Lean Thinking - Unlocking the Mysteries to Simplify Work and Improve Quality

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MS. LINNETTE GROVE:  [SLIDE 1 00:00:01]  Hello, everyone, and welcome to the 27th presentation of the Leica Pathology Leaders Webinar Series.

     My name is Linnette Grove.  I'm the IHC specialist for western PA, Western New York, and northern West Virginia for Leica Biosystems.  I will be your host today.

     Our discussion today is entitled "Lean Thinking:  Unlocking the Mysteries to Simplify Work and Improve Quality, presented by Debra Schofield, West Regional Lean Histology Consulting Services Manager for Leica Biosystems. 

     This presentation will take about 45 minutes.  Immediately afterward, we will have 15 minutes to answer questions.  If you have any questions during the presentation, please select Q&A from the menu bar at the top of your screen or send us a chat message.  We will answer all questions at the end of the presentation for everyone to hear. 

     If you're having trouble hearing the presentation, please adjust your volume settings located at the lower right of your Windows Start bar. 

     This webinar is being recorded and will be available for viewing or downloading on our website, PathologyLeaders.com, in about two days. 

     If you are viewing this webinar as a group, please have your group administrator distribute the post-event survey URL to everyone in attendance.  The survey will open in your browser after the event and must be completed to receive the PACE credit. 

     Once you have completed the survey, you will be automatically redirected to a certificate generation page.  Please take note that this link will also be emailed to you later this week.  You will have the survey link within two to three business days, just in case you do not take the survey right after the presentation.

     Also, the CPD credit for UK attendees will be available with the archive.

     At this time, I would like to present our speaker.  Debra Schofield has been involved in the field of clinical laboratory medicine since 1975 and in the diagnostics industry since 1987.  Her current responsibility involves utilization of Lean and Six Sigma tools to support AP laboratories in their efforts to design more effective and efficient work spaces, as well as develop cost-effective processes which streamline workflow, improve employee satisfaction in their work environment, and mitigate the potential for error.  Debra has degrees in biology, chemistry, and medical technology from Pacific Lutheran University.  It is with my pleasure to hand the presentation over to Debra.

DEBRA SCHOFIELD, MT (ASCP):  [SLIDE 2 00:02:59]  Thank you, Linnette.  Hello, everyone, and thank you again for your attendance and interest in this topic.  We're going to do a bit of exploring into the concept of Lean and how it can unlock the path to more simplified and higher-quality work in the anatomical pathology laboratory. 

     [SLIDE 3 00:03:21]  We're going to be discussing three major topics, which include why we're involved in Lean in health care in the first place, what are the fundamentals of Lean, and how do we adapt those fundamental principles to the AP lab?

     [SLIDE 4 00:03:41]  I think that you're probably all familiar with the issues that we face in the AP lab today.  We recognize that these issues exist and the broad effects that they can have on the organization, as well as patients that we serve. 

     Our traditional approaches to fixing these issues in the past has been either through acquiring new technology or cutting budget.  But those approaches are not netting the same benefit they once did.  We need to find a better way.

     [SLIDE 5 00:04:21]  Each day we come into work wanting to do our best possible work.  We don't intentionally make mistakes, and we in the scientific community are always introspective in studying how or why things happen, in an effort to improve and drive decreased error.  So we acknowledge that in AP, there are a significant number of labeling errors that do occur. 

     [SLIDE 6 00:04:45]  At the service-line level, great attention has been paid to the issue of errors in labeling specimens, and studies have been conducted in an effort to identify the root cause as well as the means of mitigating the potential for these errors to occur.

     Control of a specimen begins outside the boundaries of the laboratory.  And when errors occur in the surgical suite, they may or may not be caught during the laboratory accessioning or specimen data entry process.

     [SLIDE 7 00:05:19]  And the focus of attention has been raised at higher levels beyond the individual health care facility.  The Institutes of Medicine have initiated several studies in the last decade, creating a correlation between medical mistakes, resulting deaths, and the financial impact to the health care system.  The cost of medical mistakes, both from an economic and a human perspective, are significant and are no longer being ignored. 

     [SLIDE 8 00:05:50]  And as these studies are conducted, the government weighs in with its own conclusions, which typically come in the form of reduced or denied reimbursement.  Since the early eighties, with government spotlight on healthcare--originating, as some of you may recall, with cytology Pap smears and the evolution of DRGs--the tolerance for health care has narrowed.  And the government has set ever-increasing financial restrictions which, in their view, are employed to drive up quality.

     [SLIDE 9 00:06:23]  And as regulations change, the lawyers follow.  Not only are health care institutions liable, but there has evolved an increasing focus on individual accountability as well.  In this case, mislabeling a sample constituted willful misconduct because the health care worker did not follow the procedure established by their department.  It kind of makes you stop and think.

