EXPERIENCE AND CHALLENGES IN IMPLEMENTING LEAN HEALTHCARE IN PATHOLOGY LABORATORY

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VOLUME: 17 NO. 2/2020Journal of Health Management, IHM

EXPERIENCE AND CHALLENGES IN IMPLEMENTING LEAN HEALTHCARE IN PATHOLOGY LABORATORY

Ahmad Tajuddin A.H.^1*, Indera Putera K.A.S.², Mohamad N.N.¹, Louise Santana M.¹, Ahmad Kamaruddin N.B.¹, Abu Bakar S.^¹, AB Karim M.M.^¹, Abdul Hamid N.¹

1Pathology Department, Hospital Taiping

2Institute for Health Management, National Institute of Health, Malaysia.

*Corresponding author: Ainul Hana Ahmad Tajuddin, ainul_hana@moh.gov.my

ABSTRACT

Background: Customer Charter of Pathology Department Taiping Hospital outlined that Laboratory Turnaround Time (LTAT) for 90% of Urgent Full Blood Count (FBC) & Renal Profile (RP) should be within 45 minutes. However, the performance were unsatisfactory.

Materials and Methods: Thus, a prospective cohort study was conducted in Pathology Laboratory, Hospital Taiping, to improve the LTAT of both tests within Lean initiatives. Data was extracted from Laboratory Information System and tabulated into a data collection from consisting of four key metrics;

pre-analytical time (PAT), sample analysis time (SAT), validation time (VT) and LTAT. Both pre (RP, n=264;

FBC, n=445) and post-Lean assessment (RP, n=248; FBC, n=375) was done for seven days during office hours only. Ishikawa, Value Stream Mapping and Kaizen Blitz were utilized as Lean Tools. Four Kaizens were implemented; 1) fast lane for urgent samples; 2) segregation of urgent and routine sample at the main counter; 3) minimizing steps in rejection procedures and 4) separated counters for internal and external samples.

Result: Results were statistically significant for PAT and LTAT in RP, SAT and VT in FBC.

Conclusion: Implementing Lean is possible by increasing awareness, continuous improvement, perseverance and cooperation from everyone.

Keywords: Lean, Pathology, Laboratory Turnaround Time, an urgent request

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21 INTRODUCTION

Background

Clinicians have used Ninety-one percent (91%) of laboratory results in patient management, such as ruling out disease, monitoring therapy and hospital discharge or admission (Hilma-Dhiginna, et al., 2017). Laboratory processes involved three main phases; pre-analytical (receiving, accessioning, processing), analytical (analyzing in automated analyzer) and post-analytical phases (result validation and dispatch). Laboratory Turnaround Time (LTAT) is defined as the time from when a test request was received at the pathology receiving counter (pre-analytical) to the time results are reported to the clinicians (post-analytical). LTAT is considered as the most significant measure and a key indicator of laboratory performance. Full Blood Count (FBC) and Renal Profile (RP) are frequently requested tests due to their importance and impact in patient management.

Hospital Taiping is one of the major specialist hospitals in Perak state of Malaysia. It is a 608- bedded and is the main referral centre for the northern region of Perak. Thus, Pathology Department Hospital Taiping receives samples not only from in-house wards and clinics but also from district hospitals and health clinics in northern Perak region. The main pathology receiving counter which operates 24 hours a day, receive and segregate samples for Chemical Pathology, Haematology and Microbiology units.

The average of samples received in an hour could easily reach 100 during peak hours and urgent samples received in an hour could easily reach 100 during peak hours and urgent samples contribute to almost 40% - 60% of the daily workload. Urgent samples do not pass through the normal queue; they are sorted, centrifuged and analysed first compared to routine tests so

that the results are ready fast. Unfortunately, due to the increase in the urgent requests, then, they also go through the queue, causing no distinction between urgent and routine.

Our customer charter has outlined that 90% of LTAT for urgent FBC and RP should be within 45 minutes. However, there was a notable decrease of 5% in 2018 compared to 2015 in the achievement of the Pathology Customer Charter. Corresponding to this, there was an increment to 2015. Both of these crucial statistics create the opportunity to improve the management of urgent requests through Lean initiatives.

Lean

The term Lean originated from Toyota Motor Company (TMC) around 1918 with the crucial concept of defining values stream, remove waste, continuous flow of the process, use of

“pull” mechanism to support flow and seek perfection (Giannakis & Papadopoulos, 2016), (Hayes, et al., 2014) (Teich, et al., 2013).

