Learning how to achieve a seven day turnaround in histopathology


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Reducing the intervals between specimens being taken and results being made available will reduce the period of uncertainty for patients and will help to ensure that treatment can be started as soon as clinically appropriate. For inpatients reduced histopathology turnaround times can lead to reductions in lengths of stay.(Nov 2010).

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Learning how to achieve a seven day turnaround in histopathology

  1. 1. NHS NHS ImprovementCANCERDIAGNOSTICSHEART NHS Improvement With over ten years practical service improvement experience in cancer, diagnosticsLUNG and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share 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 acrossSTROKE 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 2010 | All Rights Reserved Publication Ref: IMP/comms004 - November 2010
  2. 2. NHS NHS ImprovementCANCERDIAGNOSTICS Learning how to achieve a seven day turnaround time in histopathologyHEART Clinical excellence in partnership “ with process excellence”LUNGSTROKE
  3. 3. Learning how to achieve a seven day turnaround time in histopathology 3Contents1. Foreword 4 13. Visual management 35 19. Capacity and demand 65 What is it and how is it used? Do we have sufficient capacity to meet2. Executive summary 5 the demand? Case study 10 - Daily visual 363. Introduction 6 management used to plan, monitor Case study 25 - Managing the 67Why Lean as the methodology of and act on pathway performance consultant workload with a pointschoice? Case study 11 - Visual management 38 system4. Phase one pilot sites 7 14. Value, value stream mapping, 40 20. Communication 68 flow and pull Do you have a plan?5. Learning for future 8 Improving flow, introducing pull,improvement eliminating non-value adding steps, Case study 26 - Maintaining staff 69 simplifying processes, combining steps, awareness - communicating to all6. Understanding where you are 9 re-sequencing stakeholders 70What to measure and how to collect it Case study 27 - Improving Case study 12 - Reducing turnaround 42 communications with staff and service• Baseline data – ‘Go see’ times by automating semen analysis users• Data requirements Case study 13 - Introduction of 43• SPC charts pooled medical reporting to improve 21. Leadership, engagement and 71 workflow sustainability7. How to begin 11 Case study 14 - Increasing workflow 46 How leadership affects staffTeam make-up, the wider team, through scheduled cut-up engagementexecutive support and involving users Case study 15 - Introducing a 47 consultant ‘pull’ system to smooth Case study 28 - Using ‘huddles’ to 738. Establish the measures 12 reporting flow improve team communicationIdentifying and measuring factors Case study 16 - Improving flow of 49 Case study 29 - Staff engagement 76which impact overall turnaround time specimens through the lab using an ideas bank Case study 17 - Improving consultant 519. Key enablers to specimen flow 13 reporting 22. Patients and user experience 77• Specimen taken Case study 18 - Eliminating the 53 What do the users want?• Lab booking-in and cut-up urgent workstream• Lab processing Case study 30 - Reducing turnaround 78• Reporting, typing, authorisation 15. Future state mapping 54 times – the impact on users• Office activities, all other areas How do you get there and action Case study 31 - User engagement 80 planning Case study 32 - Impact of effective 8210. The nine wastes 16 histology on MDT meetingsCase study 1 - Improving 17 Case study 19 - The link between 55transportation of specimens future state mapping, A3’s and RCA 23. Workcell design 83Case study 2 - Reducing the waste in 19the further work process 16. 5S 56 Case study 33 - Work cell design in 84Case study 3 - Reducing defects at 20 Using 5S to improve safety and morale the main laboratoryslide labellingCase study 4 - Stopping the 21 Case study 20 - Visual SOP facilitates 57 24. Accelerating implementation 86overproduction of spare unstained 5S in the cut-up roomslides Case study 21 - Using 5S principles to 58 Case study 34 - Accelerating the pace 87Case study 5 - Reducing wasted skills 22 improve laboratory organisation of changeCase study 6 - Reducing the QC of 24slides leaving the laboratory 17. Standard work 59 25. NHS Improvement contact 89 The best way to perform each process details11. A3 thinking 25 stepWhat it is and how to produce an A3 Case study 22 - Standardising 60Case study 7 - A3 thinking 26 preparation for MDT Case study 23 - Using technology to 6112. Root cause analysis (RCA) 29 enable standard work - introduction ofTechniques to determine the ‘Lysis’ templates in specimentrue cause of a problem processingCase study 8 - Using A3s and RCA to 31 18.Takt time 63improve the use of the specimen What it is and how it can be used todissecting room level the workloadCase study 9 - Root cause analysis to 33reduce defects Case study 24 - Takt time used to 64 match specimen reception capacity to demand www.improvement.nhs.uk
  4. 4. 4 Learning how to achieve a seven day turnaround time in histopathology 1. Foreword Pathology is core to the diagnosis and monitoring of a very wide range of conditions. Amongst the pathology disciplines, histopathology has a particularly important role in the diagnosis of cancer, and in providing information on which treatment decisions are based. Reducing the intervals between specimens being taken and results being made available will reduce the period of uncertainty for patients and will help to ensure that treatment can be started as soon as clinically Professor Sir Mike Richards CBE appropriate. For inpatients reduced histopathology turnaround times can National Cancer Director lead to reductions in lengths of stay. The aim of the pilots reported here was to test whether it is possible to deliver histopathology results within seven days for 95% of all patients. The results show that this is indeed achievable. However, several factors are critical to success. These include a whole pathway approach (including transport of specimens), user engagement and proactive clinical leadership. Implementation of the learning from these pilot sites will have benefits for Dr Ian Barnes histopathology services themselves and for the multidisciplinary teams of National Clinical Director for Pathology which they are an essential part. Importantly there will be benefits both for patients and for the NHS. We commend this report to all commissioners and providers of histopathology services. Dr Ian Barnes Professor Sir Mike Richards CBE National Clinical Director for Pathology National Cancer Director Department of Health Department of Healthwww.improvement.nhs.uk
