Learning how to achieve a seven day turnaround in histopathology

NHS
NHS Improvement

CANCER

DIAGNOSTICS

HEART

NHS Improvement

With over ten years practical service improvement experience in cancer, diagnostics
LUNG
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©NHS Improvement 2010 | All Rights Reserved
Publication Ref: IMP/comms004 - November 2010

NHS
NHS Improvement

CANCER

DIAGNOSTICS Learning how to achieve a seven day
turnaround time in histopathology
HEART
Clinical excellence in partnership
“
with process excellence”
LUNG

STROKE

Learning how to achieve a seven day turnaround time in histopathology 3

Contents

1. 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 meet
2. Executive summary 5 the demand?
Case study 10 - Daily visual 36
3. Introduction 6 management used to plan, monitor Case study 25 - Managing the 67
Why Lean as the methodology of and act on pathway performance consultant workload with a points
choice? Case study 11 - Visual management 38 system

4. 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 all
6. Understanding where you are 9 re-sequencing stakeholders 70
What 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 sustainability
7. How to begin 11 Case study 14 - Increasing workflow 46 How leadership affects staff
Team make-up, the wider team, through scheduled cut-up engagement
executive support and involving users Case study 15 - Introducing a 47
consultant ‘pull’ system to smooth Case study 28 - Using ‘huddles’ to 73
8. Establish the measures 12 reporting flow improve team communication
Identifying and measuring factors Case study 16 - Improving flow of 49 Case study 29 - Staff engagement 76
which impact overall turnaround time specimens through the lab using an ideas bank
Case study 17 - Improving consultant 51
9. 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 82
10. The nine wastes 16 histology on MDT meetings
Case study 1 - Improving 17 Case study 19 - The link between 55
transportation of specimens future state mapping, A3’s and RCA 23. Workcell design 83
Case study 2 - Reducing the waste in 19
the further work process 16. 5S 56 Case study 33 - Work cell design in 84
Case study 3 - Reducing defects at 20 Using 5S to improve safety and morale the main laboratory
slide labelling
Case study 4 - Stopping the 21 Case study 20 - Visual SOP facilitates 57 24. Accelerating implementation 86
overproduction of spare unstained 5S in the cut-up room
slides Case study 21 - Using 5S principles to 58 Case study 34 - Accelerating the pace 87
Case study 5 - Reducing wasted skills 22 improve laboratory organisation of change
Case study 6 - Reducing the QC of 24
slides leaving the laboratory 17. Standard work 59 25. NHS Improvement contact 89
The best way to perform each process details
11. A3 thinking 25 step
What it is and how to produce an A3
Case study 22 - Standardising 60
Case study 7 - A3 thinking 26 preparation for MDT
Case study 23 - Using technology to 61
12. Root cause analysis (RCA) 29 enable standard work - introduction of
Techniques to determine the ‘Lysis’ templates in specimen
true cause of a problem processing

Case study 8 - Using A3s and RCA to 31 18.Takt time 63
improve the use of the specimen What it is and how it can be used to
dissecting room level the workload
Case study 9 - Root cause analysis to 33
reduce defects Case study 24 - Takt time used to 64
match specimen reception capacity to
demand


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 Health



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 barriers
2. Executive summary Empowered staff
• who own the problem, find the solutions and
‘stop to fix’
In 2006 the Review of Pathology Services in England
by Lord Carter endorsed Lean as the method of Effective transport
choice for improving processes in pathology services. • transport is critical to achieving flow and
Working in partnership with the Department of needs to be owned by the laboratory
Health Pathology Programme, NHS Improvement
supported nine pilot sites to test the Lean Optimise technology
methodology to demonstrate how to deliver a seven • using electronic ordering systems, voice
day service and make improvements in quality, safety activated and digital technology solutions will
and productivity. improve safety and reduce turnaround
times.
Multidisciplinary teams worked collaboratively to test
and implement changes that deliver improvements for
patients, staff and users of the service.

Staff were trained to apply Lean methodology to their This guide provides clinical teams with the basic
work, the intention being to ensure continuous tools to make changes to their processes, along
improvement beyond the period of NHS Improvement with insight into how phase one pilot sites have
involvement. In addition, clinical leadership in used these tools across the whole patient
improvement methodology sessions were facilitated pathway.
for consultant histopathologists and specialist
registrars to highlight the need for leadership in
continuous improvement.

Over 157,000 patients will have benefited from the
improvements in:

Turnaround times: 95% of test results available for
treatment 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 requests

Innovation: Using simple visual management
techniques to improve flow, safety and productivity.

Productivity: Eliminating non value added steps,
ensuring appropriate utilisation of workforce,
demonstrating the capacity required based on the
demand, and ensuring technology is used effectively.



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.



4. Phase one pilot sites

The following sites were selected as phase one pilot Pilot sites and leads:
sites. One of the criteria for joining the programme
was to become an exemplar site, prepared to share Birmingham Women’s NHS Foundation Trust
learning with other teams. Lead: Tervinder Sokhi

Clinical teams will benefit from visiting phase one Derby Hospitals NHS Foundation Trust
exemplar sites, to observe Lean methodology as part Lead: Andrea Gooding
of everyday working and understand how the
improvements have been achieved. The Leeds Teaching Hospitals NHS Trust
Clinical Lead: Dr. Pat Harnden
The 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



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!



