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Learning from the pathology service improvement sites
 

Learning from the pathology service improvement sites

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As referred to in the Carter review, this publication demonstrates that achievements can be made rapidly, for little or no cost. (Aug 2006).

As referred to in the Carter review, this publication demonstrates that achievements can be made rapidly, for little or no cost. (Aug 2006).

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    Learning from the pathology service improvement sites Learning from the pathology service improvement sites Document Transcript

    • NHS Pathology Service ImprovementLearning from Pathology ServiceImprovement Pilot Sites andImprovement ExamplesAugust 2006 Supported by the NHS Cancer Services Collaborative ‘Improvement Partnership’
    • READER INFORMATIONPolicy EstatesHR/Workforce PerformanceManagement IM & TPlanning FinanceClinical Partnership WorkingDocument Purpose Best Practice GuidanceROCR Ref: Gateway Ref: 6884Title Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesAuthor Pathology Service Improvement TeamPublication date 14 August 2006Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs, Medical Directors, PCT PEC Chairs, GPs, Pathology DepartmentsCirculation List Service Improvement LeadsDescription As referred to in the Carter review “Learning from the Pathology Service Improvement Pilot Sites” clearly demonstrates that achievements can be done rapidly, for little or no cost. The improvements outlined in the document show immediate results to motivate others to accelerate the pace of change and demonstrate significant efficiency gains.Cross Ref Modernising Pathology Services (DH 2004)Superseded Docs N/AAction Required N/ATiming N/AContact Details Pathology Service Improvement Team 3rd Floor, St John’s House House, East Street, Leicester, LE1 6NB Tel: 0116 222 5113 Web: www.pathologyimprovement.nhs.uk
    • “ I think this project has given us the opportunity to scrutinise and improve parts of the pathology service. Seeking the views on what the service means to practices and surgery staff has been carried out too infrequently.” PCT Service Development Facilitator
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Contents Foreword 6 1 Executive summary 7 2 Introduction – Why Service Improvement? 8 3 Background to project 9 4 Pilot sites 10 5 Developing the learning 11 6 Involving patients and developing user engagement 12 Key findings from patients 12 • Patient Line of Sight (PLS) methodology 13 Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust • Establishing patient focus groups and user forums 14 Calderdale and Huddersfield NHS Trust • Using patient views to improve anticoagulation services 15 North East London Strategic Health Authority 7 Process improvement 16 Improving flow, eliminating waste 16 • Understanding the impact of delays in transport 17 Coventry and Warwickshire Pathology Network • Transport issues affecting patients attending 18 hospital for phlebotomy services Blackpool, Fylde and Wyre Hospitals NHS Trust • Removing non value adding steps 19 Blackpool, Fylde and Wyre Hospitals NHS Trust • Improving flow in specimen reception 21 Blackpool, Fylde and Wyre Hospitals NHS Trust • Reducing steps and hand offs in specimen reception 22 Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust • Reducing waiting times for patients by implementing 23 Point of Care Testing (POCT) North East London Strategic Health Authority • Identifying waste in pathology pathway 24 Calderdale and Huddersfield NHS Trust • Using 5S to remove waste in specimen reception 25 Coventry and Warwickshire Pathology Network4 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples8 Understanding demand, utilising capacity 26 Demand management • Understanding variation in demand for diabetic screening tests 27 Blackpool, Fylde and Wyre Hospitals NHS Trust • Reducing unnecessary/duplicate requests 28 for thyroid function testing (TSH) Coventry and Warwickshire Pathology Network • Reducing inappropriate testing for thrombolytic patients 29 Coventry and Warwickshire Pathology Network • Reducing inappropriate urine requests in microbiology 30 Royal Devon and Exeter NHS Foundation Trust Optimising staff skills and utilisation • Improving staff utilisation to match demand 31 Blackpool, Fylde and Wyre Hospitals NHS Trust • Understanding service demand and staff capacity 33 Calderdale and Huddersfield NHS Trust Royal Devon and Exeter NHS Foundation Trust • Improving clinical Information on immunology requests 34 to release staff capacity Royal Devon and Exeter NHS Foundation Trust • Introducing BMS cut up to release Consultant Histopathologist time 35 Royal Devon and Exeter NHS Foundation Trust Maximising technology • Introduction of Point of Care Testing (POCT) to reduce 36 turnaround times in A&E Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust • Introducing histology robotics to maximize available skill mix 37 Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust • Introducing automated liquid based cytology to reduce waiting 38 times for cervical screening results Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust9 Learning for future improvement teams 3910 Building for sustainable change 4111 References, resources, information, acknowledgements 43 and further reading www.pathologyimprovement.nhs.uk 5
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Foreword Pathology service improvement has played a key role in the Department of Health’s Modernising Pathology Programme. The National Pathology Service Improvement Team has helped to raise the profile of pathology and provided practical support across the NHS to put in place key improvements in laboratories. The Team’s work with the six pilot sites funded by DH to implement the tools and techniques of pathology service improvement in laboratories has developed vital learning for other pathology services. Their work - set out in this report - shows that service improvement in pathology delivers effective change and supports an improved service for patients and benefits for staff. Pathology has an important role to play in delivering improved choice and a more convenient health service for patients. The practical learning in this report is a key tool in bringing that about. Dr Ian Barnes National Clinical Lead for Pathology, Department of Health6 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples1. Executive summaryThe pathology service improvement pilot sites set out on a journey to test service improvement and Leanprinciples across the whole patient pathway. The pilots were funded by the Department of Health to testimprovements over a period of 12 months starting in April 2005.The key principles of the work were to compress time, reduce turnaround times, reduce the steps that add‘no value’ to the patient, maximise staff skills and use technology effectively. The focus was to meet theneeds of patients and clinical users.The learning demonstrates that:• achievements can be made rapidly, for little or no cost, demonstrating immediate results that motivate others to accelerate the pace of change, and deliver significant efficiency gainsExamples in this document include:• releasing 1.5 hours per week of non productive time by reduced staff motion• 50% reduction in average sample processing times, by reducing batching of specimens and introducing one piece flow• 50% reduction in phone calls in specimen reception• 36% increase in number of samples labelled per hour• 66% reduction in processing times in histopathology• releasing 2.5 consultant sessions per week in histopathology• 100% of patients seen in 20 minutes by introducing Point of Care Testing (POCT)Service improvement should not be seen as a one off improvement initiative that ticks a box to satisfyobjectives. Equally it must not be something that is ‘done to’ teams, where those with improvement skillswalk away without leaving a ‘legacy of learning’ to support continuous improvement. The improvementphilosophy needs to be part of the organisational culture, that gives pathology staff:• skills they can use in their everyday working life• an opportunity to learn by doing• the ability to continually look to improve flow by removing waste• a patient focused approach to service provisionWhilst Lean Improvement is the methodology of choice for pathology, it will not replace the need fororganisations to focus on a sound implementation strategy based around the key success factors of:• effective clinical leadership and executive support• involvement of ALL pathology staff• investment in dedicated time out, to reap huge rewardsWe hope you find the examples of improvement and learning useful.Ann Eason Lesley WrightNational Manager Associate DirectorPathology Service Improvement Diagnostics www.pathologyimprovement.nhs.uk 7
