Healthcare reform is front and center in conversations both personal and political. Traditional thinking has not been successful in significantly increasing effectiveness of care or in reducing costs. In fact, healthcare costs in the U.S. are expected to reach another all-time high by 2025 at 25% of the GDP. Current spending on healthcare in the U.S. is double that of other developed countries with no better outcomes.

In the same way, reform is sought-after in most transfusion services. The business needs are similar, no matter the size of the facility, the continent, or the country in which the transfusion service is located. Those business needs include the requirement to reduce overall costs, increase efficiencies and capacity, enhance process effectiveness and service levels, eliminate redundancies and error potential, better manage and utilize blood products, and optimize intellectual capital.

Lean takes a value stream approach and looks at the continuum of processes that seek to add value to the care being provided to patients. Lean involves the creation of flow and the adherence to standardized work processes and visual management, such that there is relentless pursuit of the elimination of waste (or those activities that are non-value-adding) and continuous improvement. The Lean transformation process can dramatically impact any department and any organization. Lean certainly can transform the work practices that are encompassed within transfusion services and allow transfusion service professionals to focus on providing the right blood product to the right patient at the right time for the right reason and using the right processes.

A number of transfusion services have applied Lean principles and tools to their core operations: order and specimen receipt and processing, pretransfusion and compatibility testing, blood product management, and blood component preparation, issue, administration and reconciliation. Their aim with the application of Lean was to identify process improvement opportunities and maximize labor capacity and expertise in order to provide: the right blood product, at the right time, for the right patient, for the right reason, using the right process.

The main Lean tools used to evaluate work processes were value stream maps, product and operator process flow analyses, and error potential analysis. Orders for testing or for blood products were analyzed and timed from the point of entry into the transfusion services until the end product or test result was released. Five action items were required:

Define process steps within value stream•Collect times for process steps and wait times between •processes along value streamDevelop information flow•Create current state value stream map•Perform value-added analysis of product flow and •operator processes

Processes were evaluated for the percentage of value-added and non-value-added time and assessed for improvement opportunities to increase process flow, increase the percentage of value-added time, and eliminate non-value-added activities or waste. Processes were redesigned with Lean concepts in mind, in order to optimize inputs including the labor component and to reallocate that intellectual capital in order to enhance service levels and support more effective blood management and utilization.

using lean to identify Process improvement opportunities and improve effectiveness of Transfusion ProfessionalsAuthors: Susan F. South and Jo Ann S. Hegarty

inTRoduCTion MeThods

Operations at fourteen sites among three countries were analyzed with Lean tools and thinking, to establish the base situation and identify areas for process focus and redesign. An example of one site’s current state value stream map of pretransfusion testing is shown in Figure 1. The total cycle time for pretransfusion testing in this case was 1:36:37. 22 minutes of this total process time was due to wait times, or time that patient specimens were sitting, waiting to go to the next step in the pretransfusion testing process. The specimens were involved in some aspect of being processed or tested for 1:14:37 of the total time. Batching was observed throughout the testing process. What should have taken <35 minutes to test on the particular analyzer in use, took 50 minutes.

Figure 2 shows the kaizen or opportunity bursts in this same current state pretransfusion testing value stream. Those opportunities included:

Processing patient specimens in single-piece versus •batch modeUsing a five-minute centrifugation of patient •specimens versus 10 minutesPutting centrifuged specimens directly onto analyzers•Flowing specimens in smaller batch sizes to analyzers•Level-loading batch sizes on each analyzer•

These improvements projected a reduced cycle time from 1:36:37 to <47 minutes or a cycle time reduction of 53%.

Value-added time (VAT) analysis helped refine the projections into specific operator process redesign by understanding the percentage of value-added versus non-value-added activities. Videotaping and analysis were completed for the product process flow and for select operator processes involved with the entire value stream, from order and specimen receipt through verified test results and product issue.

Value-added activities were classified as anything that changed the fit, form or function of the raw material or product for the first time and was activity the patient wanted to pay for. All other activities were classified as one of the following categories of non-value-added activity:

Transportation•Inspection•Non-value-added processing•Storage (waiting)•

The activities of the operators supporting the various processes were evaluated and activities similarly classified as non-value-added or value-added. The non-value-added activities were further analyzed to understand exactly what operators had to do and where they had to travel to do get the supplies, raw materials and information to do their work as well as to do the work itself. Videotapes were invaluable for this purpose and allowed the breakdown of activities into categories, such as time spent:

Walking•Reaching to get reagents or tools •Positioning, loading or unloading instruments or racks•Computer data entry•Manual work, such as labeling test tubes or re-capping •specimen tubesHandling paper or doing paperwork•Handling patient specimens or blood products•Taking phone calls •Inspecting forms, looking for specimens, rechecking •test results, or checking blood donor units to be released