Although Lean was conceptualized in manufacturing, application in medicine and laboratory are vast and cause significant reduction in expenses and improve the satisfaction of customers through minimizing waste, simplifying processes, eliminating defects, evaluating system, minimizes consumption of resources, shortens time between request and delivery and continuous improvement (Foreback, 2014) (Joosten, et al., 2009).

Eight types of waste can be identified in a laboratory process: transportation, inventory, motion, waiting, over-processing, overproduction, defects/errors, and waste of human potential. Waste in transportation is noticed during moving samples and conducting

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lab tests. Waste in inventory is reflected in the cost of managing supplies and consumables.

Motion can be manifested as a waste when a lot of steps arise from the poor designation of the working area. Multiple steps of complex processes can lead to over-processing or overproduction. Defects/errors can be related to poor labelling of tests and incomplete information in the patient’s request form.

Subsequently, all of these types of wastes lead to the ultimate waste that is unnecessary waiting for laboratory results. Lastly, under-utilization of the employee involved poor exploitation of employee’s knowledge, skills and creativity (Teich, et al., 2013) (Serrano, et al., 2010).

i. 5S

Standardised process can be achieved through 5S which consists of Shitsuke (Sustain: Follow regulations, self-discipline, and stable workplace), Seiso (Shine: Clean work area), Seiketsu (Standardize: Create regulations), Seiri (Sort Eliminate the unnecessary) and Seiton (Straighten: Organize materials, tools &

Documents) (Cankovic, et al., 20019). An example of 5S that can be implemented in the laboratory is separating unnecessary tools away from workspace, designing he item’s location according to the frequency of usage, ensure visibility of tools and visual sweeping to identify housekeeping issue (Stankovi, 2008).

ii. Value Stream Mapping

The value stream mapping (VSM) is an illustration with boxes, and each box represents a task within the process in a certain job.

Measurable and comparable features are added in a range of aspects, such as the processing time (PT) to complete a task, the waiting time between steps, manpower (MP) or work capacity dedicated to the performance of a task,

quantity of inventories involved (QTY) and First Time Quality (FTQ) or the percentage of correct and complete tasks (Quetz, et al., 2015). Through these details, processes that are pure waste can be addressed and strategized ways to eliminate (Serrano, et al., 2010). The current value stream detailed the current processes involved;

meanwhile, in the future value stream, processes are modified to eliminate waste and reflect the ideal workflow that was envisioned.

VSM is one of the most popular Lean tools in healthcare organizations as it wisdom system improvement opportunities and optimize fundamental healthcare requirements – cost, quality and on-time delivery (Sampali, et al., 2015).

iii. Ishikawa Diagram/Root Cause Analysis

Ishikawa Diagram/Root Canal Analysis is systematic problem resolving methodology that focuses on resolving the underlying problem instead of quick fixes. Graphic illustration of the fishbone diagram involves grouping the causes to a problem into few factors, by which on or more of the factors could have a greater impact than others and ultimately guide to the root of the problem. Consequently, recommendations to mitigate or eliminate the problem can be strategized and executed (Yuskel, 2018).

iv. Kaizen Blitz

With the meaning of Kai as change and Zen as good in Japanese, Kaizen is all about constant or continual improvement. Kaizen is the improvement that can be done to fill in the loopholes by taking something apart and putting it together in a more efficient way. Blitz is defined as a sudden empowering effort (Stankovi, 2008). Training, motivation, low-cost and low-risk improvements, and involvement of

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23 all employees are prerequisites for Kaizen to

produce measurables results (Jovicic, 1800).

v. Applying Lean Concept in Pathology Services

Since the mid-1990s, hospitals have experimented with the Lean method and in numerous cases, success was found first in laboratories (Graban, 2007). The number of Lean public health projects had increased rapidly over the years, particularly in pathology laboratory as processes in clinical and haematology testing are reminiscent of factories (Hayes, et al., 2014) (Yuskel, 2018). Acclimating the Lean concept in pathology services is proven to reduce turnaround time (TAT), reduce inappropriate requests, increase the efficiency of staff management, minimize errors in testing and reporting, and ultimate improved the quality of overall patient management (Hayes, et al., 2014)

Aim of this study

In the view of complex laboratory flows, pre- analytic errors such as misidentification and labelling errors account for nearly three- quarters of the problems in the laboratory (Angelo, 2007) (Visinoni, 2015). Cap Q-Probes study concluded that errors associated with specimen misidentification accounted for 9.6%

of the total errors. The use of the Lean method has been shown to reduce pre-analytic errors in anatomic pathology (Layfield, et al., 2010). Thus, Lean implementation with existing resources was focused on the pre-analytical phases as an initial step in this study. Therefore, the objective of the study was to improve processing time from receiving urgent requests (FBC & RP) at the main receiving counter. Ultimately, it is hoped that improving pre-analytical processes can lead to faster turnaround time for urgent chemistry and haematology tests.

