Lean Pathology: Implementing The Problem Solving...
-
Upload
truongliem -
Category
Documents
-
view
216 -
download
0
Transcript of Lean Pathology: Implementing The Problem Solving...
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 REPORT
IN A PATHOLOGY LAB
A RESEARCH REPORT
PRESENTED TO
THE GRADUATE SCHOOL OF BUSINESS
UNIVERSITY OF CAPE TOWN
IN PARTIAL FULFILMENT
OF THE REQUIREMENTS FOR THE
MASTERS OF BUSINESS ADMINISTRATION DEGREE
BY
THEONEVUS TINASHE CHINYANGA
10 DECEMBER 2010
SUPERVISOR: PROF NORMAN FAULL
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
2
ACKNOWLEDGEMENT
This report is confidential. This report may not be used or distributed without the consent
of the University Of Cape Town Graduate School Of Business.
I wish to thank Prof. Norman Faull for the valuable insights and guidance he has
provided during this research project. His knowledge of operations management and lean
principles is inspiring.
To the management at Cape Pathologists Ltd, I would like to extend my heartfelt
gratitude for the opportunity that you gave me by allowing me to experiment with your
organisation.
To the staff at Cape Pathologists Ltd, your involvement in this learning experience was
key and your support towards the completion of this report is greatly appreciated.
I certify that except as noted above, this report is my own work and all references used
are accurately reported.
Signed:
THEONEVUS TINASHE CHINYANGA
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
3
ABSTRACT
The private pathology service is an important component of the private health sector in
South Africa. Clinicians from private hospitals and practices refer specimens to
pathology services for testing, and expect to receive results in the shortest possible time
in order to make patient focused decisions. Failure to meet turnaround time is a major
source of clinicians’ dissatisfaction with pathology services (Hawkins, 2007) and might
lead to loss of business in this highly competitive marketplace. Cape Pathologists Ltd is a
private pathology practice in Cape Town that was failing to meet turnaround time on the
tests it performs.
The aim of this research was to reduce by 30% the proportion of urgent test results failing
to meet turnaround time of 2 hours at Cape Pathologists Ltd, as well as to generate theory
regarding implementation of the problem solving A3 report in a private pathology
environment. Action research methodology was found to be the most appropriate
research method to implement the problem solving A3 report in this environment.
The research only achieved a 13% reduction in samples exceeding 2 hours turnaround
time. However, the research found that the staff at Cape Pathologists Ltd believes that the
problem solving A3 report can be implemented in their environment. The study also
concluded that implementing the problem solving A3 report improved the problem
solving capabilities of the staff in the host organisation.
Key words: Healthcare, Pathology laboratory, A3 report, Lean
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
4
TABLE OF CONTENTS
LIST OF TABLES ................................................................................................ 6
LIST OF FIGURES .............................................................................................. 6
1. INTRODUCTION............................................................................................. 8
1.1 Background ............................................................................................................... 8
1.2 Problem definition and motivation for research ....................................................... 9
1.3 Research Objectives ................................................................................................ 10
1.4 Research Hypotheses .............................................................................................. 11
1.5 Research Assumptions and Ethics .......................................................................... 11
2. LITERATURE REVIEW .............................................................................. 13
2.1 Toyota Production System and Lean Principles ..................................................... 13
2.2 Lean Healthcare ...................................................................................................... 15
2.3 The A3 Report......................................................................................................... 17
2.4 Conclusion .............................................................................................................. 20
3. RESEARCH METHODOLOGY .................................................................. 22
3.1 Research Approach and Strategy ............................................................................ 22
3.2 Research design ...................................................................................................... 22
3.2.1 Background to action research ......................................................................... 22
3.2.2 Implementing action research .......................................................................... 24
3.2.3 Change management in action research ........................................................... 26
3.2.4 Applicability of AR methodology to current study ......................................... 27
3.3.5 Role of the researcher ...................................................................................... 27
3.2 Data collection methods and research instruments ................................................. 28
3.4 Sampling ................................................................................................................. 30
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
5
3.5 Data analysis methods............................................................................................. 31
4. RESEARCH FINDINGS, ANALYSIS AND DISCUSSION ...................... 32
4.1 The pre-step ............................................................................................................ 32
4.2 Organisational and environmental analysis ............................................................ 33
4.2.1 Phlebotomy service .......................................................................................... 34
4.2.2 Courier service ................................................................................................. 36
4.2.3 Pinelands Lab ................................................................................................... 37
4.2.4 The service value stream and nature of the problem ....................................... 38
4.2.5 Summary of environmental analysis ................................................................ 42
4.3 HYPOTHESIS TESTING ...................................................................................... 43
4.3.1 Hypothesis 1..................................................................................................... 43
4.3.1.1 Findings and observations............................................................................. 43
4.3.2 Hypothesis 2..................................................................................................... 51
4.3.3 Hypothesis 3..................................................................................................... 55
5. RESEARCH CONCLUSIONS ...................................................................... 59
6. FUTURE RESEARCH DIRECTIONS......................................................... 61
7. REFERENCES ................................................................................................ 62
8. APPENDICES ................................................................................................. 68
APPENDIX 1: Example of the A3 Report ................................................................... 68
APPENDIX 2: Likert Questionnaire 1 ......................................................................... 69
APPENDIX 3: Likert Questionnaire 2 ......................................................................... 69
APPENDIX 4: Example A3 report used in training ..................................................... 70
APPENDIX 5: First A3 Report..................................................................................... 72
APPENDIX 6: Second A3 Report ................................................................................ 76
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
6
APPENDIX 7: Research Log........................................................................................ 80
LIST OF TABLES
Table 1: Linking research question to methodology ......................................................... 21
Table 2: Summary of TAT on FBC and UEC .................................................................. 41
Table 3: Status A3 Report ................................................................................................. 47
LIST OF FIGURES
Figure 1: Taxonomy of lean healthcare literature ............................................................. 15
Figure 2: The action research spiral .................................................................................. 25
Figure 3: Cape Pathologists Ltd organisational chart ....................................................... 34
Figure 4: Sample arrival quantities over time (16/09/2010) ............................................. 39
Figure 5: Summary of tests performed at Pinelands lab (01/09/2010-07/09/2010) .......... 40
Figure 6: Responses to Questionnaire 1............................................................................ 52
Figure 7: Responses to Questionnaire 2............................................................................ 56
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
7
Glossary of Terms
Term Definition
JIT Just in time (JIT) is a philosophy based on the Japanese way of
manufacturing: only goods that the customer require are manufactured
as and when the customer needs such goods.
Jidoka A Japanese method of process improvement aimed at making
problems self-evident (Sugimori et al, 1977).
Lean Continuous improvement efforts characterised by elimination of steps
that do not add value for the customer (Womack et al, 1990).
TAT Turnaround Time – the interval between the times the test is requested
by the clinician to that when the result is reported back to the
clinician.
TPS Toyota Production System.
Pathology The study of the causes of diseases in human beings.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
8
1. INTRODUCTION
1.1 Background
Cape Pathologists Limited (a pseudonym) was established more than twenty years ago
and offers professional pathology services to the private health sector in the Western
Cape area. The company has nursing staff who offer phlebotomy services to patients at
the company’s 30 depots within the city of Cape Town. In addition, independent medical
practitioners collect specimens (mainly blood, body fluids and body tissues) from patients
at the practitioners’ respective private practices. A courier service operated by the
company picks up specimens from the depots, physicians’ private practices, and private
hospitals mostly from within metropolitan Cape Town for processing at the main
laboratory in Pinelands (Pinelands lab). Pinelands lab is open for sample processing 24
hours a day, every day of the week throughout the year. On average more than 1000
specimens are processed at Pinelands lab everyday. After analysis of the specimens the
results are released to the respective clinicians via the company’s secure online system.
Dr Jonas (personal communication, May 28, 2010), the general manager of Cape
Pathologists Ltd stated that during the early days samples were processed by highly
specialized medical personnel (pathologists). Over the years automation of pathology
laboratories has allowed concurrent processing of multiple specimens (Buesa, 2009). In
order to take advantage of the resultant economies of scale brought about by automation,
management at Pinelands Lab invested in high tech equipment and hired medical
technologists to operate the machines that process samples and retained pathologists to
verify results (Dr Jonas, personal communication, May 28, 2010).
Pinelands Lab has two operational areas, the pre-analysis and the analysis areas. The pre-
analysis is manual and administrative in nature, consisting of the following sections;
o Receiving – samples delivered by courier are checked for adequacy and quality in
the presence of the delivering agent.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
9
o Data capture – patient information and the requested tests are entered into the
laboratory IT system and stickers with bar codes identifying each sample are
generated.
o Toppling – bar coded stickers are applied to test-tubes and the samples are then
processed in a centrifuge machine.
Brooks (2005) posits that manual pre-processing of pathology specimens is a common
practice in laboratories within South Africa.
In the analysis section, test-tubes are manually loaded into machines (different machines
for different tests) which perform the required tests, and automatically match the results
with the patient. Medical technologists provisionally verify the results (final verification
is done by pathologists) before the results department dispatch these to clinicians as
appropriate.
This research study focused on the flow of specimens and information from the drawing
of such specimens by clinicians at depots, private practices and hospitals through to the
reporting of results back to clinicians via the online system.
1.2 Problem definition and motivation for research
With the growth of the middle class society and the expansion of the private health sector
in South Africa business has increased over the years for Cape Pathologists Ltd, and
Pinelands lab has to process an ever increasing number of specimens (Dr Jonas, personal
communication, May 28, 2010). Clinicians use laboratory results to make patient focused
decisions, and hence the speed with which samples are processed has a bearing on
patients’ duration of stay in hospital (and hence healthcare cost), and on patient outcomes
(Chigwedere, 2007). Urgent tests are mostly requested by clinicians to aid diagnosis and
treatment of critically ill patients.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
10
Dr Jonas (personal communication, May 28, 2010) mentioned that Cape Pathologists Ltd
promises its clients a turnaround time (TAT – from sample drawing and test request to
reporting results) of 2 hours on urgent samples. Increasing sample volumes have created
congestion within the Pinelands Lab, and coupled with the intricacies of other business
operations (phlebotomy service and courier), meeting the promised timelines is becoming
increasingly difficult. Dr Jonas (personal communication, May 28, 2010) estimated that
around 25% of all results on urgent samples were being reported to clinicians after 2
hours. Failure to meet strict timelines promised to clinicians does not only lead to loss of
business to competition, but also to adverse patient outcomes (Dr Jonas, personal
communication, May 28, 2010).
The study therefore focused on exploring the foregoing problem by looking deeper into
the operations of the three divisions (phlebotomy service, courier and Pinelands lab) in
order to understand causes of the problem.
1.3 Research Objectives
The research study sought to explore the implementation of the problem solving A3
report in Cape Pathologists Ltd to reduce turnaround time on pathology results as well as
to improve the staff’s problem solving capabilities. The study sought to answer the
following questions:
o Can the problem solving A3 report be implemented at Cape Pathologists Ltd to
reduce by 30% the proportion of late urgent samples results?
o Does the staff at Cape Pathologists Ltd perceive the problem solving A3 report to
be adaptable to their work environment?
o Can the adoption of the problem solving A3 report at Cape Pathologists Ltd
improve the staff’s problem solving capabilities?
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
11
1.4 Research Hypotheses
The primary hypotheses of the study are as follows
o The problem solving A3 report can be implemented at Cape Pathologists Ltd to
reduce by 30% the proportion of urgent samples results exceeding TAT of 2hrs.
o The staff at Cape Pathologists Ltd perceives the problem solving A3 report to be
adaptable to their work environment.
o The adoption of the problem solving A3 report at Cape Pathologists Ltd can
improve the staff’s perceptions of their own problem solving capabilities.
1.5 Research Assumptions and Ethics
The study at Cape Pathologists was subject to the following assumptions:
o Issues contributing to lengthy turnaround time were limited to the three divisions
of Cape Pathologists directly involved with the pathology process (phlebotomy,
courier and Pinelands lab).
o The staff could assimilate the concepts of the problem solving A3 report in the
limited time period of the research project, and would be motivated to find
solutions to contribute towards improvement.
o The interpersonal dynamics within teams and staff attitudes resulting from the
change brought about by the A3 implementation would have no impact on the
outcomes.
o Delays in reporting results to clinicians affect the relationship between Cape
Pathologists and the clinicians, and might lead to loss of business to competitors.
o Timely reporting of results on urgent samples to clinicians positively affects
patient outcomes.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
12
o The time allocated to the research project (three months) was enough to observe
the desired process improvement.
Throughout the study the researcher remained cognisant of ethical dimensions that could
have potentially impacted the research project. The researcher is not aware of any ethical
issues that arose and the following actions are hoped to have mitigated the development
of such ethical considerations:
o Access was sought from significant parties at all times.
o Participants’ consent and willingness to participate was confirmed on an ongoing
basis since the project followed an emergent process.
o Participants were continuously assured of confidentiality and information from
participants was kept in confidence and used for the sole purpose of the research.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
13
2. LITERATURE REVIEW
2.1 Toyota Production System and Lean Principles
Sugimori et al (1977) summarised the Toyota Production System (TPS) as developed by
then Toyota’s chief engineer Taiichi Ohno over the preceding two decades. According to
Sugimori et al (1977), the cornerstones of TPS are;
o just-in-time production, where only the right quality and quantity of product is
made when the customer wants the product, any excess from this being viewed as
waste; and
o Respecting and empowering employees so that they make any production
problems instantly self evident (jidoka).
