value stream mapping in anatomic pathology

© 2008 Chi Solutions, Inc. Proprietary and Confidential.

Laboratory Outreach 2008 Value Stream Mapping(Anatomic Pathology)

Hans Froehling, DBA/CMBB

June 2008


Part A: The Value Stream MapHow to Create a Value Stream Map

3 © 2008 Chi Solutions, Inc. Proprietary and Confidential.

Key message No. 1

“We know what needs to be done to reduce defects in anatomic pathology, the challenge is to implement the principles that lead us to zero defect rates”

Adapted from Dr. Barnes, professor of strategy, Nova Southeastern University


Key messages No. 2

“The hardest part of leaning out a process is living through change”

Adapted from Michael Hammer “Reengineering the Corporation”


Key Message No. 3

“Create constancy of purpose toward improvement of product and service, with the aim to become competitive and to stay in business and to provide jobs”.

W. Edwards Deming, First point of his “14 Points for Management”.


Key Objectives

Demonstrate why lean principles developed in the automotive industry can be successfully used to reduce defects and increase value of anatomic pathology services.

Give an understanding of how value stream management allows for the implementation of lean principles.

Demonstrate how a value stream map can be used to identify opportunities for defect reduction in Anatomic Pathology.

Describe the key lean tools to develop a lean value stream map that reduces the defect rate of Anatomic Pathology.

Demonstrate via a case study how lean principles can be successfully applied to anatomic pathology.


Objectives of Lean

Reduced Defects = Improved Quality

Reduced Lead Time = Improved Turnaround Time (TAT)

Reduced Costs = Increased profitability

Improved value = Decreased waste

Lean makes the defects “visible” through one-piece flow!


How does lean contribute to defect reduction?

Batch Production Inspection Feedback with delayed Action

One Piece Flow – Immediate Feedback with Immediate Action

Input

Defect-free output

Defective output


How does lean contribute to improved speed?

Batch Production Batch Production Input Output

Input

Defect-Free Output

Defective output

Constant Bottleneck

First-In => Anytime Out

One Piece Flow

Constant Flow

First-In => First Out


How does lean contribute to reduced costs?

Less Work-In-Progress

Faster Turnover

Faster collection of money

Less need for inventory stocks (reagents etc.)


How does lean contribute to improved value?

Defect Speed Cost =>Value

General Principles of Lean:

Applicable to all industries including Anatomic Pathology


Lean and Value Stream Management


Key Definitions

Value = f (product/service, price).

Value Stream = All actions required to provide service/product.

Value Stream Map = A diagrammatic summary of every step required to provide the service/product.

Current State Map = Shows current conditions of production.

Future State Map = Shows improvement opportunities.

Value Stream Management = A process developed to implement lean principles into the planning and execution of a value stream.


Value Stream

“A Value Stream is an end-to-end collection of activities that create or achieve a result for a customer of

the enterprise.”


Value Stream Mapping is a tool that helps you to see and understand the flow of material and

information as a “product” makes its way through their value stream.

You then look for opportunities to eliminate or reduce wasted time or activities in the process.

Value Stream Mapping


Value is meaningful when expressed in terms of the service which meets the client’s price at a

specific time.

Specify Value


The key question of all lean processes is:

Does the process add value to the delivery of the product or service?

Value-added defined:

1. Does this process step meet a customer need?

2. Does it change the product/service?

3. Is it rework?

Value Defined


Specify value from the standpoint of the end customer.

Identify the value stream for each product family.

Make the products flow.

Produce when the customer pulls from your operations.

Manage towards perfection.

Value Defined (cont.)


Helps you visualize the process on multiple levels.

You can see the flow and sources of waste.

Provides a common language for analyzing processes.

Provides a blueprint for creating flow and implementing lean concepts and techniques throughout the entire process stream.

Benefits of Value Stream Mapping


If a task does not add value lean considers it as “waste” (muda).

Seven Sources of “Waste”

1. Defects (Rework)

2. Overproduction

3. Wait Time

4. Unnecessary Movement

5. Excess Inventory

6. Work-in-Progress

7. Unnecessary Movement

Waste (Muda) - The Opposite of Value


1. Actitivities which actually create value as perceived by the customer.

2. Activities which are required, add no value but cannot be deleted yet (type I muda).

Certain Government Regulations/Policies.

Facility Layout.

Technology.

3. Activities which are required by the customer, and which can be deleted right away (type II muda).

Lean Kaizen Events.

