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First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience
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First steps in improving phlebotomy: the challenge to improve quality, productivity and patient experience

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First steps in improving phlebotomy: The challenge to improve quality, productivity and patient experience
In Lord Carter’s review of pathology services, the importance of improving access to phlebotomy was referenced. Working in partnership with the Department of Health Pathology Programme, NHS Improvement supported four pilot sites to test whether Lean methodology could meet the challenge of improving the quality, productivity, and patient experience for phlebotomy services (May 2011)

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  • 1. NHSCANCER NHS Improvement DiagnosticsDIAGNOSTICSHEART NHS Improvement - DiagnosticsLUNG First steps in improving phlebotomy: The challenge to improve quality,STROKE productivity and patient experience May 2011
  • 2. “When considering improvement projects andparticularly when seeking to use Lean methodology,it is key that we understand the service from thepatient’s perspective. It is surprising what can beobserved and some simple suggestions forimprovement that can come from theseobservations.Apply the same methodology to as much of theprocesses as is possible, don’t blindly accept that the ”current process is the best way of delivering.
  • 3. 3First steps in improving phlebotomy: The challenge toimprove quality, productivity and patient experienceContentsForeword 4Executive summary 5Why phlebotomy? 6Summary of learning 7Understanding the needs of patients and users 10Telling the patient story 11Our approach: Lean thinking - putting patients first 12Project approach 14Pilot sites 16Case studies 17• Doncaster Royal Infirmary - Outpatient phlebotomy improvements 17• Doncaster Royal Infirmary - Increased phlebotomy productivity 22 on inpatient wards• Whiston Hospital (St Helens & Knowsley) - A&E Department - 25 Reduced turnaround times (TAT), reduced admissions• Whiston Community Clinics (St Helens & Knowsley) - Scheduling and flow 27 of clinic start time• West Middlesex University Hospital - Dedicated ward phlebotomist 29• West Middlesex University Hospital - Phlebotomy column on real-time 31 patient management whiteboard• West Middlesex University Hospital - Early morning bleed 34• Warwick Hospital - Earlier start for bleeding patients 36• Russells Hall Hospital (Dudley) - Faster return of specimens from acute ward 38Contacts 40References 41Useful reading 42Acknowledgements
  • 4. 4 Foreword Foreword Pathology services lie at the heart of healthcare services provided to patients as they are essential to the delivery of 70% of all clinical interventions affecting diagnosis, treatment and long term monitoring of care. The vision for NHS pathology services puts patients first by providing services which are: • clinically excellent • responsive to users • cost effective • integrated. Effective phlebotomy services are the first step to providing quality pathology Dr Ian Barnes tests. Phlebotomy services can be provided by a range of healthcare National Clinical Director for professionals in a wide variety of settings. Wherever they are provided, it is Pathology essential the patients needs are considered to ensure samples are taken as local to the patient as possible, with ease of access, in a timely manner that allows early decision making regarding patient, diagnosis, treatment and monitoring. The pilot sites supported by NHS Improvement have clearly demonstrated that a greater patient focus and improvements in quality of services can be achieved by applying small measurable changes that have significant benefits. I would endorse and commend this document as a first step in improving phlebotomy services. Dr Ian Barnes National Clinical Director for Pathology
  • 5. Executive summary 5Executive summaryIn Lord Carter’s review of pathology Key learning has demonstratedservices, the importance of improving success is achieved through:access to phlebotomy wasreferenced. Working in partnership The power of datawith the Department of Health Understanding current performancePathology Programme, NHS is key and enables services to getImprovement supported four pilot back in control of their performance,sites to test whether Lean however, getting this informationmethodology could meet the can be difficult.challenge of improving the quality,productivity, and patient experience “Getting hold of goodfor phlebotomy services. consistent data has been aMultidisciplinary teams worked challenge”collaboratively to test and implementchanges that deliver improvements Go and seefor patients, staff and users of the “Unless you understand theservice. problem and what it entailsStaff were trained to apply Lean and get all the details, you Staff trained in Leanmethodology to their work, the can’t do anything. Go and methodologyintention being to ensure continuous look for yourself to get the Training and empowering staff to useimprovement beyond the period of information.” tools and techniques to focus onNHS Improvement involvement. seeing and removing the wastes. Make use of tools and techniques to Phlebotomists’ calling throughSome of the improvements focus the service around the patients for bleedingincluded: customer.• 59% reduction in average waiting “Only when we sat in the time for patients attending the waiting room as a patient “Process mapping was a great walk-in phlebotomy clinic did we see that the system tool to make our process• 32% increase in phlebotomy of calling through patients productivity on wards, from 8.85 visible and highlight the to 11.7 patients per hour wasted time, and by wastes. Understanding our• 19% reduction in the turnaround implementing a simple capacity and demand was times for viewing a blood result in change we saved time.” important’’. A&E from time the blood was taken Establishing measurable Next steps• 100% reduction in phlebotomy standards We now recognise this is a vast area service related complaints, with To allow users and providers to of opportunity and further work is positive comments now being deliver integrated clinical pathways ongoing which will be shared in the regularly received to manage effective patient care. future.• 76 % reduction in staff absence• 22% increase in number of patients bled within 15 minutes of arrival due to improved staff scheduling.
  • 6. 6 Why phlebotomy? Why phlebotomy? Each year in England approximately 800 million pathology tests are processed and reported, costing the NHS an estimated £2.5 billion per annum, of these 90% involve the taking of a blood sample. As with many areas of the NHS demand continues to increase and the pressing challenge facing pathology services is how to deliver more for less. This challenge was articulated by Lord Carter in his review of Pathology Services where he concluded 20% or £500 million was the scale of the opportunity. Focussing on: • Improving access to phlebotomy To facilitate the delivery of an efficient and high quality service which is responsive to the needs and wishes of patients, with samples collected at times and in places which are convenient for patients. (Lord Carter Report of the second phase of the independent review of NHS Pathology Services in England). Lord Carter in his review of pathology NHS Improvement was tasked to • Establishing performance recognised that: ‘In this country, it is address some of the issues of standards generally phlebotomists who collect phlebotomy services and in particular: Clear performance standards samples from patients in hospital and for the delivery of the service those attending outpatient clinics”. • Improving access to phlebotomy should be developed, and for With this scale, phlebotomy offered services for patients and clinicians ensuring the effective use of the greatest opportunity to focus on • Improving productivity to provide a the pathology service. a patient facing process, bring issues more cost effective service to the surface, and contribute to • Improving patient experience • Improving quality and safety: significant improvement. • Investigating the impact efficient • Quality of service to the public phlebotomy services can have on • Clinical quality (by reducing the whole patient pathway by: specimen labelling errors) • Admission avoidance • System quality. • Reduced length of stay.
  • 7. Summary of learning 7 Summary of learning What we have learned? ‘Voice of the project leads’ We started out to explore phlebotomy services to understand if improving efficiencies, and access can have an impact on the whole patient pathway, speeding up decisions to treat, avoiding admissions and ultimately speed of discharge and length of stay. So what has been learned? It is challenging Whilst many of the trials, pilots, and improvement suggestions seem simple making them happen is not easy. Common sense it seems is not common practice. Change is never easy and any improvement project will require dedication, focus and clear outcomes to maintain momentum and deliver results, issues which are compounded when staff on pilot sites tried to drive improvement projects as well as doing the day job.“ Allocating time and fitting it around the day job has been really difficult.” Without national targets and goals ensuring staffing levels are means that performance data outside appropriate to meet anticipated The power of data of A&E is rarely collected and demands; Delivering a predictable Understanding current performance analysed. Simply understanding daily service to patients whilst resources is key and enables services to get and hourly demand allows staff to be are used efficiently. back in control of their performance, in better control of the service, however getting this information can be difficult. “ Rota management and staff capacity has improved as a result“ Getting hold of good of understanding the data. Waiting times were on the increase consistent data has been a and seeing where additional hours and staff were needed has challenge.” helped improve things.”
