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Henry Ford Production System
Continuous Quality Improvement
in Pathology
based on
-----and-----
Lean Production Principles
Henry Ford Health System
Detroit, MI USA
Holding the Gain
Monthly HFPS Group meetings
Share successes/failures
Teach by example
Spark enthusiasm
Connection
Activity (Customer-Supplier) Pathway Improvement
Pull to Stainer Histology Timed, 12% decrease
Q 20 mins Cutter Stainer batch TAT in 9hrs
independent
Histology delay Histology lab E-mail via Reduce calls &
notification Pathologist PathLab confusion
Cut temporal Gross Standardize Reduce re-
artery biopsies Embedding processing embedding rate
at embedding Pathologist of specific Reduce delay
biopsy
“Holding the Gain” meetings are held monthly
to spark enthusiasm, maintain team spirit and
pass on knowledge to assist others.
77 Process Improvements in 3 Months
Process Redesign
1 2
Henry Ford Production System:
4
A collaborative effort of an
empowered workforce,
3 incrementally innovating to
5 move toward the ideal
1. Standardize and organize Resident work load of condition, continuously,
assigned cases
2. Standardize cutting station tools and supplies striving for a “best in class”
3. Visual cues for gross tissue standardization
4. First-In-First-Out principle for temporary tissue defect-free laboratory,
storage waiting for disposal
5. Standardized tray created for accessioning dedicated to the safety of
specimens in defined work batches
patients.
There are numerous improvement opportunities that now
arise from the adopted production and redesign principles
that include standardized tasks and workstations,
continuous process flow based on pull rather than push,
workload leveling, visual controls and change decision
making based on careful, scientific study and databased
proof of effectiveness.
Introduction
For a long time quality assurance and improvement
activities in anatomic pathology have focused on the
identification of benchmarks of performance that describe
Before After 5S
current practice and attempted to satisfy accreditation
requirements for continuous monitoring. This has often
meant striving to perform at the median or mean benchmark Grossing Station
performance level. These peer derived goals set the bar
too low. For over fifteen years this focus on quality has
resulted in no significant performance improvements. For
instance, in 1993 the 525 laboratories participating in a Q-
Probes study completed 79% of routine biopsies in one day.
That turnaround time has not improved significantly since.
The new paradigm in quality improvement is that of applying
lean production principles to the laboratory. In its ultimate
form, applications like the Toyota Production System will
change the underlying culture of the laboratory to that of a
continuously learning workforce, continually making
scientifically based rapid process improvements while
striving toward the ideal performance level. Whereas in the
old paradigm decision-making about improvements was top-
down from management, in the new lean paradigm for
improvement, ideas and decision-making are derived from Gross Counter
the bench level up. Whereas in the old paradigm the
laboratory service or product was offered “when we got to
Neat
it,” in the new paradigm the product is produced when and
how the customer wants it. In the old paradigm we would Clean
gear up for increased production with more staff but in the
new model we often find that less staff is needed to do Labeled
more. Our laboratory-wide effort to implement the Toyota
Production Principles to perfecting processes and patient Organized
safety is known as the Henry Ford Production System.
Standardized
Who We Are
5S
Henry Ford Hospital founded 1915 by
Henry Ford
• Employee participation
Henry Ford Health System
• Saturday March 18, 2006 integrated healthcare delivery
– 15 volunteers system in Southeast Michigan
– 6 task assignments 6th largest employer in Michigan
– 8 lab areas • Sort Lab founded 1917
• Set
15th largest hospital based lab USA
• Shine
• Standardize Pathology Product line
• Sustain
Main teaching hospital, 23 regional
med centers, 3 affiliate hospitals,
span 40 miles Southeast Michigan
6.5M tests/year
Central Lab leadership with
product-line authority
Focus on Quality, Informatics,
Molecular Pathology and
5 S – A continuous Education
process improvement to
organize the work place
Total Defects
Surgical Pathology
Mission, Vision, Values TOTAL DEFECTS
How We Do It
ANALYTIC
POST-
Amended Reports 13
66
Sequence of Defects
Recuts Top 4
Mission Excellence in pathology diagnosis- Analytic Phase
Immuno/Sp. Stain 2
patient care
ANALYTIC
Histo. Slides 151
Values Our people, partners & patients are Grossing 99
most important-respect, mutual Accessioning 123
understanding, cooperation
PRE-ANALYTIC
Rehab 17
Spec. Receiving 24
Objectives Change culture, empowerment,
continuous learning, improvements 0 20 40 60 80 100 120 140 160
No. of Defects
that standardize process &
eliminate non-value added waste
As a result of our data collection
Vision We will be “best in class”, striving
methodology, we discovered that the
for zero defects
majority of defects arise within the analytic
Strategy Adapt TPS principles to HFHS phase of testing rather than the pre-and
Pathology & Laboratory Medicine post-analytic phases as previously thought.
The top four analytic defects related to
Performance Balanced scorecard of pre-, intra histology slides, defects at accessioning,
Measures and post-analytic variables, data
acquired in real-time
defects in the gross examination of tissues
and in recuts. Clearly, defining this
magnitude and specificity of errors that take
place within our complex processes on a
daily basis provide us with great
opportunities for improvement.