  5. 5. Learning how to achieve a seven day turnaround time in histopathology 5 Key learning has demonstrated success is achieved through: Strong and proactive clinical and managerial leadership • to encourage, motivate, and empower staff Collection and analysis of appropriate data • to understand the current end to end pathway and to evidence improvement Walking the pathway • going to see problems first hand Executive support • providing active support and removing barriers2. Executive summary Empowered staff • who own the problem, find the solutions and ‘stop to fix’In 2006 the Review of Pathology Services in Englandby Lord Carter endorsed Lean as the method of Effective transportchoice for improving processes in pathology services. • transport is critical to achieving flow andWorking in partnership with the Department of needs to be owned by the laboratoryHealth Pathology Programme, NHS Improvementsupported nine pilot sites to test the Lean Optimise technologymethodology to demonstrate how to deliver a seven • using electronic ordering systems, voiceday service and make improvements in quality, safety activated and digital technology solutions willand productivity. improve safety and reduce turnaround times.Multidisciplinary teams worked collaboratively to testand implement changes that deliver improvements forpatients, staff and users of the service.Staff were trained to apply Lean methodology to their This guide provides clinical teams with the basicwork, the intention being to ensure continuous tools to make changes to their processes, alongimprovement beyond the period of NHS Improvement with insight into how phase one pilot sites haveinvolvement. In addition, clinical leadership in used these tools across the whole patientimprovement methodology sessions were facilitated pathway.for consultant histopathologists and specialistregistrars to highlight the need for leadership incontinuous improvement.Over 157,000 patients will have benefited from theimprovements in:Turnaround times: 95% of test results available fortreatment decision within seven days with up to 50%of results available within three days.Quality and safety: Achieving ‘right first time’ -addressing errors in specimen labelling and requestsInnovation: Using simple visual managementtechniques to improve flow, safety and productivity.Productivity: Eliminating non value added steps,ensuring appropriate utilisation of workforce,demonstrating the capacity required based on thedemand, and ensuring technology is used effectively. www.improvement.nhs.uk
  6. 6. 6 Learning how to achieve a seven day turnaround time in histopathology 3. Introduction With timely diagnostics critical to the delivery of the Cancer Reform Strategy, the establishment of a seven PDSA cycle for learning and improvement day turnaround for histopathology results is key to early diagnosis and improvements in outcomes for patients. NHS Improvement has worked with pathology teams ACT PLAN to test and prove the value of Lean methodology. What changes Objective are to be made? Questions and Clinical teams have been extremely successful and the Next cycle predictions (why) Plan to carry out the methodology is being widely adopted in many cycle (who, what, pathology laboratories and other clinical settings where and when) across the country. STUDY DO Complete the Carry out the plan The methodology and approach was further endorsed analysis of the data Document problems by Lord Carter in the ‘Report of the Review of NHS Compare data to predictions and unexpected observations Pathology Services in England’ in 2006/2008. Summarise what Begin analysis was learned of the data “No worker, particularly in healthcare, where the well- being and safety of another human comprises the core of the work, appreciates having his or her time wasted” (A3 Problem Solving for Healthcare – Cindy Jimmerson) 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 the • Use PDSA cycles (Plan, Do, Study, Act) to test pilot facilitated a collaborative approach to achieving out ideas to ensure changes make the improvements and to spreading innovation and improvement required before implementation success. (sometimes known as PDCA - plan, do, check, adjust) A buddy system for some sites was set up to support • Use data to demonstrate the impact of the sharing of best practice along with a series of improvement training and development workshops and shared • Use A3 techniques to problem solve learning events. • Understand how people respond to change • Use statistical process control (SPC) and root cause This approach has also been successfully used more analysis (RCA) widely across other diagnostics areas including • Understand communication methods and endoscopy and radiology with significant results. work as part of a team. This document contains case studies from the phase To further support and embed the improvement one pilot sites to help illustrate the changes made. methodology within the local environment and create Further case studies can be found on the website at: local ownership, an overview of Lean methodology www.improvement.nhs.uk/diagnostics was provided for all staff involved in the pathway. These two factors, combined with clinical lead commitment, are essential to the sustainability of achieved and ongoing improvement.www.improvement.nhs.uk
  7. 7. Learning how to achieve a seven day turnaround time in histopathology 74. Phase one pilot sitesThe following sites were selected as phase one pilot Pilot sites and leads:sites. One of the criteria for joining the programmewas to become an exemplar site, prepared to share Birmingham Women’s NHS Foundation Trustlearning with other teams. Lead: Tervinder SokhiClinical teams will benefit from visiting phase one Derby Hospitals NHS Foundation Trustexemplar sites, to observe Lean methodology as part Lead: Andrea Goodingof everyday working and understand how theimprovements have been achieved. The Leeds Teaching Hospitals NHS Trust Clinical Lead: Dr. Pat HarndenThe criteria for inclusion as an exemplar site are: North Middlesex University Hospital• Delivery against seven day (95%) and three NHS Trust day (50%) turnaround times Clinical Lead: Dr. Evangelia Mylona• Clear evidence of Lean methodology including: • Visual management North Tees and Hartlepool NHS • Standard work Foundation Trust • A3 Lead: Sharron Williams • Stop to fix problems via daily meetings • 5S North West London Hospitals NHS Trust,• Evidence of all staff committed to continuous Northwick Park Hospital improvement and Lean methodology Clinical Leads: Dr Tanya Levine and Dr Gillian Williams• Evidence of sustainability and committed leadership. Taunton and Somerset NHS Foundation Trust, Musgrove Park Hospital Clinical Lead: Dr. Fred Mayall University College London Hospital NHS Foundation Trust Lead: Mrs Ann Hannah Whipps Cross University Hospital NHS Trust Clinical Lead: Dr. Saimah Arif www.improvement.nhs.uk
  8. 8. 8 Learning how to achieve a seven day turnaround time in histopathology 5. Learning for the future The purpose of this document is to share the learning The key mechanisms required to achieve these from phase one pilot sites. changes are: It makes recommendations for change through evidence based case studies and encourages teams to 1. Empowered staff who can: adopt the learning, adapt within their own service, • See the waste and remove it and visit exemplar sites to discuss improvements • Test changes through PDSA cycles made, challenges faced and pitfalls to avoid. • Have information to say how we are doing • Use suggestion boards to have ideas actioned. The five key changes identified which will bring about substantial reductions in end-to-end waiting times for 2. Daily meetings established to: the histopathology pathway are: • Stop and fix problems • Encourage a culture of daily problem solving. 1. Focus on the whole end to end pathway: • Link all staff across the pathway 3. Visual management techniques to: • Use whole pathway data to understand where • Display performance data specimens, forms, blocks, slides and reports are • Promote standard work waiting. • Ensure safe working practices. 2. Adopt small batch sizes: 4. Information to support the process: • Throughout the entire pathway, including booking- • Turn real time data into information to manage the in, the prep room, lab, reporting, typing and process authorisation. • Ensure visibility of efforts • Identify problems and establish mechanisms to solve 3. Keep samples moving: • Encourage root cause analysis. • Daily through-the-day deliveries from source • Continual cut-up sessions through the day To accelerate the pace of change to reduce • Pull work through the lab turnaround times, defects and rework and improve • Continuous transcription and authorisation of quality, safety and productivity, teams should consider reports. applying: 4. Establish first in, first out: • Key enablers to specimen flow (section 9, • No prioritisation of specimens page 13) • Todays work today. Tried and tested, proven to reduce turnaround times across the whole pathway. 5. Team based organisation of work: • Work grouped by complexity, specialty, Also, consider the: (not by individual) • Co-location of people, equipment and work. • Human dimensions of change (section 21, page 71) The importance of engaging all staff. An engagement survey tool is available on the NHS Improvement website at: www.improvement.nhs.uk/diagnostics/lean Whilst this process will not be easy, the rewards are great!www.improvement.nhs.uk