  • 8. 8 Summary of learning Go and see Establish measurable standards - “On the wards they have Make them visible much bigger issues like bed “Unless you understand the Base lining the phlebotomy service highlighted the lack of clear management and IT problem and what it entails measurable standards that were systems.” and get all the details, you visible to staff and users. Establish can’t do anything. Go and clear measurable standards in Common themes look for yourself to get the conjunction with users to ensure that While there were a number of the service is focused on patients’ improvement suggestions trialled information.’’ needs and best outcomes. If there is with varying degrees of success there some measure of good performance appear to be some common themes “Encourage staff to view the this seems to add clarity and focus to and learning. service from the patients what everyone is trying to achieve. Manage with data perspective. Asking the staff In Doncaster, a maximum 30 minute Collect and understand data, use it to to sit and watch helped them wait time standard was set. design the service. Manage the flow to identify the key wastes.’’ by reducing peaks and troughs and “Staff focused on the 30 keep the service as efficient as “ When considering minute standard and this has possible. Share performance data with staff and users. Establish improvement projects and been really successful.” dashboards to display metrics and particularly when seeking to empower staff to fix problems daily. use Lean methodology it is Phlebotomy in isolation? The feedback from pilot sites was Staff trained to apply Lean tools key that we understand the that while there were key areas of Train and empower staff to use tools service from the patient’s focus that delivered tangible benefits and techniques to focus on seeing perspective. It is surprising phlebotomy in isolation cannot and removing the wastes. Make use what can be observed and deliver the significant benefits to of tools and techniques to focus the discharge and other hospital service around the patient needs. some simple suggestions for processes. When asked at the start of improvement that can come the process whether phlebotomy was Communication from these observations. an issue many replied it was, but Most of the sites piloted ideas to once improvements were made it Apply the same methodology improve communication between became clear that issues with other phlebotomists and ward staff to as much of the processes diagnostic pathways, bed providing a range of benefits. as is possible, don’t blindly management, discharge letters and Phoning ahead to manage demand accept that the current pharmacy required improvement. gave phlebotomists the chance to process is the best way of know what level of work was waiting Fixing phlebotomy in isolation does on the wards and respond. Simple delivering.’’ not have a profound effect on the visual flags to indicate when whole patient pathway, but the phlebotomists were on the ward, benefits are still significant to the indicating when patients had been patient, and can deliver efficiencies. bled so doctors did not have to waste time checking.
  • 9. Summary of learning 9Common wastesSignificant efficiencies were foundacross the sites by simply focusing oncommon wastes identified throughprocess mapping and observing theprocess. Reduce walking by havingphlebotomy trolleys stocked on theward, to an agreed standard.Dedicated phlebotomistsHaving phlebotomists dedicated towards and outpatients across anumber of sites increasedproductivity as measured by bleedsper hour. It appears that this is theresult of better working betweenward and phlebotomy staff,increased communication, andphlebotomists starting to buildrelationships with patients on theward. Recognising the need forblood samples to be taken as soon asthe decision is made for the test willrequire non phlebotomy staff toprovide this service out of core hours.Delivering samples to thelaboratoryUnderstand when ward rounds takeplace. Ensure that blood results areavailable for rounds by bleedingpatients earlier in the morning.Employ Porters or volunteers tocollect and deliver samples little andoften to the laboratory. Utilise airtube systems where available.
  • 10. 10 Understanding the needs of patients and users Understanding the needs of patients and users The importance of patient feedback A number of websites exist where patients are encouraged to provide feedback on their experience. One example is www.patientopinion.org.uk The first challenge – Have you looked at the feedback about your organisation on this website? The second challenge - Who is responsible for providing feedback to comments made about your organisation? “ The doctor saw her on Friday morning and said she could go home but the nurse pointed out that there were some blood test results that were still to arrive and he then agreed to “ Waiting for results seemed to be a ” keep her in hospital until Monday. delaying factor - I felt Patient relative that more rapid results could have “ saved some of my bed ” occupation time. My partner was waiting in A&E (after triage) Patient for two hours while blood tests could have been run - eventually when blood was taken she had to wait another two hours ” for results. Patient relative
  • 11. Telling the patient story 11Telling the patient storyBefore embarking on wholesalechanges to phlebotomy services it is Time from arrival in department to result viewedimportant to understand and definevalue from the patients’ perspective. Long delays from request to bleed Long delays from resultThis is central to understanding what (ownership, capacity, productivity) available to result viewedis important to patients and clinicians 4 Hour A&E Target or acted uponand provided areas to focus theimprovement. This took the form ofdata analysis, stakeholder and staff 50 mins 28 mins 47 mins 1 hour 20 minsfeedback, and patient experience.The end-to-end pathway providedevidence of the improvementsalready made in laboratory processes,and focussed on the potential forimprovement in other parts of the 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0pathwayOften we only look at the laboratory, Arrival to collection Collection to bookedbut it is in the whole pathway where Booked to reported Reported to viewedthe big wins appear to be.The Emergency Care Pathway:Whiston HospitalThere were perceived delays in thelaboratory that were causing patients PATIENT STORYto breach the A&E four hour target.As a result of working with the The inpatient pathwayEmergency department team we The following is a patient story of how poor processes can have ahave been able to identify the dramatic effect on the patient:complete blood pathway and haveengaged with key staff from the • Specimen taken 7.30 a.m. (for Gentamicin levels) - phlebotomist notedEmergency department. ‘patient very collapsed and not enough blood to do U&E, Full Blood Count and Gentamicin’ • Sample arrived in the laboratory 8.30 a.m. • Local lab analyser has been defective for the last 14 months (policy is all microbiology samples are analysed at hospital 10 miles away) • Lab staff spent two hours trying to contact the Senior House Officer (SHO) to ascertain which test was more important the U&E or the Gentamicin? • Sample put on first transport to external lab at 10.30 a.m. • Result back on ICE (I.T. System) at 11.45 p.m. • SHO contacted at 1.46 a.m. regarding result • Phlebotomist didn’t realise the significance of not being able to get blood out for this patient at 7:30 a.m. (i.e. collapsed from septic shock?) • Nurses left in a quandary as to whether to give the three more doses of Gentamicin due at 8.00 a.m. 4.00 p.m. and midnight.
  • 12. 12 Our approach: Lean thinking - putting patients first Our approach: Lean thinking - putting patients first “ Too often, patients are expected to fit around ” services, rather than services around patients. Liberating the NHS – Department of Health White Paper (December 2010) At the heart of Lean thinking are customers, our patients, and seeking to understand what parts of our processes they believe are valuable. In our experience with or as patients we “ Lean thinking is a way of streamlining the patient journey and making it safer, by helping staff to eliminate all kinds of waste and to treat ” may all agree that of value is safe, timely, high quality care. Very few of more patients with existing resources. us would consider waiting, queuing, endless paperwork, or mistakes to be Jones, www.leanuk.org a valuable part of any service we would be prepared to pay for. The Benefits of Lean The key to lean improvement is: “ Any process or value stream Improved customer satisfaction Go see, ask why, and Lead Time / Cycle Time • Reduced waiting understand the root • Better delivery Before • More capacity cause of the problem • Better quality ” • Improved productivity you are solving. • Improved safety After David Fillingham, Lean Healthcare Lean attacks waste here Work ... value added time Wait/waste ... non value added time Reduced waste, improved customer experience
  • 13. Our approach: Lean thinking - putting patients first 13Continuous improvement in Leanmethodology focuses on five key steps1. Specify value - The elimination ofwaste is the main characteristic of Specify VALUE fromLean. Waste is everything that the customer viewpointdoesn’t add value to the patient orprocess. There are three types ofwork: Pursue PERFECTION in Identify the• Value add – When you are adding VALUE STREAM quality and value to the patient/process (e.g. quantity by and remove prescribing medication, providing continuous Introduce Standard Working waste physiotherapy, reporting an image) improvement Remove Waste Set Up Visual Management• Necessary waste – When you are Eliminate Batching not adding value but it is a Identify Root Cause necessary step. (e.g. incubation in a microbiology laboratory)• Unnecessary waste – Where you are not adding value and these steps could be removed (e.g. walking to get or find items, initiate PULL in line Make value with customer demand FLOW waiting for staff, machines and medication).The wastes can be remembered bythe name TIM A WOODS (Leanoffice at Cooper Standard, 2. Identify the value stream steps 5. Continually improve and strivePlymouth UK) - A current state value stream map is for perfection - Continuous a visual representation of all the improvement is the final lean actions currently required to deliver a principle, which is to strive for T TRANSPORT product or a service. perfection through continuous I INVENTORY improvement. It is important to 3. Make value flow - Flow is the develop staff and give them theM MOTION continual movement of value adding capability, autonomy and activities from the beginning to the empowerment to solve the problems end of the value stream. Processes as they encounter them on a daily A AUTOMATING which add value to the patient basis. (an inefficient process) should not be held up by any nonW WAITING value adding steps or waste in the “More often than not the system. O OVER PROCESSING process is to blame not the 4. Pull value through the process people. To improve the O OVER PRODUCTION from actual demand - Flow and pull process do so by striving for D DEFECTS work to keep the entire value stream ‘clinical excellence in moving. “Flow where you can, pull partnership with process S SKILLS UTILISATION where you must” Jeffery K. Liker, The Toyota Way, 2004 excellence’.”Reference: ‘Bringing Lean to Life’, Continuous improvement inNHS Improvement Cytology, NHS Improvement
