... by applying lean technology to total laboratory operations. ... Group
Technology .... OE 5 OE 4 OE 3. OE 2. C. H. EM. Walkin freezer. Manuals.
Referral testing.
UNC HEALTH CARE SYSTEM
Combining Lean, Middleware, and Targeted Automated Systems to Unlock Lab Automation's Full Potential Case Study of a Large Medical Center’s Central Laboratory’s Journey to Automation Connie Bishop, MT(ASCP)SH Core Laboratory
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UNC HEALTH CARE SYSTEM
The Journey History Lean Six Sigma Automation Six Sigma
Lean
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
UNC Healthcare Medical Center Campus • • • • •
UNCH Memorial Hospital UNCH Neuroscience Hospital UNCH Women’s Hospital UNCH Children’s Hospital UNCH Cancer Center
Chapel Hill/ Durham Western Carolina Eastern Carolina Southern Carolina Triad
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UNC HEALTH CARE SYSTEM
Consolidation Chemistry, Hematology, Coagulation, Blood Gas, Urinalysis, Specimen Processing, Customer Service, and Reference Testing consolidated from 1995-1997 with reduction of 35 FTE’s through attrition. 15 supervisor positions consolidated to 5. Consolidation process smooth resulting in one of first thriving consolidated medical center laboratories in the country.
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UNC HEALTH CARE SYSTEM
Why Lean From 1995 to 2007 instrumentation in laboratory expanded from 8 large analyzers to 15.
Workload increased from 1.8 million tests in 1994 to 4.9 million in 2007 with no additional FTE’s or space. Desire to identify potential efficiencies in current state by applying lean technology to total laboratory operations.
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UNC HEALTH CARE SYSTEM
Implementation of Lean-2007
A fanatical devotion to the elimination of waste and non-value added activities.
The integration of the factors of production including: People, Materials and Machines into a system of data driven and well designed work units that deliver what the customer needs when it is needed the right way the first time.
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UNC HEALTH CARE SYSTEM
Tools and Data to Shape the Future State DATA
DESIGN
Activity of the Product
Cellular Layout
Activity of the Operator
Standard Work (Job Guidance)
Group Technology
Performance Measures
=
Lean Future State
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UNC HEALTH CARE SYSTEM
Tools and Data to Shape the Future State DATA
DESIGN
Activity of the Product
Cellular Layout
Activity of the Operator
Standard Work (Job Guidance)
= 1
Group Technology
Lean Future State
Performance Measures
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UNC HEALTH CARE SYSTEM
Tools and Data to Shape the Future State DATA
DESIGN
Activity of the Product
Cellular Layout
Activity of the Operator
Standard Work (Job Guidance)
Group Technology
Performance Measures
=
Lean Future State
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UNC HEALTH CARE SYSTEM
Potential Staffing Efficiencies Post-Lean
Standard Work Practices
Match Process Cycle Times to Reflect Workload
Redistribute Staffing Assignments to More Closely Match Workflow Patterns
Level Individual Workloads
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Match Process Cycle Times to Reflect Workload
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Redistribute Staffing Time of Day to More Assignments Closely Match Workflow Patterns
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19
17
15
13
11
9
7
5
3
400 300 200 100 0 1
Standard Work Practices
Number of Specimens
UNC HEALTH CARE SYSTEM
Potential Staffing Efficiencies Post-Lean Assessment of Hourly Specimen Workload
Level Individual Workloads
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UNC HEALTH CARE SYSTEM
Potential Staffing Efficiencies Post-Lean
Pre-Lean Configuration 2 stat processors Standard Work 3 routine order entry Practices 1 aliquoter 1 rover Match Process Cycle Times to Reflect Workload
Post Lean Configuration 5 order entry 1 aliquoter Redistribute Staffing 1 distributor Assignments to More Closely Match Workflow Patterns
Level Individual Workloads
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UNC HEALTH CARE SYSTEM
Current State Olympus
TOX/TDM
COAGULATION
Olympus
HEMATOLOGY
CHEMISTRY
IMMUNOASSAY
SPECIMEN PROCESSING
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ACL Tops
ACL Tops
Olympus
Olympus
Elecsys
UNC HEALTH CARE SYSTEM
Operator Walk Pattern: Future State
ADVIA
CELL ADVIA
Fusion
Fusion
Fusion
Elecsys
Specimen Processing OE 5 OE 4
OE 3
OE 2 OE 1 15
UNC HEALTH CARE SYSTEM
Cora – Robot Delivery
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UNC HEALTH CARE SYSTEM
In-Lab Turnaround-Time (Received to Reported)
% Routine Results Reported Within Each Time Period 100.00%
90.00%
80.00%
70.00% K
60.00%
CBC APTT
50.00%
TRPT UA
40.00%
Cocaine
30.00%
20.00%
10.00%
0.00%
60 min
120 min 180 min 240 min
PRE-LEAN
60 min
120 min 180 min 240 min
POST-LEAN
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UNC HEALTH CARE SYSTEM
LABORATORY Six Sigma Project Stat Turn Around Times 2008 “HOW LOW CAN WE GO?”