  9. 9. Learning how to achieve a seven day turnaround time in histopathology 96. Understanding where you areMeasuring the performance of your To determine the impact of changes made in thehistopathology pathway laboratory or other specific parts of the pathway,At the launch of a project, it is important to create an additional timings should be captured and statisticalunderstanding of what is actually happening, as process control charts (SPC) produced to evidencedistinct from what ‘should be’ or is thought to be achieved improvements.happening. Identifying the current situation shouldinclude the whole journey of the specimens, not just Recommendations include:in laboratory processes. • Date/time booked in • Date/time cut-upThe best way to do this is to ‘go see’. This means to • Date/time completed on processorphysically walk the whole pathway and produce a • Date QC’dphotographic record of the process. It is • Date reportedrecommended that this is done by the whole core • Date typedteam to ensure objectivity. • Date of authorisation (available).The pathway should then be graphically represented A sample data collection spreadsheet can be found onas a current state value stream map. Measurements the NHS Improvement website.taken as part of value stream mapping will providethe baseline against which the impact of any changes What type and how much data?to the process can be compared. We recommend you collect data on at least one week of consecutively numbered specimens to provide aEvery task undertaken while processing samples will statistically valid baseline TAT.have an impact on achieving the 95% of specimens inseven days turnaround time (TAT) and should Calculating and monitoring TAT – Usingtherefore be included in baseline measurement. TAT statistical process control (SPC)is defined as the time the specimen was taken from By collecting data from specimens at the three keythe patient to the date the result is available. stages within the pathway, variations in delay/wait times and other sources of waste can be detected,Data requirements corrected and tracked to assess how/if these areTo capture a clear and accurate TAT measure, data reduced over time as a result of improvementshould be collected for all three key stages of the changes.histopathology pathway: SPC charts provide a graphical representation of the1. Date specimen taken to date it is received in the time it takes to process a particular specimen and an laboratory specimen reception. overall view of the variation in the process.2. Date specimen received to date QC’d in the laboratory and available for reporting.3. Date available for reporting to date report is authorised and available to the referrer. www.improvement.nhs.uk
  10. 10. 10 Learning how to achieve a seven day turnaround time in histopathology Special Cause Variation process is ʻout of controlʼ Special Cause Variation process is ʻout of controlʼ Statistical control limits are calculated from the data of ‘run rules’ that are used to indicate out-of- input and are displayed on the chart along with statistical control situations please refer to the website process average (mean) and its variation about that or NHS Improvement publication ‘Bringing Lean to mean. If there is evidence of unusual variation or Life: Making Processes Flow in Healthcare’. ‘special cause’ (outlier) detected, then this ‘special cause’ should be investigated by using a root cause Your individual project can be set up on the NHS analysis technique (see section 12). Improvement Reporting System and this will enable you to track the project, add project documentation SPC tools can be accessed via the NHS Improvement and upload improvement stories. Further information Reporting System or NHS Improvement excel data on how to use the Improvement System can be template. To find out more about SPC and the types obtained via: support@improvement.nhs.uk Other important data for your baseline Turnaround times % achieved in seven days % achieved in three days % of reports available for next MDT Quality and safety (defects) % specimen pots/forms with inaccurate/illegible/ incomplete information % referrals returned to requester % of laboratory defects at QC (non-conformities) % of cases requiring extra processing/fixation Engagement Overall team engagement/morale scores at start of project and various additional points throughout the change process Number of ideas generated and % implemented on timewww.improvement.nhs.uk
  11. 11. Learning how to achieve a seven day turnaround time in histopathology 117. How to beginTeam guidance Wider team membership/steering groupBegin by identifying a credible and respected project A wider team of key stakeholders from across thelead to head up the team. This could be a clinician or pathway should provide regular input and support butmanager with the drive and enthusiasm to steer may not be a member of the day-to-day core team.changes across the patient pathway. Executive supportProject team members should be drawn from across An executive team sponsor should be identified tothe entire pathway: provide proactive support and access to relevant• Clinical /managerial lead who must provide active support services such as estates and transport, HR, support and leadership to the core team Finance and IT teams. They may be called upon to• Specimen reception/cut-up – (eg MLA) should be escalate key issues. able to contribute to discussions such as organisation of transport and cut-up for same day Protected time out sample delivery and cut-up This is essential to allow thinking time for the core• Laboratory – (eg MLA, BMS) must represent and team and any members of staff planning a Plan, Do, understand all processes from block processing to Study, Act (PDSA) cycle and may have to be facilitated QC sign-out (you must utilise laboratory managers by the departmental manger or executive lead and histopathologists as part of the core team/wider team or steering group) Communication plan• User involvement – member of an existing patient It has been widely recognised from the phase one group or suitable equivalent, likely to be a wider pilot sites that the establishment of a communication team member. plan is essential and a central information board should be positioned to inform all staff of projectCore team members must: activity and progress.• Understand the process within their stage of the pathway Training location/work room• Be able to contribute ideas/information on the Space will be required for the core team to work. An process area should be identified where the team will have• Be able to influence the decision making process space to work on projects and display information• Be prepared to test and implement changes across work sheets and maps. the pathway• Be committed to attend all team meetings, and work required between meetings. www.improvement.nhs.uk