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples 2. Introduction Why service improvement? Service improvement tools and Protected time out techniques as rigorously applied by the pathology service improvement Equally important, is the opportunity The DH publication, Modernising pilot sites have resulted in: to provide sufficient protected time Pathology Services (Feb 2004), out to give staff the opportunity to recognises the role service • patient focused pathology service test and implement change. improvement and redesign has to provision Sacrifices made in quality time out is play in providing modern pathology • lean processes that ensure clinical a small investment that needs to be services. Such services should be excellence is supported by process made, compared to the potential responsive to the challenges posed excellence gains that can be made to reap the by new scientific and technical • timely and reliable services rewards for the future. developments, changing practice • appropriate utilisation of staff and patient expectations. Finally, we cannot solve the • increased cost effectiveness • improved efficiency and service problems by looking at data alone The core principles of service flexibility and theorising about a solution. We improvement are to: • optimised use of capacity need to fully understand the actual • ensure the patient is at the heart situation, identify the root cause and of the service implement the correct solution. • streamline processes by eliminating Key factors for successful non-value adding steps service improvement • utilise staff skills appropriately • maximise the use of technology Leadership and strategic support The pathology service consists of a series of processes essential to Experience from all previous service provide value for patients and clinical improvement initiatives has taught users. To maximise value and us that success is dependent upon eliminate waste, it is important to strong effective leadership and fully understand the process. Value strategic support. The commitment must flow across the entire pathway, must start at the top of the ensuring the needs of patients and organisation and involve a whole users are met. system redesign. This is also true for pathology. The process of improving To ensure patients flow through the pathology services cannot be system, whilst receiving quality and achieved by the purchase of timely care, it is essential pathology technological solutions alone. services are fully integrated, Strong commitment, inspiring and performing the appropriate test, at motivating leadership are crucial to the right time, in the most support effective initiatives that build appropriate location to ensure results and create sustainable change. influence clinical decision making. Leaders must be prepared to challenge the culture of their organisation encouraging staff to behave differently, test ideas for change and believe in newly created processes thus gradually allowing the service to evolve.8 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples3. Background to projectPathology teams in England weregiven the opportunity to bid forfunding to become one of six pilots,to test service improvementtechniques.Successful sites were expected to:• map each pathology discipline• develop and implement an action plan• demonstrate reduced turnaround times, from decision to test to result• measure capacity and demand at key points across the pathway ensuring optimum use of pathology services• develop clear protocols and systems to ensure effective management of demand• evaluate patient choice in pathology to improve certainty for patients who wish to use pathology services• review the use of technology in improving pathology services• evaluate the role of point of care testing in provision of local pathology services• demonstrate changes in skill mix• share learning nationally• submit monthly progress report and present progress to the National Pathology Oversight Group on a regular basisProject commenced April 2005 for aperiod of 12 months www.pathologyimprovement.nhs.uk 9
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples 4. Pilot sites Blackpool, Fylde and Wyre Royal Devon and Exeter Hospitals NHS Trust NHS Foundation Trust Whinney Heys Road, Blackpool, Pathology Department, Royal Devon Lancashire. FY3 8NR and Exeter Hospital, Room A213, Barrack Road, Exeter, Devon Calderdale & Huddersfield EX2 2DW NHS Trust Huddersfield Royal Infirmary, Acre The sites chosen to be pilots cover a Street, Lindley, Huddersfield wide and diverse range of service HD3 3EA providers: Coventry & Warwickshire • Foundation Trust Pathology Network • District General Hospital with large University Hospitals Coventry & fluctuations in summer population Warwickshire NHS Trust • Dual Site Trust South Warwickshire Acute NHS Trust • Pathology network of hospitals George Eliot Acute NHS Trust including a University Teaching Department of Pathology, Walsgrave Hospital Hospital, Clifford Bridge Road, • SHA wide pathology service Coventry CV2 2DX approach for services in primary care Partnership Pathology Services - A joint venture between Frimley Whilst all the sites were very Park Hospital NHS Trust and different in size, structure and Royal Surrey County Hospital location, each identified similar NHS Trust issues and all utilised the same tools c/o Frimley Park Hospital NHS Trust, and techniques to make the Portsmouth Road, Frimley, necessary improvements. Camberley, Surrey GU16 7UJ North East London Strategic Health Authority (SHA) Eneurin Bevan House, 81 Commercial Road, London E1 1RD Including: Whipps Cross University Hospital Barking and Havering and Redbridge Hospitals NHS Trust Homerton University Hospital NHS Foundation Trust Newham University Hospital NHS Trust Barts and the London NHS Trust10 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples5. Developing the learningEach site participated in a series of Expert input was provided by the following:four workshops, the focus of whichwas to provide time to: • NHS Pathology Service Improvement Team• understand the application of Lesley Wright service improvement tools, Associate Director, Diagnostics techniques and lean methodology Ann Eason• share experiences, network, adopt National Pathology Manager and adapt service improvement ideas • Dr Ian Barnes DH Pathology LeadKey aspects of the workshops were: • Mitzi Blennerhassett• the role of leadership/ownership Patient Representative• effective communication • Deirdre Feehan• introduction to Lean techniques DH Pathology Modernisation Programme• mapping techniques• capacity and demand • Mike Hallworth• measurement for improvement Royal Shrewsbury Hospital• promoting new ways of working – skills escalator • Professor Sue Hill• patient involvement Chief Scientific Officer – Skills Escalator• managing demand • Ian Maidment• user involvement Patient Information Manager –• sustainability and spread Cancer Services Collaborative ‘Improvement Partnership’ (CSC’IP’) • Dr Stuart Smellie Bishop Auckland General Hospital • Paul Whalley Lecturer Warwick University Additional support and input included: • project manager development programme • conference calls • site visits www.pathologyimprovement.nhs.uk 11
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples 6. Involving patients and developing user engagement The importance of understanding Several methods exist for gathering • long waits to have blood taken – patient needs came to the fore with patient views, each have different varying from 10 minutes to 4 the DH publication ‘Creating a benefits and can be used to gain hours patient-led NHS’ (March 2005). and provide information: • long waits for results to be Three key aspects were highlighted: available • questionnaires • lack of privacy and dignity when • people have a far greater range of • surveys (360 degree) giving personal information to choices and information • question and answer sessions staff • there are stronger standards and • 1:1 interviews • poor access to phlebotomy safeguards for patients • posters services • NHS organisations are better at • newsletters understanding patients and their • compliments and complaints needs, use new and different • utilisation of Patient and Public methodologies to do so and have Information Groups and PALS better and more regular sources of information about preferences See Chapter 11 - References, and satisfaction resources, useful information, acknowledgements and further Patient and public involvement can reading. be a long and complex subject; it is particularly challenging for some Key findings from patients pathology disciplines where there is little, if any, direct contact with Findings from each of the sites were patients. remarkably similar: As providers of a service we cannot • patients were often unaware of assume to know what our patients the reason for the test being consider to be a good or bad performed and the implication of service. Patient satisfaction is based the results on meeting or exceeding patient • staff often gave conflicting requirements, and we need to information about the need to fast engage with them to understand before particular tests their needs. • car parking charges, difficulty finding a space, abuse of disabled spaces • lack of access to the service in the early morning/late evening and weekends for patients who work12 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesPatient Line of Site (PLS) methodologyPartnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS TrustUnderstanding the problem “When I come to see Dr X, he gets