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Cytology improvement guide: achieving a 14 day turnaround time in cytology

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This guide highlights the findings and improvements from the pilot sites who tested how the 14 day standards can be achieved using Lean methodology.This practical guide is supported by tried and …

This guide highlights the findings and improvements from the pilot sites who tested how the 14 day standards can be achieved using Lean methodology.This practical guide is supported by tried and tested case studies across the whole patient pathway which NHS staff involved in the screening pathway can adopt and adapt to meet their local setting. (Nov 2009)

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  • 1. NHS NHS ImprovementCANCERDIAGNOSTICS NHS Cervical Screening Programme (NHSCSP) Cytology improvement guide -HEART achieving a 14 day turnaround time in cytology Clinical excellence in partnership “LUNGSTROKE with process excellence”
  • 2. Cytology improvement guide - achieving a 14 day turnaround time in cytology 3Contents1. Foreword 5 Motion Case study 62. Executive summary 6 Moving the fridge reduces walking. Case study 73. Introduction 7 Sample collection trips reduced.Why Lean as the methodology of choice? Automating inefficient processes4. Phase 1 pilot sites 8 Waiting5. Learning for future improvement 9 Case study 8 Changing quality control procedures.6. Understanding where you are 10 OverproductionWhat to measure and how to collect it? Case study 9• Baseline data – ‘Go see’. Slide matching.• Data requirements.• SPC charts. Over-processing• Skyline plots. Case study 10 Removal of date stamping.7. Self assessment 12 Case study 11Score the current status of your service. Removing the day book.8. How to begin 13 Case study 12Team make-up, the wider team, executive Adjusting download times to thesupport and involving users. primary care support services.9. Establish the measures 14 DefectsIdentifying and measuring factors which Case study 13impact overall turnaround time. Zero tolerance of defects. Case study 1410. Just-do-its – recommended Improving mapping tables.immediate activities 15 Skills utilisation• Primary care. Case study 15• Laboratory. Expanding roles in prep room.• Results agency. Case study 16Case study 1 Abnormal pathway changes.Reducing batching in the screening room. 12. A3 thinking 39Case study 2 What it is and how to produce an A3?Introduction of multiple downloads. Case study 17Case study 3 Using A3s for problem solving.Reducing manual-matching and firstclass post. 13. Root cause analysis 41 Techniques to determine the true cause11. The nine wastes 22 of a problem.TransportCase study 4 Case study 18Specific bags sent straight to laboratory. Using data for root cause analysis.InventoryCase study 5Reducing the backlog. www.improvement.nhs.uk
  • 3. 4 Cytology improvement guide - achieving a 14 day turnaround time in cytology 14. Visual management 44 20. Capacity and demand 60 What is it and how is it used? Do we have sufficient capacity to meet the demand? Case study 19 Use of visual management to support Case study 28 a zero tolerance of defects. Using capacity and demand information. Case study 20 Case study 29 Introduction of yellow stickers for the 100 day plan. abnormal pathway. Case study 30 15. Value, value stream mapping, Cost avoidance. flow and pull 47 21. Communication 67 Improving flow, introducing pull, eliminating The importance of good two way non-value adding steps, simplifying processes, communication. combining steps, re-sequencing. Case study 31 Case study 21 Understanding communication issues. Removing duplicate checks. Case study 22 22. Leadership, engagement Establishing work cells. and sustainability 69 How leadership style affects staff Case study 23 engagement. Standard work and flow at late delivery times. Case study 32 Case study 24 Sustainability - managing a surge in demand. Abnormal pathway changes. Case study 33 Case study 25 Sticking to Lean principles. Changing work patterns. 23. Customer experience 74 16. Future state mapping 54 What do the users really want? How do you get there and action Case study 34 planning? Colposcopy service improvements. 17. 5S to improve safety and morale 55 25. NHS Improvement contact details 76 Case study 26 5s in the screening room, office and stores. 26. Websites and useful reading 77 18. Standard work 57 The best way to perform each process step. Case study 27 Standard work in screening. 19. Takt time 59 What it is and how it can be used to level the workload.www.improvement.nhs.uk
  • 4. Cytology improvement guide - achieving a 14 day turnaround time in cytology 51. Foreword The NHS Cervical Screening Programme (NHSCSP) is undoubtedly a major success. Over the past two decades the NHSCSP has led to many cancers being prevented and has led to significant reductions in the death rate from cervical cancer in this country. It has been established that cervical screening saves around 4,500 lives every year in England.Professor Mike Richards CBE Much of the success of the NHSCSP can be attributed to havingNational Cancer Director effective call and recall systems and quality assurance schemes. The introduction of liquid based cytology over the past few years (2003-2008) has led to significant reductions in the number of ‘inadequate’ tests (from around 9.5% to 2.5%). This means that around 400,000 fewer women need to be re-screened each year. However, we know that we can and we must do better. In many parts of the country women are having to wait far too long to receive their test results. By December 2010, all cervical screeningProfessor Julietta Patnick CBE services have to ensure that women receive their results within twoDirector NHS Cancer ScreeningProgramme weeks of the test being done.Pilot sites working with NHS Improvement have demonstrated that the 14 day standard forcervical cytology can be achieved and that this brings benefits both for the patient and for theNHS in terms of potential cost savings.This guide shows how the 14 day standards can be achieved. We commend it to allcommissioners and providers of cervical screening services.Professor Mike Richards CBE Professor Julietta Patnick CBENational Cancer Director Director NHS Cancer Screening Programme www.improvement.nhs.uk
  • 5. 6 Cytology improvement guide - achieving a 14 day turnaround time in cytology 2. Executive summary The publication of the Cancer Reform Strategy Productivity: Eliminating non value added (Nov 2007) made a promise to ‘ensure that all steps, ensuring appropriate utilisation of women receive the results of their screening workforce, demonstrating the capacity required tests within two weeks by 2010’. based on the demand, and ensuring technology is used effectively. The Scharr report (Feb 2006) highlighted that with minimal investment it was possible to Key learning has demonstrated success is deliver the service to 50-66% of women within achieved through: seven days with the remainder receiving their result within 14 days. Strong and proactive clinical and managerial leadership: To encourage, drive, In 2006 the Review of Pathology Services in motivate and empower staff. England by Lord Carter endorsed Lean as the method of choice for improving processes in Collection and analysis of appropriate data: pathology services. Working in partnership with To understand the current end to end pathway. the National Cancer Screening Programme, NHS Improvement supported10 pilot sites to test the Walking the pathway: Go to see the problem Lean methodology to demonstrate how to first hand. deliver a two week service. Executive support: To provide active support The approach involved bringing multi-disciplinary and remove barriers. teams from primary care, laboratories and recall agencies together to work collaboratively on the Empowered staff: Who own the problem, whole pathway. Staff were trained in Lean find the solutions and ‘stop to fix’. methodology, applied the learning, redesigned their own service and delivered significant This guide provides clinical teams with the basic improvements. tools to make changes to their processes, and is supported by tried and tested case studies from Over 500,000 women will have benefited from across the whole pathway. the improvements in: Turnaround times: 100% of women receiving their result within 14 days (for most sites) and over 80% of women receiving results within seven days for five out of ten sites. Quality and safety: Implementing a zero tolerance of defects in request forms and sample labelling to reduce errors. Innovation: Using simple visual management techniques to improve flow, safety and productivity.www.improvement.nhs.uk
  • 6. Cytology improvement guide - achieving a 14 day turnaround time in cytology 73. IntroductionAs the 14 day target is of national importance,there will naturally be a great deal of interest inhow Lean methodology has been used tosupport the aims of the Cancer Reform Strategy. ACT PLAN What changes ObjectiveOver the past four years NHS Improvement has are to be made? Questions and Next cycle predictions (why)worked with a number of pathology teams to Plan to carry out thetest and prove the value of Lean methodology. cycle (who, what, where and when)Clinical teams have been extremely successfuland the methodology is being widely adopted in STUDY DOmany pathology laboratories and other clinical Complete the analysis of the data Carry out the plan Document problemssettings across the country. Compare data to predictions and unexpected observations Summarise what Begin analysis was learned of the dataThe methodology and approach was furtherendorsed by Lord Carter in the ‘Report of theReview of NHS Pathology Services in England’in 2006/2008.Pilot site teams were trained to:• Understand and identify waste. Spreading and sharing the learning• Apply Lean principles to improve flow. Networking amongst clinical teams involved in• Use PDSA cycles (plan, do, study, act) to test the pilot, facilitated a collaborative approach to out ideas to ensure changes make the achieving improvements and to spreading improvement required before implementation innovation and success. (sometimes known as PDCA - plan, do, check, act). A buddy system for close locality sites was set• Use data to demonstrate the impact of up to support the sharing of best practice along improvement. with a series of training and development• Understand how people respond to change; workshops and shared learning events.• Use statistical process control charts (SPC) and root cause analysis. In addition, a number of regional learning events• Understand communication methods and were conducted by pilot site teams, supported work as part of a team. by NHS Improvement National Improvement Leads to spread some of the learning to non-To further support and embed the improvement pilot sites.methodology within the local environment andcreate local ownership, an overview of Lean This document contains case studies frommethodology was provided for all staff involved the phase one pilot sites to help illustratein the pathway. the changes made. Further case studies can be found on the website at:The training, combined with clinical lead www.improvement.nhs.uk/diagnosticscommitment, are essential to the sustainabilityof achieved and ongoing improvement. www.improvement.nhs.uk
  • 7. 8 Cytology improvement guide - achieving a 14 day turnaround time in cytology 4. Phase one pilot sites The following sites were selected by the National The phase one pilot sites are: Cancer Screening programme to take part as phase one pilot sites. One of the criteria for Leeds PCT and The Leeds Teaching joining the programme as a pilot site was to Hospitals NHS Trust become exemplar sites, prepared to share Lead: Dr Simon Balmer learning with other teams. Hull Royal Infirmary and Hull and Clinical teams will benefit from visiting the East Riding PCTs following phase one sites, where they will Lead: Ms Kathleen Young observe Lean methodology as part of everyday working and learn how the targets have been Pennine Acute Hospitals NHS Trust achieved. Lead: Mr Tom Wilson The criteria for inclusion as an exemplar site are: Norfolk and Waveney Cellular Pathology Network (Norfolk and Norwich University • Delivery against 14/7 day target Hospital NHS Foundation Trust) (min. 95% and 50%). Lead: Dr Xenia Tyler • Clear evidence of Lean methodology including: West Anglia Pathology Cytology Laboratory • Visual management (Cambridge University Hospitals NHS • Standard work Foundation Trust, Addenbrookes Hospital • A3 problem solving and Anglia Support Partnership) • Stop to fix problems via daily meetings Lead: Ms Roseanna Bignell • 5S. • Evidence of all staff committed to continuous Barts and The London NHS Trust improvement and Lean methodology. Lead: Mr Geoffrey Curran • Evidence of sustainability and committed leadership. Somerset and West Dorset Cervical Screening Service (Taunton and Somerset Hospitals NHS Trust) Lead: Dr Simon Knowles Ashford and St Peter’s Hospitals NHS Trust Lead: Mr Behdad Shambayati North West London NHS Trust (Northwick Park Hospital) Lead: Dr Tanya Levine Central Manchester University Hospital NHS Foundation Trust Lead: Dr Mina Desaiwww.improvement.nhs.uk
  • 8. Cytology improvement guide - achieving a 14 day turnaround time in cytology 95. Learning for future improvementThe purpose of this document is to share the The key mechanisms required to achieve theselearning from phase one pilot sites. changes are:It makes recommendations for change throughevidence based case studies and encourages 1. Empowered staff who can:teams to adopt the learning, adapt within their • see the waste and remove it;own service, and visit exemplar sites to discuss • test changes through PDSA cycles;improvements made, challenges faced and • have information to say how we are doing;pitfalls to avoid. • use suggestion boards to have ideas actioned.The four key changes have been identified 2. Daily meetings established to:which will bring about substantial reductions in • stop and fix problems;end-to-end waiting times for the cervical • encourage a culture of daily problem solving.cytology pathway are: 3. Visual management techniques to:1. Focus on the whole end to end pathway: • display performance data;• link all staff across the pathway; • promote standard work;• use whole pathway data to understand where • ensure safe working practices. samples and reports are waiting. 4. Information to support the process:2. Adopt small batch sizes: • turn real time data in to information to• throughout the entire pathway, including the manage the process; prep room, lab, screening room, data entry as • ensure visibility of efforts; well as primary care and the call/recall agency. • identify problems and establish mechanisms to solve problem;3. Keep samples moving: • encourage root cause analysis.• daily delivery from primary care;• pull work through the lab; To accelerate the pace of change to reduce• multiple daily downloads; turnaround times, defects and rework and• daily issue of reports. improve quality, safety and productivity, teams should consider applying:4. Establish first in, first out:• no prioritisation of samples; • Just do its – tried and tested, proven to• todays work today. reduce turnaround times – adopt as many as you can; and consider the; • Human dimensions of change – the importance of engaging all staff. An engagement survey tool is available on the NHS Improvement website. Whilst this process will not be easy, the rewards are great! www.improvement.nhs.uk
  • 9. 10 Cytology improvement guide - achieving a 14 day turnaround time in cytology 6. Understanding where you are Measuring the end-to-end pathway Recommendations include: At the launch stage of a project, it is important • Date/time primary screened to create an understanding of what is actually • Date/time rapid review performed happening, as distinct from what ‘should be’ or • Date/time report authorised is thought to be happening. Identifying the • Date recall agency received info (down current situation should include the whole electronic link), journey of the samples – not just in-laboratory • Date letter was issued. processes. A sample data collection spreadsheet can be The best way to do this is to ‘go see’. This found on the NHS Improvement website. means to physically walk the whole pathway and produce a photographic record of the Note: it may be appropriate to record measures process. It is recommended that this is done by for all test results (abnormal, negative, the whole core team to ensure objectivity. incomplete) separately so these can be monitored individually. The pathway should then be graphically represented as a current state value stream map. What type of data and how much? Measurements taken as part of value stream We recommend you collect data on at least 750 mapping will provide the baseline against which consecutively numbered specimens taken in the the impact of any changes to the process can be same week to provide a statistically valid compared. baseline TAT. Every task undertaken while processing samples Calculating and monitoring TAT - Using will have an impact on achieving the 14 day statistical process control (SPC) turnaround time (TAT) and should therefore be By collecting data from samples at the three key included in baseline measurement. TAT is stages within the pathway, variations in defined as the time the sample was taken to delay/wait times and other sources of waste can expected date of delivery of the result letter to be detected, corrected and tracked to assess the woman. how/if these are reduced over time as a result of improvement changes. Data requirements SPC charts provide a graphical representation of To capture a clear and accurate TAT measure, the time it takes to process a particular sample data should be collected for all three key stages and an overall view of the variation in the of the cytology pathway: process. 1. Date sample taken to date sample received in Statistical control limits are calculated from the the laboratory specimen reception. data input and are displayed on the chart along 2. Date specimen received in specimen with process average (mean) and its variation reception to date report authorised and sent about that mean. If there is evidence of unusual to the recall agency. variation or ‘special cause’ (outlier) detected, 3. Date report received in the recall agency to then this ‘special cause’ should be investigated date result received by woman (calculated by using a root cause analysis technique (see by adding one day to the date letter issued section 13). for first class postage or three days for second class). SPC tools can be accessed via the NHS Improvement reporting system or NHS To determine the impact of changes made in the Improvement excel data template. To find out laboratory or other specific parts of the pathway, more about SPC and the types of ‘run rules’ that additional timings should be captured and are used to indicate out-of-statistical control statistical process control (SPC) charts produced situations please refer to the website or NHS to evidence achieved improvements. Improvement publication ‘Bringing Lean to Life - Making Processes Flow in Healthcare.’www.improvement.nhs.uk
  • 10. Cytology improvement guide - achieving a 14 day turnaround time in cytology 11 Special Cause Variation process is ʻout of controlʼ Special Cause Variation process is ʻout of controlʼYour individual project can be set up on the NHS The query covers date sample taken through toImprovement reporting system and this will date added to recall system. It shows patientenable you to track the project, add project identity to enable root cause analysis for samplesdocumentation and upload improvement stories. that have taken longer than 14 days for analysisFurther information on how to use the NHS and result return. An additional field ofImprovement System can be obtained via ‘expected date of delivery’ is due to be added tosupport@improvement.nhs.uk the query shortly so full end-to-end TAT can be produced.Other important data for your baselineTurnaround times This query can be run by all recall agencies for% achieved in 14 days any specified time period, allowing analysis of data on daily, weekly or monthly cycles. The% achieved in 7 days data can be sent to laboratories via secureQuality and safety (defects) transfer (or can be run without patient% samples/forms with inaccurate/illegible/ identifiers) and together with laboratoryincomplete information sample data can be used as an alternative to SPC charts.% referrals returned to requester% reports authorised and sent to recall agency Instructions on how to run this query can bewhich required manual matching found at: www.improvement.nhs/uk/ diagnosticsEngagementOverall engagement scores at start of project In addition, each individual laboratory can runand various additional points throughout the this query through CYRES. It should bechange process. remembered that this will only show from date sample received to date results sent to recallSkyline plots agency. Ensuring a 14 day end-to-end TAT willThe East of England Screening QA Reference require all samples to be within 10 and 12 daysCentre (QARC) has developed a cervical depending on time taken by recall to sendscreening system enquiry that recall centres can letters out.use to perform a patient based search that willshow TATs in a bar chart. www.improvement.nhs.uk
  • 11. 12 Cytology improvement guide - achieving a 14 day turnaround time in cytology 7. Self assessment The Endoscopy Global Rating Scale (GRS) and Radiology Service Improvement Assessment Tool (RSIAT) were developed by the Endoscopy and Radiology service improvement teams respectively and have been used widely since 2004 to benchmark these diagnostic services and provide teams with a focus for improvements. They have been designed to allow clinical teams to see which areas they need to concentrate on to achieve the cancer waiting times targets. Whilst such a tool for cytology is currently still under development, the questions, and answers teams provide, can help to steer the focus of improvement in the direction that will create the most benefit to the screening programme. The questionnaire can be found on the NHS Improvement website at: www.improvement.nhs.uk/diagnosticswww.improvement.nhs.uk
  • 12. Cytology improvement guide - achieving a 14 day turnaround time in cytology 138. How to beginTeam guidance Wider team membership/steering groupFirstly, identify a credible and respected project It is recognised there will be a wider team oflead to head up the team. This could be a individuals who are key stakeholders across theclinician or manager with the drive and pathway who will provide managerial andenthusiasm to steer changes across the strategic support but may not be a member ofwhole pathway. N.B. full screening programme the core team for training.pathway includes colposcopy and histology: Executive support An executive team sponsor should be identifiedProject team members should be drawn to provide proactive support and access tofrom across the entire pathway: relevant support services such as estates,• Clinical /managerial lead who must provide transport, HR, finance and IT teams. They may active support and leadership to the core team be called upon to escalate key issues.• Primary care – (e.g. PCT lead, practice manager) should be able to contribute to Protected time out discussions such as organisation of transport This is essential to allow thinking time for the for same day sample delivery core team and any members of staff planning a• Laboratory – (e.g. MLA, BMS, AP, screener) plan, do, study, act (PDSA) cycle and may have must represent and understand specimen to be facilitated by the departmental manger or reception processes and the laboratory LBC executive lead and screening process (you may wish to co- opt a laboratory manager and/or Communication plan histopathologist onto the core team/wider It has been widely recognised from the phase team or steering group) one pilot sites that the establishment of a• Results issue agency – should be able to communication plan is essential and a central contribute to discussions and influence / lead information board should be positioned to changes to the results issue process inform all staff of project activity and progress.• User involvement – member of an existing gynaecology patient group or suitable Training location/work room equivalent, likely to be a wider team member Space will be required for the core team to• Colposcopy – a member from this area may be work. An area should be identified where local co–opted onto the wider team / steering training can take place and where teams will group. have space to work on projects and store information work sheets/maps with easy accessCore team members must: to these items on a regular basis.• Understand the process within their stage of the pathway• Be able to contribute ideas/information on the process• Be able to influence the decision making process• Be prepared to test and implement changes across the pathway• Be committed to attend all team meetings, conference calls and sharing events. www.improvement.nhs.uk
  • 13. 14 Cytology improvement guide - achieving a 14 day turnaround time in cytology 9. Establish the measures Identifying and measuring factors which impact overall turnaround time In addition to the global measure of turnaround times (TAT), quality, safety and staff engagement, there will be other local measures and quality indicators that can be used to asses the impact of the project. These should be focussed around: Safety - reducing avoidable harm and creating confidence that the result is accurate e.g. no errors in sample taking, request cards, data input or results letters. Customer experience - understanding of the result with relevant and timely information e.g., information at time of test and with result letters. Effectiveness of care - good quality outcomes e.g. no unplanned staff/machine/system downtime and each result produced within PCT tariff. Some examples of additional measures: • Patient satisfaction rating; • % processor/system utilisation; • % staff availability; • % inadequate/re-prep samples; • % machine/system re-runs; • % of samples with insufficient cells; • % staff absence; • Stock level replenishment; • Number of unplanned shutdowns v. target; • Department productivity v. target.www.improvement.nhs.uk