  12. 12. 12 Learning how to achieve a seven day turnaround time in histopathology 8. Establish the measures The purpose of measurement is to: Some examples of additional measures: • Understand the baseline position and how much improvement is made • % of referrals with insufficient request information • Set goals and ensure progress • Patient satisfaction rating • Prevent problems and errors • % processor/system utilisation • Work with facts and not opinions • % staff availability • Set standards • % machine/system re-runs • Recognise success • % staff absence • % staff trained in task Quality, Innovation, Productivity • Stock level replenishment and Prevention (QIPP) • Department productivity v. target. With the introduction of the QIPP Quality, Innovation, Productivity and Prevention agenda measures should be aligned to quality outcomes: Patient safety Reducing avoidable harm with confidence that the result is accurate, e.g. % errors in specimen taking, request cards, data input and results letters. Patient experience Providing a timely accurate result with relevant information, e.g. information at time of test and with result. Clinical effectiveness e.g. % of patient results available within seven working days and the % of results available for first MDT meeting. Delivery End to end turnaround times Costs People and staff Environment There will be other local measures and quality indicators which can be used to assess the impact of local improvement work.www.improvement.nhs.uk
  13. 13. Learning how to achieve a seven day turnaround time in histopathology 139. Key enablers to specimen flowThis section is designed to help teams make changes To support these recommendations, case studiesthat have been tested and proven to make a demonstrate how sites have implemented these.significant difference to turnaround times across end-to-end specimen pathwayAll parts of the process are covered. Changes shouldbe implemented in a planned and structured way,guided by the core project team and project lead.Measures should be in place to track improvementsand evidence the impact of improvement. Specimen Taken Action Why? Source 1 Send specimens to laboratory at least once a To ensure timely testing. day, even if there is only one. 2 Utilise laboratory vacuum pod systems for To support the daily levelling out of specimen delivery of small specimens to lab. deliveries to specimen reception. 3 Ensure appropriate staff are trained in the use To enable the correct information to be entered of relevant patient administration and lab onto the request form. systems and are able to use its full capability. 4 Simplify and standardise request forms To ensure correct demographics are recorded. Where available, use electronic requesting for Specimens are not returned for correction or every specimen. because hand writing is illegible - get it right first time! Lab book-in and Action Why? cut-up 1 Perform continuous cut-up processes daily for To enable more predictable flow of blocks for main specialties. processing whilst saving up to one day at cut-up stage. 2 Reduce batch sizes to a minimum. Instinct tells us batch processing ‘feels’ quicker and is more efficient. Small batches will immediately reduce your TAT - use SPC to prove it. 3 Implement a non-acceptance policy for To improve quality and safety whilst eliminating incorrect forms and specimen containers. time spent by staff dealing with omissions and mistakes, logging returns, telephoning surgeries etc. 4 Use pre-filled disposable pots rather than re- Time savings. cycling. 5 Stamp the expected date of report at This visual management enables reporting booking-in. capacity to be predicted and planned for and assists communication throughout all main laboratory processes to ensure the reporting schedule is maintained. www.improvement.nhs.uk
  14. 14. 14 Learning how to achieve a seven day turnaround time in histopathology Lab (processing Action Why? QC signout) 1 Treat all specimens with equal importance - Time is saved by not sorting/classifying at remove ‘urgent’ streams. booking-in/cut-up stages. 2 Utilise minimum batch sizes across Instinct tells us batch processing ‘feels’ quicker, embedding, sectioning, trimming. but this will immediately reduce your TAT - use SPC to prove it. 3 Stop the microscope QC stage for small Time is saved by not performing 100% checks and resection material. where errors rates are low (overprocessing). 4 Perform microscopic quality checks on 25% Waiting time is reduced for cases leaving the of slides from any one case of biopsy laboratory resulting from a lower defect rate - material with multiple slides. focus on right first time. 5 Quality checks are performed on control slides Time can be re-allocated to cover BMS advanced for special stains rather than all slides. cut-up. Reporting (typing Action Why? and authorisation) 1 Implement typing area ‘quiet time’ and/or This will allow dedicated points of contact to be pooled typing resource reporting time-slots nominated daily whilst improving the quality of during agreed periods each day (no answering concentration and productivity of typists. e-mails, remove the fax machine, phones set to silent). 2 Where available, utilise the same system of This will increase secretarial efficiencies and voice recognition / digital dictation reduce time waiting to validate / authorise. consistently. 3 Use of standardised typing check templates This will minimise unnecessary time spent that identify and address issues relating to checking and duplicated checking. errors in specimen coding, assigned pathologists and unrequested specimens e.g. • Specimen list - code • Specimen codes linked to free text • Tabulated by anatomical system for ease of use • Guidance notes regarding the formatting of text • RCP cancer data coding. 4 During planned reporting time, consultants This will alleviate the build-up of cases delivered complete the reporting and authorisation of to consultants who are not available to complete a planned number of cases. To ensure results reporting activities at time of allocation. are made available continually throughout each day, consultants should work with minimum batch sizes, adopting a ‘first in, first out’ approach.www.improvement.nhs.uk
  15. 15. Learning how to achieve a seven day turnaround time in histopathology 15Office activities Action Why?1 Type and issue reports in chronological order. A true ‘first in, first out’ system will ensure that Prevent the occurrence of older reports taking no patient or referrer waits excessively for results longer to despatch than those more recently other than for reasons of a genuine clinical requested. nature.2 Ensure correct Snomed codes are included Reporting software automatically records the when typing is received from reporting staff. correct code right first time, everytime. This can Make use of minimum dataset reporting be used with confidence to search for diagnoses software where possible. Agree departmental of new cancers quickly and when calculating standard work (or standard operating workloads. procedures) for codes to be dictated/written at reporting.All areas Action Why?1 Initiate weekly / monthly performance review To review weekly / monthly performance meetings with representation from all reporting and lateral cancer pathway impacts. laboratory areas, Consultant teams, Clinicians, This improves communication across pathway MDT / Cancer Manager and Commissioners boundaries and allows for issues / escalations to etc. be resolved quickly.2 Send out monthly reports and newsletters To improve communication, promote your communicating current TAT, achievements, improvement work, and delivery against issues etc. guaranteed and predictable TAT’s for users.3 Introduce area-by-area visual management Improves productivity. Progress is visible and showing volumes of specimens, blocks, slides, motivating. cases received (demand), processed and work left to do.4 Initiate five minute daily meetings (huddles) Enables staff to review progress against with all staff around the information board. expectation and encourages ‘stop to fix it’ culture and improves engagement.5 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. www.improvement.nhs.uk