Learning points from patients annoyed if my results aren’t ready for using PLS methodologyThe aims of this project were to: him, so when I got here I checked at • the pathology pathway for patients• take the patient line of sight and reception and they told me they were starts with getting an appointment identify how the change of ready. Although it wasn’t my fault that • costs associated with travelling to technology will have a direct impact he didn’t get them that one time, I do the hospital to have a test done are on the experience for the following feel slightly anxious because he said it a burden for many patients groups of patients: was a wasted appointment and I’d • the amount of effort patients go • a GP patient (diabetic) have to come back.” through to give what can be a • community hospital patient unique specimen (diabetic) Retesting – the patient bears • for patients with chronic long term • emergency medical admission the burden illness, their preferences may not (chest pain) It is easy to overlook the pain and coincide with those of their health • elective surgery admission discomfort patients experience when care practitioners (prostate) providing specimens. If for some • patients are generally not aware of• evaluate the pathology model of reason the specimen is unsuitable, the technical turnaround time for centralised and de-centralised inappropriate or of poor quality and their tests pathology and evaluate the benefits therefore cannot be tested, the patient • patients are most aware of issues at to both patients and clinical users bears the burden of having a repeat test. the beginning and the end of the• produce a development plan for the pathology pathway next five years based on learning “I used to have 6 samples taken with no • although patients were generally from this project anaesthetic but now I have a local. This happy with the service they received, time they knocked me out as I had to most pathology staff felt they hadFindings have 30 tests.” become isolated from the patientsOverheads incurred by patients “The sample taking procedure hurt but I they servePathology tends to discount or ignore was given cream to help the pain.” Learning points about using theoverheads borne by the patient. “I had to have the test done but I had methodologyFinancial costs to patients and carers in heard a lot of things like it hurt and the • plan and arrange story collectionthe course of giving a sample can be embarrassment of something pushed up earlysubstantial. there. I just wanted to get it over with.” • choose interviewers with goodInflated turnaround times interpersonal skills “Although I haven’t been told the actualMost patients do not know the • consider role play, the story results of my blood test my GP gave metechnical turnaround times or what the impression that everything was fine, collection technique, recruitment ofthe required standards are and are with my ECG as well, but that they patients and feedback to staffcurrently not sensitive to this issue. would perform these extra tests as “belt • easier to collect stories in general and braces” so I am here just to make clinic waiting areas especially those“Usually have blood taken at GP sure” directly controlled by pathologysurgery, told result will be back in 8 to • use an electronic template for story10 days time. I will be called if there is “I have had 4-5 blood tests in the last transcriptionanything wrong. No news is good month and I think the last one was justnews. GP’s don’t notify you if the that the locum Dr wanted to do it again Contact: Dr Ian Fryresult is normal.” himself to make sure nothing was Partnership Pathology Services, wrong.” Frimley Park HospitalPreciousness of sample christine.bannister@fph-tr.nhs.ukFor patients, providing the sample istheir experience of pathology. Apatient will only become aware of themechanics if something goes wrong. www.pathologyimprovement.nhs.uk 13
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Establishing patient focus groups and user forums Calderdale and Huddersfield NHS Trust Involving patients Benefits of focus group result being available to the referer in secondary and primary care. Questions The team preferred to talk directly to The focus group has given the were asked about the process and the patients rather than get their views pathology department food for issues for them as users of the service. through a survey / questionnaire as it thought, they have was felt that this would provide high been, and are determined to make As a result of this engagement a user quality and meaningful information. changes from the comments made. group including A&E, ICU, Medical Further work is ongoing in the primary Assessment, and CCU and laboratory • recruiting patients by directly care setting, this is seen to be the one staff has been established. approaching them in phlebotomy area that patients had clinic was difficult the most concerns with. Table 1 illustrates the examples of • recruiting patients by sending a patient and user comments and letter to a random sample of Involving users subsequent action taken. patients who had attended phlebotomy clinic was more Engaging users proved much easier. Contact: Dr Huw Griffiths successful Users were invited to join the process Calderdale and Huddersfield NHS Trust • interviews were conducted over the mapping session which started from huw.griffiths@cht.nhs.uk phone and a patient focus group the point of referral through to the established Questions asked fell into 3 categories: Table 1 • information provided about the test Patient/User Comments Action • access to pathology • results I don’t know what happens to my Poster developed – checked with patients blood once it has been taken. – put up in phlebotomy department. Comments from patients The Phlebotomist did not wash his / Alcogel installed in all cubicles and staff “ I ring my GP for the test results and I her hands before taking my blood. asked to wash hands between each patient am told its OK but I don’t really know and to do so in front of the patient. what this means, it would be better if you got a little bit more detail” I have to wait to have my blood Poster developed and displayed showing taken. busy times and quiet times. “I had tests undertaken for food allergies but was not told of the result, On one site patients arriving in Q matic system is being purchased on I can only presume that the test was phlebotomy are asked to take a both hospital sites. Patients will take a normal” numbered card. Concerns were disposable ticket from dispenser. expressed that these cards are Issues for patients reused but probably not cleaned thus posing a health risk. • patients did not know what test they were having or why A& E staff reported having IT staff informed and issues addressed for • hygiene issues in phlebotomy login/passwords issues with individuals. • patient having to wait a long time pathology reporting system. in phlebotomy clinic A & E requested a paper copy of A&E staff introduced to a “latest results” results printed out in A &E as they screen which does not time out enabling became available. Staff felt they did them to see at a glance when results are not have time to keep checking the available. IT department trained staff on computer to see if results were best way to use the screen. available.14 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesUsing patient views to improve anticoagulation servicesNorth East London Strategic Health AuthorityUnderstanding the problem Changes implemented • clinical staff given more time to concentrate on patient care ratherProvision for anticoagulation was Issues such as poor flow and waste than administrationinadequate in North East London. were addressed.The following issues were identified: Measurable outcomes Changing the process and• lack of direct patient involvement introduction of point of care testing Figure 2 demonstrates the impact of• little or no patient choice of time, had a number of benefits: the improvements made. location and type of encounter• unnecessary steps in the process • shorter waits for patients• limited flexibility and • ability to provide patient choice responsiveness• poor understanding of the cost / Figure 1 - Patient views of clinic waiting areas benefits of alternative methods of providing the service• conditions in the waiting area were poor. Patient surveys confirmed thisPatient comments about waitingroom conditions.Figure 1 demonstrates that 81% ofpatients felt the conditions weren’tas good as they could be. Contact: Karen Ward Figure 2 - Patients views of the anticoagulation service after Project Manager, the introduction of POCT North East London Pathology Network. 100 abeo@ukonline.co.uk 90 80 70 60 50 40 30 20 10 0 venous excellent above excellent good poct below average poct venous poor www.pathologyimprovement.nhs.uk 15