Literature Review

Successful comparable studies to redesign the pre-analytical process to improve turnaround time by utilizing Lean principles were reported by (Persoon, et al., 2006) in which the median pre- analytical processing time was reduced from 29 to 19 minutes and 80% of chemistry results were reported in less than one hour for 11 consecutive months. Implementing Lean in Henry Ford Health System reduces turnaround time from 10 hours to six to seven hours and five to six hours form FBC and RP, respectively, increased employee morale and satisfaction and reduced turnover (Foreback, 2014) (Graban, 2007). Lean tools such as 5S, the Kaizen Blitz, and value stream mapping allow the clinical laboratory to maximise process flow, reduce total steps in a process from 20 to 14 and eliminate errors in specimen identification (Stankovi, 2008). By applicating Spaghetti Diagram and two day Kaizen programme, 192 travel events were eliminated and only 59 of 664 tasks required technologist to leave their workstation which resulted in increased tests performed and improved productivity (Smith, et al., 2012) (Yerian, et al., 2012).

Series of Kaizen events were implemented in Riverside Medical Center, the US for 14 weeks, such as the formation of a new lab layout to reduce waste, standardize work process, 5S, visual management and Kanban system for organizing and reordering supplies. Three months after Lean implementation, the turnaround time for an inpatient potassium test reduced from 74 min to 40 min and the troponin test from 54 min to 34 min (Graban, 2007).

Implementation of Lean Value Stream Mapping in laboratory managed to save more than

$400,000 in the first year in DSI Lab, US and 70%

reduction of total steps to complete work and 90% reduction of time to do, 10% increase of

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revenues and 2% decrease of staff Bolton, US (Iswanto, 2017). (Smith, et al., 2012) concluded that Lean based quality improvement program, Kaizen, A3, process mapping improved laboratory productivity and pathology patient safety by reducing errors and near-miss-events.

In Scotland Cancer Treatment Centre, average turnaround time reduced from over 24 hours to two to three hours and in Nebraska Medical Centre Laboratory, specimen processing turnaround time shortened by 20% through Lean inventiveness (Jovicic, 1800) (Thor, et al., 2010).

Lean interventions such as a poster, pocketbooks, mentorship of junior doctors, unbundling of panel tests, and enhancing protocol adherence able to reduce the number of laboratory tests performed and costs inclined with it, saving around 350,000 euros (Vegting, et al., 2012). 5S, value stream mapping, poka-yoke devices and visual control provided evidence of a reduction in medical errors in a laboratory test (Frosini, et al., 2015). According to a study conducted in Namibian Laboratories (Yuskel, 2018), top management involvement, adequate training and proper panning are Lean enablers.

Standard Operating Procedures (SOP), root cause analysis, equipment effectiveness and visual management are the various implemented tools. SOP is deemed to be the most important as documents that construe practice need to be followed by all laboratory technicians. Lean Rapid Improvement Event links emergency and pathology department and avoided 187 km and eight days of unnecessary walking each year, producing tangible benefits in form of cost and time savings, and intangible benefits such as reduced tiredness, ability to cope with more samples under less pressure, increased motivation and increased staff morale (Hayes, et al., 2014).

Researchers done about Lean in laboratory by (Angelo, 2007) (Frosini, et al., 2015) (Graban, 2007) (Hilma-Dhiginna, et al., 2017) (Joseph, 2006) (Quetz, et al., 2015) (Serrano, et al., 2010) (Smith, et al., 2012) (Yuskel, 2018) concentrated more on the analytic phase (sample preparation and analysis), scarcely in pre-analytic phase of receiving and segregating of samples to respective units. Thus, this study can serve as a breakthrough about Lean initiatives at the receiving counter of Pathology Laboratory in a major specialist hospital in Malaysia. A similar study, focusing on the pre-analytic aspect, was done by (Persoon, et al., 2006) in which laboratories were adopting total laboratory automation, starting from the ordering of tests till the reporting of the test results. However, in this study, the laboratory still utilized a semi- automation system such as manual ordering by using forms and labels, manual validation and dispatch of results to clinicians.