Types of Waste


A Value Stream Consists Of:

The people who perform the tasks, their skills and knowledge

The tools and technology that are utilized

The physical facility and the environment

Policies, procedures and processes which govern the activities

The social system that supports the value stream

The organization and the culture of the enterprise

The values and beliefs that dictate the corporate culture

Behaviors that affect the way work is approached

The communication channels and the way information is disseminated


Managerial Aspects

Style and philosophies

Structure and hierarchy

Communication (chartage)

Values and beliefs

Information Flow

Operational Aspects

Ensure business processes, policies and procedures are cost effective and satisfy the customers needs

Information Flow

Social Systems

Titles, compensation and rewards, training supporting the value stream

Technological Aspects

Ensure technology is being utilized appropriately and leveraged to gain maximum benefit to the customer and the company

Investigate These Areas


The process map depicts “How Specimens flow through the process”

It does not show:

Information Flow

Communication Flow

Managerial Systems

Social Systems

Social Interactions

Step A Step B Step CDecision

Step D

Start

Step EStep F

No

Yes

End

Process Map: Material Flow


Customer/Physician

Supplier/Patient

Management Control

Daily Review

Demand

3,600/month120/dayK = 30

PTT = 20Trop = 30HGB = 40

Draw

Total C/T = 120 secondsValue Add: 120 secondsNVA = 0 secondsDefect = 5%Distance Traveled: 1000 ft.

Receive


Process


Centrifuge


Test

Total C/T = 900 secondsValue Add: 900 secondsNVA = 0 secondsDefect = 0.01%Distance Traveled: 60 ft.

Result


Verify


Forecast:Annual

Order:Hourly

Supervisor

Weekly

Monthly

Weekly

Current State Map: Lab Testing: ER Room

120 seconds 5 seconds 20 seconds

3 minutes

240 seconds

6 minutes

900 seconds 10 seconds

4 minutes

10 seconds

4 minutes L/T = 34.1 minutes

VA/T = 1305 seconds

Adds key informationto a generic process map

A Value Steam adds critical Information: Material Flow Information Flow Information regarding time and transportation distances

Example of Completed Value Stream Map


At What Level Do You Start a Value Stream?

Total Value Stream: Enterprise vs. Operation

Enterprise Operational StrategyOperations Operational Tactics

Enterprise/Business Unit Level

ActionAction

Operations Level

Action ActionAction

Our Focus in this part of the workshop is here.

Action Action


Document the information flow from beginning to end.

Track the work information associated with the process steps.

Track the production order associated with the specimen (tissue, block etc.) through the system.

Map the scheduling system and document tracking of the information and materials throughout the system.

Document how the system communicates with the customers and suppliers.

GO WALK IT !!!

Mapping Information Flow


Go to the Actual place where the process is performed.

Talk to the Actual people involved in the process and get the real facts.

Observe and chart the Actual process.

Reality is invariably different from perception; Few processes work the way we think they do.

The purpose of value stream mapping is to identify waste, not to develop the perfect process map.

Understand the process through facts and data!Understand the process through facts and data!

GO WALK IT!

Three Actual Rules


Customer

Number of Specimen

Number of Cassettes

Lead time (Total TAT)

Cycle time (each step)

Queue time (Wait time)

Transportation time

Travel distance

Equipment requirements

Special process requirements, etc . . .

More detail captured now, easier to improve later!More detail captured now, easier to improve later!

Customer/Physician

Supplier/Patient

Management Control

Daily Review

Demand

3,600/month120/dayK = 30

PTT = 20Trop = 30HGB = 40

Draw


Receive


Process


Centrifuge


Test


Result


Verify


Forecast:Annual

Order:Hourly

Supervisor

Weekly

Monthly

Weekly

Current State Map: Example


3 minutes

240 seconds

6 minutes


4 minutes

10 seconds


VA/T = 1305 seconds

Relevant Process Data


Customer Demand:100 pieces per Month

(Takt Time 5760 seconds)

Customer

Supplier

Information

Information

Information

Lead Time = 0 seconds

VA / T = 0 seconds

RM = 0 seconds

WIP = 0 seconds

FG = 0 seconds

Information

Management Control (2)

Customer (1)Supplier

(3) InformationFlow (8)

InformationFlow (8)

Activities/Measurements (4)

Transportation Line (6)

Summary Measures (7)

Defect Rate/Timeline (5)

Basic Structure of a Value Stream Map


1. The first step is to select one product/product family or one service/service family.

2. The next step is to define the current state….This provides the information to develop the desired future state.

3. Future-state ideas will come up as you map the current state and will be fine tuned as you perform improvement projects.

4. The final step is to form an improvement vision and plan that will optimize costs, cycle times and quality.

Key Activities of a Value Stream Map Development

Improvement Plans and Projects

Future State Map

Current State Map

Product or Service Family

KaizenKaizen


5. Begin at the internal, door-to-door level. Expand to the supplier and customer level only if absolutely required or after you understand your own business processes.

