Defining The Henry Ford Production System
The Henry Ford Production System- "It's the work, not the man that manages"Rita D'Angelo MS, Gaurav Sharma MD, Richard Zarbo MD, DMD, Pathology and Laboratory Medicine, Henry Ford Health System, Detroit, Michigan
The Henry Ford Production System (HFPS) is the quality management culture of Pathology and Laboratory Medicine, a large integrated hospital-based laboratory system composed of 775 employees handling over 11 million clinical diagnostic tests for the 6 acute care hospitals and 30 regional medical centers of the Henry Ford Health System. We have emulated the successful Deming-based management principles of the Toyota Motor Corporation to obtain an empowered workforce using defined work rules that drive standardization, a knowledge of in-process variation and waste and a scientific basis for hundreds of annual process improvements.
Over the past 4 years, we have incrementally transformed our culture of work, laboratory by laboratory starting with the main teaching hospital and now extending this culture hospital by hospital within the laboratory service-line. This in turn, has transformed the look, feel and performance of our laboratory services and enabled our workforce to effectively design and implement planned strategic initiatives and react flexibly and quickly to the challenges of our external environment. From the Toyota approach, referred commonly as LEAN management, we attribute much of our success to the partnership of leaders who's job is to continually work on the system and accountable, empowered workers who identify opportunities for improvement, create and practice standard work, self-inquiry and problem resolution leading to efficient processes and elimination of waste for the benefit of patient care. To be successful in this new work environment, all employees receive 8 hours of CEU/CME associated LEAN training at orientation and leaders avail themselves of our 2-day LEAN training program offered 5 times throughout the year. The latter training opportunity is also open to all comers externally through our website: www.henryford.com/HFproductionsystem
Practicing this approach to work, the human talent of the anatomic and clinical pathology laboratories on the Henry Ford Hospital main campus alone achieved 536 process improvements in 2009. Our founder Henry Ford once said- "There are no big problems, just a lot of little ones." In the laboratories of Henry Ford, we have created a culture that brings resolution to that statement to life.
Defect and Waste-the Twin Problems
During the identification phase of a defective process, often very little is known about in-process variation leading to waste and poor quality. As a part of the learning process prior to an improvement, defective hand-offs are observed to identify (1) If there is a process in place (2) who is the customer/supplier involved (3) the specific defects in the process. In the laboratory environment, we have defined a defect as a deviation from a predetermined outcome of a process, that is, a flaw, an imperfection, or a deficiency in specimen processing requiring work to be delayed, stopped or returned to the sender. These defects are non-interpretive defects in the production of a product or service that are critical to quality and trigger re-work to satisfy the expected standard. This is non-valued added work, and the continual focus of process improvements to eliminate it. Waste is represented in a number of forms such as- defective products, overproduction, unnecessary processing, time waiting, excessive transportation of product or material, excessive human movement and excessive stock on hand. In order to get a handle on these forms of waste and variation, in pursuit of a "zero-defects" performance goal, we have designed novel data collection tools to assess our current condition and sources of defects.
LEAN and Pull - the Right Way
A 'LEAN' workflow is a continual flow process composed of smaller evenly paced batches, bringing raw materials and workers at the right time and place with the right tools to produce a finished product that can be distributed quickly. This can be a challenge as a laboratory cannot schedule deliveries but must accept uneven batches of different specimen types from different locations, perform multiple types of analytical processes and report results to a diverse group of customers (inpatient, outpatient and non-patient physicians and other healthcare providers, insurance and regulatory agencies) each with their own set of expectations.
In pursuing these ideal aspects of "just-in-time" workflow, waste is eliminated, and often time is compressed resulting in much quicker turnaround times. LEAN requires a move away from a batch mode production based on 'push' (non-synchronous production) wherein defects are addressed at the end of a production cycle to a more 'continuous mode' wherein each step 'pulls' (synchronous production) and detects and resolves defects in real time, thereby minimizing downtime and re-work.
Standard Work and the Customer-Supplier Loop- the Solution
Standard work is the basis of standardization yet not a very easy thing to obtain as a consistent practice of all workers doing the same task. Despite the presence of a standard operating procedure (SOP), workers can get quite creative when carrying out the steps of work defined in a SOP. Standard work also requires a production cycle with predefined connections between customers and suppliers and a predefined pathway that the product or service travels. These are additional opportunities for standardization of work in order to minimize variation.
Through the HFPS culture, we've created a novel means to discuss a no-blame defective handoff by meeting with our customer to discuss processes not people. Each employee is a customer (receives a derivative of the specimen) and in turn a supplier (processes the received derivative and forwards the product for the next analytical step). Communication within customer teams is encouraged to document defects and then to communicate these during customer-supplier meetings called to address a problem. The supplier team is expected to understand the customer's expectation then re-evaluate and improve their own process steps to satisfy that requirement.
