Conducted by Joel Servais
Richard Zarbo, MD, DMD, is the Senior Vice President and chairman of Pathology and Laboratory Medicine in the Henry Ford Health System (HFHS), serving Detroit and communities in eastern Michigan. He is a board-certified anatomic and clinical pathologist and an expert in head and neck pathology who has been instrumental in defining benchmarks of laboratory quality over the past two decades. A transformative leader who has studied and defined means of reducing laboratory error for the Agency for Healthcare Research and Quality, Dr. Zarbo has integrated the laboratories of the Ford System and been one of the pathology profession's pioneers in applying quality techniques and principles of Lean manufacturing to pathology and laboratory medicine. The Henry Ford continuous improvement culture is pointing the way to the more efficient and effective anatomic pathology lab that is emerging today and will grow stronger in the future, and Dr. Zarbo's work is making that goal a reality.
Dr. Zarbo is also past president and current vice president of the United States and Canadian Academy of Pathology (USCAP). He had just returned from its 101st Annual Meeting in Vancouver, British Columbia, in March, where he presented a paper on “Making Changes in Your Health Care Organization: The Basic Strategy,” when he had the following conversation with Joel Servais, Marketing Manager and Digital Imaging Product Manager for Kalamazoo, Michigan-based Milestone Medical.
Joel Servais: Please give us your impressions of the USCAP annual meeting relative to important advances in anatomic pathology.
Dr. Richard Zarbo: I think what impressed me the most was how far digital imaging systems have progressed. Not all labs are at the point of adapting them to large practices, but they are thinking about processes they will need to create efficiencies and reduce the time needed for the process.
I think the most dominant aspect of USCAP was the integration of molecular-based technologies into the daily practice of pathology. It's very difficult now to work up some tissue diagnoses without molecular components. So for things done at the proteomic level, the genomic level, RNA/DNA and the simple molecule level, those technologies that allow us to profile things are becoming more advanced, more developed. Over the next five to ten years they'll become very commonplace, and they will most likely be done not only in academic center and reference laboratories, but in the communities as well.
That brings up the other technologies I have focused on in this environment, the basic technologies that, number one, allow us to make a correct diagnosis; number two, enable us to make that diagnosis rapidly; and number three, ensure that we have quality of specimen preservation handling. There were also technologies on view that promote a more defined, improved process within current operations, current histology laboratories.
Those are some of my thoughts about the USCAP meeting and how it relates to the future of pathology, how we'll be practicing pathology five to ten years from now—but more importantly, how we should be practicing pathology for the patients we see today. And that is my focus for the patients of the Henry Ford Health System.
Servais: I know you and your team at HFHS have deeply implemented Lean techniques throughout the facility's laboratory services. Can you explain the impact this has had on your organization?
Dr. Zarbo: In our laboratory we have championed Lean management and approaches to workflow for the past seven years, and the technologies that we had the opportunity to look at were aligned with Lean workflow. By that I mean the cycle times are more rapid, allowing technology to support continuous flow processing. For instance, just this past Monday we integrated the entire histology operation of the community hospital into this main core laboratory of Henry Ford Hospital, so we now have the workload of five hospitals being done in a core laboratory, and some hospitals are 30 miles away. The goal was to obtain slides by eight o'clock the next morning on any specimen that had been in surgery the previous day—in other words, less than 24-hour turnaround time for production and the goal of sign-out within 24 to 48 hours. The integration of the last hospital's volume took place on Monday, and that required us to develop a system of work to be able to integrate that in a seamless fashion. As we turn off one information system, we have metrics of success in both sides in a bi-directional fashion so we know that we're delivering on time, that we are delivering a higher quality and a faster product. We spent many months designing that process, and we had come to rely on two instruments in continuous flow processing to be able to handle the additional capacity of these five hospitals.
I walked into the laboratory on Tuesday morning, after the first day, to see how many specimens had been left over and not processed from the previous day, and there were about five. And those five specimens were not from any of the hospitals; they were from some of our small satellites that use skin biopsies. So in fact we accomplished that goal on Day One.
We were happy about that. But now, the next challenge is, how much faster can we do that? And that's what a system-wide anatomic pathology quality assurance meeting that we held this morning was about. Where are the gaps? Where are the potential time waste opportunities that can be looked at, so the time can be made even shorter and those things all will be done within a day?