6. Review material flow first and then information flow.

7. Have one person personally lead the mapping effort and be part of the ongoing improvement plan and vision.


Across Companies Level

Multiple Locations Level

Door-to-Door Level

Process Level

Begin Here


CustomerProcess NProcess 3Process 2Process 1Supplier

You will list cursory information about your suppliers and customers, but focus here first. Add the detailed supplier and customer data after you understand and have optimized your processes.

(1) Begin at the “shipping end”, work upstream and do a quick walk along the entire door-to-door work stream to get a feel for what is happening.

(2) Next, go back and, with pencil and paper, map the entire value stream. Have one person map the entire stream of activities.

(3) Always collect current-state information while walking along the actual pathways of material and information flow.



Cut

Total C/T = 60 secondsValue Add: 10 secondsNVA = 50 secondsDefect = 5%

Physician/Patient

1x Daily

Customer/Supplier

Process/ Measurements

Information Flow

Inventory/Work In Progress

Specimen Flow

Transportation

Pick upSchedule

People

First-In-First-Out

Work Cell Go-And-See

Key Value Stream Symbols


Management Control

Management controls the coordination between customer demand, suppliers and information and material flow.

Put management control at the center of value stream map to show that this is where the control center is.

Management controls:

Information flow

Material scheduling

Specimen flow

Work scheduling

Work distribution

Process sequence

Schedules of suppliers


Customer - Management Control - Supplier

Draw the customer icon on the upper right corner.

Draw the supplier icon (same type as the one that represents the customer) in the upper left corner.

Draw the production control icon between and slightly above the customer and supplier icons.

Note: Always draw the customer icon first as a reminder that the purpose underlying the value stream map is to ensure customer satisfaction.

Customer:Physician

Supplier:Patient

Management Control

L/T = 0 seconds

VA/T = 0 seconds


Enter Customer Requirements

Next, draw a box below or above the customer icon for entering Customer requirements:

Enter monthly requirements in the data box.

Calculate daily requirements by dividing the monthly requirements for the total number of tests and for each major type of test by the number of days.

Enter the results on the map next to the data box showing the monthly requirements.

Physician

L/T = 0 seconds

VA/T = 0 seconds3,600/monthDays: 30120/dayTAT = 2 days


Delivery and Transportation Icons

Draw a shipping icon in the bottom right corner, below the customer icon.

Draw a trucking icon between the shipping and customer icons, and enter the delivery frequency (hourly) inside the truck’s trailer.

Draw a truck icon in the bottom left corner below the supplier icon; enter the delivery frequency (hourly) inside the truck’s trailer.

Draw the direction arrow running from the supplier icon and the lower left corner, where the testing operation will be located.

Draw in a direction arrow running from the shipping icon to the customer icon.

1 x day


Delivery (Specimen/Tissue)

Customer/Physician

Supplier/Patient

Management Control

Daily Review

Order/ Daily

Order Weekly

1/day

1/day

Demand

3,600/month120/day

L/T = 0 seconds

VA/T = 0 seconds


Map The Production Process

After drawing the truck icons, draw icons representing the operations along the bottom of the sheet.

1. Determine the number of boxes you will need ahead of time so that you have enough space for all of them, keeping in mind the following:

The key operations in this case are: receiving, grossing, cutting, embedding, staining, work loading.

Remember to leave space between the operations to draw inventory work in progress (WIP) icons.

Remember to draw the operations in sequence from left to right; always draw the shipping icon furthest down stream (to the right).

2. Draw and label a box for each operation in the process.

3. Draw information boxes for attributes and measurements below the icon for each operation.


Map the Production Process

Customer/Physician

Supplier/Patient

Management Control

Daily Review

Demand

3,600/month120/day

Accession

Build Cassette

Gross/ Putin Oven

Embed

Cut

Workload

Stain

Create a box for each process step


Enter Process Attributes

Examples of measures critical in the lab industry: Defect Rate

Turnaround Time

Total Cycle Time

Value Added Time

Non-Value Added Time

Defect Deliveries

Operators

Distance Traveled

Defect Rate = 1%

Turnaround Time = 50 Minutes

Total Cycle Time = 200 seconds

Value Added Time = 20 seconds

Non-Value Added Time = 180 seconds

Units Produced = 16/hour

Total Uptime = 88%

Work-In-Progress = 5 bags

Accession


Production Lead Time (PLT = TAT)The time it takes a specimen to move all the way through the process or value stream from order to report (start to finish).

Cycle Time (CT)The time it takes a technician/assistant to go through all work elements before repeating them.

Value-Added Time (VAT)The time of those elements that actually transform the product in a way that the customer is willing to pay for.

Non-Value Added Time (NVAT)The time of those elements that to do not add value

Percent Value Added Time = Production Lead Time/Value Added Time

Note: Time spent due to government regulations are called business value added time; counted as “value added time.”

Key Terms of Time


Additional Summary Lines

TIMELINEThe timeline gives important information about the distribution of time within the process.