     [SLIDE 10 00:06:51]  And of course, there is, most importantly, the patient.  That could be your brother.  It could be your son or your nephew.  It could be you.  So this drives us to continually strive to find ways to be better, to find the next higher level of quality.

     [SLIDE 11 00:07:11]  It all begins and ends with quality.  If the quality of laboratory results is questionable, how valuable are they to the patient's diagnosis?  And from a business perspective, any company's survival is dependent, in large part, on their ability to deliver a certain sustained level of quality.

     [SLIDE 12 00:07:35]  So why Lean?  Why now?  If we didn't already have sufficient reason to accelerate process improvement initiatives, we can always look to the trending in reimbursement, or overall the cost of delivering services versus the rate at which we are paid as providers.  There is no question that we have to find new ways to adapt.

     Consider this:  reagent and capital costs only represent approximately 8% to 17% of the total operating budget for your laboratory.  Even if you reduce these costs by 70%--let's say you took them even further.  Let's say you reduced them to zero--you would not significantly close the ever-widening gap that is developing.

     This is where Lean comes in.  Some of you may already be aware of Lean initiatives which are taking place throughout other departments in your organization.  Often, some of the early adopters for this discipline are admitting--the emergency department, radiology, and even dietary.

     [SLIDE 13 00:08:43]  So first, let's explore before we talk specifically about Lean.  We'll talk about what is process improvement.  What is a process, period?  It is simply a series of tasks performed to achieve a given output.  The more steps and/or people that are involved in the series of tasks, the more opportunities for error.  And therefore, given throughput for a process will have an inherent error rate associated with it. 

     Process improvement seeks to streamline processes by eliminating unnecessary steps and error-proofing as many of the remaining steps as possible.  Therefore, process improvement allows us to increase the throughput, while keeping the errors at a minimal level.

     [SLIDE 14 00:09:34]  And Lean is fundamentally a form of process improvement.  [SLIDE 15 00:09:37]  However, it is much more than that.  Lean Six Sigma is a blend of two separate disciplines, and it's defined as a "methodical, systematic approach to addressing quality improvement through minimizing defects and costs by controlling waste and variance in a production process."

     Both seek to remove defects and decrease costs.  Six Sigma looks at variations in a process, thereby creating consistency in the output.  Lean, however, is focused on removing wasteful steps out of the process.  Both are highly disciplined methodologies, with focus on quality.

     [SLIDE 16 00:10:24]  In its most simplistic terms, Lean can be defined this way.  We look at work that should be done, and we look at ways that should not be done. 

     [SLIDE 17 00:10:38]  And as you examine your process, and you determine into which two buckets each of the steps in your process fall, you strive to eliminate the waste out of the process and streamline it, simplify it, and get work done more quickly, more efficiently, and more error-free.

     [SLIDE 18 00:11:01]  So what are these wastes that we're talking about?  Well, the slide says seven wastes, but there is actually a total of eight.  Talent was added probably in the last ten years into this list, and it was added because the talent pool, especially in healthcare disciplines, especially in histology, is declining.  And as that available resource becomes less and less available, it becomes more important--more critical that we focus on utilizing those talented people in the way in which they can be best utilized and not spent doing things that could be either automated or done more effectively in another fashion.

     [SLIDE 19 00:11:54]  So let's look at how these wastes in Lean translate into a laboratory setting.  Transportation speaks to waste that develops as specimens or product, as Lean defines them, move throughout the work process.  So typical examples would be moving samples from room to room, having a workspace layout that requires that multiple transport steps take place in order to get the specimen through all the steps of the process.  Moving equipment, tables, or carts to supplement inadequate workspace--this happens quite often in histology, where you will have a cart on wheels that you pull up next to the embedding bench so that you have that extra additional space that you need, either to provide you storage for supplies that you use, or additional countertop space that's required as you do your work. 

     But all of that additional little table that you're moving around constitutes a waste in terms of transportation and moving it into position and out of the way as you have to move back and forth between your work space and other work that you're doing. 

     Inventory waste in a laboratory shows itself as overstocking of reagents or gloves or Kimwipes or, most notably, slides--stacks and stacks of slides--that may actually represent more like several weeks' inventory, rather than just a week's worth of inventory or a day. 

     Orders build up in accessioning that need to be entered into the computer system.  That's a type of inventory as well.  And access in standing orders--standing orders may have been set a year ago.  Volumes may have changed.  They may have declined.  And without adjustment to the standing order, now all of a sudden, you're creating waste in inventory, because you've got more than you need on hand to do the work that's presenting itself.