  • 14. Cytology improvement guide - achieving a 14 day turnaround time in cytology 1510. Just-do-its (JDIs) - recommended immediate activitiesThis section is designed to help teams make structured way, guided by the core project teamsome very quick changes. These have been and project lead. Measures should be in placetested and proven to make a significant to track improvements.difference to turnaround times. To support the JDIs, the case studiesMost are simple, quick to do, with very little demonstrate how sites have implemented someeffort required. of these simple changes evidencing the improvements achieved.All parts of the pathway are covered. Changesshould be implemented in a planned and Primary Care Action Why? 1 Enforce a policy for refusing ‘out of scope’ Stop inappropriate sample testing and samples and ensure GPs and sample takers inappropriate samples being tested when a know the correct pathway for symptomatic more suitable test/intervention is required. patients. 2 Send samples to laboratory daily, even if there To ensure timely testing. is only one! 3 Ensure appropriate staff are trained in use of To enable the correct information to be put ‘Open Exeter’ and are able to use the system to onto the request form regarding the last its full capability. cytology results etc. 4 Always use pre-populated HMR101 forms or To ensure correct demographics are recorded. print offs from the primary care system. Samples are not returned for correction or because hand writing is illegible. 5 Where available – use electronic requesting for To ensure correct demographics are recorded. every sample. Samples are not returned for correction or because hand writing is illegible. Laboratory Action Why? 1 Reduce batch sizes to a maximum of 20 in the Although instinct tells us batching ‘feels’ prep room. quicker, this will immediately reduce your TAT. Use SPC to evidence the gains. 2 Reduce batch size to 10 or less in screening Although instinct tells us batching ‘feels’ room and office area. quicker, this will immediately reduce your TAT. Use SPC to evidence the gains. 3 Reduce batch size for consultants to a Although instinct tells us batching ‘feels’ maximum of four. quicker, this will immediately reduce your TAT. Use SPC to evidence the gains. 4 Implement a non-acceptance policy for Eliminates time spent by staff dealing with incorrect forms/vials. omissions and mistakes, logging returns, telephoning surgeries etc. www.improvement.nhs.uk
  • 15. 16 Cytology improvement guide - achieving a 14 day turnaround time in cytology Laboratory (continued) Action Why? 5 Implement ‘quiet time’ in the screening room This will improve the quality of concentration during an agreed period each day (no and productivity of the screeners. answering e-mails, remove the fax machine, mobile phones set to silent). 6 Introduce a staff ideas and information board. Important to engage staff in identifying issues and solutions. Essential to provide a feedback loop explaining what is happening with suggestions made. 7 Initiate five minute daily meetings (huddles) Encourages ‘stop to fix it’ culture and improves with all staff around the information board. engagement. Staff know what is expected of them and how the team is progressing 8 Introduce visual management showing Improves productivity. Progress is visible and numbers of slides/samples in (demand) and motivating. numbers out (screened) daily. 9 Stop over labelling or writing patient names on Will remove an extra step and improve safety slides. which could be compromised by potential labelling errors. 10 Stop the process of slide matching in the prep Saves staff time and frees up space. Reduces room. Ensure all slides and forms are kept in TAT. numerical order in the same batch sizes. When required, screeners collect one tray of slides and the corresponding batch of request forms before screening. 11 Implement standard work in screening - Prevents slides waiting overnight or over screening one tray of ‘primary’ followed by one weekends for rapid review. Saves BMS time tray of ‘rapids’. allocating slides. 12 Promote the use of pre-populated Prevents defects / mistakes on forms. HMR101/primary care system forms or order comms. 13 Set up multiple daily electronic downloads to If sent weekly – could save up to save seven the recall centre – at least twice daily if IT days off TAT. systems allow. Check what can be done – If sending download daily - Will save one day don’t assume it isn’t possible! for half your screening output each day.www.improvement.nhs.uk
  • 16. Cytology improvement guide - achieving a 14 day turnaround time in cytology 17Recall agency Action Why?1 Implement first class post for all results letters. Can save between two to seven days on TAT.2 Post results letters every day, Monday to Friday. Will save a minimum of five days on TAT.3 Remove the lab and recall telephone number Prevents unnecessary phone calls to the from results letter, add NHS Direct telephone laboratory and recall centre who then have to number. refer back to the GP.4 Receive numerous electronic daily downloads Will save one day for half the screening output from the laboratory – at least twice daily. each day.5 Contact all recall agencies you forward results 14 day target is: Date sample taken to to, ensure they are aware of their role in expected date of delivery of result to woman. delivering 14 day target. A result to the wrong recall agency, will need time to send to correct agency – the clock is still ticking.All areas Action Why?1 Initiate monthly meetings with the laboratory, To improve communication and resolve any recall agency, commissioners, primary care cross boundary issues. representative etc.2 Send out monthly reports and newsletters To improve communication, promote your communicating current TAT, achievements, project and the national target and manage issues etc. customer expectations. www.improvement.nhs.uk
  • 17. 18 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 1Reducing batching in the screening roomNorth West London NHS TrustSummary Effect of reduced batching of slides on length of timeChanges made in cytology screening taken from booking in to primary screenroom to reduce waste caused by batchprocessing through the screeningprocess.Understanding the problemThe need to reduce the length of timespent waiting for something tohappen:• Watching the progress a case made during its journey through the cytology screening room identified numerous occasions where the case would simply sit and wait amongst a batch until the next stage of the process could take place.• Backlogs were seen with slides waiting to be primary screened, rapid reviewed, checked and How the changes were • The move to reduce the batch size reviewed by the pathologist. implemented down further to 5 slides per tray• Slides were done in batches of 20 • Batch sizes of slides reduced to 10 resulted in a further 20% as this was the number of spaces per tray. reduction in primary screen to available on the slide tray. • Policy imposed that a screener verification TAT.• Screeners would not always take a completing a tray of primary • The effect these changes have tray of rapid review after completing screening must then take a tray of made can be clearly seen on the a tray of primary screening which rapid review. SPC chart below which displays would result in an increased number • Cases to be reported on computer the length of time taken from the of cases awaiting rapid review. immediately after screening. booking in of the case to the time• Some screeners would put their • No work to be left on desk at end it is primary screened. results on the computer only after of working day. Any uncompleted • The reduction of batch sizes has they had completed a tray of slides screening must be returned to the had the effect of pulling the work and not immediately after screening pool of work. through the department. the case. • Checkers to be more pro active in • The reporting rates for abnormality• It was common practice for a doing checking to prevent build has remained constant during this screener to leave an uncompleted up cases. time. tray of work on their desk where it • Work requiring pathologist review would remain until they returned to to be allocated to named Ideas tested which were successful work. pathologist Improvements in turnaround time• Data recorded included the date • Eight months after the above were seen wherever batching was and time when each stage of the changes were implemented the reduced or eliminated. process took place. This data was batch size of slides per tray were How this improvement benefits extracted from the computer by use reduced from 10 to five. women of a specially written computer Improved TAT without reduction in programme and then manipulated Measurable outcomes and impact quality. in Excel and analysed using SPC • Since the implementation of the charts. A numerical assessment as to reduced batching procedures within How will this be sustained/ what the backlog was at the various the screening room there have been potential for the future/ stages of the process was also kept. marked reductions in the length of additional learning?• Slides requiring checking or time cases take from when they are Reduced batch size has become the pathologist review were allowed booked in to being verified. normal practice within the department. to build up. • Changes instigated at the time of Further reductions in batch size may• The principle type of waste reducing the number of slides per be tried but we are not sure this will identified was waiting. tray from 20 to 10 resulted in a one produce further reductions in TAT. day reduction in primary screen to Contact verification TAT. David Smith Email: David.SmithB@nwlh.nhs.ukwww.improvement.nhs.uk
  • 18. Cytology improvement guide - achieving a 14 day turnaround time in cytology 19Case study 2Introduction of multiple downloadsThe Leeds Teaching Hospitals NHS TrustSummary • Agreed volumes of work, calculated Ideas tested which were successful32% of result letters are received by from demand and capacity analysis are • Lean methodology discourageswomen a day sooner than before with a collected at agreed times throughout batching. The idea was to reduce thefurther 8% being received three days each day from the laboratory to the batch size of results sent to call/recallsooner. office for registration, from the office enabling them to process the resultsTotal waiting days saved 58,800 to the prep lab for processing, and and send out the result letters the from the prep lab to the screening same day.Understanding the problem room for sending the expected • The multiple files involved restrictFuture state planning identified that in number of authorised reports in each call/recall from getting all reportedorder to improve turnaround times, daily electronic link to call/recall. authorisations dispatched as results onresult letters need to be issued on the This maximises the number of letters the same day.same day that the results are authorised dispatched on the same day that theyby the laboratory. were reported from the screening How this improvement benefits room. womenResults of cervical cytology samples were • Clearly marked, standardised On current workload figures this changedownloaded to the screening agency collection points for work completed means that over 33,600 women per yearonce a day late in the evening, are used to ensure each department will receive their cervical cytology resultsirrespective of the time the result was knows where and when to pull a day earlier than previously and 8,400authorised on the laboratory computer completed items into their area. The will receive results three days earlier.system. time of day and volume of workNo result letters were issued the same pulled is indicated through the use of How will this be sustained/day as the authorised reports, and some red/green kanban cards acting as potential for the future/letters were being delayed by up to trigger signals which alert additional learning?three days. departments to what work is ready • Standard operating procedures have and in what volume as compared to been updated to reflect the changesHow the changes were implemented the timetable. implemented.Changing to two downloads per day • This occurs three times per day with a • Daily problem solving at five minutewould initially ensure up to 50% of visual management system in place to meetings to level out any deviationsresults available to be posted out a day clearly show when deliveries are made from the planned timetable to ensureearlier. but can be increased/decreased at the target number of result letters is• To ensure a continuous flow of anytime to reflect fluctuations in dispatched. samples ready for reporting, a pull demand and 20 capacity. • Further enhancements to visual system has been set up across the • Deviations from the norm are management controls and prep lab, office, screening room and monitored daily, discussed at huddles communication will ensure that a call/recall agency. and counter measures put in place if standard minimum level of work• When the future state map was required. outstanding in each area supports flow developed to optimise workflow, the • Team members attend each others through all steps in the process. team recognised that the pace of huddles with a weekly scheduling • Further root-cause analysis and PDSA work through each department would review taking place at the Monday problem solving sessions will take be determined by the recall agency. huddle which involves all areas. place to evaluate whether changes to• A timetable was drawn up to ensure the Exeter system will enable the that the required number of samples Measurable outcomes and impact laboratory to send results to call/recall and forms are processed in a planned • On average 41% of results reported in real time. schedule throughout each working each day are now sent to call/recall at day. Visual management is in place to 11.30 am and these result letters are Contact ensure the schedule is adhered to. all posted out the same day. Hazel Eager • 38% of result letters are received by Email: Hazel.Eager@Leedsth.nhs.uk the patient a day sooner than before. • A further 8% of result letters are received three days sooner. www.improvement.nhs.uk
  • 19. 20 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 3Reducing manual matching and first class postAnglia Support PartnershipSummaryOver 17000 result letters are issuedeach month by Anglia SupportPartnership call/recall service.Approx. 2000 women are nowreceiving result letters two to threedays sooner than they would havethis time last year after reducing thenumber of non hit query cases from15% to 5%.A further two days has additionallybeen saved following theintroduction of the use of first classmail.Understanding the problem Visual management techniquesThe reduction of mismatchedreports, caused by typingdiscrepancies, booking in errors(laboratories) and out of area results demonstrate the resource savings • Introduced standard workingwas targeted as a major source of that could be made if outsourced procedures in general processesdelayed result letters. In July 2008 letter production was used. across all three agencies.between 15 and 20% of resultsreceived were mismatch/non hits How the changes were Measurable outcomes and impactcaused by invalid senders, out of implemented • The audit of costs of thearea, sender with end date in the • Visited mailing bureau, to review folding/inserting machine showedpast, incorrect source type, incorrect full pathway and undertook a that savings in excess of £7000management of women. These postal audit to assess the per year could be realised bydefects needed to be reduced so difference in delivery times switching to a mailing bureauwomen received their result letters in between the first class and assuming fully operationala more timely fashion. business class service. equipment. The time savings • Migrated whole Anglia Support would be greater when taking intoThe postal service was taking too Partnership (ASP) call/recall service account equipment failures andlong with many result letters taking to the mailing bureau. the time this had previously addedthree days from dispatch to receipt • Engaged with laboratories to on to TAT.by woman. review all senders and established • The postal audit showed that if practice codes as senders, checked first class post was used a furtherThere was manual distribution and all postcodes correctly mapped. two days could be removed fromdispatch of result letters in Norfolk, • Previously, result files were the time taken for the woman towhich caused delays due to processed throughout day then receive her letter.unreliable equipment often with two 8am next morning results letters • The non-hit/defect rate hasday breakdowns. Staff were having generated. Now the results letters reduced from 15% to 5% onto watch the equipment to deal with are generated immediately and average (see table 1).regular issues. don’t wait until the next day. • The graph on the rightSome systematic data collection was • Enabled remote access, from their demonstrates that the averageundertaken to assess the range of own desktop, for all staff across time from result received by recall‘non hits’ using visual management ASP to the Cambridgeshire, to letter received by woman hastechniques. Norfolk and Suffolk systems to reduced from five days to 1.57 enable result input and cross- days since October 2008.A postal audit was performed to working across the three agencies. • Staff comments include: ‘Theassess delivery times. • Established practice nurse and visual management of lab-link filesAn audit of costs and time for the administrative training sessions for is great because it gives an instantprocess of ‘in house’ dispatch of primary care staff on general picture of the service’. ‘The use ofletters, assessing the use of call/recall, Open Exeter and the mailing bureau is great as I nofolding/inserting machine, time spent common queries. longer have to sit and watch theand local costs, was undertaken as • Introduced visual management to folding machine whirring through’.part of a business case that would capture all lab-link activity.www.improvement.nhs.uk
  • 20. Cytology improvement guide - achieving a 14 day turnaround time in cytology 21 ‘This course has meant I’ll have Table 1: fewer telephone queries in future’. Before changes were made ‘I now have a far greater understanding of call/recall and what it all means’. Ideas tested which were unsuccessful • The first attempt at the postal After changes were made audit was unsuccessful. Inclement weather meant post could not be delivered. • The initial implementation of using mailing bureau in Norfolk was problematic because there was not enough testing done before going live. How this improvement benefits West Anglia - Oct 08, Jan 09 and Jul 09 data - result patients received by recall to letter received by women On average, 17,282 women are receiving their result letters two days earlier and on average 1.5 days after the result was authorised in the laboratories. How will this be sustained/ potential for the future/ additional learning? • The introduction of improved communication between all programme providers (call/recall, labs, primary care) will be sustained as no-one wants to return to the old ways of working. • More time is available to developIdeas tested which were originally. Although results can be further service improvements.successful input at any of the three agencies Staff are being used appropriately• Mapping/checking of all postcodes results currently have to be to do the job they are best at and enabled results to be sent to the generated from each office, but standardised working has been correct agency in the first place, this is under review to make the introduced to improve accuracy causing fewer ‘non hits’. appropriate changes so result between the lab and call/recall.• Mapping/checking all sender codes letters can be run from any of the • Potential for the future – NNUH to ensure accurate booking in of three agencies. lab should develop electronic links samples in the laboratories, • The decision to move to first class with more than two agencies to reduced sender queries and ‘non mail meant that women received enable the results to be sent to the hits’ when the results were result letters quicker. correct call/recall agency based on received. • Following the visit to the mailing patients postcode although this is• Running the CP/result letter bureau and a greater not currently possible due to production job after all lab-link understanding of the business funding issues preventing progress. files and queries had been resolved needs from both sides, meant that result letters were sent communications between the Contact the same day they were received bureau and call/recall improved Claire Robinson and processed. resulting in an improved service. Email:• Remote access to all three ‘Exeter • Feedback from the primary care Claire.Robinson@suffolkpct.nhs.uk systems’ meant immediate manual admin training sessions was very entry of results where it had been positive with comments such as sent to the wrong agency www.improvement.nhs.uk
  • 21. 22 Cytology improvement guide - achieving a 14 day turnaround time in cytology 11. The nine wastes The key to adding value is to remove waste. So, Overproduction what is waste? Producing something before it is required, or more than is required e.g. unnecessary / There are nine forms of waste and these can be inappropriate tests, batching samples, tests and easily remembered with the mnemonic – information TIM A WOODS Over-processing Duplication of data or repeat testing due to defects e.g. dual data entry, additional steps Transport and checks Material or information that is moved unnecessarily or repeatedly e.g. unnecessary Defects movement of samples. Errors, omissions, anything not right first time e.g. poorly labelled specimens and requests, Inventory insufficient or illegible information. Excess levels of stock in cupboards and store rooms e.g. specimens waiting to move to next Skills utilisation step in process, or people waiting for tests and Unused employee skills e.g. highly qualified staff results. performing inappropriate tasks Motion WASTE COSTS MONEY AND ADDS TIME Unnecessary walking, moving, bending or stretching e.g. equipment placed in wrong The following case studies illustrate how the location, unnecessary key strokes. sites have removed waste from their systems to improve turnaround times. Automating Where technology is substituted to compensate for a poor inefficient process/processes “ No worker, particularly in healthcare where the well-being and safety of Waiting another human comprises the core Waiting for samples, equipment, staff, of the work, appreciates having his appointments or results e.g. patients waiting for test and results, staff waiting for other or her time wasted.” staff, equipment or information. Cindy Jimmerson A3 Problem Solving for Healthcare.www.improvement.nhs.uk
  • 22. Cytology improvement guide - achieving a 14 day turnaround time in cytology 23Case study 4Specific bags sent straight to laboratoryNorth West London NHS TrustSummary How the changes were How this improvement benefitsReorganisation of the way cervical implemented patientscytology samples are collected from • Core team members discussed the • By implementing the use ofGP surgeries and delivered directly to issues identified with the staff dedicated cervical cytology samplethe cytology department has resulted members responsible for this bags which are delivered directly toin a reduction in the TAT of between process. the cytology department has meant0.1 and 2.5 days for approximately • Clear separation of cytology a reduction in the TAT of between90% of women. MLA staff are also specimens from other types of 0.1 and 2.5 days for approximatelysaving approximately 50 minutes per pathology samples was identified as 90% of women.day through no longer walking to and a way to make sorting easier.from pathology reception to collect • Large pink specimen collection bags How will this be sustained /the specimens. This equates to a were purchased and distributed to potential for the future/saving of approximately nine days or all sample taker practices and clinics. additional learning?110 miles a year. • Sample takers were instructed by • The practice of separating cervical letter and at meetings to use the cytology samples from other pink collection bags exclusively for pathology samples and having themUnderstanding the problem cytology work. delivered directly to the department• During their ‘walk the process’, the • Cytology samples contained in pink has worked well since its core team observed large volumes of sample bags could easily be seen introduction and has now become pathology specimens being delivered amongst the rest of pathology the normal practice. in large specimen transport bags to specimens which made the sorting • The successful use of dedicated main pathology reception. out process much quicker and cervical cytology specimen bags has• Specimens were sorted by one efficient. been noted by other pathology member of reception staff into • Drivers were later instructed to keep departments and is likely to lead to appropriate boxes for the different pink bagged samples separate from the introduction of dedicated pathology disciplines. The process other pathology specimens during specimen collection bags in other was laborious and occasional collection and asked to deliver them pathology disciplines. mistakes occurred as it was not straight to the cytology department. always clear to the person doing the Contact sorting which discipline the Measurable outcomes and impact David Smith specimen belonged to. • 90% of cervical cytology samples Email: David.SmithB@nwlh.nhs.uk• Pathology reception is located on delivered directly to cytology the opposite side of the hospital to department resulting in a reduction the cytology lab. An MLA from of between 0.1 – 2.5 days in the cytology spent up to 15 minutes TAT for these specimens. walking back and forth to collect • MLA staff saved approximately 50 specimens. On arrival, the staff minutes walking time per day. This member usually waited until all equates to a saving of approximately specimens were sorted in case any nine days and 110 miles a year, cytology work was in the bags allowing more effective and recently delivered. This was done up productive use of MLA time around to five times a day five days a week. the department.• Waiting and transport waste were • MLA staff are happier. clearly identified by core team members. www.improvement.nhs.uk