In particular, it shows total cycle time vs. value-added time for each process step.

Shown on next page

TRAVEL DISTANCEThe travel distance gives important information about the distances traveled between the various process steps.

They give indication where unnecessary movements occur.

Shown on final value stream map


Process Attributes and Timeline

Customer/Physician

Supplier/Patient

Management Control

Daily Review

Demand

3,600/month120/day

Receive


Cassette


Gross


Cut


Embed


Workload


Stain



3 minutes

240 seconds

6 minutes


4 minutes

10 seconds


VA/T = 1305 seconds

Total Cycle Value Added => 20 sec. / 180 sec. = 11.1% Time Time

Value added time can be calculated for1. Total Production Lead Time OR2. Each Step in the process (Cycle Time)


Communication Arrows

Physician

Patient

Management Control

Daily Review

Demand

3,600/month120/day

Receive


Cassette


Grosss


Oven


Cut


Workload


Embed


Forecast:Annual

Order:Hourly

Supervisor

Weekly

Monthly

Weekly


3 minutes

240 seconds

6 minutes


4 minutes

10 seconds


VA/T = 1305 seconds

Represents phone call Information Flow

Product Flow

Information Flow


Push Arrows (With Inventory Signs)

PHysician

Patient

Management Control

Daily Review

Demand

3,600/month120/day

Receive


Cassette


Grosss


Cut


EMbed


Workload


Stain


Forecast:Annual

Order:Hourly

Supervisor

Weekly

Monthly

Weekly

Current State Map: Histology


3 minutes

240 seconds

6 minutes


4 minutes

10 seconds


VA/T = 1305 seconds

Push ArrowWith Inventory

Sign

Inventory signs are important to understand where bottlenecks occur.


Physician

Patient

Management Control

Daily Review

Demand

3,600/month120/day

Receive


Cassette


Gross


Cut


Embed


Workload


Stain


Forecast:Annual

Order:Hourly

Supervisor

Weekly

Monthly

Weekly



3 minutes

240 seconds

6 minutes


4 minutes

10 seconds


VA/T = 1305 seconds

Completed Current State Value Stream Map

Process Flow + Key Information

Defect Rates/Timelines

Travel Distance Line600 feet


Kaizen

Add the sign of a “Kaizen Blitz” to show “Kaizen” or “Lean Six Sigma” interventions that help you move from the current

to the future state

Moving To The Future: Kaizen Events


Physician

Patient

Management Control

Daily Review

Demand

3,600/month120/day

Receive


Cassette


Gross


Cut


Embed


Workload


Stain


Forecast:Annual

Order:Hourly

Supervisor

Weekly

Monthly

Weekly



3 minutes

240 seconds

6 minutes


4 minutes

10 seconds


VA/T = 1305 seconds

Kaizen

Kaizen

Kaizen

Kaizen

Moving To The Future


Value Stream Mapping: Summary

Draw CustomerBox

Draw CustomerRequirements

Draw ProductionControl Box

Draw SupplierBox

Draw Transportto Production

Draw Production

Flow

DrawCommunication

Arrows

Draw Push/Pull Systems

FinalizeMeasurements

AnalyzeValue Stream

Map

IdentifyKaizen

Opportunities

DevelopFuture

State Map


Standardized Work

5S (Housekeeping)

Visual Controls Management Systems

Takt-Flow - Pull Concepts/One-Piece Flow

Cell Designs

Total Productive Maintenance

Mistake Proofing - Poka Yoke

Work Balancing (most complex to use)

Kaizen Blitzes

Key Operational Tools To Get You Started


The first step in improving a process is to ask:

Was the standard procedure for that task followed?

If the worker is following the standardized work and the defects still occur, then the standards need to be modified.

“One must standardize, and thus stabilize the process before continuous Improvement can be made.”

Imai, Kaizen

Standardized Tasks


Through a 5S program you organize a workplace and remove barriers to quality:

5S – A Key Tool for Lean

Step Japanese Literal Translation English

Step 1: Seiri Clearing Up Sorting

Step 2: Seiton Organizing Straightening

Step 3: Seiso Cleaning Shining

Step 4: Seketsu Standardizing Standardizing

Step 5: Shitsuke Training & Discipline Sustaining


5S Rules for Sorting

Dispose

UselessSorting

Keep & Monitor

Unknown Useless

Item

Keep &

Store

Useful

Useful

ABC Storage


Visual control is any communication device in the work environment that tells us:

How work should be done.

Whether work is deviating from the standard.

Examples:

Shadow tool box = a shadow of the tool that should hang at a certain place.

Graphs that show daily performance.

Standardization of filing in office settings.

Visual Control


Visual Communication Takes Many Forms

The Distinctive Aspect of Visual Communication Is That It Is Intended for a Group.