Servais: You gave a presentation at USCAP that covered some of those topics, entitled “Making Changes in Your Health Care Organization: The Basic Strategy”? How did your presentation parallel the work you have done at Henry Ford Health System over the last decade?
Dr. Zarbo: Saturday, the first day of the USCAP meeting, featured a first-time, all-day resident workshop dedicated to leadership, management, change, and collaboration. I was invited to give a talk about making change in your healthcare organization, the basic strategy. I was asked to illustrate how I had taken leadership principles that you can read about in management books and applied them in this healthcare setting over the past twelve years. I used two case studies. The first was how we went from isolated hospitals, “siloed” hospitals, into an integrated laboratory system, and what it took in order to do that from the perspective of people in human development, resources, alignment, stakeholder satisfaction, etc. So that was a major change related to a business structure. And then the second example was how we changed a management system. Becoming a Lean laboratory involved a seven-year dream of training and changing the cultural expectations of the work of nearly 800 employees—a major change. How does that change take place? My presentation was an opportunity to share that journey for an hour with residents who may have not known about that, but understood that the pathologist has more responsibility than just a slide on your scope.
Servais: How did you explain how this change came about and what impact the changes have had on the entire Henry Ford system?
Dr. Zarbo: I discussed why and how we adapted “Lean,” a process, a system for manufacturing, to a laboratory. When we began this in 2003-2004, there were no Lean laboratories. I volunteered to be a pilot in this institution for Lean process improvement. I had been trained in Lean in Pittsburgh through the Toyota production system. What we didn't realize at the start was that this was going to be more than just focusing on process improvement and improving quality; what we came to realize was that we were really, basically, giving people incentives to behave differently. We were changing a culture. That dawned on us during the first six months. When you get people aligned along a vision and try to get them to change, you run up against the existing culture, and that existing culture can stop you—unless you can incorporate everybody into a brand-new vision: the brand-new vision of what laboratories could look like, how they could operate, how people could behave and relate to one another.
This basically harkens back to Dr. W. Edwards Deming's Principles of Management. We had to adapt the principles, all fourteen of them, to create a Lean culture. We used a new technique or tool to make an improvement; we made improvements using Lean principles of workflow and mistake proofing. We created a Lean-managed culture. That culture allowed us last year to produce nearly 1,800 process improvements, leveraging a fully empowered workforce organized in structures with team leaders `a la Toyota production systems to be responsible and accountable for the quality of their own work that they produce, that is received of them, and that they pass along. And by setting up this system of work we have completely changed the attitudes and the entire culture, and not only of this laboratory. By working with and training our clinical colleagues, we are starting to have an effect within the entire organization. We have been teaching two-day Lean training programs now for four years, and we still fill those classes with 50 to 85 people. There still is great interest in what to do and how to do it. I think we have set an example of how you can successfully adapt Lean as a cultural and management system.
Servais: Recently the Henry Ford Health System has been given the Malcolm Baldridge National Quality Award, named in honor of the late U.S. Secretary of Commerce and given in recognition of performance quality in various business sectors. It's quite an honor—but how does it relate to pathology services and how has it improved patient care?
Dr. Zarbo: The Henry Ford Health System is very proud to be a 2011 Malcolm Baldridge Award recipient. That was the culmination of a five- or six-year journey for an entire system, a system of 23,000 working toward a goal. The award process is somewhat like a laboratory inspection, with quality inspectors evaluating you for an entire week, with in-depth interviews. I spent four hours with these people myself, representing laboratory and quality and process improvement. The Henry Ford Health System has a solitary focus on improved quality as a competitive advantage, but also for patient care. We are also a very low mortality hospital, a tertiary care hospital for patients who are flown in from many places by helicopter. This has been our constancy of purpose for many years. We have received national awards for this as well. The Malcolm Baldridge Award was recognition of our continued focus on improvement and innovation in the system. The laboratories were able to showcase, many times during this Baldridge visit, what we have done as a unique culture. The inspectors from the Baldridge committee weren't expecting that, and they spent an entire hour with the leaders of my staff, asking how it is we do this. This is a really unique model of our laboratory version of patient care that continually improves on a daily basis.