     Motion, like transportation, is also movement.  But in this case, motion refers to the movement of the operator themselves.  So having to get up and down from your workbench in order to retrieve supplies or samples from another area of the laboratory will constitute a wasteful motion. 

     If you have a large breach or walk distance in order to complete a process step--let's say between embedding and sectioning is actually another bench where you may do the special staining--it's out of sequence in terms of the work that has to be done, and so you have to move through that space in order to get back and forth between the two parts of the process, which are actually logically connected to one another. 

     Sneakernetting is a little bit of affectionate term I have for anything where you have to get up and run to create a communication link between you and a pathologist, you and someone in accessioning, for instance--anywhere where you're having to communicate because there is a void, either technologically, because there is not a computer, the computer connection, et cetera. 

     Waiting waste represents itself as idle equipment or people.  In other words, work is not sufficiently level-loaded so that everyone who is in different sections of the department have work to do at the same time.  So they're waiting for things to occur.  If there are 124 specimens sitting in accessioning, there is nothing for the people who may be working in the grossing area to do at that point in time, creating idle time for those individuals.

     Specimens that are sitting waiting for external courier transport also represents a wait time waste, as well as any kind of internal transport between departments.

     Overproduction is represented as multiple signatures that may be required, accessioning department making multiple copies of forms before they get moved on into grossing or transcription, duplicate or multiple information system entries, and printing a hard copy of a report when a digital copy is really sufficient.

     Overprocessing, which is closely related but different, may look like batch printing of patient labels or advanced batch printing of slides before they're needed--printing of cassettes, which may or may not get used during grossing; also, in the sectioning area, cutting additional slides, which may or may not get used later on for extra stains that get ordered by the pathologist. 

     All of this has to be evaluated individually, of course--not to say that all of this should be excluded; just areas for consideration. 

     And defect waste is simply that.  It is an error, an omission, or some other mistake that's made--incorrect specimen slide or cassette labeling, rehydrating embedded specimens because they've been processed or overprocessed in the tissue processor, a lost sample, and tissue that gets lost from the slide during staining. 

     And then we've talked already a bit about talent and skill waste.

     [SLIDE 20 00:18:33]  So this is--I like this chart because this actually comes from Toyota and how they think about Lean.  And I think it represents very well pulling together all the principles of Lean and understanding what it's built upon.  So the foundation of the pillars of Lean is the structural framework on which you use all of the Lean tools.  So this creates stability and standardization in the organization. 

     And the primary tools used in this foundation are 5S, which we're going to talk about, TPM, which is actually Total Productive Maintenance--a little bit different meaning for that acronym, but TPM emphasizes proactive and preventative maintenance to maximize the operational efficiency of equipment.  And that's probably used a little bit more in production--other types of production industry.  But it can also be applied in the laboratory in terms of predictive maintenance on equipment, understanding when an instrument may need maintenance before the need actually arises or a condition presents itself, where the instrument fails and creates work stoppage.

     Standard work or standard operations is the third component of the foundation.  And kaizen, or rapid improvement, is the fourth.

     Then central to all of this model is actually respect for people, both within and externally to the organization.  It's very important in a Lean environment, for Lean to succeed, that people be central to every consideration that's made, every change that's made.  It's very important that everyone in the organization who has hands on the work is part of a team that helps build that change, builds that environment for how the work is going to be done in the future.  So there is a great deal of empowerment of individuals.  And most of the best ideas for change in the laboratory come from the people who do the work each and every day. 

     Cross-training is central to Lean as well, so that there can be a flexible movement of workforce resources that are needed, depending upon the volume of work and where they need to be at a particular moment in time to keep work flowing. 

     The concept of hoshin is very important when we're talking about respect for people.  Hoshin is actually what I call policy deployment.  And it captures the strategic goals of the organization.  It strives to get every employee pulling in the same direction at the same time.  It achieves this by aligning the goals of the company, which is the strategy, with the plans of middle management or the tactics and the work that gets performed by all of the employees, which is operations.

     So as people are doing the work, there is an understanding of the strategy and the reason behind why things are being done.  And as it makes more sense, it's done more effectively. 

     Now, to the left on our pillars here are some of the most common resources or tools that we use in Lean.  And they are known as just-in-time resources.  So this is where the concepts of pull and flow come from--task time, which is the heartbeat of your process, heijunka, which is level-loading.  And we're going to be talking quite a bit about that when we get into applying Lean to the AP lab.  But level-loading is critical to smoothing production.

     And then cell design and a couple of other things--single-minute exchange of die, which is really another production term.  We don't use that too much in the laboratory.  It really deals with change over time, so it has more to do with equipment, potentially equipment in your tissue processing area.  But it's not too often used in AP.