  16. 16. 16 Learning how to achieve a seven day turnaround time in histopathology 10. The nine wastes The key to adding value is to remove waste. Over-processing So, what is waste? Duplication of data or repeat testing due to defects e.g. dual data entry, additional steps and checks. There are nine forms of waste and these can be easily remembered with the mnemonic: Defects Errors, omissions, anything not right first time e.g. poorly labelled specimens and requests, insufficient or illegible information. TIM A WOODS Skills utilisation Transport Unused employee skills e.g. highly qualified staff Material or information that is moved unnecessarily or performing inappropriate tasks. repeatedly e.g. unnecessary movement of samples. Inventory WASTE COSTS MONEY AND ADDS TIME Excess levels of stock in cupboards, store rooms, backlogs and waiting lists e.g. specimens waiting to The following case studies illustrate how the sites move to next step in process, or people waiting for have removed waste from their systems to improve tests and results. turnaround times. Motion Unnecessary walking, moving, bending or stretching e.g. equipment placed in wrong location, unnecessary key strokes. Automating Where technology is substituted to compensate for a poor inefficient process/processes. Waiting Waiting for samples, equipment, staff, appointments or results e.g. patients waiting for test and results, staff waiting for other staff, equipment or information. Overproduction Producing something before it is required, or more than is required e.g. unnecessary / inappropriate tests, batching samples, tests and information.www.improvement.nhs.uk
  17. 17. Learning how to achieve a seven day turnaround time in histopathology 17Case study 1Improving transportation of specimensMusgrove Park Hospital, Taunton and Somerset NHS Foundation TrustSummaryWorking with high volume, on-site High volume users delivery time - July/August 2009 vs July/August 2010Trust users has improved delivery timeswith associated improved flow, which 70%has led to increased numbers of casesbeing processed the same day with 60%subsequent downstream benefits forturnaround times. 50% 2009 2010Understanding the problem 40%Data collected for 2009 indicated that 30%66% of hospital site requests weretaking more than a working day to 20%reach the histology laboratory. 10%• A go and see activity took place with the porter attached to the 0% pathology department 0 1 2 3• Particular problems were noted in DAYS high user specialties/areas such as outpatients, endoscopy and day surgery where clinic sessions often continued to 6:30pm• Outpatients was visited only twice • The acquisition of a new xylene free Ideas tested which were per day with dermatology being the processor has aided the unsuccessful most productive implementation of automated rapid • Difficulties identifying those who• Endoscopy was reliant on their own processing. had any real influence in a given staff to deliver specimens when they area/specialty could which led to batching and Measurable outcomes and impact • Agreements with two users to often only at the end of a session • Improved delivery has enabled modify their delivery times failed or• Day surgery was reliant on theatre processing of smaller batches and were not sustainable support workers to deliver at the improved flow of specimens within • Use of the air tube system for end of a session causing late delivery the laboratory. As a consequence delivery from certain areas failed on• Triage at pathology main specimen more cases are processed the same health and safety and risk after a reception added to the delay and day and others are brought forward rigorous independent assessment created some additional batching. by up to 12 hours in the cycle • High volume users stopped their • Overall the number of cases from current in house delivery practiceHow the changes were the high volume users arriving the which they were asked not to do.implemented same day has improved by 100%• Go and see activity with the • The number of cases rapidly How this improvement benefits laboratory porter which identified processed the same day as receipt patients clinical areas covered within the has improved by 100%. • An additional 20 cases rapid trust processed the same day as receipt• Meetings with high volume users to Ideas tested which were successful • An additional 12 cases per day discuss the specimen delivery data • Go and see activities brought forward into the system by• Trial of temporary dedicated • Engaging with the high volume at least 12 hours histology porter for one month to service users to communicate the • The use of an automated xylene free collect four times per day from high aims of the project and to present processor for rapid processing has volume users current state data reduced the risks associated with a• Specimen volume data collected • Use of the PDSA testing concept to manual rapid process instrument. throughout each day and analysed manage the change – trial of porter• MLAs now carry out two retrievals followed by in house MLAs and per day at 08.30 and 14.30 from modification of collection times. the high user areas and deliver directly to histology, ie no general pathology triage/wait/batching www.improvement.nhs.uk
  18. 18. 18 Learning how to achieve a seven day turnaround time in histopathology How will this be sustained and what is the potential for the future /additional learning? • Further improvements to be identified to smooth specimen flow from source and allow more same day delivery. We need to better understand specimen delivery issues from off site users such as GPs and treatment centres • Further testing of rapid process programmes to allow more same day processing • The benefits from this study have been highlighted to the Trust executive management, who have instigated a portering service improvement initiative across the Trust • Potential to increase MLA collection frequency and extend to other service users subject to staffing levels/investment • Service user engagement will be maintained and extended. Contact Garry Sweet Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust garry.sweet@ydh.nhs.ukwww.improvement.nhs.uk
  19. 19. Learning how to achieve a seven day turnaround time in histopathology 19Case study 2Reducing the waste in the further work processMusgrove Park Hospital, Taunton and Somerset NHS Foundation TrustSummary • This was tested for six weeks and its Ideas tested which wereIntroduction of an Excel database to usage was reviewed (using the PDSA unsuccessfulallow multiple pathologists to cycle). Due to the benefits of the The database required some softwaresimultaneously request extra work system, it was fully implemented ‘tweaks’ to allow it to be used by largefrom the laboratory. and confirmed as the new standard departments with more than 10 way of working. pathologists. Some pathologists do notUnderstanding the problem like using computers.The previous system of requesting Measurable outcomes and impactextra work required pathologists to fill • The database has eliminated wasted How this improvement benefitsin paper slips and place them in a movement of 208 kilometres per patientsrequest box in the laboratory. They annum; approximately 60 hours It allows extra work requests to bewere then transcribed by lab staff into of walking by pathologists correctly processed, first time everyan extra work book. Problems • It has eliminated illegible requests time, and improves turnaround times.included:· and transcription duplication of• Wasted movement - average of 38 requests How will this be sustained and metres covered on a daily basis • The progress of requests can be what is the potential for the future• Illegible writing - 5% not processed easily tracked by pathologists and /additional learning? right first time lab staff In-house development of software is• Duplication by transcription of paper • Later copies of the database were an under-exploited solution to work slips in to request book given to the other labs participating flow problems. Labs are often• Difficulties in tracking progress of in the national pilot project and constrained by immutable commercial request many of these labs are now using software. Labs should be encouraged• Forgotten requests - approximately the database. to pursue their own software 2% solutions.