Lean laboratories: the prerequisite to survive rising pressure to deliver?
Lean principles offer laboratories a chance to revitalise services for the age of genomics and personalised care. Dr Gene Elliott* explores how decades-old car manufacturing ideas could now help laboratories support better patient outcomes, lower costs and meet hugely rising demand.
Patients’ expectations of health care are rising. An endless evolution of social and digital media is driving greater public awareness of new technology and treatment options either now or imminently available.
The possibilities for patient engagement on social media coupled with free-flowing information are unprecedented, so clinicians and healthcare workers are faced with new service delivery demands from an increasingly complex landscape of rising co-morbidities and better informed customers.
Laboratories are certainly feeling the knock-on resulting pressures. Healthcare growth areas range from genetic profiles through to new techniques in screening for diseases and monitoring chronic conditions, point-of-care and personal device testing, and each one invariably depends on some form of supportive traditional laboratory testing.
The number of stakeholders who now have an interest in the services offered also challenges laboratories. These may include healthcare workers, payers, institutions, environmental agencies and increasingly, patients wanting ownership of their information by accessing their results as part of personalised medicine.
To meet the shifting demand in work type and service, laboratories have had to adapt and become more efficient. At the same time, funding models have changed to emphasise patient benefit and better outcomes over traditional models of fee for service. There is a pressing need for operational efficiency that must be met despite challenges that include shrinking funding, escalating input costs and pressure on existing resources.
The convergence of all these factors has made managing a laboratory extremely complex with legacy laboratory information management systems (LIMS). Sophisticated information systems are now needed to support the logistics, measurement, planning and analytics involved to avoid overburdening staff with manual processes.
Laboratory consolidation is not the only way to cut costs
Healthcare systems across the world are pursuing consolidation strategies to improve efficiency. In the UK, the February 2016 Carter Report confirmed that consolidated pathology services first recommended in a 2008 review were now the most efficient pathology organisations anywhere in the English National Health Service. New technologies and scalable operations have resulted in a significant savings to the NHS while quality has been maintained or improved.
Beyond consolidation, even greater efficiency gains are possible with an ongoing improvement program. Transforming laboratories into an agile and responsive pathology service capable of continuous improvement, however, requires new-generation software that captures and delivers real-time relevant information in a manner that supports a responsive evidence-based decision-making at the coalface.
Health care has generally been slow to adopt the techniques that have improved quality and safety in other industries. Many claim that medicine is too different and too complicated — that advances in other industries are not applicable to the care of patients. Others argue that the prevalence of medical errors and a lack of processes — often only exposed by litigation — mandate that changes be made.
Lean principles can revitalise laboratory services
Recently, there has been a surge in the number of healthcare initiatives utilising lean principles that centre on continuous improvement but maintain respect for the rights of individual consumers. These aim to address service and quality issues while containing healthcare costs that have been spiralling upwards at levels above inflation in almost every country.
Some laboratories have adopted lean principles in response to increased demand. Lean, originally developed in car manufacturing, is a systematic approach to process improvement. It focuses on reduction of variations and elimination of waste, aiming to balance the process or workflow. In the laboratory, focusing on lean principles creates an opportunity to revitalise processes, streamline workflows and improve service delivery.
Lean adoption brings its own challenges. Significant change faces inevitable resistance, as people fear losing their jobs or not coping with new requirements, and can be difficult to manage. Challenging preconceived and embedded beliefs about laboratory work requires uncomfortable critical thinking about the actual value to the customer of many routine or historically accepted tasks.
Determining the real value of each action allows development of the most suitable protocols to achieve the desired outcomes. You can design a process from end to end to optimise each step, taking advantage of automated platforms and parallel tracks to enable sorting and workload allocation. Standardising processes reduces variation in outcomes and allows comparison and benchmarking across sites to continually improve efficiency.
Overcoming resistance with evidence
Lean initiatives can only overcome resistance to change and go on to deliver continuous improvement, however, with evidence that they work. This is now practical with modern information systems. Laboratories can monitor compliance with procedure and process, capture and analyse data to produce useful information and provide the knowledge required to make better decisions both in real time and for strategic planning.
When improvements in turnaround times, costs and the quality of test results are all captured, then enhanced operational performance can actually be proven. Better quality of results also improves safety for patients and employees. The reduction of errors and faulty results reduces retesting, reducing costs, and minimises wastage of reagents and manpower.
Quantifying waste reduction associated with lean processes and gauging the impact, however, requires built-in measurement of individual performance indicators and cost drivers. Accurate measurement proves to management and funders that the laboratory is more efficient and effective and benefit of interventions is quantifiable. Management dashboards that monitor real-time data relevant to the laboratory’s operational function and performance, and are flexible enough to enable responsive planning, also support more agile responses to changing circumstances.
Quantifying the actual cost, both fixed and variable, to perform tests enables better utilisation of resources and available budget. Managing stock for just-in-time ordering and reducing reagent costs contributes to lower overheads. Software that captures and reveals each cost supports day-to-day management of processes and facilitates planning and budgeting. Understanding the volume of tests and expected demand allows logistic planning and staff management. Most legacy LIMS today do not have these capabilities.
Going beyond LIMS
Demands to measure and understand performance are necessitating a new breed of system, which InterSystems calls a laboratory business management system (LBMS). New-generation IT platforms that support the operational input requirements of laboratory processes and make the data visible via dashboards and easy-to-use analytics are essential for the local management teams to implement lean principles. Service-level agreements continue to demand improvements and require governance and robust technology support of systems designed to demonstrate compliance with the improvement cycle.
Following standardisation of existing processes laboratories can reduce development times for new tests and streamline their implementation process. The laboratory can quickly increase its repertoire of tests to remain competitive with the least disruption to the existing service. An LBMS that provides full traceability and audit capabilities is now increasingly needed to enable compliance with onerous accreditation processes and audits that may otherwise require days or weeks of preparation. This incorporates the assessment process in daily activities that is easily visible on the day of the accrediting authority visit.
Ultimately, pathology is often seen as a driver of medical cost that in many parts of the world continues to receive a shrinking slice of healthcare budgets. There is an understandable fear that new technologies and tests — including personal genetic testing, other molecular testing and an expanding repertoire of diagnostic molecules — could escalate costs.
Any service improvement must consequently be evaluated against a clinical outcome that is measurable and quantifiable for the patient. This requires easy integration of laboratory results with the electronic patient record to support clinical decision-making and minimise over-ordering of tests.
In this environment, driving continuous improvement is a prerequisite for laboratory survival, as is the need for underpinning information analysis that supports the management of the laboratory and empowers staff to contribute to sustainable service provision.
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