  • 14. 14 Project approach Project approach The experience from previous learning has demonstrated that the Factors for achieving sustainable improvements factors in the graphic on the right are vital to achieving sustainable improvement. Understand the current process In healthcare, we are used to taking clinical measures such as temperature, pulse, blood pressure, respiration rates, urine outputs etc in order to understand the current status and demonstrate if conditions are getting better or worse. Project timeline Identify Evaluate Data Pilot the and analysis solutions wastes sustain To improve your current process, data is required to understand the root cause of the problem you are trying to address, a set of measures need to be agreed. It isn’t always easy to collect data for Map the process Measures might include: this baseline. If you can’t get the A critical starting point in any • Quality – End to end information from the electronic problem solving or improvement turnaround times systems, you will need to collect the work is to map the process in its • Cost – Improve productivity information manually. current state. One of the tools used • Morale – reduce staff time doing to capture the current state or ‘as is’ wasteful activities Data and measures are also performance is the value stream map • Patient experience – reduction in important to demonstrate and prove (VSM). waiting times. that change has occurred, and what difference this makes for all those Current State VSM involved in the process including A current state value stream map is a patients and staff. Whether the visual representation of all the actions change was a success or a failure, currently required to deliver a product you still need to demonstrate it! or a service. The output however is more than just the current state, you
  • 15. Project approach 15also look to map where the value inthe process happens, and where PDSA cycle for learning and improvementwaste in the process is. This thenguides group discussions andproblem solving to produce tangiblesolutions and ideas to reduce thewaste and increase the value in the ACT PLAN What changes Objectiveprocess. Remember as defined earlier are to be made? Questions and Next cycle predictions (why)in this booklet value can only be Plan to carry out thedefined by the end customer. In cycle (who, what, where and when)healthcare the customer is usually thepatient. Value is any activity that STUDY DOdirectly contributes to satisfying Complete the Carry out the plan analysis of the data Document problemsneeds of the patient. Any activity that Compare data to and unexpected predictions observationsdoesn’t add value is defined as Summarise what Begin analysiswaste. was learned of the dataFuture State VSMOnce you understand the currentpicture of what really happensthroughout the value stream, you canbegin to agree what needs to happenand then analyse the gap betweenthe current and future states. From Once suggestions for improvement the only sustainable way to strive foryour current state map you will be have been tested on a smaller scale perfection.able to identify where the significant and demonstrated they work, onlyproblems occur. This might be the then can we we roll out those Areas to focus onmost prevalent waits and delays, the changes across the whole service. Having defined patients’ value, thelargest amount of work in progress This will require planning, mapping, waste identification andbetween process steps or where consideration for potential obstacles, staff discussion began to focus onthere is considerable duplication. and a plan to manage those changes. key areas and potential forOnce the future state Value Stream However, changes are made in the improvement:Map is completed, it is then essential knowledge that they have beento review measures, analyse the gap piloted, have demonstrated their • Understand the end to endbetween current and future state success and how they improve the pathway – don’t assume the faultand then agree an action plan to trial process. lies with the laboratorythe changes. • Capacity and demand – Continuous improvement understand daily/hourly demandTake action and pilot solutions Continuous improvement is the final and capacityTake action, pilot suggestions for Lean principle, which is to strive for • Use visual management toimprovement, measure the effect and perfection by embracing the Lean demonstrate performancecontinue to improve until you have a philosophy and tools. The staff are a • Engagement with clinical teamsworkable solution to reduce waste. fundamental part of Lean. It is • Productivity – How to improve theEven small scale pilots can provide important to develop staff and give number of patients bled per hourenough data and feedback to them the capability, autonomy and • Use the evidence to design theestablish if the solution delivers empowerment to solve the problems service.benefits and increases value, before as they encounter them on a dailyrolling out large service wide changes basis. Teaching and expectingthat are untested. rigorous problem solving by all staff is
  • 16. 16 The pilot sites The pilot sites NHS Improvement worked with West Middlesex University the following pilot sites: Hospital NHS Trust The West Middlesex University Doncaster and Bassetlaw Hospital is a busy urban acute Hospitals NHS Foundation Trust hospital located in Isleworth, West (Doncaster Royal Infirmary) London providing services primarily to Doncaster Royal Infirmary is one of residents of the London Boroughs of the key hospitals in the Doncaster Hounslow and Richmond upon and Bassetlaw Hospitals NHS Thames. Employing some 2,250 Foundation Trust. The hospital people (including our partners in provides a full range of services Ecovert FM), the hospital has over appropriate to a large district general 400 beds. The Trust has an annual hospital in 800 beds. Each year the budget in excess of £130 million and hospital treats around 150,000 provides services to a population of patients along with 95,500 A&E around 400,000. patients (combined figures for Doncaster Royal Infirmary and The Dudley Group of Hospitals Montagu Hospital). NHS Foundation Trust (Russell’s Hall Hospital) St Helens and Knowsley Teaching Russell’s Hall Hospital is the largest of Hospitals NHS Trust (Whiston three hospitals in The Dudley Group Hospital) of Hospitals providing the full range Whiston Hospital is one of two of surgical and medical specialties for Merseyside hospitals (along with St its inpatient services, together with Helens Hospital) managed and run by some outpatient and therapy services St Helens & Knowsley Teaching with over 750 beds. Hospitals NHS Trust. The new hospital offers the full range of acute South Warwickshire NHS healthcare services along with Foundation Trust (Warwick specialist burns care through the Hospital) Mersey Regional Burns and Plastic While working with our pilot sites, Surgery Unit. It has 15 operating NHS Improvement had an theatres, diagnostic facilities, and opportunity to link with South over 800 beds. Warwickshire NHS Foundation Trust who are taking part in a flow cost and quality programme with the Health Foundation.
  • 17. 17 ONE.CASE STUDYDoncaster Royal InfirmaryOutpatient phlebotomy improvementsSummary How the changes were59% reduction in average waiting implementedtime for patients attending the walk-in phlebotomy clinic at Doncaster • Numerous formal and informalRoyal Infirmary (DRI) meetings and discussions with the phlebotomy team to agreeUnderstanding the problem changes.Patients attending the phlebotomy • The walk-in clinic relocated to thewalk-in service at DRI often had to main out-patient area.wait over an hour to have their • A patient queue managementblood taken. Regularly it was system was installed. This systemstanding room only in the waiting enables each phlebotomist to callarea, staff morale was low and staff the next patient through to theirabsence was high. The long waiting cubicle as soon as they are ready,times for phlebotomy led to knock- using a small keypad. The patientson problems in outpatient clinics, see a number display and hear anleading to complaints from clinicians audible announcement in theand patients. A high number of A receptionist recorded the waiting waiting area. The keypad informsprimary care patients also attended time for phlebotomy on the hour, the phlebotomist how long thethe walk-in service and were equally every hour over many months. patient has waited to be called,dissatisfied with waiting times. and how many people are in the Staff issued a questionnaire to all queue.The phlebotomy area was co-located patients attending the walk-in clinic • A dashboard was developed,with the pathology laboratory so all throughout the week of 23-27 utilising the output data from theoutpatients had to travel round the November 2009, to provide patient queue managementhospital site to have their blood feedback on why they had chosen to system. The team print thetaken. Patients reported to a attend DRI for phlebotomy and to dashboard to create a very visiblereceptionist as they arrived, who gain information about how long display of daily, weekly andchecked their identification and they had to wait. monthly performance.placed their request form in a box in • Demand information wasorder of arrival. As each Phlebotomists sat in the patient requested from every inpatientphlebotomist became free, they took waiting area and observed the ward each morning before thethe next request form from the box, process from the patients’ point of phlebotomy round started to assistwalked out into the waiting area, view. Phlebotomists timed each overall rota management.called the patient by name and stage of the process and then • The staff rota was co-coordinatedwaited for the patient to respond agreed which steps were value across inpatient services and theand return to the blood taking area creating and which were ‘waste’. walk-in clinic to match capacity towith them. demand as closely as possible, with a number of changes being made over time.