MATERIALS AND METHODS Lean Tools

Lean tools applied in this study were Current and Future Value Stream Mapping, Root Cause Analysis/Ishikawa Diagram and Kaizen Blitz.

i. Value Stream Mapping (Current) The samples received in the laboratory encounters a complex journey. As a stepping stone, the current Lean initiatives was focused mainly in the pre-analytical phase. Therefore, the Current VSM encompassed 15 detailed steps in the pre-analytical process starting from receiving samples until segregation to respective units, as illustrated in Figure 1. Generally, all internal and external samples were received at the main counter of the Pathology Laboratory with two operating counters. Therefore, there

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Figure 1: The Current Value Stream Mapping (VSM)

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was congestion at the main counter and this led to lengthy waiting times for the samples to be received. Indirectly urgent requests were compromised as it had to compete with non- urgent requests. Once the request form was clocked at the counter, the laboratory staff will check the samples and request forms. If there is no rejection, then it will be received and segregated into baskets according to units, namely Haematology, Chemical Pathology and Microbiology. An exchange basis for consumables like sample tubes and containers was practice in this hospital. Hence, the used tubes/containers will be exchanged with the same new consumables. All urgent and non- urgent requests will be pooled in one basket and then distributed to respective units. In the units, only then, the urgent and non-urgent requests will be segregated. If there is rejection according on the consignment form/dispatch book and inform the rejection to the requesting doctors.

Clearly, there were many rooms for improvements with Lean implementation.

ii. Root-Cause Analysis / Ishikawa Diagram

During the brainstorming and subsequent formation of Ishikawa Diagram, a few factors that contributed to prolonged LTAT of urgent FBC & RP during office hours were identified, such as team factors, work/care environment factors and individual staff factors. Team factors can be classified into communication skills such as less proactive inter-department communication, incomplete documentation, and human resource factors such as an inadequate number of staff and high workload or low motivation. Unviability and inaccuracy of health information as lab request forms had to be filled up manually, and unnecessary work processes due to illegible handwriting are main

subpoints under task and technology factors.

Work/care environment factors consists of physical environment such as no automated system to process urgent request, information technology such as no notification system to alert that results are ready to be validated and no design system to automatically print results in wards/unit once results are validated in laboratory. Individual staff factors encompass personal staff attitude and discipline, stress, high workload and also interpersonal skills such as teamwork and relationship to other staff.

iii. Kaizen Blitz

A total of four Kaizens were implemented, which were a fast lane for urgent samples (counter separated into A, urgent and B, non-urgent), segregation of urgent and routine samples at the main counter, minimizing steps in rejection procedures and separate counters for internal and external samples. All external samples were directed to be received at the Referral Unit instead of the main receiving counter to reduce congestion/waiting time at the main counter.

Additionally, a dedicated urgent section was created to efficiently cater the urgent requests.

iv. Value Stream Mapping (Future) After identifying value-added and non-value- added activities from the current VSM, in the future VSM, five steps considered as waste was planned to be eliminated and executed four of them. With very limited resources, we could not afford to establish a third counter as it will involve renovation costs. Therefore, as an alternative, we directed all external samples to be received inside our Pathology Laboratory by Referral Unit team to reduce congestion at the main counter. Two operating counters were separated into an urgent and non-urgent

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Figure 2: The Future Value Stream Mapping (VSM)

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counter. The urgent counter is used as a fast lane for urgent internal samples to reduce waiting time at the main counter. Rejection procedures were simplified. We only inform verbally requesting the doctor if the sample is precious such as body fluids or cerebrospinal fluid.

Furthermore, only one rejection form will need to be filled up and eliminated redundancy of rejection procedures Figure 2 summarizes the future VSM after Lean implementation.

v. Sampling

This study was a prospective cohort study, pre and post assessment, conducted in Pathology Laboratory, Hospital Taiping. Sampling involved all urgent RP & FNC tests received during office hours for seven days for both pre- and post-Lean assessment. Total samples analyzed were 265 and 445 for RP and FBC, respectively, for pre- Lean assessment and 248 and 375 for RP and FBC, respectively, for post-Lean assessment.

vi. Data Collection & Analysis

Data collection form was created to tabulated information about RP and FBC samples such as accession number, date of analysis, time of tagging completion, time of testing completion and time of results validated. All the former data was extracted from Schuylab Laboratory Information System (LIS). Subsequently, using the data extracted, four key metrics were created that is, pre-analytical time (PAT), sample analysis time (SAT), validation time (VT) and LTAT. PAT is the duration between sample received and the completion of sample tagging.

