Deconstructing the Fab Lab

What makes an in-house fabrication laboratory or a central fabrication facility shine—making it truly a "fab lab"?

One way to measure an ideal lab or central fabrication facility is in terms of performance and results, such as producing consistent, high-quality devices that meet or exceed expectations; achieving prompt, consistent turnaround times; reducing or eliminating costly waste and redundant work; and providing a positive and safe work environment.

The facility's physical structure, design, and layout can play an important role in helping the facility achieve these results. Fabrication labs and facilities can become bogged down with crowded workspaces, misplaced tools, inconveniently placed supplies, inefficient layout, and clutter. Any of these can lead to wasted time, energy, and materials, as well as higher costs and frustration. Even well-run, efficient labs may have areas that can be improved for even better performance.

The O&P EDGE deconstructs the fab lab as we take an indepth look at how Texas Scottish Rite Hospital for Children (TSRHC), Dallas, and the University of Michigan Orthotics & Prosthetics Center (UMOPC), Ann Arbor, turned to lean principles to redesign their facilities and reorganize their processes to improve their fabrication systems. Their experiences may spark ideas that you can use in your own in-house lab or central fabrication facility. We'll also provide insights for creating a disaster-resistant facility, gleaned from the experience of a practitioner who rebuilt his O&P patient care facility using innovative design concepts after an EF-5 tornado destroyed his building.

UMOPC used the opportunity for improvements when it underwent a major renovation, which greatly increased the facility's overall physical size; TSRHC reorganized its orthotics fabrication lab by redesigning the layout while making minimal interior structural changes, and streamlining processes without increasing the lab's square footage.

The core idea of lean organizational thinking is to maximize customer value while minimizing waste—creating more value for customers with fewer resources, according to the Lean Enterprise Institute. Lean also involves respect for people and working cooperatively with others for continuous improvement, a philosophy called Kaizen, notes lean consultant, author, and speaker Mark Graban (www.leanblog.org).

A key step, which both TSRHC and UMOPC use, is the "5S" process. An online lean site, Kaizenworld® (www.kaizenworld.com), explains 5S as:

Sort—remove all unnecessary items from the workplace.
Set in order—create a specific location for everything.
Shine—clean the work area.
Standardize—establish and follow best practices within the workplace.
Sustain—never slip back into the old ways.

Creativity Before Capital

"Often people think the solution to overcrowded space, clutter, and inefficient processes is simply more space," says TSRHC Vice President of Facilities and Process Design Donald Katz, MHA, CO, LO, FAAOP. So organizations might decide to make large capital investments in expanding or rebuilding, he says, when the better solution may be to eliminate waste and improve workflow by making better use of the space and resources currently available.

Like many other healthcare entities, TSRHC has been considering applying lean principles and processes, with the orthotics laboratory serving as a sort of pilot project, according to Katz.

The redesign and reorganization achieved documented results on staff performance and patient care, which Katz demonstrated in his Hamontree Lecture Series award-winning presentation, "Using Lean Principles to Document Changes in Staff Workflow and Patient Services," at the American Orthotic & Prosthetic Association (AOPA) World Congress in September 2013.

The hospital's O&P departments and the labs that support patient care are busy places. Combined annual patient visits for the most recent completed fiscal year totaled more than 9,300, with about 7,600 for orthotics services (an average of about 635 per month); annual orthoses and prostheses delivered totaled 4,481, with orthoses accounting for 4,150 (345 per month). The O&P staff comprises 14 prosthetists/orthotists, two residents, nine technicians, and three office staff. The lean initiative focused on eliminating waste and improving flow, including some interior structural design changes, for more positive outcomes. Results were quantified to see if meaningful improvements were accomplished.

TSRH

Staff engagement and buy-in is critical, Katz says. In lean thinking, respect for people is key. Goals and strategies should flow from the top down (from management to staff); ideas and solutions should flow from the bottom up (from staff to management).

The redesign aimed to improve lab layout and reduce workspace overcrowding and walking distances. With the growth of clinical activity and staff for more than 25 years, "people were practically on top of each other," Katz says.

The initiative looked at three main areas: transitioning from workbenches to workstations with computers; establishing a more purposeful community bench; and reducing walking distances and improving access to stock items to eliminate wasted time and motion.

Workbenches to Workstations

Before the redesign, orthotists and technicians shared a main lab, with each individual having an assigned workbench. However, over time orthotists began using their workbenches more as desks, while computers were shared in another room. In the redesign, the workbenches were transitioned to modular workstations with file storage and a dedicated computer and phone for each orthotist. Technicians use a dedicated space for work and a separate room for shared phones, computers, and files.

