theory of
motivation. It also speaks to the “mastery” in Pinks’ SDT theory.
Theoretical validity:
Participants mentioned many themes that are supported and mentioned in theory.
Koenigsaecker (2013) identified 7 types of waste in a process that can be eliminated to
make the process a lean one. The participants mentioned doing things in less time, errors
that they have to fix, and doing their work in less steps. These 3 themes speak to the
waiting time, deficits and over processing types of waste identified by Koenigsaecker
(2013).
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Five of the six participants identified computers and instrumentation as a tool to
increase efficiency. This speaks to the “technology” mentioned by Langley et al., (2009)
as a tool to cause fundamental change.
The fact that these themes were supported by literature and emerged genuinely in
the data provides the triangulation that supports the validity of the data.
Researcher Identity
Multiple selves:
Looking into how people think and change requires playing multiple roles. Some
of these roles this paper researcher needs to play them out of work responsibility. Roles
like researcher, helper, educator, guide, mentor, problem solver and preceptor. There are
other roles that the researcher should be aware of as part of how he is perceived. These
roles are boss, leader, enforcer and company man. There are also roles that this researcher
plays simply because of who he is. These roles are employee, coworker, colleague and
student. The researcher also perceives himself to be an educator, guide and mentor.
Some of the listed roles will have an impact on this research. Being the leader,
boss or supervisor of the group might make some members of the group reserved about
sharing how they truly think. They will not be able to share the true reasons for why they
do not want to change, the way they think, or do things. There will always be some sense
of reserve or fear of repercussion if they completely open up. This is a barrier that this
researcher has tried to overcome by encouraging discussion, and focusing on what
benefits the employee, blood bank and the patient. Having the administrative assistant,
rather than himself, do the interviews was meant to help the participants open up more.
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Another role that might have an impact is to be perceived as thinking of the
organization more than the people. Some employees might be threatened by new ways
that they are not accustomed to. The threat can emanate from fear of losing a job or
privilege, being afraid of not being competent in the new way, fear of the unknown, or
fear of trying new things. Focusing on the welfare of the organization and the benefit to
the patients, while caring for the employees’ feelings and needs, will mitigate these fears.
Realizing, how the employees will benefit from reducing time wasted on unnecessary
tasks and how new ways will make them do their work more efficiently, will make them
feel more productive and enjoy work more.
Othering:
As I was writing the previous paragraphs, it became evident to me how easy it is
to fall in the othering phenomenon. I wrote so many “they” referring to the group that I
am studying or working with. One strategy to overcome othering that I learned from
Reinhartz (1997) is to do work with the group. There are a couple of advantages to that.
First as a researcher it will be easier to understand what the group goes through in doing
the work. Second the group will be able to open up more. They will see the researcher as
a person who wants to help them. This should reduce feelings of reserve, fear and
apprehension that comes with the supervisor-employee relationship mentioned above.
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Chapter four – Results
The raw results of observation and interviews are included in the appendix. There
were 3 observations and 9 questions in the interview. Two of the observations, issuing
blood process and no typenex, were suggested ideas. The filing observation was a
suggested idea by the participants. The interview questions and answers are organized in
a table that can be located in the appendix. The responses and reactions of the participants
were handled in the following manner:
• Participants were given the fictitious names instead of numbers. In the interviews,
they were referred to as Sue, Sarah, Jill, Jane, Fay and Kay. In the no typenex
observation they were referred to as Amy, Ann, Agnes, Alicia, and Aly. In the
filing report observation Mendy was used.
• The responses and reactions of the participants were grouped in tables as they
related to lean, change and motivation. These tables can be located in Appendix
II.
• The results are presented below as they pertain to lean, change and motivation.
Lean is subdivided into principles, waste and process. Change is subdivided into
TTM theory, fundamental causes and reaction. Motivation is subdivided into
ARCS and SDT. These findings came from grouping the data in tables. These
tables are found in the appendix.
• Only themes that received at least three responses are presented with the quotes
from the participants that correspond to these theme.
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Lean principles, waste and process
Lean principles:
Koenigsaeker (2013) listed 2 principles for lean. The first is the “concept and
practice of continuous improvement”. The participants saw lean as a way to improve their
work. Fay said, “Being lean is trying to find better ways of doing a task”. Kay looked at
lean in a way to improve efficiency, “come up with a more efficient way to do that
process”.
The second principle of lean is “the power of respect for people” (Koenigsaeker,
2013, p. 11). Participants identified this principle in a different way. Respect came
through teamwork, discussion and building consensus. Fay was able to connect team
work to lean and efficiency by saying “Teamwork – having people work together to think
of ways to be more lean and efficient.” Many participants pointed to the importance of
discussion in the blood bank and Sue was very specific in saying “Try to find a
consensus” as means to change a process to a more efficient and lean one.
Eliminating waste:
Koenigsaeker (2013) listed 7 types of waste that can be eliminated from any
process to make it lean and more efficient. These are overproduction, defects,
transportation, inventory, over-processing, time and unnecessary motion. There were no
reactions nor responses that matched the waste of over production. Moreover, there was
one observation or response that matched each of the wastes of transportation and
inventory. The rest of the wastes were observed by the participants and they are identified
as follows:
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Defects:
Defects were noticed by the participants in different formats that affected their
efficiency. Two participants, Sarah and Kay, asked for “less interruptions” to do their
work more efficiently. They found some “phone calls” are barriers that made it harder for
them to do their work more efficiently.
Another interesting finding is that Sarah, Jill, Jane and Fay mentioned “other
departments” in the hospital as barriers that made it harder for them to do their work
more efficiently. Sarah described it as “Babysitting other departments”. Jill described it
as “roadblocks from other departments”. Fay thought that “Other departments (within the
hospital) wanting things done in a certain way and that may not be the best way for the
blood bank”, was a barrier that made it harder for her to do her work more efficiently.
Another defect that was identified by Sarah is “faulty equipment”. This was more
obvious than the “attitudes” mentioned by Jane and “Lack of knowledge of others
working in BB / constant questions and looking for reassurance” mentioned by Kay. The
latter two point to the effect of team work and care among healthcare professionals
towards each other to increase efficiency and have a leaner process.
Over-processing:
The participants were cognizant of the over processing waste. Jill and Fay pointed
out that efficiency is doing a process in “less steps”. When Amy heard about the idea of
No typenex process, her first reaction was “Few less steps”. Sarah provided the most
eloquent definition of efficiency and lean operations in the blood bank by saying “getting
a particular task done in the least amount of time, steps but still maintaining accuracy.”
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Waiting Time:
The participants were very cognizant of their time and wanted to use it wisely.
Sue pointed out, “We can do things that don’t need times in between things we do where
we have to set timers for – fill in”. She would also “get coolers ready ahead of time so we
don’t have to wait an hour for cancer center transfusions.”
In her definition of efficiency Sara said, “getting a particular task done in the least
amount of time”. Jane corroborated in her definition of efficiency when she said, “When
you can do the work accurately in a very good system that results in a fast manner”. The
participants pointed out saving time when not putting reports in binders.
Unnecessary motion:
The participants pointed out earlier that they would try to do a task in less steps.
In the issuing blood observation, the movement of the printer to a closer location was
perceived as a good idea since it reduces the amount of steps. The step of putting the
reports in binders was eliminated as unnecessary motion that would save effort in
punching the holes in the paper before putting them in the binder. Kay was very clear on
this by saying, “Lean operations would need to include the most direct way”.
Lean Processes:
Lean processes where depicted by Jones (2013) in the following diagram, as was
presented in figure 2.
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The healthcare professionals at the blood bank were asked to list the steps they
would take to make a process lean and more efficient. The process has 5 steps and goes in
a cycle.
1. Identify customers and specify value
2. Identify and map the stream
3. Create flow by eliminating waste
4. Respond to customer pull
5. Pursue perfection
The participants listed steps that correspond to each of the 5 steps. However, there
were only 2 responses that correspond to the first step of identifying the customer and
specifying the value. The other steps had at least 3 responses that correspond to them.
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Identify and map the stream:
The participants related to this step by looking at the process and assessing it.
Sarah said, “Look at the process” while Fay said, “Assess the process in the blood bank”.
Kay went further in her description by saying, “Show reasons why a process does not
work” which bridges this step with the next step of eliminating the waste.
Create flow by eliminating the waste:
“Think of feasible steps to attain the goal.” This is what Jane said. The feasible
steps are the flow according to Jones and the goal is to eliminate the waste. Sarah was
more specific in describing the waste when she said, “determine failing parts”. She
combined the idea of flow and eliminating waste by saying, “Write possible changes to
the process to fix failing parts”.
Respond to customer pull:
Responding to customer pull for the participants was through discussion and
approval. Fay said, “Discuss the new way to improve the process”. The changes and
improvements in the process are discussed in the blood bank and need approval. The
approval is within the blood bank department if the changes are only related to them. If
the changes are related to other departments in the hospital, the approval needs to come
from the administration of the lab and other departments affected by the change. As Jill
said, “Get approval beyond the blood bank”.
Pursue perfection:
This step is accomplished through testing. The proposed changes are tested. Both
Sarah and Fay requested to “test” the changes. If the process is improved the changes are
implemented. According to Fay, the improvement has to be more efficient to be
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implemented, “Implement improvement if more efficient”. New changes are expected to
bring additional new changes and improvements.
One step singled out by the participants that cannot be grouped with any of the
indicated steps by Jones is identifying the pros and cons of the changes. Two participants,
Sue and Fay, listed identifying the “pros and cons” as a step in changing a process to a
leaner and more efficient one.