     Then on the right-hand side of this diagram, we have jidoka.  And jidoka is the concept of automation with a human touch, or I prefer to call it human-centered automation.  And there's a lot involved in this category, but I would probably say--and we'll get into just a little bit of how that applies to the future of technology in the next slide. 

     But the most commonly used concepts out of this side of pillar are puka yoke, which is error-proofing systems.  An example of error-proofing would be the fact that when you get into your vehicle in the morning, and you the key in the ignition, a couple of error-proofing concepts are that you have to step on the brake, and the car has to be in neutral, or it will not start.  Those two factors are actually a way of error-proofing, to make sure that you can't just turn on the vehicle, and if it were in gear, it would just immediately race forward or backward, potentially causing an accident.  That is a form of error-proofing.  5 Whys and built-in quality are another couple of concepts that we use. 

     And all of these Lean concepts and pillars build up to the ultimate output, which is customer satisfaction.  And in the laboratory, a customer can be several.  You can have the pathologist is your customer, the patient, of course, is your customer, and you can also have other internal and external customers and forms of clinicians and clients that you serve.  And ultimately, business success comes out of this model if well-applied.

     [SLIDE 21 00:25:42]  So let's talk about jidoka for just one moment, because this is an important concept that frequently gets forgotten in the whole concept of Lean.  But it isn't something that your vendor partners have forgotten, because this concept of automation with a human touch is evolving equipment.  You're seeing it come out in terms of automation for IHC, where the instrument is doing more and more of things that used to have to be manually done by the operator are now fully automated.  Tissue processors that have the ability to tell you when alcohols need to be exchanged out, because they keep track of it instead of you having to manually keep track of it. 

     So this is really the concept--this and automation, which is a concept of jidoka, are in the works behind the scenes with your vendor partners and developing the future of automation, where more and more, you're going to see AP equipment come out with less human interventions necessary to make it do its basic functionality.  So it's thinking machines.

     [SLIDE 22 00:27:04]  So let's talk about the five key Six Sigma--Lean Six Sigma principles.  First, understanding Lean, we go all the way back to the origin, which is really the patient.  And we understand that value is created.  The only way value is recognized, let me say, is from the customer's perspective.  If the customer was able to biopsy that spot on their arm themselves, put it onto a slide, and hand it to a pathologist and ask him, do I have cancer, and get an answer, that's exactly what they would do. 

     But since they're not able to do that, we're all employed.  And in light of that, we need to understand that everything that we do with that tissue specimen once it's taken from a patient has to be something that they would be willing to pay for because they can't do it themselves.  So fundamentally, value is created when the product is--the fit, form, and function of that tissue product or tissue specimen is changed.

     So when we think about everything that happens in histology, from the time it hits the doorway until it's in the hands of the pathologist, the steps that really change the form or function are grossing, tissue processing, embedding, sectioning, and staining.  Everything else that transpires may be absolutely necessary, but it is a form of waste.  It may be necessary waste, but it is a form of waste.  And it doesn't add value that the customer would be willing to pay for.

     Second key principle in Lean Six Sigma is pull.  And this is the concept that work is synchronized and designed to match demand.  And most things in the AP lab are very much a pull system.  There isn't any way to create work before there's a demand for it.  Tissue specimens are presented and actually work through the system in a pull environment. 

     However, inventory, on the other hand, is most often very much a push.  If you look at most labs, we're overstocked with supplies.  And that is kind of a push inventory system, where we think we're going to need it, but it may be way over the volume that's actually required.

     Flow is so critical, it's mentioned three times here.  This is where level loading comes in.  It's all about the concept of continuous, and ultimately single-piece, flow.  So it's getting to your lowest possible inventory of product and supplies and having those at point of use and just in time, eliminating large batches, getting to your smallest batch size. 

     And Lean is not a one-time thing that we do.  Lean really is a culture that we develop in the organization for continuous improvement.  It's about systematic change and renewal.  And it's about bringing about innovation to continuously drive out costs and reduce the cycle time.

     And fifth and final is something that's a little bit foreign to us.  We all know that, as we get a job, we have a job description.  And from the perspective of Lean, job descriptions come at the very end of designing the process.  So in other words, even though I may be a histotech, and I'm assigned to this particular bench, and this is what I know, and this is what I do, in Lean, the roles actually are defined by how the best possible process works and then what do people need to do to complement that process and make it work most effectively.

     So it's a little bit different approach to understand roles and responsibility in the laboratory, because it does flow out of whatever process you have designed.