  • 23. 24 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 5Reducing the backlogNorfolk and Norwich University Hospital NHS Foundation TrustSummary • Stopped checking of previousThe Norwich laboratory processes and computer system and addingscreens over 60,000 samples per year numbers by office staff, as it wasand is pilot site for HPV testing. By not used anymore.applying Lean methodology to remove • Stopped writing management advicewaste and improve the flow of work on green forms.we were able to: • Stopped ‘special attention’ stamping• Remove the backlog of screening of abnormal results. samples.• Take in-house additional screening Measurable outcomes and impact: whilst coping with a 48% increase By February 2009 the lab had data to in demand (February 2009). demonstrate:• Still achieve 97% meeting the 14 • 10.5 days average receipt in the lab day TAT by July 2009. to issue TAT with a range 2-22 days maximum.Understanding the problem • Backlog reduced from 4,000 to 655In October 2008 the lab faced the by (February 2009).following situation:• A backlog of over 4,000 samples An increase in demand in February with some being set out for 2009 took the backlog back to over screening to another site. 5,000 by the first week in May 2009.• 24 day average for receipt to authorisation turnaround times (TAT) By continuing with the changes with a range of 2-44 days. already made and introducing others by August 2009 the lab couldSPC charts provided the evidence to demonstrate:demonstrate the waiting at each step • Backlog of less than 500 by Augustof the pathway. 2009, representing only two days work.To achieve the goal of 100% in 14 • 7.4 days average receipt to labdays changes had to be made across issues TAT with a range of 2-16the whole pathway, with the support days (July 2009).of a multidisciplinary team of staff • All work is now screened in-houserepresenting the whole pathway. and the lab is in a position for other work.How the changes wereimplementedUsing the Lean tools gained from Norfolk and Waveney - Receipt to authorisenational events and on-site training,small changes were made to theprocess and SPC charts were used tomeasure the benefits.The changes implementedincluded:• Stopped re-screening of abnormal samples if they had already been seen by checker screening trainees work.• Removal of excess checking of ‘open exeter’, to stop over-processing.• No hard copy reports were printed for some GPs (who requested no paper copy) eliminating over- processing.www.improvement.nhs.uk
  • 24. Cytology improvement guide - achieving a 14 day turnaround time in cytology 25 Norwich backlog data How will this be sustained/ potential for the future/ 6000 additional learning? By reducing the backlog staff have 5000 seen several benefits including: Number of slides waiting • Screening staff comment that they 4000 no longer feel under pressure to do more all the time. 3000 • Clerical staff have freed up time by 2000 reducing non-value adding activities to enable them to concentrate on 1000 the parts of their job that add value to the process. 0 • There is now the potential for taking in work from other laboratories in 0 1 k9 1 k1 /12 2 k1 /01 1 02 02 k2 /03 k2 /03 k2 /03 04 k3 /04 05 k3 /05 k3 /06 06 k4 /07 07 8 0 W 7 /1 W 0 /1 W /1 W 2/1 k1 /0 /0 W 3/1 W 02/ W 16/ W 13/ W 11/ W 22/ W 20/ 24 8 5 W 19 W 02 W 16 W 30 W 27 W 25 W 08 W 06 03 the area still struggling with 2 1 2 1 3 k3 k5 k7 1 k1 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 k1 k1 k2 k2 k3 k3 k4 W W W backlogs as a result of the increased demand. ContactIdeas tested which were successful • Introduced bar-code readers in Carol Taylor• Stopped linking of old Sunquest. screening to eliminate the over- Email: CAROL.TAYLOR@nnuh.nhs.uk reports, saving approximately one labelling of slides with patients hour/person/day. name which has released office• Bell to alert porter, office staff time time, saved money on labels/printing saved approximately one hour per and prevented slides waiting before day. going through for screening.• Accepting pre-printed HMR forms • Lab introduced letter informing saves time on phone calls and stops sample senders of out of scope sample processing delays. samples to reduce inappropriate• Call/recall centre advising lab of demand. wrong recall by email and phone • PCT core team member re-enforced call. Changes made and re-sent non-acceptance of out-of scope electronically. This has removed samples by letter in GP magazines paper, cut down TAT by 24 hours and by writing to GPs separately. and saved lab staff time.• Each screener now has their own PC How this improvement benefits to enter results etc, so eliminating patients the waste of waiting to use a piece Over 60,000 women in the Norwich of equipment. area can now expect to receive their• Day books were eliminated (over results within 14 days of the sample processing) saving time for more being taken. screening and allowing the screening of five extra slides per day per screener.• Screeners doing their own slide filing has released ½ a days time in the office.• Infection information is now circled and not written on forms, again removing the waste of overproduction. www.improvement.nhs.uk
  • 25. 26 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 6Moving the fridge reduces walkingThe Leeds Teaching Hospitals NHS TrustSummary then back across the room to the Three of these changes released timeWaste of motion reduced. 123.7 miles coverslipper. A bowl was placed in the sample preparation area. Aof walking per year has been removed, between the prepstain and the timetable has now been devised thatequivalent to 8.25 working days of coverslipper for this purpose. enables 12 runs per day (576 samples)capacity now available for other Area 4 to be processed daily which meets theduties. Rapid pre-screening results were current demand and enables samples entered onto the computer in the to be processed on the same day orUnderstanding the problem cytology office and the forms then the day following receipt in the• The core team walked the pathway returned to the screening room. These laboratory. from the time a cervical cytology are now entered onto the computer in sample was received at specimen the screening room The time saved in area 4 (pre- reception to the time the result screening) releases time for the letter was sent out by the screening Measurable outcomes and impact office staff to register samples. agency and produced a value stream • Area 1 (stock room). A saving of map. 16,048 yards/year (38% decrease How will this be sustained/• During the walk, two initial areas of in time). potential for the future/ waste which could be reduced were • Area 2 (fridge). A saving of 76,365 additional learning? identified - distance from fridge to yards/year (100% decrease in The building housing the current lab and distance from stock room to time). accommodation is to be closed. lab. • Area 3 (bowl). A saving of 79,685• Process sequence charts were yards/year (4% decrease in time). Lessons learned from the service produced detailing all steps of the • Area 4 (pre-screening). A saving of improvement journey will inform process. 45,653 yards/year (15.5% planning the layout of the new• The time taken and distance decrease in time). accommodation. Awareness of waste travelled at each step of the process • A total saving of 217,751 yards or due to travelling time has been raised, was recorded. 123.7 miles per year, the and the team will aim to minimise• By looking at the process sequence equivalent of 4.72 marathons travelling distances further in their charts we identified two more areas • At a walking pace of two miles per new accommodation. in the lab where waste in the form hour these changes have released of motion could be reduced - 8.25 working days of capacity for Standard operating procedures have distance from prepstain machine to other duties i.e. more processing been updated to reflect the changes sink and distance from screening time to help achieve our targets. implemented. room to office for prescreening sheets. How this improvement benefits Contact patients Hazel EagerHow the changes were These savings will help to improve the Email: Hazel.Eager@Leedsth.nhs.ukimplemented turnaround time of all cervical cytologyArea 1 samples.The gynaecology consumablesstockroom was moved to a roomnearer to the preparation laboratory. Distances travelled per day pre and post changesArea 2 500Samples waiting processing were 450 432stored in a cold room in the specimen Pre change 400 Distance in metresreception area which was 69 metres Post changefrom the laboratory. A refrigerator 350was placed in a room adjacent to the 300 276preparation laboratory. Samples were 250stored there until the backlog of 200 174samples to be processed was removed 154and storage was no longer required. 150 100 94Area 3At the end of processing on the 50 36 0 9prepstain machines, trays of samples 0were carried to the sink across the Area 1 Area 2 Area 3 Area 4room to tip off the excess alcohol Area of laboratorywww.improvement.nhs.uk
  • 26. Cytology improvement guide - achieving a 14 day turnaround time in cytology 27Case study 7Sample collection trips reducedAshford and St Peter’s Hospitals NHS TrustSummary Number of samplesNumber of samples found at each collection found at each collectionChanges made have resulted in thereduction of the waste of motion in 50unnecessary trips to the pathology 45specimen reception area releasing 40 NG G Number of samplesapproximately 20 days per annum of 35staff time for value added activities. 30 35Understanding the problem 20The cytology department is in the 15basement of the pathology lab. The 10regular five minute journey to collect 5samples from the pathology lab 0sample reception was totalling 80 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00minutes each day. Time of day (24 hour clock)Analysis of the situationidentified that:• Time was wasted by unnecessary • Telephones were installed in both How will this be sustained/ trips to the specimen reception area gynae and non-gynae prep rooms to potential for the future/ when there may be nothing to make calling reception easier. additional learning? collect. • The use of a reversible card added Visual management provides the day• The MLAs collection trips were Visual management indicating to day control of motion between the random and so they didn’t know whether someone had collected cytology lab and specimen reception. that someone else was already en samples or not. route or had just been. In the longer term continued• The time of sample collection was Measurable outcomes and impact awareness of delivery times and not coordinated among MLAs • Overlapping stopped because trips volumes will ensure collection journeys resulting in overlapping in 25% were planned and visual are appropriately timed. them. The schedule of trips to management provided the control. reception were not clear during • Trips to specimen reception were Contact handover. reduced from 80 minutes to 45 Steve Blackman minutes per day, saving 35 Email: steve.blackman@asph.nhs.ukHow the changes were minutes per day of work time.implemented• Delivery times by the collection Ideas tested which were successful vehicles to specimen reception were • Telephones installed in the prep noted and cytology sample rooms. collection trips were adjusted to fit. • Visual management card to indicate• Sample collections were changed to collection of specimens. a set time to maximise trips to • Study and re-evaluation of specimen reception delivery times and adjustment of • first thing in the morning and sample collection trips accordingly. from 1.30pm until 3pm, collections were scheduled every How this improvement benefits 30 minutes patients • at all other times, a phone call to An efficient department where skilled reception every 30 minutes staff work efficiently has contributed established whether there were to the reduction in turnaround time. any samples to collect. www.improvement.nhs.uk
  • 27. 28 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 8Changing quality control (QC) proceduresCambridge University Hospitals NHS Foundation Trust, Addenbrookes HospitalSummary 2. The process was mapped using a started work or during the day andChanging the timing of the QC grid to collect data. The team another group of staff were notprocess reduced the turnaround time looked at who was carrying out this picking up QC at all.by one day during the week and by task and the numbers of slides beingthree days at weekends. The removal QC’d. They identified that although This caused the following problems:of waiting means that samples are the initially stated preference of staff • Individuals were re-creating largernow authorised on the same day that was to do the task in the morning, batches of work.they are screened, instead of waiting several people were leaving the • No QC was available for some staffuntil the next working day. slides until the afternoon. They also after they completed their primaries. identified uneven work distribution • Surplus of QC appeared later in theUnderstanding the problem: amongst QC staff. day when there was less staff toQC used to be done in the mornings. complete the work (caused byThis was based on a traditional idea A brainstorming session was held to earlier batching activity).that this was because staff felt they identify how best to design the • Uneven distribution of workwere fresher. It was ‘because we’ve workflow ensuring slides would be between members of staff.always done it that way’. available for QC as soon as possible after completing the primary screening Further explanation of the reasonsThe slides primary screened the day step. The intention was to keep behind the change and re-emphasis ofbefore were distributed to staff the movement of staff to minimum and one tray into QC - one tray out for QCnext morning by a senior BMS. This ensure an even distribution of work. have now been successful.did not guarantee all the QC would bedone on the same day as unauthorised One suggestion was to have a cut-off Measurable outcomes and impactcases could be missed due to staff sick point for primary screening each The majority of slides which requireleave. Once QC’d the results were day. This was rejected as there would the primary and QC processes are nowreleased overnight to the call/recall still be a number of QC requiring screened and the reports authorisedoffice for result entry and letter authority at a time in the day when on the same day.printing. An audit of workflow fewer staff worked and thosehighlighted this step as a major source remaining are needed to deal with the The SPC chart shows the period beforeof the waste of waiting. peak time for sample delivery. the changes started where there was longer TAT and variation in the timeHow the changes were 3. The batch sizes for primary taken for a sample to be authorised.implemented screening were reduced to 10 slides The second period shows the initialIt was agreed that slides should be which removed the need to transfer change period where there was someQC’d on the same day that they were them to smaller trays for QC. improvement to TAT but there is stillprimary screened to minimise the TAT. The screening staff then alternated considerable variation in the timeChanges were made in three phases: one batch of primary screening with samples took to authorise. The third one batch of QC. period shows that the TAT has now1. Batch sizes for primary screening dropped and is smooth, with more remained the same (20). Primary Each staff member was asked to consistency in samples being screeners put batches of 10 slides place their completed primaries in a authorised. into a central QC area on a tray, fill in a chart (with initials and continuous basis through the day. time) and then pick a corresponding Screeners were to pick up QC tray to QC. throughout the day, carry out the task and authorise them After an initial PDSA cycle, an immediately. assessment was made of progress. There were still slides waiting to be Any discrepancies to be passed onto QC’d at the end of the day – these the checking staff straight away to represented women who would maximize the number of slides have to wait longer to get their authorised on the same day. result letters. On further investigation, some staff were not This change did not increase the following the new workflow. number of samples authorised on One group of staff were picking the same day. more than one QC when theywww.improvement.nhs.uk
  • 28. Cytology improvement guide - achieving a 14 day turnaround time in cytology 29 Changes in QC process - Samples in lab to result issued How this improvement benefits the organisation It was initially underestimated how staff would react to a change that was not of their instigation and represented such a different approach to what has been the routine for years. It has taken several months of persistence - communication, monitoring and reminders. The team Before changes Initial change Final change needed to agree that the old way of working meant that women were waiting too long for their result, agree with the desire to reduce TAT (to 14 days or less) and engage in the stepsIdeas tested which were successful morning’ and it was ‘safer’ but there needed to remove waste from theirThe team learned that clear was no evidence to support this view part of the end to end process.communication, backed up with and the PDSA cycle provided evidenceunambiguous instructions, is needed to the contrary. Contactto ensure a standard approach to work Joy Bishopand its completion with minimal Ideas tested which were unsuccessful: Email:defects. The first change did not increase the joy.bishop@addenbrookes.nhs.uk number of cases authorised on the dayStaff need to understand why they are of screening.changing the way they work and theyneed to feel ownership and The second change in process gotresponsibility for delivering the results. more cases thriugh but there were stillRelating changes back to the as many as 40-50 slides left at the enddifference being made for women and of the day.highlighting when the new processhad not been followed was key to The third change and greater efforts tosuccess. engage staff has made the difference.Explaining the numbers of women How this improvement benefitswho would be waiting longer for a womenresult letter helped everyone to 65,000 women that the laboratoryunderstand that there was a good reports cervical screening samples forreason for making the change to the each year will now receive their resultsprocess. within 14 days.Staff were invited to come forwardwith suggestions for altering theprocess. They were also asked whythey were holding on to previousprocesses. The initial view had beenthat they ‘preferred to QC in the www.improvement.nhs.uk
  • 29. 30 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 9Slide matchingBarts and The London NHS TrustSummary • The screening staff take the first • The team also thought that the taskThe process step of matching the tray of 10 slides and match it with of matching the slides and formsslides and request forms has been the first batch of 10 request had been moved from the MLA staffremoved. By removing this step the forms. These details are checked to the screening staff. During theteam has reduced the delay from the and the slides screened and pilot study, the staff realized thattime of data entry and slide staining to labelled by the same person in this was not the case as thewhen the stained slides reach the one continuous process. screening staff were checking thescreening room. Space has been slides and request forms ongained in the laboratory staining area Measurable outcomes and impact collection in the screening room.and MLA time has been saved. • One step has been removed from • This process hasn’t worked for the the process. slides that require reprocessing as • There is now no delay of slides the request form is required whenUnderstanding the problem waiting in the prep room. this is done. The team now has• There was a delay from the data • MLA time spent matching slides system for slides which require entry office which caused a backlog (approximately 90 minutes per day) reprocessing to ensure the form of slides in the staining area. has been saved. always accompanies the sample• There wasn’t enough space for the • The bench used for matching slides and/or slide. backlog of slides or to match the in the prep room is no longer forms back to the slides and the chaotic. The bench is clear and tidy How this improvement benefits area was chaotic. for other MLA duties. patients• Although there were no untoward • It is now easier to find request • This improvement benefits all incidents in this area, there was the forms. There were three potential women screened at Barts and The potential for errors to occur. places to find a request form which London NHS Trust.• There was no value to the step of has been reduced to two. • The matching step in the chaotic matching slides to forms as the • The slides are in the screening prep area has been removed screeners perform a second check of laboratory earlier which enables the reducing the risk of errors. the slides and forms before screeners to know exactly how • The MLA staff now have quality screening. much work is waiting to be time to spend on other duties. screened.How the changes were How will this be sustained/implemented Ideas tested which were successful potential for the future/• The team removed the process of • The initial idea to remove the additional learning? matching the slides and request matching has been a success. The PDSA cycle was proven along with forms in the staining area. • The meticulous planning, team work the communication and team work.• Before implementation the team and excellent communication at the reviewed any potential risks, ensured daily huddles aided the smooth Contact all staff were briefed about the new transition from the old to new Geoffrey Curran process and defined the timescale process. Email: for the PDSA cycle. • The team used the PDSA cycle to Geoffrey.Curran@bartsandthelondon.• The new process was a success and resolve any issues and improve on nhs.uk now runs in the following way: the initial pilot study. • Batches of 10 are data entered in the office and taken directly to Ideas tested which were the screening laboratory instead unsuccessful of the staining area. • The team was initially concerned • Slide trays of 10 are taken directly about the removal of this step. It from the staining area to the was thought that the changes screening laboratory and do not would add errors and not speed up wait for the request forms to be the process. These perceptions were returned from the office. proved unfounded as there have • It is imperative that all the slides been no errors, time has been saved and request forms are in for the MLA staff and the numerical order. slides/request forms are reaching the • When the screeners require work, laboratory in a timely manner. the work is available to be pulled.www.improvement.nhs.uk
  • 30. Cytology improvement guide - achieving a 14 day turnaround time in cytology 31Case study 10Removal of date stampingThe Leeds Teaching Hospitals NHS TrustSummary It was agreed that such a process How this improvement benefitsEight hours per week saved by would meet the CPA requirement. patientschanging the way received samples are The team have freed up the timetime/date stamped. Standard work was agreed. As each referred to above to be able to focus crate of samples is received into on the value steps in the processUnderstanding the problem specimen reception the date and time thereby reducing the overall TAT toThe team was aware that the process is written on a label attached to the deliver results to women.for time and date stamping each form crate. This date and time is thenin specimen reception was taking up written on the first form, in red pen, in How will this be sustained/time whilst also causing or risking the same place on the front form of potential for the future/errors. each batch of forms. additional learning? This suggestion came from an• Each specimen and form was The date and time entered by data individual who was initially skeptical unpacked; the A4 size form was entry staff now accurately reflects the about the benefits of Lean. Since this unfolded and placed in a date actual time the sample is received by idea they have continued to make stamping machine. The form was the lab rather than the time it is suggestions and have shown a keen then refolded and put back in the unpacked. interest, playing an important role in bag with the specimen to await continuous improvement. numbering. Measurable outcomes and impact• Each person presented forms to the The new process is saving 15 seconds Contact machine slightly differently resulting per specimen. Given that the lab Hazel Eager in date stamps appearing in processes approximately 100,000 Email: Hazel.Eager@leedsth.nhs.uk different places on each form and, samples per year, this change is saving in some cases, obscuring other eight hours per week as well as the information. small cost saving on the printer and• Some stamps were either poor or ink (which is still used for non-gynae completely illegible. Because the samples). date stamping was being done in batches, dates often fell out of Ideas tested which were successful sequence with the subsequent The staff member in the lab who was numbering of forms and vials. responsible for this process identified• The time and date of receipt this potentially unnecessary activity stamped on the form was included when the core team walked the path in the data entry by the office stamp of the process. when they registered the sample onto the laboratory information Ideas tested which were system. unsuccessful The team initially wrote the date andThe team recognised this as a waste of time on a post it note which was stuckover processing to meet the CPA to the first form in the batch.requirement. They noticed that the post it notesHow the changes were were at risk of becoming detachedimplemented from the forms and changed toThe team referred to their pathology writing directly on the form.quality manager to check the CPArequirements. They suggested thatthe first form on each batch bemarked up with the time and date ofreceipt and the office staff wouldinput this data for each sample in thebatch being handled. www.improvement.nhs.uk