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples 7. Process improvement Improving flow, Access to results Eliminating Waste - eliminating waste Surveys of pathology users 5S approach demonstrated significant delays and Establishing an effective flow of difficulty in accessing pathology 5S is a Lean technique that work through the pathology process results. Although departments report provides pathology teams with is crucial to ensure rapid turnaround electronically, many users do not the first step to develop stability times. Techniques such as value have relevant access to the IT and promote flow by removing stream, process and spaghetti systems. Many clinical areas i.e. obvious waste in a standardised mapping illustrate non value adding wards or outpatient clinics have no and sustained approach. steps and demonstrate poor flow. or too few terminals. Hard copy These techniques point to the areas reports are subject to delays Sort (seiri) – sort through items where changes and improvements associated with processing and and keep only what is needed. need to be made. At each point of transporting to the appropriate Dispose of anything that is not the pathway there are barriers to location. Many inpatients have been needed flow. discharged when the paper report arrives on the ward. Straighten (seiton) – organise Access to phlebotomy and label a place for everything. Waste in pathology “a place for everything and Work with patients at each site uncovered delays to phlebotomy To improve flow we need to everything in its place” services. These ranged between 1 eliminate waste, i.e. actions day and 4 weeks. On reaching the undertaken that do not add any Shine (seiso) – clean it clinic patients experienced delays in value to the final result. waiting for phlebotomy. Standardise (seiketsu) – Waste can be classified as: create procedures to maintain Transport the first 3S • over production • waiting – patients and staff Delays caused by both internal and Sustain (shitsuke) – make it • transport external transportation of specimens mainstream, use regular audits • motion can be particularly dramatic. to stay disciplined. Continually • defects improve. • inventory Specimen reception • customer time Implementing this technique Here the impact of delayed and • intellect and skills in isolation will not improve batched transport systems is a (case study example, see page 23) process flow, but will start to frequent occurrence. highlight associated problems. Validation of results Significant delays can occur at validation of results and is most often associated with manual validation.16 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesUnderstanding the impact of delays in transportCoventry and Warwickshire Pathology NetworkUnderstanding the problem Figure 3 demonstrates variation and delays in transportation from primaryWork was undertaken to identify the care.true extent of transport delays, bothexternal and internal on pathologyservices. Figure 3 - Time lag for GP phlebotomy samplesLearning 80 5 hours delayIn order to reduce the time it takes 70from the patient having a test to 60receiving the results, it is necessary 50 Quantityto analyse this data. Pathologyservices must take a lead to use this 40data to influence transport provision, 30highlighting the impact on 20turnaround times and imbalance ofworkload flow and staff capacity. 10 0 8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 17.30 Time in 30 minute intervals Sample taken Sample arrived in lab Contact: Steve Smith Coventry and Warwickshire Pathology Network steve.smith@uhcw.nhs.uk www.pathologyimprovement.nhs.uk 17
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Transport issues affecting patients attending hospital for phlebotomy services Blackpool, Fylde and Wyre Hospitals NHS Trust Figure 4 demonstrates how patients use transport to attend for Figure 4 - Patients use of transport to attend pathology tests pathology tests. 350 Findings 300 • 317 (72%) patients used the car 250 to attend – this has a significant Quantity impact on already overstretched 200 car parking facilities 150 • average journey time to hospital was 35 minutes 100 50 Figure 5 shows the number of patients attending hospital based 0 phlebotomy services each week. Car Public Walked Patient Taxi Other Transport Transport Of patients attending for phlebotomy:: • 172 (38%) patients were asked to • 24 patients (5.3%) were requested This information has been presented attend by their GP to attend by the Admissions & to local primary care trusts to • 269 (59%) patients were Discharge Lounge influence future service provision. requested to attend from within • 212 (47%) patients attended the the hospital site for no other reason than Contact: Wendy Lewis-Cordwell • 148 (33%) from outpatients phlebotomy Blackpool, Fylde and Wyre Hospitals NHS Trust wendy.lewis-cordwell@bfwhospitals.nhs.uk Figure 5 - Patients attending hospital based phlebotomy services each week 200 180 160 140 120 Quantity 100 80 60 40 20 0 O c W t an e y ho ck l ic D e e th l ch l nt G P er s A Su U E R e D tist m ian ita u a ica ni R a a rd i og ng tr in & in se a c A th e U io A ea ic M en ic sp n n rg cl ca o r ol ac Lou ed n a iet th di th ill tie E er m & l pa rd A Ca O ay ut M O D18 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesRemoving non value adding stepsBlackpool, Fylde and Wyre Hospitals NHS TrustFigure 6 demonstrates the pre-analytical process map. Figure 6 - Pre-analytical process map Reception Services Pre-analytical Phase - CurrentUnderstanding the problem Reception ReceiveMapping the service demonstrates: (reception desk, WardPod)• non value adding activity• lack of multi skilled staff• work spread across a wide area Receive (Pods, Sort and Check, label Match form CSR A&E, ward, prioritise & spin to sample (see figure 6) Haem/Onc)• significant delays caused by prioritisation, leading to wide Transport Sample to Form, CSR Form office Sample variance in turn around times (TAT) CSR to office to CSR to lab encouraging requesters to flag samples as urgent ~Office• inconsistent flow of samples to the PID analysers creating backlogs• capacity of staff did not match Laboratory workload demands Analysis• unnecessary movement due to (see figure 8) • layout of the rooms • position of necessary equipment • interruptions by telephone Figure 7 demonstrates pre-analytic process enquiries averaging 2.3hrs map (post implementation) per day • impact of incorrectly labelled samples Figure 7 - Pre-analytical process map (post-implementation) • delays caused by large batches Reception Services Pre-analytical Phase - New and prioritisation increasing turnaround times by 59 minutes Reception Receive (reception desk, WardPod) Receive (Pods, Sort and Check, label CSR A&E, ward, PID prioritise & spin Haem/Onc) Transport Sample to Sample CSR to lab ~Office Laboratory Analysis www.pathologyimprovement.nhs.uk 19
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Changes implemented • layout of equipment and work area reconfigured. (See figure 9) (See case study on page 21) • non value adding steps were removed • over processing waste reduced • number of handoffs reduced • batching minimised • unnecessary travel eliminated Measurable outcomes Table 2 Measurable outcomes Pre-Implementation Post-Implementation Sample processing time 59 min 26 min Number of steps in the 11 8 process. Figure 7 Staff movement 2,000 mtrs /day 474 mtrs /day Figure 9 Number of work areas 3 2 Contact: Wendy Lewis-Cordwell Blackpool, Fylde and Wyre Hospitals NHS Trust. wendy.lewis-cordwell@bfwhospitals.nhs.uk20 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesImproving flow in specimen receptionBlackpool, Fylde and Wyre Hospitals NHS TrustUnderstanding the problem Figure 8 - Original spaghetti map of central specimen reception The movements of one member of staff during a 10 minute periodLack of flow in specimen receptionresulting in unnecessarytransportation of staff andspecimens.Spaghetti map findings• one member of staff walks 1.2 miles each day• 5 staff walk a total of 6 miles each day• at 4 miles per hour, this equals 1.5 hours working time• an operator can prepare 48 samples for analysis in this time• this is a cost equivalent to £2200 - £2900 per annumChanges implemented• reconfigured layout• individual workstations Figure 9 - Reconfigured layout spaghetti map of central specimen reception standardised• equipment repositioned to support workflow• specimens processed in smaller batches• each batch of samples are labelled checked and loaded into the centrifuge by a single operativeMeasurable outcomes• see table on page 20Contact: Wendy Lewis-CordwellBlackpool, Fylde and WyreHospitals NHS Trustwendy.lewis-cordwell@bfwhospitals.nhs.uk www.pathologyimprovement.nhs.uk 21