     [SLIDE 23 00:31:47]  Lean tools that we use--level-loading, for one--we're going to be talking about this with regards to tissue processors and also embedding and sectioning.  It's about getting away from badging and having a consistent, even flow of work through the department.

     Standard work is not just about standard operating procedures in your procedure manual, because those are important.  But standard goes deeper than that.  It actually defines what the work space looks like, what's contained in it, and how people do that particular work.

     Standard work is well-represented, and if you've ever been to a Kinko's or what are now called FedEx Office stores, if you walk in, and you go to use one of their copiers, you'll see that, at the work space, they have taped off everything in terms of where a stapler goes, where paper clips reside, where extra paper is located.  Everything is labeled.  And that is a standard workbench.  Every single copier that you walk up to in a FedEx Office store is going to have that very same presentation.  And that is a model of standard work.

     Layout analysis is understanding how your laboratory is set up in relationship to the process steps.  And is that layout consistent with the sequence of steps that you have to go through to get the work done each day.  Is there anything that could consolidate the footprint of the work that has to be done, so that you have less transportation, less motion.  So it's very much, I would say, key to making sure that you have the most efficient laboratory process possible.

     Layout is, as I said, critical to both transportation and motion, which can equate to an impact of 25% in terms of productivity--so very critical Lean tool.

     5S, which we'll go into some detail in in a moment, visual management, which was the Kinko's example--those are some types of visual management, and we'll be talking about that in a moment; and then error-proofing. 

     [SLIDE 24 00:34:25]  [SLIDE 25 00:34:27]  So where do we start?  And Dr. Harry from the Six Sigma Management Institute says we have a bit of homework that we have to do first to first understand our entire process before we embark on ways to fix it.  And it's okay that we don't know everything about our process.  We're buried in it every day in so much detail and so much work that we barely have time to come up for air and really examine what we're doing from a more analytical perspective.

     But this is an important thing to understand.  We really don't know what we don't know.  We can't act on what we don't know.  And we won't know until we search, and we won't search if we don't question, and we won't question what we don't measure.  And unfortunately, in the laboratory, we can be very data-poor.  AP systems, LIS systems, have not consistently helped us in providing good data in order to make good decisions about our process. 

     And so if we look at the end of this quote first, that's where we have to begin.  We have to begin by figuring out how we're going to measure our work, what kind of metrics are we going to set up to establish what our success is and how we're going to make change in the laboratory.

     And most importantly, as we make changes, how has it impacted the metrics?  If we have, let's say for instance, a metric where we want 90% of our slides out to the pathologist by 9:00 in the morning, and we change something in the system, and it reduces our output consistently down to 83%--we may have had a gut feeling that that was the right way to do it, but having the metric tells us that no, that's not the way to do it.  So measuring and understanding our system first is critical to success. 

     [SLIDE 26 00:34:37]  The way I do that when I go into a lab to help them set up baseline metrics is to do a value stream analysis. 

     [SLIDE 27 00:36:47]  Now, this is an I-Chart--not important to read.  But just understand that this is the whole flow of work, flow of information and communication, and movement of people and product through the process of going through core histology.

     Where we have red inventory points are a kind of alert that hey, there's a lot of product--in this case, tissue samples that are building up at these particular points.  Here, we've got 124 cases that are going into specimen receipt and haven't even been accessioned yet.  We've got an 18-hour window or wait point between specimen receipt and accessioning, and so on and so forth. 

     So this is a way of identifying and quickly understanding gee, these are some--with these kaizen bursts, this is an alert point.  This is where I need to look kind of dig in.  And after we understand where all the stopping points or concern points are for our laboratory, then we can prioritize those and decide which ones we want to tackle and take on first.

     [SLIDE 28 00:38:00]  So let's talk about this principle of flow, because I've been talking about level-loading your tissue processors, for instance, and what does that mean.  It doesn't make a lot of sense at this point.  So let's take a look at a typical poor histology workflow through tissue processing, embedding, and sectioning.  So this lab has three tissue processors.  They run a pretty traditional overnight run on two of them for large tissues and breast, fatty tissues, that kind of thing.  And then their third tissue processor is doing one short biopsy run in the middle of the morning.  And then it does a longer, six-hour run for smaller specimens later in the day.  And then you can see the workflow that ensues from there and what these eight techs are doing and how they're impacted as work comes off of the tissue processors. 

     [SLIDE 29 00:38:59]  So hold that thought for a moment, and let's talk about what we can do with regards to this workflow and how it looks from a different perspective.

     So essentially, at 4:30 in the morning, they're taking off, on average, 350 cassettes off the tissue processor.  And by 11:00 in the morning, they've got that 350 processed through everything and assembled and into the hands of a pathologist. 