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UNC HEALTH CARE SYSTEM
Processing Flowchart Measure Analyze
Specimen rec’d in Core tube station
Specimen picked up from tube station, placed in processing bucket
Different Specimen locations
Phleb draw Floor with barcode labels
ED
Req
If ED, match requisition to specimen
If req, verify labels with tubes & req
If from floor using a barcoded label & no req proceed to receipt verified
If Phleb draw, labels already attached, proceed to receipt verified
No req If no paper req record on ED log Specimen receipt verified into computer system Place in spec storage rack until orders arrive Specimen placed into processed rack
Aliquoter picks up specimen for Hem, Chem, Coag Hem Chem
Coag
Hematology Specimen
Chemistry Specimen
Coag Specimen
Specimen loaded onto robot for delivery to Hem area
Specimen loaded into Chem centrifuge for 5 min spin
Specimen loaded into Coag centrifuge for 5 min spin
Hem Tech picks up specimen
Specimen unloaded from centrifuge
Specimen unloaded from centrifuge
Aliquot needed Specimen moved to instrument rack Specimen aliquoted
If yes
If no Specimen loaded onto “Cora” delivery robot
Specimen delivered to Core Chem analyzer for analysis
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UNC HEALTH CARE SYSTEM
Chemistry Processing Original times vs 9/25 Pilot Improve Chemistry Comparison: Original Processing vs Pilot 9/25/08
7 6.4 6
6.3
5 4
4.5
Minutes
3.7
3.5 3 1.6
2 1.6 1
1.3 0.3
0 Order, label
Wait time
Centrifuge
Wait time
0.2 Cora to analyzer 9/25 Pilot
Original
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TAT's Evening 2008-2009 Hgb
Routine K
S
t p e
N
ov
9 -n 0 Ja
Stat K
M
ar
M
ay
Goal 90%
Routine Hgb's
Stat Hgb's
Ma r Ma y
ly u J
No v Ja n-0 9
M
ay
100 95 90 85 80 Ju ly Se pt
100 95 90 85 80
Ma y
% Within Limit
TAT's Evening 2008-2009 K % Within Limit
UNC HEALTH CARE SYSTEM
Evening TAT’s 2008-2009
Goal 90%
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UNC HEALTH CARE SYSTEM
Why Automate? Patient Safety Employee Safety Valuable Human Resource Utilization Future Growth
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Referral testing
Staff Offices
Manuals
Hematology
Hematology
Coagulation
CHEM
CHEM CHEM
UNC HEALTH CARE SYSTEM
Work Cell Design
Work Cell Coagulation
CHEM
Specimen Processing OE 5 OE 4
OE 3
Walkin freezer
OE 2 OE 1 23
Manuals
Hematology
Hematology
Coagulation
CHEM
CHEM CHEM
UNC HEALTH CARE SYSTEM
Core Laboratory May 2010: Work Cell Plus Automation
Work Cell Coagulation
CHEM
Specimen Processing OE 5 OE 4
OE 3
Walkin freezer
OE 2 OE 1 24
UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
Total System Design Four Multi-platform Chemistry Analyzers Automation Automation Controller Instrument Manager BioRad Unity Quality Control System
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UNC HEALTH CARE SYSTEM
Multi-Platform Chemistry Analyzer Integrated chemistry system - combines dry slide, wet chemistry and immunoassays. 10 open-channels/instrument.