  • 18. 18 Measurable outcomes and impact Reduction in average waiting time • 59% improvement in average 25 waiting time. Pre improvement Post improvement • Average waiting time improved Average waiting time (inpatients) from 18.6 to 7.6 minutes. 20 • 53% improvement in maximum Average waiting time waiting time 15 • Maximum waiting time reduced from 87 to 41 minutes (averages per month) 10 • Reductions in average and maximum waiting times achieved despite increasing demand, and 5 with no increase in staff numbers. • 12,699 hours of waiting time 0 saved since improvement work Aug Sep Oct Nov Dec Jan Feb Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 11 11 (approx. 1,154 less waiting hours Month per month). • Feedback has been hugely positive, transforming 10 written complaints in 2009/10 to 21 written compliments in 2010/11 Reduction in maximum waiting time along with hundreds of verbal 140 compliments. Pre improvement Post improvement Maximum waiting time (inpatients) 120 The following quotations are taken from some of the written 100 compliments received: Maximum waiting time 80 “I have been attending 60 phlebotomy for 12 years as a patient of Dr M. Since your 40 reorganisation in the last few 20 months, the reduction in waiting time is both 0 Aug Sep Oct Nov Dec Jan Feb Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb significant and welcome. 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 11 11 Month Well done in improving so much the patient experience" “ This is so much better than before, in and out, clean area and friendly staff”
  • 19. 19 • Feedback from clinicians has beenReduction in waiting time while activity increases equally positive, with many 140 8,000 consultants contacting Pre improvement Post improvement phlebotomy staff to inform them 120 7,000 how pleased they are that their patients are being seen quickly. Waiting time (inpatients) 6,000 100 • No issue with seating in the 5,000 waiting area as the queue does 80 not build up. 4,000 • Most outpatients do not have to 60 3,000 travel round the hospital corridors to have their blood taken, as 40 2,000 phlebotomy is now co-located in 20 the main outpatient area. In 1,000 addition, the free park and ride 0 0 bus stops just outside the Aug Sep Oct Nov Dec Jan Feb Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb 09 09 09 09 09 10 10 10 10 10 10 10 10 10 10 10 11 11 phlebotomy and outpatient Month waiting area. Maximum waiting time Average waiting time Attendees • Staff morale has improved significantly. The phlebotomy team meets regularly in work hours. Communication foldersStaff absence - Phlebotomy (DRI) and notice boards have been introduced and most staff 10 participate in social functions Pre improvement Post improvement 9 outside work: 8 • Since the improvement work Phlebotomy commenced, staff absence has Percentage absence 7 reduced from 6.6% to 1.6% 6 over the last twelve months. 5 • 926 more staff hours at work that were previously absent in a 4 year. 3 2 1 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 09 09 09 09 09 09 09 09 Dec 10 10 10 10 10 10 10 10 10 10 10 10 11 11 11 Month
  • 20. 20 Ideas tested which were Daily dashboard example successful • Installing patient queue management system: • Removing waste (phlebotomist no longer going into waiting area to call patient). • Phlebotomist able to see waiting time of current patient and number of patients in queue on keypad. • Dashboard displays created using data from system – to make performance very visible. Daily, weekly and monthly dashboards are used (see examples on the right). • Data from system used to match staff rotas (capacity) to demand as closely as possible. • Reducing phlebotomy hours on inpatient wards and moving them to walk-in clinic. • Relocating to main outpatient area. How this improvement benefits patients • Significant reduction in waiting time for patients. • On average every patient waits only 7.6 minutes, rather than 18.6. • Visual and audible display in waiting area, so improvement for patients with hearing difficulties. • Outpatient clinics not held up by patients queuing to have blood taken.
  • 21. 21 How will this be sustained,Monthly dashboard example potential for the future and additional learning • Ongoing use of data by management team and phlebotomists. • Visible displays of performance to staff and patients. • Roll-out of patient queue management system, staff processes and rotas to Bassetlaw hospital walk-in clinic (positive patient feedback and evidence of waiting time improvements used to achieve business case approval). • Fine-tuning of staff rotas in line with demand. • Data used to support recruitment as activity increases (evidence for funding application). Contact Sarah Bayliss Email: sarah.bayliss@dbh.nhs.uk
  • 22. 22 TWO. CASE STUDY Doncaster Royal Infirmary Increased phlebotomy productivity on inpatient wards Summary 32% increase in phlebotomy productivity on wards, from 8.85 to 11.7 patients per hour. Understanding the problem • Phlebotomists were frequently reaching the end of their shift, running out of time, and leaving some inpatient wards without a phlebotomy service. Different phlebotomists went to each ward each day, working in pairs, and there was little or no teamwork between phlebotomists and ward staff. • The phlebotomists were unable to bleed some patients. A team of phlebotomists and ward • Separate ward and walk-in clinic • The ward phlebotomists would staff undertook a process mapping phlebotomy teams were collect together to get specimens exercise. Phlebotomists timed each established. ready for transport to the stage of the process and the team • Only one phlebotomist goes to laboratory, have a break, and then agreed which steps were value each ward instead of working in would phone the manager to creating and which were ‘waste’. pairs, so they are on the ward for inform her how many patients had Changes were agreed and longer; therefore, there is a greater not yet been bled. implemented to reduce ‘waste’ and opportunity for the doctor to place • Staff morale was low and absence thereby increase value as a additional requests. levels were high. percentage of the total service time. • ‘Phlebotomist on the ward’ • Feedback from wards was poor. magnets are displayed on the How the changes were ward ‘status at a glance’ boards to Ward 26 (a respiratory medical ward) implemented indicate their presence. agreed to work with the phlebotomy • Suggestions from staff from team to improve the service. process mapping session and other meetings. Phlebotomy representatives observed • Demand information was what was happening on ward 26, requested from every inpatient then met with a team of staff from ward each morning before the ward 26, listened to their views of phlebotomy round started. the phlebotomy service and • The staff rota was coordinated ascertained what changes they across inpatient services and the would like. The phlebotomists then walk-in clinic to match capacity to shared this information with their demand as closely as possible, colleagues. with a number of changes being made over time. • Every ward was asked to indicate their ideal time for the phlebotomy round.
  • 23. 23• Same phlebotomist on each ward each day, so soon built rapport Staff absence - Phlebotomy (DRI) with ward team. Also got to 10 know ‘their’ patients, so fewer Pre improvement Post improvement 9 unable to bleed events.• Ward phlebotomy trolleys were 8 Phlebotomy Percentage absence established, rather than 7 phlebotomist having to transfer a 6 trolley between wards (reduce time waiting for lifts, and improve 5 infection control) and a standard 4 layout agreed for each trolley. 3• Pilot on ward 26 to test out changes. 2• Discussion at matron’s meetings to 1 agree roll-out across all wards. 0• Proposed trolley changes Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 09 09 09 09 09 09 09 09 Dec 10 10 10 10 10 10 10 10 10 10 10 10 11 11 11 coordinated as part of electronic Month requesting and reporting system.Measurable outcomesand impact• 32% improvement in Ideas tested which were • Use of ward-based trolley for productivity on inpatient wards. successful phlebotomy, rather than taking a• 33% reduction in phlebotomy • Establishing a ward-based trolley from phlebotomy round staff hours on inpatient wards, phlebotomy team. every ward. yet wards no longer left without a • Named phlebotomist per ward. • Standard layout for every trolley service. • Only having one phlebotomist to agreed and implemented.• Positive feedback from ward staff service each ward, so they are on and phlebotomists. the ward for a longer period. How this improvement• Reduction in number of ‘unable to • Displaying ‘phlebotomist on ward’ benefits patients bleeds’. magnets. • Happier staff.• Staff morale has improved • Delaying coffee breaks until ward • Phlebotomist gets to know the significantly and phlebotomist work is completed. patients on their wards, which: absence has reduced from 6.6% • Reducing phlebotomy hours on • increases their success rate at to 1.6%. The phlebotomy team inpatient wards and moving them obtaining high quality blood meets regularly in work hours. to walk-in clinics (matching samples. Communication folders and notice capacity to demand). • means they can spot when a boards have been introduced and • Changing the order in which request form is missing. most staff also participate in social phlebotomists attend each ward to • builds rapport with the patient functions outside work. align the service with ward and helps to put them at ease.• 926 more staff hours at work that rounds. • Enables blood to be taken as soon were previously absent in a year. • Varying how specimens are as possible after the clinician transported to the laboratory to requests it, and transported to the ensure they are processed as soon laboratory for analysis, thereby as possible. supporting timely treatment or discharge of patients.
