26 IndustrialEngineer

CARE COMPRESSIONA3 thinking and lean and

Six Sigma tools successfully

consolidate many healthcare

laboratories into one BY CYNTHIA L. SEAVER

September2012 27

In 2007 the Spectrum Health healthcare system in Grand Rapids, Mich., was in the preliminary stages of a lean jour-ney when leadership determined that the lab system had outgrown its physical locations. Spectrum Health had become the largest healthcare provider in West Michigan after a 1997 merger between Butterworth Hospi-tal, Blodgett Hospital and Helen DeVos Children’s Hospital (located within Butter-worth). Blodgett and Butterworth each had a major lab serving their inpatients and outpatients. Leaders decided to consolidate these labs into a new facility in downtown Grand Rapids. They believed the move would serve the region and best support the healthcare system’s future needs.

Lab management personnel teamed up with an experienced professional from the new Department of Process Improve-ment to design optimal workflow for the consolidated lab before architects began their design process. The goal was to develop lean workflow and design the new physical space to support that work. The team used principles and techniques from the Toyota Production System toolbox, 2P methodologies, A3 thinking methodology and Six Sigma.

Thinking up the plan via A3To begin, a steering committee was formed that included representatives from the labs and the facilities, project management, tech-nical information systems and the system’s operational improvement departments. This steering committee opted to use A3 thinking methodology to design the new system lab and have a Spectrum Health process improvement engineer teach and facilitate throughout the process.

A3 thinking dates back to the concepts of “ideal state” and the “four rules in use” described in the 1999 Harvard Business Review article “Decoding the DNA of the Toyota Production System” by Steven Spear and Kent Bowen. They concluded that these simple concepts and rules are the

fundamental drivers of the Toyota culture of work. A3 thinking consists of gathering and analyzing information for the background; defining the current state, situation and problem; developing an ideal future state; completing a gap analysis; and creating and completing an action plan to address the gap from the current state to the future state.

With these steps in mind, the steer-ing committee, with the guidance of the process improvement engineer, developed a strategic A3 report that would be used to communicate and guide them through-out the project. This report included four sections: the business case, a current state analysis, a future state analysis and an action plan describing how to move from the current state to the future state.

The business case was easy to pull together following an outside consultant’s assessment of the business. After review and input by the steering committee, the final business case included findings related to process redundancies, high costs, exces-sive transport, limited capacity for growth, and staff and patient safety risks. There were 2.6 million tests and more than 300,000 specimens processed in 2007; lab volumes were expected to double to more than 5 million annually by 2014.

The A3 current state analysis represented reality as observed and documented by the steering committee. This analysis included documentation of lab locations, physi-cal space, departments and staffing levels, current test volumes, outreach volumes and inpatient volumes.

The steering committee spent many hours documenting and understanding the current state. Participants who did not work in the lab were taken on Gemba walks, a Japanese term that means “to go where the work is done.” Following these walks, the committee documented issues related to duplication among departments, lack of standardization in services, inefficien-cies and waste built up over time, excessive staff travel between sites and lack of space

for expansion. The system had more than 400 lab employees, staff safety and working conditions were not ideal and staff satisfac-tion was declining. Workflow issues were emerging at the labs due to compartmental-ization, especially during off-shifts.

Sharing and understanding the current state analysis guided the steering commit-tee as it determined the system’s desired future state. The committee also used marketing reports, demographic infor-mation, hospital strategies and emerging technologies. With lab volumes expected to double, the future state was clear: Design a consolidated facility that would improve efficiency; reduce operating costs; improve key process metrics; use greater automa-tion in specimen tracking and testing; offer services appropriate for emerging healthcare system changes; and improve staff, provider and patient safety and satisfaction.

The action plan focused on how to design a single lab that would close the gap between the current state and the proposed future state. The strategic A3 report’s action plan included the following:

• Hire a consolidated laboratories project coordinator.

• Establish oversight committees (process improvement teams, steering commit-tee, executive committee, leadership).

• Conduct process improvement work-shops to document future state workflow and design the physical layout around that workflow.

• Use process improvement tools to evalu-ate lab infrastructure, where applicable.

• Establish communication plans (system and lab) for all staff.

• Complete programming to determine how big the consolidated lab will be.

• Complete planning to determine how the lab will be laid out.

• Complete design to determine what the lab will look like.