The publication of TPS by Sugimori et al (1977) attracted research interest from scholars
and academics (e.g. Schonberger, 1982a; cf. Hall, 1983a; Monden, 1983). However,
dissemination of the Japanese production system came to the fore much later; around
1991, after the publication of ‘The Machine That Changed The World’ by Womack,
Jones and Ross in 1990 (Holweg, 2007). ‘Lean production’ is a term that was coined by
the International Motor Vehicle Program (IMVP) after a comprehensive study of the
world’s automobile industry (Womack et al, 1990). According to Womack et al (1990),
Japanese car manufacturers utilised methods that were in stark contrast to the mass
production system prevalent in the West because they were short on resources after the
Second World War. Lean production took root in the Japanese industries from around
1950, and by the 1960s, the key features of a lean production system were fully
developed (Womack et al, 1990). During the period of the IMVP study TPS was the best-
known example of lean production (Holweg, 2006).
Lean production is a method that seeks to continuously improve the process by removal
of waste from the flow of material during production (Womack et al, 1990). According to
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
14
Sugimori et al (1977), Taichi Ohno identified the following as sources of waste in the
automobile production industry:
o Transportation – unnecessary movement of parts during production.
o Inventory – stock of material waiting production or finished goods not yet shipped
to customers.
o Motion – unwarranted movement of shop floor staff working on products.
o Waiting – unnecessary waiting by employees on the production line to begin the
next step.
o Over-Processing goods with steps that do not add value for the customer.
o Over-Production of products not needed by the end customer.
o Defects in the product resulting in rework.
Other scholars have included additional types of waste, e.g. goods and services that do
not meet the customer’s needs (Womack and Jones, 2003); underutilisation of people
(Liker and Meier, 2005).
Womack et al (1990) argued that the lean philosophy can be transferred to most settings
including outside the manufacturing industry. Womack and Jones (2003) posit that ‘lean
thinking’ is the best way of getting rid of waste and can be achieved in any organisation
by following five Lean Principles;
o Specify value from the perspective of the end customer.
o Identify activities/processes that add value and eliminate waste.
o Establish flow in the value creating steps.
o Let the customer determine production (make to order)
o Continuously improve the process by seeking better ways of satisfying the
customer
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
15
Lean is based on the tenets of achieving greater customer satisfaction with fewer
resources (Liker and Meier, 2005).
2.2 Lean Healthcare
Figure 1: Taxonomy of lean healthcare literature
Lean principles were first applied to healthcare settings around the turn of the 21st
century. In a study of lean healthcare literature, De Souza (2009) noted a yearly increase
on the subject from 2002, probably indicating enhanced interest in implementing lean to
the health sector. De Souza (2009) divides the literature into theoretical and case studies
depending on the approach that the researchers have taken:
o Theoretical literature relates to attempts in translating manufacturing principles
into the health sector without experimentation (speculative), or provides guidance
as regards the steps practitioners have to follow in order to transform to lean
(methodological).
o Case studies mainly consist of attempts that have been made by scholars and
practitioners to bring lean into hospital departments that deal with patients
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
16
(patient flow studies – e.g. Jimmerson, 2007; Friderichs, 2009; Boysen, 2007),
and other departments characterized by flow of materials such as pathology,
radiology and pharmacy (manufacturing-like).
The latter literature type is of particular importance to the current study.
Some scholars such as De Souza (2009) and Liu (2006) contend that lean principles can
provide an effective way to harness the runaway cost of healthcare prevalent in the world.
Healthcare organisations that have adopted lean thinking and concepts have benefited
through reduced crowding, improved service quality and efficiencies (Dickson et al,
2009; Buesa, 2009). De Souza (2009) envisages the next revolution in health services to
be the integration of the whole supply chain, as has happened in the auto industry, in
order to recoup the benefits associated with lean systems thereby harnessing the runaway
cost of healthcare.
Pathology laboratories are a crucial part of the healthcare system, aiding with the
diagnosis of disease. Samples from patients (blood, urine, stool etc.) are processed using
large volume automated machines to determine clinical markers of disease. Simple
administrative work such as data entry into systems is done manually in most cases. Liu
(2006) posits that traditional workflow techniques should be used to improve efficiencies
in laboratory administrative tasks since automation has greatly increased the number of
samples that can be processed simultaneously. Similar sentiments appear in De Souza
(2009) who argues that the flow of material in a pathology laboratory is akin to that of
material in a manufacturing environment, and hence lean principles can be applied to
these environments with minimal modification. Automation has also standardised not
only the cost of processing, but also quality across pathology laboratories, and hence
more emphasis is being placed on lead times (Smeds, 1994). Increased efficiencies
resulting from lean transformation in pathology settings have been reported (e.g. Brooks,
2005; Chigwedere 2007; Buesa, 2009).
Increased efficiencies in pathology entail improving the turnaround time that pathology
services offer on test requests from clinicians. In medical laboratory testing literature
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
17
there are variations in the definition of turnaround time (TAT). Lundberg (1981) defined
the ‘brain to brain’ turnaround time as the interval between the time that the clinician
orders the test to time that action (treatment decision) is taken by the clinician after
receiving the result for the test. Other definitions of TAT restrict the time period to intra-
laboratory throughput time arguing that steps such as specimen collection, specimen
transport, result interpretation and clinical action are outside the control of the laboratory
(Hawkins, 2007). However, some researchers (e.g. Manor, 1999) posit that extra-
laboratory activities contribute greater than 96% of TAT and conclude that application of
lean principles to the laboratories only will not yield the envisaged turnaround time
improvements.
2.3 The A3 Report
Jackson (2006) states that Toyota utilises a wide variety of the commonly known A3
report, and use this report to succinctly communicate the story of continuous
improvement in a visual and standardised format so that all parties see the story from the
same perspective. Two of these reports are briefly described below:
a) The problem solving A3 report
As part of its management process in lean production, Toyota developed the A3 report: a
report meant to capture problems that an organisation encounters on a single sheet of
paper, and to foster greater problem solving capabilities among staff members (Shook,
2008). The report is usually prepared on paper size A3 (roughly 11 X 17 inches). See
Appendix 1 for an example of the A3 report. A wide range of literature contain
completed examples of the A3 report, e.g. Jackson (2006), Chakravoty (2009), Shook
(2008), and Sobek and Smalley (2008).
The 11" x 17" paper is symmetrically divided into two right and left portions, and each
portion has a set of headings. The names of the headings can be changed to fit the
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
18
organisational context for which the A3 is intended (Jackson, 2006). The A3 report has
roughly nine key elements critical for implementation (Jackson, 2006; Shook, 2008).
o The title/theme names the problem that is to be addressed in a single sentence
(Shook, 2008).
o The owner/date identifies the person who ‘owns’ the issue and the date that the
A3 was last modified (Shook, 2008).
The foregoing two elements are important components to foster accountability and the
ease with which the problem is conceptualized by all concerned parties (Shook, 2008).
The following headings typically appear on the left hand portion of the A3 report.
o Background – “contains a description of all pertinent information needed to
understand the scope of the problem at hand” (Chakravorty, 2009 p. 8). Sobek and
Smalley (2008) posit that the author of the A3 report should be aware of the
requirements of the audience, and should tie the background to organisational
goals so that the use of resources to solve the problem is inherently justified.
o Current condition – depicts the information known about the problem in graphs,
charts, and tables for the audience to easily comprehend what is currently
happening (Sobek and Smalley, 2008). Storm bursts and notes can be used to
highlight the problems on the current process, especially when a value stream
map is used (Rother and Shook, 1998). Sobek and Smalley (2008) argue that the
current situation should be quantified by inserting information such as takt time,
percentage of defects etc, in order to present a fact-based perspective of the
problem.
o Goals/targets – clearly identifies the envisioned outcome. “A quantifiable
standard against which one can compare results is important to determine whether
a change has resulted in improvement” (Sobek and Smalley, 2008, p. 39).
o Analysis – the root cause of the current problem is determined using various
techniques. The 5 Why’s method (asking probing questions five times or more)
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
19
and the Ishikawa/fishbone diagram are examples of such tools (Sobek and
Jimmerson, 2004; Womack and Jones, 2003). According to Sobek and Smalley
(2008), most problems have multiple causes, and experimentation may be
required at this stage to establish cause-and-effect relationships.
The right hand portion of the A3 report often includes variants of the following headings;
o Target condition – Proposes some corrective action (countermeasures) to close
the gap between the current condition and the desired outcome until a better
alternative is found (Sobek and Jimmersom, 2004). Jimmerson (2007) stresses the
need for diagrammatic and/or quantitative representation of the target condition
so that the difference from the current condition presented on the left side is easy
to understand.
o Implementation plan - records the necessary steps to be taken, assigns
responsibility to the action plan, prescribes a timeline by which the improvement
process is to be carried out and identifies expected outcomes (Chakravorty,
2009).
o Follow up – “Creates a follow up review/learning process and anticipates
remaining issues” (Shook, 2008, p. 7). Accountability is reinforced at this stage
by clearly identifying who will do the follow-up, when the follow up will be done
and what test will be done to assess the progress of the improvement process.
b) The status A3 report
Sobek and Smalley (2008) describe another variant of the A3 report: the status A3 report.
The status A3 report focuses mainly on the Check and Act phases of the PDCA cycle,
and is used to report the progress of an improvement initiative. In addition to the theme
that addresses the content to the audience, the status A3 report has got the following
components (Sobek and Smalley, 2008):
o Background – contains a summary of the information pertinent to the project.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
20
o The current condition – describes the changes that have taken place over the
preceding course of the project. Under ideal conditions, this current state should
mirror the future state envisioned at the beginning of the improvement process. A
comparison of the before and after states may help the audience to conceptualize
the difference.
o Results – objectively communicates the impact of the project in a quantitative
format. A baseline measurement should be available for comparison in order to
judge the effectiveness of the improvement.
o Unresolved issues – identifies actions that need to be completed and assigns
responsibility to such action items. Actions may include responding to
divergences between the planned outcome and the actual state achieved.
2.4 Conclusion
The transfer of lean manufacturing principles into healthcare has gathered momentum
over the past decade (De Souza, 2009). The lean movement has offered organisations
solutions to real problems that they encounter in practice (Shook, 2008). Organisational
members continue to provide valuable insights on how the transformation towards lean
can be achieved. However, most of the literature that is sprouting regarding lean
healthcare is in the form of case studies, many of them from the developed world.
Although experimentation with lean in the South African context is on the rise (e.g.
Brooks, 2005; Booysen, 2006), more cases are needed to form an opinion about the effect
of this process improvement principle due to the wide and varied nature of healthcare in
South Africa (Leon and Mabope, 2005).
The pathology sub-section of healthcare is considered similar to a manufacturing
environment, and therefore much more apt to realise the benefits of lean manufacturing
principles (De Souza, 2009). However, several authors have bemoaned the impact of
extra-laboratory activities as a stumbling block for lean implementation within the
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
21
laboratory (Brooks, 2005; Chigwedere, 2007). Smellie, Galloway and Johnston (1995)
posit that laboratories that are in control of most of the extra-laboratory activities,
especially the courier service, can realise greater improvement in turnaround time since
they can optimise operations by experimenting with lean through the entire value chain.
The implementation of the A3 report within organisations in South Africa is still in the
early stages. Friederichs (2009) reported successfully implementing such a tool in a
community health centre. The current study sought to add to the foregoing literature by
experimenting with the A3 report in a pathology service environment.
Table 1: Linking research question to methodology
RESEARCH QUESTION RESEARCH DESIGN
Can the problem solving A3 report be implemented
at Cape Pathologists Ltd to reduce by 30% the
proportion of urgent sample results exceeding TAT
of 2 hours?
Action research methodology and
quantitative assessment of results
achieved.
Does the staff at Cape Pathologists Ltd perceive the
problem solving A3 report to be adaptable to their
work environment?
Triangulation between field notes
and Likert Questionnaire 1.
Can adoption of the problem solving A3 report at
Cape Pathologists improve the staff’s problem
solving capabilities?
Triangulation between field notes
and Likert Questionnaire 2.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
22
3. RESEARCH METHODOLOGY
3.1 Research Approach and Strategy
The researcher followed an Action Research (AR) methodology. The researcher began
with premises that were initially taken to be true (Leedy and Ormrod, 2010), collected
data from ongoing research and developed theory by deduction (Saunders, Lewis and
Thornhill, 2003), regarding A3 implementation in pathology labs. Leedy and Ormrod
(2010) posit that deductive logic is extremely useful in evaluating and testing hypothesis
and theories.