     The small run that comes off at midnight is only about 50 samples, and it's done very quickly thereafter.  At peak hours of production, they're at about nine FTEs doing all of this work. 

     [SLIDE 30 00:39:43]  So let's look at this in a slightly different way.  What about if, the day before, we did something just a little bit different with those 350 cassettes that were created? 

     We take the biopsy, or the smalls, and we put them into three successive biopsy runs, two-hour biopsy runs throughout the day, and leave our midnight run in place as well.  The following morning, we have 284 cases--or cassettes, rather, instead of the 350 that we had previously.  Now, from a Lean perspective, this is not complete level-loading.  But it is significantly better than what we had previously.  And it requires fewer hands on deck to get all this work done by the time that they've prescribed to have cases out to the pathologist. 

     [SLIDE 31 00:40:41]  And how that impacts the work is shown in this tissue processor loading model.  So we still have two overnight runs that are being performed in the lab, but we've got two six-hour runs now, and we've got multiple two-hour biopsy runs going.  So this lab had always been operating somewhere around 18 hours a day.  But now, cases are coming out in smaller quantities.  It's requiring less resource to be able to get those cases out to the pathologist.  And you see a good staggered effect of the work throughout the day. 

     Now, all eight technologists are still very busy people.  It's just that they are now freed up to be able to work in other areas in terms of the increased IHC work that's being done in the laboratory.  So the resources are still intact and deployed for useful purpose.  But they're able to take attention to some of that other work instead of being consumed with such large quantities coming off the tissue processor for H&E for initial case read. 

     [SLIDE 32 00:42:08]  Another way of looking at this is when we look at embedding and microtomy; what's the impact of these large runs that are coming off the processor, and how people are working at the embedding bench and the sectioning table.

     A lot of times, just the sheer volume of work coming off of a tissue processor gets everyone in the laboratory working on embedding those cases before they even start sectioning.  And if that's the approach that's taken, we know from studies that embedding is about two to three times faster than sectioning those blocks.

     And so if you think that, at 4:30 in the morning, you've got three people embedding for an hour before anybody starts sectioning, they've already created six to nine hours of work for one sectioning person. 

     So with that in mind, and understanding the pace of that work, then like you've now loaded the tissue processor, you would want to do something similar with embedding and sectioning where you stagger that labor.  And maybe after three people come in and start embedding for a half an hour, and then two of them peel off and start sectioning, you're going to see a much better flow of work through sectioning.  You'll see slides getting onto the stainer earlier and into case assembly and out to the pathologist.

     [SLIDE 33 00:43:50]  This kind of model also holds true in IHC staining.  And this is a pretty traditional way that IHC has been done for years and years, even before advanced staining equipment was available.  So workloads would be pulled.  It may be three or four times a day at 9:00, 12:00, 2:00, and 5:00, just before they left.  And then IHC runs would be set up as well for three times a day.  And the work that would be coming off the work list between 9:00 and 2:00 would go on to the latest run.  That coming on work list between 2:00 and 5:00 would go on to the first run of the day.  And then anything that was on a work list after 5:00 and before 9:00 would go onto that midmorning run.  And this was a pretty traditional way of batching IHC. 

     However, the technology exists today to be able to actually do work on demand.  And as slides are cut for a case for IHC, it's pretty simple to put them onto the stainer the case at a time and get that work through in a continuous flow pattern as well.

     [SLIDE 34 00:45:23]  Now, I want to talk just briefly about 5S and understanding the importance of 5S.  And this is why we care about it.  We walk into the lab every day, and we tune out the clutter that surrounds us.  We dig into our work that has to be done, and we think little about the stuff that gets in our way or has to be moved so that we can open the cabinet to get something out or causes a tripping hazard as we go about tending to the tissue processors.

     However, environmental noise is actually distracting.  It decreases productivity, and it does increase the potential for an error to occur.  The more we have to visually sift through in order to see the important things, the longer it takes to see those things, and the more likely it is that we will miss something important.

     [SLIDE 35 00:46:09]  So what is 5S?  Well, it is an orderly process that systematically delivers and maintains a clean, orderly, and productive work place.  It's one of the key elements, as we talked about in the beginning--foundational elements of Lean.  It's not housekeeping.  It's a little bit like that, but it's really not housekeeping.  It is a fundamental discipline that helps ensure the ongoing structure of a Lean environment.  And it is true that, if you do the small things well, the bigger ones will fall into place more easily.  We develop a culture of 5S as we lay the foundation of Lean. 

     [SLIDE 36 00:46:50]  So what are the five S's?  The first thing we do is we simplify.  We clearly distinguish between what we need or what's necessary and what's not, and we dispose of or relocate the unnecessary items.

