Continually Maximizing the Client’s Value By Minimizing Waste

Definition

“Lean” is a system of organizational management intended to eliminate redundancy and wasteful activities, and to create value for the client.

Lean is not an acronym. It actually means lean, and is an attempt to strip an organization’s activities of all non-productive steps.

Lean was introduced in 1913 by Henry Ford, and later improved by Toyota. It is therefore also known as the Toyota Production System.

Principles

It is based on the following five principles:

Value: The organization defines the value of the process for the client. Does the client find the service, its speed, and its accuracy worth the money spent? For the laboratory, the “value” refers to the user’s needs. Both the patient and the clinician are users.

Value stream: The organization identifies waste. Waste means all unproductive processes and activities. In a laboratory, the following wasteful steps often occur:

The patient arrives for registration. He is sent to the cashier for payment. The cashier does not have change for the large-denomination currency provided by the patient, and somebody runs to the nearby marked searching for smaller currency notes. Then the patient is sent to one laboratory for an X-ray, is sent to another laboratory for blood tests, by which time the patient has taken something to eat, and some blood tests or ultrasound tests are not possible. The patient is asked to come the next day.

Sample collection is on the ground floor. It is sent to the laboratory on the first floor for “routine investigations”, then to the laboratory on the second floor for “special investigations”, and so on. At each step a ward boy is required to carry the sample. The ward boy spends time waiting to be received at each station.

Equipment is out of order. The engineer is called. The engineer identifies the defect. The laboratory asks for quotations for the defective part, selects the supplier, asks for purchase approval from the finance department, and buys the part.  All this is avoidable if the laboratory has a comprehensive maintenance contract with the firm.

A physician refers a patient to the laboratory for a test. The patient is registered, and the sample is drawn. Unfortunately, the laboratory technician does not understand what exactly the referring physician wants. The technician spends time trying to contact the physician, whose telephone number is unavailable.

Overproduction is one of the most serious forms of waste. Unnecessary investigations, inappropriate processing, unnecessary inventory, unnecessary manpower: all of these contribute to waste in the laboratory.

Once these are eliminated, the remaining steps can be considered the value-added steps.

Flow: The organization’s work must flow continuously through these value-added steps. In a laboratory, a single window for the patient will go a long way towards eliminating wasteful time expenditure. Today’s equipment can carry out a large number of tests. The machine menu is wide, and it is possible to avoid the need for multiple laboratories. A comprehensive maintenance contract with the machine supplier can include a clause for zero or minimum down-time, and the laboratory does not need to spend time chasing quotations and finance departments. Implementation of Lean principles result in uniformity of work processes. They increase efficiency, reduce turnaround time, and minimize nonconformities. There is a marked improvement in the work flow, and the safety as well as confidence of the employees is enhanced.

Pull: To ensure this flow, the process is designed with in-built checks and triggers for whatever needs to be done. This ensures that the process manages itself. One step pulls the previous step. In a laboratory, a well-designed QMS ensures that the discovery of a nonconformity sets into motion the root cause analysis, immediate action, and corrective and preventive actions.

Continuous improvement: There is constant attempt at achieving perfection.

Lean in the Standard

Although the ISO15189 Standard does not mention Lean by name, it nevertheless stresses on most of the principles of Lean. For example, the Standard repeatedly refers to the importance of looking at the user’s needs. It has devoted a clause to continual improvement. The emphasis of the Standard is on the process, not on the procedure itself. If we implement all the requirements of the Standard, Lean will automatically be implemented.

Designing a laboratory

The literature does not seem to stress this aspect of Lean, but I believe that planning is everything. Otherwise, when the unexpected occurs, there is a knee-jerk reaction, and ad hoc decisions are taken.

Some laboratories make illegal constructions, hoping to get away with them. I don’t think it’s always possible to bribe your way out of these situations, and I have known at least one laboratory having had to knock down these constructions. It’s really important to plan properly.

When I designed a laboratory for a new hospital, I appointed a Quality Manager. With the QM I planned the role of the departments, laboratory structure, workload, procurement of the specimens. For example, the laboratory was designed in a way that it was not dependent on people carrying specimens from one place to another. The handling of the specimen was planned in the beginning.

Lack of coordination between architects and the management of the organization can lead to massive waste. I have seen new laboratories in which the machines and manpower arrive much before the building is fully ready. This is one of the most colossal forms of wastage. Often the equipment malfunctions while it waits to be commissioned, and loses its warranties even before a sample is processed.

We had found that clinicians frequently called the staff, requesting results, and this led to a considerable expenditure of a technician’s time on the telephone. Contact information for all referring clinicians was available. Clinicians were informed that the laboratory would call as soon as the reports were available, reducing the incoming calls.

Sometimes a blood report requires the preparation of a slide to cross-check results. With the quality of instruments available, we were able to program the instruments to flag results that required microscopic examination of slides. The instrument was also programmed to automatically prepare slides when blood reports met certain criteria.

Our hospital had arranged an excellent dining room within the premises. Our staff did not need to go outside, and spend long hours in the markets, whenever it was time for lunch. In this way, staff facilities can actually improve productivity.

When reagents finish, replacements are ordered. Often the laboratory in-charge runs frantically for tenders and purchase approvals, trying to acquire replacements quickly. Laboratories should have triggering mechanisms for ordering replacements in time. If the inventory control is planned as recommended in the Standard, these problems should not occur. I have seen something similar occur with a license for running a blood bank. The blood bank’s license had expired, and the renewal came after a year of unlicensed (and therefore illegal) blood bank functioning.

Swaroop K Sood