6. Understanding where you are

Measuring the performance of your To determine the impact of changes made in the
histopathology 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 statistical
understanding of what is actually happening, as process control charts (SPC) produced to evidence
distinct from what ‘should be’ or is thought to be achieved improvements.
happening. Identifying the current situation should
include the whole journey of the specimens, not just Recommendations include:
in laboratory processes. • Date/time booked in
• Date/time cut-up
The best way to do this is to ‘go see’. This means to • Date/time completed on processor
physically walk the whole pathway and produce a • Date QC’d
photographic record of the process. It is • Date reported
recommended that this is done by the whole core • Date typed
team to ensure objectivity. • Date of authorisation (available).

The pathway should then be graphically represented A sample data collection spreadsheet can be found on
as a current state value stream map. Measurements the NHS Improvement website.
taken as part of value stream mapping will provide
the 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 a
Every task undertaken while processing samples will statistically valid baseline TAT.
have an impact on achieving the 95% of specimens in
seven days turnaround time (TAT) and should Calculating and monitoring TAT – Using
therefore 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 key
the 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 are
To capture a clear and accurate TAT measure, data reduced over time as a result of improvement
should be collected for all three key stages of the changes.
histopathology pathway:
SPC charts provide a graphical representation of the
1. 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.



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 time



7. How to begin

Team guidance Wider team membership/steering group
Begin by identifying a credible and respected project A wider team of key stakeholders from across the
lead to head up the team. This could be a clinician or pathway should provide regular input and support but
manager 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 support
Project team members should be drawn from across An executive team sponsor should be identified to
the 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 project
Core 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.



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.



9. Key enablers to specimen flow

This section is designed to help teams make changes To support these recommendations, case studies
that have been tested and proven to make a demonstrate how sites have implemented these.
significant difference to turnaround times across end-
to-end specimen pathway

All parts of the process are covered. Changes should
be implemented in a planned and structured way,
guided by the core project team and project lead.
Measures should be in place to track improvements
and 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.



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.



Office 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.



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.



Case study 1

Improving transportation of specimens
Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust

Summary
Working with high volume, on-site High volume users delivery time - July/August 2009 vs July/August 2010
Trust users has improved delivery times
with associated improved flow, which 70%
has led to increased numbers of cases
being processed the same day with 60%
subsequent downstream benefits for
turnaround times. 50%
2009 2010
Understanding the problem 40%
Data collected for 2009 indicated that
30%
66% of hospital site requests were
taking 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 practice
How 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



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.uk



Case study 2

Reducing the waste in the further work process
Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust

Summary • This was tested for six weeks and its Ideas tested which were
Introduction of an Excel database to usage was reviewed (using the PDSA unsuccessful
allow multiple pathologists to cycle). Due to the benefits of the The database required some software
simultaneously request extra work system, it was fully implemented ‘tweaks’ to allow it to be used by large
from the laboratory. and confirmed as the new standard departments with more than 10
way of working. pathologists. Some pathologists do not
Understanding the problem like using computers.
The previous system of requesting Measurable outcomes and impact
extra work required pathologists to fill • The database has eliminated wasted How this improvement benefits
in paper slips and place them in a movement of 208 kilometres per patients
request box in the laboratory. They annum; approximately 60 hours It allows extra work requests to be
were then transcribed by lab staff into of walking by pathologists correctly processed, first time every
an 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 as
How the changes were an improvement. One pathologist Musgrove Park Hospital, Taunton and
implemented 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



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.uk



Case study 4

Stopping the overproduction of spare unstained slides
The Leeds Teaching Hospitals NHS Trust

Summary Measurable outcomes and impact Contact
50 days of staff time have been • No recorded clinical incidents due to Jane Ramsdale
released annually by addressing lack of spare sections. Lack of spare The Leeds Teaching Hospitals
overproduction of spare unstained sections necessitated further NHS Trust
slides from small biopsy specimens. sectioning for only 0.6% of cases jane.ramsdale@leedsth.nhs.uk
Projected 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 sections
Understanding 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
How 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.



Case study 5
Reducing wasted skills
Birmingham Women's 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 out



Ideas 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 were
unsuccessful
• 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 benefits
patients
• This has resulted in speedier results
to referring clinicians allowing
patient treatment to be commenced
earlier.

How will this be sustained and
/additional learning?
• The improvements have already
proven to be sustainable· Further
refinements to the process and
technology are being planned.

Contact
Tervinder Sokhi
Birmingham Women's NHS
Foundation Trust
tervinder.sokhi@bwhct.nhs.uk



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 (MLA's). 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 patient's 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 QC'd 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
changes



11. A3 thinking for problem solving
An A3 is literally a one-page, A3 size document that Describing the entire process - from current state,
records the agreed problem statement, it's analysis, through analysis to future state on a single sheet of
potential counter measures and the action plan to paper requires concise information. Creation of an
resolve. A3 necessitates logical discussion and thinking - with
ultimate agreement on experimentation to seek a
The report template itself serves as a guide for better way forward. Distilling the information to only
understanding a problem, identifying the point of the most relevant details for communication to the
cause and eventual true root cause in a systematic rest of the team ensures that a thorough
way. 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 of
you are trying to solve, the left hand side of the page information being misinterpreted and inappropriate
is 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 the
to solving the issue towards the future state. problem and analysis without any explanation. Often,
a graphical or pictorial representation of the issue at
Since Lean is primarily the description of a hand is better than a text summary.
methodology to routinely solve problems everyday so
that the daily work is delivered to specification, A3 The A3 report itself represents a shared understanding
thinking 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 a
It is the structured 'thinking' that is of most consistent message is able to be discussed and
importance, the A3 report is of no significance in the scrutinized. Ultimately, it allows the team to ensure
absence of structured, agreed understanding and that an agreed action plan is followed.
thought processes.



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 didn't 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 wall



Transport A3

Internal defects A3


Learning how to achieve a seven day turnaround in histopathology

Learning how to achieve a seven day turnaround in histopathology

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