  • 31. 32 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 11Removal of the day bookNorfolk and Norwich University Hospital NHS Foundation TrustSummary How the changes were How this improvement benefitsFor many years screening staff had implemented womenkept a personal ‘daybook’ where This idea was suggested by one of the By increasing time for screening, thehandwritten details of each case screeners after learning about waste in turn around time (TAT) has beenscreened were recorded. This practice the pathway and examining their own reduced, therefore approximatelywas in place to enable the screener to area of work. 60,000 patients will benefit frommonitor their workload and check the receiving their results within 14 days.outcome of a particular case. • One cyto-screener stopped using a daybook for a week as a trial. How will this be sustained/While undergoing Lean training this • The effects were evaluated and all potential for the future/step was identified as the waste of the screening staff agreed to stop additional learning?over-processing. using daybooks. It is unlikely that the lab will revert to • The screeners have easily adapted to using a book to record results asThe practice was discontinued within a this change as the suggestion came removing this step has resulted in:few weeks of becoming a pilot site from them.which resulted in time saved, a • Significant time savings.marked increase in productivity and Measurable outcomes and impact • Removal of duplication.improvement in work flow. Writing the details of each case in the • Staff looking at the whole process day book was quantified: and questioning the purpose andUnderstanding the problem value of each step.Handwritten day books preceded • One minute per case - each screener • Staff morale improved as backlogcomputer records of results and were was saving up to 30 minutes each disappeared.a convenient way for screeners to day.monitor their personal screening • Enough time to screen four extra Contactfigures. slides per screener, allowing 30 extra Carol Taylor slides to be screened each day (150 Email: CAROL.TAYLOR@nnuh.nhs.ukThere was no benefit in continuing the per week/7,500 per annum.practice since all the information • Screeners reported improved workwritten in the books could be flow around their work station withextracted from the computer if the book removed.needed for performance analysis. Although the significant backlog of samples in the lab was already reducing before this change was introduced, the rate at which the backlog reduced increased dramatically.www.improvement.nhs.uk
  • 32. Cytology improvement guide - achieving a 14 day turnaround time in cytology 33Case study 12Adjusting download times to theprimary care support servicesAshford and St Peter’s Hospitals NHS TrustSummary Histogram of PCSS turnaround - May 2009The time results are sent to call/recall 600was adjusted so that result letterscould be printed and posted the same 500day that the result is reported, instead Number of occurrencesof results waiting to be processed the 400following day. 300The percentage of women receiving 200their result letters the day after theirresult is reported has increased from 1006% to 67%. 0 1 2 4 5 15Understanding the problem DaysResults were being sent by electronictransfer to the call/recall centre once aday between 3:30pm and 4:00pm.This did not allow sufficient time to Measurable outcomes and impact How will this be sustained/process the file and print the result 61% of patients received their results potential for the future/letters before the post room closed a full day earlier. additional learning?and so result letters were printed and This improvement is a permanentposted to patients using first class post By June 2009, 68% of women change in procedure so the benefitsthe following day. received their results within seven days will be sustained. and 99.85% within 14 days.This was identified as having a Showing how a simple change cannegative impact on efforts across the Ideas tested which were successful have such a big impact has improvedpathway to meet the new seven and Collaborative working between the staff morale and motivated everyone14 day turnaround targets. laboratory and the call/recall centre to look for more ways to improve. identified this opportunity and made the change possible. ContactHow the changes were Steve Blackmanimplemented How this improvement benefits Email: steve.blackman@asph.nhs.uk• Laboratory staff visited the call/recall patients centre to improve joint 61% of patients now receive their understanding of the process. results a full day earlier.• It was agreed that the electronic run would be changed to 1:00pm. This would allow time for the file to be processed and letters printed off and posted the same day.• The May 2009 histogram shows 67% of result letters for the month following the change arrived the next day proving that the process change made a difference. www.improvement.nhs.uk
  • 33. 34 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 13Zero tolerance of defectsHull and East Yorkshire Hospitals NHS TrustSummary Cytology department - cervical sample request cardMonitoring of defects highlighted Please fully complete the request card as all the details are used either toerrors on the forms and vials that the identify the patient or for the clinical screening process.laboratory spent time dealing with.A potentially serious issue wasrecognised by clinical governance anda zero-tolerance of errors wasintroduced resulting in a consequentdrop in errors of 1% per month and asaving of approximately 120 hoursannually of lab staff time whichequates to £1,020/annum.Understanding the problemData collected over a two week periodshowed that 154 errors from primarycare were identified.Time management issues forprocessing and admin staff groupswere raised due to the excessiveamount of working time lost trackingand correcting request forms and • All samples which had errors were • Implementation of visualspecimens received from primary care. returned to sender. management for request cards, with • The exemplar form shown above mandatory information clearly• Monitoring evidenced the amount was sent to all sample takers. identified in an attempt to mistake of non-value added time lab/admin • Laboratory staff gave presentations proof a manual process. staff spent chasing minor at sample taker update meetings • Standard work - zero tolerance of discrepancies and delays in and GP forums. defects. processing due to more serious errors. Measurable outcomes and impact How this improvement benefits• The number of samples returned per • A reduction in returns by approx 30 women month was counted and monitored samples per month. Improved quality and safety for all to identify trends. • Approximately 10 hours a month samples processed by ensuring patient• Wastes identified: of lab staff time saved (or 15 days information is correctly provided from • Defects - ranging from missing per annum). source i.e. that the HMR101 form is information on vial/request card to • Cost saving of approx £85 per month. filled in completely and correctly. wrong information on either or a mismatch between the two. Ideas tested which were successful How will this be sustained/ • Unnecessary waiting - delays • Communication with primary care potential for the future/ were caused by samples being teams: The problem of incorrect additional learning? returned to the GPs practice - data on request forms sent into the • Error logs will continue to be extending turnaround times by an lab was highlighted at LBC working completed. average of four days. party meetings between lab staff • Returns will continue to be • Over processing - at data entry and clinical governance managers, monitored by trust clinical due to duplication or rework of where it was agreed that there was governance team. every defective sample received. a high risk of a potential incident • Persistent offenders are, and will occurring. continue to be, visited by a clinicalHow the changes were • These were to be treated as ‘near governance manager.implemented misses’ and clinical incident forms• A ‘Shared Learning Notice’ was sent completed, generating a clinical Contact out to all sample takers in the governance issue. This allowed a June Dixon primary care sector from the clinical training and continual assessment of Email: june.dixon@hey.nhs.uk governance teams of the relevant competencies approach to be PCTs informing them of the established by the clinical changes. governance team.www.improvement.nhs.uk
  • 34. Cytology improvement guide - achieving a 14 day turnaround time in cytology 35Case study 14Improving mapping tablesBarts and The London NHS TrustSummary How the changes were Ideas tested which were successfulChanges to the laboratory mapping implemented A close working relationship betweentable reduced the reject rate for ‘Test • The laboratory team thought they the call/recall manager, the cytologyafter Sender Ended’ and ‘Sender knew the solution and changed the service manager and the cytology dataUnknown’ at the call/recall centre. entire mapping table, only to find manager was key to resolving this that there was no change to the issue.Understanding the problem number of mismatches.• Since the links from laboratory to • Future changes were trialled using After the initial change failed the team the call/recall centre were introduced the PDSA cycle which enabled the adopted a PDSA cycle for future ideas. in 2004, there had always been a team to trial a number of small This enabled them to trial changes on large number of rejects. Since the changes without dedicating a lot of a small scale without investing too Exeter software changed in 2007 time to something which may not much staff time there have been a large number of have had any impact. ‘Test after Sender Ended’ and • After a number of trials, the team Ideas tested which were ‘Sender Unknown’ rejects. found the correct mapping table, unsuccessful• The GMC code (national GP code) is implemented the change and, when The team thought they knew the used to transfer the results from the the trial was successful, rolled out solution and spent a number of hours laboratory to call/recall. Unless this an updated mapping table. changing the mapping table without code is correct, and the information • The newly updated mapping table understanding the true root cause of on each system matches, the links every requester to a GP the problem. This was a waste of time womans information does not national code. but was a valuable learning process. transfer across the interface.• It was evident that the number of Measurable outcomes and impact How this improvement benefits rejects due to these two codes was • Data showed 60 GPs were causing women above average and work was started 100% of the rejects, which equates • There are no delays in the letter by both teams to understand the to 20-30% of each file transferred being sent to the patient. problems. to call/recall. • It is a safer process as there is no• Data was collected to identify the • The data highlighted a total of 187 manual input where error could extent of the rejects for the ‘Test rejects for two codes in one week. occur. after Sender Ended’ and ‘Sender This did not include other Unknown’ codes. mismatches (i.e. NHS number, How will this be sustained/• When the laboratory introduced address, DOB etc) potential for the future/ additional twice daily downloads, these • Each day the rejects caused learning? mismatches became a greater approximately two hours extra work • This improvement has forged problem and any rejects on the for three call/recall staff. greater links between call/recall and second file of the day were delayed • When call/recall were unable to the laboratory. by one day. resolve an issue, they would contact • Any mismatches can be corrected• Findings showed that the rejects the cytology data manager who immediately now the process is occurred when there wasn’t a GP would resolve the outstanding understood. code assigned to every requester issues. The data manager was • PDSA cycles are key to ensuring (i.e. sample taker in a health centre) receiving approx 15 requests per changes work before full or a resigned, retired or otherwise week which on average would take implementation. expired GP code was being used. five minutes each to resolve • A future development could see equating to approx 40 hours per practice codes being used instead of month saving for the call/recall staff senior partner codes. and five hours per month for the laboratory staff. Contact • As a result of the reduction in rejects Geoffrey Curran the laboratory is now able to send Email: the morning file half an hour later Geoffrey.Curran@bartsandthelondon. thus increasing the number of nhs.uk authorised cases for which the letter is posted the same day. www.improvement.nhs.uk
  • 35. 36 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 15Expanding roles in the prep roomTaunton and Somerset NHS Foundation Trust, Musgrove Park HospitalSummary Backlog reduction targetsEarly analysis using a value streammap showed some significantproblems in the prep room with largebatches, unpredictable and irregularoutput, unused capacity during normalworking hours and consequent delaysin workflow.The prep room is now staffed withoutinterruption from 07:00 to 18:00 on adaily basis by extending the roles ofthe MLAs and has increased flexibilityand sustainability.There is a continuous flow of workleaving the prep room and the skill mixof staff has improved. Actual Target 2000 1000Flow throughout the laboratory hassmoothed with a minimum of one daytaken off the turnaround time as aresult of more efficient processing and • Data entry staff became senior After the improvements:prep room productivity increased by MLA’s with training that included • Work leaves in small, manageable15%, with a greater level of both prep room duties. This enabled the batches throughout the day,safety and quality in prep room prep room work to begin from 7am. increasing workflow and putting lessprocessing. • Analysis of all job roles and re- pressure on office staff. assignment of tasks to more • Daily output of trays increased byUnderstanding the problem appropriate staff. 15%, from 23 to 26.When lab staff were asked what issues • Recruitment of a new full-time MLA.needed to be addressed, a number Ideas tested which were successfulsuggested that the prep room was not Measurable outcomes and impact • Continued cover of the prep roombeing used to its full capacity. There The chart above highlights the backlog throughout the day - the creation ofappeared to be long delays waiting for reduction from the 23 of April to the senior MLA posts enabled this tomachines to finish and long periods of 31 July. happen.time where the room was unoccupied • Implementing Kanban within thewhich it was felt were leading to Initially there was a steady reduction prep room to decrease errors anddelays in the workflow. until there was no screening buffer in promote standard working the screening room, highlighted by the regardless of who is working in theTo understand these issues, further first red line. The second red line prep room.investigation included: indicates when prep changes were • Removal of second check.• An audit of the typical working implemented. The backlog line • 5S of prep room and labelling of hours of the prep staff. continues to fall but now at a more inflammable store to reduce wasted• Analysis of the times when work left acute gradient, showing that the time and movement when prep staff the prep room through the use of improvements in prep had a significant are locating chemicals (this also checklists completed by the prep effect on work flow within the aided work on stock control). staff. laboratory overall. • Changing chemicals on the staining• Analysis of spaghetti map after machine twice daily at a set time, walking through the entire process. Utilising the prep room to its full instead of every five racks (this capacity was made a priority to meet was suggested by one of the newHow the changes were the turn around times. prep staff after observing timeimplemented wasted on unnecessary changes).A series of PDSA cycles and small Before prep room changes:changes (Kaizen) were introduced over • Work came out in large batches ata period of several months. These random times of the day, often tooincluded: late to be screened on the same day (see the graph on the next page).www.improvement.nhs.uk
  • 36. Cytology improvement guide - achieving a 14 day turnaround time in cytology 37Ideas tested which were Record of trays leaving prepunsuccessfulKeeping the prep room covered from 1207:00 until 18:00 meant a number of Before prep changespeople working in the prep room 10throughout the day. Most had theirown way of doing things which Number of trays After prep changes 8initially led to problems and mistakes.This was countered through the 6implementation of standard work andvisual management (Kanbans). 4How will this be sustained/ 2potential for the future/additional learning? 0 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-18.30• Expanding the number of staff with prep room competencies adds to Time of the day (24 hour clock) sustainability in the long term.• Continued integration of senior MLAs into lab and processing procedures will free up further screener time.• The next step is to introduce a formal processing timetable to further improve workflow.ContactDr Simon KnowlesEmail: simon.knowles@nhs.net.uk www.improvement.nhs.uk
  • 37. 38 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 16Abnormal pathway changesNorfolk and Norwich University Hospital NHS Foundation TrustSummary Average reporting times of pathologist/ABMSPAt the start of the project, the teamreporting cases referred from checkers 6consisted of five pathologists. 5Following the appointment of an Pre AP appointmentadvanced practitioner in June 2009, Post AP appointmentthe team was reduced to the AP and TAT (days) 4three pathologist. 3The turnaround time from the checkersending the case to the pathologist tothe report being authorised has 2reduced from an average of 3.9 daysto 1.7 days. 1Understanding the problemThe baseline SPC for TAT evidenced a 0 1 2 3 4 5 6 Overallwide range of reporting times, with a Pathologist/ABMSPsignificant number taking several daysmore than the other samples.Analysis of these outliers showed that Pathologist / ABMSP reporting TAT for all reports:the majority were abnormal samples 5 Pathologist Overall 3 Pathologist & ABMSP Overalland many of these had required anHPV test (carried out twice weekly in Average TATBristol). In order to keep within the 14 (days) 2.7 – 5.6 3.8 0.9 – 3.2 1.7day target and allow for the additionaldays required to get an HPV result, itwas obvious that the pathologists’ Measurable outcomes and impact How this improvementstep in the process had to be • The average TAT for reporting by benefits patientsimproved. pathologists and the AP is now 1.7 The TAT for virtually all samples days, ranging from 0.9 – 3.2 days. requiring a pathologist opinion is nowHow the changes were • The TAT for samples not requiring within 14 days.implemented an HPV test is on average 0.5 daysIn order to decide the optimum team and for those requiring an HPV test How will this be sustained/size, various facts were taken into is on average 6.8 days. potential for the future/ additionalaccount including: • The number of outliers is now learning?• Anticipated pathologist workload reduced. The few remaining outliers The quality of the service has improved based on the workload of the lab. are those requiring HPV testing with a reduced TAT and less variability.• Minimum annual requirement of which adds three to six days to the The smaller team is easier to organise 750 cases per pathologist. TAT depending at which part of the and it is easier to track where samples• Number of pathologists needed to week the sample is received. are, so that senior staff time has been cover annual leave and other duties. • This has not only improved the % saved. achieving 14 day TAT to 99% forOf the five pathologists, two had a September 2009, but has also Contactsignificantly longer TAT than the eliminated the time wasted by Xenia Tylerothers. The range of average senior staff chasing up unreported Email: xenia.tyler@nnuh.nhs.ukreporting times within the team was cases.2.7 – 5.6 days. Two were invited toleave the team enabling them to use Ideas tested which were successfulthe released time to deliver in other The decision to reduce theareas of the cellular pathology service. pathologists team was made in order to address the fact that most of the pathologists had not achieved the 750 minimum target the previous year and that an AP was being appointed.www.improvement.nhs.uk
  • 38. Cytology improvement guide - achieving a 14 day turnaround time in cytology 3912. A3 thinking for problem solvingAn A3 is a one-page, A3 size document that Describing the entire process – from current state,records the agreed problem statement, it’s analysis, through analysis to future state on a single sheet ofpotential counter measures and the action plan to paper requires concise information. Creation of anresolve. A3 necessitates logical discussion and thinking – with ultimate agreement on experimentation toThe report template serves as a guide for seek a better way forward. Distilling theunderstanding a problem, identifying the point of information to only the most relevant details forcause and eventual true root cause in a systematic communication to the rest of the team ensuresway. It serves as a collaborative problem solving that a thorough understanding of the issue hastool. been attained.Beginning with a consensus on the problem or A precise A3 report prevents massive amounts ofissue you are trying to solve, the left hand side of information being misinterpreted and inappropriatethe page is completed to document the current conclusions being reached by a multitude of staff.state. The right hand page is the innovative or The best A3s convey the understanding of theexperimental approach to solving the issue towards problem, and analysis without any explanation.the future state. Often, a graphical or pictorial representation of theSince Lean is primarily the description of a issue at hand is better than a text summary.methodology to routinely solve problems everyday The A3 report represents a shared understandingto ensure that the daily work is delivered to of the consensus of opinion on solving the problemspecification, A3 thinking is the rigorous and should initially be completed in pencil allowingapplication of the plan, do, study, act (PDSA) alterations to be made. As a document, itapproach. encourages reflection on the learning that hasIt is the structured ‘thinking’ that is of most taken place and ensures that a consistent messageimportance – the A3 report is of no significance in is able to be discussed and scrutinised. Ultimately,the absence of structured, agreed understanding it allows the team to ensure that an agreed actionand thought processes. plan is followed. The A3 report Title: Version: Author: Date: Problem: Proposed countermeasures: Current condition: Plan: Target condition: Root cause analysis: Follow up: Responsible: Team members Agreed by: Date: www.improvement.nhs.uk
  • 39. 40 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 17Using A3s for problem solvingThe Leeds Teaching Hospitals NHS Trust taking up time in both the lab and • The team have not solved their the office. They also knew that problem yet but are convinced that returning samples added days to the the A3 is the right tool to take them time taken to report results back to to the solution and they will be the woman. using the same approach for the • The team weren’t able to complete other gaps in their future state plan. the whole A3 document in one go The A3 brings together all their Lean and began to realise that was the learning, provides them with a whole point! The first step was to robust framework, keeps everyone quantify the problem. This is involved and engaged and is a living important to make sure that the document that provides a constant problem is as big as first thought visual focus.Summary and is worth the time investment toA3s provide a problem solving solve. Ideas tested which wereapproach that ensures the user gets to • Soon after starting their A3, the unsuccessfulthe true root cause of problems and team stopped to ‘go see’ what The initial idea for tracking the timeissues. They are simple, visual, happens in the lab when a sample is taken for returned samples to comeengaging and everyone in the team received that needs to be returned. back was looking back through thecan understand and get involved. They then created a value stream returns book and tracking individual map of all the processes in the lab samples back through the system. ItUnderstanding the problem (and the ones they hadn’t at first was decided that this would be tooThe team had made great progress in thought about in the office) and time consuming. The prep lab PC wasreducing end to end TAT from 29 to timed each of them. This told them due for replacement so a spreadsheet10 days in a period of 10 months. they definitely had a problem has been created so all information isThey knew however that they could worth solving! entered directly, removing the need forreduce this even more but were not • The team also agreed that they a manual book.absolutely sure what to tackle next. needed to gather data on the length of time before sample takers correct How this improvement benefitsHow the changes were the data and return the samples to patientsimplemented them (because this is the major A3s have provided the team with an• The team had previously created 14 impact on TAT and the length of efficient, focused problem solving tool and seven day pathways showing time it takes the women affected to that will facilitate continued efforts to ideal future state for the end to end get their result). reduce the time taken for the 100,000 process (from sample taken to result • After an hour or so of work the samples screened ensuring women reported). They revisited these team had a list of six actions that receive their results earlier. pathways (ticking off their would make sure they really successes!) and identified the steps understood the size of the problem How will this be sustained / of the process that still needed before moving on to root cause potential for the future / work. analysis. additional learning?• With a meeting with one of their By creating A3s on flip chart paper PCTs imminent they chose to focus Measurable outcomes and impact and posting them on the wall the core efforts on returns (receiving samples In around 40 minutes the team were team can involve the whole lab’ team and/or forms with incomplete or able to establish that what they and their PCTs in problem solving. poor quality information). thought was a problem was actually They will also maintain a typed up soft• The national improvement lead wider reaching than first thought, was copy so that they have a lasting record explained how an A3 would help well worth addressing and they had of their work. the core team to really understand started to quantify the possible gains. the problem and its root causes as Contact well as engage and involve both Ideas tested which were successful Hazel Eager their own wider team and the PCT • The team have posted the A3 on Email: hazel.eager@leedsth.nhs.uk so, they took a blank piece of paper the wall where they have their and were off! Monday huddle. This huddle is a• They began by clearly stating what it little longer than other days and was felt the problem was. This now the whole team are involved in wasn’t as easy as they thought it this problem and are invited to add would be! It was understood at a their thoughts on post-it notes. high level that the problem waswww.improvement.nhs.uk