Change theory, fundamental causes, and reaction:
Change theory:
According to the TTM theory, Prochaska (1977), people go through 6 stages to
change from one status to another. These are pre-contemplation, contemplation,
preparation, action, maintenance and termination. The participants exhibited behaviors,
reactions, and gave responses that showed they were going through all stages of change
except termination. What follows is the stages and the behaviors that are consistent with
each of them.
Pre-contemplation:
At this stage a person is not aware of the new status. It is like what Agnes said
when she was presented with the new idea of no typenex. She said, “We had a problem
with the wrong patient drawn and this is the only measure we have to catch it”. The
person at this stage will be afraid of the change since he or she does not know if they will
succeed in the new status. Some participants were clear about expressing their emotions.
Ann said, “The idea gives me goosebumps” when presented with the idea of no typenex.
Sue put it more clearly by saying, “Letting go of the old is probably the hardest”.
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Contemplation:
At this stage a person thinks about changing. They start exploring what the new
status looks like and weighing the pros and cons to changing. Most of the participants’
behavior, reactions, and responses were consistent with this stage. The participants learn
about the new status through new studies, a seminar or new people joining and telling
about their experiences in different blood banks. Sue said, “Sometimes new people
coming in and telling you what they did” when she was asked about how to change a
process to a more efficient one, although it has been practiced for a long time.
Sue, Sarah and Fay, three of the 6 participants, mentioned the need for “pros and
cons”. This is a typical sign of being in the contemplation status. The person needs to
identify pros and cons and needs to make sure that the pros outweigh the cons to be able
to move to the next stage. A person at this stage would ask a lot of questions to make sure
they will succeed in the next stage. An example of this is when Agnes asked “What are
they?” She wanted to know what safety measures were in place instead of the typenex
that will help her feel comfortable giving up the use of the typenex, a practice that has
been established for a long time.
Preparation:
At this stage the person starts thinking about steps to take to move to the new
status. Sue suggested to “brainstorm” new ways to make a process more efficient. Sarah
was more specific by asking to “Write down possibilities to change parts of process that
are failures”.
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Action:
At this stage the person starts taking steps in the new changed status. Some of the
participants showed initiative towards this efficiency. One suggested eliminating the
binder in the filing process. Sarah suggested to “Try/test each possibility” in the process
of modifying a process to a more efficient one. Testing the change before implementing it
widely was also a strategy preferred by Sue.
Maintenance:
At this stage the person would make more steps towards the new status and
eliminate the reasons that would lead to going back to the old status. The participants
interpreted that as finding more opportunities in the new efficient process to improve
other processes. They believed that fixing one thing will lead to fixing others. Kay said,
“when you fix one thing it trickles down to something else that can benefit from that
change”.
In other instances, the participants were able to identify lean processes and point
them out. In the no typenex observation, Amy said, “Few less steps” and Alicia was very
clear to call it “This is lean”. These are signs that some of the participants are ready to
move to the last stage, termination.
Fundamental causes of change:
Langley et al., (2009) listed five factors that can cause fundamental change. These
factors are underlined below. Under each factor is the observations, reactions and
responses that correspond to that factor. One factor, creative thinking, was excluded. In
this factor the participants are expected to produce “innovation through provoking new
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thought patterns” (Langley et al., (2009) p.129). There were no behaviors consistent with
this factor.
Logical thinking about the current system:
To execute this factor properly, a flow diagram is created of the current status and
looks for ways to improve it. A flow chart of the current status of how blood was issued
was presented to the participants and a proposal to improve it was suggested. It is worth
noting that the participants themselves did not request or suggest a flow chart. They
suggested looking at the process, discussing it and looking for ways to improve it. Sarah
described change as “Look at the process – determine what part of the process has
failures / problems. Write down possibilities to change parts of process that are failures /
problems. Try / test each possibility. Change it”. This is another form of thinking
logically about the process and changing it.
Benchmarking or learning from others:
Learning from others is another cause of fundamental change. It is practiced by
observing how others dealt with the same problem. The participants achieved that
through new studies, seminars or fellow health care professionals that joined from other
blood banks. Sue drove this point home when she said, “Sometimes new people coming
in and telling you what they did.”
Using technology:
The use of computers and scientific equipment is a factor causing change. Almost
all the participants mentioned technology as a tool to make the work more efficient.
Three participants, Sue, Sarah and Fay, mentioned “computer” in specific. Another two,
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Jane and Kay, mentioned “instrumentation”. This points to the fact that the participants
are comfortable with fundamental change using technology.
Change concepts:
Langley et al., (2009) enumerated 72 change concepts that can be used to cause
fundamental change. Twenty-eight of them are related to lean culture and processes.
Analyzing the participants’ observations, reactions and responses, five specific concepts
were identified. They are listed below with the change concept between parenthesis.
• Eliminating the binder (Remove intermediaries)
• Less steps (Eliminate multiple entry)
• Use waiting time (Schedule into multiple processes)
• Instrumentation (Use automation)
• Issue blood workflow (Smooth workflow)
Reaction to change:
People react to change by exhibiting one or more or the following behaviors:
resistance, apathy, compliance, conformance and commitment. The participants’
observations, reactions and responses were consistent with all of these behaviors at
varying degrees. There were more observations consistent with resistance and
commitment than the other three; apathy, compliance and conformance. The later three
had one or two observations. The observations related to resistance and commitment are
described below.
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Resistance:
What is meant by resistance is responding with emotions or behaviors that are
meant to slow the change. Some of the participants’ behaviors were consistent with this
definition.
Agnes’s response to the no typenex idea is one example: “We had a problem with
the wrong patient drawn and this is the only measure we have to catch it”. Sue provided
an explanation of why there could be a resistance when she said, “Letting go of the old is
probably the hardest”.
The emotion that was mentioned in specific was fear. Ann said, “The idea gives
me goosebumps” reacting to the idea of no typeex. Aly said, “little scary” reacting to the
same idea. Fear was the only emotion that was identified. Other emotions were not
identified. This does not confirm their absence. The degree of emotion changes with the
amount and type of change required.
Commitment:
What is meant by commitment is to be emotionally or intellectually bound to the
change (Langley et al., (2009)). Some of the participants’ observations, reactions and
responses can be described as such. Alicia’s response to the no typenex idea is a good
example of this as she said, “This is lean”. More commitment was exhibited when asked
about ideas that came from the employees themselves. The idea of eliminating the binder
from the filing process received good commitment. One participant pointed out “It is lean
not to put it in a binder”. Other participants pointed out different savings in space, time,
equipment and effort, celebrating the idea as an example of more efficiency in the blood
bank.
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Motivation:
Motivation is tackled through Kellers ARCS model of motivation and Self-
Determination Theory according to Pink.
Keller’s ARCS model of motivation:
The four elements of Keller’s model are attention, relevance, confidence and
satisfaction. Each of these elements have factors that facilitate it. The participants’
observations, reactions and responses were evaluated to see it these factors exist for them
and assess their motivation. What follow is a listing of the four elements and the
participants’ observations, reactions and responses that are consistent with them.
Attention:
The factors that facilitate attention are incongruity and conflict, concreteness,
variability, humor, inquiry and participation. Participants’ observations, reactions and
responses corresponded to all of these factors in attention except humor and concreteness.
Sarah and kay described the work in the blood bank as “fast paced” and that is what they
liked about working in the blood bank. Sue said something similar, “I like the busy pace.”
The fast pace and busy nature of working in the blood bank is an attention grabber and
motivating factor for the participants.
Another motivator for the participants is the mysterious and unpredictable nature
of work in the blood bank. Sue said specifically “I like the mystery of blood banking”.
The mystery in the blood bank is in solving patient cases and finding the right blood for
them. Fay explained this by saying, “Thought process behind working up difficult
patients” when she was asked about what she likes about blood banking.
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Participation is a factor that promotes attention, and hence, motivation. Three of
six participants, Sue, Sarah and Jane, stressed the importance of “communication”.
Moreover, the participants looked for discussion and talking about a process as means to
improve it and make it more efficient. Fay listed “Discussion among the BB workers to
assess the process” as the first step to improve it and make it more efficient.
Relevance:
The factors that facilitate relevance as a motivator are: experience, present worth,
future, usefulness, need matching, modeling and choice. Participants’ observations,
reactions and responses corresponded to all of these factors except experience and choice.
The participants liked blood banking because it is relevant and makes a difference for the
patients. When asked what they liked about blood banking, Fay said, “The work itself is
beneficial to the patients”.
Efficiency and lean process provide future usefulness for the participants, and
hence, motivation through relevance. Participants see it as an opportunity to do more with
less steps. Jill stated, “Coming up with new ideas to do the same job with less steps and
just as efficiently”. It will help them attain their goals.
The participants understand that their work is relevant to the patient. However, its
relevance to other departments in the hospital is not well defined or established. They
perceive other departments as having too much influence on them. Jill went as far as
saying, “Everything we do in Blood Bank is governed by what everyone else needs from
blood bank”. Sarah and Fay expressed annoyance from “other departments” in the way
some functions in the blood bank need to be tailored to accommodate them.
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Confidence:
Motivation through confidence is attained through learning requirements,
difficulty, expectations, attributions and self-confidence. Participants’ observations,
reactions and responses can be connected to all of these factors. For example, when Jill
was asked about what she likes about blood banking she said, “Still so much to learn”.
This is despite the fact that she has been working as a blood banker for more than 5 years.
Jane likes blood banking because it “makes you think”. The learning part in the blood
bank is a motivator, and as Sarah puts it, “I love that it is challenging”.
Efficiency and lean processes provide positive expectation for the participants,
and hence, increase their motivation through confidence. Fay affirmed this when she said,
“when you fix one thing it trickles down to something else that can benefit from that
change”. Many participants celebrated the savings in time, effort, equipment and material
associated with eliminating the binders in the filing observation.