SAT is the difference between the time of testing completed and the time of tagging complete. VT is the time lapse between the completion of sample testing and validation of results. Finally, LTAT is calculated from the time of receiving the

sample until the validation of results.

Throughput for LTAT (T) is the percentage of samples that achieved the target LTAT (within 45 minutes). Data collection forms were tested and verified for the first 30 samples. A similar methodology was used previously to evaluate the effectiveness of Lean in improving Turnaround time (Hilma-Dhiginna, et al., 2017) (Raab, et al., 2008) (Smith, et al., 2012).

Pathology customer charter in Hospital Taiping was used as standard and it outlined that 90%

LTAT for urgent request RP & FBC should be within 45 minutes. All the data were analyzed using SPSS software. Figure 3 explains the framework of study done.

Formation of Value Stream Mapping, Root Cause Analysis/Ishikawa Diagram

Pre-Lean Assessment: Data extraction, tabulation into 4 key metrics (PAT, SAT, VT,

LTAT) & analysis

Implementation of Kaizen Blitz

Post-Lean Assessment: Data extraction, tabulation into 4 key metrics (PAT, SAT, VT,

LTAT) & analysis

Comparison analysis of Pre & Post Lean implementation

Figure 3: The framework of the study done

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29 RESULT

Table 1 shows the data for the pre- and post- Lean Assessment for RP. The mean for PAT, SAT, VT, LTAT for RP showed improvement after the implementation of Kaizens. For RP, reduction of

time was evident for all key metrics in post-Lean except for the slight increase in maximum time for SAT and TAT and mode for VT and LTAT. On the positive note, post-Lean RP throughput increased from 68% to 52% compared to pre- Lean.

Table 2 shows the data for Pre and Post Lean Assessment for FBC. Similarly, for FBC, improvements were conspicuous during the post-Lean except for mean for PAT, VT and LTAT,

the minimum time for LTAT and mode for VT and LTAT, the minimum time for LTAT and mode for VT and LTAT. Throughput of LTAT managed to achieved 100% during post-Lean.

As the strengthen the findings, data were analyzed using Wilcoxon signed ranks test to determine the impact of Lean implementation on Pathology Laboratory Hospital Taiping. From the analysis done, there was a significant

improvement statistically in PAT and LTAT for RP and SAT and VT for FBC, as tabulated in Table 3 (significant p>0.05). Even though some of the metrics did not achieve significant p-value, the cumulative process was improved.

Metrics Pre-Lean (Time) Post-Lean (Time)

Mean Min Max Mode T (%) Mean Min Max Mode T (%)

PAT 0:11 0:01 1:00 0:06 - 0:08 0:00 0:43 0:04 -

SAT 0:26 0:10 1:13 0:19 - 0:25 0:06 1:26 0:16 -

VT 0:09 0:00 0:53 0:02 - 0:08 0:00 0:46 0:03 -

LTAT 0:48 0:21 1:41 0:36 52% 0:42 0:13 1:42 0:45 68%

Metrics Pre-Lean (Time) Post-Lean (Time)

Mean Min Max Mode T (%) Mean Min Max Mode T (%)

PAT 0:08 0:00 0:42 0:06 - 0:09 0:00 0:30 0:05 -

SAT 0:08 0:00 1:05 0:06 - 0:07 0:00 0:34 0:04 -

VT 0:02 0:00 0:25 0:00 - 0:04 0:00 0:23 0:01 -

LTAT 0:18 0:05 1:23 0:16 99.5% 0:21 0:06 0:43 0:20 100%

Table 1: Pre and Post Lean Assessment for RP

Table 2: Pre and Post Lean Assessment for FBC

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DISCUSSION

The result of our study were consistent with the conclusion by (Persoon, et al., 2006), by which they managed to reduce the total turnaround time after the implementation of Lean principles. 5S initiatives in the main receiving counter were proven to be successful as indicated by (Souza, 2009), in which, the use of 5S has managed to reduce 40% of floor space utilization and 17% increase in storage space and ultimately increased staff morale. Implementing 5S and VSM able to increase the percentage of fast track quality in the error-prone pre analytics phase leading to reduced waiting time for laboratory results (Quetz, et al., 2015). This study had shown that standardized procedures, created order, reduced space and work in progress (sample accumulating waiting to be segregated to units), and improved visibility to quickly assess the state of operations (Joseph, 2006). Process redesign in the main receiving counter of Pathology Laboratory had improved the turnaround time, same as the Haematology and Chemistry Lab of Pittsburgh General Hospital, by which laboratory test result reporting time reduced by more than 85% and

inventory usage by 50%. Similar Kaizen implementation of reorganization created order in the previously haphazard layout in Massachusetts General Hospital, Boston and had increased process efficiency by decreasing the LTAT of troponin by 33 minutes (37.5%) (Thor, et al., 2010).