While the first hypothesis for the study lent itself to quantitative evaluation, the ensuing
sub-questions required a qualitative analysis. Therefore the researcher utilised a mixed
methods strategy. Coghlan and Brannick (2005) contend that action research has the
potential to achieve greater validity and reliability when mixed methods are used than
when a single method strategy (either quantitative or qualitative) is used in isolation.
3.2 Research design
3.2.1 Background to action research
The following concise definition of action research was put forward by Shani and
Pasmore (1989, p. 439): “Action research may be defined as an emergent inquiry process
in which applied behavioral science knowledge is integrated with existing organisational
knowledge and applied to solve real organisational problems. It is simultaneously
concerned with bringing about change in organisations, in developing self-help
competencies in organisational members and adding to scientific knowledge. Finally, it is
an evolving process that is undertaken in a spirit of collaboration and co-inquiry”
Action research developed largely from the work of Kurt Lewin (Coghlan and Brannick,
2005). Lewin (1946) proposed a cyclical approach to solving problems consisting of a
pre-step (naming the problem) and three core steps;
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
23
o Planning – conceiving an overall plan regarding what action to take as the first
step.
o Action – taking the first step, and
o Fact finding – assessing the first step, learning from the initial step and
formulating the basis for the next step.
Building up on Lewin’s work, Argyris, Putman and Smith (1985, p. 8-9) summarised the
main principles of action research as follows:
a. “Action research involves providing assistance to client systems by generating
solutions through change experiments.
b. Involves a continuous spiral of steps from identifying a problem, planning action,
taking action and evaluating the results of action.
c. Re-education of participants through evidence generated from the research so that
the participants exercise free choice to engage in new kinds of desired action.
d. Challenging the status quo from a participation lens; this also adds to effective re-
education.
e. Simultaneous contribution to the problem at hand and to basic knowledge in
social science.”
In the context of this research project, the specific change experiments involved
improving the process at Cape Pathologists Ltd in order to meet promised sample results
turnaround timelines.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
24
3.2.2 Implementing action research
Brooks (2005) successfully transferred lean principles (waste elimination, value stream
mapping etc) into a pathology laboratory at a central hospital setting, but did not utilise
the A3 report as the process improvement tool. A successful implementation of the A3
report in a healthcare setting was recorded by Friderichs (2009), who advocates for
building interdepartmental small teams to focus on each problem to be solved using the
report. The research drew insights from implementation of the A3 report in a
manufacturing environment (Chakravorty, 2009) because in both environments, service
agents interact with non-human components of a process to create value.
Davidson, Martinsons and Kock (2004) identify five stages of robust action research:
researcher-client agreement, cyclical process model (CPM), theory, change through
action, and learning through reflection.
o Researcher-client agreement (RCA) - the RCA manages the relationship of the
researcher and the organisation. Chakravosky (2009) contends that the RCA is
vital for establishing internal validity of the findings, and must give the
researcher the right to access all data and people relevant to successfully
complete the study. Davidson et al (2004) posit that the RCA indicates the degree
of commitment of the organisation to the change initiative. As an initial step, the
researcher sought a viable RCA with the relevant stakeholders. Stakeholders in
this research included the management and staff close to the flow of specimens
and results at Cape Pathologists Ltd.
o Cyclical process model - There are many variants of the cyclical model of action
research, and different authors include varying numbers of steps in a cycle (cf
Coughlan and Coghlan, 2002; cf Susman and Evered, 1978). Susman and Evered
(1978) proposed a model consisting of five stages: diagnosis, planning,
intervention, evaluation and reflection. Kemmis and McTaggart (1988) modified
the cycle into a spiral, with each successive evaluation leading to revision of the
initial idea, and the beginning of another improvement cycle towards perfection.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
25
Brainstorming and reflection sessions to conceive ideas for process improvement
are an important starting point for the change initiative (Chakravorty, 2009).
According to Sobek and Smalley (2008) the problem solving A3 report coincides
with the planning stage of the action research spiral. The current study therefore
started with a problem and followed a structured approach to problem solving
enforced by the A3 report.
While other researchers argue that “a masters core AR project need only progress through
one planning, acting, observing and reflecting cycle of management practice to
demonstrate mastery of the research methodology” (Perry and Zuber-Skerritt, 1991, p.
77), Grundy and Kemmis (cited in French, 2009) contend that a single cycle is the tip of
an iceberg and hardly constitute action research. The researcher aimed to progress
through two AR cycles as suggested by Saunders et al (2003), but time constraints
prevented successful completion of the second cycle.
Figure 2: The action research spiral
o Theory - McKay and Marshall (2001) posit change initiatives that are completed
without a thorough grounding in theory do not qualify as action research.
Davidson et al (2004) also proposed that problem diagnosis and alternative
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
26
solutions should have a strong theoretical backing. This research project was
undertaken with thorough reference to theoretical tools and models (e.g. A3
report, fish bone diagram). Participants were mentored on how to use these tools
effectively before implementation commenced.
o Change through action- Action research is not only about forming a world view,
but also to take action so as to arrive at the desired outcome (Coughlan and
Brannick, 2001). “Changes may operate at both personal and organisational
levels. Individuals in the organisation may experience changes in roles and
responsibilities, and be required to develop news kills” (Davidson et al, 2004).
When the A3 report is implemented in an organisation, the processes as well as
individuals are transformed (Charkravorty, 2009).
o Learning through reflection- Learning is an important aspect and is specific to
action research (Lau, 1997 as cited in Davidson et al, 2004). The researcher
should make sure that learning is taking place within the organisation, and should
communicate such learning through e-mails, learning logs and bulletin boards
(Davidson et al, 2004). Cady and Caster (2000) suggest that during the learning
phase, judgements and facts should be kept separate so that readers can make
their own assessments and interpretations. The researcher spent a significant
amount of time with the participants reflecting on ongoing activities. The learning
process was captured in the research log and was fed back to participants on an
ongoing basis.
3.2.3 Change management in action research
Action research involves challenging the status quo and changing the way people within
a system normally perform their duties. Biazzo and Panizzolo (2000) posit that the
transformation towards lean operations changes the culture within an organisation as
manifested by worker-worker and worker-management relationship changes. These
changes often go unnoticed as researchers concentrate on measurement of metrics such as
cycle time; capacity and throughput (Biazzo and Panizzolo, 2000). Managing change
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
27
starts with a strategic vision and intent by management but the ‘bottom-up’ approach
innovation and learning should be promoted (Smeds, 2010). McHugh (1997) suggests
that inclusion of organisational members in change planning and implementation is vital
to the success of change initiatives because neglecting the needs of workers will lead to
increased stress which can manifest in costly ways that derail change initiatives.
3.2.4 Applicability of AR methodology to current study
According to Coughlan and Coghlan (2002), action research is applicable when the
research question obligates the researcher to describe events concerning solving an issue
in an organisation over a period of time, including the development of ideas and the
learning that results from the action taken on those ideas. Furthermore, O’Brien (1998)
states that action research is the methodology of choice when the research requires people
to participate in solving real problems, especially when a change has to occur quickly or
holistically.
Cape Pathologists Ltd was experiencing issues of concern around long lead times and
congestion within the laboratory. The study sought to solve these problems, and entailed
the participation of frontline people in developing and championing the solutions. As
suggested by Smeds (2010), the strategic intent had been created by management and the
shop floor staff given the mandate to change things with the researcher facilitating the
said change. Within the context of the foregoing literature review, the researcher argues
that Cape Pathologists Ltd provided an ideal environment for action research and the
implementation of the A3 report as a problem solving tool.
3.3.5 Role of the researcher
O’Brien (1998) outlines some of the roles that an action researcher assumes during the
action research process. These roles include facilitator, teacher, catalyser, listener,
observer, reporter and synthesiser. The main role of the researcher is to facilitate
dialogue, reflection and action, and to nurture organisational participants to the point
where they are in a position to take responsibility for the process and are able to
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
28
continuously replicate the action research spiral when the researcher leaves (Coughlan
and Coghlan, 2002; O’Brien, 1998). Nurturing participants requires the researcher to
create a learning environment in which participants are able to develop insights in
themselves and the environment (Burnes, 2004).In action research, the researcher has to
balance two objectives: the creation of knowledge as well as positive contribution
towards company goals (Westbrook, 1995). The researcher’s background and experience
has the ability to impact success since these variables can assist the researcher to grasp
the complexities of the environment under study and to infer knowledge from it (Argyris,
1983).
The researcher contends that his medical background and experience contributed
positively towards understanding the business. Throughout the project the researcher
strove to mentor participants to exercise their own initiative in discovering superior
solutions to problems by encouraging open discussion, inquiry and reflection on actions
taken.
3.2 Data collection methods and research instruments
Action research exposes the study to both qualitative and quantitative data collection.
Collection of multiple data types can lead to better understanding of the study through the
process of triangulation (Leedy and Ormrod, 2010). Coghlan and Brannick (2005)
contend that in action research methodology, data is not merely collected but generated as
well through the continued interaction of the researcher-participants in action research
cycles.
Primary data generation was driven by the A3 problem solving report modeled on a
PDCA cycle. Two problem solving A3 reports were prepared during the course of the
research. The first A3 report focused on reducing the throughput time of specimens at
Pinelands lab while the second A3 report focused on reducing courier time for urgent
specimens. During the preparation of the A3 reports, secondary data sources were also
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
29
utilised. In order to place reliance on secondary data sources, the researcher ought to
understand the reason why such data was collected (Coghlan and Brannick, 2005). The
main sources of secondary data were the Disalab® IT system and textual work
instructions. The Disalab® IT system is meant to provide a store of information for tests
performed at Pinelands lab as well as an audit trail of specimens through the various
departments delivering the pathology service. These data sources landed themselves for
analysis pursuant to the current study since data contained therein is objectively recorded
as mandated by rules and regulations (Dhatt and Peters, 2001).
Nadler (1997, as cited in Coughlan and Brannick, 2005) argues that survey instruments
used within action research generate data by eliciting observable behavioural
phenomenon in participants: data that the researcher can record during the reflection
phase to corroborate findings. In the current study two Likert type questionnaires were
used (Appendices 2 and 3). The questionnaires were simplified to a five-point response
scale since some of the participants lacked autonomy by working under strict standard
operating procedures and therefore may have diminished decision making ability to
complete an eight-point scale questionnaire (Bernal, Woody and Schensul, 1997, as cited
in Friderichs, 2009). The first questionnaire was developed to measure the perceptions of
the staff regarding the usefulness of the problem solving A3 report in Cape Pathologists
Ltd. The questionnaire was distributed to participants at the end of formal and informal
meetings, as well as after one-on-one coaching and mentoring. The second questionnaire
was given out to participants at the end of the research project and was designed to
measure the staff’s own perceptions of growth in problem solving capability after
participating in A3 problem solving over the course of the project.
Documenting reflections in a research journal is of utmost importance in action research,
and is conveniently done by the researcher in private soon after engagement with other
participants (Coghlan and Brannick, 2005). Together with meeting transcripts and notes,
these data sources form the core of field notes in action research (Coughlan and
Brannick, 2005). Over the course of the project, the researcher kept such a journal
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
30
(Appendix 8), and data from it was used to triangulate findings from questionnaires.
3.4 Sampling
According to Leedy and Ormrod (2010) sampling in action research relates to both types
of data gathered during the research cycles. The study under review utilised both
quantitative as well as qualitative methods. Sampling therefore involved selecting
participants to complete the Likert questionnaires and selecting data to analyse for
quantitative measures.
Cape Pathologists Ltd has a staff complement of around 200, approximately 130 of them
(mainly nurses, clerks, data capturers, topplers, transport coordinators, drivers and
technologists) involved directly with the handling of specimens and results. Staff from
the pre-analysis and the analysis areas totaling 20 participated in the A3 report concerned
with reducing throughput time at Pinelands lab while 5 coordinators participated in the
A3 report aimed at streamlining the transport system. Purposive sampling was the most
appropriate sampling technique in this setting and hence questionnaires were distributed
to the staff that participated in A3 problem solving since they were deemed to have the
requisite knowledge to form an opinion on the matter. 100 copies of the first
questionnaire were distributed repeatedly to 25 participants and 85 responses were
received while 25 copies of the second questionnaire were distributed, eliciting an 80%
response rate. The foregoing response rates are generally higher for surveys especially in
a hierarchical environment where participants might have felt obliged to take part in the
study.
For the purposes of primary quantitative data generation, urgent FBC and UEC tests
formed the population from which convenience sampling of the specimens was
undertaken on certain days to indicate either the current condition or the achieved
outcome of the problem solving A3 report. Simple random sampling of secondary data
from a population of urgent FBC and UEC tests was also done to corroborate primary
data generation.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
31
3.5 Data analysis methods
The first research question lends itself to quantitative data analysis since it points towards
a quantitative reduction (30%) in the proportion of sample results that are reported late to
the clinicians. Simple descriptive statistics were used to analyse the available data to
answer the first research question.