Self-confidence as a means of motivation happened in the blood bank through
teamwork. Jill was “encouraged by co-workers” to work in the blood bank. Kay put it
more clearly that “constant questions and looking for reassurance” was a barrier for her
from doing her work more efficiently. Fay suggested, “Teamwork – having people work
together to think of ways to be more lean and efficient” as a mean to improve efficiency
in the blood bank. Open discussion with everyone, building consensus and teamwork
help increase self-confidence, and hence, motivation for the participants.
Satisfaction:
Motivation through satisfaction is attained through natural consequences,
unexpected rewards, positive outcomes, negative influence and scheduling. Participants’
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observations, reactions and responses can be traced to all these factors except negative
influence and scheduling.
There are good positive outcomes that satisfy the participants and make them
motivated. The epic of these outcomes is saving lives. Jane likes to work in the blood
bank because it gives her a “gratifying feeling of working hard and saving lives”. Other
positive outcomes are from efficiency and lean process. Jill looks at them as “ways to
making your job easier”. They lead to good natural consequences like less redraws to
patients as in the no typenex observation. It also leads to an unexpected reward that was
obvious to Jane who discovered that “productivity is more because you are happy doing
your job”. This is a good example of satisfaction that motivates.
Self-Determination Theory (SDT) according to Pink:
In SDT, people are motivated by intrinsic factors. Pink postulates that these
factors are autonomy, mastery and purpose. The participants’ observations, reactions and
responses were evaluated to see it these factors exist for them and assess their motivation.
What follows is a listing of these factors and the participants’ observations, reactions and
responses that are consistent with them.
Autonomy:
Autonomy in Pink’s SDT is self-direction. The participants’ observation,
reactions and responses exhibited a sense of self direction that motivated them to work.
In some way it made them like blood banking. Fay said, “I like that a lot is still hands on
– there is instrumentation but most is hands on.” Moreover, efficiency and lean culture
provide participants with more self-direction since it advocates for the employees to
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generate ideas that make work more efficient. This is how Jill looks at it, “Coming up
with new ideas to do the same job with less steps and just as efficiently”.
What goes against autonomy in the blood bank is the perception of other
departments having an influence on the way blood bank operations are run. As Fay puts
it, “Other departments (within the hospital) wanting things done a certain way and that
may not be the best way for the Blood Bank”.
Mastery:
Mastery in Pink’s SDT is becoming better at something that matters. Since
nothing matters more than saving lives, the participants behavior was consistent with this
factor. They were motivated to figure out challenging patient cases and perceived it as a
mystery to solve. Sue looked at her work in the blood bank as a mystery. When asked
about what she likes about blood banking, her response was, “I like the mystery of blood
banking”. The participants felt that they were the masters of solving this mystery.
Purpose:
Purpose in Pink’s SDT is cause greater and more enduring than themselves.
Participants’ behaviors, reactions and responses exhibited having a purpose beyond
themselves. The purpose is saving lives. It motivated them. Jane described it well by
saying, “gratifying feeling of working hard and saving lives”. Participants like the fast
pace and busy nature of work as they are saving lives. Another purpose is patient care.
When presented with the no tynpenex idea, Aly said, “less redraws”. Although the idea
was “little scary” for her, she thought about the patients and how the change will provide
better care for them by having less blood redraws.
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Chapter five – Discussion
This study aims to answer the question: How do blood bank healthcare
professionals describe adapting to lean culture and efficiency in blood bank
operations? Operations at a trauma II hospital blood bank and the healthcare
professionals working in it were the focus of the study. Observations and interviews were
conducted to answer the question.
The literature pointed to three areas that will help answer this question. These
areas are:
• Lean principles, waste elimination, and processes
• Change theory, fundamental causes, and reaction
• Motivation by intrinsic values to facilitate change
The observations and interviews provided themes that match some of the
elements in each of these areas.
Lean principles, waste elimination, and processes:
Lean principles and waste elimination. (Koenigsaecker, 2013, p.11)
Participants’ responses and reactions were consistent with all principles of lean.
Healthcare professional in the blood bank at the trauma II designated hospital see
continuous improvement as doing things better and in a more efficient way. Respect
for them can be achieved through team work, and discussions to attain consensus.
Lean processes means eliminating 7 wastes. The healthcare professionals in the
blood bank identified 6 of the 7 wastes. There were no responses that identify with the
waste of over production, maybe because the blood bank is a service oriented operation
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and would provide the service when requested. Otherwise, there were some production
defects that can be eliminated. They are in the form of:
• Interruptions
• Unnecessary phone calls
• Faulty equipment
• Other departments not doing their job correctly
• Coworkers having attitudes or lacking confidence in what they do.
Movement or transportation waste was identified in the form of moving the printer
closer and eliminating the need for a binder. The latter was also an evidence of
reducing inventory waste. The over-processing waste is described by the healthcare
professionals as doing the work in less steps. The waste of waiting time is very clear for
the healthcare professionals in the blood bank. They like to do things fast, direct and in
the least amount of time. One suggested doing tasks while waiting for other tasks to
finish. Also preparing things ahead of time so as when they are needed, there is no
waiting. Participants seem to be very conscientious about their time and want to use it in
the most efficient way. The last waste of unnecessary motion is viewed as doing things in
the most direct way and reducing the steps, efforts and material needed to accomplish a
task.
Lean processes (Jones 2013):
The main components of Jones (2013) lean process are value, stream, flow, pull
and perfection. Healthcare professionals at the blood bank would find value by
brainstorming, or finding an idea. Stream for them is by looking at the process and
assessing it. Flow and eliminating waste is to identify what is wrong with an existing
process and fixing the failing parts or defining the steps to achieve a goal. There was no
mention by the participants of creating a flow chart. This could be a tool to
familiarize them with it. Defining the customer, was another component that is
missing. This had negative ramifications in perceiving other departments’ needs from the
blood bank as interruptions and faults in the process.
The healthcare professionals at the blood bank looked at pull through discussing
changes as a group and getting internal and external approval, if needed. The perfection
for them is through testing and implementation. One component they introduced was
identifying the pros and cons. This has multiple purposes. It can be part of identifying
the value. It also serves other purposes in the change process as we will see later.
Change theory, fundamental causes, and reaction:
Change theory: Trans-Theoretical Model (TTM) of Change. Prochaska (1977)
As people change, they go through 6 stages: pre-contemplation, contemplation,
preparation, action, maintenance and termination. The participants exhibited reactions
and statements corresponding with all stages of TTM theory except termination. In the
pre-contemplation phase some participants expressed not knowing any other way and
being scared from experiencing or doing something different. According to the TTM
theory, to move the participant from this stage to the next, a person needs to acknowledge
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the harm in the current status and know the benefits from the new statue. For the
healthcare professional in the blood bank, this can come in a form of new people with
different experiences, new study or a seminar they attend. One participant
acknowledged the need for a fresh mind. The participants exhibited typical reactions of
being in the contemplation phase, like the need to know the pros and cons and to think
about it for some time. To move from this stage, a person needs to know that the pros
outweigh the cons. Questions from the participants about the reasons why a process
does not work, how long the new process will take, and what the new safety measures
are, help the participants move to the next stage. It is noted that the of majority of the
responses fill in this category, indicating that the participants are mostly in a
contemplation phase. In the preparation stage, the participants want to brainstorm and
write a plan with attainable steps. In the action stage, the participants fix problems and
test the change, which is consistent with the TTM theory. At this stage a person needs a
lot of recognition and positive feedback. This is exhibited by building consensus and
talking about it. In the maintenance phase, some participants found that changing one part
will lead to other changes and improvements, a typical finding in the TTM theory at this
stage. Being in lean was described as doing less steps. This is a good sign that shows that
some participants are ready to move to the final stage, termination. There was no sign
that any participant was at this stage. A person at this stage would actively change all
processes to lean ones.
Fundamental causes of change:
There are five causes that can lead to fundamental change according to Langley et
al., (2009). Participants exhibited behaviors consistent with fundamental change causes.
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The flow diagram of issuing blood helped in understanding the need for change. In the
interviews, there was no mention of this concept. The participants preferred discussion,
and pros and cons as form of logical thinking about the process referenced by Langley
et al., (2009).
Benchmarking and learning from others was exhibited by the participants in the
form of learning from the experience of new people joining, new study or a seminar.
Technology is a familiar method of fundamental change that was exhibited by the
participants as most of them talked about computers, instrumentation and analyzers as
tools to help them do their work more efficiently.
Creative thinking as a cause of fundamental change was very limited in practice
and was not noticed in the interviews. The idea of eliminating the typenex was
provoking. The reaction to it varied. It cannot be characterized as “new thought patterns”.
Some of the change concepts identified by Langley et al., (2009) were proposed
and used by the participants. Participants’ observations and the corresponding concepts
are:
• Eliminating the binder (Remove intermediaries)
• Less steps (Eliminate multiple entry)
• Use waiting time (Schedule into multiple processes)
• Instrumentation (Use automation)
• Issue blood workflow (Smooth workflow)
Reaction to change:
People react to change differently. Langley et al., (2009) listed these reactions as
resistance, apathy, compliance, conformance and compliance. All expected reactions to
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change were exhibited by the participants. Resistance could be identified in the form of
feelings like scary, goosebumps, only measure, and hard to let go of the old. Apathy
was seen in one participant’s reaction in only listening. Compliance could be identified
in the reaction by one participant to continue to think about it. This is not a concrete
evidence, as it is not clear if the participant was privately disagreeing. Conformance was
exhibited when one participant accepting the change after being mocked by another for
not accepting the change because it was an old practice. This observation points out the
importance of peer pressure. Commitment was observed as some participants could
identify and celebrate a lean process and its advantages.