• Complete construction.• Coordinate and complete the move.

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Project planning changesDespite proper planning, other signifi-cant and unexpected projects affected this multiyear consolidation project. In 2008, Helen DeVos Children’s Hospital began building a new facility across the street from the planned consolidated lab. In 2009, Blodgett Hospital announced a major renovation that included its in-house lab processes. And a local medi-cal group with its own small lab joined the healthcare system. Spectrum Health executives decided to close that lab and roll its services into the new lab as well.

As a result, the steering committee continually revisited its A3 thinking process and A3 report to assess the impli-cations of these changes. Plans had to be revised continually, managed and wrapped into previous decisions. What began as a lab consolidation for three hospitals ended up being a consolidation

for six entities: three hospitals, two clini-cal specialty divisions (cardiology/heart and oncology) and a medical group.

Process mapping for a physical layoutAfter hiring a project coordinator and developing the A3 report, the next step was to use Toyota Production System principles and process mapping tools to design the new lab’s workflow. Instead of the traditional “design-review” used by many architects, the steering committee designed the lab based on workflow. This emerged from the current state and future state analyses. There were two goals. One was to design processes that would reduce the seven traditional process wastes, or “muda” (defects, inventory, transportation, motion, overproduction, overprocessing and waiting). The second was to work with the architect to translate

the future state processes into a physical layout that supported those processes.

An effective facility layout is critical to reducing operating expenses. Studies have shown that 20 percent to 50 percent of total operating expenses can be attrib-uted to materials handling.

Other studies, as described by J.A. Tompkins and colleagues in their 2003 book, Facilities Planning, have demon-strated that efficient facility design can reduce these costs by 10 percent to 30 percent and provide an excellent return on investment. Therefore, the committee aimed to optimize the flow of specimens, minimize staff walking distances, and limit specimen transport and supply management.

The lab processes were divided into six subgroups based on similarity of processes, specimens and workflow: a pre-analytical team, four analytical

care compression

bubbling up Figure 1. This bubble diagram shows department adjacencies on two floors.

Alex’s Office Audrey’s Office Emily’s Office

Windows

Top Floor

Dumbwaiter

Manual Chem

Tox & Chem II

Immuno

TIS Support Offices

Immuno

Storage Room Rgts & supplies

Flammable Storage Room

POCT

Patient Service Room – 2nd floor?

PhlebSweat Cl Testing

Conference Room

Conference Room

Core Lab/ Automated Lab

Heme/Coag/Urines/Chem

Lab Central

Blood Bank

Employee Lounge (Restroom, Locker, Coat room, Dining

room)

Specimen storage

Courier & Supplies

Phleb

Ref Freezer

Registration

Specimen Receiving

Specimen Reports

Call Center

Elevators

Leadership & Admin Offices

Fine needle Aspiration – room

for patients

Slide & block storage

Utility room for biohazards Waste

Storage Flammable

PathologistsOffices

Pre-analytical AP/Micro/Viro

Station

Cytology

Histology

Microbiology

FungusTB

Viro

Dark room Scope

September2012 29

groups and a post-analytical processes group. A chart displaying the groups is available at www.iienet.org/IEmagazine/sep2012/Seaver. Each group had a team of at least 10 staff members from its area and members from the steering committee. All teams were trained in the principles of the Toyota Production System and A3 thinking. They worked to understand the current workflow and identify wastes in the processes they were responsible for. Time spent process mapping opened many eyes as they began to see where waste occurred and the steps needed to achieve optimum workflow. The process improvement engineer facilitated six workshops in the first summer, one with each of the subgroups to complete their current state process mapping.

After the key processes were mapped and information captured, the process improvement engineer facilitated another set of six workshops with the teams to create future state processes. Each team started its future state workshops with training on what makes a good process and how to avoid building in process waste. This training proved critical for creating an effective workflow and elimi-nating unnecessary steps.

Team members were excited about using process mapping to create their future workflow. Architects, informa-tion services personnel, lab managers and representatives from other depart-ments were included at the workshops to help them understand the new workflow and how it would affect the design and physical layout of the new laboratory.

Each team also identified what had to be changed to allow consolidation into one lab. This included identifying different methods, analyzers, equip-ment, roles and responsibilities at each existing location and understanding the unique patient population needs at each of the six entities involved.