  • 40. Cytology improvement guide - achieving a 14 day turnaround time in cytology 4113. Root cause analysisThe most obvious contributor to any problem is Analysis should be fact and data based. Accuraterarely the root cause. data/measures should be used as an objective means to identify occurring problems which giveAn effective problem solver uses A3 thinking to rise to deviation from specification requirements.investigate an issue until they identify the one Determining the root cause of these deviationscause that, if dealt with, would eliminate all future should provide a clear understanding of theoccurrences of the problem in hand. necessary solutions.All process problems result from either: There are a number of principles to bear in mind:1. a poorly specified activity2. an unclear connection • Don’t assume you know the cause –3. a complicated or undefined pathway preconceived ideas will prohibit a useful analysis. • Always go to the location of the problem andIt is imperative that countermeasures are designed observe it first hand.to prevent repeat episodes of the same problem • Continue your analysis until the true cause of thewithout the necessity to perform a ‘workaround’ issue is identified.solution. • The goal is always to identify problems that can be corrected by the problem solver.Finding the root cause may require some • A thorough analysis with factual data willexperimentation. A useful method for identifying indicate the corrective action required.the root cause of a problem is the five whys • Determining the result when the causes aredeductive technique – literally asking ‘why?’ five detected is as important as examining thetimes until final causality is established. problem itself.Alternatively, an Ishikawa or fishbone diagrammight be useful but the repetition of asking ‘why’forces critical thinking to challenge each cause-effect relationship.The goal of the ‘root cause analysis’ section of theA3 report is to show that either experimentation orlogical deduction has established the true ‘cause-effect’ relationship in the current state. Reasonedagreement within the team should separatesymptoms and opinions from the true cause-effectand a summary of the main findings should bepopulated in the relevant A3 report section. www.improvement.nhs.uk
  • 41. 42 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 18Using data for root cause analysisHull and East Yorkshire Hospitals NHS Trust, Hull Royal InfirmarySummary Measurable outcomes and impactAnalysis of turnaround data showed • Root cause analysis performed on all SPC charts.unnecessary waiting for delivery to the • Identification of outlying peaks highlighted faults throughout the process.laboratory, abnormal samples waitingfor pathologists reporting and January TAT for HRIreturned samples due to errors inpatient labelling.Following root cause analysis, moreappropriate and timely managementof problems which had resulted indelays in reporting was instigated toreduce end-to-end turnaround times,including a policy of zero tolerance ofdefects on forms or samples.Understanding the problemIt was evident that there were delaysalong the processing pathway whichwere resulting in unnecessary delays inreporting of results.• Samples data was analysed using SPC to identify the extent of any variation.• The SPC graphs identified peaks which were outside of the upper and lower control limits (three How the changes were Ideas tested which were successful standard deviations). implemented • Timely transportation - the• Performing root cause analysis on Evidencing delays through data importance of the need to send in the individual samples outside the enabled the department to identify samples straight away to avoid upper control limit identified the root cause and address identified delays in the process was reinforced reasons where and why along the issues. to primary care. pathway they were being delayed. • Reducing defects - a policy of • The importance of the need to send zero-tolerance of errors fromThis showed: samples straight to the laboratory primary care was also introduced• Defects - samples were being daily to avoid delays in the process reinforcing the need to provide returned due to errors in patient was reinforced to primary care. accurate patient details on request information provided by the sample Individual practices were contacted cards and samples sent to the takers. by telephone followed by the laboratory.• Unnecessary waiting - some GP sample taker mentors and LBC • Reduced waiting - closer practices were not sending their working party members. collaboration between pathologists samples to the laboratory on the day • A position of zero-tolerance of any and a flexible approach to work the test was performed. errors was agreed with the trust distribution based on excess capacity• Inventory - a number of abnormal clinical governance team and all was agreed. Visual management samples were sitting in pathologist samples with errors were returned systems were put in place to offices waiting to be reported. to sender. measure ‘goal v actual’ for the • A system has been put in place to screener and consultant’s workload. monitor the volume of work each pathologist receives and their turnaround times. The pathologists worked out a share scheme so that no one pathologist had an unmanageable workload.www.improvement.nhs.uk
  • 42. Cytology improvement guide - achieving a 14 day turnaround time in cytology 43How this improvement benefitspatientsBy understanding the real root causeof the problems, waste has beeneliminated, and the processstreamlined, resulting in a moreefficient service provision, both in timeand quality for the benefit of allservice users.How will this be sustained/potential for the future/ additionallearning?• Identification of wastes has enabled the team to put in place measures which have made other service providers accountable for their part of the patient pathway.• A better record of sample accuracy on receipt in the lab has been achieved resulting in less time wasted on corrective measures, with the associated cost implications.• The monthly monitoring of samples using SPC will be incorporated into working practice after the pilot project ends.• All of this has allowed the laboratory to forge closer links with other agencies within the patient pathway.• Pathologists are more aware of the need to maintain a constant flow of abnormal reporting in line with requirements to meet the 14 day TAT and so have adopted a more flexible approach in order to accommodate demand.• The changes have resulted in the elimination of waste within the process which has benefited staff by improving moraleContactJune DixonEmail: June.Dixon@hey.nhs.uk orSusan GilbertEmail: Susan.Gilbert@hey.nhs.uk www.improvement.nhs.uk
  • 43. 44 Cytology improvement guide - achieving a 14 day turnaround time in cytology 14. Visual management Visual management is everywhere, from traffic Visual management allows teams to: lights, to the numbers on the front of buses, petrol • see the work in progress; indicator lights in cars, a water level on a kettle, or • recognise flow stoppers; a cricket scoreboard. • assess inventory levels; • identify defects; These visual indicators allow us to easily • see deviations from the standard; understand the situation and take action where • enable interventions. necessary. There are two types of visual management: Visual management is a simple, yet highly effective • ‘Visual display’ is the provision of way of indicating what should happen (by setting a information; standard) and what is actually happening in the • ‘Visual control’ is associated with action. work environment. At a glance, colleagues, supervisors, managers and visitors to the area Both provide the maximum amount of information should be able to understand the process and see without having to leave the work environment or what is under control and what isn’t without interrogate an information system such as a asking a single question. spreadsheet or database. Visual management provides knowledge, certainty and makes our life, and those of our patients, safer. You can use visual management to answer, amongst others, the following questions: • Are we up to date with the work? • How much work is in the system today? • How many samples/ slides/request forms are in the laboratory? • How many letters have we processed today • How many mismatches were there in recall? • What are our three biggest problems in the area and what is being done to resolve these problems? • How do staff know that their ideas have been listened to? • Who is trained to perform each task? • Is there daily responsibility for supervision? Who is it today? • How do you know where staff are – break, annual leave, study leave? • How do you know if the stock has been ordered?www.improvement.nhs.uk
  • 44. Cytology improvement guide - achieving a 14 day turnaround time in cytology 45Case study 19Use of visual management tosupport a zero tolerance of defectsTaunton and Somerset NHS Foundation TrustSummary Taking a cervical cytology sample? Taking a cervix biopsy sample?There was a 4.75% defect rate in Then please use these Then please use thesecervical cytology samples prior to theproject, mostly from substandardrequest form completion and samplelabelling. A total of 1.2% of allsamples were returned to the sampletaker for correction.This problem caused a variety ofwastes, mostly of staff time:• Specimen transit time - up to three weeks to get the specimen back Then send to cytology department Then send to histology department from the sample taker.• Sample taker time – managing the return. Send-back policy change • Saving in consumables used for• Senior cytology staff time – • Sample takers were informed of packaging and in transport costs. responsible for organizing the send- policy change three months before it back process. was actioned. How this improvement benefits• Patient time – some of the serious • Change in policy reminders were women defects required retesting for the sent out with each defect returned • Minimising defects in patient patient. during same three month pre- identity details reduces clinical risk. implementation period. • Over 500 women each year noA series of changes to the way request longer suffer a delay of severaldefects were handled had the aim of Following the three month weeks waiting to receive their resultreducing time spent managing the testing period due to send-backs.defects, reducing the number of • Minor discrepancies are now recorded • Improvement in overall specimenwomen whose result is delayed by the but not sent back to sender. turnaround time for all 50,000send back procedure and reducing • Major discrepancy samples are samples screened annually due to:error and clinical risk. discarded and the sample taker • Smoothing flow in specimen informed. reception and prep.Understanding the problem • New cytology ‘send-back’ section • Re-allocation of seniors to morePoor quality sample and form data has been added to laboratory appropriate roles.was being received from sample system to record major discrepancies • Decreased telephone calls to andtakers, resulting in significantly and produce standard report for from practices correcting defects.increased turnaround time or inability GP/sender.to perform test. How will this be sustained/ Measurable outcomes and impact potential for the future/The problem was identified from: The effect on the turnaround time of additional learning?• Audit of telephone calls (performed these changes cannot yet be calculated • New send-back section added to as part of quiet time initiative). because the team were still working laboratory computer• Incident reports involving poor through a backlog generated by an • Ongoing use of visual management sample and form data quality. increase in demand earlier in the for sample takers.• Audit of discrepancy request flags project. • Better informed sample-taking staff. on laboratory computer system. • Standardisation of work practices• Root cause analysis (five whys) of However, there have been tangible impacts elsewhere involving defects. delayed samples which were • Quality system for recording major highlighted as outliers on SPC charts. • Improved communication with sample takers. discrepancies. • Large reduction in the number of • Process reinforced as part of routineHow the changes were major defects received. sample taker training and updateimplemented • Effective use of senior staff time sessions.Visual management information sheetswere produced and sent to sample impacting on turnaround times Contacttakers. All visuals were also loaded elsewhere in the specimen journey. Lynne Williamsonto the cytology pages within the • Saving in staff time within specimen Email: lynne.williams@nhs.net.ukpathology intranet site so that users reception/prep with a significantcan print off extra copies as required. improvement in staff morale. www.improvement.nhs.uk
  • 45. 46 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 20Introduction of yellow stickers for the abnormal pathwayAshford and St Peter’s Hospitals NHS TrustSummary TAT for abnormal results - July 2009The use of visual management toensure ‘abnormal’ cases achieve the July data showing much improvement with14 day TAT, has reduced the turn the implementation of yellow stickersaround time for 50% of cases to lessthan six daysUnderstanding the problem• Analysis of SPC charts showed that the majority of the reports that missed the two week TAT were abnormal results.• The abnormals were taking longer as they needed more checks and to be checked by a consultant.• The consultants were not aware of first in first out. There was a need to help them prioritise, making demand, and therefore turnaround times visual. This change alone was not enough to How this improvement benefitsHow the changes were reduce the time taken and work the organisationimplemented continued to be batched by Changes will be sustained throughFrom May 2009 a yellow sticker was consultants before it was returned. daily monitoring of the incomplete listadded to the forms for positive cases and keeping the consultants and APsstating the date by which the form How this improvement benefits involved in delivery of the TAT targets.would be required back into the office. women The stickers will continue to be useful The changes made have contributed as the team strive to achieve the sevenConsultants agreed to return positive to the overall reduction in turnaround day turnaround for abnormals.cases within seven days enabling times.achievement of the 14 day turnaroundtime. TAT for abnormal results - Jan/June 2009However, the SPC chart evidenced that January data before June data after implementationsignificant enough gains had not been implementation of yellow stickers of yellow stickers with not muchmade. improvementMeasureable outcomes and impactThe agreed seven day turnaround byconsultants was not fast enough toenable achievement of the 14 daytarget so after further discussion thetimetable was reduced to three days.As a result, some of the positives arenow turning around within seven dayswith the remainder meeting the 14day target.Ideas tested which wereunsuccessful ContactThe first steps in improving work flow Steve Blackmaninvolved giving consultants a small Email: Steve.Blackman@asph.nhs.ukquantity of abnormal results on a dailybasis rather than waiting until a trayhad been filled.www.improvement.nhs.uk
  • 46. Cytology improvement guide - achieving a 14 day turnaround time in cytology 4715. Value, value stream mapping, flow and pull to identify the ‘ideal’ or ‘future’ state; the Specify VALUE from idealised notions of the process in a perfect the customer viewpoint world, where all the steps are only value added steps. Pursue PERFECTION Identify the in quality & quantity VALUE STREAM by continuous and remove As improvements to current processes are made the improvement waste current state VSM should be updated. Introduce Standard Working Remove Waste Why do we need a VSM? Set Up Visual Management The purpose of a VSM is to: Eliminate Batching Identify Root Cause • Provide the customer (woman) perspective and keep focus on delivering to their expectations. • Provide a complete, fact-based, timed representation of the activities required to deliver a service. Iniate PULL in line with Make value • Provide a common language and common customer demand FLOW view to analyse the value stream. • Show how information flows to trigger and support the activities.• Lean starts and ends with the customer. In our • Show where activities add value and where case, the woman or another department they don’t. involved in that woman’s journey.• A value stream map is used to describe all How is a VSM created? activities performed and information required A VSM should be created to represent what is to produce and deliver the product or service. actually happening rather than what should be• Whether a step is ‘value add’ is determined by happening. The best way to capture the steps the woman. that a sample or woman goes through is to ‘go• To ensure value in a process, focus on see’; do a ‘Gemba walk’ meaning to go to improving flow, creating pull and striving for where the process happens and observe what perfection. actually happens and how long each step takes. In order to understand and analyse the processWhat is a value stream map (VSM)? you will need to capture certain informationThis tool captures and specifies the activities, including cycle time, changeover time, inventoryinformation and timing in the process. It differs (backlog) levels and the number of staff carryingfrom a process map in that it includes waiting out the task.times and inventory (backlogs) between stepsand the number of people involved at each stage Every step in the value stream needs to bein the process. understood by asking: • What is the actual time required to performIt should ideally be a hand drawn representation the task in the process step?of how all the steps in a process line up to deliver • What is the waiting time before each step?a service. As well as the flow of information that • What is the transport time?triggers each step of the process into action, itincludes the flow of materials and the flow of A VSM should also include a representation ofinformation. information flow. This is critical to the timely and effective execution of the process. Location,The steps in the process are timed and quantity and frequency of information flowcategorised as value-added and non-value-added. should be shown.Teams will create more than one VSM. The first To identify this detail, ask these questions:should show the current state (the way things • What information is being transmitted?are now). A subsequent VSM should be created • When is the information being sent? www.improvement.nhs.uk
  • 47. 48 Cytology improvement guide - achieving a 14 day turnaround time in cytology • Who receives the information? samples would have to flow through the process • Where within the value stream is the information one at a time with no excess inventory, no defects, transmitted? no rework and no equipment break downs. • Is the information sent manually or The only way that we can get close to this ideal is electronically? to apply standard methods of working with Lead time minimal variation and to reorganize work This is the amount of time it takes for one piece environments. (sample) to move through the whole process from Flow is difficult because it doesn’t fit with the start to finish. It includes transport, process time, natural way humans think. We tend to organise waiting, etc. It should be from the time the things into batches because we think it is more woman has her sample taken until she gets the efficient. result letter. Lead time includes value added (VA) and non value added (NVA) activities. In single piece flow documents and samples are handled less, use less space and are completed A VSM includes a continuous line along the more quickly. Single piece flow is not achievable in bottom representing the lead time for each step. a laboratory environment but batch size reduction The line looks like the turrets of a castle with each has achieved proven time savings. turret being the time it takes for each step to be performed and the gaps between turrets being the Pull waiting time. Pull and flow work in harmony with one another to keep the entire value stream moving at the rate Quantifying and qualifying value added (VA) that is required by the woman. Steps in the process should be described as value added (VA) and non value added (NVA). Lean uses level scheduling practices to keep the system operating at a steady achievable pace. One Non value added steps can be further of the most common examples of a pull system is a subdivided into: supermarket where only the specified amount of a • Non value added but necessary product is placed on a shelf. When the product • Non value added and not necessary. level runs low, the empty space acts as a signal for the stock person to replenish the product. Value added processes or activities must meet three key criteria: In a laboratory the pull system should be driven by • The customer (woman) must be willing to ‘pay’ the customer (woman) demand which signals all for it. Payment is generally thought of in the activities upstream to build or replenish what monetary terms but could include time or other has been used. Upstream activities are not resources. initiated until a signal from the steps downstream • The activity must transform the product or is received. service in some way. Instead of building up an excess of samples at any • The activity must be performed correctly the step in the process, work should be performed only first time. when the sample is required downstream – a ‘take Anything that does not meet the above criteria is one, make one’ system. non value added (NVA) and is, therefore, a waste When successfully implemented in conjunction of some type. with flow and perfection, pull systems result in less inventory (backlog), reduced floor space and faster Flow processing of samples. Flow refers to the creation of a steady stream of products or services to the customer. The ideal state is that, from the time the process starts, the sample never stops until the result reaches the woman. To achieve this ideal state,www.improvement.nhs.uk
  • 48. Cytology improvement guide - achieving a 14 day turnaround time in cytology 49Case study 21Removing duplicate checksCambridge University Hospitals NHS Foundation Trust, Addenbrookes HospitalSummary visual indicator. Over time this check Ideas tested which wereThe adequacy check prior to primary had become (for some staff) an unsuccessfulscreening was removed. This step had assessment of overall adequacy The initial assessment of the problembeen originally introduced to rather than an assessment of one did not use clear evidence and theretechnically monitor the T3 Thinprep particular problem. were different opinions as to the valueprocessors and provide an early alert • Assessment was then needed to of the step.process for inadequate preparations, quantify the slides involved andrequiring reprocessing. The elimination whether there was an unnecessary How this improvement benefitsof this step removed waiting and over overproduction; if the assessment womenprocessing releasing 61 hours staff was not being applied consistently The slides will be available fortime annually for other duties and did it have any value? screening quicker and therefore thethe slides are now available for TAT reduced. Staff time released forscreening sooner. How the changes were other duties, cost of consumables not implemented used in over processing.Understanding the problem • The number of slides processed• A visual and microscopic check of during February 2009 was 5,622; of How this improvement benefits prepared slides was done on all which 62 were reprocessed, 1.1% the organisation slides prior to leaving the of the total. Recognition that deviations from the preparation room for primary • A review was carried out to re- SOP occur over time and staff should screening. This task took additional evaluate the 62 slides which had be reminded to keep to them. time and delayed the slides. The been marked as requiring Standardisation is key with clear value and point of the task was reprocessing, to determine whether unambiguous instructions and questioned - why was it being they did actually fit the agreed understanding of the task to ensure it done? criteria for another slide to be made. is consistently carried out.• The laboratory became involved in a The slides were reviewed by two GMEC Analyser monitoring people using clearly defined criteria Contact programme, recording adequate/ to assess whether the first slide was Claire Geary suboptimal preparations. The QC adequate and whether the second Email: check was necessary whilst slide therefore had an added value. claire.geary@addenbrookes.nhs.uk participating but the value of the • Only 16% (10 of the 62) samples step was questioned after the trial were unnecessarily reprocessed. ended. The QC check involved a • Therefore of the 5,622 samples visual evaluation of all preps, often examined under this check only 52 – leading to a further microscopical 0.95% actually required further check, prior to being available to the action. The 14 minutes per day primary screener. This task took spent on this task was out of additional time and delayed the proportion to any value of slides being available for screening. identifying reprocessing on minority• It highlighted that there was of samples. considerable variation in how the • The step was therefore eliminated. task was carried out despite the existence of the SOP. There was a Measurable outcomes and impact lack of consistency in applying • Over processing step removed. assessment parameters and criteria • Waiting removed. with varying outcomes. • Over production reduced• Discussion by the senior team • Time saved: 14 minutes per day agreed the purpose and standard procedure of the task. The task was Ideas tested which were successful: to identify slides with large patches Audit using clearly defined criteria and of material missing which required parameters and endpoint is a useful reprocessing to produce a suitable tool to make decisions. Reliable data is slide for screening. A green mark key to making informed decisions was placed on these slides as a when changing or removing processes. www.improvement.nhs.uk