  • 24. 24 How will this be sustained, potential for the future and additional learning • Ideas piloted on ward 26 have been rolled out to other wards following discussion at matrons’ meetings. • Use of ward-based phlebotomy trolley to be rolled out as part of the electronic requesting and reporting system implementation (a ‘clinical cart’ is being developed that will combine provision of IT hardware and software with the facility to transport phlebotomy and other clinical consumables). • Ongoing use of data by management team and phlebotomists. Contact Sarah Bayliss Email: sarah.bayliss@dbh.nhs.uk
  • 25. 25 THREE.CASE STUDYWhiston Hospital (St Helens & Knowsley) - A&E DepartmentReduced turnaround times (TAT) andreduced admissionsBackgroundWhiston Hospital is a new PFI which Whiston A&E blood pathwayopened in March 2010, with 900 3.50beds, approximately 250 A&E 19% reduction overallpatients attending per day, 3.21 3.25pathology had approximately 100 June Octoberpatient bloods per day. The location 2..53 Turnaround Timesof this unit was approximately 100 2.44 2.24meters away from the existingpathology service. National target 1.55 POD reliability improved Raised awareness in AEDfour hour wait – impact on moving Porter collects sample Coordinator roles when POD down stablishedpatients / admissions high – charges 1.26 Phlebotomist 1.20to PCT, how could this be challenged trialled in AED 0.57(see EAU on the following page). 0.50 0.52 0.47 0.47 0.40 0.28 0.28Summary 0.25 0As a result of working with the Arrival in AED Collected to boked Booked in lab to Results available TotalEmergency department team we to sample collected in lab system results available to results viewedhave been able to identify the end-to-end blood pathway and haveengaged with key staff from theEmergency department. A measure Understanding the problem • Patient blood samples areof the end-to-end blood pathway To understand and measure the booked in to the pathologywas undertaken, and a process performance of the blood pathway computer - Receivedmapping day held to map the within our Emergency services • The pathology process ispatient’s journey. This process department. To investigate the completed (i.e. Emergencyproduced an action plan and impact the blood pathway has on department staff are able tomeetings were then held every two hospital admissions. view results) - Authorisedweeks to monitor the introduction of • Results are viewed in thethe changes. This engagement with our Emergency department - emergency department identified a Viewed.The process showed an overall possible link between the blood • Hospital admissions (expressed asreduction in the blood pathway of pathway and admissions to the a percentage).19%. Trust. We were confident that the existing blood pathway could be Data was extracted electronically improved and wanted to use the from both the emergency hospital admissions data as an department system and the indicator / measure of this pathology computer. Some manual improvement. data extraction was also carried particularly for results viewed. Time Data collection for this area falls collected was only provided on under the following headings: approximately 40% of requests. • Emergency blood pathway Completed data sets were processed • Patient arrival time in the and the outcomes discussed to emergency department - improve the level of understanding Arrived at the appropriate workstream • Patient has blood collected - meetings. Transport
  • 26. 26 Outcomes All relevant departments were Reasons for admission engaged in the process mapping 100 event. Actions were captured in a 90 plan; this was then delivered over 91 several weeks with varying success. 80 70 Number admitted The following changes were made: 60 • Take blood samples earlier in the patients journey. 50 • Transport changes 40 • Trust air tube system – Improve 30 • Improve air tube failure reporting process 20 21 19 • Improve access to porters 10 14 when/if air tube fails. 8 4 2 0 • Action pathology blood results Awaiting Extended Waiting for Waiting for Waiting for Waiting for Other Bed Clinical Blood Transport Specialist Imaging earlier by viewing using patient Pathway Results Opinion (eg Troponin) (eg Orthopaedics) enquiry or scrolling screens. Reasons for Admission • Improve team work between Trust phlebotomy team and emergency assistants, this resulted in improved coverage of previously un-staffed sessions. Emergency Admissions Challenges • Re-launch clinical nursing lead for Unit (EAU) • Consistent engagement over time. every shift to provide support and This 16 bed unit accepts patients for • Data quality and understanding of standard working. a whole variety of reasons / the impact. • Frequent meetings to discuss and conditions. We decided to look in • Extraction of data, time sustain improvements / introduce detail at four days over a period of consuming and therefore this had new changes. two weeks. To gather information to be limited. we used the EAU ward admissions • Introduction of changes /timescale. Following on from the action plan it register and the trust Electronic • Multi team working, efforts being was clear that we needed to identify Document Management System made to co-ordinate the different those patients that had been (EDMS) for all patients admitted over teams. admitted to hospital due to a delay the period. See results above. • Changes to targets. in the blood pathway. After • PCT structure /changes. discussions with the medical The outcome of this work was admissions unit ward manger we felt shared with the Emergency Contact it was best to concentrate on a unit department mangers that used this Chris Westcott called the emergency admissions and other data to introduce planned Email: chris.westcott@sthk.nhs.uk unit. pathways for specific conditions. This work is ongoing and therefore the outcome can not be fully assessed at this stage. It is felt however that it will have an impact on the hospital admission rate.
  • 27. 27 FOUR.CASE STUDYWhiston Community Clinics (St Helens & Knowsley)Scheduling and flow of start timeAlong with other national sites we • The data showed the distance We undertook reviews of severalset out to answer the following patients travelled was not phlebotomy areas, one of thesequestions: excessive, so choice was areas had recently been handed over acceptable – No action taken. to our team and we had changed• Are patients waiting excessive days • The demand on occasions did the service significantly but some before having blood taken? exceed capacity but this was felt issues remained. This service was• Are patients waiting for long to be limited, this area needs to be based in a new PFI PCT build called periods when they arrive at a reviewed on a regular basis as the Newton Community Hospital. The phlebotomy session? percentage increase in workload phlebotomy service was an on• Are patients travelling excessively changes. demand service. All patients were to have blood taken? handed a number on arrival by the• How is the capacity in relation to This years increase for primary care PCT receptionist, and once our limit the demand? will see a further 28,000 (M11 had been reached for that session all forecast) patients being bled other patients were then turnedUnderstanding the problem compared to the previous 12 months away.Our initial plan was to concentrate of April 09 – March 10. This equateson primary care based staff and then to another 1.65 WTE phlebotomy With demand and service provisionincorporate any transferable hours required to deliver this offset, the majority of patientsimprovements/changes to our additional capacity - Action taken, waited at least half an hour or moresecondary care based team. As we have increased our service by to be bled:there was no data available with three additional community sites allregards to accessing phlebotomy we at the request of the PCT’s, lessons • 50% of patients waited up tocollected data to form a baseline and learnt have been used at these new half an hour to be bled.enable us to understand the process. sites • 80% of patients were seen in 50All the data needed to be collected minutes from arrival.manually. On analysing this data itwas felt that there were long waitingtimes for patients to be able to gainaccess to phlebotomy clinics and Percentage time to be seen from arrivalthen each patient would haveencountered long waits in various 100settings for their blood to be taken. 90 80• The data showed that the community clinic we had chosen 70 showed delays from the request Percentage 60 being made to the patient arriving 50 to have blood taken but that these were predominately due to patient 40 choice – No action taken. 30• The data showed patients who 20 had arrived at a community 10 phlebotomy session were waiting an excessive amount of time 0 0 to 5 11 to 15 21 to 25 31 to 35 41 to 45 51 to 55 61 to 65 71 to 75 before they had their blood taken mins 6 to 10 mins mins 16 to 20 mins 26 to 30 mins 36 to 40 mins 46 to 50 mins 56 to 60 mins 66 to 70 mins mins mins mins mins mins mins – Main focus for action. Time from arrival
  • 28. 28 Our team decided to drill down our data and improve the phlebotomy Percentage bled service at our chosen clinic; we looked at all the factors below: 80 70 71.9% • Capacity and demand. January 2010 October 2010 60 • Service delivery - start time. • Patient flow. 50 Percentage 50.3% • Staff moral / patient experience. 40 40.7% 30 All of the baseline data required 20 could be easily accessed with the 18.8% exception of staff moral / patient 10 experience. This was collected by 0 improving staff feedback with senior % in 15 minutes % in 30 minutes members of staff and monitoring patient complaints from this clinic. By starting the service 30 minutes earlier the phlebotomist was able to Results The PCT staff within the clinic are reduce the number of patients January 10 happier as fewer patients are waiting more than 30 minutes • 50% patients bled within 30 complaining, our phlebotomy staff significantly. We also provide minutes are happier and are returning to the additional phlebotomy resource on a October 10 main St Helens Hospital base earlier, Tuesday. We are reviewing the • 72% patients bled within 30 this helps productivity at this site and requirement for an afternoon minutes. also staff morale as they are session; however this will depend on supporting their colleagues at St future workload and demand. January 10 Helens Hospital over lunch times. • 19% patients bled within 15 From November 2009 – October minutes. Blood samples are returning to the 2010 we received eight complaints, October 10 laboratory earlier therefore most of these were in relation to • 41% patients bled within 15 turnaround times (TAT) and patient flow and excessive waiting minutes. reporting to the GP will be times. A few of these were centered improved, with the number reported on patients being asked to return to Overall average time to be bled has on the same day being higher than the clinic another day due to the fallen from 33 minutes in January previous. capacity being exceeded. The 2010 to 23 minutes in October number of patients bled per three 2010. Contact hour session on average is 45. The Chris Westcott data showed that within the first 250 patients are bled per week, on Email: chris.westcott@sthk.nhs.uk hour over 25 patients were average 10 minutes per patient time attending the clinic which made it saved, this equates to more than difficult for a single phlebotomist to 2,100 hours patient waiting (or 90 match the demand. days) saved per year.