Motivation by Intrinsic values to facilitate change:
Kellers ARCS model of motivation:
Motivation is integral to any change. Kellers model of motivation relies on four
concepts: Attention, Relevance, Confidence and Satisfaction (ARCS). Healthcare
professionals working at the blood bank exhibited signs of motivation according to
Keller’s (ARCS). What grabbed their attention the most is the fast pace and busy nature
of work. This is the variability referenced by Keller. On equal footing is communication
and discussion in the department. This is the participation in Keller’s model. Next is the
mystery, problem solving and resolving difficult patient cases. This is the inquiry
referenced by Keller.
Incongruity and conflict as a way of grabbing the attention of the participants took
a different form. One participant felt an obligation to accommodate the attitude of other
employees for the sake of making the work continue. The new forms of grabbing the
attention is in the form of technology, new and change ideas. Initial reactions to change
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ideas could be fear, a reaction that should be understood and dealt with. Nevertheless, it
is an attention grabber.
Relevance is another motivator in Keller’s model. The participants exhibited
behaviors that conformed with this. One participant chose to pursue blood banking as the
need for blood bankers increased, which is the needs matching referenced by Keller.
Another participant saw the importance of this work to the patient, and that is the present
worth referenced by Keller. New employees’ experience was relevant to current
employees, which is the modeling referenced by Keller. Doing the same job in less steps
and more efficiently, is a core lean principle and provides the future usefulness
referenced by Keller.
The new theme in the relevance part of motivation (highlighted in blue in the
table) is the feeling by many participants that work in the blood bank is influenced a lot
by other departments in the hospital. One participant described it as babysitting other
departments, another as governed by other departments and a third looking for things to
happen differently. On one hand this shows how relevant the work in the blood bank is to
other parts of the hospital. On the other hand, the participants feel it infringes on their
work.
Confidence is a motivator in Keller’s model. Participants exhibited some
confidence attributes. Education, learning and the ability to think were motivators in the
blood bank. These reflect the learning requirement in Keller’s model. One participant
liked the challenging nature of working in the blood bank. This corresponds to the
difficulty in Keller’s Model. As lean is adopted in the blood bank, the participants look
for a proof of a better way and see improvement leading to more improvement. These are
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the expectations in Keller’s Model. A couple of participants observed that changes that
are agreed upon in the blood bank can be implemented in the blood bank without further
approval. This is the attribution in Keller’s model.
Some observations related to self-confidence were puzzling. There was a need for
encouragement for one participant to join the blood bank. Another observed that other
coworkers lack the knowledge and looked for continuous reassurance. These are signs of
low self-confidence. It was also further observed that there is a need to build consensus,
teamwork, cooperation and understanding the pros and cons to make decisions. Team
dynamics plays a big role in building the confidence within participants.
Satisfaction is another source of motivation in Keller’s model. Signs of
satisfaction were observed by the participants. Less redraws, more improvement that
happens after implementing lean, and following lean principles and processes
brought a sense of joy. This points out to the natural consequences in Keller’s model.
Participants felt an increased productivity and doing work with less steps. This is the
unexpected rewards in Keller’s model. Participants were satisfied with a sense of
accomplishment, their jobs become easier and they felt the gratification of saving lives.
This is the positive outcome in Keller’s model. The other source of satisfaction that was
discovered (highlighted in blue in the table) is the harmonious relationship and
working with nice people.
Pink’s SDT values:
Pink is an advocate of the self-determination theory. People are motivated by
intrinsic factors. These factors are autonomy, mastery and purpose. Participants exhibited
behaviors consistent with autonomy like coming up with lean ideas and resolving
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difficult patient cases. It was further observed that influence from other departments
affected their feeling of autonomy and self-direction. This is the same observation that
affected their feeling of being relevant when analyzing Keller’s model of motivation. It
has roots in not seeing or defining these departments as costumers as explained in the
lean principle section.
Participants exhibited mastery in resolving difficult patient cases, conducting and
identifying lean processes. They also exhibited purpose in considering their work as
saving lives and helping patients get less blood redraws as a consequence of a lean
project initiative. Savings in time, effort, space, equipment and steps are all lean
objectives and a purpose to achieve.
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Chapter six – Conclusion
Improving the quality of healthcare and decreasing its cost has been an imperative
goal for many people. One strategy to achieve this goal is instituting lean culture in the
healthcare organization. This is achieved by behavioral and conceptual change.
Organizations that succeeded in implementing lean culture gained improved healthcare
(Spear, 2005), higher employee morale (Wellman, Hagan and Jefferies 2011), and
reduced cost (Caton-Hughes and Bradt, 2007). The key to success is to identify the
change factors and educational process that lead to adopting lean culture. Blood bank is
an integral department of any hospital. By identifying how blood bank healthcare
professionals describe adapting to lean culture and efficiency in blood bank
operations, the change factors can be characterized.
A trauma II designated hospital that is working on adopting lean culture since
2012 was the site of the study. Healthcare professionals in the blood bank of the hospital
are trying to adapt to this change. The observations and interviews of the healthcare
professionals provided insights on how they describe lean and efficient processes, the
change dynamics and intrinsic values that help adapt to lean culture and improved
efficiency of the blood bank operations, and hence, the healthcare organization. These
insights can be further used by other healthcare professionals, and especially the ones that
share the same working environment as these do.
Lean and efficient processes characteristics:
One participant defined efficiency and lean processes as, “Getting a particular
task done in the least amount of time, steps but still maintaining accuracy”. This captures
the essence of lean processes in the most direct way. The 7 wastes eliminated by adopting
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lean culture from the blood bank healthcare professionals’ perspective are summarized in
the table 2 below:
Table 2. Waste elimination from the blood banker perspective.
Waste Characteristic
Overproduction • None identified
Defects • Interruptions
• Unnecessary phone calls
• Faulty equipment
• Other departments not doing their job correctly
• Coworkers having attitudes or lacking confidence in what they
do
Movement or
transportation
• Moving things closer to where they are needed
Inventory • Eliminating unnecessary items
Over-
processing
• Less Steps
• Direct
Waiting time • Fast
• Least amount of time
• Preparing things ahead of time
Unnecessary
motion
• Reduce the amount of steps, efforts and material needed to
accomplish a task
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The process of change to a lean culture and more efficient processes is similar to
the cycle by Jones (2013). Participants would look at the process, identify the failing
parts in it, discuss and brainstorm how to fix them, test the change and then implement it.
They are very conscientious about their time and want to use it in the most efficient way,
making waiting time the highest priority to eliminate. Discussion and identifying the pros
and cons is important for the healthcare professionals working in the blood bank to make
the process more efficient. One tool they could benefit from is to map the process in a
flow chart before identifying the failing part. It was also noted that they perceive other
departments as interruptions to their work rather than costumers to collaborate with for
the benefit of the patient. However, they value communication as a tool to increase
efficiency.
Change characteristics:
Healthcare professionals in the blood bank are receptive to fundamental change
concepts (Langley et al., 2009). Ideas for change come to them from new people joining,
new study or a seminar. Technology is favored as a means for fundamental change.
Creative thinking is an area that still needs to be developed as a means to accept change.
Change concepts that are lean driven and were favored in the blood bank are:
• Remove intermediaries
• Eliminate multiple entry
• Schedule into multiple processes
• Use automation
• Smooth workflow
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Healthcare professionals in the blood bank exhibited behaviors that are consistent
with people going through 5 change stages starting with pre-contemplation and through
maintenance. There was no evidence of being in the termination stage indicating that they
have not fully adopted lean culture. Most behaviors were consistent with being in the
contemplation stage. This explains the need to know more about the pros and cons of
change proposals.
Healthcare professionals in the blood bank react to change similar to what
Langley et al., (2009) describe. Resistance, apathy, compliance, conformance and
commitment were observed. It was noticed that resistance to change stems from being
scared of it. Bradt G. (2007) explains the roots of this feeling “Change brings uncertainty
and often uncertainty brings fear” p.34. Dealing with this feeling should facilitate a
smoother change. Another factor that can facilitate change is peer pressure, given that
there is a harmonious feeling among team members.
Intrinsic values characteristics:
One observation that stood above all is that health care professionals working in
the blood bank are attracted by the fast pace nature of the work, and perceiving it as a
mystery to solve. Another attribute that attracts them is saving lives. This grabs their
attention and motivates them. Attention is the first attribute in Keller’s ARCS model of
motivation. Relevance, the second attribute, is were some work needs to be done. There
is a good feeling of how relevant the work is for the blood bank professionals and for the
patient. What is affecting the participants’ motivation is the perception of other
departments’ needs from the blood bank as an intrusion on them. This perception needs
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to be changed to show how relevant the work being done in the blood bank is to other
departments and that both parties are part of a team to serve the patient.
Confidence, the third attribute in Keller’s Model, was evident in the behavior of
the blood bank professionals. It seems that it is driven by their work together. Teamwork
within the blood bank is an important booster of confidence. It also explains why peer
pressure can help facilitate change among the blood bank professionals. Teamwork and
the harmonious relationship observed also drives satisfaction, the forth attribute in
Keller’s Model. Evidence of satisfaction in implementing lean and more efficient
processes was observed.
Pink’s intrinsic values of autonomy, mastery and purpose were evident in the
behavior of the blood bank health professionals. One feature of working in the blood
bank is saving lives. This serves as a purpose for them. Tying lean and efficiency to
patient care and saving lives helps facilitate change. It is a feature of the healthcare
professionals pointed out by Grant and Hofmann (2011)
Future work:
Healthcare professionals working in the blood bank are expected to be competent,
follow standards of work regulated by government and professional agencies and do
critical thinking under pressure. In the new culture of lean processes and increased
efficiency they are expected to add problem solving and continuous improvement. Other
healthcare professionals that are expected to do the same are nurses in the emergency
department, surgical operating rooms and labor and delivery. Some pharmacists in the
hospital are expected to do the same. It will be interesting to see if nurses and
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pharmacists working in hospitals describe lean and efficiency in the same way as blood
bankers.