This Helps People to Pull in the Same Direction

Visual Communication Can Be:• A Sign• A Label• A Photograph• A Display• A Trend Chart• A Color Scheme• Whatever Serves the Purpose

A Visual Message Is Observed by Everyone Working in a Given Area, Everyone Who Passes Through the Area and Everyone Who Comes Into Range of Visibility


Situation Before: Solution:

% Improvement: Space Inventory Lead Time Quality Safety ProductivityN/A

Toolbox totally disorganized with many unnecessary tools. There were three personal toolboxes like these.

Created 3 shadow boards for workstations. Eliminated 2 of 3 personal tool-boxes.

N/A N/A N/AN/A N/A

The Visual Workplace


Takt Time

The heart of “One-Piece Flow” is takt time

Takt = German name for rhythm or meter

Rate of customer demand

Rate of which customer is buying

Calculation:

Total work time = 440 Minutes (7 hours/20 minutes), 20 days a month

Total demand = 17,600 units per month

Takt time = 17,600/8,800 = two per minute or one piece every 30 seconds


The optimally lean process is characterized by “One-Piece Flow”

No Work-In-Progress inventory costs

No quality defect

Shortest Cycle Time

No Waste

One-Piece Flow/Pull system


Pull System (mass customization):

Reduce cost of inventories by producing the product when the customer needs it.

Ideal: Build product or deliver service exactly when the customer orders it.

Push System (mass production)

Distribute product to the customer when the company is ready for it.

Ideal: “I wish they would make a meeting planner that would plan a meeting when I am ready .”

Push vs. Pull System


Builds in Quality

Creates Real Flexibility

Creates Higher Productivity

Frees up Floor Space

Improves Safety

Improves Morale

Reduces Cost of WIP Inventory

Benefits of One-Piece Flow/Pull System


Process C is a bottleneck:

“A bottleneck is one process in a chain of processes, such that its limited capacity reduces the capacity of the whole chain”

The maximum the chain of processes can process in one hour is 18 units!

Most if not all lean projects attempt to identify and overcome the process bottleneck(s).

Process A20 Units

Process B80 Units Process C

18 Units

Bottleneck


Cell Design Options

Pod Pattern Characteristics:

Ideal for craft work

Low throughput

Low variety

Tough changeover

High takt

Pod Design


Cell Design Options

“L” Shaped Line Flow Pattern Characteristics: Well suited to assembly operations with Point of

Use storage inside L. Easier expansion of critical, high fixed assets

space if located in the turn area. Allows fitting lengthy series of operations into

limited space. Lets feeding line start on aisle and end at point of

use.

“L” Shaped Line Design


Cell Design Options

“U” Shaped Line Flow Pattern Characteristics: One operator can see and attend all machines with minimum of

walking. They are flexible in the number of operators they can

accommodate (capable of responding to changing production

levels). Single operator can monitor work entering and leaving a cell to

ensure that it remains constant (JIT flow). Operators can conveniently cooperate to smooth out unbalanced

operations and address other problems as they surface.

“U” Shaped Line Design


Cell Design Options

Combination Line Flow Pattern Characteristics: Lands itself to two-way flow and to easy

access at multiple points. Branches can be segregated by function

or special requirements. Well suited to sequences of operations

that change or vary from job to job or

part to part. Permits multiple routings with

automated integration of process,

handling, and controls.

Combination Line Design


Cell Design General Rules

1 or 2 operator assembly Straight Line

3 to 8 assembly stations L or U Shape Line

More than 8 Serpentine, U or

Multiple U


Cell Design Wrap-Up

This is not an easy process

Let the process drive the shape and direction

Cover all bases

Evaluate alternatives

Perform simulations

Get the buy-in of the project area team

Get the buy-in of the management


The main function of a withdrawal Kanban is to pass the authorization for the movement of parts from one stage to another.

Once it gets the parts from the preceding process and moves them to the next process, remaining with the parts until the last part has been consumed by the next process.

The withdrawal Kanban then travels back to the preceding process to get parts thus creating the cycle.

Withdrawal Kanban


The primary function of the production Kanban is to release an order to the preceding stage to build the lot size indicated on the card.

The production Kanban card should have the following information:

Materials required as inputs at the preceding stage

Parts required as inputs at the preceding stage

Information stated on withdrawals Kanban

The first two pieces of information are not required on the withdrawal Kanban as it’s only used for communicating the

authorization of movement of parts between work stations.

Production Kanban


The goal is to get to Scheduled Maintenance

Breakdown Maintenance

Maintenance Prevention

Corrective Maintenance

Reactive

Scheduled Maintenance

Total Productive Maintenance (TPM)

Proactive


Poka Yoke – Dual Focus

DefectsMistakesProcess

PreventionPoka-Yoke that focuses here works on mistake prevention or making mistakes impossible.