  • 29. 29 FIVE.CASE STUDYWest Middlesex University HospitalDedicated ward phlebotomistImproved relationship between Waste: The feedback showed the personal development to gainphlebotomists, doctors, staff on the frequent change over of regular experience in each of thesewards and patients by providing a phlebotomists on the pilot wards areas.dedicated phlebotomist to the pilot was leading to low morale for the • A dedicated phlebotomist waswards. Extending the existing two phlebotomists. It was also allocated to each of the pilotweek phlebotomy ward rota to three introducing delays with doctors not wards for a three month period.months. realising who the phlebotomists were and subsequently not passing Measurable outcomesUnderstanding the problem newly created urgent requests to and impactProject problem statement: The them when they were on the wards. Working relationship between theaim of the project was to improve phlebotomist and the ward staff wasthe efficiency and flow of the How the changes were improved. Phlebotomists alsoinpatient phlebotomy pathway from implemented reported an additional benefit ofthe moment the request is made • Solution identified – A dedicated getting to know the patients betterthrough to the result being viewed. phlebotomist on each of the pilot which facilitated the phlebotomyBy improving this we then hope to wards was proposed, and three process. This was found to beimpact on delays in results being months was agreed as a especially true on the medical warddelivered which in turn should reasonable period of time. A which had a slower turnover ofreduce length of stay by allowing longer period was not thought to patients compared to the acuteprompt and informed decisions to be be practical as different wards and medical unit. The number of patientsmade with regards to patient outpatient clinics accommodate bled was also seen to increase overdischarge. quite different patients, so it is the duration of the three month important for the phlebotomists’ roster period on both wards.Identification: The issue of a lack ofteam working between thephlebotomists and the ward staffwas identified via initial feedback Dedicated Phlebotomist Trial: Rate of Bleedfrom the phlebotomy team when for AMU1/MAU & Osterley 1 Dedicatedthe project was first introduced. phlebotomists on holiday so trialPhlebotomists described feeling 12 suspendedisolated and almost like an intruder Number of patients bled per houron the wards. Ward staff and 10doctors both reported not being sureif the phlebotomist was on the ward 8as they didn’t recognise them. 6Data collection: Qualitative datawas collected via discussion and 4feedback at phlebotomy teammeetings, junior doctor meetings MAU/AMU1 (SC) OST1 (DM)and meetings with nursing staff and 2surveys. 0 1/11/10 8/11/10 15/11/10 22/11/10 1/12/10 6/12/10 13/12/10 20/12/10 27/12/10 Week commencing
  • 30. 30 Ideas tested which were How will this be sustained, successful potential for the future and • The idea of introducing a additional learning dedicated phlebotomist onto the This initiative has led to an improved wards to improve team working working relationship between the between the doctors, ward staff doctors, the ward staff and the and the phlebotomy team came phlebotomists and has helped to from feedback given by the all improve the efficiency of the three staff groups when the phlebotomy rostering to continue to project was first initiated. provide a dedicated phlebotomist on • A process mapping session was all wards is being put in place. held involving all staff groups involved in the phlebotomy Contact pathway i.e. junior doctors, Sian Sutton nursing staff, phlebotomists and Email: sian.sutton@wmuh.nhs.uk laboratory staff. This session helped to develop the solution of introducing a dedicated phlebotomist. How this improvement benefits patients The benefit to the patients has come from ensuring that doctors, ward staff and phlebotomists work as a team. Leading to better communication which in turn facilitates the patient’s phlebotomy pathway and reduces delays due to lack of communication. Patients on the longer stay medical ward also benefitted from getting to know their phlebotomist over the course of a few days.
  • 31. 31 SIX.CASE STUDYWest Middlesex University HospitalPhlebotomy column on real-time patientmanagement whiteboardImproved communication between Data collection: Data was collected this mark (X) if the patient hadphlebotomists and doctors to ensure manually and electronically for the been bled and leaves the mark (/)that any outstanding blood test whole pathway, via the if they had not been able to bleedrequests left following the phlebotomist’s daily paper ward the patient. In this way doctorsphlebotomists round are highlighted record sheet, the ICE order comms could see at a glance whichimmediately so that doctors/nursing system and Winpath lab computer patients still required bleeding. Thestaff can arrange to take the blood system. solution was introduced on boththus minimising delays to patient pilot wards and was trialledresults being returned. Data collected: successfully for a number of • Date/time of request. weeks.Understanding the problem • Date/time patient bled. • The Trust then introduced anProject problem statement: The • Date/time logged on laboratory electronic patient/bedaim of the project was to improve system. management system (in real-time)the efficiency and flow of the • Date/time result reported. which replaced the manualinpatient phlebotomy pathway from whiteboard.the moment the request is made Waste: The data from request to • A phlebotomy column was addedthrough to the result being viewed. bleed time highlighted a large to the electronic whiteboard viewBy improving this we then hope to number of cases where there were on the real-time system andimpact on delays in results being long gaps between the request instead of a (X) being used thedelivered which in turn should being placed and the patient being doctors were asked to put an (R) inreduce length of stay by allowing bled. Feedback from the doctors the column for patients whoprompt and informed decisions to be however showed that many of these required bleeding and themade with regards to patient related to requests that were placed phlebotomists would then put adischarge. with the intention of their being a (B) for bled or (F) for fail in long gap i.e. cases where the doctor response at the end of their round.Identification: The problem of poor had placed the requests in the This was trialled for two weeks oncommunication between the evening ready for the next morning one of the pilot wards and thenphlebotomists and the doctors was with the intention of the patient feedback obtained. Feedback fromidentified via initial feedback from being bled in the morning and not the junior doctors stated that theirdoctors on the pilot areas when the that night. However there were input into the column was felt toproject was first introduced. Doctors cases identified by the doctors where be a duplication of informationexplained how they were unaware the expected morning bleed had not they already had to hand on theirof which patients had been bled by taken place and patients had not paper patient lists but that thethe phlebotomist and which patients been bled until mid afternoon thus phlebotomists entry was extremelystill required bleeding following the introducing a 2-4 hour delay. useful for them and did help tophlebotomists ward round. This led ensure no outstanding bloodsto doctors sometimes having the How the changes were were missed. The addition of afalse impression that their patient implemented date in the entry was requested tohad been bled only to find out a few • Solution identified – phlebotomy help avoid any confusion forhours later when searching for the column added to the patient patients having more than onetest results that the bloods had not management whiteboard on each blood test over the course of theirbeen taken, thus delaying the test, of the two wards. Doctors to admission.result and possible discharge of the indicate which patients required • The trial was adapted with onlypatient. bleeding by placing a (/) in the the phlebotomist entering column against the patient’s information as to which patients name. The phlebotomist at the they had bled and rolled out end of their round to then cross across both pilot wards.
  • 32. 32 Measurable outcomes and impact In the last week, number of delayed discharges due to: Communication between the phlebotomist and the doctors was Communication Delay in bloods Results not Quality of greatly improved which benefited being taken being back service not only the patients but also the Baseline 3.4 7.1 6.8 4.3 working relationship between the Both two staff groups. wards Follow-up 5.0 4.0 4.3 7.1 Ideas tested which were Variance 1.6 -3.1 -2.5 2.9 successful The idea of introducing a measure to improve communication between Doctors Also reporting more bloods taken, fewer delayed the doctors and the phlebotomy reported improved discharges due to waiting for results and overall a team came from feedback given by communication. significant improvement in services. the junior doctors when the project was first initiated. A process mapping session was How this improvement How will this be sustained, held involving all staff groups benefits patients potential for the future and involved in the phlebotomy pathway The benefit to the patients has come additional learning i.e. junior doctors, nursing staff, from ensuring that any outstanding This initiative has led to an improved phlebotomists and laboratory staff. bloods not taken by the working relationship between the This session helped to develop the phlebotomist are identified promptly doctors and the phlebotomists and solution of introducing a and addressed by the doctors or has helped to improve the efficiency phlebotomy column initially on the nursing staff on the ward. Thus of the phlebotomy pathway. This in manual patient management minimizing delays to the patient’s turn has ensured that pathology whiteboard (and subsequently on bloods being tested and results information is available to clinicians the electronic whiteboard in real- being available to inform the to inform their decisions as early as time). patient’s clinical management and possible for all patients in the pilot potential discharge. wards. The junior doctors entering which patients required bleeding into the Contact phlebotomy column was Sian Sutton unsuccessful as it was felt by the Email: sian.sutton@wmuh.nhs.uk doctors to be a duplication of information they already had to hand on their paper patient lists and information the phlebotomists also already had (via the request forms) so was not seen to be beneficial.