Other changes involved reorganizing storage areas. The number of old positive molds cluttering up the area near workbenches while necessary items were farther away had been a problem in the lab, Katz says. Many of the molds were thrown out and others were moved to the stockroom. Soft goods, such as premanufactured hip abduction orthoses and walking boots, for example, were previously stored in the stockroom—a 170-foot round-trip walking distance from the patient exam rooms. In the redesign, soft goods were moved closer to patient exam rooms and a doorway was eliminated, reducing walking distance between patient rooms and soft goods storage to about 30-50 feet—a more than 70 percent reduction.

Community Bench Initiative

Before the reorganization, the workspace shared by all staff members in the department, the community bench, was plagued by crowding around the bench by the doorway and along the wall, plus a lengthy roundtrip walk from the patient rooms to the primary work area. All staff members participated in the layout of the prototype design of the new community bench. Incorporating the new design and eliminating a doorway reduced round-trip distance by almost 75 percent—from 136 feet to only 36 feet. Since most patient care and custom fittings require multiple trips between the patient rooms and the community bench, the time saved adds up fast.

TSRH

The new bench includes an island for 360-degree access, two peninsulas for heat-flaring—the area of highest use—and duplicated functionality on both sides, which eliminates wait times. Key supplies are at arm's reach and elevated off the work surface. Hand tools are stored in drawers lined with material that contains cutout impressions in the shape of each tool, which makes tools easy to find and quick to put back in their place after use.

Results

The lab redesign resulted in significantly less walking time required for fittings (deliveries), which allows orthotists to spend more time with patients during fitting visits, and reduces overall delivery times. Overall delivery times for custom-molded orthoses were reduced by 6 percent. Overall delivery times for unilateral AFOs showed an 11.3 percent reduction; custom foot orthotics, a 25.5 percent reduction; and supramalleolar orthoses saw a 10.1 percent reduction. However, bilateral short articulating ankle foot orthoses (SAAFOs) did not have a significant change in fitting times.

Off-the-shelf (OTS) fitting times had an overall reduction of 5 percent. Eight types of these devices had more than a 10 percent reduction in the mean fitting-visit duration. Four kinds of OTS devices had an increase in fitting duration; however, these had the smallest sample sizes and high standard deviations. Hip abduction orthoses had a 47 percent reduction and bilateral arch supports showed a 7 percent reduction.

Katz's presentation summarized several important points: Shorter patient visits mean more deliveries are possible each day; more deliveries equal greater access to care.

Adopting the "creativity before capital" approach noted by Graban and other lean thinking experts can result in a one-time capital improvement investment without increasing square footage requirements, which would be a considerably more expensive venture.

UMOPC Implements Lean

In 2012, its 100th anniversary year, UMOPC underwent a $1.2 million renovation that considerably enlarged its facility to allow for the care of an increasing number of patients—about 25,000-30,000 annually, according to "UMOPC Undergoes $1.2M Renovation."

Hallways were revamped for better traffic flow, explains Jeffrey Wensman, BSME, CPO, clinical and technical director, and one full-size gait room and two smaller ones were replaced by three spacious casting and gait rooms. One has an overhead lift system so patients at risk of falls can be safe while standing for casting or trying devices.

Following lean thinking, standard rooms were created. Now there are three standard room formats: gait rooms, rooms with water, and rooms without water. Furnishings and supplies are standardized and are placed in the same locations in each type of room, making it easier to find supplies and saving trips in and out of the rooms. "We also have access to our electronic medical records (EMR) system in each patient room," Wensman adds. "We don't have to leave the room to get a piece of paper or a form; we can create it right there with the patient."

Redesigning the Fabrication Lab

As part of the renovation, the fabrication lab was redesigned for better organization and flow using the 5S system. Dedicated work zones were created for various tasks, such as cutting, vacuum forming, sewing, and finishing. "We looked at each function of fabrication and created work zones around that," Wensman says. Examples of this principle include creating a plastics work zone with a new vacuum pulling station near the ovens and plastics materials and a dedicated workbench for each technician to use for finish work. There are rooms for plaster and lamination processes with the materials on hand, which eliminates the need for technicians to go back and forth to accomplish their tasks. All of this, he says, makes the spaces more comfortable, keeping people from crowding and out of the traffic flow, and saves time.

"The technicians created the improvements," Wensman adds. For example, even before the new vacuum pull station came, they used a template the size and shape of the station, moving it around, thinking about where they would stand and how much space they needed to perform the vacuum forming process. "The technicians did most of the work in the lab—they created their space based on how they work," he says.