Lab Personnel- the Movers
For problem resolution, HFPS is dependent on a worker driven 'bottom up' approach rather than the conventional management driven 'top down' approach to problem solving. Problem resolution is based in the Plan-Do-Check-Act of the Deming cycle using the A-3 tool used by Toyota. Our approach is not slavish to data collection and statistical analysis but rather simply frames the problem with data that can be used in root cause analysis and to assess the impact of any intervention. We have created a quality improvement organizational structure aligning lab personnel with their team leader by workcells into small teams (3-5) who identify the nature and scope of a defect, stimulate and guide discussion on possible solutions, and implement/test a solution until it can address the scope of the defect. This cooperative approach hinges on a 'no blame but all accountable' sense of process ownership amongst lab personnel. The work expectation then is "never pass a defect".
Presentations- the Motivators
HFPS promotes presentation of defect resolution experiences, both successes and failures, by the workers themselves using monthly 'Share the Gain' meetings segregated into the two major divisions of anatomic and clinical pathology. The goals are to inform fellow team members as a "lessons learned", sustain the continual expectation and pace of one process improvement per workcell per month. These forums are helpful to disseminate successful defect solutions and best practices that may be affecting multiple laboratories. Further, the open discussion and focus on the defects and their resolution reinforces the 'no-blame but all accountable' culture, fosters group learning and recognition of both teams and individual achievements.
Visual Cues- the Helpers
HFPS encourages the use of simple and prominent visual and color-coded cues in the workplace that are used to identify predefined workstreams and guide the movement of a specimen (or its derivative) as it moves through the laboratory. Wall posters and white boards are available at the workbench for easy communication of instructions and recording of defects by the workers.
Order inventory kanbans are also used to define, locate and re-order supplies by pulling the card at the pre-determined order point and passing it on to inventory staff. Multiple staff members have been trained to perform this function reducing time lost because of unavailable resources. In this manner inventory stock is reduced to a minimum and former stockroom space reclaimed for other valuable use.
Technology- the Enablers
HFPS reinforces its quality standards, work rules and use of quality tools through its informatics infrastructure by introducing new technologies like barcode driven histology workflow and digital photography. We have also launched system-wide online availability of ISO compliant manuals, policies and procedures and standard work guidelines that support our paperless operations across all sites.
We have standardized to one common Laboratory Information System to map the movement and processing of specimens and electronically deliver reports (also in standardized formats) across numerous locations and physician offices. These standardized reports build upon synoptic menus to eliminate omission of essential diagnostic information (especially in anatomic pathology) and facilitate clarity of interpretation for the end-user.
Teamwork- The Results
In surgical pathology division, within 1 year, leveraging roughly 100 process improvements per year, the number of surgical cases with defects (in-process waste) of any type (including specimen receipt, specimen accessioning, grossing, histology slides, and slide recuts) was reduced by 55% from 1 in 3 cases to 1 in 8 cases. This then reduced again the following year, to 1 in 40 (91% from baseline) at which point the goal of fixing defects in real-time according to a defined rework pathway has been achieved. Through the implementation of process redesign and bar code specified histology work processes, internal in-process misidentification defects were reduced by 62% overall with a 95% reduction in slide misidentification defects while increasing technical throughput at the microtomy work station by 125%.
After several years of our initial learning experiences in surgical pathology, we introduced these same HFPS principles of management and process improvement methodology in our clinical pathology Core Lab division and have been rewarded by similar success. The baseline performance was 98% of all clinical lab test results were reported by 6am the next morning in the electronic medical record. In less than one year, again after hundreds of process improvements, that turnaround time has been considerably reduced to 98% results reported by midnight of specimens received by 5pm. The prospects of success in a clinical laboratory are potentially more difficult since these laboratories were early adopters of technological automation, autovalidation and standardization, leaving greater opportunities for pre-analytic process improvements that involved personnel activities from specimen collection, through transport, core lab receipt and in-lab delivery to testing platforms.
Transforming and sustaining a 'LEAN' culture is hard work, but rewarding. It requires recognition of new roles that make the workplace an opportunity for leaders and workers to form teams that understand and create better work environment. This is the continual driver of not only better quality but higher productivity and worker satisfaction. It has been said that not much in modern medicine occurs without laboratory test results. The positive quality outcomes demonstrated here have the potential for laboratories to gain recognition for their often unobserved role in strengthening the economic future of the hospital systems that they serve.