Lean: Blazing a New Trial

“By standardizing our processes, we are doing today's work today, doing it once and doing it right”
-Dr Theodore S. Lawrence, Chair of Radiation Oncology

Cancer Center Clinical Trials Office goes Lean at UMHS

The Comprehensive Cancer Center Clinical Trials Office implemented lean strategies to reduce the amount of time between receiving notification of a clinical trial and approval to enroll the first patient from around 200 days to about 150.

Front: Jeannie Kain, Theresa Royce-Westcott, Cari Krzyzaniak, Linda Beekman, Mary Louise Good, Dennis Cooperson, Monica Orians, Janet Tarolli, Tina Wilbee. Back: Kristen LaVasseur, Matt Innes, Shelagh Elliot, Ffabian Rollins, David Browning, Pam James, Marlon Wardlow.

In addition to reducing waste in time or materials, going “lean” improves staff satisfaction and customer service. Just ask Linda Beekman, R.N., M.B.A., administrative director of clinical research for the Comprehensive Cancer Center Clinical Trials Office.
“There were delays in the activation of new studies and we didn’t always know where things were in the process. We wanted to streamline what we were doing to improve customer service to research teams,” says Beekman.
Along with Marcy Waldinger, Cancer Center chief department administrator, David Smith, M.D., CTO director, Marlon Wardlow, lean coach, and the Cancer Center CTO management team, Beekman implemented lean strategies to reduce the amount of time it takes to activate a trial (the time between receiving notification of a clinical trial and approval to enroll the first patient).

The Changes
The Cancer Center CTO now starts each trial with a feasibility meeting—a meeting in which regulatory, finance and data management staff meet to discuss various aspects of trial conduct and identify potential obstacles with respect to budgets, space, IRB approval and equipment needs.

The team also created an online database that staff can access to find out exactly what is happening in the trial, and keep the principal investigator and study team informed of the project’s status.

Calendars are being developed for all new studies, enabling the data managers and study teams to know when required testing is to be performed, and ensuring study compliance. This also will streamline billing and potentially reduce protocol deviations.

The Results
The gains achieved by the process were significant. Beekman estimates that lean processes may have saved approximately $260,000 in new staff hires, while noticeably improving staff morale and greatly reducing the lead time needed to get a trial up and running. She notes that her office has achieved about a 25 percent reduction in the timeline. What used to take around 200 days now takes about 150—and the gap is continuing to close.

This effort is one of the first Michigan Quality System projects dealing with research and one of more than 70 MQS projects under way in various Health System units and departments in the past year.

Improving Workflow with Water Spiders – Pathology gets Lean at the University of Michigan Health System

The lean team from Pathology, (clockwise from top left) Steven Mandell, M.D., Merry Muilenberg, Michael McVicker, Diana LeBlanc, Mary Jane Liu and John Perrin, worked together to reduce the time to cycle a blood specimen from 32 minutes to nine minutes.

If you ask Steve Mandell, M.D., why Pathology invested time in a slate of lean projects for their Central Distribution area, he says simply, “We process more than 6 million tests a year.” Mandell is an assistant professor in the Department of Pathology, director of MLabs and Central Distribution, and the project champion of the Pathology lean team.

Lean project sponsor Jay L. Hess, M.D., Ph.D., Carl V. Weller Professor and chair of Pathology, sees that 6 million figure as the tip of the iceberg.
 
“The amount of testing we do is ever increasing. In addition, we’ll soon begin to design a new building to house our clinical laboratories,” Hess says. “It was essential for us to develop more awareness of lean processes and improve our workflow so that we don’t just design what we already have—only bigger.”

To make changes in the areas of phlebotomy (blood collection), the design of the laboratory and specimen analysis, the lean team applied several lean processes such as continuous improvement cycles, workflow analyses and “water spiders.”

Water spiders are not really insects. It is a lean term used for anyone who travels around a work environment, enabling workers and processes, usually by “carrying” materials quickly—but never disturbing the substance of the work performed.