• Duplicate requests - approximately Ideas tested which were 1%. successful Contact The database was accepted by staff asHow the changes were an improvement. One pathologist Musgrove Park Hospital, Taunton andimplemented described it as "the best thing to Somerset NHS Foundation Trust• The problem was discussed at a come out of the project". fred.mayall@tst.nhs.uk daily huddle and an Excel database was developed in house, with conditional formatting that used colour to flag the status of requests• The Excel database could be shared across the network to allow multiple pathologists to simultaneously view the progress of requests and add new requests. Commonly used requests could be chosen from a drop down menu www.improvement.nhs.uk
  20. 20. 20 Learning how to achieve a seven day turnaround time in histopathology Case study 3 Reducing defects at slide labelling University Hospital of North Tees, North Tees & Hartlepool NHS Foundation Trust Summary Labeling slides at section cutting has Before improvement reduced transcription errors by 60%. Process Random Sort Attach Match Ensuring cases are kept together from and embed section Label in Stain into printed with QC pencil blocks to slides facilitates faster QC in cases cutting cases label form with 2 hours of wait time and 1.5 8 step process hours of MLA time saved daily. The 2 sorting steps 2 labelling steps latter has addressed a CPA non compliance through the introduction of block checking. Block check Process Section Sort Attach Match Label Understanding the problem and embed in cases cutting in cases slide Stain into cases printed label with form QC Value stream mapping highlighted 7 step process work in progress backlogs 1 sorting step After improvement accumulating at QC due to incomplete Lab staff time - BMS staff no change, 1.5 hours MLA time used to block check 1 labelling step 1 additional QC step cases moving along laboratory Specimen wait time - reduced by 2 hours Quality - 43% reduction in errors in first month processes between section cutting, - 70% reduction in errors to date staining and QC. A department audit Set up time is longer (sorting into cases, printing of labels) but this is done in revealed that 74% of laboratory non- parallel as the blocks are on the processor, therefore, there is no overall impact to lead time. Reduction in lead time is gained at the QC end of the process. conformities were transcription errors at section cutting / slide labelling. From observed practice and presentations at other pathology departments and conferences, it was • Defects - has been reduction in How this improvement benefits decided to adopt slide labeling as non-conformities arising from patients sections were cut as whole cases at a transcription errors from 74% to • Overall quality has improved from time. Additionally, slide labelling was 20% reduction in laboratory generated time consuming which delayed cases • Over Processing - cases were being errors and duplicated effort of Bio-Medical split at section cutting and sorted • Delivery is quicker as slides are Scientists (BMS) and Medical back into cases at QC stage - available sooner for reporting Laboratory Assistants (MLA). duplication in effort was removed • Time has been released to allow an saving 1.5 hours of MLA time daily. additional QC step as required by How the changes were CPA implemented Ideas tested which were successful • Labels are printed at data entry and Adopting the slide labeling approach How will this be sustained and attached to request form used across other Histology labs what is the potential for the future • Blocks and associated request forms proved to be relevant. /additional learning? / labels kept together throughout All staff now recognize the direct section cutting, staining and Ideas tested which were benefit of removing laboratory non- collation unsuccessful conformities and improving safety by • Sections are cut and labelled with Labelling the slide with the printed keeping whole cases of slides slide label before staining· label only. Governance concerns raised together; all of which can be achieved PDCA cycles undertaken to ensure by Pathologist staff (both internally without additional resource. An correct placement of the label on and at referral centres), and the ongoing audit will ensure the slide possibility of labels lifting from slides, measurement against a zero tolerance resulted in the department returning goal. Measurable outcomes and impact to labelling the slide in pencil before Wastes removed adding the printed label. Although Contact • Motion - there is significant slightly more time consuming, the Sharron Williams reduction in matching up forms and overall impact is minimal and does not University Hospital of North Tees, slides detract from the benefits of this North Tees and Hartlepool NHS • Waiting - cases now move to the change. foundation Trust reporting stage 2 hours earlier sharron.williams@nth.nhs.ukwww.improvement.nhs.uk
  21. 21. Learning how to achieve a seven day turnaround time in histopathology 21Case study 4Stopping the overproduction of spare unstained slidesThe Leeds Teaching Hospitals NHS TrustSummary Measurable outcomes and impact Contact50 days of staff time have been • No recorded clinical incidents due to Jane Ramsdalereleased annually by addressing lack of spare sections. Lack of spare The Leeds Teaching Hospitalsoverproduction of spare unstained sections necessitated further NHS Trustslides from small biopsy specimens. sectioning for only 0.6% of cases jane.ramsdale@leedsth.nhs.ukProjected annual cost savings of (for further work or if original H&E£1,229 in consumables have been slide was irreparably broken).·identified. By reducing the number of spare unstained sectionsUnderstanding the problem • 279 hours of sectioning time• Waste of unstained slides was released, equating to 37 working identified when walking the lab days annually pathway • 103 hours of time spent producing• Spare unstained sections had labelled slides released, equating to automatically always been taken 13 working days annually· from small biopsies at initial Estimated £1,229 saved annually microtomy from consumables budget.• Affected approximately 250 blocks per day How this improvement benefits• For some specimen types, spare patients sections were used on very rare By freeing up the equivalent of an occasions extra staff member one day a week,• Valuable staff time was involved in the capacity for sectioning has boxing the spares and disposing of increased. This alongside other them· Spares were stored for at measures has seen the lab block least two months in several large backlog (peaked at c.5,000) being heavy boxes reduced to nil (August 2010).• Large quantities of slides were being disposed of with cost implications. How will this be sustained and what is the potential for the futureHow the changes were /additional learning?implemented By reducing one of the seven wastes• Pathologists identified that spare identified during the original waste unstained sections were not required walk, staff have been able to for gastric, cervical and small / large appreciate the positive effect of bowel biopsies tackling wastes. It has been a surprise• Sectioning protocols were changed to see how one small change has accordingly released so much time and saved so• Pathologists provided feedback if much money. lack of spare sections caused problems. www.improvement.nhs.uk