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Reducing steps and handoffs in specimen reception Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust Understanding the problem Number of steps and handoffs before and after process change • analysis of the process identified Figure 10 - Amount of samples Figure 11 - Number of steps and unnecessary steps and handoffs. unpacked by one MLA and numbered handoffs before and after process Simplification of the process by another MLA in an hour change allowed the team to make better 150 use of resources and increase 140 130 141 12 efficiency and productivity in 120 11 12 125 specimen reception 110 10 100 9 90 8 9 Changes implemented Amount Number 80 7 70 6 Changes were made to the usual 60 5 working practice. One Medical 50 4 4 40 3 Laboratory Assistant (MLA) would 30 2 3 deal with the numbering and 20 1 unpacking to decrease the number 10 0 Steps Handoffs 0 of steps and handoffs. Operator 1 Operator 2 Name Before After Measurable outcomes • increase productivity (see figure 10) Additional audits were undertaken to assess the impact • fewer steps and handoffs (see figure 11) Figure 12 - Number of phone calls Figure 13 - Impact of change in reducing • reduce time spent on non-value before and after process change in time spent dealing with problems in adding activities specimen reception specimen reception (mins) (see figures 12 and 13) 100 250 Contact: Dr Ian Fry 90 Partnership Pathology Services. 80 200 christine.bannister@fph-tr.nhs.uk 70 Number of calls 60 150 Minutes 50 40 100 30 20 50 10 0 0 Before After Before After22 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesReducing waiting times for patients byimplementing Point of Care Testing (POCT)North East London Strategic Health AuthorityUnderstanding the problem Measurable outcomes• excessive waiting times in anticoagulation clinics (up to Figure 14 - Waiting times for patients before and 120 mins) after the introduction of POCT• patients waiting in cramped and poor conditions 100• staff over whelmed and 90 undertaking unnecessary non 80 Percentage of patients clinical duties Before change After change 70Changes implemented 60 50• improved waiting areas provided 40• point of care testing implemented• provision to be made in primary 30 and secondary care settings 20 10Contact: Karen Ward 0Project Manager, 10 to 20 20 to 30 30 to 60 60 to 120 >120North East London Pathology Waiting times - minutesNetwork.abeo@ukonline.co.uk Figure 15 - Rate of introduction of new methods 350 Number of patients tested per week Venous POCT Self Community 300 250 200 150 100 50 0 Aug Sep Oct Nov Dec Jan Feb Mar Month in 2005 www.pathologyimprovement.nhs.uk 23
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Identifying waste in the pathology pathway Calderdale and Huddersfield NHS Trust Table 3 Type of Waste Examples Waiting Patient waits to attend phlebotomy or clinic i.e. waiting for samples or equipment Patient waits at clinic Waiting for specimens to arrive Delays to booking Waiting for analysis Waiting for machines to finish Delays to validation Waiting for results to be released out of hours Requester awaiting results Patient waits for results Transportation Patients travelling to secondary care when request was made in primary care i.e. unnecessary movement of specimens Samples travelling from GP practices to the lab equipment or reagent due to poor layout. Location of the pathology service Motion Twisting to access equipment i.e. unnecessary movements made by Bending to reach poorly located reagents or kit staff as a result of poor ergonomic design Performing unnecessary key strokes when recording information on IT system Inventory Over ordering of stock i.e. stock reagent or work in progress Large batches of reagent made Specimens in progress awaiting next process step Overproduction Unnecessary test requests i.e. too much or too soon Sorting and resorting of specimen Unnecessary barcodes or labels More specimens taken from the patient than required Re entry and duplication of data Batches of specimens awaiting next processing step Defects Haemolysed samples Specimen received with insufficient details Wrong sample type Result not available as required Intellect and skills Clinical staff performing admin Scientists performing non scientist duties Customer time Patients attending appointment where results are not available Staff phoning for results or information that should be accessible elsewhere As a result of identifying this waste an action plan was established to systematically remove this waste and improve flow. Contact: Dr Huw Griffiths Calderdale and Huddersfield NHS Trust huw.griffiths@cht.nhs.uk24 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesUsing 5S to remove waste in specimen receptionPartnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS TrustUnderstanding the problemArea cluttered, hindering effectiveflow and standard working for staff.5S implemented to identify itemsthat could be:• moved to a more appropriate location• discardedChanges implemented• waste removed• standard workstations developed• improved utilisation of spaceMeasurable outcomes• space released in data entry room and specimen reception• work areas tidier and more organised• effective way of changing practice, taking 11 2 days of effort including works department to remove cabinets• working conditions improved• teamwork improved• staff appreciated additional space and organised area• generated interest in the service improvement programmeContact: Dr Ian FryPartnership Pathology Services.christine.bannister@fph-tr.nhs.uk www.pathologyimprovement.nhs.uk 25
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples 8. Understanding demand, utilising capacity Demand management “Being trained to carry out factory “Automation can provide a more V Leiden testing in Haematology. efficient way of doing the wrong Demand for pathology services has Using the molecular has been very thing.” increased considerably over the past beneficial to me, enabling me few years. Data demonstrates that to learn and practice new techniques Reengineering the Corporation clinical chemistry laboratories saw as well as supporting my personal an increase in workload of 15-30% development and improving the “Automation can actually cost the between 2000/2001 and services.” lab more money if the overall 2002/2003. This has increased process is not first considered.” Trainee Clinical Scientist, further as a result of key NHS Advance Haematology reforms such as the Quality and Outcomes Framework. In addition Developing a truly patient focused Utilising technology the Healthcare Commission (2005) service will depend upon the highlighted a number of common To cope with the increasing successful combination of: problems including: workload it has been necessary to invest in new technology. • streamlining the processes • an estimated 25% of common • utilising skills of staff Experience world wide has shown tests are duplicated and have no • maximising the use of technology that this investment should not be additional impact on patient care made without prior consideration • many requests are illegible, contain and understanding of the pathology insufficient clinical information, process. causing significant delays and rework • poor contact with clinical users – 20 - 25% of ward managers Figure 16 - Relationship between process, workforce and technology reported that delayed access to to ensure the patient is at the heart of the service pathology results had a significant impact on care or discharge of PROCESS patients at least once per week Optimising staff skills Pathology services are facing issues of an ageing workforce and difficulties in recruiting new staff. To lessen the impact we need to optimise staff skills and utilisation. PATIENT FOCUSED SERVICE WORKFORCE TECHNOLOGY26 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesUnderstanding variation in demandfor diabetic screening testsBlackpool, Fylde and Wyre Hospitals NHS TrustUnderstanding the problem Figure 17 - HbA1c requests per thousand patients forDemand data was collected and Blackpool PCT (April - June 2005)analysed from the primary care usersof the pathology service. The data 30highlighted significant differences in 26 No. of requests per 1000 patients 25 25requesting patterns of individual 24 23 registered at each practice 22surgeries. 20 19 18 17 17 17Learning 16 16 16 16 16 15 15 15 14Further investigation highlighted that 11 11 10nursing staff were not requesting 10according to protocols developed bythe PCT.The data has been used to influence 0 P81159 P81072 P81714 P81066 P81081 P81052 P81042 P81172 P81063 P81043 P81054 P81162 P81722 P81004 P81681 P81115 P81684 P81074 P81016 P81629 P81706 P81754 P81713future requesting patterns and toimprove usage of the pathology GP Practiceservice by GP practices. Contact: Wendy Lewis-Cordwell Blackpool, Fylde and Wyre Hospitals NHS Trust. wendy.lewis-cordwell@bfwhospitals.nhs.uk www.pathologyimprovement.nhs.uk 27
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Reducing unnecessary/duplicate requests for thyroid function testing Coventry and Warwickshire Pathology Network Understanding the problem Measurable outcomes Monitoring of Thyroid Stimulating Table 4 Hormone (TSH) requests demonstrated an increasing number Month TSH requests Number rejected Percentage rejected of duplicate tests. After discussions between the pathology department Oct 9006 371 3.96 and endocrinologist it was decided to reject TSH requests made Nov 8796 313 3.44 within one week of a previous request. Dec 6927 251 3.50 Jan 9247 300 3.24 Changes implemented Feb 8725 257 2.95 Initially tests were rejected when a previous result had been given Mar 9664 414 4.28 within 7 days; this was then extended to 2 weeks. Apr 8853 310 3.50 May 9597 372 3.88 Contact: Steve Smith Coventry and Warwickshire Pathology Network steve.smith@uhcw.nhs.uk28 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesReducing inappropriate testing for thrombolytic patientsCoventry and Warwickshire Pathology NetworkUnderstanding the problem Measurable outcomesSignificant thrombolytic (D-Dimer) Significant reductions in the numberrequests were felt to be of requests for D-Dimer were seen.inappropriate. (See figure 18).Changes implemented Figure 18 - Changes in D-Dimer request patterns• the pathology network redesigned the request form for use within the A&E department 500• profiles of tests for specific 450 conditions were agreed with 400 clinical teams• staff now indicate a possible 350 diagnosis (eg chest pain) when 300 Tests requesting pathology tests 250• requests for D-Dimer tests are only 200 accepted if a Wells score is appropriate. 150 100 50 0 Oct 2005 Nov 2005 Dec 2005 Jan 2006 Admissions Unit, St Cross A&E Hospital of St Cross Emergency Department Observation Ward WGH Contact: Steve Smith Coventry and Warwickshire Pathology Network steve.smith@uhcw.nhs.uk www.pathologyimprovement.nhs.uk 29
