Michael Astion CLN July 2015

Q&A with Mike Astion, MD, PhD, editor-in-chief, Patient Safety Focus

We are doing a Lean project to reduce errors and eliminate waste. Overall, my lab team is game for quality improvement but they dislike that parts of their work are called “waste.” They also don’t like the use of the outside consultant, and they do not like the comparison of the lab to an auto assembly line. Could you give me some tips for making the staff more comfortable?

A Lean and Six Sigma are disciplined approaches to solving problems and they work well across a broad range of industries, including healthcare. Lean involves many kinds of useful tools and methods like value stream maps, process maps, spaghetti diagrams, and a variety of timing studies. These methods are relatively easy for clinical lab workers to learn and use effectively. But even the most successful clinical labs have struggled to adopt them. The reason you are having a problem with your Lean project is not due to comprehension. It is due to resistance to change and other cultural factors.

Here are the keys to overcoming resistance to change and unleashing Lean or any other disciplined problem-solving method:

1 Minimize the use of outside consultants to those who are very experienced, and limit their engagement. Most Lean projects do not require an outside consultant. The best lab consultant would look tired, and maybe not as beautiful as he or she used to be, because they had worked in a hospital or lab for many years and suffered through and overcome: mislabeling, misorders, lost specimens, laboratory information system implementations, data entry errors, angry doctors, angry nurses, apologies to patients, construction projects, labor disputes, and the like.

2 Minimize new jargon and acronyms and speak plainly so everyone understands. This also helps communicate our efforts both to patients and the public and minimizes problems due to language comprehension.

3 Over-communicate that the need for change does not mean people are doing a bad job. Change must occur because it is our mission to perform more testing for more patients quicker and with fewer errors. To accomplish our mission, quality improvement and the changes associated with it can never end.

4 Create a sense of purpose. Laboratory workers have the privilege of working in a meaningful environment where we alleviate suffering. Quality improvement grows this privilege. It is up to you to remind your staff of the importance of quality improvement through patient safety stories, visits by patients, relationships with frontline nurses and doctors, and similar interventions to improve connectedness.

5 Implement Lean with a sense of humor. This deals directly with the question at hand. I have spent a career teaching lab management and lab quality using humor as my main teaching tool, especially when combined with actual painful laboratory experiences.

Q What about the concept of waste? A In Lean, waste refers to all the delays, overwork, unnecessary steps, errors, rework, and lost human potential in a process. Waste is not a funny word. Waste is sad and smelly, and lab workers often find it extreme. It is nonrelational. No two human beings were ever brought closer by waste.

scraping burnt toast CLN July 2015 patient safety focusTo teach about getting rid of waste in the lab, try an alternative. My favorite is to talk about all rework as the scraping of burnt toast, and refer to methods that correct errors produced by lousy systems, as “scraping burnt toast” methods. The burnt toast metaphor in quality improvement was first shared with me more than a dozen years ago by Gary Conkle, a quality improvement (QI) expert from Beckman Coulter, and is one that seems to resonate deeply with lab workers, most likely because we are regular people who eat lots of toast. Lab workers like toast because it is a versatile and pleasant food, and a source of happiness, serving as a transporter for butter, sandwich meat, cheese, bacon, eggs, mayo, mustard, and jam. I have yet to meet the person whose day was made worse by a tasty spread riding on warm toast. However, most people are appalled by burnt toast, and have experienced it. Nobody likes scraping burnt toast, and a day that starts with burnt toast often turns out to be a bad day. 

Eliminating rework is a focal point of Lean. Common lab rework includes cleaning up a confusing or incomplete test requisition, re-entering data that was mistyped, or redrawing a specimen for nearly any reason such as quantity not sufficient or specimen collected in wrong container. Every corrected report involves significant rework. Commonly, laboratory client service centers spend 25% of their time in service recovery, which is the scraping of the burnt toast.

If you want your staff to understand rework, describe all the rework in the lab, NOT as waste, but as the scraping of burnt toast, and as you describe each bit of rework, dramatically make the universal scraping of burnt toast gesture as if you had a knife in your right hand and the toast in your left and you are slightly bent over the sink with an “I’m overwhelmed” look on your face. I have found that the scraping of burnt toast metaphor spreads virally across labs and hospitals, especially if you remember to use the dramatic, universal scraping of burnt toast hand movements and facial expressions. See if you can get the whole lab to communicate nonverbally by doing the universal burnt toast movements whenever rework, or a method to correct or workaround errors, is being described.

Humor and connection to patients are the anchors for Lean projects that aim to create great toast, rather than wasting time scraping it. Humor and humanity may be the key to unleashing Lean and other disciplined problem-solving methods in your laboratory.

If you have any other funny meta­phors that might help lab leaders improve quality, please share them with michael.astion@seattlechildrens.org or mastion@uw.edu. I shall share them with readers at a later date.


  1. Astion M. Smoothing workflow and reducing errors in specimen processing. An interview with Albert Dalbello Jr. and Linda Nesberg. Clinical Laboratory News 2009;35(7):14–5.
  2. Astion M. Disconnection from patients and care providers: A latent error in pathology and laboratory medicine. An interview with Dr. Stephen Raab. Clinical Laboratory News 2009;35(4):14–5.
  3. Astion M. Continuous systems improvement, I Love Lucy, and scraping burnt toast: An interview with Gary Conkle. Laboratory Errors and Patient Safety 2005;2(1):4–7.

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