7 UNCH user defined assays. methotrexate, free phenytoin, aldolase, urine total protein, propoxyphene, IGG-csf, ceruloplasm. Performs testing previously performed on 10 analyzers
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UNC HEALTH CARE SYSTEM
Automation Front End Processing, Specimen Transport, Specimen Storage Sample Entry/Exit Unit Centrifuges Decapper Aliquoter Recapper Specimen Sorter and Storage Sample Entry/Exit Unit
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UNC HEALTH CARE SYSTEM
Controller Brain of the automated system. Monitors all of the automated components. Contains test routing information for all tests performed on the chemistry analyzers. Monitors error codes. Sophisticated timing and rerouting programming.
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UNC HEALTH CARE SYSTEM
Instrument Manager Consolidates result verification for all chemistry analyzers. Allows development of customized result verification for individual analytes based upon result and interference levels (degree of hemolysis, icteria, lipemia. Provides flexibility in managing and organizing results by specimen information: priority, location, tests.
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UNC HEALTH CARE SYSTEM
Biorad Unity Quality Control Data Management System Software interfaced with Instrument Manager. Handles approximately 800 quality controls results daily. Offers flexibility in managing and reviewing results.
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
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UNC HEALTH CARE SYSTEM
Highlights of GO-LIVE!
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Pre-AutomationTurn Around Times
Post Automation Turn Around Times
1600
2000
1400
1800
800 600
Turn Around Time-Minutes N=3645
170
160
150
140
130
120
10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170
110
0 100
0
90
200 80
200
70
400
60
400
1000
50
600
1200
40
800
1400
30
1000
1600
20
1200
10
# of Routine Potassiums
# Routine Potassiums
UNC HEALTH CARE SYSTEM
In-Lab Turn Around Time Received to Reported
Turn Around Time-Minutes N=3706
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UNC HEALTH CARE SYSTEM
Routine and Stat Turn Around Times
Dry Slides
Troponin
Routine
37 minutes
48 minutes
Stat -enGen
30 minutes
41 minutes
Stat Centrifuged 22 minutes Before Placed On enGen
34 minutes
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UNC HEALTH CARE SYSTEM
Automation Outcomes Improved laboratory test turn around times. Focused highly skilled technologist resource on test interpretation and problem solving. Improved patient safety due to bar-coded specimen aliquots. Improved employee safety due to less exposure to patient specimens. Reallocated technologists to other growth areas of laboratory.
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UNC HEALTH CARE SYSTEM
Improvement Activities are Continuous Specimen processing optimized: centrifuge batch size customized to workload, centrifuge specimen wait time decreased. Specimen routing further customized for UNCH samples. Instrument manager redesigned for UNCH dashboard. Ortho inventory management system implemented.
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UNC HEALTH CARE SYSTEM
Inventory Management System Remotely monitors reagent usage via e-connectivity. Projects reagent order based upon usage patterns and minimal stock levels. Levels reagent usage from month to month. Provides management tools for budget review. Coordinated with in-house developed instrument loading programs.
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PERFORMANCE
UNC HEALTH CARE SYSTEM
Goal - Establish A Baseline Without stable and standardized processes, you cannot have sustainable improvement STANDARDIZATION INITIAL LEAN PROJECT
STD
STANDARDIZATION TRADITION
TIME Steve Friedland-Ortho Diagnostics
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UNC HEALTH CARE SYSTEM
Core Laboratory Green Belt Project Redesign of specimen processing AFTER Automation
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FREQUENCY DATA BY SHIFT Plot and Analyze Frequency Data – Box plots Arrival to Receipt in SCC BY SHIFT
100
80
60
Minutes
UNC HEALTH CARE SYSTEM
MEASURE
40
20
0 Days
Evenings By Shift
Midnight
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UNC HEALTH CARE SYSTEM
ANALYZE
Verify Root Cause: No FIFO vs. FIFO
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UNC HEALTH CARE SYSTEM
ANALYZE
Manual vs. Automation
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UNC HEALTH CARE SYSTEM
IMPROVE
IMPROVEMENT NOTED BY SHIFT BEFORE & AFTER THE PILOT p value