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Reducing inappropriate urine requests in microbiology Royal Devon and Exeter NHS Foundation Trust Understanding the problem Figure 19 - Algorithm for urine dipstick testing It was felt that a significant number of urine requests were inappropriate, Reason for leading to unnecessary workload urine dipstick and delays to results for patients. Symptoms of infection eg Routine urinalysis Changes implemented eg new admission, frequency, dysuria, fever, groin pain, unexplained confusion diabetic Trust and community users of the OR pathology service were willing to Pre op screening eg urology, orthopaedics engage in this piece of work, particularly after a visit to the Record results and if positive make available laboratory to see the intensive to trained nurse or Protein nature of processing urine Blood One or more tests doctor negative positive, send MSU specimens. LE for culture Nitrite After meetings with users a new Do not send a urine for urine testing protocol was developed culture unless there is a specific indication and has been distributed within the No need to send urine RD&E Trust. A separate algorithm is for culture unless doctor specifically requesting being developed for community users. The urine request form is undergoing redesign to support users to provide sufficient information to the laboratory, and this can be used with the 2D Contact: Mike Burden barcode system already successful Royal Devon and Exeter in clinical chemistry. NHS Foundation Trust. mike.burden@rdehc-tr.swest.nhs.uk Measurable outcomes • A reduction in urines received by the lab. This will be regularly audited to ascertain success of algorithm30 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesImproving staff utilisation to match demandBlackpool, Fylde and Wyre Hospitals NHS TrustFigure 20 demonstrates themismatch of staff capacity against Figure 20 - PID staff demand chartthe demand on the service. Thiscauses significant delay in simple 160 5processing. Staff Forms 4.5 140Changes implemented 4 120 3.5• administrative and technical staff Number of PIDs 100 3 are combined into one team• batch sizes have been reduced to a 80 2.5 maximum of 16 in boxes 60 2 numbered in order of arrival 1.5 (first in - first out) 40 1• each batch of samples is checked, 20 0.5 labelled and loaded into the 0 0 centrifuge by a single operative 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 17.30 18.00 18.30 19.00• whilst samples are in the Time of day centrifuge the operator inputs patient and test data. On completion samples are taken to Measurable outcomes the laboratory to be loaded on to the analysers• standard workstations established, Table 5 - Sample processing time, number of stages in the process with each station housing its own centrifuge and PC Measurable outcomes Pre-implementation Post implementation• the number of workstations increased to 11 with one Sample processing time 59 min 26 min dedicated to ‘urgent’ samples• samples that cannot be processed Number of steps in the process. 11 8 immediately are placed in a Figure 7 “problem box” to be dealt with by Staff movement 2,000 m/d 474 m/d another operator Figure 9• all causes of problem samples are identified, reviewed, and protocols Number of work areas 3 2 developed to deal with problems• each day one operator is designated to deal with difficult (See case study on pages 19/20) requests and phone calls• staff working hours and rosters modified to meet demand www.pathologyimprovement.nhs.uk 31
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Staff benefits include: • improved morale and reduced pressure on staff • staff taking ownership of work targets • individual workstations eliminated waits for centrifuges • problem samples removed from general workflow Extended benefits include: • continuous flow of samples to the biochemistry and haematology analysers • processing of samples will not be held up by a shortage of staff or equipment in one part of the process Future development Although demand and capacity is still out of balance, staff are experiencing the benefits of the changes already made and are now more open to roster changes. In addition there is a greater scope for career development by the introduction of supervisory and team leader posts in the future. Contact: Wendy Lewis-Cordwell Blackpool, Fylde and Wyre Hospitals NHS Trust wendy.lewis-cordwell@bfwhospitals.nhs.uk32 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesUnderstanding service demand and staff capacityEach of the six pilot sitesdemonstrated a mismatch between Figure 21 - Calderdale and Huddersfield NHS Trustdemand and capacity at variouspoints across the pathway (see CRH - Tues 13/12/2005examples from sites in figures 20021 and 22). 180With these factors in mind it is 160important to make best use of the Capacity Demandresources we have by: 140 Number of requests• having a clear understanding of 120 demand 100• influencing clinicians requesting patterns 80• maximising the technology 60 available• using technology appropriately 40 20Contact: Dr Huw GriffithsCalderdale and Huddersfield 0 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30NHS Trust Time of dayhuw.griffiths@cht.nhs.ukContact: Mike BurdenRoyal Devon and Exeter NHSFoundation Trust. Figure 22 - Royal Devon and Exeter NHS Foundation Trustmike.burden@rdehc-tr.swest.nhs.uk 500 30 450 25 400 Staff Requests 350 20 300 Specimens Staff 250 15 200 10 150 100 5 50 0 0 00.00 01:00 02:0- 03:00 04:00 05:00 06:00 07:00 08:00 09:00 10:00 11:00 12:00 13:00 14:00 15:00 16:00 17:00 18:00 19:00 20:00 21:00 22:00 23:00 Time www.pathologyimprovement.nhs.uk 33
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Improving clinical information on immunology requests to release staff capacity Royal Devon and Exeter NHS Foundation Trust 27% of factor V Leiden requests Fig 23 - Impact of improving contained insufficient clinical the process on skill mix and information to allow appropriate time processing of this type of request causing significant delays. 120 110 Clinical scientist minutes 100 Changes implemented 90 MTO 1 minutes 80 • request form redesigned to capture 70 necessary request information 60 • eliminated non value adding steps 50 40 of clinical scientists contacting 30 requesters for additional clinical 20 information 10 0 Previous Current Measurable outcome The amount of time required to obtain necessary clinical information has significantly reduced. Clinical Figure 24 - The redesigned process map scientists are now free to carry out other duties. Checked If criteria met, requestor is emailed Sample against straight away. On average, reply booked onto website: can take between 24hrs and 1 IPS: Contact: Mike Burden 9:35am week. Some requestors never 11:00am reply! No extraction can be started Wednesday Royal Devon and Exeter NHS Wednesday until reply is received. Foundation Trust. mike.burden@rdehc-tr.swest.nhs.uk Sample checked by Criteria met by Sample booked scientist against request form onto IPS system criteria on website Criteria not met by info on request form - Criteria met by requestor emailed by request form scientist & blood stored In a sample Reply - criteria not month, out of met & blood stored 15 samples received, 4 needed the requestor No reply - blood stored34 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesImplementing BMS cut up to releaseConsultant Histopatholgist timeRoyal Devon and Exeter NHS Foundation TrustUnderstanding the problem Figure 25 - Pathologist consultant time saved by advancedPressure on the histopathology BMS completing small section cut updepartment to maintain turnaround July 2004 - December 2005times and cope with the workload. 2500Changes implemented Small section cut up completed per month 2000Advanced practitioner BiomedicalScientists (BMS) were trained inhistopathology cut up. 1500Measurable outcomes 1000• time saved – 10 hours consultant cut up time per week 500 (2.5 consultant sessions per week)• 30.5 % of cut up now performed 0 by advance practitioners Jul 04 Aug 04 Sep 04 Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Jul 05 Aug 05 Sep 05 Oct 05 Nov 05 Dec 05 Advanced Technical BMS Staff Total small section cut up per month Pathologist Staff Technical BMS Staff“We must be working along theright lines in developing advancedpractitioners in cut up because whenwe are not able to perform Contact: Colin Heapythis role teddies are thrown from Royal Devon and Exeter NHS Trustprams.” colin.heapy@rdehc-tr.swest.nhs.uk www.pathologyimprovement.nhs.uk 35