Lawrence Savoy, patient care technical assistant (water spider)

The idea of water spiders is so good I wish I’d thought of it myself,” says Cathy Howe, a phlebotomist in Pathology.

Howe is well acquainted with water spiders. In her world, water spiders are real-life human runners who take blood samples from 25 drop-off points in University Hospital directly to Pathology Central Distribution where they are delivered in 15-minute intervals around the clock.

“Any steps a phlebotomist can save during lab draws are helpful,” says Howe. “Now I don’t even have to leave the area. I can pick up requisitions, draw blood from patients and drop off samples at the handy drop-off points.”

It used to take around 32 minutes to cycle a blood specimen. Now it takes about nine minutes.

Previously, stat—or rush—requests were 40 percent of total blood draw requests. Now staff have faith in the system’s efficient turnaround, and the rate of stat requests is expected to drop to the single digits. The lean team also tackled standardized stocking of phlebotomy carts. “No matter which cart you take,” says Mandell, “you’ll have what you need, and you’ll know exactly where to find it.”

Thanks to lean design concepts, Pathology also redesigned three key parts of the core laboratory. In one instance, it took lab technicians 30 touch points—and 2,500 feet—to move a specimen from the patient to an analyzer. The new process, incorporating design changes to the lab and water spiders, improves turnaround times by 38 percent, reduces distance traveled by 33 percent and slashes waiting time by 78 percent. “In time, lean processes will be implemented throughout all our labs,” Mandell says. “This is just the beginning.”

Radiation Oncology: A LEAN Michigan Quality System Machine

When it comes to a cancer diagnosis, time is of the essence. That’s probably why Radiation Oncology’s first lean project meant so much to patients with bone and brain metastases—it reduced multiple trips over multiple days into same-day service and quicker access to treatment.

In the past, such patients would usually come in for a consultation, go home, come back for radiation planning, go home, and then come back to receive their first treatment. The process meant three trips to U-M for the patient, and a process that could take up to a week. Some patients—about 43 percent—did get all of this done in one day during one visit, but each case took a lot of effort. The system needed help.

So the Department faced a challenge: getting same-day treatments for more patients in a way that wouldn’t overburden faculty and staff.

Kathy Lash, R.T.T., director of clinical operations, Radiation Oncology, and Theodore S. Lawrence, Ph.D., M.D., chair of Radiation Oncology and the Isadore Lampe Professor of Radiology, formed a team of 16 to work together to think lean and improve their process.
“All of us thought we knew the processes, but it turned out we all had different perceptions,” says Lash. “You have to get cross-functional groups together. You have to get out into the workplace. And you have to become engaged in the processes.”

The team developed a standard method of scheduling and preparing all the inputs to the process (medical documents, imaging studies/reports, physician notes, insurance information). This reduced the number of process steps from 27 to 16.

“This same-day treatment has not meant more work for us,” Lawrence says. “On the contrary, by standardizing our processes, we are doing today’s work today, doing it once and doing it right. The staff were empowered by making these improvements, and the patients arem pleased to start treatment right away. Everyone—patients, staff and doctors—has benefited from this program.” “We now do same-day treatment essentially 100 percent of the time for patients who want it,” adds Lash. “This is about 94 to 96 percent of our total patients.”
If you are thinking about going through the lean process, just do it. According to Lash, “A lot of times, people think we’re adding work by collecting data. But the lean tools—data collection and mapping out the current state of affairs—help make the work visible.” And that is key to making improvements.

To date, Radiation Oncology has taken on four more official lean teams and many more small workgroup teams to improve systems for patients, and increase faculty and staff satisfaction.

The Michigan Quality System (MQS)

The Michigan Quality System (MQS) builds on our Continuous Quality Improvement Program (PDF) tools and methods and the philosophy of the Toyota Way to help us improve the way we care for patients every day. Each of us has a critical role to play to ensure that care at UMHS meets all six aims of health care:
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable – not varied due to gender, ethnicity, geography, socioeconomic status

The Michigan Quality System (MQS) is based on the "Lean Thinking" approach to quality improvement first developed by Toyota and now widely used in manufacturing, the service industry, and increasingly in health care. Its five core principles are:
• specifying value from the customer's perspective
• identifying the value stream for each product – the process by which we add value from the customer’s perspective
• making value flow without interruptions
• letting the customer pull value from the producer
• pursuing perfection – doing all of this every day, in all our work

The overarching mission of the Michigan Quality System (MQS) is:
“The endless transformation of waste into value from the customer’s perspective in the delivery of health care.”