Some of the findings were not statistically sound, p>0.05 (SAT, VT for RP and PAT for FBC) as some of the kaizens are still in progress such as change

‘exchange basis system’ to ‘indent system’ and to add in another counter and pigeon hole to receive specimens from district hospitals &

clinics and to dispatch results respectively.

Hereafter, it is hoped that the ratio of urgent to routine requests can be reduced, 100% of routine biochemistry and routine haematology tests reported in less than one hour and no segregation of urgent and routine testing.

Requests for rapid turnaround time or urgent requests are becoming alarming in such a way that, in the future, there might not be routine testing anymore (Persoon, et al., 2006). Hence, laboratories need to thrive to improve their processes to efficiency cater to this demand.

Quoting (Joosten, et al., 2009), Lean is 100%

Test Metrics Mean ± SD (pre)

95%CI (pre)

Mean ± SD (post)

95%CI (post)

p value

RP PAT 0:11 ± 0:08 (0.100, 0.120) 0:08 ± 0:06 (0.0728, 0.0872) 0.000 SAT 0:26 ± 0:10 (0.248, 0.272) 0:25 ± 0:13 (0.234, 0.266) 0.279 VT 0:09 ± 0:09 (0.0792, 0.101) 0:08 ± 0:08 (0.0704, 0.0896) 0.313 LTAT 0:48 ± 0:17 (0.459, 0.500) 0:42 ± 0:17 (0.399, 0.441) 0.002 FBC PAT 0:08 ± 0:05 (0.0754, 0.0847) 0:09 ± 0:05 (0.084, 0.096) 0.379 SAT 0:08 ± 0:05 (0.0654, 0.0747) 0:07 ± 0:04 (0.0652, 0.0748) 0.001 VT 0:02 ± 0:03 (0.0172, 0.0228) 0:04 ± 0:04 (0.0352, 0.0448) 0.000 LTAT 0:18 ± 0:07 (0.173, 0.186) 0:21 ± 0:07 (0.202, 0.218) 0.000 Table 3: Statistical summary of the four metrics

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31 positive as it improves safety, quality, staff

morale and reduces cost at one go. Nonetheless, it requires effort, cooperation and continuous involvement of all employees and endless improvement. Nonetheless, it requires effort, cooperation and continuous involvement of all employees and endless improvement.

CONCLUSION AND RECOMMENDATIONS This study is still ongoing, and for the next phase, the focus is on the analytical and post-analytical aspect of laboratory process, and most importantly to tackle the abuse of urgent tests (unnecessary request for urgent tests).

There still lacking studies published regarding Lean in Pathology Laboratory, particularly in chemistry and haematology laboratory in Malaysia. This study was done in a single institution and the findings might not be generalizable to other clinical laboratories with different laboratory process flows. Different hospital settings may have different procedures and standards. Sampling time was also short, the number of samples collected was limited and we mainly focus the processes during office hours only. Kaizens were mainly focused in the pre- analytical phase and customer satisfaction following implementation of process improvements was not accessed. Therefore, we would recommend the future researcher to focus on these areas for improvement of laboratory workflows.

From our experience, the most challenging part was to change the mindset of laboratory employees and the clinician as most of them were comfortable with the existing procedures and some were unenthusiastic for change.

Dealing with human factors requires more effort and perseverance in creating awareness and education regarding the vast benefits of Lean

implementation. There is an impression that employees are less inclined with the concept as it is perceived as extra work instead of the long- term impact and betterment of the process for efficient patient management and care.

Hopefully, by showcasing benchmarking and examples of other similar hospitals with Lean implementation could modulate this mindset.

ACKNOWLEDGEMENT

The authors would like to thank the Director- General of Health, Ministry of health Malaysia, for permission to publish this article. The completion of this project would not be possible without the support from our colleagues; Sanada Abu Bakar, Mohd Mustaqim AB Karim, Norehan Abdul Hamid and Narwani Hussin. We also would like to thank Institute for Health Management team for providing guidance and direction. We extend our gratitude to Hospital Taiping Director, our Head of Pathology Department and all supporting staff for their contribution.

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