  22. 22. 22 Learning how to achieve a seven day turnaround time in histopathology Case study 5 Reducing wasted skills Birmingham Womens NHS Foundation Trust Summary • Secretarial time spent on • The administration team have re- Implementation of a digital dictation amendments took approximately organised the work and are now system has reduced the waste of skills one day per week equating to available to provide more support to and contributed to a reduction in £4,000 per annum secretarial time pathologist staff and the laboratory turnaround time. • The double checks by pathologists team added a further day per week of • The majority of reports are typed Understanding the problem wasted Pathologist time which and sent the same day as the • Secretaries typed reports for the equates to £15,000 per annum. specimen was made available to pathologists from handwritten Delay at this step when reports report. This is having a positive documents or analogue dictated needed amendments could add two impact on morale within the tapes to five days to turnaround times department and is evident in the • No system to drop off or pick up the • Difficulty deciphering handwriting or daily staff meetings and the staff reports and the Pathologists had to difficulty hearing the report due to survey physically deliver the work to the poor quality tapes would slow down • Length of dictation can be easily office (some worked in a different the process for the secretaries and seen allowing admin team to more building creating further transport contribute to the rework at the first effectively manage the work problems and delays) check. • Very urgent reports are highlighted • Batching caused backlogs and in red so that they can be prioritised periods of time when there were no Wastes addressed by this improvement • There is no lost dictation tapes to process activity - Transport, motion, defects, • There is now clear, audible dictation • Several reports would be dictated waiting, human potential. leading to fewer errors onto one tape. As only one • Pathologists dictate name and date secretary could type from the tape How the changes were of birth so that secretaries can remaining reports queued and were implemented immediately type with no need for a delayed further • A digital dictation system was card check • There were times in the office when purchased from an office supplier at • Typed reports can be checked by no work had arrived and times of very low cost pathologists immediately in their great pressure. The pressure to get • Two pathologists conducted a trial own office and sent to print out the reports and keep the and once the initial problems had • The three day turnaround time has backlog down also resulted in more been addressed all but one of the improved from 41% to 77% errors remaining Pathologists adopted the • Most of the time one secretary can • Each day work had to be carried new system manage the workload in the office . over and this led to delays in reports • Initially the team continued to work Three staff are then re-deployed in going out. with existing processes e.g. other parts of the department until matching dictation to request forms. required to type reports. This Manual data capture was used to They then started to identify equates to £60,000 of resource. record when reports were delivered to improvements and make changes. the office, how long each report took to type, and how long it had been Measurable outcomes and impact waiting in the office to be typed. A The introduction of digital dictation defect log was also recorded. resulted in the following benefits: • Baseline performance of three day • Reports arrive electronically as soon turnaround times was 41% as the pathologist has dictated • Delays from specimen available to them, removing pathologist time report sent for a significant number spent transporting tapes and the of cases was as long as a month and subsequent delay before typing typically four days starts • A lost or damaged tape could take • The reports can flow one at a time one hour of pathologist time to be instead of being batched which reworked which equates to £1900 means secretaries can manage the per annum workflow more easily and • All reports were checked twice by turnaround the reports as soon as the pathologists and 30% required they are dictated amendments before the second check when they would be authorised to send outwww.improvement.nhs.uk
  23. 23. Learning how to achieve a seven day turnaround time in histopathology 23Ideas tested which were successful• Removing excessive checks in the process• Removing the need for the copy referral card to be used to identify the patient by ensuring Pathologists dictate a standard identifier for each patient.Ideas tested which wereunsuccessful• Six of the pathologists adopted the system immediately. One pathologist took longer to be convinced and adopt the change• The system does not easily allow pathologists to dictate at cut-up and a solution to this problem is being worked on• The current IT is an obstacle preventing the electronic authorisation of the report.How this improvement benefitspatients• This has resulted in speedier results to referring clinicians allowing patient treatment to be commenced earlier.How will this be sustained andwhat is the potential for the future/additional learning?• The improvements have already proven to be sustainable· Further refinements to the process and technology are being planned.ContactTervinder SokhiBirmingham Womens NHSFoundation Trusttervinder.sokhi@bwhct.nhs.uk www.improvement.nhs.uk
  24. 24. 24 Learning how to achieve a seven day turnaround time in histopathology Case study 6 Reducing the QC of slides leaving the laboratory University College London Hospital NHS Foundation Trust Summary • Number of slides returned by Microscopic checking of every slide pathologists with errors associated Ideas tested which were successful leaving the laboratory has ceased. with the error log list collected • Removing duplicated quality checks 360 hours of BMS time saved before and after the removal did not result in increased errors annually. microscopic QC stage escaping to the next process. Contributed to reduction in laboratory • Collating and microscope checking turnaround time from 1.5 days to 0.8 staff used error tracking book (inc. Ideas tested which were days. tick boxes) unsuccessful • One senior was nominated daily to Initially ran the QC checking stage at Understanding the problem be in charge of work through the collation bench with same staff • A microscopic check of every stained lab. This enabled closer association (MLAs). Senior BMS of the day slide before leaving the laboratory with staff in the collating area interacted in more proactive way with covered the quality of staining, • Daily case list generated and ticked collating staff. orientation, quality of section, tissue off by the collating staff to enable type correlation and patients details continual verification on the LIMS of How this improvement benefits • A visual check for the same quality cases leaving the laboratory patients issues was also being completed in • Isolation of one QC step for small • Work now moving through the collating area before the and resection material decreased the analytical laboratory stage to microscopic check batch sizes of cases leaving the consultants faster • Checks caused delays to slide laboratory • Marked improvement in the level of availability for pathologists to screen • Microscope QC stage for small and right, first time work • Quality checks were not applied in resection material was stopped • Used change in conjunction with standard way (despite SOP). • Only 25% of slides of any one case others to cut total end