workflow consulting for the histology lab, perspectives on safety and efficiency

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Make Better, More Informed Decisions

One lab can change a patient’s life forever

J. Hylton Surrett, MBA, MHA, LSSMBB

Workflow Consulting Solutions

Ventana Medical Systems, Inc.

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Objectives

Workshop objectives:

1. Review some of the ever evolving challenges in Histology operations and safety

2. Review several examples of typical operational issues as seen through a lean perspective

3. Review a few basic tools and how they impact patient safety, chain of custody and case integrity

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Agenda

• AP industry challenges • See the AP lab through the eyes of a lean

practitioner • What can you start focusing on today• Closing remarks • Open Q&A discussion

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Key challenges for AP labs

• Histology is still a very manual process and therefore hard to scale without adding staff

• Productive plateaus will exist throughout the process since human ability will set both the pace for production but also are the error prevention safety net

• Reducing the number of manual steps and interventions in the histology process is critical to greater efficiency and safety

• Determining the balance between the aspects of histology that are and should be “art” and what should be “automated”

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The AP lab is challenging

One data point from a 2-week study in histology 1

– Close to 30% of cases had manual rework totaling 159 hours or 1.3 FTEs

– 89% of defects were made in the analytic phase

– Approx. 1.5% misidentification rate, 67% of those in slide labeling

– All misidentifications would have been addressed by an integrated identification system

Typical savings found in service businesses 2

– 30–60% reductions in cost (over time)– Cycle time improvements of up to 50%– Capacity recapture of 20% (with no additional

staff)

1 Am J Clin Pathol 2007; 128 p423

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George Group results, Lean Six Sigma for Service

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NEJM Study shows cost of medical error is greater than $500,000

– 1,452 closed claims– 73% that involved medical error received compensation– Average compensation: $521,560– Administrative costs: $52,521-$112,968

Source: New England Journal of Medicine: http://www.nejm.org/doi/full/10.1056/NEJMsa054479#t=articleBackground

A medical error averages >$500,000

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Why are lean approaches necessary?

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Patient case integrityOne study showed that the average AP lab helps 93 patients per day

If One patient becomes 8 Artifacts…thats 744 discrete items every day and 186,000 A

YEAR!

How do we ensure every case’s integrity?

– How many times is each item handled by the lab staff?

– How do we know where all the items are?

– How do we know who did the work and when?

– How do you know when something is lost?Plan A market research study

2,100 lab study, average of 24,000 cases per year, 152M to 330M H&E per year

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Labs battle human error because of the consequences for patients

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Who are we as lean practitioners?

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Lean workflow

•Quality

–Error Reduction

–Consistent results

–Continuous improvement

•Productivity

–Faster turnaround times

–Higher testing capacity

–Streamlined workflow

•Cost Reduction

–Reduce wasteful activities

–Balance workload demands

–Integration and adoption of technology

•Lab Design/Redesign

–Integrate Lean workflow principles

–Increase efficiency by design

–Automate good workflow practices

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Ventana workflow locations

North America

Well over +250 different engagement types ranging from Full Laboratory Workflow assessments to

Targeted Solutions Internationally12

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Increase efficiency

Seamless alignment of automated solutions improves safety and reduces costs.

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See the lab through the eyes of a

Lean practitioner…

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What a lean practitioner sees…..

Many people moving work along in non-linear patterns

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What a lean practitioner sees...

Batch Accessioning where errors may not be caught…

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Batch Cassette Marking and Verification where same tissue types follow

each other

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Batching results with potential for mix-ups

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Manual documentation reduces efficiency

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Illegible Identifiers …Smudged cassettes

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Excessive & Illegible handwriting

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Mismatched specimen and cassettes

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Mislabeled slides lead to errors and rework

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Interruptions may cause mismatching

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Sorting Through MaterialsWhat a lean practitioner sees...

Slides labeled up to 3 times prior to reaching the MD

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So what can I focus on today to address these issues in our lab?

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• Single Piece Flow

• Reducing Touches

• 5s & Visual Controls

• Poka yoke

• Barcoding

AP lab improvement via basic lean principles & enabling technologies

Eliminate Waste

– Errors

– Overproduction

– Wait Time

– Transportation

– Rework

– Inventory

– Motion

– Unrealized Talents

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Single piece flow error rate prevention & technology

An integrated software

solution can help to

prevent & help

eliminate these errors.