The second and third research questions are qualitative in nature, and analysis of the data
was achieved by simply counting the frequency of responses to each question. An
arithmetic average was then calculated for each question to give a single response to the
said question. The author acknowledges loss of meaning that happens when qualitative
data is numerically coded (Leedy and Ormrod, 2010), but argues that triangulation of
field notes and Likert questionnaires in each of the two sub questions added to the
substance of the research. The open ended questions in the two questionnaires were
interpreted by the researcher.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
32
4. RESEARCH FINDINGS, ANALYSIS AND DISCUSSION
This section has been organised in the following sub-sections: 1) the pre–step highlights
activities that were carried out before the actual A3 implementation. 2) The
organisational and environmental analysis gives an overview of the operations of the
organisation Cape Pathologists Ltd that were under study. 3) The hypothesis testing sub-
section details the findings that relate to each respective hypothesis before analysing and
discussing those findings and gives an opinion on the hypothesis.
4.1 The pre-step
Several steps were necessary before implementing the problem solving A3 report at Cape
Pathologists Ltd. To begin with, Dr Jonas and Mavis (pseudonym -operations manager)
and the researcher mapped out the objectives and scope of the project in a researcher-
client agreement (RCA). Some of the details included in the RCA were that:
o the client was committed to TAT improvement and would grant the researcher
unlimited access to the business operations and premises, the employees and all
pertinent company information and data;
o the researcher would provide process improvement coaching and training in
informal and formal meetings to employees;
o the researcher would document all process improvement efforts in a research log
and provide feedback regularly to management and employees; and
o All employees would be available at their respective work stations during off-
peak periods (10h00 to 12h00 and 15h00 to 16h00) to provide feedback to the
researcher on the improvement efforts.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
33
Since the research was exploring the implementation of the problem solving A3 report,
the A3 reports became the default tool to document and communicate the improvement
initiatives. The process improvement leaders (Dr Jonas and Mavis) suggested the use of
simple process improvement tools in order to increase the participation of shop floor
workers who did not have the necessary skills to understand sophisticated tools. In the
laboratory part of the operation, technologists use sophisticated quality tools such as
statistical process control. However, these tools have been introduced to measure quality
of results in relation to an established benchmark (precision and accuracy) and have
never been applied to the measurement of TAT.
The organisation has been exposed to process improvement initiatives in the past. Lean
manufacturing principles were presented to the organisation by a pathologist who has
since left the company. No changes were initiated after the presentation, and the
enthusiasm left the organisation with the said pathologist who attempted to implement
lean principles. As a result, organisational members had rudimentary knowledge of
process improvement. The researcher had to take an active role in designing the contents
of the training program. The main elements of the training program revolved around
using the A3 report in solving process problems that the organisation experienced on a
daily basis. Instead of viewing the A3 as a record, the researcher emphasised the
structured approach that this tool brings to problem solving. Tools incorporated in the A3
report included value stream mapping, the concept of waste in healthcare, 5 Why method,
fish bone diagrams and process flow diagrams.
4.2 Organisational and environmental analysis
The following findings are based on observations by the researcher and information from
meetings (formal and informal) held by the researcher and organisational members
during the course of the research project. The organisational chart below shows the
hierarchy of various departments within the organisation.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
34
Figure 3: Cape Pathologists Ltd organisational chart
In light of the foregoing literature, the definition of TAT has been modified to suit Cape
Pathologists Ltd. Since the company operates a phlebotomy service and a courier service,
the company is therefore in control of the extra-laboratory activities offered by these
departments. For Cape Pathologists Ltd TAT is the interval from the time that the
clinician orders a test to the time that the result is reported back to the clinician. The
research project therefore focused on three departments involved in the process of
handling specimens and results (phlebotomy service, courier service and Pinelands lab).
A brief description of the activities carried out in these departments is as outlined below
4.2.1 Phlebotomy service
The phlebotomy service is offered by the nursing department. Cape Pathologists has 30
depots dotted within metropolitan Cape Town and these depots are staffed by a mixture
of nurses and clerks, nurses forming up to 75% of the 80 staff complement. 15 depots
have permanently stationed clerks while the other 15 are serviced by three clerks on a
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
35
rotational basis. About 20% of the nurses are locum employees (part-time) who are called
upon as and when they are required. 17 depots are located within private hospitals while
the remaining 13 are stand-alone sites. Nursing staff at hospital depots participate in ward
rounds with the doctors, typically around 07h00, and collect samples for tests as ordered
by the doctors. During the rest of the day, they wait in the depot either for ward staff to
call them for specimen collection when required, or for walk-in patients referred from the
outpatients departments. For the depots that are not in close proximity to hospitals, the
nursing staff waits for walk-in patients either referred by independent medical
practitioners from their practices, or self referred.
When the patient presents at the depot, s/he is given a laboratory test request form to fill
in the details, if s/he does not have one already from the referring clinician. When
available the clerk will highlight the requested tests for improved visibility further down
the value stream. The nurse will then collect the type of specimen that has been
requested. The main type of specimen collected at the depots is blood, normally
transported in 5 milliliter test tubes. The number of patients attended to at each depot is
variable depending on the size and site of the depot, generally ranging from 5 to 80
patients per day. The amount of specimens collected per patient is very variable and
depends on the nature of the tests that have been requested. After phlebotomy, the nurse
notifies the courier service at Pinelands Lab and communicates the urgency of the test
required (urgent versus routine).
According to the nursing manager, the staff turnover rate within the department is low
(approximately 5% to 10% per year). However, the following challenges were noted:
o Limited communication from the nurses to the nursing office at Pinelands lab
regarding leave days, leading to short-term staff shortages.
o Low rates of utilisation of the available resources such as the internet and
company database.
o Failure to check completeness of patient information on forms when sending
specimens to Pinelands lab.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
36
4.2.2 Courier service
The transport manager oversees the courier service, and the office is stationed at
Pinelands lab. The courier service utilises small vans and motorbikes as the forms of
specimen transport from different sites to Pinelands lab. The staff complement is made up
of transport coordinators and drivers. The coordinators receive telephonic notification of
specimens for collection from depots, hospitals or medical practices and dispatch a driver
to the requesting site. The workload is divided into three categories depending on the
priority demanded by the clinicians as follows:
1) Stat specimens are those samples on which clinicians require results immediately.
When coordinators receive requests for stat specimens, a driver is immediately
dispatched to the requesting site from the pool of stat drivers waiting at Pinelands
lab for such requests.
2) Urgent specimens are samples from all the private hospitals that the laboratory is
serving. Specimens are collected by a pool of drivers allocated to various hospital
routes at 2 hourly intervals from 07h00 to 19h00 and normally 5 to 6 rounds are
completed in a day.
3) Routine specimens are those that come from independent medical practices and
such specimens are collected by a third pool of drivers. Drivers normally present
at the lab from the 2 rounds around 13h00 and 17h00.
The following challenges were noted in the courier department:
o Nursing staff at depots call in with vague information regarding the urgency of
tests requested thereby hindering coordinators from making the best decisions.
o Staff at hospitals has a tendency of marking samples as stat with the hope of
getting the results sooner than usual. However, this practice leads to coordinators
dispatching stat drivers unnecessarily to collect samples that might otherwise
have been collected by the hospital drivers on their usual rounds.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
37
o Traffic jams during the morning and evening rush hours prevents smooth flow of
the courier service.
o The distance from Pinelands lab to depots is variable and therefore presents a
difficulty in standardising the time needed to perform the service.
o Drivers often call in sick causing service delivery failures.
4.2.3 Pinelands Lab
Pinelands lab performs the actual tests that are requested by clinicians. The lab operates
24 hours a day, seven days a week throughout the year, and the staff therefore operates on
a shift basis. The morning shift commences at 05h00 and ends at 14h00 when the
afternoon shift starts. The afternoon shift ends at 22h00 and a skeleton night staff
oversees the laboratory until the beginning of the morning shift of the next day. The lab is
divided into pre-analysis and analysis areas.
The staff in the pre-analysis section does either of two roles, data capturing and checking
or toppling:
1) Data capturing involves entering patient information and tests requested into the
Disalab® IT system used by the lab while data checking is a control step to verify
if all information from the form has been entered as well as linking the
information to the relevant billing system. On any given shift on average 4 people
capture data while 2 people check the quality of the data entered.
2) Toppling involves labeling the specimens with bar codes and centrifuging
specimens as needed depending on specimen type, as well as physically taking
the specimen to the relevant department in the analysis section. 1 or 2 people are
usually allocated to this work station. The station utilises 4 centrifuge machines
with a combined capacity to run 130 specimens concurrently. However a single
specimen can be processed in any of the centrifuges.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
38
The analysis area comprises 4 departments: histology, microbiology, chemistry and
hematology. On a given shift each department is normally manned by 1 or 2 qualified
technologists with the support of a laboratory technician. The actual analysis of
specimens is done by automated machines after the specimens have been loaded into
such machines. The machines can typically process over 100 specimens at the same time
and more specimens can be loaded continuously while analysis is continuing on other
specimens already loaded. Each of the 4 departments has two machines that can perform
the same tests; the one machine serving as back up while the other is being used.
The following challenges were noted at Pinelands lab:
o High staff turnover, especially in the pre-analysis area, of around 30% - 40% per
annum (Dr Jonas, personal communication, May 28, 2010).
o Calls from outside the laboratory to the pre-analysis area disrupt service delivery
and the flow of samples.
o Incompletely or erroneously filled forms result in trouble shooting by data
capturers leading to further delay of sample processing.
o The protocol for urgent specimens was not being followed as it is documented in
the work instructions.
4.2.4 The service value stream and nature of the problem
In order to understand the nature of the problem at hand (failure to meet TAT of 2hrs or
less) the researcher and the management at Cape Pathologists Ltd decided to map out the
operation with a high level value stream map. The foregoing description in 4.1.1 details
the set up of the departments in isolation but these departments interact continuously to
deliver value for the customer. The service was therefore conceptualised to be composed
of 3 phases, all contributing to the TAT. Phase 1 is the phlebotomy service, whereby
nurses from the organisation’s 30 depots collect samples (blood, body fluids and body
tissues) from patients at the depots or in the hospital where such depots are located. In the
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
39
same phase, independent medical practitioners at their practices also collect samples from
patients for analysis. In phase 2, a driver is dispatched from Pinelands (after notification
either by a nurse at the depot or by the doctor at his practice) to collect the sample and
bring it to the lab in Pinelands for analysis. In phase 3, the specimen progresses through
the stations at the lab culminating in the analysis of the specimen and the subsequent
release of the results to the requesting clinician.
Since all specimens end up at Pinelands lab, this location provided a station where data
could be collected to quantify the problem at hand. At the receiving bay, specimens are
physically counted and recorded, noting the priority of the tests requested. Sample arrival
volumes for 16 September 2010 were analysed and revealed the nature of the demand as
depicted below in Figure 1. For ease of modelling demand the arrival time of samples
was rounded off to the nearest hour, e.g. samples arriving between 14h30 and 15h30 were
taken to have arrived at 15h00.
Figure 4: Sample arrival quantities over time (16/09/2010)
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
40
On that particular day, a total of 1075 specimens were received at Pinelands lab, almost
30% marked as urgent. About 60% of the samples were received from the 17 hospitals
that are serviced by the company while the remaining 40% of the samples were received
from independent medical practices and stand alone depots.
A random sample of secondary data was extracted from the Disalab® IT system (from
01/09/2010 to 07/09/2010 inclusive) and Figure 2 below shows the main characteristics
of the tests. The laboratory performs numerous tests, with actual analysis of some tests
such as liver function and cardiac enzyme tests lasting more than 90 minutes. Achieving
a 2 hour turnaround on tests that take long to analyse is therefore unlikely. The run time
for the tests Full Blood Count (FBC) and Urea Electrolytes & Creatinine (UEC) is at
most 10 minutes: therefore, these tests were chosen as a proxy for all urgent tests that
should be able to meet the TAT of 2 hours.
Figure 5: Summary of tests performed at Pinelands lab (01/09/2010-07/09/2010)
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
41
A total of 14600 tests were performed over the week and 40% of all the tests were urgent.
FBC and UEC (routine and urgent) formed 14% of the total. One fifth of the tests did not
have the time of specimen drawing from the patient recorded/noted and these tests were
excluded from further analysis. Just under half of the tests that had the time of sample
collection recorded had been labeled as urgent (45%), urgent FBC and UEC making up
9% of the total.
The abovementioned urgent FBC and UEC were further explored to quantify the problem
of failure to meet TAT of 2 hours. The time from sample drawing to registration was
used as a proxy for the time taken by the courier service to deliver the sample, while the
time from registration of the sample on the Disalab® IT system to the time that the result
got recorded on the same system was used as an indicator of the throughput time of
samples at Pinelands lab. The table below summarises the important insights gained from
the analysis of the 1517 FBC and UEC tests used.
Table 2: Summary of TAT on FBC and UEC
ITEM PARAMETER VALUE
Delivery time Average 66 minutes
Delivery time Standard deviation 43 minutes
Delivery time Median 60 minutes
Pinelands lab throughput time Average 39 minutes
Pinelands lab throughput time Standard deviation 26 minutes
Pinelands lab throughput time Median 30 minutes
Total TAT Average 105 minutes
Total TAT Standard deviation 62 minutes
Samples processed within 2 hours Percentage 69%
Samples processed after 2 hours percentage 31%
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
42
The analysis revealed that 470 specimens failed to meet the TAT of 2 hours or less. The
company has no standard time within which specimens are suppose to be delivered by the
courier to Pinelands lab and there is also no standard throughput time at Pinelands lab.