to end turn of biopsy material with multiple around time for laboratory phase for How the changes were slides microscope checked 90% of our work in one working implemented • Only control slides for special stains day. • Quality check process and specimen microscope QCd for each case types assessed to check if all or • All control slides kept and dated How will this be sustained and some of the wastes of until the appropriate audit is carried what is the potential for the future duplication/overprocessing could be out /additional learning? removed. Decided initially to • Random sample of special stained • Continue using the patient pathway microscopically check only slides/cases audited every three analyser to highlight areas of waste biopsy/skin lesion and special stains months as part of an audit for false • Variation from new standard • Moved on to reduce the % of negatives. operating procedures will be biopsy/skin lesions checked, monitored checking only control slides for Measurable outcomes and impact • Ensure all staff understand standard special stains • Quality defect rate has dropped operating procedures are key to • TAT data was collated to evidence from 2% to 1% and any good process and any suggested the process before and after mismatches or other issues now changes need to be discussed by all changes identified at the collating bench of the staff • Minor error log for microscope and where they are corrected • Staff have clear instructions and an collating area was compared and list • SPC charts showed the decrease in understanding of the task through of minor errors tabulated to identify process and batch sizes had the competency procedure that. only those areas relevant to both. decreased TATs from the laboratory Errors included patient (booking in to release from lab) from Contact demographics, specimen type and 60% in 1.5 days to 90% in 0.8 Gary Brown number of pieces and quality of days University College London Hospital staining and section • Audit of special stained slides/cases NHS Foundation Trust • Percentages of work sent back for showed no false negative results gary.brown@UCLH.nhs.uk repeat work against this list was • Total annual time saved from collected removing duplicated quality • Statistical process control (SPC) checking amounted to 360 hours. charts generated to confirm if This was re-assigned to cover AP process was speeded up by changes cut-up short fall in specialist registrar • Error type and percentages also numbers. monitored to evidence impact of changeswww.improvement.nhs.uk
  25. 25. Learning how to achieve a seven day turnaround time in histopathology 2511. A3 thinking for problem solvingAn A3 is literally a one-page, A3 size document that Describing the entire process - from current state,records the agreed problem statement, its 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 to seek aThe report template itself serves as a guide for better way forward. Distilling the information to onlyunderstanding a problem, identifying the point of the most relevant details for communication to thecause and eventual true root cause in a systematic rest of the team ensures that a thoroughway. It serves as a collaborative problem solving tool. understanding of the issue has been attained.Beginning with a consensus on the problem or issue A precise A3 report prevents massive amounts ofyou are trying to solve, the left hand side of the page information being misinterpreted and inappropriateis completed to document the current state. The right conclusions being reached by a multitude of staff.hand page is the innovative or experimental approach The best A3s convey the understanding of theto solving the issue towards the future state. problem and analysis without any explanation. Often, a graphical or pictorial representation of the issue atSince Lean is primarily the description of a hand is better than a text summary.methodology to routinely solve problems everyday sothat the daily work is delivered to specification, A3 The A3 report itself represents a shared understandingthinking is the rigorous application of the Plan, Do, of the consensus of opinion on solving the problem.Study, Act (PDSA) approach. As a document, it encourages reflection on the learning that has taken place and ensures that aIt is the structured thinking that is of most consistent message is able to be discussed andimportance, the A3 report is of no significance in the scrutinized. Ultimately, it allows the team to ensureabsence of structured, agreed understanding and that an agreed action plan is followed.thought processes. www.improvement.nhs.uk
  26. 26. 26 Learning how to achieve a seven day turnaround time in histopathology Case study 7 Using A3 thinking Derby Hospitals NHS Foundation Trust Summary Having fully understood the problem, The action plan was used and updated A3 thinking provides a structured evidenced the current state and throughout the process to remind the approach to identifying and resolving identified the wastes the team moved team to go see, collect data, to ask problems and issues within the on to root cause analysis using the what often felt like obvious questions histology process. fish-bone technique, deciding on the and most of all to communicate to the specific problem and attributing the wider team/department what was Understanding the problem causation factors to the appropriate happening. Value stream mapping by the core arms of the fish-bone. As with all the team visualised the value steps in the preceding steps this required great As the future state and counter service from the users perspective and thought and discussion and, finally, measures were agreed, PDSA cycles highlighted areas for improvement. agreement. were also added to the action plan with time-frames and measures. After evaluating the value stream map Some team members found the time it and considering staff feedback and took to complete the left hand side of The team went on to use A3 thinking suggestions, the core team identified the A3 frustrating and wanted to go to steer their work on the big problems that appeared to be straight to Future State and the Action • Small batch working having the greatest impact on plan. Having invested the time • Pull system turnaround times. however it was clear that all of this • Externally created errors work ensures the team knows exactly • Internally created errors These gut instincts and hunches what the problem is (having started • Transport needed to be investigated and with a vague statement), what is • Immunohistochemistry. supported by data but the team ended happening in the current state and up with lots of data with little agreed what the root causes are. All this way forward. preparation ensures that the future state and countermeasures are How the changes were designed to address the right problem. implemented The core team was facilitated through their first A3 document which focused on the current push system used to distribute work to consultants. Rather than using A3 paper, the team used flipchart paper to create something that would be easier for all to see and contribute to. First the problem was defined as best as the team was able given their limited investigation so far. The current state was partially represented by the data already collected and the team agreed what else they needed to collect and validate. The current state was further evidenced using photographs, graphs and diagrams. When identifying wastes the team found that some headings didnt apply to the problem in hand but others had a long list. The first and biggest A3 - push system for distributing work to consultants. It now takes up a whole wallwww.improvement.nhs.uk
  27. 27. Learning how to achieve a seven day turnaround time in histopathology 27Transport A3Internal defects A3 www.improvement.nhs.uk