The feeling of fear and how to mitigate it is another area to be explored. Bradt G
(2007) found that major change evokes strong emotions, “anger, fear, sadness and
anxiety are common”, p.30. He suggested the following techniques to handle emotions:
• Talk to a trusted friend
• Write about it on paper
• Walk / hike / run
• Do not project your feelings on others
• Professional counseling
• Change the way you think about the situation changes your feelings about it.
(Bradt G, 2007, p. 31)
Acknowledging these emotions and using some of the suggested techniques could
help decrease the resistance or apathy towards change. How can these be used in the
healthcare setting, and will they work is yet to be explored.
Another area of further interest is to find a new teaching methodology that is
suitable to the fast pace and mystery nature of work in the blood bank. One suggestion is
a game that combines the elements of mystery, speed, and teamwork. Many games are
used for educational purposes. Herakovic, N.; Mellikovic, P.; and Debevec, M. (2014)
demonstrated how a motivational lean game is used in production companies to show
how the pull production strategy is better than the push one. Employees who played the
game saw first-hand how the pull strategy is more efficient and less stressful. The game
was also a strategy to involve and inform them so they can implement it. An engagement
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strategy will decrease the likelihood of implementation problems.
Another study compared the use of a simulation game versus a digital serious
game to measure the effect of lean training. “The results show that both approaches
promote trainee motivation and knowledge acquisition and suggest that they can be used
in a complementary way to achieve more effective learning results” (Vaz de Carvalho,
C.; Lopes, MP, and Ramos, AG (2014) p.11). What game can be used to facilitate
learning efficiency in the blood bank and similar environments? Is there a game that
combines mystery, speed and teamwork? Future work on this will be very helpful.
Concluding Remarks:
Healthcare professionals in the blood bank like the fast and mysterious nature of
their work. They follow regulatory standards and thrive under stress. Lean processes,
increased efficiency and continuous improvement for them is “Getting a particular task
done in the least amount of time and steps but still maintaining accuracy”. They are
adapting to lean culture changes. The use of flow charts, interruption reduction, creative
thinking techniques, and a perception change about other departments will enable them to
excel. They are highly motivated with a purpose; saving lives.
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Glossary
Definitions
• AABB: American Association of Blood Banks.
AABB is an international, not-for-profit association representing
individuals and institutions involved in the field of transfusion medicine
and cellular therapies. The association is committed to improving health
by developing and delivering standards, accreditation and educational
programs that focus on optimizing patient and donor care and safety.
http://www.aabb.org/about/who/Pages/default.aspx
• (ARCS) Model of motivational design: A model of motivation (Keller 1999).
The ARCS model of motivational design provides a systematic, seven-step
approach to designing motivational tactics into instruction. It incorporates
needs assessment based on an analysis of the target audience and existing
instructional materials, supports the creation of motivational objectives
and measures based on an analysis of the motivational characteristics of
the learners, provides guidance for creating and selecting motivational
tactics, and follows a process that integrates well with instructional design
and development. The analysis of motivational needs and corresponding
selection of tactics are based on four dimensions of motivation. These
dimensions were derived from a synthesis of research on human
motivation and are known as attention (A), relevance (R), confidence (C),
and satisfaction (S), or ARCS. p.39
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• Blood Bank: An institution where blood is donated, processed, stored and
distributed to transfusion service to give to patients.
• Blood components: Products that are produced from the donated blood. These
are Red Blood Cells (RBC), Fresh Frozen Plasma (FFP), Platelets and Cryo
precipitate. Each of these products help cure patients in a different way.
• CAP: College of American Pathologist.
The College of American Pathologists (CAP), the leading organization of
board-certified pathologists, serves patients, pathologists, and the public
by fostering and advocating excellence in the practice of pathology and
laboratory medicine worldwide.
http://www.cap.org/web/submenu/about?_adf.ctrl-
state=17uy1ubg8m_4&_afrLoop=644180403551764#!
• CLIA: Clinical Laboratory Improvement Amendments (CLIA).
The Centers for Medicare & Medicaid Services (CMS) regulates all
laboratory testing (except research) performed on humans in the U.S.
through the Clinical Laboratory Improvement Amendments (CLIA). In
total, CLIA covers approximately 251,000 laboratory entities. The
Division of Laboratory Services, within the Survey and Certification
Group, under the Center for Clinical Standards and Quality (CCSQ) has
the responsibility for implementing the CLIA Program.”
https://www.cms.gov/Regulations-and-
Guidance/Legislation/CLIA/index.html?redirect=/clia/
95
• CMS: “The Centers for Medicare & Medicaid Services, CMS, is part of the
Department of Health and Human Services (HHS).”
https://www.cms.gov/About-CMS/About-CMS.html
• FDA: Food and Drug Administration. A United States Government agency.
“FDA is responsible for protecting the public health by assuring the safety,
efficacy and security of human and veterinary drugs, biological products, medical
devices, our nation’s food supply, cosmetics, and products that emit radiation.”
http://www.fda.gov/AboutFDA/WhatWeDo/
• Flow: One of five principles of Lean. Sequence of events and values leading to
the customer.
• Lean: Lean as a manufacturing concept is principled around exposing value and
reducing waste. Every organization that adopts lean manufacturing defines what
lean means for it and its costumers.
• Medical laboratory scientist: A healthcare professional who works in a clinical
laboratory.
• Patient Blood Management: A practice associated with blood transfusion.
Patient blood management (PBM) is an evidence-based, multidisciplinary
approach to optimizing the care of patients who might need transfusion.
PBM encompasses all aspects of patient evaluation and clinical
management surrounding the transfusion decision-making process,
including the application of appropriate indications, as well as
minimization of blood loss and optimization of patient red cell mass.
http://www.aabb.org/pbm/Pages/default.aspx
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• Self Determination Theory (SDT): A motivation theory.
SDT represents a broad framework for the study of human motivation and
personality. SDT articulates a meta-theory for framing motivational
studies, a formal theory that defines intrinsic and varied extrinsic sources
of motivation, and a description of the respective roles of intrinsic and
types of extrinsic motivation in cognitive and social development and in
individual differences. Perhaps more importantly SDT propositions also
focus on how social and cultural factors facilitate or undermine people’s
sense of volition and initiative, in addition to their well-being and the
quality of their performance. Conditions supporting the individual’s
experience of autonomy, competence, and relatedness are argued to foster
the most volitional and high quality forms of motivation and engagement
for activities, including enhanced performance, persistence, and creativity.
In addition, SDT proposes that the degree to which any of these three
psychological needs is unsupported or thwarted within a social context
will have a robust detrimental impact on wellness in that setting.
http://www.selfdeterminationtheory.org/theory/
• The Joint Commission: An accreditation agency
An independent, not-for-profit organization, The Joint Commission
accredits and certifies nearly 21,000 health care organizations and
programs in the United States. Joint Commission accreditation and
certification is recognized nationwide as a symbol of quality that reflects
an organization’s commitment to meeting certain performance standards.
97
http://www.jointcommission.org/about_us/about_the_joint_commission_
main.aspx
• Theory of Planned Behavior (TPB): A change theory
According to the theory, human behavior is guided by three kinds of
considerations: beliefs about the likely consequences of the behavior
(behavioral beliefs), beliefs about the normative expectations of others
(normative beliefs), and beliefs about the presence of factors that may
facilitate or impede performance of the behavior (control beliefs). In their
respective aggregates, behavioral beliefs produce a favorable or
unfavorable attitude toward the behavior; normative beliefs result in
perceived social pressure or subjective norm; and control beliefs give rise
to perceived behavioral control. In combination, attitude toward the
behavior, subjective norm, and perception of behavioral control lead to the
formation of a behavioral intention. As a general rule, the more favorable
the attitude and subjective norm, and the greater the perceived control, the
stronger should be the person’s intention to perform the behavior in
question. Finally, given a sufficient degree of actual control over the
behavior, people are expected to carry out their intentions when the
opportunity arises. Intention is thus assumed to be the immediate
antecedent of behavior. However, because many behaviors pose
difficulties of execution that may limit volitional control, it is useful to
consider perceived behavioral control in addition to intention. To the
98
extent that perceived behavioral control is veridical, it can serve as a proxy
for actual control and contribute to the prediction of the behavior in
question. http://people.umass.edu/aizen/pdf/tpb.measurement.pdf
• Transfusion Service: A department in a hospital that provides blood components
for transfusion.
• Transtheoretical Model (TTM): A change theory
TTM is an integrative, biopsychosocial model to conceptualize the process
of intentional behavior change. Whereas other models of behavior change
focus exclusively on certain dimensions of change (e.g. theories focusing
mainly on social or biological influences), the TTM seeks to include and
integrate key constructs from other theories into a comprehensive theory
of change that can be applied to a variety of behaviors, populations, and
settings (e.g. treatment settings, prevention and policy-making settings,
etc.)—hence, the name Transtheoretical.
http://www.prochange.com/transtheoretical-model-of-behavior-change
• Value: A lean principle. Defined by the user of lean from the standpoint of the
end customer of the product. http://www.lean.org/WhatsLean/Principles.cfm
• Value Stream: A lean principle. The steps leading to the value added to the
customer while eliminating steps that do not add value, whenever possible.
http://www.lean.org/WhatsLean/Principles.cfm
• Waste: Any activity that consumes resources but creates no value for the
customer. http://www.lean.org/lexicon/waste
99
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Appendix Observation - Suggested ideas
A. Issuing blood Work flow
Figure 4. Diagram of the blood bank. Numbers represent the following. 1: tube station. 2: Refrigerator. 3: Work station. 4: Printer.