  • 49. 50 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 22Establishing work cellsHull and East Yorkshire Hospitals NHS Trust, Hull Royal InfirmarySummary • Keen to streamline the data entry How this improvementA work cell was established to reduce process to a one at a time benefits womenmotion and batch sizes and maintain throughput. Reduced process time and henceworkflow in the laboratory by moving • Inventory ~ samples waited pre turnaround-time for all samples.data entry from the office into the analysis between receipt and datapreparation room. entry causing unnecessary batching. Contact June DixonThis also addressed the concerns and How the changes were Email: June.Dixon@hey.nhs.uk oranticipated increase in defective implemented Susan Gilbert Email:returns to primary care due to the • Moved data entry into preparation Susan.Gilbert@hey.nhs.ukimplementation of a zero-tolerance room. This required a computerpolicy for errors. terminal, label machine and relocation of office staff.In addition, approximately nine miles • Standard work was introducedper annum of wasted walking has requiring the sample to be checkedbeen saved. by the data entry person before the vial was separated from the form.Understanding the problem • Data was entered immediately afterA review of the current state value sorting and checking and thestream map identified that data entry, sample loaded to the rack forsample sort and check could be analysis.combined. • Any defects (mismatches/incomplete information) were put into a ‘redSample forms and vials were cross bin’ and dealt with later in thatchecked by lab staff for matching session – so maintaining flow.purposes in the specimen reception • This enabled reduced batch sizesarea of the prep lab and the vials and increased flow.loaded in order onto processing trays. • This was a massive change for staffThe request forms were then taken for as teams were brought together indata entry into the office. the work area, and data entry clerks were moved to a clinicalWhere a discrepancy was picked up environment.that warranted the sample beingreturned to sender, the corresponding Measurable outcomes and impactvial then had to be retrieved from the • 0.75 miles walked per monthtray, and all the vials moved along to saved.fill the gap. Ideas tested which were successful• The anticipated increase in returns • Established work cell – sample due to the implementation of a checking, data entry and LBC zero-tolerance of errors meant that analysis. it was more straightforward if data • Value stream mapping and spaghetti entry was moved into the processing mapping tools defined the extent of room to create a continuous flow of the problem. work. • On going data collection of• Motion and transport waste was defective samples received. identified..• Spaghetti mapping showed the number of times a data entry clerk had to walk between the office (36 steps and three doors) and the lab unnecessarily.www.improvement.nhs.uk
  • 50. Cytology improvement guide - achieving a 14 day turnaround time in cytology 51Case study 23Standard work and flow at late delivery timesCambridge University Hospitals NHS Foundation Trust, Addenbrookes HospitalSummary How the changes were • The staff initially pulled in to helpCreation of flow and standard work implemented can continue with other tasksenabled the laboratory team to Two approaches were tested: (primary screening and QC) and somanage a change to the delivery 1. Four people worked in pairs. One more samples are authorised.schedule. This included overnight person opened the specimen bags • Staff have needed to stay late onlyprocessing to create availability in the and did a quick check of some occasionally and for a short timeearly morning for screening. patient demographics. The second and therefore the impact on them person did a full demographic check has not been as great as was initiallyUnderstanding the problem and put barcode labels on the forms feared.Deliveries of samples are received and vials.several times during the day from Ideas tested which were successfuldifferent sources. The main bulk of There was the potential for Standard work with steady, one piecesamples were previously received at mismatch errors as there were flow got the work done in the samelunchtime, unpacked, processed and separated forms and vials lying on amount of time with half the numberstained. the bench and other people were of people it had been thought then picking them up. There was necessary. No additional resourcesThe department was notified that the duplication of the checking part of have been required.time for this main delivery was to the task.change to late in the afternoon to Ideas tested which weremeet demand for sample collection to The space was limited and therefore unsuccessfulother pathology disciplines such as crowded with four people working Leaving some samples until the nextblood sciences. in the same area. It was also day was suggested. This would add at noticed that lab accession numbers least a day to their TAT and wasThis presented a problem for cytology were not being used in order. Theas there are less staff available in the rejected. The samples need to be on work got done in a short time but the processing machines so they canlate afternoon to receive, unpack and on observation the process wasprocess. The team were concerned be stained and screened the following rushed and chaotic. day.that some samples would not beprocessed until the following morning 2. The second change was to instigate The first approach to managing theor staff could be needed to stay late in a first in-first out (FIFO) approach to peak work arrival introduced theorder to get all the samples unpacked the unpacking process and have a potential for mismatch errors andand onto the T3000 machines for one piece flow of standardised introduced duplication of steps. Theprocessing. work. work was rushed.They investigated the following The bench area for the unpacking How this improvement benefitsbefore taking action process was relocated and women• What time were the delivery times redesigned to give separate spaces Women can attend a screening actually going to be and would they for each of two staff to work side by appointment later in the day without be consistent? side. adding extra days before receipt of• How many samples would be on the their result letter. delivery run? Each person took a sample and did• How quickly could the samples be the complete task - remove from the bag, check the patient How this improvement benefits unpacked, labelled and got onto the the organisation machine without an increase in the demographics and label the forms and vials with barcodes before Further work is required on standard defect rate? work for the unpacking process as two• How many people would be needed placing in a processing tray different approaches have evolved to do the task? from the initial model. Measurable outcomes and impactData was collected before and after • The samples are unpacked and The team are measuring the timethe changes in delivery times on how ready for processing without the taken and defect rate for each methodmany samples arrived in each delivery. need for additional staff to help and assessing which has the bestThere has been a shift to a greater with the task. time/quality outcome.number of samples being received • The increased number of sampleslater in the afternoon. being delivered later in the day has Contact been managed. Joy BishopThe team were asked for their views • Samples are processed overnightand suggestions for how they might Email: and are ready for staining at lab joy.bishop@addenbrookes.nhs.ukmanage this change in work flow. opening the next morning. www.improvement.nhs.uk
  • 51. 52 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 24Abnormal pathway changesThe Leeds Teaching Hospitals NHS TrustSummary Reporting times (days)The results of abnormal samples werebeing authorised on average 10 days Week Negatives Abnormals Differenceafter negative samples. 1 18 27 9As a result of the changes made 2 17 27 10abnormal results are now issued 1 day 3 14 21 7after the negative results with anassociated time saving equivalent to 4 13 18 547.8 working days per year. 5 12 13 1Understanding the problem• A delay in the system for checking and reporting of abnormal samples • A scheduling system was introduced How this improvement benefits was causing a delay in authorizing where fixed quantities of slides are women results on abnormal samples. sent to the reporting room at set Approximately 5% of cases reported• The turnaround time for negative times of the day in line with have an abnormal result. At current and abnormal samples, recorded on capacity/demand. workload this equates to 5250 women a weekly basis, highlighted the • Daily communications between the receiving their result up to nine days issue. first checker and pathologist/ earlier than before.• Analysis of the processes showed consultant BMS are used to balance that the main cause of the delay capacity and demand. How will this be sustained/ was the waste of waiting. • A pathologist/consultant BMS rota potential for the future/• After primary screening samples was introduced to maximize additional learning? awaited separation of negatives reporting capacity. • The changes have had a significant from abnormals. At this stage an • Deviations from the norm are positive impact on service provision extra QC step was performed, monitored daily, discussed at without compromising quality. correlating the pre-screening and huddles and counter measures put • In future the adverse effects of QC primary screening results. in place if required. checks will be considered as well as• After separation, the potential the benefits. abnormal/abnormal cases were Measurable outcomes and impact placed in a checking box for senior • Turnaround times for abnormal Contact staff to screen. cases are now only one day more Hazel Eager• After checking, the abnormal cases than for negatives. Email: hazel.eager@leedsth.nhs.uk then were taken to the reporting • Removal of the extra QC check has room to wait reporting by a saved 85 minutes per day, an pathologist/ consultant BMS. equivalent of 47.8 working days per year.How the changes wereimplemented Ideas tested which were successful• Primary screeners now separate out • In the past the screeners did their own potential abnormal/ separate out their own abnormals. abnormal cases. However, this was changed several• The extra QC step has been years ago when pre-screening was removed. introduced.• An outstanding list is now run • After a buddy event the team frequently to ensure that no looked at the process again and discrepancies between pre- and decided that running the primary screening results are missed. outstanding report would provide• A seniors’ rota was implemented to the required QC check and release assign the role of checking to 85 minutes per day. specific people on a daily basis.www.improvement.nhs.uk
  • 52. Cytology improvement guide - achieving a 14 day turnaround time in cytology 53Case study 25Changing work patternsPennine Acute Hospitals NHS TrustSummary How the changes were Ideas tested which were successfulIndividual screeners are no longer implemented A jumpstart event identified thisleaving unfinished batches of work on • It was agreed that screeners would change as a ‘just do it’ opportunity.their desk until their next working day work on a first-in-first-out basis andand less work is outstanding at the that everyone would complete one How this improvement benefitsend of each day, resulting in an tray of primaries immediately patientsimproved TAT for delivery to recall by followed by rapids and so on The number of cases outstanding atone day. In addition, results entry and through the day. the end of the day has reduced byauthorisation now occurs on the same • Part-time staff were asked to place 50% and enabled all reports to beday. any unfinished work back on the sent in the order in which they were shelf for screening when they finish received reducing variation in ourUnderstanding the problem for the day. These slides are placed turnaround times.• Part-time screeners working on the top of the pile so that they mornings left any unfinished are taken first. This ensures slides How this improvement benefits batches of slides on their desks to are screened in date order. the organisation be continued on their next working • Any slides from a part completed Similar systems are used to ensure that day. batch that had been primary the number of cases transmitted to• This pattern of work could delay as screened were passed straight for the call/recall agencies are maximised many as 66 (220 when using large rapid review (rather than being when multiple downloads are batch sizes) slides per day returned to the shelf with the implemented. depending on the number of staff unscreened slides). working. This represented • Staff who work to the end of the So far, focus has been on preventing approximately 30% of daily day in the department take the screening carrying over from one day screening workload. incomplete trays of slides and to the next. The team will now• Slides that had been screened and complete them. develop their thinking to find a way to entered on to the computer system • Slides that were being left on the prevent cases carrying over to the were placed on the shelf for a rapid re-screening shelf overnight following days download. Multiple second person to rapid re-screen. are dealt with the same day so that daily downloads will become the driver These slides were often left until the they are not delayed until the day of a pull system. following day which delayed reports after. A cut off point at which all going over the electronic link to the staff would switch to rapid reviews Contact screening agency. If this scenario was agreed to ensure the maximum Richard Lambert occurred on a Thursday, then the number of results being captured by Email: Richard.Lambert@pat.nhs.uk reports would not arrive at the the daily download. screening agency until Monday morning, adding three days to Measurable outcomes and impact turnaround. • All slides with results entered on the• Screeners had individual preferences computer on a given day are for which time of day they would authorised the same day. complete rapid reviews. • Time taken for the results to reach the screening agency is reduced by one day to three days. • Changing working patterns have not had a detrimental impact on safety (defects) or quality. • Morale – changes were accepted and are seen to contribute to an improvement in service. www.improvement.nhs.uk
  • 53. 54 Cytology improvement guide - achieving a 14 day turnaround time in cytology 16. Future state mapping Whilst the current state VSM is a snapshot of Don’t disregard the concept of a future state map where you are and what your service looks like showing the ‘ideal’ service. When people are now, it is important to articulate where you are ‘allowed’ to let go of current constraints and going - your future state. imagine where everything is right to deliver only value to the customer, radical thinking results and A future state map can either represent what your breakthrough opportunities can be identified. ‘ideal’ service would look like, with only value added steps, or a more realistic state. The latter Using the PDSA methodology and measuring would be more straightforward to implement before and during improvement activity, ideas can relatively quickly through a focussed action plan be tested to ensure they make a positive difference with SMART goals (specific, measurable, agreed, to the process. realistic, trackable). For more information on value stream mapping, As soon as the ‘future state’ is achieved it becomes please refer to section 26, websites and useful the ‘current state’ and a new future state map reading. should be drawn. This is part of the Lean culture of continuous improvement and the principle of striving for perfection. This approach allows incremental improvements to be made by reducing waste and any non value add steps. Analysis of a value stream map should determine any non value add steps that can be eliminated along with value add steps that can be either combined, simplified or re-sequenced to achieve the future state.www.improvement.nhs.uk
  • 54. Cytology improvement guide - achieving a 14 day turnaround time in cytology 5517. Using 5S to improve safety and morale• 5S means the workplace is clean and safe - a STANDARDISE - Create consistency. Identify an place for everything and everything is in its place. area to store 5S supplies (cleaning supplies, labels,• 5S is the starting point for implementing coloured tape, boxes and other necessary items) improvements to a process. and schedule time and responsibility for restoring• To ensure your gains are sustainable, you must work area to the proper condition regularly. start with a firm foundation.• Its strength is contingent upon the employees SUSTAIN - Maintaining 5S. Audit the area and organisation being committed to regularly and expand 5S activity to other areas. To maintaining it. maintain discipline, practice and repeat until it becomes a way of life.Note: Unless you are working in a small area don’tundertake 5S for the whole department at once. Use this graph as a general guide for decidingYou will overwhelm everyone and you will risk where to store items.shuffling unnecessary items around, rather thaneliminating them. Before you start the 5S processdetermine the boundary of the area you areaddressing. Do not 5S another individuals Aworkspace. Frequency of use5S is one of the foundations for Lean as it: B• Reduces waste.• Means less searching and decreases walking C and motion.• Reduces downtime, accidents and mistakes. Distance• Improves flow.• Makes better use of space. Why use 5S at all:It is also a precursor to other tools such as: • A clean workplace indicates a quality product• Pull systems/inventory replenishment. and process-dust and dirt cause product• Standardised work. contamination and potential health hazards.• Setup reduction. • Creates a safer work area.• Mistake-proofing. • Gains space, removes waste and shortens travel distances.5S Stands for: • Visually shows what is required or is out of place and so saves time not searching for items.SORT – Separate and remove clutter and items not • More efficient to find items and documentsneeded in the workspace. Remember that (silhouettes/labels/shadow marking).extraneous items impede the flow of work.SET IN ORDER/STRAIGHTEN - Arrange andorganise all items to minimise movement, makethings clear.SHINE (AND INSPECT) – Clean the area,workspace, storage, equipment, etc. and inspectfor warning signs of breakdowns. www.improvement.nhs.uk
  • 55. 56 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 265S in the screening room, office and storesCambridge University Hospitals NHS Foundation Trust, Addenbrookes HospitalSummaryIntroducing 5S in the screening room,office and storage areas has savedtime as staff are able to locate slides,control stock levels and find what theyneed quickly.Standard work for where authorisedcases are kept on screeners’ desks hassaved one to two hours per weekof senior staff time. Before AfterUnderstanding the problems• Cases checked and requiring Measurable outcomes and impact How this improvement benefits consultant authorisation are • Waste of motion removed – the organisation returned to the screener for between one and two hours Simple and quick solutions can be very feedback. Each screener previously per week. effective. put them in a different place on • Improved staff morale. their desk. One to two hours of The team also recognises that 5S has senior staff time was wasted Ideas tested which were to be an ongoing process to sustain searching for cases required for a unsuccessful the efficiency gains they have query. The team initially tried sending emails achieved.• Stock items such as stationery and on a distribution list asking all staff to prep room consumables often ran look on their desks for required slides. Contact out because there was an This failed either because staff didn’t Joy Bishop inconsistent approach to ordering. check their emails or their screening Email:• Equipment for preparation, time was interrupted and wasted joy.bishop@addenbrookes.nhs.uk processing and movement of stock whilst they searched their desk. was kept in variable locations which wasted staff time. How this improvement benefits womenHow the changes were More time is available for reportingimplemented samples.• The team began to use 5S and introduced shadow marking and stock level indicators to ensure standard work.• Each staff member was given a tray with a laminated card with a big red A on it. This is the only place authorised cases are to be placed making them easy to locate when needed for a query.• Shadow marking in the prep store room ensures equipment is returned to its standard storage area and stock levels can be controlled.www.improvement.nhs.uk
  • 56. Cytology improvement guide - achieving a 14 day turnaround time in cytology 5718. Standard workWhat is standard work? Making standard work flexible – usingStandard work refers to the most efficient work a pull systemcombination that can be put together. A work Standard work allows the practice of just-in-timecombination is the mix of people, processes, processing. This means maintaining little or nomaterials and systems/machines that come WIP by using a ‘pull’ system.together to enable completion of a work process. In a pull system, each department supplies theOutside manufacturing it is common to hear downstream department/process with the rightcomments like “… we’re not robots, we don’t forms/samples, at the right time, in the rightmake cars”, but standard work happens in all quantity. In essence, the recall agency makes awalks of life: request for (‘pulls’ authorised reports from) the electronic download, which ‘pulls’ from the volume• A speaker uses standard work, called an outline. of authorised, reported samples in the screening• A chef uses standard work, called a recipe. room. The screening room ‘pulls’ processed and• A football manager used standard work, dried samples from the prep lab. The prep lab called a game plan. ‘pulls’ registered forms from the office and so on up stream.It’s worth noting that standard work does notmean work standards. You will already have work These planned re-order (kanban) points should bestandards e.g. standard operating procedures, but set to fit with daily capacity. Small buffers of workthey do not ensure standard work. should be used to balance workload requirements of the next department where volumes ofIt is once you have mastered standard work that forms/samples ‘requested’ cannot be met.variation in what and when work is done can beminimised. Variation and wasteful activities are Visibility and communication of what is expectedrestricted by standard work to avoid compromising and when should be available alongside what isthe final outcome whether it be a delivered speech, actually received is key to this ‘processing’ system.restaurant meal for two, winning a football gameor issuing the woman’s test result within 14-days. As requests are met, the supplied forms/samples are used in a first-in, first-out flow. This method ofStandard ‘work-in-process’ inventory is the levelling work flow takes out variation inminimum amount of work-in-progress (WIP) productivity and improves the predictability of(forms/processed/screened samples) that must be achieving the overall seven and 14 day TAT targets.held at or between your work processes for It’s effectiveness can be monitored throughsmooth completion of a work sequence (i.e. test statistical process control charting. It also givesresult). If this quantity of completed work does screening teams a consistent plan and delivers on-not happen at each step, it is impossible to time, uniform sample volumes from upstream prepsynchronise work operations. lab and office processes. If however you operate with high errors/machine downtime it will be challenging to master a level schedule. www.improvement.nhs.uk
  • 57. 58 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 27Standard work in screeningBarts and The London NHS TrustSummary Delay from primary screening to review October 2008 and August 2009The introduction of standard work inthe screening room ensures a saferwork environment and reducedturnaround time. Alternating screeningof primaries and rapids has resulted in30% of results sent and posted on the Dayssame day.Understanding the problem• There was no standard work in the screening room.• Reviewing, checking and filing was not completed in a timely manner – there was no standard way / time when these were to be completed.• Some slides missed the review/rapid screening. After primary screening, these slides were added to the filing Measurable outcomes and impact Ideas tested which were pile. Once the slide was known to • Reduction in turnaround time. unsuccessful have not been reviewed, it was very • 100% of slides are reviewed same This initiative was a success but it did time consuming to find it. day or following day after primary take a number of attempts to get all screening. staff onboard and working to this newHow the changes were • The standard pathway for every slide standardised way. The project wasimplemented and request form through the successful due to good communication• Standard work was established. screening room provides a safer and persistence. Every screener alternated between system. If a slide isn’t in a one tray of primary then one tray of designated place, it is clearly evident How this improvement rapid screening. that there is a problem. benefits women• Once the tray of 10 had been rapid • Staff now have ownership of the • Women now receive their result screened, the negative slides were process. earlier. filed immediately by the same • 100% of negative slides are filed • The system is safer. person who had completed the immediately. • This standard system ensures a first rapid screen. • By introducing a standard way of in first out system. No slide is• The team had a separate filing alternating the screening trays of waiting longer than one day for room, but a drawer from the main primary and rapids, 30% of results primary and review screening to be filing unit was placed in the can be sent to the recall agency. completed. screening room.• Batch sizes were reduced from 20 Ideas tested which were successful How will this be sustained / to 10. • The team used the 5S tool to clear potential for the future /• It was agreed that slides should no the work space and mark out each additional learning? longer be left on screeners’ desks area. There is now a clearly defined Standard work has been sustained overnight. area for primary, rapids, consultants, and will continue. Continuous slide filing and request for filing. improvement will maintain and • Alternating small batches of primary improve the system. and review screening is working effectively. Contact • Filing is now completed immediately Geoffrey Curran and it is now very easy to find any Email: slide. Geoffrey.Curran@bartsandthelondon. nhs.ukwww.improvement.nhs.uk