Lean thinking and teaching at UMOPC actually began long before Wensman came in 2009. The team attended off-site retreats to discuss the current state of the facilities and possible future improvements, he explains. One process the team developed was the "pull system."

"Instead of our lead technicians telling everyone what to do, the technicians know what needs to be done," Wensman says. Each day the clinicians add their work orders with the patient's name, the device type, and the due date for completion to a "pull list" paper form. Technicians pull jobs from that list in the order they need to be done; each day the pull list is updated and sorted by due dates. When technicians take a job, they enter the job into the Lab Log production database, initialing the pull list so that the team knows who is working on the job. When a job is finished, the technician completes the job in the Lab Log and brings the device to a quality assurance (QA) table where the job is checked by a peer before it is brought to the ordering practitioner's bench. The technician then repeats the process by "pulling" another job. The technicians are currently cross-trained, or in the process of cross-training, in the fabrication of all the device types.

Another lean step that came out of the retreats is a list of "mutually agreed upon expectations"—what the technicians expect of each other, Wensman says. "They created a beautiful poster with these expectations which hangs on the wall of our lab. That's been great for morale and team feeling."

Standard Turnaround Times and Work Processes

"Standard turnaround times and standard work processes are another part of lean," Wensman explains. "There are expectations that everyone knows. For instance, the turnaround times for all devices are posted. We know that once the insurance approval or patient payment has been completed, we can tell the patient when their device will be ready. The lab is virtually 100 percent successful in meeting these turnaround times. Obviously there are variations in patients' needs which fall outside of these turnaround times, such as hospital emergencies and patients who need expedited service because they are leaving town, but we have an on-call technician to meet this need.

Standard turnaround times require standard work processes, Wensman observes. The team has evolved certain processes over time and written down those regarded as standard procedures. Standard procedures help to reduce confusion, which can occur when multiple practitioners are teaching multiple technicians how to do things their way. Wensman emphasizes that only processes are standardized; the devices are still custom made to fit the individual patient's needs. With standardized processes and procedures, training is easier, work goes faster, and quality is more consistent.

"Kanban"—Streamlined Inventory Management

Using "kanban" principles, Jill Petkash, CTPO, inventory manager/techinical co-lead, set up the lab's inventory system. Kanban is a lean materials planning technique in which work centers use a card to signal when they need to withdraw parts from feeding operations or supply bins. As Wensman explains, "When you remove an item from the shelf, you just have to drop a card in a folder and it gets reordered." Each part has a reorder point. When a certain number of items are removed, a card is seen signaling time to reorder. "It's a very efficient, low-maintenance system," Wensman says. "Jill has also worked hard to store inventory near where it is most frequently used."

Building the Disaster-Resistant Facility

Three years after an EF-5 tornado tore through Joplin, Missouri, claiming 161 lives and causing an estimated $3 billion in damages, the city is rising from the devastation as residents rebuild homes, businesses, and their lives. The Advanced Orthotics & Prosthetics patient care facility took a direct hit from the tornado. It was rebuilt on its same site to withstand disasters.

ADVANCED ORTHOTICS & PROSTHETICS

REBUILT FACILITY. Photographs courtesy of Frank Ikerd, Advanced Orthotics & Prosthetics.

"We used ICF [insulated concrete form] construction," says owner Frank Ikerd, CPO. "There's six inches of concrete and a combined five inches of insulating foam on interior and outside walls; it's 30-40 percent more energy efficient. The construction can withstand winds up to 200 miles per hour and is fire resistant. Adding to its strength and consistency is the use of Helix™ micro-rebar, consisting of tiny twisted steel fibers, to replace traditional rebar in the concrete. The micro-rebar improves crack resistance and shear strength and increases durability."

For increased energy efficiency and air quality, the new building is heated and cooled via a variable refrigerant flow (VRF) system, which moves refrigerant to zones—independently climate-controlled single or multiple rooms within a structure. Lab odors do not mix with air circulated to other parts of the facility, and negative airflow pulls out lab odors and filters the air. Energy-saving and water-conservation measures include dual-flush toilets and water heaters set on a timer to heat only during operational hours.

As Ikerd's example demonstrates, building a new facility offers an opportunity to incorporate better overall designs and processes. However, even without major structural changes, the interior design, layout, and workflow processes can be improved using principles of lean thinking to help create a "fab lab."

"Lean principles are something that every company should do," Wensman says. "Just start where you are. Some people are already well along on this path."

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at