Making the Most of Lean Six Sigma in your Laboratory | LTS Health
By Johann Eybers, Senior Consultant
The popularity of Lean in diagnostics laboratories is undisputed – and with reason: it combines easy-to-understand tools and methods with a systems thinking approach to operational improvement in laboratory performance. With all its good intentions, there are certain pitfalls that could become unavoidable if they are not identified and dealt with through accurate prioritization of initiatives, setting goals based on facts and ongoing performance tracking. Johann Eybers, Senior Consultant at LTS explores the pitfalls of Lean and how to avoid them in your laboratory.
How do you make sure that your Lean initiative amounts to success?
It is a simple question that few can answer: What was the ROI on your Lean initiative? It is a common question that many managers and staff have asked. If you have worked in a pathology laboratory over the last two decades, you would have seen a growing trend towards Lean initiatives, in laboratories across the globe. It’s also likely that you’ve been part of a Lean initiative. And if you’re anything like laboratories we have worked with, you may even have the scars to show for it! The question stands: just how do you ensure that your Lean initiative amounts to a quantified improvement to your efficiency and productivity, reduces your sample turnaround time and improves your quality?
In order to answer that question, let’s first take look at Lean itself.
In simplified terms, Lean thinking fundamentally promotes common sense. It’s about lining up value-creating activities in the best sequence, conducting these activities without interruption and performing them more and more effectively. For example, you may decide to split registration of samples in prelab by discipline but what would the affect be of splitting the samples only by priority and batching the routine work?
The methodology originates from the 1950s, when automotive manufacturer Toyota developed it into its production system to ensure continuous improvement in the way they manufacture cars. The famous book "The Machine That Changed the World: The Story of Lean Production" by James P. Womack, Daniel T. Jones and Daniel Roos popularized systems thinking in the manufacturing industry. Since then a range of tools and concepts that are understandable, relatively easy to apply and made systems thinking practical to the everyday person have become part of Lean. In the last couple of years, the concept of Lean Thinking in diagnostics laboratories and beyond has become wildly popular.
An example of a typical Lean initiative that we see across laboratories is the application of Lean for Cytology screening laboratories to achieve 14 day reporting targets. A number of sites we have worked with have applied Lean through the use of the Define, Measure, Analyse, Improve and Control. These initiatives started with high levels of energy from staff to engage and identify waste, improve flow and improve communications. The initiatives had set targets which in general revolved around achieving 14 days TAT for reporting and made good use of Lean tools such as 5S, A3 problem solving, root cause analysis and daily stop and fix meetings. The results of these cytology initiatives showed that laboratories managed to improve by reducing batch sizes, establishing first in – first out policies, keeping samples moving through system and considering the whole sample pathway. However, enthusiasm disappeared quickly and questions were raised around whether there was an appropriate data baseline to measure improvement against, data accuracy, benefits realization against quality improvement and investment, and sustainability of the initiative while maintaining the initial momentum.
What contributes to Lean initiatives in the laboratory falling short of expectations?
LTS has nearly two decades of experience in diagnostics performance improvement and over this period, we have time and again come across the same three common pitfalls.
Pitfall #1: The voice of the customer may not always be the best way to prioritise initiatives
Traditionally, Lean uses the voice of the customer or the principle of “first in, first out” (FIFO) to prioritize initiatives, but this does not balance the investment required and the quantified value of the initiative. One aspect that is commonly overlooked is the investment that is required in order for continuous improvement to be successful. The implementation of continuous isn’t simply a once-off event; it requires substantial investment in the form of time, people and especially, capital. This necessitates a return on investment that cannot always be quantified, as the costs of a Lean initiative stretches further than a sum of money. A recent study on Lean found that, out of more than a thousand studies on Lean in healthcare, not one study could adequately quantify the impact of Lean in financial terms. In addition, this makes the discussion around goal setting and prioritisation even more complicated. If cost reduction or growth in revenues make up any part of your ability to sustain your laboratory (which they should), goal setting and prioritisation may actually steer the whole Lean initiative in the wrong direction. Lean can help to identify where improvements can take place but it becomes a lot more complex when prioritizing based on the financial and operational impact of a proposed change on the end-to-end process.
Pitfall #2: Lean does not set performance targets based on facts
Operational performance targets should be S-M-A-R-T (Specific, Measurable, Attainable, Realistic and Time related), for example a SMART goal may be to get the TAT for 95% of urgent chemistry samples within 4 hours. The two most common approaches to setting performance targets in Lean is to either use benchmarking from other similar processes or to set “bold” goals to encourage a change in the continuous improvement culture. Benchmarking is a good approach if quality data is available for comparable processes, but in practice this is often difficult to obtain. How can you be sure that the goals that are set are attainable, and how do you re-evaluate goals based on changing operational variables? Setting unattainable goals can lead to failure becoming excusable, acceptable and even expected! We believe inaccuracy is inexcusable, and that setting poor goals not based on facts leads to poor results.
Pitfall #3: Engagement and excitement around the initiative is great at the start, but fizzles out due to ‘business as usual’.
Sometimes, the most exciting thing about a change initiative is the thought of the initiative itself. Once the process kicks off, heels are dug in and everyone including senior management try to resist the inconveniences that comes with innovation. Even when initiatives only start with relatively small effort (such as adopting smaller batch sizes in cytology screening, implementation of non-acceptance policy for samples before processing) by focusing on the “low hanging fruit”, enthusiasm for the Lean change initiative wanes and the impact-to-effort curve increases exponentially – adding additional unaccounted costs to the bottom line.
To prevent this type of “change fizzle”, Lean often requires Kaizen Promotion Offices to act as change agents in the laboratory and ensure that key milestones in the change initiative are achieved. The problem is that these promotion offices come at a price of their own. In fact, out of a total budget, Kaizen Promotion Offices could make out more than half of the total financial investment that goes into initiating Lean in a healthcare organization.
How can you and your laboratory get around these pitfalls?
Along with these principles, always try to prioritise the required efforts to make your continuous improvement initiative a successful one by overall impact on turnaround time, quality and of course the bottom line! Changing sample batches may be a good idea when looking at the process from a pre-lab perspective, but of course, it is the impact of that change on the rest of your processes that will determine success or failure.
Make sure the goals you set in your organization are attainable and realistic. Rather than relying on your weekly Excel spreadsheet from the IT department to measure your performance, utilize modern-day BI dashboards that can show the KPI’s that you are interested in - in real time if needed.
Ensure that the excitement around your change initiative doesn’t fizzle out by tracking true performance. Also make sure what you are trying to achieve is clear and quantified, so that you are able to compare progress. You can access a lot of useful data from your LIS to clearly articulate what your targets should be. These targets should be displayed everywhere and the progress towards it will either drive excitement or create the necessary sense of urgency. This drives an appetite for improvement by keeping daily work challenging, relevant and rewarding.
The role of people and technology has changed in today’s complex processes and some of the tools that were developed are not fit for purpose anymore. When real improvement is achieved the continuous improvement methodology will retain management support which, in turn, will allow more investment. This is the key cycle that will bring real change in an organization. While Lean is a strong and prevalent methodology, organizations should recognize its pitfalls and leverage technology to optimize decision making.