Continuous Flow and Anatomic Pathology – Theory vs...
Transcript of Continuous Flow and Anatomic Pathology – Theory vs...
Continuous Flow and Anatomic Pathology –
Theory vs Reality
Kenneth Batts, M.D.Hospital Pathology Associates
Allina LaboratoriesMinneapolis, MN
Notice of Faculty Disclosure
In accordance with ACCME guidelines, any individual in a position to influence and/or control the content of this ASCP CME activity has disclosed all relevant financial relationships within the past 12 months with commercial interests that provide products and/or services related to the content of this CME activity.
The individual below has responded that he/she has no relevant financial relationship(s) with commercial interest(s) to disclose:
[Kenneth Batts]
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My Experience/Backdrop
• 9 years on staff Mayo Rochester– Exposure to Lean– Staffed the frozen section lab
• 14 years Hospital Pathology Associates– 36 pathologist private practice group– Cover large hospital system (Allina)
• Multiple hospitals and numerous clinics• We designed histology, cytology, pathology areas
– 2 year’s experience with it
– Cover busy physician’s office laboratories• We designed a GI office histopathology lab
– 7 year’s experience with it
“Lean” fixes things by eliminating waste. What are you interested in fixing?
Worker productivity?
Turnaround time?
Wor
ker
Productivity –use worker’sperspective
TAT – use specimen’sperspective
Spec
imen
s
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Theory: Continuous Flow Reflects a Specimen-focused LEAN Approach
LEAN
ContinuousFlow
We will discuss
this.
What is “Continuous Flow”?
• Continuous-flow manufacturing (CFM) is a manufacturing strategy that produces a part via a just-in-time and kanban production approach
• . . calls for an ongoing examination and improvement efforts which ultimately requires integration of all elements of the production system.
• The goal is an optimally balanced production line with little waste, the lowest possible cost, on-time and defect-free production.
‐Wikipedia
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A Pretty Good Continuous Flow System
Value Added Step
A necessary manipulation of the product that improves it
The buyer is willing to pay for it
There still may be some waste within
Examples: Grossing
Fixing
Interpretation
Transcription
Something that does notadd value
The buyer is not willing to pay for it (it is yourproblem, not theirs)
Entirely waste
Examples: Queues (“Muda”)
Awaiting something
Deeper levels
Reprocessing
Non-Value AddedVA Wait
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A Tiny Queue A Big QueueA Modest Queue
A Big QueueA Modest Queue
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A Pretty Good Continuous Flow System
Single units (no
batch)
No queues due to
proximitiesNo
defects
Each step Each step adds value
(closer to fire)
Focused effort (no
wasted energy)
“Ok, I’m interested in hearingmore but I want
less theory and more practicality.”
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Case Study: Practical Application of Continuous Flow in our Labs
Attempted to get as close to continuous flow as possible: Eliminate queues whenever possible
Create physical proximities; coordinate schedules
Eliminate unnecessary steps when able
Applied it to a GI office practice and a hospital system practice
Step 1 – Find a champion, and give them resources and
authority.
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Step 2 – Understand your system(work flow analysis)
Some understanding is critical
Use your judgment to balance depth of data gathering with practicality
consultants will usually want more data
ClinicianSpecimen
Wait
VA
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AccessionGross
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PathologistTranscription
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Your AP work flowprobably looksa lot like ours.
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Clinician/Specimen
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Getting data on actual times
will create your lab’s “fingerprint” and
allow youto prioritize (look for the most “bang for
the buck”).
Step 3 – Attack queues first
total waste
usually largest sources of delay
The empowered champion can do a lot fixes often don’t involve perturbing an individual
worker’s “style” (more easily “sold”)
smart physical layout can make a MAJORimpact; if you have a chance to design anew lab space don’t blow the opportunity
Wait
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Clinician/Specimen
VA
VA
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PathologistTranscription
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No waiting - The Holy Grail of TATAn unattainable goal but worthy target
Physical Proximities
Proximities - Physician Office Lab
Acc.Grossing
Fix
Emb.
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Ass..