Servais: What do you see as near- and long-term challenges facing your laboratory services, and how do you think the Lean approach might be useful in addressing them?
Dr. Zarbo: Our primary challenge is financial. We are getting reimbursed less for doing more, and that may be for simple laboratory testing or it may be for complex molecular testing, or for uninsured testing. So that means with less money coming in the door, in order to provide the same quantity and quality of service or product, you have to reduce the cost of doing business—your unit cost has to come down. The only way you can do that is to eliminate waste within process or processes. That is the focus of continuous improvement: to continue looking at the process, the handoffs, the gaps, the value streams, so you understand where the waste is identified, who identifies it, even at the minutiae level, and how it can be removed by continually redesigning it. So a Lean approach is going to help us not just to survive, but to thrive. Our intent is to dominate laboratory testing in Southeast Michigan. We hope to be not just the lowest-cost, but the highest-quality provider for laboratory services. It's a very difficult balancing act, and without a Lean culture we would never even be able to attempt to reach that goal.
Servais: And that involves leveraging the brain power of the people who work with you?
Dr. Zarbo: That's exactly right. We are now tapping, leveraging, the creativity and brain power of employees. The expectation of workers in the Henry Ford laboratories is that they will contribute to the work they do today so that tomorrow it will be done better, faster, quicker, and less expensively. This approach to work empowers employees, giving them some control. They can directly contribute to the success of the enterprise. They can directly influence the outcome. They are asking themselves, what can we do, what can change, what can we not do anymore. We respect the lives and minds of the individuals that we trust to work with patients every day. Their days are days of creativity, not mindless toil.
A minimum of eight hours of Lean training is mandatory for anybody who comes to work for the laboratories, and then annual refresher training. Our engagement scores are very high, which indicates to us that employees basically own the process and their opinions are very valued. They participate with their leadership in our day-to-day operations and our improving them. That's a metric that indicates to us that the culture in fact works. Employees also turn out a number of process improvements, which is another measure that tells us we have an effective, team-based approach to quality.
All leaders get two days of leadership training. You're looking at a culture that has innovated and learned together as leaders. We have continuing meetings on a weekly basis where we learn from each other, so it's an ongoing learning process. I don't think we'll ever be finished learning how to lead better and how to engage our employees.
Servais: What single change do you see as most critical to the pathology community to meet the needs of patients over the next five years?
Dr. Zarbo: That's a good one, Joel. If I were a patient, I would like direct access to my pathologist. I'd like direct access to my results electronically. I'd like to be able to speak with that pathologist about my results one on one. That's a long-range vision. In the state of Michigan we're not allowed to deliver laboratory test results directly to our patients, so they have to go to the ordering physician. That doesn't mean they can't be vetted and shared through the physician on a website. I think that connection between pathologist and patient would go a long way toward changing the perception of the laboratory as a black box as opposed pathologists as very well-trained physicians who do unique things for patients but are often not recognized as being part of that patient-care team. That leap outside of the laboratory boundary or over that wall of visibility to the patient is a big challenge. It may come to pass that molecular testing can be designed in such a fashion that there's genetic counseling, etc., and some of that may reside within pathology departments. It depends on how we handle that as a profession going forward.
I think the biggest challenge to pathology will be who does the molecular profiling of human disease going forward. Is that something that will remain within the pathology departments, or will it be taken by other clinical departments that will start their own laboratories? That is probably the biggest near-term threat. How does pathology stay in the game with what we know now, not what we did 50 years ago? The pathology profession has evolved. The question is, how do we stay current and germane as a testing laboratory? Who is the customer? Is it the clinician, is it the patient, is it both? It's really both; how do you satisfy both? And in this environment it's also the financial arm of the laboratory. I think a lot of laboratories are going to be looked at from a financial perspective, and many hospital administrators are going to be looking to buy laboratory services at less cost. So, unless you keep focused on the strategy that allows you to continue to reduce your cost over time, you are going to have a very busy day as a solo act out there. All that I have been talking about—the Lean culture, the focus on quality, integration to one large boat instead of many small lifeboats—are strategies that will allow us to survive whatever storms come our way.