Figure 3 shows an example of the VAT analysis of a STAT T&S test, product process flow at one of the transfusion service sites. The perception at this site was that STAT T&Ss should be processed by a manual column agglutination method as that was faster than using an analyzer. The Lean product process flow VAT analysis showed that the total cycle time for the STAT T&S was 1:13:44. Specimens were in storage or waiting nearly 55% of the total time. These STAT specimens waited for 36 minutes before they ever reached the testing area, sitting on the specimen receipt counter, sitting in Styrofoam cups, sitting in racks, waiting

ResulTs

Routine Electronic InformationRoutine Information

2nd ABO/DRoutine Paper Report FlowRoutine Material Flow

(Ground level — specimens not taken to lab areas — testing personnel have to go

downstairs to pick up specimens)

Collection software

Process of unbagging, sorting, and racking specimens, & saving bags in drawer

Process of putting specimensinto LIS, checking scanned requisition, tests ordered. & historical records, & sorting and writing B, G, or R in red on specimen label before putting into blue racks. (Batch record inputted if applicable.)

Using disposableplastic lids

Specimen tubes go from waiting in Specimen Distribution until lab personnel comes and picks up and takes to Transfusion Service upstairs, where specimens are dropped off and wait again

Pack

ages

: tube

s an

d req

uisitio

ns

RequisitionScanning & Data

Entry

4C Temporary StorageNot part of assessment process

Hospitals:

20Clinics:

3Collection

Sites:81

Collation Centers:

2

Wait Times: 00:22:00Process Time: 1:14:37Total Cycle Time: 01:36:37

I23

1

1

1

1 1

SpecimenDistribution

CTTPFPYBX

28 s654 s100%

23

CTTPFPYBX

4 sec96 s

100%23

CTTPFPYBX

600 s600 s100%

24

CTTPFPYBX

3 s70 s

100%23

CTTPFPYBX

3 s57 s

100%20

CTTPFPYBX

50 min50 min

100%18

Figure 1. Transfusion ServiceCurrent Value Stream: Pretransfusion Testing

Barcode Scan Process

SpecimenReceipt

Specimen Distribution:Sort and Triage of Specimens

ManualCentrifugation

Racking intoLarge Sample

RacksRacking into

AV Racks

CTTPFPYBX

2 s34 s

100%18

Recapping of Tubes

Manual TestingI.S. XMs

70% G&S Tests

3 min 5 min 10 min 4 min

(30/day)

paper report copy

paper report copy

Test Requisitions

Batch

reco

rdBa

tch re

cord

Scope — Transfusion Services Group & Screen TestsMaterial = Tube of BloodDemand = 250 Tubes/Day on Weekdays

Analyzer 1 &Results Release

90%

Samples with positiveantibody screens or other

atypical resultsNot part of study

(5/d manual Ab screens& 4 Ab ID/d)

CAT 1 CAT 2

Manual Testing:Ab ID, AHG XMs,

or Ab ScreensOther Testing

CTTPFPYBX

10 s187 s94%

18

Barcode Specimento Storage

Position & Check Pending Work

Analyzer 2 & Results

Release (10%)

Same approximatemetrics as above

instrument

96 sec180 sec

654 sec300 sec

600 sec 70 sec600 sec

57 sec 3000 sec240 sec

This process was done differently by different personnel.

Some recapped tubes at AV while

most recapped near specimen storage

check area.

Log Book in Transfusion Service for Expected Specimens/Testing/

Transfusion

Done either at Collation Sites or Central

Laboratory Specimen Processing Site

Transfusion Service Logistical Triage:

Making sure samples will arrive in time to meet demands for units intended

for transfusion

I23

I29

I18

I29

I23

I23

I29

I20

I29

LIS

paper storage

1

1

Suppliers CustomersHospitalHospital

Routine Electronic InformationRoutine Information

2nd ABO/DRoutine Paper Report FlowRoutine Material Flow

(Ground level — specimens not taken to lab areas — testing personnel have to go

downstairs to pick up specimens)

Collection software

Process of unbagging, sorting, and racking specimens, & saving bags in drawer

Process of putting specimensinto LIS, checking scanned requisition, tests ordered. & historical records, & sorting and writing B, G, or R in red on specimen label before putting into blue racks. (Batch record inputted if applicable.)