     We straighten things.  We organize the necessary items so that they can be used and re-inventoried quickly.  We scrub or clean the floors, the equipment, the furniture in all areas of the workplace.  Everybody likes to work with clean equipment. 

     And we stabilize that 5S system, and we maintain and improve the standards that we built in the first three S's.  And then finally, we sustain that model by achieving a discipline or a habit of properly maintaining the 5S procedures.

     [SLIDE 37 00:47:42]  So let's start with the place we can all relate to, our office or desk space.  It really becomes a collection zone for all things important or in question or simply because no one knows who else should handle it, so it ends up on your desk.  As this problem grows--and I've been guilty of it myself--people will start putting things on your chair, because it's the only space they can be sure you will see when you come back into your office.

     [SLIDE 38 00:48:17]  In inventory, we see 5S play out in a much more organized inventory space, much easier to find things, a place for everything, and everything in its place.  5S eliminates the space that's traveled to find or obtain items.  And it also eliminates the time lost looking for things. 

     Visual management allows you to walk into a work area and easily assess the situation.  [SLIDE 39 00:48:49]  And that's what we're going to talk about next. 

     [SLIDE 40 00:48:54]  So which sign is easier to understand?  If you're headed 70 miles an hour down the freeway, and you're coming up on a curve, wouldn't you rather see the sign on the right than the sign on the left?  And visual management works to reduce the variation in understanding directions, and it can reduce the amount of time spent trying to comprehend a task.  And that's why we put visual management tools in place.

     [SLIDE 41 00:49:20]  We talked about how this plays out at FedEx Office.  And you can do the very same thing in the laboratory by shadowing or taping, by color coding, and by creating a Kanban inventory system so that, when you walk up to your work space in sectioning, you'll know immediately if something is missing.  You'll know if you have enough slides for the day, or if you need before you even sit down.  You'll know if you have all the tools that you need, et cetera.

     [SLIDE 42 00:49:48]  And color-coding is all around us.  Colored cassettes and slides tell us and signal to us the origin or priority of the case.  We use colored pens and pieces of paper in tissue blocks to identify who embedded it or signal some other activity that needs to take place downstream in sectioning. 

     [SLIDE 43 00:50:10]  And this was kind of a clever way that--I took pictures of it, a customer account--of a way that they had a visual cue for their inventory.  Instead of printing labels and putting on everything, they actually took pictures of the inside of their cupboards and then put them inside plastic sleeves, so that they could quickly tell what was inside the cabinet if they needed what was in there.  And then when they needed to bring it back, they would know exactly where it needed to be restocked.

     [SLIDE 44 00:50:43]  And proof of this was once you opened the cabinet, you could see the effectiveness of their system, because everything was exactly where it should be, based on the outside cabinet label.

     [SLIDE 45 00:50:56]  Kanban systems for managing IHC QC inventory can be very helpful.  In this case, this Kanban system was set up so that there was a notation.  The 2 indicates that two slides are the minimum inventory, and ten are what are needed for a two-week maximum-length inventory for this particular stain.  Once that inventory slide is reached, it goes into a replenishment bin, and that goes into cutting.  And then just based on that visual signal, the person who's cutting IHC QC knows exactly how many slides--in this case, 20--need to be cut for that particular stain. 

     [SLIDE 46 00:51:48]  So how does all this play out in histology?  In a real-life example of a histology redesign project, these were the results of going through 5S laboratory layout redesign, level-loading their work.  Their reduced average routine surgical turnaround time dropped by 58%, from 48 hours down to 20.  They reduced their average biopsy turnaround time by 33%, from 24 hours down to 16.  And they reduced their overtime by 72%, which had a very positive impact on morale.  So the concepts of Lean do work very effectively in histology to help improve quality, as well as turnaround time and deliverables out of your department. 

     [SLIDE 47 00:52:45]  So, in summary, what are we striving for?  We're really looking for the right combination of people, process, product, and performance, so that we can achieve the highest quality, adopt best practice, and create the ideal workplace.

     [SLIDE 48 00:53:04]  And with that I will open it up to questions.  Thank you all for your attention.

MS. GROVE:  Thank you, Debra, for a great presentation.  So this concludes the presentation portion of this event.  Many thanks for listening.  I hope the presentation was as interesting and helpful to your work. 

     We've received several questions for you, Debra.  If you have a specific question for your lab, and you would like to take advantage of the live Q&A session, please click on the Q&A button at the top of your screen to initiate an instant chat session.  If your question is not answered within the remaining time, please send an email to PathologyLeaders@LeicaBiosystems.com, and you will receive a response. 