  • 58. Cytology improvement guide - achieving a 14 day turnaround time in cytology 5919. Takt timeTakt time is the rate at which units of work (e.g. Capacity vs. demand based on current dailycytology test result letter) must be produced to work volume - Takt timemeet customer demand (e.g. woman receiving her 70test result 14 days from when her sample wastaken). 60 59.81 50 45.58 42.49It is calculated as the total available work time per Seconds 40 42.49 42.49day/shift (e.g. total number of minutes within the 30 37.78shift minus breaks/lunches) divided by required 20daily output quantity (e.g. number of test resultletters to be issued). 10 0 Pre lab Office ScreeningCycle time is the time taken to finish tasks Actual max time per completed work item (secs) Planned max time time per completed work item (secs)required for a work process and is typicallymeasured from the point of completing theprevious task to completion of the next task.To get an accurate reading of cycle time, it is Work sequence is the order of tasks performedrecommended that at least two team members to make the work process within takt time.record the time taken to perform each department A number of forms are typically used here e.g.task 20 times. This can be done using a time process sequence charts (see website for example)observation sheet. and standard work combination sheets as they are helpful for collecting information about theIt is not uncommon to find department cycle times sequence of tasks, who completes them and theare higher than the takt time, meaning that staff time/distance needed to complete each task. Stackmembers could not complete all work in a normal charts may also be used to clearly quantify value-shift on the same day it was received or process add and non-value add, or wasteful, tasks.higher volumes of work than received to reduceany backlog. Where this happens, potentiallyavoidable department agency and overtime costsare incurred. Stack chart showing waste analysis 120 100 16.2 16.2 % Takt time 80 3.1 5.9 5.5 58.3 0 60 32.4 4.3 0 40 68.9 8.5 4.6 20 41.2 28.6 0 0 Pre lab Office Screening Recall Task # Wait Set-up Over processing Transport/motion Checking Value add www.improvement.nhs.uk
  • 59. 60 Cytology improvement guide - achieving a 14 day turnaround time in cytology 20. Capacity and demand Definitions and measurement What do you need to do? To provide an effective service it is important first • Understand the demand on your service; to understand the capacity required to meet the measure it and look for patterns in variation. demand placed upon it. To do this, the measurement of capacity and demand must be • Plan the capacity required based on 80% of the collected in the same units, the unit of time. variance in demand, this will prevent a queue or backlog from building up. Demand • Number of sample/slides • Ensure the correct skills/people are available to x time taken to process them. deal with the peaks and troughs in demand. Capacity • Reduce unnecessary demand by examining • Number of pieces of kit referral thresholds. x staff time available to run /screen. • Increase capacity by removing waste by process Activity redesign: usually only 5% of activities add value • Number of samples/slides processed in a system. x time taken. • Reduce variation by: Backlog/queue • Eliminating batching, adopting a first in - first • Number of samples/slides in the queue (waiting) out (FIFO) system x time to process. • Pooling reporting amongst clinicians. • Levelling the work schedule to ensure staff When the demand (requests) and the total capacity utilisation is optimal by synchronisation of the (kit and staff) are converted to time, excel tables processes. and analytical charts can be used to demonstrate • Pulling work through the process. the gaps between the two. • Deal with the backlog: Understanding variation • measure and monitor backlog Monitoring demand over time will demonstrate • use temporary short term increase in capacity natural and predictable variations, i.e. seasonal and (overtime etc) bank holidays. Specific actions can cause additional If a backlog exists and is constant, it is variation, including transportation, batch unlikely there is a problem with capacity. processing of samples, screening information, • Monitor capacity and demand weekly using transcription and IT downloads, all of which are SPC charts. under our control and can be changed. Daily transportation, eliminating batching, and multiple • Use visual management techniques such as a daily downloads will eliminate this variation. Staff clinical dashboard to: can work more effectively when variation is • Display the key measures to monitor daily and eliminated. weekly demand versus the number processed (activity). • Display statistical process control (SPC) charts of the end-to-end pathway including key points along the pathway for consecutive patients. • Display the total number of samples/slides waiting at the end of each week.www.improvement.nhs.uk
  • 60. Cytology improvement guide - achieving a 14 day turnaround time in cytology 61And some important don’ts• Carve out for specialisation and ‘urgent’ cases, it will cause a backlog.• Use activity as a proxy for demand.• Use averages.• Go for 100% utilisation of your skill/assets.Business cases for additional capacity will be morerobust if clear evidence of capacity and demandcan be provided.Further information on capacity and demand,including simulation models showing:• How a backlog or waiting list will build up if demand and capacity are mismatched.• The impact of prioritizing urgent cases (carve out).• The impact of 100% utilisation and how the flaw of using averages to set capacity will result in a backlog (queue).These have been developed by Mr Richard Steyn,Consultant Cardiothoracic Surgeon and areavailable at: www.steyn.org.uk.Alternatively, visit the NHS Improvement website toaccess the Improvement System capacity anddemand analysis tools.The following case studies demonstrate howcapacity and demand analysis has been used toredesign the service. www.improvement.nhs.uk
  • 61. 62 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 28Using capacity and demand InformationCentral Manchester and Manchester University Hospitals NHS TrustSummary Measured outcomes and impact How this improvement benefitsThe laboratory team are now able to • The number of samples that needed womenaccurately plan their workload and to be screened in order to bring This will have an impact on 92,300staffing using demand and capacity down the backlog could be women annually.data. They now forecast the number predicted.of slides that need to be screened to • The backlog was reduced from How this improvement benefitsreduce the backlog, staff can be 21,390 to 11,700 in 91 calendar the organisationallocated effectively and work planned days. The team is continuing to monitorappropriately. This resulted in • The team progressed ahead of plan daily output and ensure that thereduction of the backlog from 21,390 and the date of expected backlog changes implemented areto 11,700 in 91 calendar days clearance has moved forward from maintained.approximately eight months earlier May 2010 to the end of Septemberthan predicted. 2009. Contact Yvonne HughesUnderstanding the problem Ideas tested which were successful Email: Yvonne.Hughes@cmft.nhs.uk• The team couldn’t predict or plan • A specific area was identified in the what the workload would be or screening room within which to lay how to reduce the backlog. out each days work.• There were high levels of stress • Slides for screening each day are put amongst the team. out and clearly labelled with the• The backlog was increasing despite date of receipt and marked as overtime and locum staff whether it is rapid or full screening appointments. along with the different specimen types.How the changes were • A white board was placed in theimplemented screening room and the number of• They started by collecting data, slides screened and authorised is measuring volumes received into the updated daily along with the department, volumes being expected date to clear the backlog. screened and the available hours for This visual management approach screening. has helped with morale as it feels• Process sequence charts were good to see the progress being prepared showing the whole process made. with the appropriate timings required for each step. Ideas tested which were• Inventory (backlog) that was waiting unsuccessful in the department was logged – this The team tried putting out a volume was a one off count which could of slides to match each days’ capacity then be updated daily by recording but as they have two different sample incoming work and screening types and not all screeners can deal completed using an Excel with both they found it difficult to spreadsheet. achieve the right number of samples• Knowing what was being received and still keep working in date order. and the daily screening capacity meant they could then plan the reduction of the backlog.• The numbers of samples screened is entered on the daily huddle board for all to see and the expected date for clearing the backlog.www.improvement.nhs.uk
  • 62. Cytology improvement guide - achieving a 14 day turnaround time in cytology 63Case study 29100 day planThe Leeds Teaching Hospitals NHS TrustSummary • A demand and capacity model was Some of the key changesThe average turnaround time from built which showed that without implemented weredate of sample taken to receipt of increased capacity in the office and • Batch sizes were reduced to improveresult has been reduced to 14 days as screening room, or a large reduction flow and reduce wait times.planned. in demand, the team would be • Office – batch sizes reduced from 24 unable to reach their goal. The to 12.In addition, 77.5 hours of screener team used this information to • Screening room – batch sizestime (capacity) has been released decide on the capacity needed to reduced from 16 to eight.weekly and a £30k saving by reduce the backlog to 14 days to • Daily targets were introduced inavoidance of annual overtime costs. result authorization by the end of each of the areas within the July 2009. laboratory.Understanding the problem • The laboratory pathway was walked • Lab – process 12 runs per day (576).After initial training from the NHS by the core team and extra • Office – register 48 batches of 12Improvement team, the core team members drawn from the forms per day (576 forms).walked the whole pathway from the preparation laboratory, office and • Screening room – screen six slidestime the sample was received in the screening room and new waste ID per hour/screener (including pre-laboratory specimen reception to the charts were completed. screen and result sign-out).time the result letters were posted • Problems in each area were • Date stamping on arrival for eachfrom call/recall. identified and put into a fish bone sample was eliminated, and replaced diagram. with date/time received written onWaste ID sheets were filled in by all • Problems with a low/medium effort first form of each batch.members of the team. to resolve with a high impact on • A seniors rota was introduced in results were identified and the screening room to allow seniorProcess sequence charts were prioritized for action. staff more time to primary screencompleted detailing all aspects of the • A ‘5 whys’ analysis was performed slides.pathway stating distance travelled, on the key action points totime taken for each process, checking determine the changes that shouldtime and waiting time. be made. • A PDSA (Plan, Do, Study, Act) planHow the changes were was drawn up for all changes to beimplemented implemented, and expected benefits• A future state plan was agreed were noted. detailing the changes needed in the • A control plan was produced to next six months to achieve the 14 ensure that proposed changes were day target. implemented.• Initial changes were identified from • Using the process sequence charts, the waste ID sheets as quick wins the waste was quantified. that could be implemented by the • A 100-day plan was implemented in end of November. order to achieve a turnaround of 14• Initial progress was good. Due to a days from date sample taken to 29% increase in demand from report authorization by reducing February to June 2009 as a result of waste, improving the flow of work media coverage of cervical cancer, through the department, and progress then slowed considerably. maximizing capacity.• A jumpstart event was held in April 2009 to formulate a plan to help the team reduce the turnaround times in each area with a view to getting back on track to achieve the 14 day target. www.improvement.nhs.uk
  • 63. 64 Cytology improvement guide - achieving a 14 day turnaround time in cytologyMeasurable outcomes and impact Average turnaround times during How this improvement benefits• Since the implementation of the the 100 day plan patients 100-day plan to the end of July the • An improvement in turnaround 30 average turnaround time from date times from 24 days to 14 days Turnaround times (days) of sample taken to result 25 within the laboratory resulted in authorisation has been reduced 20 women receiving their results 12 from 24 days to 14 days. days earlier than in April 2009. 15• 77.5 hours – screener time (capacity) released weekly. 10 How will this be sustained/• £30k - now avoiding annual 5 potential for the future/ overtime costs. additional learning? 0 April May June July • The turnaround times continue to Month fall with an end-to-end turnaround time of 14 days for 98% of women in September 2009. • Standard operating procedures haveWaste Baseline Current % Change been updated to reflect the changes• Transportation (m) 117392 44275 - 62.3 implemented.• Wait time (%) 96 67 - 29 • Demand and capacity tools• Motion (%) 0.8 4.9 +4.1 updated daily.• Inspection (%) 0.1 4.1 +4.0 • By 31 March 2010, the next state• Value Add Ratio (%) 4.1 23.6 +19.5 pathway planned to achieve 95% of results received by day seven, 40%Performance Baseline Current % Change received by day four.• Avg TAT (days) 24.32 0.5 -69,2 • Ownership already transferring to• % in 14/7 (days) 3/0.13 98/58 +98/58 day-to-day management away from• Work outstanding 2407 716 -70 core team through daily problem• No of reports 6.1 6.7 +8.9 solving and agreed control plans. authorised (pd) • Control plans have allocated roles/responsibilities for: • Lean service improvement training • Regular go and see waste walks. Ideas tested which were • PDSA problem solving. unsuccessful • Routine dept use of • The team work in an off-site demand/capacity and takt time building nine miles from the base tools. hospital. The computer network link • Upkeep of performance measures is too small resulting in constant and control charting. delays in logging on to the system • Deptartment head led best and during data entry. practice reviews. • Log sheets were completed for all • Section head to audit team delays and sent to the head of leaders workplace assessment/5S department. However, an schedule and ensure any failures application to upgrade the computer are acted upon. network link was rejected by the trust on financial grounds as the Contact team will be relocated back to the Hazel Eager main hospital site within the next Email: Hazel.Eager@leedsth.nhs.uk two to three years. • The problem has been partially resolved by the use of thin clients which reduce log on time by 60%.www.improvement.nhs.uk
  • 64. Cytology improvement guide - achieving a 14 day turnaround time in cytology 65Case study 30Cost avoidanceHull and East Yorkshire Hospitals NHS Trust, Hull Royal InfirmarySummary • Inventory - the logistics meant that could be instigated if a build up inA cost avoidance of £72,000 has there was a necessary time lag backlog of work became apparent.been achieved as a result of more before reports could be issued by • Interruptions in the screening roomappropriate and timely management the laboratory in Hull. A number of were monitored and whereof workflow using the ‘lean’ abnormal samples were identified in necessary changes implemented tomethodology introduced into the the outsourced work but checking avoid themdepartment as a pilot site. This money and reporting by a pathologist was • In October 2008, two members ofrepresents the expected spend on only carried out once the samples the screening team returned tooutsourcing. had been returned. This resulted in work after a long period of absence. a further delay in abnormalA drop in demand for tests brought reporting. Measurable outcomes and impactabout by the introduction of LBC • Defects - discrepancies in screening The graph below illustrates the volumetechnology, changes to screening protocols meant that thresholds for of work which was out-sourced eachintervals and recall have also unsatisfactory samples differed, week over a prolonged period of time,contributed to the ability to bring resulting in more, and unnecessary, and the related costs to thework back ‘in-house’. work for the team. department for using this service.Understanding the problem How the changes were • The cost of £72,000 for sendingOver a consistently long period of time implemented work out for screening was saved asthe laboratory had insufficient capacity Highlighting the reasons for the added the changes within the departmentto cope with demand due to long expense incurred by the department in enabled the work to be performedterm sickness and an agreed leave of outsourcing the work, and the delays without the provision of extraabsence amongst screening staff. It in reporting incurred, enabled the resources.became necessary to outsource department to address the issues • There was a dramatic reduction inapproximately 33% of the workload which were raised. end to end TAT as a delay of 11of the laboratory over a prolonged • Changes to standard working days was instantly removed.period of time from July 2007 until practice were implemented after • Quality was ensured as unnecessaryDecember 2008. consultation and agreement from all steps were removed from the staff. process.• The annual budget for cellular • A visual management system was • Staff morale improved because of pathology could not accommodate put in place to monitor the output the improved capacity to manage the expense of out-sourcing 33% of of work from the department on a our own workload. workload for screening, and as no daily basis so that remedial action other form of finance was available this was recorded as an overspend on the departmental accounts. Number/costs of slides outsourced per week• The amount of samples sent for external screening on a weekly basis were logged and carefully monitored for audit purposes. Costs incurred were recorded via invoicing between departments at £6 per test including quality control of negatives.• Unnecessary waiting - delays identified as a minimum of 11 days because of the logistics involved in sending the samples away for screening and receiving them back for authorisation and processing by patient data services. www.improvement.nhs.uk
  • 65. 66 Cytology improvement guide - achieving a 14 day turnaround time in cytologyIdeas tested which were successful How this improvement benefits• Adoption of Lean working patients methodology in the department Work was completed in-house in a which came as a result of inclusion timely fashion and the delays caused in the pilot project raised awareness by out-sourcing are avoided, which of all members of the team to improves service delivery for the working differently. women concerned. Avoiding the• The five minute staff meeting held enhanced rate of out-sourcing means at the start of each day was used as the trust can use the savings more an opportunity for all staff members appropriately. to make suggestions that they felt would improve workflow through How will this be sustained/ the department. Many of the potential for the future/ changes that were implemented additional learning? came as a result of this process. There is now a system in place where• Minor changes to working patterns staff can make suggestions for in the screening room impacted improvements to service provision, significantly on work flow. knowing that they will be assessed • A designated time in the using PDSA methodology and mornings was set aside for rapid implemented where appropriate. review of negative and Money was saved because the out unsatisfactory samples, so that sourced work had been paid at a they could be authorised and sent significantly enhanced rate compared out promptly. to the cost of doing the work in- • A new standard working practice house. to screen a rack of eight slides, and then rapid review and Contact authorise a rack of eight slides June Dixon throughout the day was Email: June.Dixon@hey.nhs.uk introduced. • A cordless phone enabled staff members, when necessary, to look up and answer telephone queries from service users, without having to leave their work station, thus minimising disruption.• Closer collaboration between pathologists, and a flexible approach to work distribution based on excess capacity has enabled the department to manage abnormal reporting backlogs, keeping delays to a minimum.• A department wide workforce assessment aimed at addressing some of the issues surrounding capacity enabled a long term workforce planning package to be put in place a for the future.www.improvement.nhs.uk
  • 66. Cytology improvement guide - achieving a 14 day turnaround time in cytology 6721. CommunicationThe importance of good two waycommunicationAnswering a telephone call, attending ameeting, receiving an email, having a face-to-face conversation with a colleague, reading anewsletter or watching a news article; these areall communication activities that we frequentlyexperience.Establishing the framework for, and maintaining,good two way communication is critical to thesuccess and sustainability of any improvementactivity.• ‘Go and see’ the process you are trying to improve. Speak to patients, users and people involved with the process, see and hear what is happening and ask questions to deepen your understanding.• Communicate with and involve key people as early as possible during the planning stage of any improvement activity.• Share information regularly. Use monthly project meetings and daily five-minute meetings to confirm progress, to allow ideas to be raised and questions answered. Always allow sufficient time for feedback on actions.• Communicate visually - ‘A picture is worth a thousand words’. • Use A3s to support problem solving, to set out improvement proposals and to confirm the status of an improvement project. • Create a communication board to support two way communication, to review progress and to support problem solving.• Listen to the opinions of colleagues, including those that differ with your own. Seek to create an environment where discussion can take place in an open and fair way.It is everyone’s responsibility to ensure good twoway communication takes place. With a wellinformed, well engaged team, yourimprovement activity will have the solidfoundation it needs to make it a success. www.improvement.nhs.uk
  • 67. 68 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 31Understanding communication issuesCambridge University Hospitals NHS Foundation Trust, Addenbrookes HospitalSummary How the changes were Ideas tested which wereCommunication is the key element to implemented unsuccessfulachieving successful change. The team asked their national • Talking about the changes at team improvement lead for help and took briefings did not give staff theAlthough everyone was invited to the following steps: feeling of ownership or the feelinghighlight problems and offer of empowerment – visuals were alsosuggestions to improve the process, • A recap on the principles of Lean needed.staff still felt they were not listened to was given by the Improvement lead • A ‘suggestions implemented’ boardand that any suggestions they made with the recognised ‘grief loss’ was posted in the staff rest roomwere ignored. It was recognised that model included. but tended to be overlooked by staffthe team went through the well • Staff were given the opportunity to and some felt this imposed on theirdocumented grief loss cycle and found openly vent their feelings without personal time.themselves at the bottom of the cycle the senior team present. • Although thanks and praise werein despair. • A feedback session was conducted given at the team brief we realised a with the management team visual reminder of success was alsoA display area in the main • A suggestions wall was set up with needed.thoroughfare was designated for three sections - staff post their ideassuggestions, discussion, feedback and and suggestions, receive feedback How this improvement benefitsoutcomes. Staff became enthusiastic on those ideas from all colleagues womenand willing to offer suggestions. and can then track progress of all The better morale has improved team ideas and outcomes. working resulting in an enhancedUnderstanding the problem workflow and shorter turnaround timeDuring the early stages of the Feedback is also given at the daily for womens’ results.improvement process, most staff were team brief and open discussion ofwilling to take on changes albeit with ideas encouraged. How this improvement benefitsa degree of scepticism. As the the organisationimprovements developed, and activity Measureable outcomes and impact We all need constant and relevantincreased staff started to feel • The staff engagement surveys were communication. We need to knowoverwhelmed with constant change. embraced by all with 100% of staff what affects us and what is expected completing and returning them. of us. The actions taken haveThey started to feel that change was • Survey scores showed a 4% drop improved the working environmentbeing imposed, they didn’t have over the period that the team were and will help the team to sustain Leanownership and many of their recognising the need to address as the way of working long term – notsuggestions were ignored. As a result communication. just a one off project.of this: • By April 2009, 22% of the team felt their personal morale had improved Contact• Motivation began to fall. since the start of the project. Joy Bishop• Staff became antagonistic to the Email: senior team. Ideas tested which were successful joy.bishop@addenbrookes.nhs.uk• Changes were misunderstood. • The introduction of the suggestion• Ideas and suggestions stopped wall gave everyone the opportunity• Any changes communicated to see the ideas suggested, the received negative comments like progress being made and the ‘that won’t work’. outcomes.• Communication that was in place • Data was collected before and after began to break down. any changes to prove the change• The senior team felt they were worked. praising and listening but staff did • Daily team briefings allow open not recognise it. discussion of suggestions giving• The senior team became everyone ownership. despondent. • Notes from the daily brief are posted on the suggestions wall for a rolling week.www.improvement.nhs.uk
