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Using Principles of Disruptive Innovation and Lean Manufacturing to
Lower Costs and Improve Quality in the Mohs Laboratory
Jeffrey B. Stricker, D.O., M.B.A., C.P.E., FCAP, FAOCP
VPMA, Skin Cancer and Cosmetic Dermatology Centers, Chattanooga, Cleveland, and Kimball TN; and Dalton, Rome, and Calhoun GA
Abstract
Lean properties
Disruptive Innovation
Mohs surgery is a skin-sparing technique used to treat
skin cancers meeting certain criteria. It requires rapid
processing of a tissue sample by frozen section
technique, allowing review shortly after submission to the
laboratory. By applying Lean manufacturing principles
and a disruptive innovation philosophy to the process of
tissue submission through results reporting, we have
more than doubled our output while decreasing
turnaround time, cost, and patient wait times both in the
room and waiting for a surgery date.
In general, Lean manufacturing processes focus in two areas: Improving quality and
eliminating waste4. As the MMS lab was the rate limiting step in the clinic’s ability to
serve more patients, it was critical to identify and eliminate time wastes.
Simultaneously, to protect our patients and the clinic, our overall quality needed to
increase. Each area was approached in a stepwise manner:
1)
Personnel: The first goal was to properly train existing technical personnel and
increase the available pool of qualified technicians. There is an overall shortage of
qualified technicians5, so it was important to invest in current workers. Initially a
cryotechnician training manual was created with a 3 month intensive training period
for new personnel. Later, the clinic supported technical staff’s acquisition of
Histotechnologist Board Certification through an online program combined with 2
hour in-house educational lectures taught by a retired technologist. Finally, all lab
staff were expected to go through the cryotechnician training course to expand the
pool of available technicians. The addition of a dermatopathologist to review cases,
rather than a Mohs surgeon, was also key in improving the quality and throughput of
the MMS lab.
2)
Faster turnaround time: Decreasing the amount of time patients waited helped
eliminate wasted time among clinical staff, and increased patient satisfaction with
the overall experience. Additionally, the less time they spent in surgery, the less
complications arose. Thus it was important to decrease turnaround time. Specimen
flow was changed to better replicate the natural flow of the lab, and specimens were
to always “keep moving.” The traditional staining technique hemotoxylin and eosin
takes 9 minutes, however the toluidine blue stain takes 1 minute and readily
identifies basal and squamous cell carcinoma, by far the two most common skin
cancers in the United States. These changes, combined with better trained
personnel making fewer mistakes, have led to an overall 50% reduction in
turnaround time.
3)
Better specimen control: Specimen safety and identification are key quality
measures. Initially, a clipboard with specimen paperwork and the specimen on
gauze was received. New “box-style” clipboards, allowing separation of tissue and
records, were added. A MMS control number was given to each patient seen that
day to better facilitate reporting. Using Sharpie markers, each specimen seen that
day was also given a unique color to be used on the mounting media once it had
frozen. This was to better track specimens once processed in case recuts were
necessary.
Clayton M, Christensen’s theory on disruptive innovation describes a product or service
consisting of off-the-shelf components put together in an architecture that is often
simpler than prior approaches6. Our clinic took existing resources and a management
theory geared toward manufacturing and was able to transform the MMS lab into a
model which we have replicated in 3 additional clinics. These additional clinics are in
smaller locations where no Mohs service would usually be available, hence meeting
Professor Christensen’s definition of “new market disruption7.” As the MMS lab has
now been streamlined, the clinic is able to schedule 2-2 ½ times the number of patients
in a given session without significantly increasing personnel. This lowers the overall
cost per patient and allows room to schedule free clinic and health department cases
that would otherwise go without care. There has also been a decrease the wait time
from diagnosis to surgery to about 2-3 weeks (commonly 4-6 months in some areas).
Anecdotally, speaking with many other MMS surgeons, they frankly do not believe the
clinic’s output or that such efficiency is possible.
Background
Mohs micrographic surgery (MMS), developed by Dr. Frederic E. Mohs in the 1930s,
has become the gold standard for treating many forms of primary and recurrent
contiguous skin cancers and offers the highest cure rates and maximum tissue
conservation compared with other modalities1. There are an estimated 2 million cases
of skin cancer per year2, and that figure is likely to rise as the popularity of tanning has
increased and as lifespans continue to extend. As MMS is often performed in the
outpatient setting, it is often more cost effective than traditional excision3. The purpose
of the laboratory is to process the excised specimen into a microscopic slide to rule
out residual tumor at the tissue margin using the fresh frozen technique while the
patient waits until all the tumor is gone. Initially, our MMS lab included a Mohs
surgeon, one partially trained technician, and one technician without a medical
background. Currently we utilize the same Mohs surgeon, but have added a
dermatopathologist, five board certified histotechnicians, and five intensively trained
cryotechnicians.
Summary and Conclusion
Using concepts borrowed from Toyota’s Lean manufacturing practices
coupled with Dr. Christensen’s concept of disruptive innovation, we
have significantly increased efficiency in the MMS laboratory. This
allows for a sharply decreased turnaround time and increased quality,
leading to increased patient volumes while lowering overall costs and
wait times. As constant upheaval in medical delivery and a looming
shortage of qualified physicians looks to become more pronounced,
utilizing medical resources to their fullest extent will become critical to
physician leaders.
MMS chart with site and unique identifying number. Other identifying information is on
the chart, but not included here for patient privacy.
References
Combined Toluidine blue and Hemotoxylin and Eosin staining station
Sharpie use indicating patient (color) and block
number (dots)
1) Trost LB, Bailin PL. History of Mohs surgery. Dermatol Clin. 2011 Apr;29(2):135-9.
2) Patel RV, Frankel A, Goldenberg G. An update on nonmelanoma skin cancer. J Clin Aesthet Dermatol. 2011 Feb;4(2):20-7.
3) J Tierney EP, Hanke CW. Cost effectiveness of Mohs micrographic surgery: review of the literature. Drugs Dermatol. 2009
Oct;8(10):914-22.
4) Womack, J.P. & Jones, D.T., 2003. Lean Thinking: Banish Waste and Create Wealth in Your Corporation, New York: Free
Press.
5) Laboratory Medicine: A National Status Report. Critical Values. 2008 Oct;1(4): 12-3.
6) Christensen, Clayton M. (1997). The innovator's dilemma: when new technologies cause great firms to fail. Harvard Business
Press.
7) Christensen, Clayton M. (2003). The innovator's solution: creating and sustaining successful growth. Harvard Business Press.
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