     So for the questions, Debra, what is the easiest thing that we can do in the lab that does not cost us any money?

MS. SCHOFIELD:  I would have to say that I would probably start with the foundational elements of Lean, which we talked about 5S was one of those critical elements.  5S has a huge impact on reducing environmental noise, and therefore it also, in turn, reduces error potential.  And hand-in-hand with that would be the elimination of batching, or at least drastic reduction of batching and going to a level-loaded environment.

     And sometimes, 5S is difficult, because it's like an elephant.  You walk in, and there's so much to do that you don't know where to begin.  And the answer really is to just start with one piece at a time.  Take one drawer, one cupboard, and tackle that one day when you have the time to do it and move on incrementally.  If the whole team is working toward that end, you can achieve 5S.  It does take some time. 

     But most importantly, I think, to impacting the workflow and getting cases through smoothly is figuring out, first, ways to level-load in tissue sectioning and embedding, as we discussed, and then the more difficult level-loading with tissue processing.  I think you'll get your greatest impact, and it's not going to cost you any money to do that.

MS. GROVE:  Excellent.  So we have our second question:  how do you go improving a lab that is very old and really needs to be remodeled, but there's no budget for new cabinets and such?

MS. SCHOFIELD:  Okay, well, in keeping with the idea of laboratory layout being important to impacting about 25% of your productivity, I would say first, tearing down walls or removing anything is going to cost money, so you need to avoid that.    

     Actually, labs are designed such that a lot of times, there are a lot of separate or individual rooms that activity takes place in.  So I would lay out a design or floor plan of a lab, and I would map out your process, the order in which things occur.  And it's always consistent, especially in grossing, tissue processing, embedding, sectioning, et cetera.  And then I would look at the rooms that you have available to work in or the space that you have.  And then at least put the order of the process and sequence with one another so that you reduce as much transportation and motion time as possible. 

     Then in older laboratories, where you do have this kind of structure, and you've got so many walls and drawers and doors and of cabinets that aren't big enough, I would remove cabinet doors, and I would remove--I would actually remove as many of the doors as possible on those cabinets, freeing that up to be able to access things more quickly. 

     So other than that, you start getting into major redesign projects in older laboratories, which can be extremely expensive.  So that would be my suggestion there.

MS. GROVE:  Excellent, excellent.  We have another question from one of our participants.  How have you worked through pathologists resistant to histology workflow changes?  Your graphs on workload are spot-on with the issues that they faced in their lab.  But changes on level-loading were not accepted by the pathology group--risky for their workflow.

MS. SCHOFIELD:  Okay.  Well, that is a little bit more challenging, and I can certainly understand the concern.  What we have to focus on in histology is what we can control.  And everything from the time a specimen hits the door until it goes into a folder and goes down the hall to the pathologist, is really our domain and our expertise to work through.  And yes, consultation with pathologists on optimizing stain quality or tissue processing time goes hand-in-hand, and there has to be some discussion around that and some agreement.

     But for the most part, even if you can't get past the hurdle of the tissue processing issue, you can certainly level-load at many other places in the process, most notably at embedding and sectioning. 

     And I would say 90% of the laboratories that I'm going into are doing this work as batching work.  Everybody embeds until all of the cassettes are embedded.  And then everybody sections until everything is completed there.  So if all you can touch right now is embedding and sectioning, you'll still have a dramatic impact on your workload.  And maybe proving that out there will open some interest in taking a further look at tissue processing.

MS. GROVE:  Excellent.  Thank you again, Debra.  Unfortunately, this is all the time we have.  When exiting the presentation, a short survey will pop up on your screen.  For North American participants, - - will update CEU credit.  Please complete the survey.

     Upon completion of the survey, your browser will automatically redirect you to a certificate generation page.  The credentialing body is ASCLS and PACE. 

     [SLIDE 49 01:00:17]  Also, for people attending as a group, please have your group administrator distribute the post-event survey link to everyone in attendance.  URL is above pop-up.

     Again, this URL will be emailed to everyone who registered later this week.  Usually, it takes about two or three days.  The survey must be completed to receive the PACE credit.

     Please mark your calendars for the next webinar in our Pathology Leaders series.  On May 14th, we have "From Diagnosis to Treatment — The Story of a Breast Cancer Patient, Part 4 of 4, Molecular, E-pathology, and Post Screening," featuring Dr. Thomas Decker. 

     June 25th, we have "IHC Workup for Carcinoma of Unknown Origin," featuring Dr. Regan Fulton.  You can register for these webinars and find more information at PathologyLeaders.com.

     Again, the webinar will be available on our website shortly.  Have a great day, and thank you again for participating in today's webinar.

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