Single Piece Flow

Accessioning reduced

slide labeling errors by

<75%

QP094 – Mislabeling Rate of Specimens, Blocks, and Slides in Surgical Pathology 28

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Single piece flowConfidence at each step means free to move forward faster• Improve throughput and turn over time

- 10 to 30% increase

• Create capacity to grow the business by uncovering more productivity

• Less need for scheduled or unexpected over-time

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VANTAGE rework reductionProcess safeguards reduce mistakes and any rework they create

Total annual savings of $298,195

$174,613Data

capture

savings

26%Turnaround

time

$51,090Overtime

savings

$63,492Bar coding

savings

Workflow Consulting Case Study = Reference Lab

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Primary staining without automation

Place basket

into oven

Load basket

on

coverslipper

& start

Unload

basket from

coverslipper

Move

slides to

archive

drawer

Retrieve

& label

slide

Unload

basket from

stainer

Confidential and Proprietary Information

Move slide

to warmer

Place slide

into basket

Travel to

oven

Remove

basket from

oven

Load basket

on stainer &

start

Slide is stained

Slide drying

Move slides

from basket

to folder

Travel to

bench

Travel to

oven

Travel to

stainer

Travel to

bench

Travel to

stainer

Travel to

coverslipper

Travel to

bench

Slide is

coverslipped

Travel to

coverslipper

Travel to

slide sorting

area

Mount tissue

on slide

Dry

Is load

position

occupied?

No

Place basket

next to

stainer

Travel to

bench

Yes

Is basket

in unload

position?

Travel to

benchContinue

other work

Continue

other work

No

Stain

Type of

coverslipping

Automated

Manual Travel to

manual

station

Wait for

cover-

slipper to

complete

run

Is coverslipper

run complete?

Yes

No

Remove slide

from basket

Apply

coverslip

Place slide in

basket

Place label

on slide

Slide is reviewed

by pathologist

Folder

delivered to

pathologist

Order recut?

Yes

NoFolder is

returned to

lab

Recoverslip

necessary?

No

Yes

Retrieve slide

folder

Move slides

from folder to

tray

Travel to

oven

Place tray in

oven

Slides dry

overnight

Travel to

bench

Travel to

oven

Remove tray

from oven

Yes

Coverslip

Review &

Archive

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Automated primary stainingIncreased Consistency & Throughput

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0Mislabeled

slides since

go-live

140Eliminated

manual steps

per day

Increased

productivity

Reduce error, improve productivity

Case study: community hospital

& eliminated handwriting while reducing

dependency on paper

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The 5s system/process

•to separate the needed items from the un-needed items

Sort

•to arrange in a way for how the remaining items will be

usedSet In Order

•to maintain the work area in a clean and orderly fashion

supporting the sorted and set-in-order itemsShine

•to replicate and ensure consistency across all users

Standardize

•to maintain and improve

Sustain

Make errors difficult to create, easy to detect and eliminate the

non-value added activities

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Examples of 5s (before)

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Example of 5s (after)

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LabelerWater Bath

Lamp

Blocks

Slide Holder

Slides Tray

ScannerIce

Materials:

Blades,

Cotton, etc.

Microtome

Tray

Microtome

Vantage

5s improves throughput at the cutting station

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5s improves throughput at

case assembly

Identification & tracking via barcodingBarcodes give you a connection to each sample, cassette and slide

• Real – time visibility at key points in your process

• Provides historical audit trail for every block, slide, and sample

• Supports process reporting for CAP, JCAHO or other agency goals

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The Case for VANTAGE Histology Challenges

Manual & paper processes



Limited or no process data




Limited or no system integration



Limited or no system integration

Opportunity for error

The Case for VANTAGE

Histology Challenges


VANTAGE Workflow Solution

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Case studies: Create a safer, effective,

efficient lab environment

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• Tandem microtomists sit in mirror image of each other

• Single case flow improves case-specific TAT, quality

Improve throughput

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• Save time and reduce errors associated with stopping and starting work at Embedding and Microtomy workstations

Organize Accessories

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• Reduce case set-up and preparation by 2 hours per day

Improve visual controls

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• Visual slide marker marks spot where slide was removed; facilitates faster, accurate slide replacement

Reduce lost slides in archiving

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• Create linear histology workflow to increase TAT

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PathologyLab

Symphony Symphony

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Visit www.smartdraw.com or call 1-800-768-3729.