The process of issuing blood starts with receiving a requisition at the tube station
where No. 1 is shown in the diagram in Figure 4. The participant would be usually sitting
at the work station where No. 3 is shown in the diagram. The participant travels from 3 to
1, picks up the requisition and reeds the name of the patient needing the blood. Then
moves to the refrigerator containing the blood which is located where No. 2 is in the
diagram. The participant picks up the blood and goes back to station 3 to process the
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requisition in the computer. Forms are printed on the printer located where No. 4 is in the
diagram. The participant travels from 3 to 4 to pick up the printed forms and travels back
to 3 to attach the forms to the blood, do a final matching between the paper and the blood,
then travels to 1 to send the blood through the tube station to the nursing station where
the blood is needed to be transfused to the patient.
In summary, the participant moves from 3 to 1 to 2 to 3 to 4 to 3 to 1. The
suggested idea was to move the printer from 4 to 3. This way the printed forms will be
closer to the participants and eliminates the need to move between 3 to 4 to 3. The idea
was presented to the participants. There were mixed reactions. Few participants were in-
different about the idea and did not accept or reject it. Some liked it. Couple of
participants had the following conversation.
Participant A: This is a good idea
Participant B: But we have always done it that way.
Participant A: Don’t be silly.
Participant B did not respond.
B. No typenex
The blood bank has been requiring that each patient who might need blood must get an
extra bracelet called typenex in addition to the hospital identification bracelet. This
bracelet goes on the patient’s wrist and has the patient’s name, medical record number,
date of birth, and a set of labels that have a unique number. All the labels have the same
number. When a blood sample is drawn from the patient, the unique number is attached
to the blood sample. The blood sample then goes to the blood bank for testing. The blood
bank prepares the blood for the patient and adds the unique number to the blood label.
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When the patient needs blood the nurse looks at the typenex unique number and provides
it to the blood bank. The blood bank matches the number to the number on the blood
label before releasing the blood to the nurse. The nurse matches the number on the blood
label with the number on the patient’s wristband before starting the blood transfusion.
This assures that the right blood goes to the right patient.
This is a safety measure that has been practiced for a long time. According to the
College of American Pathologists (CAP) which provides standards to the hospital and
conducts regular inspections to assure that these standards are met, this safety measure is
the second best thing to do. The best thing is to do is to draw two blood samples at two
different times and make sure the blood type matches from the two samples. The hospital
blood bank implemented this practice at the end of 2015. During implementation, it was
made known that if the implementation is successful, the blood bank will eliminate the
need for the typenex.
In May 2016, the blood bank supervisor revived the issue of eliminating the
typenex after complaints about wrong application of the typenex number on the blood
sample. A document was prepared that contained the objective, reasoning, pros and cons,
and the process needed to eliminate using the typenex. It was presented to the blood bank
staff in a huddle format and feedback was requested.
This is a capture of the participants’ reactions:
Participant A (Amy). Few less steps. There is no computer work needed to
implement it. If the typenex number is not entered in the computer, the computer will not
ask for it.
Participant B (Ann). The idea gives me goosebumps. I will only listen.
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Participant C (Agnes). The following dialogue happened between the Participant
(Agnes) and the Supervisor (S)
Agnes: We had a problem with the wrong patient drawn and this is the only
measure we have to catch it
S: We have 3 safety measures implemented to prevent this from happening
Agnes: What are they?
S: BB confirm (new measure implemented in 2015), Lattice (computer software
assures the blood sample is drawn from the right patient) and Transfusion Administration
Record (TAR) (computer verification and tracking of blood transfusion that makes sure
the right blood is going to the right patient)
Agnes: If a person puts the wrong label on the blood sample, how will we know?
S: Yes, how will we know?
Agnes: You mean by BB confirm
S: Yes.
Participant D (Alicia): This is lean
Participant E(Aly) : Was in vacation when the huddle happened and was told
about the proposal after coming back. The following dialogue happened between the
Participant (Aly) and the Supervisor (S)
Aly: Less redraws
S: This is what was discussed in the pros and cons
Aly: little scary
S: There are safety measures to compensate
Aly: How about the people who do not use lattice or TAR
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S: They use BB confirm
Aly: I will think about it throughout the day
S: Please think of all scenarios and let’s make sure they are all addressed.
Participant came back with different scenarios and the three safety measures in
place covered them.
In a huddle few days later. The participants were asked about how they feel about
it and what is a good live implementation date they feel will be good a good date. They
agreed on 7/1/2016. It was explained that they were the first to know about it. Other
departments in the hospital are impacted and implementation date depends on when it
will be good for them too.
Observation - Sought after ideas
Filing instrument quality control and error reports
The normal process of filing the reports is for the supervisor to review them and
put them in on a shelf every day for later filing. Every so often, they are taken from the
shelf, sorted by date and instrument number. Then they are filed in a file Binder. When
the binder is full, the reports are moved to Boxes. These boxes are then taken to an
outside facility to store and dispose of after 5 years.
One participant suggested skipping filing in the binder. The reports are taken from
the shelf, sorted and put in the storage boxes right away. The researcher welcomed the
idea. Some participants welcomed it too while some were indifferent. One participant
said “It is lean not to put it in a binder”. One participant pointed out saving space where
the binders are held. Other savings pointed out are time, effort and equipment to punch
holes in the papers before putting them in the binder.
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Interviews
Participants were interviewed in accordance with IRB guidelines. There were 6
participants that signed the consent form approved by the IRB. The administrative
assistant transcribed the data and provided a word file containing the information. No
voice recording was provided to the researcher to keep the confidentiality of the
participants.
The data was tabulated with the nine questions on the first left column. The
response of each participant to each question was put in the raw containing that question.
This allowed comparison of all 6 responses to the same question. Table 11 contains the
questions and answers.
Table 3 Interview questions and answers tabulated for easy comparison
Participant 1 Sue
Participant 2 Sarah
Participant 3 Jill
Participant 4 Jane
Participant 5 Fay
Participant 6 Kay
1. How long have you been working in the blood bank?
Deleted to keep the privacy of the participants
Deleted to keep the privacy of the participants
Deleted to keep the privacy of the participants
Deleted to keep the privacy of the participants
Deleted to keep the privacy of the participants
Deleted to keep the privacy of the participants
2. How did you become a blood banker?
I’ve always liked Blood Bank – became more interested as the need increased for Blood Bankers – rotated first, gravitated towards Blood Bank.
Job opportunity Encouraged by co-workers
Part of Medical Technology – start as a Generalist, then concentrated on Blood Bank
Job opening
Trained on the job.
3. What do you like about blood banking?
I like the problem solving. I like the busy pace. I like antigen typing. I like the mystery of Blood Banking.
I love that it is challenging. Fast paced. Unpredictable.
Still so much to learn
Makes you think, exciting, a gratifying feeling of working hard and saving lives. My co-workers are very nice which is a plus
I like that a lot is still hands on – there is instrumentation but most is hands on. I like having to figure out antibodies – it’s
Fast paced Thought process behind working up difficult patients New and upcoming technology
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– harmonious relationship – productivity is more because you are happy doing your job.
complexity The work itself is beneficial to the patients
4. How do you define efficiency and lean operations?
Working together as a team for the good of the Lab and the patient.
Efficiency is getting a particular task done in the least amount of time, steps but still maintaining accuracy. Lean operation is how you set up to do your task in the most efficient manner.
They are ways to making your job easier.
When you can do the work accurately in a very good system that results in a fast manner.
Being lean is trying to find better ways of doing a task, not necessarily making it easier but maybe less steps
Efficiency is everyone doing all steps the same way Lean operations would need to include the most direct way for all shifts, not just one. Lean operations that work for one shift, don’t necessarily work for other shifts.
5. How can you do your work more efficiently?
We can do things that don’t need times in between things we do where we have to set timers for – fill in Use the computer
I can do it more efficiently with less interruptions, less phone calls, better protocols and more communication
Coming up with new ideas to do the same job with less steps and just as efficiently. Accomplish the same goal.
Paying attention. Do your priorities first, and then the other extra works resulting in more
We have already developed some lean – there is always room for more Teamwork – having people
Less interruptions.
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to look up histories. For people who have complicated histories, we have a file cabinet for how the patient’s previous panels compared.
with other departments involved.
productive way of accomplishing your work.
work together to think of ways to be more lean and efficient.
6. Tell me about the tools that help you do your work more efficiently? What are they? Do you use them? And how often?
Computer helps We get coolers ready ahead of time so we don’t have to wait an hour for cancer center transfusions. Massive Transfusion cooler organization helps us know what our next step is. Communication – Correct orders. We label tubes with the Blood Bank number for the day so we can
The computer is the biggest tool Organization Cooperation Communication
Follow the procedures in place on a day to day basis.
Instrumentation Good quality & proper reagents Use these regularly every day Procedure books as resources
Computers – every day Analyzers help do the work more efficiently – every day Pneumatic tube system for blood transport – every day
Instrumentation – daily
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find that tube easier when we have to add on units.
7. Tell me about the barriers that make it harder for you to do your work more efficiently?
Communicate – incorrect orders. Finding out a person has a Dana Farber # after you have already cross matched non-irradiated units. When you go to issue a unit and you find out the typenex was not entered – this requires finding the sample, entering the typenex, reprinting of labels, reprinting of unit tags. If transfusion requirements are at the bottom of a very long history – it can get missed.
Lack of space Lack of the ability to organize due to lack of space Faulty equipment Unnecessary phone calls Babysitting other departments in the hospital
Everything we do in Blood Bank is governed by what everyone else needs from Blood Bank – nursing procedures, doctor’s orders, not totally our decision. Different computers in different departments effect out processes – roadblocks from other department’s policies.