Some in health care worry about the use of the term “customer,” thinking it refers to patients only, rather than to anyone affected by our work. We can also use the term “those we serve” to avoid this confusion. Customers can be either internal or external. While patients are usually our "end" customer, there are many other customers we must consider, including each other. When one department needs a piece of information from another department to perform a task, that first department is the customer. For example, when radiology needs a requisition from our physician to schedule and perform an MRI, the ordering physician is an internal customer, just as the patient is the external customer. The Michigan Quality System will consider the needs of all customers as we improve how work is processed.

The Michigan Quality System (MQS) is not an effort to cut people or costs (though costs often do decrease as a result of process improvements), or to make people work harder. Rather, it is an effort to make workflow smoother, more productive, more valuable to the customer, and easier for the worker. The philosophy is a natural extension of our goal of "Putting Patients and Families First."

Background about "Lean Thinking"
The term "Lean Thinking" was first applied to describe the Toyota Production System of product development, production, supplier management, customer support and planning, according to Womack and Jones, in the book, (Lean Thinking). In industry, this approach uses fewer "inputs" – such as time, human effort and materials – than traditional manufacturing to produce a wider variety of products with fewer defects more quickly. The Toyota Way has been applied successfully to a variety of industries, to companies that provide services to people, and increasingly to health care delivery.

The Health System leadership has committed to helping us all make this transforming journey, to create at UMHS a new system for continuously improving all we do. We have named this journey the Michigan Quality System (MQS). We selected this approach for several reasons. We believe together we can create the Michigan Quality System (MQS) that builds on the learnings at Toyota and GM – a system that:
• Creates the most value while consuming the fewest resources
• Helps us see the root causes of waste and errors
• Helps us solve the root causes, to transform waste into value from the perspectives of our patients, our co-workers, our payers and the communities we serve
• Helps every worker at UMHS, clinician and non-clinician alike, continuously search for ways to make our work easier, safer, faster, and with fewer errors
• Helps us do this every day

Eight Forms of Waste in Health Care

• Overproduction and Production of Unwanted Products:
  o The most important form of waste – leads to all the others
  o Any health care service that does not add value to the patient
  o Antibiotics for respiratory infections
  o CT screening for coronary disease
  o Medication given early, testing and treatment done ahead of time to suit staff schedules and equipment use
  o Appropriateness – the key dimension of QI in health!
• Material Movement:
  o Moving patients, meds, specimens, samples, equipment
• Worker Motion:
  o Searching for patients, meds, charts, supplies, paperwork
  o Long clinic halls
  o No printer in exam room for prescriptions, patient education
• Waiting:
  o ER staff waiting for admission, can’t see next patient
  o Waiting for test results, records, information
  o Nurse waits for blood draw, transport, OR cleaning
• Over-processing:
  o Bed moves, retesting, repetitive paperwork, multiple consent forms, logging requests
• Inventory:
  o Bed assignments, pharmacy stock, lab supplies, specimens awaiting analysis
  o Patient waiting for anything – tests, visits, discharge, phone cues
• Correction of defects:
  o Medication errors, wrong patient, wrong procedure, missing or incomplete information, blood re-draws, misdirected results, wrong bills
  

To learn more about the Michigan Quality System at UMHS refer to our website at http://www.med.umich.edu/mqs/mission/index.htm.

UMHS places a strong emphasis on training lean healthcare concepts and ongoing employee involvement. Therefore, training is held regularly for employees and programs are also available to the public. To learn more about our lean healthcare training programs, refer to http://interpro.engin.umich.edu/Healthcare.htm.