Designing the physical layoutThe team members from the initial workshops reconvened to review the combined process maps, which were now set into a “swim lane” or cross-functional process map. They reviewed the future state workflow and confirmed work-flow relationships between what would become the new consolidated labora-tory’s departments. With help from the team members, bubble diagrams were created to demonstrate the departments’

relationships. Since the new lab was on two floors of a new building, the bubble diagrams separated the departments into two floors based on those relationships. This analysis led to locating the histology, cytology, pathology and microbiology departments on one floor and the core lab (chemistry, hematology and coagula-tion), immunology and toxicology on the second floor, as shown in Figure 1. Next, block diagrams were created to define the space, size and layout of each depart-ment on its appropriate floor (Figure 2).

blocking it out Figure 2. The block diagrams for the consolidated laboratory were based on the earlier bubble diagrams.

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These block diagrams were arranged with the same team members in attendance to help address everyone’s issues and ideas.

At this point, the architect drew the details of the physical spaces based on the completed future state analysis and the workflow documented by the teams. Once again, the teams from each area were shown diagrams of their proposed areas. They reviewed how specimens and staff would flow through each area. Spaghetti maps of specimen flow and staff movement were completed and analyzed, and these added to the discussions and decisions regarding physical layout.

2P process and preparation phaseIn 2P methodologies (process, prepara-tion), the second step is to simulate the work environment prior to the actual build; a mock-up of the workspace is created and staff members are asked to evaluate the workflow. The process improvement engineer and members from the various departments used 2P principles to map proposed loca-tions for benches and equipment by placing tape on the new lab’s floors. The workflow was re-evaluated, and changes were proposed and examined for feasibility with the architect. Staff members were invited back for further workflow evaluations as benches began to be set in place. Changes were made once again where possible, such as altering the type of work surfaces and locations for storage cabinets and equipment. This process was enhanced by the portable, easily moved casework selected for the lab.

Another example of using 2P method-ologies was in the cytology department. Cytotechnologists were concerned about the space available in the layout of their desktops because they would be working with a new computerized

imaging system alongside a standard microscope.

The process improvement engi-neer brought in large cardboard boxes and, along with the cytotechnologists, cut out various workstation layouts proposed by the subgroup team. The staff brought in each microscope, along with other items used at the work-station, to simulate the new working environment. Using Visio software, the process improvement engineer drew a customized workstation to fit the new workflow. The vendor used this drawing to design and build that area’s workstations.

Designing automation processes Automated processes are a critical component of any lab’s success. Staff members in chemistry, the most auto-mated department in the Spectrum Health lab system, had used one vendor for years and were reluctant to examine other systems.

However, the steering committee ulti-mately chose to use Six Sigma’s quality functional deployment (QFD) tool to understand automation needs, pick the best vendor, and come to an objective decision.

To begin, analytical requirements and process needs were collected from the chemistry team and lab management personnel. This information, combined with future hospital system require-ments, was used to complete the first matrix in a QFD, known as the voice of the customer (VOC) matrix. The team ranked these requirements to identify the most critical ones for the new system. The highest-ranking requirements were added to a second matrix on the QFD, the feature ranking matrix. The VOC matrix requirements were compared to the features available on various auto-mated lines, and those features were

ranked. This completed matrix became the prioritized list of features the chem-istry team wanted in a system.

Technical teams from various vendors presented their features and specifica-tions. A third matrix was created to evaluate each vendor’s offerings against the prioritized list of features. This process narrowed the options to two vendors. These two vendors returned to showcase their system and develop a cost analysis for the lab. The two vendors were so close that the chemistry team completed a pros and cons analysis of the two systems. The team then selected the new analytical testing system.

Specimen movementThe steering committee recognized the importance of eliminating or minimiz-ing travel and specimen handling. Three critical specimen movement issues had to be addressed. How should couriers be handled as they brought specimens in from all over the West Michigan region, including Blodgett Hospital (located two miles away) and the medi-cal group? How should specimens from the facilities located across the street from the new lab be handled? (This included Butterworth Hospital, Helen DeVos Children’s Hospital, the cardiol-ogy/heart institute and the oncology division.) And finally, how should thou-sands of specimens move within the lab to the new automation line?