However, roughly 17% of the specimens that did not meet the TAT of 2 hours were
delivered already late (after 2 hours). 8% of the specimens that did not meet the
prescribed TAT were in the lab for over 2 hours.
4.2.5 Summary of environmental analysis
Cape Pathologists has been failing to meet the TAT promised by the company to
customers. Approximately 31% of all urgent specimens are delivered later then the
promised TAT of 2hours. The three departments involved in the handling of specimens
are the phlebotomy service, the courier service and the Pinelands lab: all of them
contribute to the lengthy TAT observed in analysed data from the Disalab® IT system.
The following problems were conceptualised to be causing a delay in the progression of
specimens and results through the value chain and hence a longer TAT than planned.
o Incorrect or missing information on forms
o Extra specimens send to Pinelands lab by the phlebotomy service as well as by
independent medical practitioners.
o Calls directed to the pre-analysis area from depots do not only add to the
workload of staff in that department, but also interrupt normal workflow, further
delaying processing.
o The phlebotomy service provides insufficient information regarding urgency
status of tests requested.
o The courier does not have standard intervals and routes for delivering specimens
from the sites that the company is serving, and delivers specimens later than 2
hours.
o The protocol for urgent specimens is hardly followed at Pinelands lab.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
43
4.3 HYPOTHESIS TESTING
4.3.1 Hypothesis 1
Ho: The problem solving A3 report can be implemented at Cape Pathologists Ltd to
reduce the proportion of urgent samples results exceeding TAT of 2hrs by 30%.
Method of Verification Source Material
Quantitative & Qualitative – Action
research cycles undertaken at Pinelands lab
Data generated during research, secondary
data from the Disalab® IT system and field
notes.
4.3.1.1 Findings and observations
4.3.1.2 Action research cycles
The list of challenges identified under the summary of organisational and environmental
analysis (section 4.2.5 above) formed the problems to be solved using the A3 report. An
initial attempt was made to draw a single A3 report with the theme “reduction of the
proportion of urgent specimen results exceeding 2 hours TAT”. However, the problems
identified above tended to be department specific e.g. the nursing staff had no knowledge
of the protocol at Pinelands lab. A decision was then made to disaggregate the problem
into its components as outlined above, each department identifying problems that were
specific to it. This gave people close to the process an opportunity to apply their
knowledge and experience of work to structured problem solving. The planning part of
the action research cycle coincided with the drawing of the A3 report and was followed
by the implementation of the plan, checking the follow up plan and responding to
divergences from planned outcomes to complete the cyclical process model of AR.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
44
4.3.1.3 First AR Cycle: reduction of throughput time at Pinelands lab
Over the period beginning early September 2010 to late October 2010, the staff in three
departments (phlebotomy, courier and Pinelands lab) was involved in A3 report
simulations exercises, informal discussions, and one-on-one coaching. In addition, the
environmental analysis was done over the same period, culminating in a thorough
understanding of the problems that needed attention. On the 26th of October 2010, the
first non-simulation problem solving A3 report was started by the staff at Pinelands lab.
The morning shift staff started the process and the late shift staff continued contributing
insights in the afternoon. Over the entire week iterations were made to several sections,
especially the implementation plan and the countermeasures sections. On 01 November
all the 20 members of the pre-analysis and the analysis sections met to finalize the A3
report and agree on the implementation plan. The final A3 report drawn is as shown in
Appendix 5.
The planned changes started taking effect on the 2nd of November 2010. Most of the
proposed changes were procedural in nature and required participants to follow the
protocol. The researcher observed the protocol implementation on the first 2 days and
entrusted participants to continue with the practice. Over the 2 days that the researcher
observed the process, the following steps were adhered to as planned.
o On arrival of specimens labeled urgent, the data capturers’ team leader distributed
these equally to the 4 team members available. Data capturers would then
complete capturing current forms before immediately turning to the urgent
specimens.
o After capturing, data capturers placed specimens in a red bucket that was centrally
located from all of them.
o The team leader notified the toppling desk about the urgent specimens by
shouting “urgent!!”
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
45
o The toppling bench had 2 people working at all times. On every shift, one person
from toppling was responsible for collecting urgent specimens from the red
bucket and processing these when available. The ‘urgent’ person would help with
routine work after processing urgent specimens.
o The ‘urgent’ person would take the specimens to the appropriate station in the
analysis area and notify the technologist at that station.
The lab supervisor and the researcher followed up by observing the system on the 10th of
November 2010. Moreover, a random sample of urgent test results was extracted from
the Disalab® IT system to validate findings. Although the protocol was observed to be
working as planned, 20% of urgent test results had exceeded the envisioned throughput
time of 29 minutes. Technologists blamed the ‘urgent’ people for not delivering
specimens on time, who in turn blamed data capturer team leaders for not shouting
“urgent!”
In response to the foregoing challenges, participants reconvened and agreed that the
protocol was sound. Proposals were put forward for a bucket that would make the
presence of the urgent specimens visually obvious from the toppling desk. An alarm
system was originally suggested as well but the idea was discarded because it was
thought to be disruptive and irritating due to the high volume of urgent specimens per
day. The technologists proposed an electronic time stamp on all samples between the
toppling desk and the analysis section. Two meetings were later held to discuss the time
stamp, which will be implemented early next year.
4.3.1.4 The second AR cycle: reducing courier delivery time.
The participants from the courier department started working on the problem solving A3
report around the 5th of November 2010. Coordination of efforts was much easier since
the team was smaller than for Pinelands lab. One major setback was that drivers were not
able to attend the A3 meetings and informal sessions since their availability tended to be
unreliable. The resultant A3 that was drawn therefore presupposed that drivers would buy
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
46
into the proposed action plans. Execution of action items started on the 15th of November
and therefore only took effect for 15 days. Appendix 6 shows the final A3 report that the
participants put forward for implementation.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
47
4.3.1.5 Status A3 Report
Table 3: Status A3 Report
Theme: Reduction (by 30%) of the proportion of urgent test results exceeding TAT of 2
hours
Background
Three departments (phlebotomy, courier and Pinelands lab) at Cape Pathologists responsible
for TAT on specimens. Approximately 30% of urgent tests result reported late to clinicians,
resulting in poor relations and possible loss of business
Current Condition
Throughput time at Pinelands lab observed to have been reduced to 29.1 minutes on
30/11/2010. Current value stream map is as below:
X3-4
DATA ENTRY
X2
TOPPLING
X2-3
ANALYSIS
X1
RECEIVING
X2
REPORTING
1.2-5
1.9
1.4-3
2.2
5.5-6.3
5.7
2.1-4.1
2.55.0-10.0
7.7
1.3-3.4
2.6
1.3-3.0
1.9
1.2-2.4
2.0
2.1-3.2
2.6
WASTE 10.1Min
TOTAL 29.1Min
C/T: 5.5 minC/O: 0.5min
C/T: 1.5-5 minC/O: 0.5min
C/T: 1-5 minC/O: 0.5min C/T: 1-2 min
C/O: 0.4minC/T: 5-10 minC/O: 0min
KEY Inventory
C/TCycle Time
C/OChange over time
Proportion of samples exceeding 2 hours in lab= 3%
Data entry for urgent specimens done by all capturers on a shift. One toppler
dedicated to processing urgent samples on every shift.
Transport –specimens delivered after 2hrs = 6%
New drivers are getting training from old drivers.
Web system tracking urgent specimens and transport on pilot phase since 18/11/2010.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
48
Results
Parameter Before After (observed) After (IT system)
Pinelands
throughput time
39 minutes 29.1 minutes 38 minutes
Specimens in
lab>2hrs
8% Not measurable 3%
Delivered after 2hrs 17% 6%
Average delivery
time
66 minutes 68minutes
Proportion of
specimens with
TAT> 2hrs
31% 27%
Percentage reduction achieved =13%
Other results:
Protocol for urgent specimens in place at Pinelands lab.
Coordinators learning the new web based specimen and vehicle tracking system.
Remaining issues
Activity Status Responsibility
Time stamp between pre-analysis
and analysis at Pinelands
In progress
(implementation
01/2011)
IT department
Training of drivers To start 07/12 Coordinators
Conversion to web-based transport
tracking ( do away with pen & paper)
To start 15/12/2010 Coordinators
Errors on forms, extra specimens A3 TBD Nursing department
Training of lab staff TBD Lab supervisor
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
49
4.3.1.6 Analysis and Discussion
At first glance, testing the above hypothesis seems to involve a quantitative evaluation of
the proportion of urgent test results that went beyond two hours after the implementation
of the problem solving A3 report. However, such an approach does not recognise the
piecemeal nature in which the problem solving A3 report was implemented. Under the
current hypothesis, implementing the problem solving A3 report in each of the
departments identified (phlebotomy, courier and Pinelands lab) should lead to the
reduction of the proportion of urgent test results exceeding the TAT promised to
clinicians. Since the implementation was not completed in all three departments as
planned, each A3 report outcomes ought to be evaluated to measure the contribution that
was made towards realizing the hypothesis.
a) Evaluating the first A3 report outcomes
The outcomes of the first A3 report are as outlined in the status A3 report above (Table
2). The aim was to improve the throughput time at Pinelands lab by eliminating waste by
50%. The envisioned throughput time was therefore 28.5 minutes. A random sample of
15 urgent specimens was observed as it progressed through the lab. The average
throughput time was 29.1 minutes, just 30 seconds beyond the expected time. However,
when such a finding was checked against data that was available on the system, the
average throughput time was 38minutes, a minute’s reduction from the average noted
prior to the improvement process. Although the implementation of the A3 did not reduce
throughput time significantly, the proportion of samples that exceeds 2 hours within the
laboratory dropped from 8% to 3%.
The random sample of 15 urgent specimens was probably too small to yield
representative results for the workload of all urgent samples processed at Pinelands lab.
Convenience sampling was used to generate data for analysis and hence results obtained
were subjective. Coghlan and Brannick (2005) posit that participants may increase the
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
50
pace of working when they are being watched resulting in signs of throughput
improvement (the Hawthorne effect). The secondary data from the Disalab® IT system is
much more representative of the workload at Pinelands lab. A total of 1075 urgent FBC
and UEC tests were extracted from the Disalab® IT system and used in the analysis. The
researcher therefore argues that the Hawthorne effect explains the paradox between the
data obtained from the Disalab® IT system (indicating minimal improvement) and that
observed by the lab supervisor and the researcher (showing considerable improvement).
b) Evaluating the second A3 report outcomes
The action items on the second A3 report were executed over a 15 day period. The web
based transport monitoring system was implemented to generate standard courier time by
region (distance from Pinelands lab). At the end of the research period, data was still
being generated to inform coordinators of possible average courier time per route. The
average delivery time did not improve from the baseline. However, the proportion of
samples delivered to Pinelands lab after 2 hours significantly dropped from 17% to 6%.
Observing delivery times on urgent specimens is difficult and would consume a lot of
resources. The researcher therefore posits that although the data used in this evaluation
was secondary data, the results are credible since the data is objectively recorded as
mandated by law.
Conclusion
As presented in the status A3 report, the project achieved a 13% reduction in the
proportion of specimens exceeding TAT by 2 hours.
Reject Ho: The problem solving A3 report can be implemented at Cape Pathologists Ltd
to reduce by 30% the proportion of urgent samples results exceeding TAT of 2hrs.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
51
4.3.2 Hypothesis 2
Ho: The staff at Cape Pathologists Ltd perceives the problem solving A3 report to be
adaptable to their work environment.
Method of Verification Source Material
Qualitative – Feedback was sought from
participants over the 15 week period of the
project.
Likert Questionnaire 1 and field notes
Likert Questionnaire 1 was distributed repeatedly to participants over the 15 week
period of the study. Responses to the each of the five scored questions were aggregated
respectively every week to arrive at an average that was taken to represent the
perceptions of the overall group of participants. An open ended question 6 sought more
clarification about why participants perceived the A3 report as being adaptable or
otherwise to their work environment.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
52
4.3.2.1 Findings and observations
Figure 6: Responses to Questionnaire 1
The perceptions of participants were compiled over the course of the project. The line
graph above shows the various responses to the five questions that were scored from 1
(strongly disagree) through to 5 (strongly agree). The trends observed in the responses to
Likert Questionnaire 1 (Figure 6) can be summarised as follows.
1) The participants generally found the discussions and one-on-one coaching
sessions useful as indicated by a score greater than 4 over the course of the
project.
2) In most cases, the facilitation skills of the researcher were held to be of a high
standard.
3) Most participants initially had difficulties in understanding lean principles
covered in discussions, but from the fourth week onwards, comprehension was
above average.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
53
4) In the initial stages of the study, the majority of participants did not feel confident
to articulate A3 concepts to someone, while the reverse held true at the end of the
study.