  • 33. 33
  • 34. 34 SEVEN. CASE STUDY West Middlesex University Hospital Early morning bleed To establish if the time of a patient’s Waste: Patients waiting to go home • A daily sample size of two patients discharge from hospital can be same day whose discharge is per day was agreed with the lead achieved earlier in the day by their delayed due to their results not nurse and matron for the ward. bloods being taken at 7 am on the being back in time for the doctors’ morning of their estimated discharge ward round. Measurable outcomes and the results returned prior to the and impact doctor’s ward round on the acute How the changes were • The data seemed to suggest that medical unit. implemented there were not that many patients • Solution identified – The that had a blood request, were Understanding the problem phlebotomy early morning round scheduled for discharge, and Project problem statement: The starts at 8.00am, it was felt that actually went home. Only 10 of aim of the project was to improve an earlier bleed was required to the trial sample of 48 patients the efficiency and flow of the get the results back by the doctors were discharged form the trial inpatient phlebotomy pathway from ward round. ward on the same day, suggesting the moment the request is made • Data was collected every two that prioritising phlebotomy for through to the result being viewed. weeks to identify how many discharge may be difficult unless a By improving this we then hope to patients each day were due to be better indication of the patient’s impact on delays in results being discharged same day and also had position on the discharge pathway delivered which in turn should an outstanding blood request. This can be given. reduce length of stay by allowing was done to allow us to estimate prompt and informed decisions to be the size of the workload and the made with regards to patient capacity required to undertake it discharge. during the trial. Identification: From review of times patient’s results were available compared to the timing of the Trial Period 07/03/2011 9/04/2011 doctors’ ward round and following feedback from the junior doctors. Number of sample patients reviewed as eligible to 48 go home same day during trial. Data collection: • Number of patients with a same Number of patients reviewed as eligible to go 24 day discharge who had home same day during trial but no blood request form available for the early bleed or no bloods outstanding blood test requests. required. • Date/time of early morning bleed. • Date/time bloods logged on lab Number of patients bled early. 24 system. • Date/time result reported. Number of patients bled early but not discharged 4 • Date/time patient discharged. same day. Analysis to be undertaken Number of patients in trial bled early but 10 comparing results for patients transferred rather than discharged. involved in the trial to other patients on the ward during the same period Number of patients in trial bled early and 10 and averages for previous months. discharged same day
  • 35. 35 On trial Admission date/time Date/time patient bled Results authorised date/time Discharge date/time YES 12/03/2011 17:39 13/03/2011 05:00 13/03/2011 07:55 13/03/2011 16:19 YES 31/03/2011 09:29 01/04/2011 06:00 01/04/2011 08:23 01/04/2011 18:31 YES 14/03/2011 15:15 16/03/2011 08:00 16/03/2011 10:24 16/03/2011 17:23 YES 15/03/2011 22:57 17/03/2011 06:00 17/03/2011 08:53 17/03/2011 15:36 YES 14/03/2011 21:23 16/03/2011 08:00 16/03/2011 10:12 16/03/2011 13:22 YES 16/03/2011 16:53 18/03/2011 07:00 18/03/2011 08:24 18/03/2011 15:17 YES 19/03/2011 07:42 21/03/2011 07:25 21/03/2011 10:28 21/03/2011 13:00 YES 31/03/2011 08:20 01/04/2011 06:00 01/04/2011 08:33 01/04/2011 17:02 YES 26/03/2011 21:14 30/03/2011 06:00 30/03/2011 10:03 30/03/2011 13:18 YES 04/04/2011 02:08 05/04/2011 06:30 05/04/2011 08:24 05/04/2011 11:57When looking at the patients that How will this be sustained, • If this perception persists, can thiswhere bled the number of data potential for the future and be improved by a closer workingpoints where so few that any firm additional learning relationship between ward staffconclusions may be difficult to draw, Based on the feedback form doctors and phlebotomy staff as indicatedbut some further observations were it was believed that earlier bleeds in an earlier trial documented inof interest. and test results would have a this publication (case study 5 positive impact for patients. The Dedicated ward phlebotomist).• Despite similar bleed times the benefit to the patients is that their • If blood tests do not delay discharge times were very variable discharge from hospital will not be discharge, what is holding up regardless of when the report was delayed waiting for pathology results earlier discharge and what can be authorised indicating other issues and may mean that they can go done to better align all the tasks were delaying discharge not the home earlier in the day. However that need accomplishing to ensure timing of the blood results. while the patients were able to be patients can leave earlier? bled earlier the desired impact on • Based on these results, it is notIdeas tested which were discharge was not evident and this clear if sustaining early bleeds issuccessful trial has raised some interesting suitable at the moment until more• The night staff were able to bleed questions that require further is done to understand how this those patients indicated as analysis and investigations: can lead to earlier discharges, planned for discharge enabling which seem to include other bloods to get to the lab quicker. • Why do so many doctors and patient pathways aligning to nurses have the perception that enable discharge.Ideas tested which were blood test results often delayunsuccessful discharge? Contact• Ultimately the early bleeds did not Sian Sutton in this trial lead to significantly Email: sian.sutton@wmuh.nhs.uk quicker discharge.
  • 36. 36 EIGHT. CASE STUDY Warwick Hospital Earlier start for bleeding patients Availability of blood results by This also resulted in patients being • Review of phlebotomists’ infection 10.30 am from samples taken that given inappropriate treatments: e.g. control technique: only gloves day have increased from less than patient on anticoagulation therapy required, not gowns, for non 15% to 100% of full blood count will be given inappropriate does of barrier nursed patients, saving (FBC) and 70% of chemistry blood anticoagulation, antibiotics money and time between patients. results. (gentamicin, intravenous fluids and • Porters start at 7.45 am and follow other drugs based on an out-of-date the phlebotomists round the Understanding the problem result. wards delivering small numbers to All Warwick Hospital inpatient blood bloods samples to the lab. results (apart from intensive care) are The main delay is due to: • One lab technician starts at 8 am at least 24 hours out of date when • The phlebotomists rounds (9 am to and processes the blood samples reviewed on the consultant or junior 11.30 am) occurring while the as soon as they arrive. doctor rounds. This was a major doctors are doing their rounds. safety issue. We created a • The inpatient bloods samples are Measurable outcomes multidisciplinary team of a delivered to the lab in a big batch and impact consultant, junior doctor, ward sister, just as the GP practice and • From < 15% blood results back by phlebotomist, portering manager, outpatients samples are arriving in 10.30 am on the day of request, lab receptionist and technicians to the lab. to 100% of FBC and 70% of map the process and understand the • The results are not processed until chemistry blood results. main delays in the in-patient blood the afternoon when the doctors • Safer care: consultants and process. We discovered that the are elsewhere. registrars have now noticed the blood tests requested on the ward change in the blood result round on day one, were drawn by How the changes were availability: right care, on time, the phlebotomists after 8 am on day implemented every time for inpatients. two while the ward round was • Night nurses ensure the blood • Predictable system; if a blood happening. The bloods were requests are where the patients result is not back by 10.30 am delivered to the laboratory after the are (have patients moved wards?). then the chances are that the ward rounds had ended. These • Night nurses label the blood forms blood sample is abnormal: this is a inpatient blood samples hit the lab with bed, bay and barrier status to warning that the doctors must just as the outpatient and GP reduce the wasted time of the phone the lab to check on sample samples were coming in, meaning phlebotomists hunting for and review the patient at the results were not available until patients. lunchtime. the late afternoon when the doctors • Phlebotomists start at 7.30 am • One day off the length of stay were no longer on the wards. As a and leave earlier in the day. (LOS) for those patients where the consequence, results were not • The domiciliary phlebotomists join blood result is the key to reviewed until the following day’s the inpatient or outpatient discharge. ward round on day three. phlebotomists to keep the hospital • No increase in cost. work flowing to the lab in the early morning before going out to do the domiciliary visits.