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Introducing Point of Care Testing (POCT) to reduce turnaround times in A&E Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust Understanding the problem Measurable outcomes Equipment downtime When small teams of staff are Some of our patients needed a Full Blood Count (FBC) in A&E dedicated to specific analysers, quicker turn around time (TAT) than • 65 samples / day downtime levels were halved. the clinical laboratory could provide. • 66% of all FBC requests done by POCT Reduction in laboratory tests The POCT performance and • 90% of FBC only requests done For some tests laboratory usage utilisation was compared with the by POCT dropped to zero e.g. troponin. clinical laboratory. • decreased lab workload Skill mix We reviewed the use of the Pentra Gases/chemistry Ward based Medical Technical analyser in A&E and found 10% of • 180 samples / day Assistants (MTAs) play a key role in: samples that could have been tested • 100% of gases done at POCT • freeing up clinical medical at POCT were sent to the laboratory. • duplication seen with U&Es* resource A user audit was performed to • no obvious decrease in lab • reducing inappropriate use of review use of the POCT in two workload but difficult to audit POCT regular clinics. • increasing uptake of equipment POCT Costs The POCT was reviewed to highlight Calculated with respect to laboratory High Acceptance of POCT in A&E opportunities for: savings and wider investment in setting POCT analysers A survey of junior doctors • laboratory savings documented: • skill mix change Turnaround times for Royal • 100% acceptance of POCT as • further investment Surrey County Hospital clinic essential • reducing duplicate testing Averages “not able to make the A&E 4 hour • optimising capacity • arrival to venepuncture (VP): target (government directive) 13 minutes without it” Findings: • some samples were being retested • VP to POCT results (on LIMS): Unused capacity overnight 29 minutes • not all results can be recorded on • Consultant Haematologist • VP to first lab results: the laboratory system because of discovered inadequacy with 1hr 33 minutes analyser configuration deficiencies analysers Turnaround times for Frimley • in current POCT we have unused Park Hospital clinic capacity which could be used by Changes implemented other parts of the hospital Averages • reduced duplication • arrival to venepuncture (VP): Contact: Dr Ian Fry • introduction of POCT facilities in 9 minutes Partnership Pathology Services. additional clinical areas • VP to POCT FBC result: christine.bannister@fph-tr.nhs.uk • medical technical assistant role 4 minutes introduced • VP to lab FBC result: 2 hours * because laboratory computer does not automatically hold the result, but does for FBC36 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement ExamplesIntroducing histology robotics to maximiseavailable skill mixPartnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS TrustUnderstanding the problem Measurable outcomesThere were difficulties in recruiting • improvements affect 30,000suitably qualified staff to a highly patientsmanual process, a large backlog of • speedier diagnosis followingspecimens had built up. Design of surgerythe building was inadequate. There • first phase shows processing timewas poor utilisation of space and reduced by 66%inefficient workflows. • reducing fluctuations in slide production, consultant reportingChanges implemented efficiency was improved• processes mapped Key findings• reviewed system performance measures (TAT, request backlog, Improved turnaround times instituted an ongoing data Robotic technology is useful in collection of case throughput improving processing times: statistics, consultant reporting • first phase of implementation has throughput, number of improved turnaround times outstanding cases over specified significantly time periods) • second phase will further improve• purchased and installed robotic processing time technology to process samples continuously rather than batching Skills mix for overnight processing • potential for skill mix redesign• extended day and weekend around this system working partially implemented. Discussion ongoing with staff Contact: Dr Ian Fry Partnership Pathology Services. christine.bannister@fph-tr.nhs.uk www.pathologyimprovement.nhs.uk 37
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Introducing automated liquid based cytology to reduce waiting times for cervical screening results Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust Understanding the problem Screening backlog Liquid Based Cytology (LBC) was Pre LBC: Before introduction to LBC introduced as a result of guidance the backlog was up to 13 weeks. from the National Institute for Health The NHS Cancer Screening and Clinical Excellence (NICE). A Programme (CSP) standard is 6 regional training laboratory for Kent, weeks maximum. Surrey and Sussex was established in our catchment area. Post LBC: After LBC was introduced 30% of cervical smears were being Changes implemented reported in 4 weeks and 100% within 6 weeks. • purchased and installed LBC processing equipment Contact: Dr Ian Fry • mapped the additional processes Partnership Pathology Services. required by LBC christine.bannister@fph-tr.nhs.uk Measurable outcomes • improvements affect 56000 patients • inadequate sample rate reduced from 10% to 1-2%. As a consequence laboratory workload has been reduced by 20% • all cervical cytology samples were reported within 4 weeks (June 2005) • reduction of workload would allow this laboratory to take on more work38 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples9. Learning for future improvement teamsInvolve patients Take responsibility Walk the walkUnderstand what patients need from Accept responsibility for the role of All staff including high levelthe pathology service. When it is pathology in the patient pathway. managers should ‘walk the walk’ ofnecessary to make changes in an the specimen pathway forarea, for which pathology is not If the pathology pathway is unable themselves to ensure they have adirectly responsible, it is important to to demonstrate the impact of thorough understanding of thework across organisational transport on their service then who pathology process. Identify the rootboundaries to support change.This else can? Who else has the ability to cause of problems, never act on datacould include transportation, see it from the pathology or information that has not beeninformation about pathology tests, perspective? verified.access to phlebotomy or access to There is always a solution to beresults. Teach those who are doing the day found; it is about understanding job to see waste, empower them to what we can do, not why we cant. make change.Involve clinical users andcommissioners of pathology Start smallservices Identify training needs and Undertaking service improvement provide necessary supportThe key to supporting end-to-end can be daunting, begin with a shortpatient care is to understand the Some of the changes clinical teams non complicated process and gain need to make will firstly requireneeds of clinical users’ at each point experience in using the servicein the patient pathway. Engage investment in training and improvement tools and techniques. development of staff. Do notcommissioners by working in Small changes often have thepartnership to ensure patients needs instigate change without first biggest impact. ensuring staff are prepared andare best served. supported throughout Involve everybody implementation.Have a vision Ensure ALL staff are aware andDetermine the long term vision of involved in any service improvement Address skill mix issuesthe pathology service. Ensure the effort. Communicate effectively andlong term quality agenda focuses on Review the process to determine the repeatedly so all staff understand the skills necessary at each point. Onlyproviding value for patients in value that pathology adds to theassociation with the traditional after this has been done can you patient pathway. Build a culture of start to change the skill mix in eachquality assurance methods. Work to identifying and fixing problems aseffectively integrate the service into area. Do not implement new roles they arise. Give all staff regardless of on poor processes.the entire healthcare pathway. their position in the organisationSeek perfection, not only in terms of authority to highlight problems andquality but by providing exactly what recommend changes. Establish aclinical users require, at the right forum to share and discuss potentialtime with minimum waste. changes. www.pathologyimprovement.nhs.uk 39