Improve specimen flow

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Improve reflex testing and consult flowAdvanced Staining Bench

• Advanced Stain orders are printed

• HT picks up the order(s) & pulls as required

• Block(s)

• Unstained slide(s)

• Controls (if not TMA appropriate)

• Consult cases

• HT places in empty slide tray for case integrity

• Order is QC’ed and any additional slides required (negatives) are

ordered and staged for pick-up by HT

Consult Cases

LIS Terminal (QC)

Block &

Unstained

Slide

Staging

Control

Pull

Station

PrinterConsult

Cases

To Microtomy

Advanced Stain Cases

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• Lab runner, water spider establishes continuous flow

• Reduces 356 ft/case or 38% of total distance traveled

Microt

omy

Microt

omy

Microtomy

Microtomy

Embe

dding

Speci

al Stain

ers

Gross

ingGr

ossing

Grossing

TPTPTPTP

TP

TPTP

Microt

omy

Case

Assem

bly

H&E S

taining

Recut

s and

Speci

als

XTXT

XT

XT

XTUL

TRA

SS

SS

SSSS

SS

SS

Reduce bottlenecks, increase TAT

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Open Q&A Discussion

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Closing Remarks

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I need to reduce errors and risk...

I need to increase my quality tracking documentation…

I need to increase my staff’s efficiency…

What reason resonates with you?

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99.7%Reduction in

mislabeled

slides since

VANTAGE go-

live

& improved staining quality and consistency

1,100Eliminated

manual steps

saving 5

hrs/day

25%Reduction in

duplicate

slides resulting

in rework

Reduce errors, streamline operations

Case Study: Reference Lab

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& annual savings of $298,195

$174,613Data capture

savings

26%Turnaround

time

$51,090Overtime

savings

$63,492Bar coding

savings

Reduce costs with VANTAGE

Case study: reference lab

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Business

Non Value- Added 30%

Non-Value Added 65%

Value- Added 5%

A typical workflow process

Before Leaning a process, most activities are NVA

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Primary staining without automationTypical H & E Stainer Supported Process

Place basketinto oven

Load basketon

coverslipper& start

Unloadbasket fromcoverslipper

Moveslides toarchivedrawer

Retrieve& label

slide

H&E Workflow with Symphony Steps

Unloadbasket from

stainer

Confidential and Proprietary Information

Move slideto warmer

Place slideinto basket

Travel tooven

Removebasket from

oven

Load basketon stainer &

startSlide is stained

Slide drying

Move slidesfrom basket

to folder

Travel tobench

Travel tooven

Travel tostainer

Travel tobench

Travel tostainer

Travel tocoverslipper

Travel tobench

Slide iscoverslipped

Travel tocoverslipper

Travel toslide sorting

area

Mount tissueon slide

Drying

Is loadposition

occupied?

No

Place basketnext tostainer

Travel tobench

Yes

Is basketin unloadposition?

Travel tobench

Continueother work

Continueother work

No

Staining

Type ofcoverslipping

Automated

Manual Travel tomanualstation

Wait forcover-

slipper tocomplete

run

Is coverslipperrun complete?

Yes

No

Remove slidefrom basket

Applycoverslip

Place slide inbasket

Place labelon slide

Slide is reviewedby pathologist

Folderdelivered topathologist

Order recut?

Yes

NoFolder isreturned to

lab

Recoverslipnecessary?

No

Yes

Retrieve slidefolder

Move slidesfrom folder to

tray

Travel tooven

Place tray inoven

Slides dryovernight

Travel tobench

Travel tooven

Remove trayfrom oven

Yes

Coverslipping

Review & Archiving

Hylton Surrett, MBA, MHA, MBBSenior Manager, Advanced WorkflowMobile: (520) 306 - 0589Fax: (520) 299 - [email protected]

Contact information

workflow consulting for the histology lab, perspectives on safety and efficiency

Health & Medicine