Attitudes – because when you come into work and others are already upset and you still continue doing your work. You have to take it easy and make it work.
Inadequate communication slows us in our work in BB – from other hospital departments – If they don’t communicate with us, we can become back logged.
Other departments (within the hospital) wanting things done a certain way and that may not be the best way for the Blood Bank. Sometimes the computer can also be a barrier because it does not do something we want it to – re: does not have ability to do certain things (programs) Example: Computer recognizes Type & Screen is good for 72
Set up in the Blood Bank does not necessarily work for all 3 shifts Lack of knowledge of others working in BB / constant questions and looking for reassurance Constant phone calls / interruptions
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hours, and if blood is ordered after 72 hours T&S is still good but the PC order gets a new BB (accession) number, so there are added steps to cancel PC order and add it to current T&S – or create a TSNB.
When the instrument is not working properly: Example: When we get no interpretations on the screens we have to do a Gel screen.
8. How do you change a process to a more efficient
Brainstorm. Think of the pros & cons. Try to find a consensus.
Look at the process – determine what part of the process has
Come up with an idea Talk about ways to change it in the Blood Bank
What is your goal or aim of the job you are doing ? Think of
1-Discussion among the BB workers to assess the process – talk
Show reasons why a process does not work and come up with a more
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one? List steps.
Introduce to department. Test it.
failures / problems Write down possibilities to change parts of process that are failures / problems Try / test each possibility Change it
– then it has to go beyond us
attainable steps that pertain to the goal you have. Work as efficiently as you can, having your goal – feasible steps that you can do and you will reach it.
about how it can be done better – pros & cons. Discuss new, how to improve the process. BB specific can be implemented within department. Involving hospital wide needs administration discussion & approval etc. 2-Try to see if it works – trial / pilot 3-Implement improvements if they are found to make process more efficient
efficient way to do that process.
9. If you are used to doing something for a long time what will make
Sometimes new people coming in and telling you what they did. A new study you read. Something you
Changes in the process not under my control Education
If it is a good idea – if it makes sense. It cuts down the time to do it.
You should always have a fresh mind in doing things – you have to have a good habit in doing
Always improvements that can be made to processes. New employees have different
If it takes too long to do it.
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you think about doing it in more efficient way?
hear about at a seminar. Letting go of the hold is probably the hardest.
Pros & Cons Discussion Proof of a better way
things – you should be able to determine that it is a good habit – doing the right thing. No excuse for shortcuts unless you do it the right way – do the right thing even when no one is looking at you.
experiences from other facilities. As we make a lean improvement, it typically leads to another lean improvement – because when you fix one thing it trickles down to something else that can benefit from that change.
How long have you been working in the blood bank?
The 6 participants have worked in the blood bank between 6 and more than 20
years.
How did you become a blood banker?
Five participants new about blood banking from their school and concentrated on
it on the job. The sixth participant trained as a blood banker on the job.
What do you like about blood banking?
The participants mentioned the following attributes making them like blood banking:
• Problem solving
• Fast Pace (3 participants mentioned this)
• Mystery (2 participants mentioned this)
• Challenging
• Unpredictable
• Much to learn
• Makes me think (2 participants mentioned this)
• Exciting
• Gratifying to work hard and save lives
• Team work
• Hands on
• Beneficial to the patient
• Complexity
• New and upcoming technology
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How do you define efficiency and lean operations?
The participants’ responses had the following themes:
• Team work for the good of the lab and patient
• “Getting a particular task done in the least amount of time, steps but still
maintaining accuracy”
• Making the job easier
• A system to do the job accurately and fast.
• Doing a task in a better and faster way, not necessarily easier.
• Most direct way of doing a task.
• Everyone doing the same steps the same way.
• Lean operations that work for one shift might not work for another shifts.
The themes that were consistent among many participants is fast, accuracy and less
steps. One participant connected efficiency to the patient. Another noted that efficiency
does not mean easier. The same participant that looked at lean operations as everyone
doing the steps the same way, also noted that what works for one shift might not work for
another shift.
How can you do your work more efficiently?
The participants’ responses had the following themes:
• Do things while waiting between steps
• Less interruptions (mentioned by 2 participants)
• Less phone calls.
• Better protocols
• More communication with other departments
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• Do the same job with less steps
• Pay attention
• Prioritize
• Work together to find more efficient ways.
Less interruptions were specifically mentioned by 2 participants. Communication
within the department and with other departments is another way that the participants felt
will help them find more efficient and lean ways. Many themes pointed to the importance
of saving time, or do more with less time, although not mentioned directly. Themes [do
things while waiting between steps], [do the same job with less steps] and [prioritize] talk
about being conscious about time, not wasting it, and do more with it.
Tell me about the tools that help you do your work more efficiently? What are
they? Do you use them? And how often?
The participants’ responses had the following themes:
• Technology
o Computers (mentioned by 3 participants, 50%)
o Instrumentation (mentioned by 3 participants 50%)
o Pneumatic tube to transport blood.
• Procedure books (mentioned by 2 participants)
• Be ready before the emergency.
• Checklist
• Numbering system for faster tracking.
• Organization
• Cooperation
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• Communication
• Good quality and proper testing reagents
Technology is the most emphasized tool by all participants except one. That
participant mentioned only the procedure book as a tool for efficiency. The use of
procedure book as a tool was also mentioned by another participant. Communication was
a theme found in the answers to this question and the question before.
Tell me about the barriers that make it harder for you to do your work more
efficiently.
The participants’ responses had the following themes:
• Incorrect blood orders
• Missing information
• Computer entry errors
• Unorganized information
• Lack of space
• Faulty equipment (mentioned by 2 people)
• Unnecessary phone calls
• Doing the job that should be done by other departments of the hospital
• Lack of total control on the process due to
o nursing procedures
o Doctor orders.
o Different computer screen used by different departments
o Other departments’ policies. (mentioned by 2 people)
• Coworkers’ attitudes.
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• Inadequate communication from other hospital departments
• Limitations in the computer system
• Blood bank set up is not best for all 3 shifts
• Interruptions
o Phone calls
o Other inexperienced coworkers
Phone calls were mentioned twice in different context, as an interruption and
unnecessary. Coworkers were also mentioned twice in different context, attitude and
inexperience. The effect of the other departments was mentioned 3 times in different
contexts: errors, influence and communication.
How do you change a process to a more efficient one? List steps
Participants’ responses were sorted in a list format and theme format. In a list
format:
Participant 1:
1. Brainstorm
2. Pros and Cons
3. Consensus
4. Introduce to department
Participant 2:
1. Look at the process
2. Determine failing parts
3. Write possible changes to the process to fix failing parts
4. Test each possible change
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5. Implement change
Participant 3
1. Come up with an idea
2. Discus changes in the blood bank
3. Get approval beyond the blood bank
Participant 4
1. Find Goal
2. Think of feasible steps to attain the goal
3. Work efficiently
Participant 5
1. Assess process in the blood bank
2. Talk about how it can be done better
3. Mention pros and cons
4. Discuss the new way to improve the process
5. Approval
a. If blood bank specific, it can be implemented within the group
b. If hospital wide, needs administration discussion and approval
6. Test it
7. Implement improvement if more efficient.
Participant 6
1. Show reasons why process does not work
2. Come up with a more efficient way to do it.
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The participants’ responses sorted in a theme format:
• Brainstorm
• Think of pros and cons (mentioned by 2 people)
• Consensus
• Introduce idea to others (mentioned by 3 people)
• Process
o Evaluate (mentioned by 2 people)
o Find issues (mentioned by 2 people)
o Talk about how it can be done better (mentioned by 2 participants)
o Write options
o Discuss new (mentioned by 2 participants)
o Change parts causing issues
o Test (mentioned by 3 people)
o Implement if improvement is more efficient.
• Discuss/assess changes in the blood bank (mentioned by 2 participants)
• Approval
o beyond team (one participant)
o Within team if it relates to blood bank
o Hospital administration if hospital wide
• Set a goal
o Think of steps to achieve goal
o Find efficient ways to reach goal
o Steps are feasible
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If you are used to doing something for a long time what will make you think about
doing it in a more efficient way?
The participants’ responses had the following themes:
• New people sharing their experience (mentioned by 2 people)
• New Study
• Seminar
• Education
• Pros and Cons discussion
• Proof of a better way
• Good/makes sense (mentioned by 2 participants)
• Cuts down time to do it
• Fresh mind
• Good habit
• One lean improvement lead to another
• If it takes too long to do it.
The following comments and feelings were also mentioned by the participants.
• Letting go of the old is the hardest
• Changes that are not under my control
• Doing the right thing
• No excuse for shortcuts
• Do the right thing even if no one is looking at you.
• Always improvements can be done to a process.
125
• When you fix one thing it trickles down to another thing that benefits from the
change.
126
Tables containing elements and corresponsing themes from the responses.