Using disposableplastic lids

Specimen tubes go from waiting in Specimen Distribution until lab personnel comes and picks up and takes to Transfusion Service upstairs, where specimens are dropped off and wait again

Pack

ages

: tube

s an

d req

uisitio

ns

RequisitionScanning & Data

Entry

4C Temporary StorageNot part of assessment process

Hospitals:

20Clinics:

3Collection

Sites:81

Collation Centers:

2

Suppliers Customers

Wait Times: 00:22:00Process Time: 1:14:37Total Cycle Time: 01:36:37

I23

1

1

1

1 1

SpecimenDistribution

CTTPFPYBX

28 s654 s100%

23

CTTPFPYBX

4 sec96 s

100%23

CTTPFPYBX

600 s600 s100%

24

CTTPFPYBX

3 s70 s

100%23

CTTPFPYBX

3 s57 s

100%20

CTTPFPYBX

50 min50 min

100%18

Figure 2. Transfusion ServiceCurrent Value Stream: Pretransfusion Testing

Barcode Scan Process

SpecimenReceipt

Specimen Distribution:Sort and Triage of Specimens

ManualCentrifugation

Racking intoLarge Sample

RacksRacking into

AV Racks

CTTPFPYBX

2 s34 s

100%18

Recapping of Tubes

Manual TestingI.S. XMs

70% G&S Tests

3 min 5 min 10 min 4 min

(30/day)

paper report copy

paper report copy

Test Requisitions

Batch

reco

rdBa

tch re

cord

Scope — Transfusion Services Group & Screen TestsMaterial = Tube of BloodDemand = 250 Tubes/Day on Weekdays

Analyzer 1 &Results Release

90%

Samples with positiveantibody screens or other

atypical resultsNot part of study

(5/d manual Ab screens& 4 Ab ID/d)

CAT 1 CAT 2

Manual Testing:Ab ID, AHG XMs,

or Ab ScreensOther Testing

CTTPFPYBX

10 s187 s94%

18

Barcode Specimento Storage

Position & Check Pending Work

Analyzer 2 & Results

Release (10%)

Same approximatemetrics as above

instrument

96 sec180 sec

654 sec300 sec

600 sec 70 sec600 sec

57 sec 3000 sec240 sec

This process was done differently by different personnel.

Some recapped tubes at AV while

most recapped near specimen storage

check area.

Log Book in Transfusion Service for Expected Specimens/Testing/

Transfusion

Done either at Collation Sites or Central

Laboratory Specimen Processing Site

Transfusion Service Logistical Triage:

Making sure samples will arrive in time to meet demands for units intended

for transfusion

I23

I29

I18

I29

I23

I23

I29

I20

I29

LIS

paper storage

1

1

HospitalHospital

Balance load oneach analyzer

Put specimens directlyonto analyzers

Test smaller batch sizeson analyzers

Use 5 mincentrifugation

Process specimens in single piece flow

to go into the centrifuge, and sitting in the centrifuge after centrifugation was completed. In reality, the cycle time should have been and was redesigned to be 47 minutes from receipt to result.

Figure 4 shows the path of the samples, both the STAT tests and routine. These paths required multiple handoffs and touch points, which raise error potential.

Operator walk patterns were also captured and distance and time analyzed as was VAT. Figures 5 and 6 show examples of the VAT of operator processes: distribution and specimen and order processing, manual testing, and solid phase analyzer testing. Pure waste in these analyses represents time when the operator or operators were idle, such as waiting for printers to complete printing or waiting for an analyzer to complete cycling.

What these figures showed were opportunities to improve the processes by removing waste and optimizing labor units. For example, Figure 5 represents the operator flow for the position responsible for receiving orders for blood products and test requests. 92% of the operation is some form of required waste and 8% was pure waste or idle time. Further breakdown of the required waste shows some important things:

Nearly 32% of the time is spent handling paper or •doing paperwork12.6% of the time is spent walking•

Redesign of work assignments resulted when the Lean work team asked questions about “Why there was so much paper?,” and “Why so much time was spent walking when the main functions were at the receiving desk?”

Figure 6 shows an example of the VAT analysis of the operation of an automated testing instrument. What is shown in this graphic is that 54% of the operator time was spent with required waste activities, and 46% of the time represented pure waste or time when the operator was idle. In this situation and for several days in a row, the analyzer froze at the point results were ready to release, which necessitated re-starting the instrument and re-booting the instrument’s computer. This required the operator to repeat the testing and babysit the instrument and resulted in 46% lost intellectual capacity and lost testing capacity. Instead of taking approximately one hour for a large batch of routine T&Ss to be tested, the process took >3 hours.

The breakdown of the required waste in Figure 6 demonstrates the intensive operator activities that are required with this particular type of analyzer:

19% of the time spent inspecting various parts, the •computer screen, and process steps15.3% of the time spent positioning testing components •and patient specimens22.1% of the time spent with manual operations•7% of the time spent walking•

ResulTs

TOTAL STORAGETIME: 54.9%

TOTAL NON-VALUE-ADDEDTIME: 3.8%

TOTAL VALUE-ADDEDTIME: 41.3%

Figure 3. Specimen Flow: STAT Manual T&S

Current Product Process Flow: STAT Manual T&S

Total time from receipt to result: 1:13:440:00

TT

SP

TA

0:14 0:28 0:43 0:57 1:12 1:26

36min.