Path1
Path2
Path3
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Histology CollationOne flat at a timeDelivery is 4 steps
PathologistOne flat at a time1-3 pathologists
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This largely eliminated numerous batches
This largely eliminated numerous batches
This largely eliminated
numerous queues
This largely eliminated numerous batches
This largely eliminated numerous batches
This largely eliminated
numerous queues
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Coordinate with Grossing
12:30PM-1:30 PM5:30 PM-6:30 PM
Coordinate with Grossing
1:30PM-2:30 PM6:30 PM-8:30 PM
(bigs)
Dual processors; one hour cycle for GI Biopsies
Clinician/Specimen
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Minimized the queue (1 hour
max) and shortened fix
time
Minimized the queue (1 hour
max) and shortened fix
time
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Clinician/Specimen
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Waiting for courierWe limited queue
with mid-day pickups, but still a
major source of delay
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Waiting for accessioning
Largely eliminated this with
coordinated staffing/dropoffs
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Clinician/Specimen
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TranscriptionWe eliminated these
with electronic (drop down)
documentation
TranscriptionWe eliminated these
with electronic (drop down)
documentation
TranscriptionWe eliminated
these with electronic (drop
down) documentation
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Await ClinicianEMR > FAX > Mail
Aim for before 5 PM or before their
arrival in AMPrelim notes in
EMR?
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Clinician/Specimen
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Accession
Gross
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Outcome in GI Lab – AM Samples
Couriers 11:30-12:45Signout 3:30-5:30
- Special stains 8 AMResults to clinician
queue via EMR
Clinicians Pleased- write letters sooner- call pts. sooner- remember the case- tidy up pre-Vacation
One automated stainer with histotechassembler
Three immediately
adjacentpathologists
Our Continuous Flow “Sweet Spot”- 3:30-5
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Clinician/Specimen
Transport
Accession GrossFix
EmbedCutStainAssemble
Pathologist
Sign
Results in GI Lab – PM Samples
Couriers 4:30-6:00 PMSignout 8:00-11:00 AM
- Special stains in PMResults to clinician
queue via EMR
Clinicians Happy
PATHOLOGY
Cyt. Histo
AIDES
COURIERASS. ASS.ASS. ASS.
Hospital System Lab(Centralized)
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PATHOLOGY
Cyt. Histo
AIDES
COURIERASS. ASS.ASS. ASS.
Hospital System Lab(Centralized)
-Prioritize-Distribute(minimal queues)
DIMO
L
BR
5A 7A 7AGU
GI
D
HBRBR AV
CY
GY
M RESDI
CP
CP
AIDES
COURIER
ADM
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Relative Priorities
1 – Hospitalized patients with biopsies, and
masses/possible cancer biopsies
2 – Regular biopsies
3 – Resections for significant diseases
4 – “Back burners” (tonsils, appendices, etc)
System used by histology, path. aides,pathologists, and transcription
Cyt. Histo
DIMO
L
BR
5A 7A 7AGU
GI
D
HBRBR AV
CY
GY
M RESDI
CP
CP
AIDES ADM
Optimized for Key BiopsiesGross ‘til 10 PMOvernight HistologyShortest poss. processor4:30 AM Path Aide5 AM PathologistOn site (4-6 hour) special stainsOn site expert reviews
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Clinician/Specimen
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Accession Gross
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PathologistTranscription
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What about eliminating waste
at these steps?
Step 4 – Attacking The “Value Added” Steps
Usually fairly unimportant from continuous flow perspective (where specimen is the focus) 2 min. vs 4 min. to do task – saves 2 minutes
Can be very important from a productivity and staffing perspective (where person is focus) 2 min. vs 4 min. to do task – doubles productivity
VA
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Miscellaneous Points
Residents are generally a queue be innovative (good luck)
A defect in the system interrupts continuous flow (“always move forward”) Try to fix the root cause of the defect so it
doesn’t happen again
Wait
X
Summary Don’t let the obligate “batch” steps preclude you
from attacking the rest of the steps
Eliminating/minimizing queues (our red boxes) will have best yield; go for the “biggies” first
“Leaning” the value added steps (green boxes) makes only a small impact on TAT, and more likely to irritate workers, but can have considerable impact on staffing (that would be a different lecture)
Setting up case prioritization system can at least focus TAT on the cases that need it the most
YOU WILL NEVER REACH PERFECTION(AND THAT’S OK)
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