DetectionPoka-Yoke that

focuses here works on mistake detection, or making sure mistakes

do not turn into defects.

People and systems do make mistakes. A portion of mistakes turn into defects.


There Are 2 States of a Defect:There Are 2 States of a Defect:

Error About to Occur

Defect About to Occur(Prediction)

Warning Signal

Control/Feedback

Shutdown(Stop Operation)

Error Has Occurred

Defect Has Occurred(Detection)

Warning Signal

Control/Feedback

Shutdown}M

IST

AK

E-P

RO

OF

FU

NC

TIO

N

Mistake Proofing – Poka Yoke


1

6

5

432

7 8

Mistake Proofing – Examples


Part B: Case Study:Apply Value Stream Mapping to reduce errors and improve TAT in commercial Anatomic Pathology Lab.


DEFINE: Define the

Project

Goal

IMPROVE: Implement Solutions &

Evaluate Results

ABCD

ANALYZE: Analyze to

Identify Causes

CONTROL: Standardize & Make Future

Plans

MEASURE:Measure the

Current Situation

=1.0

=3.0

IMPROVE: Implement Solutions &

Evaluate Results

CONTROL: Standardize & Make Future

Plans

Next Section: Case Study


Background

A commercial service provider of anatomic pathology services is facing increased turnaround times for reporting to client physicians

The commercial service provider would like to know where and how to best improve the existing process

The site director, medical director and director of the anatomic pathology subdivision sponsor a value-stream map exercise to identify opportunities for TAT improvements

Develop Value Stream Map

Identify Kaizen Opportunities

Create Future State Map

Implement kaizen opportunities


Project Charter - Kaizen Week

Business Case: Opportunity Statement:

Physicians complain that TAT for commercial anatomic pathology reports takes too long and is unpredictable. This results in lost goodwill.

Improve work flow; Reduce Defect.

Defect Definition: A “workload” that is not in the hands of the pathologist within one business day.

Goal Statement: Project Scope:

Reduce TAT from 2 days to 1 day. Process Start Point: Specimen is delivered by transportation to accessioning in the accessioning room.

Process End Point: Workload is handed off to transportation (off-site) or handed to pathologist for review (on-site).


Generic Process Map and Project Scope

GenericFlowChart

Start AccessionCreateLabel

Gross

CutMount

Embed

StainDistributeEnd

High Level Work Flow

Project Scope: From accession to distribution of tissue stains to pathologists.


Process Performance - Example Before

The process is in control, but has high variability. Be aware that a process can actually become more

erratic if it is not in control before you start the Kaizen eventsNote: Example data

Observation

Indiv

idual V

alu

e

464136312621161161

26

24

22

20

18

16

14

12

_X=21.01

UCL=25.11

LCL=16.90

12

Control ChartPast 50 days


Key Information

Defect Rate

TAT for total process

Cycle Time for each key process (CT = TAT for process step).

Value Added Time for each key process (VAT).

Non-Value Added Time for each key process (NVAT).

Transportation/Walking Distance.

Work-In-Progress (Work not yet performed).

Data generated through observations and validated by time stamps generated by IT system.

All shifts included.

Duration of data gathering: two weeks.


Current State Map

Value Stream Map represents the current flow of tissue specimensand information through the process.

Customer Demand:

TAT = 1 day

Physician

Accession

Total C/T = 60 minutesValue Add: 1 minutesNVA = 59 minutesCustom Data1: 12 '

Distribute

Total C/T = 300 minutesValue Add: 0 minutesNVA = 300 minutes

Service Provider

Schedule Work

Patient provides specimen

Information

1 minutes

60 minutes

3 minutes

60 minutes

300 minutes 30 minutes

300 minutes

15 minutes

180 minutes

5 minutes

50 minutes

5 minutes 5 minutes

300 minutes Lead Time = 1260 minutes

VA / T = 364 minutes

NVA = 896 minutes

WIP = 960 minutes

PCE = 28.9%

Traveled = 1542 feet

59 minutes 57 minutes 0 minutes 270 minutes 165 minutes 45 minutes 0 minutes 0 minutes 300 minutes

12 feet 200 feet 200 feet 500 feet 10 feet 10 feet 10 feet 600 feetTravel

Daily Drop Off by Courier Service

Stain


Cut


Gross


Build Cassette


Embed


Create Workload


Supervisor

Supervisor

Distribution topathologist

Monthly

Weekly

WeeklyWeekly

Daily

DailyDaily

Daily

Occasionally

Oven


Prep.