5) During the early weeks of the research, most participants could not form an
opinion on whether the A3 report was adaptable to their work environment.
However, at the end of the project overwhelming responses pointed out that the
A3 report was adaptable to Cape Pathologists Ltd.
Responses to question 6 were variable. During the first week, responses such as “This is
my first time seeing this report and I cannot comment about it” and “My point of view
regarding any tools does not matter in this organisation” were not uncommon. As the
project progressed and participants got used to the tools, more positive themes started to
surface. A certain participant commented that “The A3 does not require a high level of
education to be used, I can also use it with my matric level”, while another responded that
“the A3 method makes problem solving easier by proposing a structure that allows
exploration of the problem before jumping to conclusions and solutions.” Most
participants who stated that the A3 report was not adaptable to their work environment
bemoaned the presence of exacting work instructions as a stumbling block hindering their
active participation in process improvement. Participants also highlighted the increased
responsibility that the tool brought to their work, and wondered if management would
entrust them to make improvement decisions in the absence of the researcher.
The researcher observed that the participants were skeptical about the motive of the
project during the early days. Some participants thought that management was out to get
them while others believed the researcher was a disguised employee of the organisation.
Questionnaires were therefore made anonymous to address the participants’ concerns.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
54
4.3.2.2Analysis and discussion
The trends observed in responses to question 5 reveal that during the early days of the
study, most participants did not regard the A3 report to be transferrable to their
environment. However, as the research progressed, participants overwhelmingly
contended that the A3 report was indeed adaptable to Cape Pathologists Ltd. The
researcher argues that participants had no previous experience in lean principles and tools
to immediately comprehend what the tools entailed. Therefore, the participants could not
form a sound and informed opinion regarding the A3 report. Over the life of the study
participants got more knowledge and were able to give a better assessment of the A3
report. The reasoning above is corroborated by the trend observed in question 3, which
shows that the understanding of the A3 report and lean principles was below average in
the first three weeks, steadily rising over the course of the project to an aggregate score
above 4 at the end of the study. The field notes gathered by the researcher also point
towards a similar interpretation.
The researcher used purposive sampling to elicit responses to the questionnaire. While a
representative sample of workers at Cape Pathologist Ltd would have been more
appropriate to deduce externally valid conclusions, the researcher argues that other
organisational members had no knowledge of the A3 method and lean principles, and
could not have given informed opinions on the subject matter. Visich and Wicks (2010)
posit that employees need basic knowledge of lean and the A3 method in order to
comment on the merits of the A3 report.
The researcher acknowledges the subjective nature of the interpretations. One way of
adding credibility to the interpretations would have been to ask participants to validate
the researcher’s assertions. However the respondents had given anonymous feedback and
hence it was not possible to identify individual participants. Discussing the findings in
meetings would also have raised ethical issues regarding confidentiality of responses. The
researcher could not involve an external researcher to validate the findings because the
environment under study was not open to outside observers. However, the researcher
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
55
believes that triangulation between the field notes and the questionnaire findings increase
the validity of the findings.
Conclusion:
Cannot reject Ho: The staff at Cape Pathologists Ltd perceives the problem solving A3
report to be adaptable to their work environment.
4.3.3 Hypothesis 3
Ho: The adoption of the problem solving A3 report at Cape Pathologists Ltd can improve
the staff’s perceptions of their own problem solving capabilities.
Method of Verification Source Material
Qualitative – Feedback was sought from
participants at the end of the research
project.
Likert Questionnaire 2 and field notes
Likert Questionnaire 2 was distributed to participants at the end of the study. Responses
from the three scored questions were respectively aggregated to give an average view of
the said participants. All participants who responded willingly identified themselves in
the questionnaires that they answered.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
56
4.3.3.1 Findings and observations
The findings from the three scored questions are depicted in the bar chart below.
Figure 7: Responses to Questionnaire 2
The findings from the scored questions can be summarised as follows:
1) Most participants found the research project useful.
2) The staff would want to continue using the skills that they learnt over the course
of the project.
3) The respondents thought that the project improved their problem solving
capabilities.
Findings from the open ended question eliciting an explanation to scored question 3
yielded varied answers. One respondent commented that “I have never received training
in problem solving before, so I am much better at problem solving” while another
participant said that “If I know the problem, I will categorise the causes before thinking
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
57
of the solutions.” A few common themes that emerged and were validated by respondents
include:
o Participants regarded highly the structured approach to problem solving that the
A3 report brought to their daily work and lives in general.
o Respondents believed that they no longer had to wait for the supervisor to provide
all the solutions but could also make suggestions.
o Respondents felt more confident to give advice to others in difficult situations.
The researcher also spent a significant amount of time with the participants over the
course of the project. The researcher observed that participants started engaging each
other more often, and would collaborate is solving small problems that they were
encountering during the course of their work. The preparation phase involved participant
involvement in A3 report simulations and participants were mentored on drawing up the
A3 report. When the actual A3 reports were drawn, participants showed more confidence,
enthusiasm and an above average comprehension of the problems that were being solved.
Suggestions for root causes and countermeasures were easier to elicit from participants
than in the A3 simulation phase.
4.3.3.2 Analysis and discussion
The findings from the questionnaire articulated above were verified by respondents and
hence the assertions are valid. Taken together with the observations that the author made
while he was in the field, these findings seem to point towards improved problem solving
capabilities among the participating staff.
The author acknowledges the shortcomings of using a sample that did not represent the
composition of Cape Pathologists Ltd. However, the question sought to elicit responses
from those who would have participated in the project. The results could have been more
robust if there was a pre-test and a post-test to objectively assess the problem solving
capabilities of the staff. The researcher argues that since he had no knowledge of the
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
58
participants’ background, he could not have provided a fair test of problem solving ability
because such abilities depend on one’s educational background and experience (Liu,
2006).
Conclusion
Cannot reject Ho: The adoption of the problem solving A3 report at Cape Pathologists
Ltd can improve the staff’s perceptions of their own problem solving capabilities.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
59
5. RESEARCH CONCLUSIONS
Action research in an organisation ought to satisfy two goals: contribution to theory as
well as towards finding solutions for real organisational problems (Coghlan and
Brannick, 2005). The aim of the research was to address the issue of turnaround time on
urgent tests at Cape Pathologists Ltd while exploring the implementation of the problem
solving A3report in an organisation operating in private pathology services. The major
problem was broken down to department level and the problem solving A3 report was
implemented in Pinelands lab and the courier departments, two of the three departments
contributing to long lead times on results. The researcher also sought to explore the
perceptions of the participants regarding A3 report implementation in the environment
under study. Prior to implementing the problem solving A3 report, participants
underwent training on lean principles and the A3 report. A high level value stream map
was then developed in order to conceptualise the problem and identify departmental
activities that needed improvement. Thereafter teams were set up in each department to
implement the A3 report, under the guidance of the facilitator-researcher, to address the
identified process failures.
Notwithstanding the constrains of time on the project and failure to fully implement the
A3 report in all three departments, the researcher concluded from hypothesis 1 that the
problem solving A3 report could not reduce, by 30%, the proportion of urgent test results
going over 2 hours TAT. Even though the study fell short of meeting the improvements
set forth in the hypothesis, valuable insights were gained from the research.
Organisational members at Cape Pathologists Ltd were able to view their service delivery
value stream, and to understand how failures in other departments can negatively impact
the performance of departments down the value chain.
The researcher also concluded that the staff at Cape Pathologists perceived the A3
problem solving report to be useful and adaptable to their environment. The problem
solving A3 report was also shown to improve the staff’s problem solving capabilities.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
60
However, apart from accepting the A3 report as a tool for process improvement, several
other conditions have to hold true for improvement initiatives to be successful. Although
participants merely believed the A3 report to be useful, turning that belief into action did
not follow since improvement only happened when the participants were actively
observed.
Several researchers posit that the actions of management in organisations can go a long
way towards sustaining change initiatives (Biazzo and Panizzolo, 2000; Smeds, 1994;
McHugh, 1997). The management at Cape Pathologists Ltd has initiated the
transformation towards lean using the A3 problem solving report. Working through the
remaining issues and sustaining the gains already realised will therefore depend on how
management chooses to act going forward in the absence of the researcher.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
61
6. FUTURE RESEARCH DIRECTIONS
There implications for future research emanating from this A3 implementation
experiment in a pathology lab are twofold. First and foremost, tools for problem
identification and prioritisation need further investigation. The current research utilised a
high level value stream map to identify the source of problems in an organisation that
delivers a service across three intertwined departments, all of them potentially
contributing towards a major observable problem. In the scenario investigated, the major
challenge faced was how to conceptualise the problem: whether the problem ought to be
broken down into component parts and delegated to the respective departments for
solutions, or whether to set up a single team that spans across departments to drive
change. Chakravorty (2009) also reported experiencing challenges in finding and
prioritising problems for process improvement. Zimmerman and Weiss (2005, cited in
Chakravorty, 2009) argue that most improvement initiatives fall apart because the
problems have been incorrectly identified and prioritised. Tools already under
investigation in literature include Six Sigma, lean and theory of constraints (Chakravorty,
2009).
Secondly, participant management in improvement initiatives calls for further
exploration. Several authors posit that the human side is a critical success factor in
change and improvement endeavors (Chakravorty, 2009; French, 2009; Dickson, 2009).
Womack et al (1990) contend that the foundation of lean principles is respect for and
empowerment of people involved in processes, but these foundational aspects are hardly
recorded on improvement documents as change agents concentrate on tools under the
presupposition that participants are inherently motivated to be involved in the envisaged
change. More research is needed to provide insights on how to successfully manage
participants so that they become proactive in improvement initiatives. Chakravorty
(2009) recommends in-depth analysis of how team composition and incentives contribute
towards success or failure in improvement initiatives.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
62
7. REFERENCES
1. Argyris, C. (1983). Action science and intervention. The Journal of Applied
Behavioural Science, 19(2), 115 – 140.
2. Argyris, C., Putman, R., & Smith, D. (1985). Action Science. San Francisco, CA:
Jossey-Bass.
3. Biazzo, S., & Panizzolo, R. (2000). The assessment of work organisation in lean
production: the relevance of the worker's perspective. Integrated Manufacturing
Systems, 11(1), 6 – 15.
4. Brooks, S. (2005). A lean services environment experiment: Introducing TPS and
lean principles to a pathology laboratory. Unpublished MBA research report,
University of Cape Town Graduate School of Business, Cape Town.
5. Booysen, T. (2006). Lean in Healthcare: Applying value stream mapping and lean
in the accident and emergency unit at G. F. Jooste Hospital. Unpublished MBA
research report, University of Cape Town Graduate School of Business, Cape Town.
6. Buesa, R. J. (2009). Adapting lean to histology laboratories. Annals of Diagnostic
Pathology, 13, 322 – 333
7. Cady, S.H., & Caster, M.A. (2000). A diet for action research: an integrated problem
& appreciative focused approach to organisational development. Organisation
Development Journal, 18, 79 – 92.
8. Chakravorty, S. S. (2009). Process Improvement: Using Toyota’s A3 Reports. Quality
Management Journal, 16(4), 7 – 26.
9. Chigwedere, R. (2007). Application of TPS and Lean principles to healthcare:
Process improvement in a HIV laboratory. Unpublished MBA research report,
University of Cape Town Graduate School of Business, Cape Town.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
63
10. Coghlan, D., & Brannick, T. (2001). Doing Action Research in Your Own
Organisation. London: Sage.
11. Coghlan, D., & Brannick, T. (2005). Doing Action Research in Your Own
Organisation. London, Sage Publications Inc.
12. Coughlan, P., & Coghlan, D. (2002). Action research for operations management.
International Journal of Operations & Production Management, 22(2), 220 – 240
13. Davidson, R., Martinsons, M., & Kock, N. (2004). Principles of canonical action
research. Information Systems Journal, 14(1), 65-86.
14. De Souza, L. B. (2009). Trends and approaches in lean healthcare. Leadership in
Health Services, 22(2), 121 – 139.
15. Dhatt, G. S., & Peters, S. (2001). Accreditation of medical laboratories in South
Africa. Accreditation and Quality Assurance: Journal for Quality, Comparability and
Reliability in Chemical Measurement, 7(7), 290 – 292.
16. Dickson, E. W., Anguelov, Z., Vetterick, D., Eller, A., & Singh, S. (2009). Use of
lean in the emergency department: A case series of 4 hospitals. Annals of Emergency
Medicine, 54(4), 504 – 510.
17. French, S. (2009). Action research for practicing managers. Journal of Management
Development, 28(3), 187 – 204.
18. Friderichs, C. (2009). An experiment in a lean services environment: An A3 approach
in a community health centre. Unpublished MBA research report, University of Cape
Town Graduate School of Business, Cape Town.
19. Hawkins, R. S. (2007). Laboratory turnaround time. The Clinical Biochemist Reviews,
29(4), 179 – 194.
20. Holweg, M. (2007). The genealogy of lean production. Journal of Operations
Management, 25, 420–437.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
64
21. Jackson, T. L. (2006). Hoshin Kanri For The Lean Enterprise. Productivity Press,
New York
22. Jimmerson, C. (2007). A3 Problem Solving for Healthcare: A Practical Method of
Eliminating Waste. Productivity Press, New York.