Figure 4. Specimen Flow: T&S Testing

Routine/Analyzer Sample Flow:• 3 Handoffs• 7 Touch Points• 58 feet

STAT/Manual Sample Flow:• 3 Handoffs• 7 Touch Points• 45 feet

PURE WASTE:8%

REQUIRED WASTE:92%

VALUE-ADDED:0%

COMPUTER:13.9%

PARTS:1.3% TOOLS:

3.2%MANUAL

OPERATION:21.1%

MATERIALHANDLING:

11.0%WALK:12.6%

OTHER:5.4%

PAPER:31.5%

Figure 5. Operator Process Flow: Distribution Operator Example

8% pure waste

31.5% of required wasteis related to paper

Analysis of Operations: Distribution 1Summary of Current Work

Analysis of Operations: Distribution 1Summary of Current Required Waste

PURE WASTE:46%

REQUIRED WASTE:54%

VALUE-ADDED:0%

COMPUTER:16.4%

PARTS:4.9% TOOLS:

2.1%MANUAL

OPERATION:22.1%

MATERIALHANDLING:

5.1%

WALK:7.0%

UNLOAD:0.3%INSPECT:

19.0% POSITION:15.3%

PAPER:7.7%

Figure 6. Operator Process Flow: Analyzer T&S Testing

46% pure waste

22.1% manual operations, 19% inspectionand 15.3% positioning tubes or parts

Analysis of Operations: Analyzer TestingSummary of Current Work

Analysis of Operations: Analyzer TestingSummary of Current Required Waste

Poster presented at the Society for the Advancement of Blood Management Annual Meeting, September 2010, San Juan, Puerto Rico

© Ortho-Clinical Diagnostics, Inc., 2010 ValuMetrix® is a registered trademark of Ortho-Clinical Diagnostics, Inc. OC10608

The application of Lean tools uncovered significant opportunities for process improvement. When coupled with the use of the automation, exponential improvements were identified and implemented with sustained success. In multiple instances, improvements have been realized for over 12 months and labor resources reallocated to transfusion utilization, quality programs, and safety operations. Average annualized cost savings in most of these sites has exceeded $190,000, not including savings from improved blood product inventory practices and utilization. All of these sites are now better positioned to meet their business needs, having transformed their processes with Lean thinking and tools.

ConClusion

These results are client specific, individual results may vary.

Table 1. Summary Table of Range of Time and Labor Percentage Reductions Using Lean Analysis in 14 Sites*

Category Turnaround Time for sTAT T&s

Turnaround Time for Routine T&s

specimen/order Receipt Processing & issue

Manual T&s Testing

Automated T&s Testing

Compatibility Testing

Identified Range of % Reduction in Time or Labor Required

11 to 39% 6 to 60% 17 to 65% 16 to 91% 17 to 64% 27 to 36%

*2 of 14 sites are in process of implementing and measuring improvements

ResulTs (continued)

About the AuthorsSusan F. South, MAOM, MT(ASCP)SBB, is a Lean Six Sigma Black Belt and Worldwide Senior Consultant with ValuMetrix® Services, Scottsdale, AZ. Email: ssouth2@its.jnj.com.

Jo Ann S. Hegarty MT(ASCP)SBB, is Worldwide Marketing Director, ValuMetrix® Services, Raritan, NJ. Email: jhegart1@its.jnj.com.

In this case, the questions revolved around “Why do we have an analyzer in place that requires so much time to position parts, inspect, handle materials, and walk, let alone causes wasted labor units?”

Table 1 represents a composite summary of the improvements that were identified with Lean tools and thinking in 14 sites. Representative processes and projected ranges in time and labor unit savings are included in the table. Two of the 14 sites are in the process of implementing and measuring results; the other 12 sites have achieved their improvement projections. Turnaround times from sample receipt in the transfusion service to verified results were reduced by 11 to 39% for STAT request processes and 6 to 60% for routine test request processes. Labor unit savings were realized for the processes of specimen and order receipt (17 to 65%), manual testing (16 to 91%), automated testing (17 to 64%), and compatibility testing (27 to 36%). Most of these time reductions were achieved with:

Co-location and organization of processes •and disposablesCreation of improved process and operator flow•Implementation of standardized work and visual •management controlsRedesigned task assignments •

In one site, some of the labor unit savings was reallocated, creating a full-time position to work with care givers for enhanced blood product utilization. Most of the other sites re-directed their saved labor units to support other transfusion service activities and quality efforts.