The Inventors
Collected Data
Defect
Type
Change Top-down Bottom-up
directive empowerment
Andon-like Production Mass production Beyond production
Board Push Pull
Capacity/Forecast Continuous
flow/demand
Innovation Automation Autonomation
Suppliers Short term contract Long term partners
Detail
Menu Goal Waste, Non-value
time added steps
Data Collection Poster from Senior Staff Outcome Maximize profit Maximize quality
Pathologists
As a result of staff surveys, nine data
collection posters were created and posted In the Henry Ford Production System, we have
in each work unit, such that 57 personnel in built on the original Henry Ford approach to
anatomic pathology could identify defective mass production, melded with automation and
cases in real-time in a public display for a elimination of waste and time, to include the
two week period. This approach mimicked Toyota Production Principles that go beyond
the Toyota Andon board of illuminated mass production. The latter refinements include
defects as seen in the manufacturing mass continuous production flow based on demand,
production line. pull production, autonomation and an
empowered workforce incrementally innovating
to move toward the ideal condition, continuously.
Our Journey Customer Supplier Meetings
November 2004
Introduction of leadership to 5 day Pittsburgh
Regional Health Initiative training Custom er Meeting/Training Occurances
Decem ber, 05-May, 06
Spring 2005 120
Reality test Toyota Production System in 100
Employees
Employees
Henry Ford Surgical Pathology 80
Meetings
60
Fall 2005 – Funding/recruitment QI Coordinator
40
January 2006- Toyota Training 20
Team leaders - pilot in Surgical Pathology 0
2 days Pittsburgh/2 days on-site Henry Ford
March 2006 – Organize, educate, begin rapid
process improvements, hold 5S exercise Beginning in November, 2005,
there were no meetings,
communications or discussions of
customer requirements. As of
May, 2006, we are holding 20
meetings a month with up to 100
customer - supplier interactions.
Result of increased communication:
77 process improvements
HFPS in 3 months
“Strength in Numbers”
WE WILL
Customer – Supplier Interactions Team Members
Anatomic Pathology Staff
• Weekly meetings
Team Members=76 Add your name here
• Forced connections, now
expectation 5 5 24 17 16 4 5
Accession- Gross Histology Pathologists Sec.s Infor-
Transcription Room Residents matics
• Downstream consequences
of defects defined Team Cheryl Beckie Dr. O Bev Dr. N Debbie Dr.T
Leaders
• Customers list requirements
Group Leaders Rita Dr. Z
• Suppliers respond by
changing process Support Staff Ruan Anjna Informatics
A key to our success is founding the HFPS
So, whatup? (voice of Detroit) organizational structure on a a bottom up,
Culture is changing employee-empowered foundation. This inverted
structure aligns 76 staff in Surgical Pathology
into functional teams, each coached by a leader
trained in Toyota Production System principles.
Teams are coordinator by group leaders who are
supported by staff with expertise in informatics,
data analysis and education.
Surgical Pathology Processes Staff Survey of Key
and Personnel Defects
SP Major Personnel in Sequence In the Henry Ford Production System,
Processes we have attempted to define the true
magnitude of defects that arise within
Biopsy/Label Surgeon, Nurse, Medical Assistant the surgical pathology process from
Clinic Assistant or Medical Center pre-analytic through post-analytic
Transport
Lab Tech phases. We began by polling all AP
professional, technical and secretarial
Accession Pathology Accessioner / staff, asking them to list the top ten
Transcriptionist defects they commonly encounter that
Tissue Gross Pathologists Assistant (PA), Resident required them to accept less than
Exam or Pathologist standard work, to stop work, to fix an
error or to return work to the sender.
Processing Histotechnologist From this information we defined 100
Embedding Histotechnologist indicators of potential defects in
surgical pathology.
Cutting Histotechnologist
Survey Results: Histology
Staining/Cover Histotechnologist
Recuts
3
Case Collation Histotechnologist
Indicators
Tests
7
10
Delivery Histotechnologist Slides
14
Blocks
Microscopic Pathologist, Resident
17
Tissue
Exam 0 5 10 15 20
Number of Responses
Report Sign-out Pathologist, Resident Series1
Process Maps Team Leaders
Process maps were developed to
identify bottlenecks, multiple handoffs
and redundant paths during
processing. The maps were developed
into posters, placed in areas of interest
and used to visually illustrate
improvements.
Micro T able
scope To
Histology
T ranscription
2 3
2 3
Storage
Cutting S tations
Problem 4
Specimens 11 4
Buckets
SMART
Tags
PC
PC PC Cassette To Gross Lab
Printer
Accession
Cassette PC PC Scanner
PC PC
Printer
T ag Entry
Storage Cutting Station 3
To Gross Lab
Cutting Station 2 Cutting Station 1
Computers
Specimen Buckets Delays
Cassette Printers
Cutting Station 4
Storage
HF Production Re-Design Goals What We Did – Initial Steps
Opportunities Value Stream Mapping
Standardized tasks and workstations Staff survey of defects
Continuous process flow, convert to ‘pull’
Kick off meeting to share
Workload leveling Mission, Vision, Values, Goals
Cultural change, fix problems as they Photo documentation of
occur
processes
Visual controls
Data collection of current state
New technology
Staff education in Henry Ford
Decision making
Production principles
• Scientific basis, careful study,
consensus 5 S day
• Autonomous yet integrated work 1. Sort
cells
2. Set
Grow and develop our people
3. Shine
Sustain by continuous learning &
improvement 4. Standardize
5. Sustain
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