OrderingPhysician


Summary Data - Time related data

Total Turnaround Time = 21 hours (1,260 Minutes)

Value Added Time = 6 hours (364 minutes including oven)

Percent Value Added Time = 28.9%

Traveled Distance = 1,542 feet

TAT = 1260 minutes (= 21 hours)

Value Added Time = 364 minutes (= 6 hours)

Non Value Added = 896 minutes (= 15 hours)

Work In Progress = 960 minutes (= 16 hours)

Percent Value Added Time = 28.9%

Traveled Distance = 1542 feet

Defect Rate = < 1%


Summary Data - Work Balancing Graph

Work Balancing Graph shows the biggest bottlenecks and depicts value added vs. non-value added times

Longest non-value added times: Distribution Embedding Accessioning Build Cassette

Work Balancing

60 m.1 m.

59 m.

60 m.3 m.

57 m.

300 m.300 m.

0 m.

300 m.30 m.

270 m.

180 m.15 m.

165 m.

50 m.5 m.

45 m.

5 m.5 m.0 m.

5 m.5 m.0 m.

300 m.0 m.

300 m.

Takt Time 2.25 m.TotalVA

NVA

Constraint Constraint


Lost in “Spaghetti World” (Womack)

Accessoning

Acce

ssion

ing

Workload/Distribute

Cassette Building

Gross

Ovens

Gross

Gross

Cut

Workspace

Workspace

Embed

Cove

r slip

Cut/Embed

Cover Slip

Prep

are S

lides

Storage

Fridge

Carrier Drop Off

Accession Label Print

Label Print Gross Gross Cover slip

Oven Distributionto pathologists

Start

End


Embed(30 per hour)

Cut(60 per hour)

Cut

EMBED

EMBED

Embed

Classical Work Set up - Linear Lean Set Up - Cell Design

Summary Data - Work Flow Design

60 units

30 units

Cut

30 units

Work Cell (U shaped)


Summary of Key Issues

Accessioning

Schedule of workers not synchronized with schedule of drop offs.

Drop off starts at 5:00 p.m., but real accessioning doesn’t start before 8:00 a.m.

No supervision in the accessioning area (7:00 p.m. - 3:00 a.m. shift).

No procedure for hand-off to cassette building.

Cassette Building Printer for labels in room different from computer that generates

the labels.

Long wait times for tissue specimens due to delays in accessioning.

Unpredictable inputs.


Summary of Key Issues (cont.)

Grossing Grossing in different room from Cassette Building.

No synchronized flow from accession cassette building grossing.

Oven technology old/no productive maintenance schedule/frequent break downs.

Preference for large batch sizes rather than scheduled shorter runs of smaller batch sizes.

No “First-In-First-Out!



Embed/Cut/Mount/Stain/Cover Slip Schedule of workers not synchronized with schedule of grossing

(both 1st and 2nd shift).

First batch of tissues comes out of oven at 4:00 p.m., but shift starts at 7:00 a.m.; real work does not start before 7:30 a.m. due to set up time long wait time.

No cell design for embed/cut/mount/stain.

Little supervision from existing supervisors (technical rather than managerial expertise; time breaks are not synchronized with flow of inputs from grossing).



Distribution to Physician Distribution assistant works in a room that is different from

Embed/Cut/Stain.

Reporting structure of assistant not clear.

No full coverage of two shifts (1 FTE for two shifts).

Physician offices in different locations.

Physicians release reports in batches.

Other No timely reporting (one week after the fact).

Employee morale is low.

Communication issues about re-stains between pathologists and Histotechs when pathologists are in a different building.


Identify Kaizen Interventions

Problem: How will you prioritize the kaizen interventions?

Answer: Use a toolkit based on theory of constraints, lean principles and continuous quality improvement techniques.

Value StreamManagement

Lean Principles

Six Sigma Q

uality

Theo

ry o

f Con

stra

ints


Identify and Use The Right Tool

Analysis and Diagnostics – Identify Improvement Opportunities

Improvement – Taking Action and Achieving Results

Sustaining – Build upon Improvements and make it a new way of life.

If You Only Have A Hammer….If You Only Have A Hammer….Everything Will Look Like A NailEverything Will Look Like A Nail


The process is capable of meeting your clients’ specifications (six sigma).

The report is available when needed.

The process has the right levels of capacity.

Only Perform Value Added Steps (Remove Waste)

Create Flow Where Possible (Cell Design)

Create Pull (Let your customer pull production)

Continuously improve your process (Manage towards Perfection)

Goals That Help You Identify The Right Tools


Identify Kaizen Interventions

One Week Kaizen event addressed the areas showing the “Kaizen Burst” clouds.

Many “root causes” can be identified during Value Stream Mapping exercise, but some other issues will be detected during the individual kaizen events.