23. Kemmis, S., & McTaggart, R. (1988a). The Action Research Planner. Deakin
University, Melbourne.
24. Leedy, P. D., & Ormrod, J. E. (2010). Practical Research: Planning and design.
Pearson Education, Inc, New Jersey.
25. Leon, N., & Mabope, R. (2005) Chapter 3, South African Health Review, Health
systems Trust, Available at: http://www.hst.org.za/uploads/files/sahr05_chapter3.pdf
26. Liker, J., & Meier, D. (2005). The Toyota Way Fieldbook: A Practical Guide for
Implementing Toyota’s 4P’s. New York: Mc Graw-Hill.
27. Liu, W. (2006). Clinical research the six sigma way. Journal of the Association for
Laboratory Automation, 11(1), 42 – 49.
28. Lundberg, G. D. (1981). Acting on significant laboratory results. Journal of the
American Medical Association, 245, 1762 – 1763.
29. Manor, P. G. (1999). Turnaround times in the laboratory: a review of the literature.
Clinical Laboratory Science, 12, 85 – 9. McHugh, M. (1997). The stress factor:
another item for the change management agenda? Journal of Organisational Change
Management, 10(4), 345 – 362.
30. McHugh, M. (1997). The stress factor: another item for the change management
agenda? Journal of Organisational Change Management, 10(4), 345 – 362.
31. McKay, J., & Marshall, P. (2001). The dual imperatives of action research.
Information Technology and People, 14, 46–59.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
65
32. McKellar, L., Pincombe, J., & Henderson, A. (2009). Encountering the culture of
midwifery practice on the postnatal ward during Action Research: An impediment to
change. Women and Birth, 22, 112—118.
33. Nutt, P. (2002). Why Decisions Fail: Avoiding The Blunders and Traps that Lead to
Debacles. San Francisco: Berrett-Koehler Publishers, Inc.
34. O'Brien, R. (2001). An Overview of the Methodological Approach of Action
Research. In Roberto Richardson (Ed.), Theory and Practice of Action Research. João
Pessoa, Brazil: Universidade Federal da Paraíba.
35. Oliver, N., Schab, L., & Holweg, M. (2007). Lean principles and premium brands:
conflict or complement? International Journal of Production Research, 45(16) 2007,
3723–3739
36. Peck J, et al. Axiomatic approach for efficient healthcare system design and
optimization. CIRP Annals - Manufacturing Technology (2010),
doi:10.1016/j.cirp.2010.03.033
37. Perry, C., & Zuber-Skerritt, O. (1991). Action research in graduate management
research programs. The First World Congress on Action Research & Process
Management, 1(6), 67 – 79.
38. Rother, M., and Shook, J. (1998). Learning to see. The Lean Enterprise Institute, Inc.
Brookline, MA.
39. Saunders, M., Lewis, P., & Thornhill, A. (2003). Research Methods for Business
Students. Harlow, England: Pearson Education.
40. Shani, A. B., & Passmore, W. A. (1985). Organisational inquiry: Towards a new
model of the action research process, in D. D Warrick (ed.), Contemporary
Organisation Development: Current Thinking and Applications. Glenview, IL: Scott,
Foresman, 438 -448.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
66
41. Shook, J. (2008). Managing to learn: Using the A3 management process to solve
problems, gain agreement, mentor, and lead. Cambridge, Massachusetts: The Lean
Enterprise Institute, Inc.
42. Smeds, R. (1994). Managing change towards lean enterprises. International Journal
of Operations & Production Management, 14(3), 66 – 82.
43. Smellie, W. S., Galloway, P. J., Johnston, J. I. (1995). Laboratory turnround time:
closing the loop. Journal of Clinical Pathology, 48, 372 – 375.
44. Sobek II, D. K., & Jimmerson, C. (2004). A3 Reports: A tool for process
improvement and organisational transformation. In Proceedings of the Industrial
Engineering Research Conference,Houston, Texas.
45. Sobek, D. K., & Smalley, A. (2008). Understanding A3 thinking: A critical
component of Toyota’s PDCA management system. Taylor & Francis Group: Boca
Rotan.
46. Sørensen, E. W., & Haugbølle, L. S. (2008). Using an action research process in
pharmacy practice research – A cooperative project between university and internship
pharmacies. Research in Social and Administrative Pharmacy, 4, 384–401.
47. Sugimori, Y. , Kusunoki, K. , Cho, F. & Uchikawa, S. (1977). Toyota production
system and Kanban system Materialization of just-in-time and respect-for-human
system. International Journal of Production Research, 15(6), 553 – 564.
48. Susman, G., & Evered, R. (1978). An assessment of the scientific merits of action
research. Administrative Sciences Quarterly, 23, 582 – 603.
49. Visich, J. K., & Wicks, A. M. (2010). Practitioner’s perceptions of the A3 method for
process improvement in healthcare. Decision Sciences Journal of Innovative
Education, 8(1), 191 – 213.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
67
50. Westbrook, R. (1985). Action research: a new paradigm for research in production
and operations management. International Journal of Operations and Production
Management, 15(12), 6 – 20.
51. Womack, J. P., & Jones, D. T. (2003). Lean thinking. New York, Free Press.
52. Womack, J.P., Jones D.T., & Roos, D. (1990). The Machine that Changed the World:
The Story of Lean Production. Toronto: Harper Perennial.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
68
8. APPENDICES
APPENDIX 1: Example of the A3 Report
Adapted from Shook (2008), p. 145.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
69
APPENDIX 2: Likert Questionnaire 1
6. Can you please explain your answer to question 5 above
………………………………………………………………………………………………
……………………………………………………………………………………………..
APPENDIX 3: Likert Questionnaire 2
QUESTION 1.Strongly
disagree
2.Disagree 3.Neutral 4.Agree 5.Strongly
agree
1. Did you find the research
project useful?
2. Do you wish to continue
utilising the skills that you
have learnt?
3. Do you think the project
improved your problem
solving capabilities?
4. Can you please explain your answer to question 3 above
………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………….
QUESTION 1.Strongly
disagree
2.Disagree 3.Neutral 4.Agree 5.Strongly
agree
1. Did you find the session
useful?
2. Did the facilitator clearly
articulate what you were
expected to do?
3. Did you understand the
lean principles covered in the
discussion?
4. Would you be able to
explain the A3 problem
solving report to someone?
5. Do you think A3 problem
solving can be adapted to
Cape Pathologists to solve
problems?
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
70
APPENDIX 4: Example A3 report used in training
Title: Reduction of time spent following up results for specimens referred to other
laboratories
Process Owner: S. Williams Date: 28 September 2010
Background
Some of the specimens received at Viking are referred to other labs – specialized
tests/cost effectiveness
• Referral labs include Lancet, MDS, Pathcare, Tygerberg, Red Cross, WPBT.
• On average 50 – 70 specimens/day
• Results are often delayed and have to be followed up
• Following up takes time
• Doctors become disgruntled – damaged relationships
Current Condition
• Call referred from one department to the other
• Typical call progresses as depicted below:
• Average calling time 7 – 15 Min
• Follow up list averages 80 tests per day, therefore 560min (7minx80 >8hrs)
needed.
• Work piles up over time and other results remain outstanding for over 1 week.
Goals
• Calls directed straight to the responsible department
• Reduce calling time to under 5 minutes
Root cause analysis
Using the 5 Why method
Tests are done in different departments
Other specimens are further referred e.g. from Lancet to NHLS Johannesburg.
No record to indicate what tests are done in what lab and in which department
No record of telephone numbers of different departments
Call switchboard Transfer to histology Transfer to virology
Transfer to genetics and get results
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
71
Proposed countermeasures
Compile an alphabetical list of tests with respective telephone numbers and departments
responsible for those tests. The list should be in the following format:
TEST TAT DEPT TEL CONTACT
PERSON
TB Culture 1 Week UNISTEL-TB 021432156 Mark
Implementation Plan
Williams will compile the list of numbers in the above format in an A4 book
already provided.
All tests that are performed at referral laboratories will be compiled in
alphabetical order in the first column by Friday 08 October 2010.
Other details will be filled in on an ongoing basis as results are followed up from
different labs.
Every Friday a S. Williams will draw a Gantt chart to show the progression
towards completion, and submit it to laboratory supervisor.
Follow up
Lab supervisor will follow up and monitor progress as informed by the Gantt
charts every Friday.
If progress is deemed slow, lab supervisor will authorize calls to find out the
information without following specific results.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
72
APPENDIX 5: First A3 Report
Title: Reduction of throughput time in the lab from receipt of specimens to dispatch
of results to clinicians.
Facilitator: Tinashe Chinyanga
Process Owners: Team Leaders
Participants: Topplers and Data capturers
CURRENT CONDITION Current layout and value stream map for urgent samples at Pinelands Lab is as below:
X1
DATA ENTRY
X1-2
TOPPLING
X2-3
ANALYSIS
X1
RECEIVING
X2
REPORTING
1.5-5
2
1-17
7
5.5
5-15
75-10
6.5
1-5
2
1-2
2
1-8
3
1-5
3
WASTE 19Min
TOTAL 38Min
C/T: 5.5 minC/O: 0.5min
C/T: 1.5-5 minC/O: 0.5min
C/T: 1-5 minC/O: 0.5min C/T: 1-2 min
C/O: 0.4minC/T: 5-10 minC/O: 0min
KEY Inventory
C/TCycle Time
C/OChange over time
Whose task?
1 capturer?
specimen: where?
Waste accounts for half of throughput time
Standard deviation = 26minutes)
8% of urgent specimens last >2hrs in lab.
33% of urgent specimens last > 40 minute
BACKGROUND Specimen volumes are increasing at Pinelands lab averaging 1100 daily, with over 40%
requiring urgent processing within 2 hours. Over the years the standard operating
practices have remained unchanged and workarounds divergent from the protocol are
common. Urgent tests are often delayed leading to sour relationships with referring
clinicians. Failure to meet timelines imposed by clinicians might lead to loss of business.
All data capturers
shout ‘urgent!’
No one has clear
responsibility of
taking samples to
toppling desk –
data capturers &
toppling staff
move around.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
73
APPENDIX 5 (CONTINUED)
GOALS
Reduce throughput WASTE by 50% from current state level.
Envisioned throughput time < 30 minutes.
Establish a protocol for urgent specimens that all participants can relate to.
CAUSE ANALYSIS
Using the fish bone diagram:
Waste =½ of
throughput time
Machine
Materials
Methods
People
Protocol for urgents is unclear
Machines are down 3% of the time
Errors on forms delay data entry
Missing information of forms
Extra specimens add to work load
Topplers batch samples
Topplers do not prioritise work
Team leaders assign
Urgents to 1 capturer
1 toppler absent most of the time
Data capturers do not shout “urgent”Routine specimens labelled as urgent
Strain the system
Urgent specimens out of sight
of topplers
New toppler recently started work
No standard time for performing tasks
Missed tests add to rework
Poor station communication
Other queries directed at toppling
Specimen cannot be traced once in lab
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
74
APPENDIX 5 (CONTINUED)
TARGET CONDITION
The envisioned layout is as shown below.
PROPOSED COUNTERMEASURES
Reduce waste in
throughput time
by 50%
People
Methods
Materials
Machine
Establish electronic time
between analysis and toppling
Clarify protocol for urgents
& paste a visual map
Establish 1 visible point to place
urgents after data capture
Generate time for tasks
for inclusion in protocols
Direct all queries to help desk
Follow protocol for servicing machines
At least 2 people to countersign
for servicing a machine
All forms with missing information/errors
to help desk for follow up
Nursing department to tackle errors
and form labelling
Train people on urgents protocol
Assign 1 toppler for urgent specimens
Prioritise urgent specimensTeam leader is responsible for
notifyingtopplers about urgents
Distribute urgents equaly to
available data capturers
Protocol for urgent
1) Only team leader
shouts ‘urgent!’
2) All data capturers
place urgent
samples in a red
bucket centrally
located – no
movement required.
3) Toppling staff
collect urgent
samples from red
bucket.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
75
APPENDIX 5 (CONTINUED)
IMPLEMENTATION PLAN
WHAT WHO WHEN WHERE
Protocol training Team leaders 02/11/2010 Pinelands lab
Toppling desk roaster (with
2 people/shift)
Toppling staff 02/11/2010 Pre-analysis area
Paste 2 visual copies of
protocol in lab
S. Williams 02/11/2010 Pinelands Lab
Lean coaching T. Chinyanga Ongoing Pinelands lab
Implement protocol for
urgent specimens
All participants 04/11/2010
and thereafter
Pinelands lab
FOLLOW UP
Lab supervisor and T. Chinyanga to observe a random sample of urgent
specimens go through the protocol on 11/11/2010 and on 30/11/2010.
Lab supervisor to extract data from the Disalab® IT system on 30/11/2010 to
track progress in achieving throughput time.