An analysis of how couriers would use the elevators from the new parking garage was developed using time stud-ies of simulated elevator rides. After estimating that there would be 120 drop-offs per day, the team proposed installing a dumbwaiter between the parking garage and the lab. The time study showed a 50 percent time savings for each courier using the dumbwaiter versus carrying each delivery to the lab. The cost of a dumbwaiter was

care compression

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$120,000, but it would save eight to 10 minutes per drop-off per day. The return on investment was easy to determine, and a dumbwaiter was added to the building plans.

Six Sigma tools were used to complete a statistical analysis of a pneumatic tube system for moving specimens to the new lab from the buildings across the street. The analysis showed that during the morning draw (4 a.m. to 8 a.m.), the lab would receive an average of 100 pneu-matic tubes per hour and would need to return 100 tubes in the same hour. This was a critical catch by the process improvement engineer, who deter-mined that the current system could not handle these high volumes. Leader-ship agreed, and a new engineering plan was developed and implemented for the pneumatic tube system.

Walking couriers had to carry speci-mens that did not fit into the pneumatic tube system or that had specimen integ-rity issues. An analysis developed an efficient courier route through the two hospitals, the two clinical specialty divi-sions and adjoining services to collect and transport specimens to the new lab. Also, a special process was developed to move stat specimens (the most urgent ones) much more quickly.

The specimen receiving area’s lab manager identified a concern related to the third issue, managing specimens inside the lab. Due to the design of the physical layout of the new automation line, the architect could not place speci-men receiving near the dumbwaiter or the pneumatic tube system. The process improvement engineer and a lab manager worked with a vendor to design a narrow 50-foot conveyor to move and sort single blood tubes from the dumbwaiter and the pneumatic tube system onto the automation line. This conveyor allowed specimens to flow continuously, eliminating the need

to batch and carry the test tubes to the line.

5S: Maintaining the environmentTwo years prior to the move to the new building, a widely used lean tool known as 5S was implemented in the labs. This workplace organization method uses a list of five Japanese words that trans-late into English as sort, straighten, shine, standardize and sustain. The use of 5S increases productivity by ensuring needed supplies are available, improves quality by having a clean area with the right supplies, and benefits employee health and safety by address-ing ergonomics and other safety issues identified during the 5S process.

The project coordinator and process improvement engineer selected this tool to sort and identify what was not needed and therefore wouldn’t be moved to the new lab. 5S was imple-mented and continued to be used up to the time of the move, and the 5S philos-ophy and tool was brought over to the new lab. Storerooms, workstations and cabinet storage throughout the lab still are handled using 5S principles. For example, staff members continue to evaluate their physical areas and change the casework to increase their efficiency. Maintaining a clean, organized work space continues to promote employee efficiency, productivity and safety.

The fruits of hard laborOver a five-year span, the steering committee used many tools and prin-ciples from the Toyota Production System to design the workflow and features of the new consolidated labo-ratory. Toyota’s lean model has been used for nearly every type of business, so it was not a surprise when it was used in the construction of this new lab.

So far, Spectrum Health’s lab has

maintained or improved its turnaround time for all critical analytical tests. Lab productivity has improved by 9 percent since the move in 2011, even as volumes grow and staffing decreases through attrition. These efficiencies continue to be critical, with ongoing pressure from payers to limit or reduce reimbursement amounts and the need for ever-increas-ing staff efficiency, space utilization and overall cost-effectiveness.

Almost as important as the initial success of the lab has been the learn-ing acquired about continuous process improvement. Staff and management involved with the overall design have become problem solvers and continue using the principles of process improve-ment in ongoing efforts to improve their daily work. This lab has become yet another model at Spectrum Health for how healthcare systems can be guided into the future by A3 thinking, 2P meth-ods, Six Sigma and the principles of the Toyota Production System. d

Cynthia Seaver is a senior process engineer in the Process Improvement Department at Spectrum Health Hospitals in Grand Rapids, Mich. Certified as a Six Sigma black belt and lean expert, she has been training and leading continuous improvement teams for more than 25 years. In 2007, she left the chemical industry and moved into healthcare. Several of her process improvement teams have been named as the top performing projects in the hospital system. Seaver is a faculty member in Baker College of Michigan’s Continuous Quality Improvement (CQI) Program, which she helped develop. She teaches statistical process control, design of experiments, quality theory, Six Sigma green belt and the introduction to lean manufacturing classes. Seaver graduated from Michigan State University with a degree in microbiology and public health and from Grand Valley State University with a degree in analytical chemistry.