Customer Demand:

TAT = 1 day

Physician

Accession


Distribute


Service Provider

Schedule Work


Information

1 minutes

60 minutes

3 minutes

60 minutes


300 minutes

15 minutes

180 minutes

5 minutes

50 minutes

5 minutes 5 minutes



NVA = 896 minutes

WIP = 960 minutes

PCE = 28.9%


59 minutes 57 minutes 0 minutes 270 minutes 165 minutes 45 minutes 0 minutes 0 minutes 300 minutes

12 feet 200 feet 200 feet 500 feet 10 feet 10 feet 10 feet 600 feetTravel


Stain


Cut


Gross


Build Cassette


Embed


Create Workload


Supervisor

Supervisor


Monthly

Weekly

WeeklyWeekly

Daily

DailyDaily

Daily

Occasionally

Kaizen Intervention

Kaizen Intervention

Kaizen Intervention

Kaizen Intervention

Kaizen Intervention

Oven


Prep.


OrderingPhysician

Kaizen Intervention


Summary of Key Interventions

Instituted First-In-First-Out (FIFO - continuous flow).

More frequent runs of oven at set intervals (one-piece flow/small batches).

Moved distribution into histology room (remove unnecessary transportation).

Conducted 5S exercise in preparation of work cells (continuous flow).

Created window to enable hand off between accession and grossing (remove unnecessary transportation).

Created work cell for embed/cut/mount/stain/cover slip (one-piece flow/small batches, worker flexibility, reduce unnecessary movements).

Large tissues not processed in cell (work balance).


Summary of Key Interventions (cont.)

Created daily reporting for each function (visual workplace).

Created daily reporting at noon to determine what percentage of specimens has not been distributed (standardized work).

Synchronized schedules for all functions (one-piece flow/small batches).

Clarified roles and responsibilities for all functions (standardized work).

Synchronized schedules of delivery to off-site facility with flow of specimens (one-piece flow/small batches).

Created schedule whereby physician releases one report at a time (one-piece flow)

Created “hot line” for physicians to call in with requests.


Summary of Lean Tools

Standard Work

Visual Workplace

Teamwork

Make defects visible

5S

Work Cell

Worker Flexibility

Work Schedule

Focused Operation (Factory)


Key Outcomes

Reduced risk of data entry errors in accessioning.

Reduced TAT to 1 day at on-site, 2 days at off site.

Improved employee morale.

Created employee suggestion program to continuously improve the process.


Future State Map

Customer Demand:

TAT = 1 day

Physician

Accession


Distribute

Service Provider

Schedule WorkMonthly


Information

1 minutes


3 minutes

20 minutes

5 minutes

60 minutes

240 minutes

30 minutes

15 minutes

20 minutes

4 minutes



NVA = 127 minutes

WIP = 395 minutes

PCE = 67.8%


4 minutes 17 minutes 0 minutes 60 minutes 0 minutes 30 minutes 5 minutes 1 minutes

12 feet 200 feet 200 feet 3 feet 600 feet 50 feetTravel


Oven


Gross


Build Cassette


Create Workload




Supervisor

Supervisor



Monthly

Daily

DailyDaily

Daily

DailyDaily

Daily

Work cell: Embded/ Cut/Mount/Stain

Daily Report

Daily Report

Daily Report

Daily Report

WorkCell


ReferringPhysicisn

The process was simplified by creating a work cell design for embed/cut/stain/mount/process/prepare for delivery.

WorkCell


8-step process for Kaizen

Events

StartTrain the

TeamPerform

VSM

Evaluate &Control

Changes

Implementthe

changes

PublishFindings

AssignActionItems

PresentFindings

DevelopFSM

End

Process of Conducting Kaizen Events

Developing Future State Map and conducting kaizen events can Become an interactive process.


Kaizen Newspaper

Team: Date: Page:______ of

ItemNo. Description of Problem Counter Measure

PersonResponsible Due Date

DateComplete

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

25% 100%

50% 75%

%Complete

Kaizen / Continuous Improvement Rolling Action Item List

Make sure to conduct follow up meetings (weekly) to ensure the changes become implemented!


Challenges of Sustainability

Histo techs reluctant to change schedules.

Histo techs reluctant to work in work cells (individual work pace vs. team work).

Work cells only work when all three histo techs are present (be aware of sick time, vacation time).

Measurement system requires systematic update and distribution of report at 7:00 a.m. and noon.

Clarification of roles and responsibilities requires culture change.

New flow impacts work schedules of pathologists.

The bottleneck moves!

Continuously manage the value stream and avoid inertia!


Traditional Thinking:

Large batches

Low unit costs

Work at full capacity

Tight Schedules

High WIP Inventories

High level of Specialization

Long Cycle Times

Lean Thinking:

Small batches

N/A

Work at necessary capacity

Flexible Schedules

Low WIP Inventories

Cross-training

Short Cycle Times

Summary: Lean vs. Traditional Thinking


Value Stream Management: A Win-Win

value stream mapping in anatomic pathology

Health & Medicine

value lean

lean value stream map

value stream management

opposite of value

value definedcont

key definitions value

entireprocess stream

lean processes