All participants to reconvene on 01/12/2010 to discuss progress.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
76
APPENDIX 6: Second A3 Report
Title: Reduction of courier time for urgent specimens from receipt of phone call to
delivery of specimens to Pinelands lab
Facilitator: Tinashe Chinyanga
Process owners: Transport coordinators
Participants: Drivers
BACKGROUND
The courier service at Cape Pathologists is an integral part of the business, and is
responsible for the delivery of all specimens from depots and private hospitals/clinics.
The service delivers on average 1100 specimens daily and roughly 40% of these samples
need urgent transporting and processing. The courier must therefore provide an efficient
service for TAT to be met as promised to doctors.
CURRENT CONDITION
Analysis of a random sample gives the trends depicted below.
17% of urgent specimens are delivered well after the TAT promised to clinicians.
Current throughput time at Pinelands lab is 40 minutes: courier must deliver within 80
minutes – 30% of specimens are delivered after 80 minutes.
Drivers use different routes resulting in variable delivery time across depots.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
77
APPENDIX 6 (Continued)
GOALS
Reduce (by 40%) proportion of urgent specimens delivered after 1 hour 30
minutes
Envisioned goal is to have at most 18% of urgent specimens exceeding 1 hour 30
minutes in the short term.
CAUSE ANALYSIS
30% URGENT
SAMPLES DELAYED
MACHINES
MATERIALS
METHODS
PEOPLE
Vehicles down 3% of the time
Maintenance carried
out during the week
Traffic congestion at peak times
Weather conditions affect traffic flow
Unclear communication
from phlebotomy
Protocol for dispatching
drivers not clear
No standard routes
No monitoring system to
inform improvements
Drivers dont know why the rush
Absenteeism of drivers
High turnover
among drivers
Newer drivers dont
know shorter routes
Coordinators dont match vehicle
type with time of day
Routine specimens labelled urgent
Sometimes coordinators delay to dispatch drivers!
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
78
APPENDIX 6 (Continued)
COUNTERMEASURES
The proposed countermeasures are as depicted by the reverse fish bone diagram below:
REDUCE BY 40 % SAMPLES
DELIVERED >1HR20
MACHINESMETHODS
MATERIALSPEOPLE
Communication training for staff
Establish protocol for
dispatching drivers
Establish standard routes
Install monitoring system
with audit trail
Train drivers about
importance of pathology
Investigate cause of and
remedy absenteeism
Ongoing orientation of new drivers
Match vehicle type with time of day
When possible use
motorbikes at peak hours
Nursing department to label
specimens accurately
Schedule maintenance
on weekends
Adhere to vehicle service plan
Proposed web based transport and specimen tracking system will function as below:
Com
pute
r
Computer
Use
r
Use
r
Message Formats
Message Formats
1. Patient details & urgency of
requested test entered at depot:
time automatically recorded
2. Details pop up in coordinator’s
worklist
3. dispatch driver within 5 minutes: time
automatically recorded (screen turns red
after 5 min)
4.Drive
r re
turn
s with
in s
tipula
ted ti
me
for re
gion: s
cree
n turn
s re
d after
tim
e
for th
at reg
ion h
as e
lapse
d &
coord
inat
or fo
llows
up
Web based tracking system will generate data by region that will be used to create
standard time for courier along the routes.
Standard routes will also be created.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
79
APPENDIX 6 (Continued)
IMPLEMENTATION PLAN
ACTION ITEM RESPONSIBILITY TIMELINE LOCATION
Establish protocol
for vehicle
prioritisation &
dispatching drivers
Transport manager &
coordinators
15/11/2010 Courier office
Train coordinators
on new web-based
tracking system
IT Department 15/11/2010 to
22/11/2010
Courier office
Pilot web-based
tracking system
Coordinators 15/11/2010 to
30/11/2010
Courier office
Train nursing staff
on new web-based
tracking system
Nursing manager &
clerks
01/12/2010 to
15/12/2010
Depots/Pinelands
nursing office
Go live with web
based tracking
system
IT department,
coordinators and
nursing staff
16/12/2010
Train drivers on
pathology
Technologists Every Wednesday Pinelands Lab
Orientation and
training of new
drivers
Senior drivers Every Friday Courier routes
Weekend service
schedule for
vehicles
Senior driver and
transport manager
Monday of every
month
Courier office
FOLLOW UP
Monthly transport meetings to assess progress towards envisioned goals.
Transport manager to analyse data from the web-based tracking system weekly.
Transport department to establish standard time for routes within 4 months.
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
80
APPENDIX 7: Research Log
DATE PARTICIPANTS LOCATION TYPE OBJECTIVES OUTCOMES
28/05/2010 Dr Jonas Cape Grace
Hotel
Meeting Introduction to Cape
Pathologists Ltd
business environment
Dr Jonas explained
challenges faced in
terms of failing to meet
promised turnaround
time (TAT) on urgent
tests
Tinashe explained
probable research
opportunities that might
help the company
Dr Jonas agreed to host
Tinashe at Cape
Pathologists Ltd offices
23/06/2010 Dr Jonas, Mavis Pinelands
Lab
Company tour To find out more
about Pinelands lab
Specimens processed in
pre-analysis and
analysis areas
Pre-analysis area people
typically have matric
level education, analysis
area staffed by degreed
technologists
Specimens pass through
receiving, data capture,
toppling and analysis
Mood generally
welcoming
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
81
GSB Reflection Training needs to take into account the education level of
would be participants
Keep material simple and avoid MBA jargon when
talking to shop floor employees
Several visits are needed to understand the flow of work
at Pinelands lab
22/07/2010 Dr Jonas Pinelands
Lab
Meeting To discuss scope of
process improvement
project
Dr Jonas accepted to
host the project on
behalf of Cape
Pathologists
Agreed to have a RCA
outlining the scope of
the project by end of
August latest
Dr Jonas to set up
appointments with
heads of departments
GSB Reflection TAT as defined by Cape Pathologists need the
involvement of three departments in the project
The project needs to start early if results are to be
realised in all three departments to impact TAT
29/07/2010 Prof Norman
Faull
GSB Meeting To discuss research
project and
supervision possibility
Prof Norman Faull
happy to supervise
project but will need
formal proposal
Advised to keep
research journal to
reflect on what is
happening
02/08/2010 Transport Pinelands Meeting To get an overview of Overview of how the
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
82
manager Lab (courier
office)
the courier service department works
highlighted
Challenges include
absenteeism, traffic
jams and
communication
difficulties with depots
GSB Reflection Transport coordinators have matric level education; most
started as drivers and they know the routes well. Their
involvement in problem solving for the department is
important
Training needs to be tailored to what the department is
doing
11/08/2010 Nursing manager Pinelands
lab (nursing
office)
Meeting To understand how the
department works
Department has 80
staff, mainly nurses
Low turnover of staff
GSB Reflection Nursing manager is new to department and does not have
a nursing qualification. Avoid clinical jargon when
communicating with him
Deputy nursing manager has a nursing qualification and
has experience of working in phlebotomy department.
Her experience will be beneficial for the project
Getting all nursing staff at one venue would be difficult
and probably not fruitful; managers may need to identify
change champions to mentor others
17/08/2010 IT department Pinelands IT
office
Meeting Overview of databases
and data that can be
useful for analysis
IT department happy to
provide secondary data
for evaluation of
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
83
current state.
GSB Reflection Databases are a good source of secondary data, but how
objective is this data? Are there any legal requirements
for the data to be recorded objectively?
Will need to find out what the compliance requirements
are before depending on the data
25/08/2010 Senior
management
Pinelands
Boardroom
Meeting Discuss probable scope
of project
Introduce process
improvement concepts,
lean, TPS and A3 tools
Discuss researcher-
client agreement
(RCA)
Research project to
involve 3 departments
(phlebotomy, courier
and Pinelands lab)
Senior management
happy to host project
and believe there is
need to change
RCA drafted and to be
signed by GM and
researcher
GSB Reflection Strategic intent for change is evident amongst senior
managers and would count in favor of the project
RCA provides unlimited access to company data, staff
and premises: this will be very helpful for the project
27/08/2010 Prof Norman
Faull
GSB Meeting Discuss project
proposal
Proposal generally
good and advised to
start project
12/09/2010 Dr Jonas, Mavis
Laboratory staff,
courier staff and
nursing staff
Pinelands
Boardroom
Workshop Presentation of key
lean principles
Introduction to A3
problem solving
Lean principles
generally accepted and
understood
Participants indicated
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
84
Problem definition and
scope of project
they would need
coaching
GSB Reflection Group was probably too large to be involved
individually with researcher-facilitator
Follow up workshops with smaller groups important.
Operations of three departments seem to be distinct and
people in one department generally do not have enough
knowledge of other departments to suggest
improvements
Consider splitting tasks by departments
13/09/2010 Pre-analysis staff Pinelands
lab
One-on-one
coaching Mentor participants on
A3 problem solving
Progress in learning
generally slow
Regular follow up
sessions to be arranged
GSB Reflection Most participants jump to solutions when confronted
with a problem
Simulation exercises might be important so that
participants support each other
Participants a bit skeptical about the motive of the
project; some believe management is out to get them
14/09/2010 Depot staff Kuils River,
Bellville
Melomed
Depot Visits To understand
phlebotomy service
Depot staff believes
Pinelands lab needs to
improve
15/09/2010 Driver Hospital
route
Courier route
experience To walk the courier
‘gemba’
The visit went well.
Several vehicles
clashed at one depot
twice
21/09/2010 Courier staff,
phlebotomy staff
and Pinelands lab
Pinelands
lab
Meeting/workshop High level value stream
mapping and
identification of
Phlebotomy and
courier difficult to
conceptualise as
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
85
staff problems distinct steps/stations
for value stream map
VSM for Pinelands lab
drawn: process flow
diagrams for courier
and phlebotomy drawn
22/09/2010
to
24/09/2010
Pinelands lab
staff
Pinelands
lab
A3 simulation
workshops/one-
on-one coaching
Improve staff’s A3
skills before drawing
actual A3s
Staff’s perceptions of
the project improving
Enthusiasm is going up
and tendency to jump
to solutions is fading
04/10/2010 Courier staff
(transport
coordinators)
Pinelands
office
A3 simulation
workshops/one-
on-one coaching
Improve staff’s A3
skills before drawing
actual A3s
Staff motivated to find
solutions to problems
Low representation of
drivers worrying
06/10/2010 IT Department IT office Meeting Extract secondary data
from Disalab® IT
system
Data made available
for analysis
08/10/2010 Technologists Pinelands
lab
One-on-one
coaching Mentor participants on
A3 thinking
Progress of
technologists much
faster
Some offered to help
mentor pre-analysis
staff
11/10/2010 Pinelands lab
staff
Pinelands
lab
Data analysis and
observation of
current state
Objectively map the
current state of the lab
Generate data for
future reference
Participants
successfully generated
data for current state
12/10/2010
to
Pinelands lab
staff
Pinelands
lab
A3 simulation
discussions Skills transfer to
participants.
Participants more
confident in drawing
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
86
15/10/2010 A3s.
Some wonder if the
increased workload
will result in higher
incentives
Others highlight the
challenges they face in
suggesting
improvements when
there are hard and fast
work instructions and
protocols
18/10/2010 Courier staff Pinelands A3 discussions Mentoring of
participants
A3 simulations
Work instructions
viewed as stumbling
block to process
improvement
20/10/2010 Management,
Pinelands lab &
courier staff
Pinelands Meeting Report back about
current state findings
Prioritization of
problems identified
Improving throughput
time in laboratory and
courier delivery time
identified as problems
for immediate attention
Problems relating to
nursing and
phlebotomy to be
solved at a later stage
25/10/2010
to
29/10/2010
Pinelands lab
staff
Pinelands
lab
Discussion Drawing of A3 to
improve throughput in
lab
A3 successfully drawn
and approved by
management for
implementation
10/11/2010 Lab supervisor Pinelands Observation visit Observe the new Apparent improvement
Copyright UCT
LEAN PATHOLOGY: IMPLEMENTING THE PROBLEM SOLVING A3 IN A PATHOLOGY LAB
87
lab protocol in action
Generate data on new
state
noted.
Secondary data
obtained from IT for
analysis
11/11/2010 Pathologists, IT
Department,
Technologists
Pinelands
Boardroom
Meeting Discussion of time
stamp between pre-
analysis and analysis
areas in lab
Participants believe the
suggestion is valuable.
Participants to propose
plans for a follow up
meeting on 18/11/2010
12/11/2010 Courier staff Pinelands
courier
office
Discussion Drawing of A3 for
transport system
A3 successfully
completed
IT department needs to
be involved
15/11/2010 Transport
manager, IT
department
IT office Meeting IT system for vehicle
and specimen tracking
Training to start
16/11/2010
Go live date to be
discussed after piloting
for 2 weeks
24/11/2010 Prof Norman
Faull
GSB Meeting Discussion of findings
and progress made
Advised to get a draft
out soon for review.
Prof satisfied with
progress
30/11/2010 Lab supervisor Pinelands
lab
Observation Observe and generate
current state data
New protocol observed
in action
06/12/2010 Prof Norman
Faull
GSB Draft report back Comment on draft
submitted
Several changes
suggested