Table 4. Participants' responses and themes to lean principles and processes
Principle Participant
• The concept and
practice of
continuous
improvement
• Being lean is trying to find better ways of doing a
task
• talk about how it can be done better
• Show reasons why a process does not work and
come up with a more efficient way to do that process
• Implement improvements if they are found to make
process more efficient
• The power of
respect for people
• Teamwork – having people work together to think of
ways to be more lean and efficient
• Try to find a consensus
• Discussion among the BB workers to assess the
process
• Overproduction
(making more than
what you need or
before you need it)
• Producing defects • less interruptions (X2)
• Correct orders (Answer to Q. 6)
• incorrect orders (Answer to Q.7)
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• When you go to issue a unit and you find out the
typenex was not entered
• Faulty equipment
• Unnecessary phone calls
• Babysitting other departments in the hospital
• roadblocks from other department’s policies
• Other departments (within the hospital) wanting
things done a certain way and that may not be the
best way for the Blood Bank
• When the instrument is not working properly
• Sometimes the computer can also be a barrier
because it does not do something we want it to
• Constant phone calls / interruptions
• determine what part of the process has failures /
problems
• Attitudes (Answer to Q.7 – Barrier to lean)
• Lack of knowledge of others working in BB /
constant questions and looking for reassurance
(Answer to Q.7 – Barrier to lean)
• Movement or
transportation (this
does not actually
make the material
• Other savings pointed out are time, effort and
equipment to punch holes in the papers before
putting them in the binder
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closer to what a
customer of the
process would
value)
• Inventory (the
storage of
overproduction)
• saving space where the binders are held
• Over-processing
(the classic
inefficiency that
we might usually
look for)
• Efficiency is getting a particular task done in the
least amount of time, steps but still maintaining
accuracy
• less steps
• Coming up with new ideas to do the same job with
less steps
• Few less steps
• Less redraws
• Waiting time • Efficiency is getting a particular task done in the
least amount of time, steps but still maintaining
accuracy
• We can do things that don’t need times in between
things we do where we have to set timers for
• We get coolers ready ahead of time so we don’t have
to wait an hour for cancer center transfusions
• When you can do the work accurately in a very good
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system that results in a fast manner
• the most direct way
• Other savings pointed out are time, effort and
equipment to punch holes in the papers before
putting them in the binder
• Unnecessary
motion
• When you can do the work accurately in a very good
system that results in a fast manner
• the most direct way
• Other savings pointed out are time, effort and
equipment to punch holes in the papers before
putting them in the binder
Table 5. Participants responses and themes to Jones (2013) lean cycle.
Jones (2013) Participant 1 Participant 2 Participant 3
Participant 4
Participant 5
Participant 6
1. Identify
customer and
specify Value
Brainstorm
Look at the process
Come up with
an idea
Find Goal
Assess process in the
blood bank
Show reasons
why process
does not work
2. Identify and
map the stream
Pros and
Cons
Determine failing
parts
Discus changes
in the blood
bank
Think of
feasible steps to
attain the goal
Talk about how it can
be done better
Come up with a
more efficient
way to do it.
3. Create flow by
eliminating
waste
Consensus Write possible
changes to the
process to fix
failing parts
Get approval
beyond the
blood bank
Work
efficiently
Mention pros and cons
4. Respond to
customer pull.
Introduce to
department
Test each possible
change
Discuss the new way to
improve the process
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5. Pursue
perfection
Implement change Approval
- If blood bank specific,
it can be implemented
within the group
- If hospital wide,
needs administration
discussion and
approval
6. Test it
7. Implement
improvement if more
efficient.
Table 6. Participants' responses and themes to TTM change stages
Stage Observation
Pre-
contemplation
• We have always done it this way
• Letting go of the old is probably the hardest
• We had a problem with the wrong patient drawn and this is the
only measure we have to catch it
• The idea gives me goosebumps. I will only listen
• little scary
Contemplation • Sometimes new people coming in and telling you what they did
• A new study you read
• You should always have a fresh mind in doing things
• Something you hear about at a seminar
• Pros & Cons (2 times)
• If it takes too long to do it
• Show reasons why a process does not work
• I will think about it through the day
• What are they?(safety measures from the typenex observation)
Preparation • Brainstorm
• Think of attainable steps that pertain to the goal you have
• Write down possibilities to change parts of process that are
failures/ problems
Action • Try to find a consensus. Introduce to department
• Discuss new, how to improve the process
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• Test it
• Try / test each possibility
Maintenance • As we make a lean improvement, it typically leads to another
lean improvement
• when you fix one thing it trickles down to something else that
can benefit from that change
• Change it
• Few less steps (typnex observation)
Termination
Table 7. Participants' responses and themes to fundamental change concepts.
Concept Observation
Logical thinking about
the current system.
• Create a flow
diagram of the
how the current
system work and
look for ways to
improve it.
• Flow diagram of issuing blood was presented but not
suggested by participants
• Show reasons why a process does not work and come
up with a more efficient way to do that process
• Look at the process – determine what part of the
process has failures / problems Write down
possibilities to change parts of process that are
failures / problems Try / test each possibility Change
it
• Discussion among the BB workers to assess the
process – talk about how it can be done better – pros
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& cons. Discuss new, how to improve the process.
BB specific can be implemented within department.
Involving hospital wide needs administration
discussion & approval etc. 2-Try to see if it works –
trial / pilot 3-Implement improvements if they are
found to make process more efficient
Benchmarking or
learning from others.
• Look for how
others dealt with
the same problem.
• Sometimes new people coming in and telling you
what they did
• A new study you read
• Something you hear about at a seminar
Using technology.
• Use scientific
tools like
computers and
new instruments
• Computer helps
• The computer is the biggest tool
• Instrumentation X 2
• Computers –
• every day analyzers help do the work more efficiently
Creative thinking.
• Innovation
through
“provoking new
thought patterns”
(p.129).
• No typenex idea
Using Change concepts. • Eliminating the binder (Remove intermediaries)
135
• Use one or more
of the 72 change
concepts
identified by the
authors, 28 of
which are lean
culture related.
• Less steps (Eliminate multiple entry)
• Use waiting time (Schedule into multiple processes)
• Instrumentation (Use automation)
• Issue blood workflow (Smooth workflow)
Table 8. Participants' responses and themes to reactions to change
Reaction Observation
Resistance:
• responding with
emotions or behaviors
meant to impede
change that is
perceived as
threatening
• Letting go of the old is probably the hardest
• But we have always done that way
• We had a problem with the wrong patient drawn
and this is the only measure we have to catch it
• The idea gives me goosebumps.
• little scary
Apathy:
• feeling or showing
little or no interest in
change
• I will only listen
Compliance:
• publicly acting in
• I will think about it through the day
136
accord while
privately disagreeing
with the change
Conformance:
• changing behavior as
a result of real or
imagined group
pressure
• Participant A: Don’t be silly
• Participant B did not respond and accepted the
new change
Commitment:
• becoming bound
emotionally or
intellectually to the
change
• This is lean
• It is lean not to put it in a binder
• One participant pointed out saving space where
the binders are held. Other savings pointed out are
time, effort and equipment to punch holes in the
papers before putting them in the binder
Table 9. Participants responses and themes to ARCS model of motivation.
Motivational concept Observation
Attention
• Incongruity and
conflict
• Concreteness
• Variability
• Humor
• I like the problem solving
• I like the busy pace
• I like the mystery of Blood Banking
• Fast paced. (X2)
• Unpredictable
• Thought process behind working up difficult patients
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• Inquiry
• Participation
• New and upcoming technology
• Paying attention
• Communication X 3
• Introduce to department
• Discussion among the BB workers to assess the
process
• Attitudes – because when you come into work and
others are already upset and you still continue doing
your work. You have to take it easy and make it work.
• Sometimes new people coming in and telling you what
they did
• A new study you read
• Something you hear about at a seminar
• The idea gives me goosebumps. I will only listen.
• little scary
Relevance
• Experience
• Present worth
• Future
usefulness
• Need matching
• Modeling
• became more interested as the need increased for
Blood Bankers
• The work itself is beneficial to the patients
• Coming up with new ideas to do the same job with less
steps and just as efficiently
• Good quality & proper reagents
• Everything we do in Blood Bank is governed by what
138
• Choice everyone else needs from Blood Bank
• Babysitting other departments in the hospital
• Other departments (within the hospital) wanting things
done a certain way and that may not be the best way
for the Blood Bank
• Think of attainable steps that pertain to the goal you
have
• New employees have different experiences from other
facilities
Confidence
• Learning
requirements
• Difficulty
• Expectations
• Attributions
• Self-confidence
• Encouraged by co-workers
• I love that it is challenging
• Still so much to learn
• Makes you think
• Do your priorities first, and then the other extra works
resulting in more productive way
• Teamwork
• Cooperation
• Lack of knowledge of others working in BB
• constant questions and looking for reassurance
• Try to find a consensus.
• Talk about ways to change it in the Blood Bank
• BB specific can be implemented within department
139
• Involving hospital wide needs administration
discussion & approval etc
• Education
• Pros & Cons
• Discussion
• Proof of a better way
• when you fix one thing it trickles down to something
else that can benefit from that change
Satisfaction
• Natural
consequences
• Unexpected
rewards
• Positive
outcomes
• Negative
influence
• Scheduling
• gratifying feeling of working hard and saving lives
• My co-workers are very nice
• harmonious relationship
• productivity is more because you are happy doing your
job
• They are ways to making your job easier
• Accomplish the same goal
• Organization
• As we make a lean improvement, it typically leads to
another lean improvement
• Few less steps
• It is lean not to put it in a binder
• Less redraws
• This is lean
140
Table 10. Participants' responses and themes to Pink's SDT values.
Values Observation
Autonomy
• Self-direction
• I like that a lot is still hands on
• I can do it more efficiently with less interruptions, less
phone calls
• Coming up with new ideas to do the same job with less
steps and just as efficiently
• Everything we do in Blood Bank is governed by what
everyone else needs from Blood Bank
• roadblocks from other department’s policies
• Other departments (within the hospital) wanting things
done a certain way and that may not be the best way for
the Blood Bank
• You mean by BB confirm
• It is lean not to put it in a binder
Mastery
• Becoming
better at
something
that matters
• Thought process behind working up difficult patients
• I like having to figure out antibodies
• I like the mystery of Blood Banking
• This is lean
Purpose
• Cause greater
and more
• Makes you think, exciting, a gratifying feeling of working
hard and saving lives
• doing the right thing
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enduring than
themselves
• savings pointed out are time, effort and equipment to
punch holes in the papers before putting them in the
binder
• Less redraws