  • 37. 37 Ideas tested which werePlan Do, Study Act Cycles 1 and 2 (June and August 2010) successfulNumber of inpatient U&E results out 9am to 9.59am Mapping the process. Trialing the earlier start times for: 70 • Phlebotomists. Number of results out 9.00 to 9.59 60 Phlebotomists starts at • Porters. 7.30am. Two porters start at 7.45am to 9.45am. • Laboratory staff to book in the 50 Lab technician starts samples. at 8am 40 How this improvement 30 Lab technician off sick. benefits patients 20 Technician not • Potential for reduced length of available until 9am stay. 10 • Safer care – Referring clinicians Weekend service 0 have the right result in a timely Control Day Control Day Control Day PDSA 1 Wed PDSA 1 Thurs PDSA 2 Mon PDSA 2 Tues PDSA 2 Wed PDSA 2 Thurs PDSA 2 Fri Sat 7/8/17 Sun 8/8/18 manner to give best possible care. Tues Wed Thurs 16/6/11 17/6/12 2/8/14 3/8/13 4/8/14 5/8/15 6/8/16 8/6/10 9/6/11 10/6/12 Day How will this be sustained/ potential for the future/ additional learning Benefits gained are now beingPercentage of inpatient FCBs released by 10.30am - PDSA 3 applied to the emergency care 120 pathway. All emergency diagnostic 100% bloods for A&E and Medical 100 Assessment Unit are now delivered Percentage 80 by the air-tube with a 50 minute TAT 60 as the target. This allows for a 40 target of two hours from arrival at % SFBC Release 1-.30 hospital to a consultant plan for 20 treatment (which may include 0 8/9/10 16/9/10 24/9/10 2/10/10 10/10/10 18/10/10 26/10/10 3/11/10 discharge) for all emergency 12/9/10 20/9/10 28/9/10 6/10/10 14/10/10 22/10/10 30/10/10 7/11/10 patients. Day Contact Kate Silvester Email: kate.silvester@swft.nhs.ukPercentage of inpatient U&E released by 10.30am - PDSA 3 120 100% 100Percentage 80 60 40 % U/E Release 10-.30 20 0 8/9/10 16/9/10 24/9/10 2/10/10 10/10/10 18/10/10 26/11/10 12/9/10 20/9/10 28/9/10 6/10/10 14/10/10 22/10/10 Day
  • 38. 38 NINE. CASE STUDY Russells Hall Hospital (Dudley) Faster return of specimens from acute ward Following observations of the Waste: Up to an hour or more could Measurable outcomes process one area of delay in the elapse between the first specimen and impact system came from waiting to being taken and it appearing back in Bringing the specimens back earlier transport samples from wards back the laboratory and more regularly resulted in the to the laboratory as a drop off average delay between specimen system was in operation. Getting How the changes were collection and receipt back in the samples transported more frequently implemented laboratory being reduced from over may enable samples to get to the • Solution identified: There had an hour to just 13 minutes for the laboratory quicker and in smaller already been discussion about main tests requested. The overall batches, with anticipated potential changing the order of the wards time from specimen collection to benefits being faster turnaround of so that A1 was bled first. This was results being available reduced from blood results for acute ward and first trialed for two weeks to an average of three and a half hours delivery of specimens back to the ensure there was no adverse effect to just over two hours. laboratory smoothed. on the other wards. • Additional resource was to be Understanding the problem identified to bring specimens back Project problem statement: There to the laboratory earlier and more is often a delay in getting blood frequently, and to book these specimens taken by the ward specimens in as soon as possible. phlebotomists back to the laboratory This was to be trialled for two to after collection. Minimising this delay three weeks in the first instance. could enable results to be available more quickly and potentially help timely discharge; in addition we wanted to understand the broader Average time taken from specimen collection to receipt in laboratory benefits for the laboratory that may be derived by smoothing the flow of 1.26 samples received for analysis. Before After 1.12 Identification: Ward A1 is an acute, short-stay ward where timely 0.57 Time taken return of results is essential to the rapid discharge of patients. There 0.43 had been instances where A1 had not had all their patients bled as they 0.28 were the last ward to be bled in their group. 0.14 Data collection: Qualitative data 0 Bone CRP EGFR Liver Renal Full Blood was collected via discussion with the Profile Profile Profile Count senior management, medical Main tests carried out representatives and matron for ward A1. We also held a process mapping day with some of our phlebotomists which helped us understand the overall process a little better.
  • 39. 39 Average time taken from specimen collection to results being available 4.19 Before After 3.50 3.21 2.52 Time taken 2.24 1.55 1.26 0.57 0.28 0 Bone CRP EGFR Liver Renal Full Blood Profile Profile Profile Count Main tests carried outIdeas tested which were How this improvement How will this be sustained/successful benefits patients potential for the future/• The use of hospital volunteers to What became clear from the results additional learning bring the specimens back to the is that while there are significant • Continued use of hospital laboratory. patient benefits from the trial there volunteers is being explored for• Getting samples back to the were also benefits for staff in ward A1. laboratory sooner delivered particular the laboratory staff. • Further investigation into future quicker results to the ward. It should also be noted that the proofing this approach, can• Smaller batches in to the hospital volunteers also enjoyed the volunteers remain or do we need laboratory smooths the flow, responsibility of assisting with a member of staff. contributing to quicker turnaround processes, making a significant • The next step is to explore how times, resulting in improved contribution to improving patient results back quicker can drive morale of the laboratory staff. care. clinicians to make decisions sooner, and ultimately assist in • Blood results are back with the speeding up discharge. ward earlier in the day for decision • A questionnaire is being circulated making. around all wards to gain feedback • Earlier decision making has on the current phlebotomy service potential to assist with earlier and when ward rounds take place. discharge. This information will be used to • Smoother flow and smaller optimise the time of return of batches into the laboratory specimens from all wards. benefited laboratory staff and flows of work. Contact Jim Young Email: james.young@dgoh.nhs.uk
  • 40. 40 Contacts Contacts For further information on any aspects of this work please contact: NHS Improvement Team Lesley Wright Director lesley.wright@improvement.nhs.uk Jamie Balloch National Improvement Lead jamie.balloch@improvement.nhs.uk Peter Gray National Improvement Lead peter.gray@improvement.nhs.uk Ian Snelling Senior Analyst ian.snelling@improvement.nhs.uk Ana DeGouveia Diagnostics Team PA anabela.degouveia@improvement.nhs.uk Telephone: 0116 222 5122 Victoria Ward Diagnostics Team PA victoria.ward@improvement.nhs.uk Telephone: 0116 222 5123
  • 41. References 41ReferencesNHS Improvement – DiagnosticsPublicationsCytology improvement guide - achieving a 14day turnaround time in cytology (November2009).Continuous improvement in cytology -sustaining and accelerating improvement(September2010)Learning how to achieve a seven dayturnaround time in histopathology(November 2010).Bringing Lean to Life (May 2010).Department of HealthEquity and Excellence: Liberating the NHS(2010).Report of the Review of NHS PathologyServices in England (August 2006).Chaired by Lord Carter of Coles(An Independent Review for the Department ofHealth)Report of the Second Phase of the Reviewof NHS Pathology Services in England(December 2008).Chaired by Lord Carter of Coles(An Independent Review for the Department ofHealth)Other ReferencesImproving quality and safety by reducingSpecimen labelling errors (ASCP Layfield /Anderson)
  • 42. 42 Useful reading Useful reading A3 Problem Solving for Healthcare Learning to See Cindy Jimmerson Mike Rother & John Shook ISBN 978-1-56327-358-2 ISBN: 0-9667843-0-8 Demonstrates how to use A3 to problem An easy to read practical workbook for solve. Contains practical examples from creating a value stream map to evidence USA healthcare that can be easily waste in a process. translated to UK. Managing to Learn Lean Healthcare – Improving the John Shook patient’s experience ISBN: 978-1-934109-20-5 David Fillingham How A3 enables an organisation to ISBN: 978 -1- 904235-56-9 identify, frame, act and review progress Written by CEO of Bolton NHS Trust as an on problems, projects and proposals. account of his experience of the long term perspective of using Lean to support Making Hospitals Work whole healthcare. Marc Baker and Ian Taylor with Alan Mitchell The Toyota Way A Lean action workbook from the Lean Jeffrey Liker Enterprise Academy. ISBN: 978-0071392310 Explains Toyota’s unique approach to Lean First break all the rules Management – the 14 principles that Marcus Buckingham and Curt Coffman drive their quality and efficiency obsessed What the worlds greatest managers do culture. differently. Creating a Lean Culture Value stream mapping for healthcare David Mann made easy ISBN: 978-1-56327-322-3 Cindy Jimmerson Helps Lean leaders succeed in ISBN: 978-1-4200-7852-7 transformation. A critical guide to Demonstrates why value stream maps developing and using a lean management are a fundamental component in system. applying Lean. The New Lean Toolbox John Bicheno ISBN: 0 954 -1-2441 3 A guide to Lean tools and concepts
  • 43. Acknowledgements 43AcknowledgementsOur thanks go to all the pilot sites that have tested andimplemented changes and produced the case studiesfor others to benefit from.
  • 44. NHS NHS ImprovementCANCERDIAGNOSTICS NHS Improvement NHS Improvement has over 10 years improvement experience. With our practical knowledge and ‘how to’ approach we help improve the quality and productivity of services through using innovative approaches as well as tried and testedHEART improvement methodology. Over the last 12 months we have tested, implemented, sustained and spread improvements with over 250 sites to assist in improving services in cancer,LUNG diagnostics, heart, lung and stroke. Working closely with the Department of Health, trusts, clinical networks, other health organisations and charities we have helped deliver key strategies and policies to improve the delivery and implementation of improved services for clinical teams and their patientsSTROKE across the NHS. 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 ©NHS Improvement 2011 | All Rights Reserved Publication Ref: IMP/comms015 - May 2011 improvement agenda for the NHS

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