  • 68. Cytology improvement guide - achieving a 14 day turnaround time in cytology 69 22. Leadership, engagement and sustainability What is the definition of sustainability, and These elements are similar and consistent with how do we achieve it? redesign in other clinical services and are not unique to pathology. The work undertaken by the“ Holding the gains, evolving as required, ‘Cancer Services Collaborative Improvement Partnership’ around sustainability of service and definitely not going back to the improvement supports these findings and builds on old way….” the existing body of knowledge about Jean Penny - Human Dimensions of Change sustainability. The presence of certain factors is crucial, not only A sustainability model and toolkit (NHS Institute for to ensure sustainability, but also to foster a culture Innovation and Improvement - 2003) has been of continuous improvement. developed for clinical teams covering similar areas to those identified above. The following were identified by the Pathology Service Improvement Team in 2006 in the Leadership and engagement document ‘Learning from Pathology Service A staff survey was introduced during phase one as Improvement Pilot Sites and Improvement a tool to measure the impact of changes on staff. Examples’. It was communicated as a morale survey and teams asked their staff to complete it on a quarterly basis. Teams were not given any guidance on how to use the survey or the results beyond obtaining a percentage score and, not surprisingly, there was little evidence of any action being taken to address the results. Some sites did not share the results with their team. Staff quickly became disengaged with the survey itself. The key learning point is that this survey should not be used purely as a measure but as a tool to facilitate change through understanding and working to improve staff engagement and developing leadership capability. “What we do Leadership is a behaviour - as leaders is more important than what we say.” Sir Nigel Crisp • Leadership focus and executive support. • Engaged, motivated and empowered staff. • Understand user and patient needs. • Investment in continuous quality improvement. • Value adding processes supporting all pathways. • Data to support and evidence service improvement. www.improvement.nhs.uk
  • 69. 70 Cytology improvement guide - achieving a 14 day turnaround time in cytology What is engagement? Why bother? The aim of the engagement survey (referred to as Recent research (Gallup) reveals that a 10% the morale survey) is to encourage and support a increase in engagement will produce a 6% rise in culture of open and honest feedback which will effort and a 2% rise in performance. When motivate leaders at all levels of the organisation to people feel genuinely able to ‘strongly agree’ with act on results and improve their leadership the questions in the survey they are feeling in a capability. good place and want to stretch to be their best. Efforts to change processes and systems alone will Where staff are saying they ‘strongly agree’, drive improvements but sustainability could be at consider whether they are backing up these risk. Developed leadership capability and answers with comments that explain them. Where improvements in staff engagement will maximise there are no comments it is possible the team are gains, enable sustainability and spread and ticking the boxes that will either ‘protect’ a well facilitate the cultural shift to becoming a liked (but not necessarily effective) manager or are continuous improvement organisation. looking for a ‘quiet life’. Only the manager of the team will know the real situation. The survey has been developed to reflect the work of the Gallup organisation and more can be Spread learned from ‘First, break all the rules’ by Marcus The study of the spread of ideas suggests that it is Buckingham and Curt Coffman (see section 26, relatively rare for ideas to spread instantly. The websites and useful reading). process of adoption and adaptation of ideas often occurs through conversation and interaction There are 12 questions covering: amongst peers. • How staff feel they are treated. • The extent to which they feel able to perform Changes may go through a process of re-invention their role effectively. to fit with organisational systems and procedures • The level of engagement which exists between as they are adopted. the person completing the survey and their leader(s). It is not only about the direct Ideas that spread more rapidly, often: relationship a staff member has with their first • Have qualities that show a clear advantage over line supervisor. the current way of doing things. • Are compatible with current systems and values. The level of performance a manager can expect to • Are straightforward changes with simple get from their team will be dependent on a implementation. number of factors which can be directly influenced • Have an ease of testing before full by that manager. The survey addresses these implementation. factors and will provide managers with a range of • Have easily observable impacts. information about their team that they can explore and should act upon. The purpose of this document is to publish the learning from phase one pilot sites for other teams More detailed preparation support is provided on to adopt. the NHS Improvement website. It recommends sites to visit to discuss improvements made and the benefits and possible pitfalls of adopting the changes.www.improvement.nhs.uk
  • 70. Cytology improvement guide - achieving a 14 day turnaround time in cytology 71Challenges to sustainability – copingwith surgePhase one sites began to evidence improvements intheir turnaround times as a result of changesintroduced within a few months of beginning theirprogrammes.High profile media attention on cervical cancerfollowing the death of Jade Goody resulted in anunprecedented increase in demand across thecytology service. This increase threatened thesuccess of the work being undertaken as somesites questioned the benefit of the time outrequired to continue working with Lean tools.‘Jumpstart’ events were held to refocus teams ontheir end goal and to identify further steps thatcould be taken to either maintain focus or get backon track.Employing the Lean principle of ‘pull’ is ofparticular importance in times of surge. Retainingsamples at the point of receipt and pulling themthrough in accordance with screening capacitymaximises output.Standard work and visual management should beused rather than re-introducing priority workstreams. Exception cases can be identified andprocessed immediately (and not batched) beforeproceeding through the lab on a first in, first outbasis. It is important to identify the point at whichit is no longer necessary to pull these cases out toensure the 14 day TAT is met.The following case studies identify howlaboratories coped with this demand increase.Further case studies can be found on the NHSImprovement website. www.improvement.nhs.uk
  • 71. 72 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 32Sustainability - managing a surge in demandTaunton and Somerset Hospitals NHS TrustSummary • Executive sponsor walks the process How will this improvementIt is possible to achieve the 14 day every month to discuss value stream benefits patientsturnaround time in the face of and address roadblocks or issues. • Delivery of 14 day predictableincreased demand. • CEO visited the department, spent turnaround times, a year ahead of time with staff and worked through schedule.Consistent and unwavering road blocks with significant success. • Elimination of backlog sooner thanmanagement and executive support anticipated, reducing clinical risk ofencouraged the team to maintain the Measurable outcomes and impact adverse outcome.new ways of working. • Capacity and demand data • Improved safety for patients with confirmed it would have taken at the introduction of order comms.Understanding the problem least three weeks longer to eliminate • Improved communication with• 130% increase in demand. the backlog had the team sample takers in primary care• Time from receipt to data entry transferred staff from screening to prompted by this and other increasing and backlog building up. reception/prep work. improvement initiatives.• Rollout of electronic test requesting • Managing the surge in a systematic • Highlight the importance of the (order comms) stalled at fashion allowed the team to screening programme to senior trust implementation stage. proceed with Lean driven changes executives.• Needed a secure server for scanned to laboratory processes. During the request form images. period of the backlo TAT reduced• PC upgrades required for all staff, by a further 1.5 - 3 days within How will this be sustained/ especially screeners. the screening room (dependent on potential for the future/• Printer requirements (purchased but whether the slide was negative on additional learning? not installed). primary screening). Successes achieved evidence the• HR support required for enhanced • After initial discomfort with the strength of the improvement process: and redefined data entry/MLA roles. visual impact of the backlog, staff • The team feel they have achieved a• Needed to establish electronic data morale improved despite the change in culture over the last nine download to one of the result pressure. months. agencies. • Consistent executive support • Produced benefits far beyond those (including a huge cake from their within the screening service as theHow the changes were Chief Executive, Jo Cubbon) was improvement philosophy is rolledimplemented critical to the process and has been out to a broader audience in the• Samples stockpiled at point of greatly appreciated by all staff. trust. receipt. Unpacked and processed in • The electronic test requesting sufficient daily quantities to pull process developed fresh momentum To sustain the cultural changes will work, first in first out (FIFO), through with over 60% of Somerset GP require effort invested in: the screening room. practices operational by the end of • Developing and maintaining• Cases identified as urgent the project. standard work for managers. (colposcopy, or returns having been • The trust PC refresh programme • Ensuring senior executive support sent back due to error detection delivered five new PCs immediately shown within the hospital is also previously) were prioritised and after raising the issue with the CEO, reflected in the other NHS processed the same day, then dealt and a further eight PCs five months organisations involved in this multi- with on a first in, first out basis later. agency service. along with the days routine cases. • A trial of old versus new PCs • Collaborating with non clinical• Sample takers were kept informed demonstrated a saving in time of services, including HR and IT. at all times of the turnaround time 30% for a full primary screen • Sharing learning and expertise with and backlog via the pathology including history check. the new hospital service intranet site. • HR rapidly processed a re-banding improvement team.• CEO and executive sponsor receive exercise for MLA staff. copies of monthly local and national Contact reports which are also brought to Simon Knowles attention of full executive. Email: simon.knowles@nhs.net.ukwww.improvement.nhs.uk
  • 72. Cytology improvement guide - achieving a 14 day turnaround time in cytology 73Case study 33Sticking to Lean principlesAshford and St Peter’s Hospitals NHS TrustSummary management used to show progress • Visual management providing dailyIn the face of an increase in demand and engage the whole team in the figures raised and maintained staffof 80-100%, the team maintained continuous improvement. awareness and engagement.their commitment to changes made • The team were not confident that • Visual management in the form ofand continued to adhere to Lean this approach was important but the yellow stickers with dates on forprinciples. idea was put to the wider staff team ‘abnormal’ results so consultants and the majority thought it would know how long they have to reportThey are now adamant they don’t be a good idea. the result to meet the turnaroundwant to return to the old ways of • White boards now show daily times.working and will carry on pursuing demand and activity and staff are • Going to see the whole patientcontinuous improvement via PDSA more interested in what is pathway and working collaborativelycycles. influencing the results they can with the PCSS to agree the best now see. time to send the result runs.Understanding the problem • Staff are now more interested in the• 80 -100% increase in demand as a project and contribute ideas of their How this improvement benefits result of media attention. own. women• Recognised that to achieve success • Five minute meetings were In July 2009, 100% of women the whole department should be introduced to ensure everyone keeps received their result in 14 days with on-board with the Lean principles. pace with the changes. 60% receiving them in seven days,• A need to focus on eliminating compared to 72.7% of women waste so staff could concentrate on Measureable outcomes and impact receiving there results in 14 days and the value added steps in the The team persevered with the changes 0% in seven days in October 2008. processes. and were back to achieving 90%• When sharing their plan to achieve turnaround time within 14 days by How this improvement benefits 14 days TAT the core team found May 2009. The department were then the organisation that most people thought it would able to screen work for other Being aware of the challenges be a waste of time and would laboratories who were struggling with surrounding change and being willing create extra work. large backlogs. and able to embrace them will support the team desire for continuousHow the changes were Ideas tested which were successful improvement.implemented • Printing Open Exeter for womenThe team decided to implement small with abnormal or early recall history With good communication, listeningchanges in the beginning: only - reducing the waste of paper to each other and continuing to apply• Reducing batch sizes from 20 to 10 and time. the Lean principles, the changes made made a significant difference to TAT • First in - first out in the prep room - will be sustained and developed and improved work flow, with very removed separation of ‘urgent’, further. little effort from the prep room, ‘private’ or colposcopy samples and office and screening staff. added them to the routine batches. Contact• Process sequence charts were used • Using root cause analysis to find the Steve Blackman to identify checks that did not make real problems. Email: Steve.Blackman@asph.nhs.uk a positive contribution to quality. After consulting with the QA department and the cytology team, January/April/June 2009 lab turnaround data comparison unnecessary checks were removed.• Over labelling of slides with patient names was removed.• 5S was used to improve the working Slide numbers environment in the prep room, with visual management photos used to ensure changes are sustained.BUT the team recognised that noteveryone was engaged:• The core team visited another lab to see how they had used the Lean tools. They observed the visual www.improvement.nhs.uk
  • 73. 74 Cytology improvement guide - achieving a 14 day turnaround time in cytology 23. Customer experience A fundamental principle of Lean is to identify ‘value from the customers’ perspective’ and make value flow. In healthcare the customer is usually the patient. In cytology it is the woman. Since the Cervical Screening Programme has a preventative agenda, customer/patient engagement has proved to be the greatest challenge since ‘patients’ are essentially ‘well’ women and a patient questionnaire has not been appropriate. PCTs have adopted different approaches to customer engagement: • Some are currently involved in a social marketing exercise to increase take up of invitations to attend for screening. • Some have increased awareness amongst women of the new guaranteed and predictable turnaround times via newsletters and working with frontline sample taking staff. As turnaround times (TATs) reduce dramatically to less than 14 days, women should be made aware at the time of the appointment of the improved TATs to manage their expectations. Recent experience has demonstrated the receipt of earlier than expected results can cause unnecessary worry and anxiety. Engaging the PCT lead, GPs and sample takers will ensure improvements in the service are communicated effectively to the women.www.improvement.nhs.uk
  • 74. Cytology improvement guide - achieving a 14 day turnaround time in cytology 75Case study 34Colposcopy service improvementsCambridge University Hospitals NHS Foundation Trust, Addenbrookes HospitalSummary The issues: • Lab staff made an assumption aboutThe colposcopy service has improved • Inequality – women with a normal how much information the call/recallthe service and experience it provides result were receiving their results service provided meaning that theto the 1,395 women per year being ahead of those women needing a information included in thereferred, due to improved information colposcopy referral. colposcopy reports was initially notprovision by the laboratory. This • Safety – need to ensure women are suitable for their needs.enables the units to provide optimal seen for investigations appropriate • Daily reports were initially copiedmanagement for each patient in a to their grade of abnormality. and pasted into an email – thistimely fashion, allowing effective • Patient experience – providing a format was not suitable for printingtriaging and counselling. joined up service that recognizes the and use by colposcopy. potential worry and distress • The next step was to print theChanges to the process have saved experienced by a woman being reports before scanning them and2.25 hours per week in the laboratory, advised of an abnormal result. attaching them to an email.(approx 13 days per year). Colposcopy could work with this How the changes were format but the process for creatingUnderstanding the problem implemented it was not ideal ,with the scanningThe process: • Interrogation of the system machine being located on a• The direct referral process to established that the lab could different floor to the senior staff colposcopy (three units) was produce colposcopy lists on a daily member who completed the task. completed on a weekly basis with basis. The scanner was subsequently hard copy lists being sent. • A secure email facility was arranged relocated and the task assigned to• Colposcopy reported the abnormal to send results direct to the the administrative team result to the woman along with an colposcopy units. • Realising that this process was still appointment invite – patients were not ideal, the reporting system was waiting up to two weeks after the Measurable outcomes and impact interrogated further and a way to result was reported by the lab to • Reduced turnaround time – result import and export data into a discover their abnormal result. letters for women referred to suitable format was identified,• Suffolk call/recall changed their colposcopy are now sent out removing the need to print and process to send results letters daily Monday to Thursday. scan. in early 2008 and included writing • Most women now receive their to women with requests to contact colposcopy invitation letter two days How this improvement benefits colposcopy. after the result is reported. women• The colposcopy unit received a • Patient care has improved as The 1,395 women who we refer to call/recall report at the same time colposcopy staff are able to triage colposcopy each year receive their but it contained insufficient the patient and give appropriate results quicker. They also experience information to manage the patient counselling and advice. better care when they contact appropriately when they telephoned • 2.25 hours per week of lab’ staff colposcopy for an appointment and to ask for an appointment. time saved (116.25 hours per year). information about their result.• Staff were not receiving the cytology report until after patients had Ideas tested which were How this improvement benefits telephoned and faced difficulty with unsuccessful the organisation counselling women as they were not • The first step with the daily printed The process continues to evolve with clear on the patients potential reports to colposcopy was to send Cambridgeshire call/recall moving to condition. them via the internal postal system. replicate the Suffolk practice of issuing Reports were delayed and women colposcopy invite/result letters. telephoned the colposcopy units in response to their letters before the Contact unit received their full result report. Claire Geary Email: claire.geary@addenbrookes.nhs.uk www.improvement.nhs.uk
  • 75. 76 Cytology improvement guide - achieving a 14 day turnaround time in cytology 24. Contact details NHS Improvement Team Lesley Wright Director lesley.wright@improvement.nhs.uk Susie Peachey National Improvement Lead susie.peachey@improvement.nhs.uk Lisa Smith National Improvement Lead lisa.smith@improvement.nhs.uk Zoe Smith National Improvement Lead zoe.smith@improvement.nhs.uk Alan Lewitzky National Improvement Lead alan.lewitzky@improvement.nhs.uk Amy Hodgkinson National Improvement Lead amy.hodgkinson@improvement.nhs.uk Peter Gray National Improvement Lead peter.gray@improvement.nhs.uk Suzanne Horobin National Improvement Lead suzanne.horobin@improvement.nhs.uk Senior Analyst TBC Ana DeGouveia Diagnostics Team PA anabela.degouveia@improvement.nhs.uk Telephone: 0116 222 5122 or 0116 222 1423 Maggie Herbert Information & Systems Development Manager support@improvement.nhs.ukwww.improvement.nhs.uk
  • 76. Cytology improvement guide - achieving a 14 day turnaround time in cytology 7725. Websites and useful readingWebsites The Toyota Way Jeffrey LikerNHS Improvement - Diagnostics ISBN: 978-0071392310www.improvement.nhs.uk/diagnostics Explains Toyota’s unique approach to Lean Management – the 14 principles that drive theirCytology Improvement quality and efficiency obsessed culture.www.improvement.nhs.uk/cytology• Cytology improvement guide – Achieving a Creating a Lean Culture 14 day turnaround time in cytology David Mann• Case studies ISBN: 978-1-56327-322-3 Helps Lean leaders succeed in transformation. APathology Improvement critical guide to developing and using a leanwww.improvement.nhs.uk/pathology management system.• Case studies• NHS Improvement Pathology Toolkit The New Lean Toolbox John BichenoImprovement Leaders’ Guides ISBN: 0 954 -1-2441 3NHS Institute for Innovation and Improvement A guide to Lean tools and conceptsSustainability Tool Learning to Seewww.institute.nhs.uk Mike Rother & John Shook ISBN: 0-9667843-0-8NHS Cervical Screening Programme An easy to read practical workbook for creatingwww.cancerscreening.org.uk/cervical a value stream map to evidence waste in a process.Useful reading Managing to LearnA3 Problem Solving for Healthcare John ShookCindy Jimmerson ISBN: 978-1-934109-20-5ISBN 978-1-56327-358-2 How A3 enables an organisation to identify,Demonstrates how to use A3 to problem solve. frame, act and review progress on problems,Contains practical examples from USA projects and proposals.healthcare that can be easily translated to UK. Making Hospitals WorkLean Healthcare – Improving the patient’s Marc Baker and Ian Taylor with Alan Mitchellexperience A Lean action workbook from the LeanDavid Fillingham Enterprise AcademyISBN: 978 -1- 904235-56-9Written by CEO of Bolton NHS Trust as an First break all the rulesaccount of his experience of the long term Marcus Buckingham and Curt Coffmanperspective of using Lean to support whole What the worlds greatest managers dohealthcare. differently.The Gold Mine Value stream mapping for healthcareFreddy and Michael Ballé made easyISBN: 978-0974322568 Cindy JimmersonComprehensively introduces all the lean tools by ISBN: 978-1-4200-7852-7means of a vivid personal story showing how Demonstrates why value stream maps are ahearts and minds are won over. fundamental component in applying Lean. www.improvement.nhs.uk
  • 77. 78 Cytology improvement guide - achieving a 14 day turnaround time in cytologywww.improvement.nhs.uk
  • 78. NHS NHS ImprovementCANCERDIAGNOSTICSHEARTLUNG NHS Improvement With ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, shareSTROKE improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart, lung and stroke services. NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB Telephone: 0116 222 5184 | Fax: 0116 222 5101 www.improvement.nhs.uk Delivering tomorrow’s improvement agenda for the NHS ©NHS Improvement 2009 | All Rights Reserved Publication Ref: IMP/cytology001 - November 2009