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Invest wisely in technology Communicate, communicate, communicate Introduction of new technology should not be used as a substitute The need for good communication is for improving processes. Always ask often underestimated. All staff need the following questions: to be aware of any improvement work being undertaken. Use all • how does this technology support communication methods that are value adding processes? available. Staff meetings, • does it eliminate waste? newsletters, improvement notice • if demand changes can the boards where maps and data can be technology adapt without displayed, are useful in providing all necessitating further expensive staff with up to date information. investment? Communicate regularly with users • does the technology support and those on whom the changes will laboratory staff in continuous impact. Feedback progress and improvement of the process? results to patient and user groups. • is it the most flexible and least Provide feedback to executive and complex available? management leads. • is technology being used as a sticking plaster to solve the symptom of a problem where poor process is the root cause? “I think this project has given us the opportunity to Liker. JK, Meier. D. (2006) scrutinise and improve parts of the pathology service. Seeking the views on what the service means to Accelerating the pace of change practices and surgery staff has been carried out too Whilst the pilot sites were engaged infrequently.” to test the learning and develop the changes over a period of 12 PCT Service Development Facilitator months, it is now clear that rapid improvements utilising these techniques and Lean Principles can be achieved in a relatively short period of time. Lean Kaizen events over a period of 5 days enable issues to be identified, improvements to be implemented and the impact of changes felt immediately. This in turn encourages others that the time invested early on reaps huge rewards40 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples10. Building for sustainable changeBuilding for sustainable change Figure 26 - Factors for achieving sustainable improvement asAs part of the learning, the pilot identified by the pilotssites were asked to consider thefactors for achieving sustainableimprovement. Figure 26 identifies Leadershipthe main elements the teams focus andconsidered were essential to build executive supportsustainable change. Data to Engaged,These elements are similar and support and motivated andconsistent with redesign in other evidence service empoweredclinical services and are not unique improvement staffto pathology. The work undertaken Timelyby the Cancer Services Collaborative effective‘Improvement Partnership’ around Patientsustainability of service improvement focused servicessupports these findings and buildson the existing body of knowledge Value adding Understand processes user andabout sustainability. supporting all patient pathways needs Investment in continuous quality improvement “ Spread and sustainability. The project has stimulated interest in pathology service improvement and is providing a sound basis to extend and continue these processes” Royal Devon and Exeter NHS Foundation Trust www.pathologyimprovement.nhs.uk 41
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Looking to the future we need to What are the challenges? understand the characteristics that will define a redesigned service, and • identifying and establishing strong be prepared to meet the challenges clinical leadership and executive and actions required to achieve this. support • mapping the service, identifying What are the characteristics of a and eliminating steps that add no redesigned service? value • gaining feedback from patients • efficient and reliable patient and other service users focused services • collecting, interpreting and • timely access and timely results understanding data • implemented evidence based • design and accreditation of protocols new roles to support redesigned • agree standards against which the processes service is regularly performance • supporting streamlined patient managed pathways and requesting patterns • appropriate use of skill across all staff groups with training and What are the key actions to investment as required achieving this? • empowered and motivated staff with strong leadership – displaying • understand user requirements – a ‘can do’ attitude gain patient and user feedback • a culture that is not resistant to regularly attempting change, where all • pathology staff using service job descriptions reflect an element improvement tools and techniques of service improvement on a daily basis • robust data collection systems • give staff the first opportunity to • processes in place that add value solve problems and support excellent clinical skills • agree measures that reflect • flexible capacity with the ability to end-to-end patient experience meet changing service needs • appropriate development and utilisation of skills • use technology to support value adding processes • don’t underestimate the work involved!42 www.pathologyimprovement.nhs.uk
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples11. References, resources, useful information, acknowledgements and further readingPathology Service Improvement Useful websitesPathology: National Framework for Service Pathology Service Improvement WebsiteImprovement - Sept 2005 www.pathologyimprovement.nhs.ukChallenges and Top Tips for Pathology Service Improvement - Department of HealthSept 2005 www.dh.gov.ukModernising Pathology Services Toolkit - A Practical Guide to Cancer Services Collaborative ‘Improvement Partnership’Redesign - Sept 2005 www.cancerimprovement.nhs.ukWhat a difference a day makes - Oct 2005 Cancer Patient Information and Experience www.cancerimprovement.nhs.uk/patientexperienceAll documents available at:www.pathologyimprovement.nhs.uk 18 weeks delivery programme www.18weeks.nhs.ukEmail: pathology@cscip.nhs.uk Commission for Patient and Public Involvement in Health www.cppih.orgDepartment of Health Database of Individual Patient ExperiencesModernising Pathology Services - 2004 www.dipex.orgModernising Pathology: Building a Service Responsive Department of Health. Patient and Public Involvementto Patients - Sept 2005 www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/ PatientAndPublicInvolvement/fs/enCreating a Patient-Led NHS - Mar 2005 Expert Patients ProgrammeAll documents available at: www.dh.gov.uk www.expertpatients.nhs.uk Improvement Leaders’ Guides. Involving patients and carersCancer Services Collaborative www.cancerimprovement.nhs.uk/nhs_ma_publications.html‘Improvement Partnership’ Patient Advisory Liaison Service (PALS)Sustaining Cancer Waiting Times Through www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/PatientEffective Pathway Management - June 2006 AndPublicInvolvement/PatientAdviceAndLiaisonServices/fs/enHow to Guide ... Achieving Cancer Waiting Times - Feb 2005 - Royal College of Pathologists. Patient ResourcesJune 2006 www.rcpath.org/index.asp?PageID=11High Impact Changes for Achieving Cancer Waiting Times - What do patients want from primary care?Feb 2005 http://bmj.bmjjournals.com/cgi/content/full/331/7526/1199?ijke y=6UQvnx7hLRtfxP7&keytypeAll documents available at:www.cancerimprovement.nhs.uk www.pathologyimprovement.nhs.uk 43
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples Further reading Resources Bicheno J. (2000) Cause and Effect Lean. Lean Operations, Six Pathology discussion board provides email communication Sigma and Supply Chain Essentials. PICSIE Books ISBN 0 9513 system to support queries. Help share best practice and 8301 9 experiences. To join contact: Carey RG. Lloyd RC. (1995) Managing Quality Improvement In Healthcare. A Guide To Statistical Process Control Applications. Shirley Steeples Quality Resources. ISBN 0527762938 Tel: 0116 222 5113 www.pathologyimprovement.nhs.uk Goldratt E.M., Cox J., (2003) The Goal. Gower. ISBN 0 566 07418 4 For further information on pathology service improvement and the application of lean in pathology contact the Pathology Goldratt E.M., Schragenheim E., Ptak C.A. (2000) Necessary Service Improvement Team. But Not Sufficient. The Nort River Press Publishing Corporation. ISBN 0 88427 170 6 Pathology Service Improvement Team 3rd Floor, St Johns House, East Street, Leicester LE1 6NB Harrignton H, (1998) Statistical Analysis Simplified. The Easy Guide to Statistical Process Control and Data Analysis. Tel: 0116 222 5113 McGraw-Hill Education. ISBN 0079137296 Email: pathology@cscip.nhs.uk Hart. MK, Hart RK. (2002) Statistical process control for healthcare Acknowledgements Duxbury Thompson Learning ISBN 0-534-37865-X We would like to acknowledge the support and contribution Liker. JK, Meier. D. (2006) The Toyota Way Fieldbook. McGraw of the pilot sites who tested the toolkit and the service Hill ISBN 0-07-144893-4 improvement tools and techniques. Also to Shirley Steeples PA to the Pathology Service Improvement Team for providing Womak JP. Jones Daniel T. (2003) Lean thinking. Banish Waste support and co-ordinating the workshops. and Create Wealth in your Corporation. Free Press. ISBN 0- 7432-4927-5’ Womak JP. Jones DT, Roos D. (1991) The Machine That Changed the World. The Story of Lean Production. First HarperPerennial. ISBN 0 06 097417-644 www.pathologyimprovement.nhs.uk
    • “Achievements can be made rapidly, for little or no cost, demonstrating immediate results that motivate others to accelerate the pace of change, and deliver significant efficiency gains.”
    • Learning from Pathology Service Improvement Pilot Sites and Improvement Examples46 www.pathologyimprovement.nhs.uk
    • NHS Pathology Service ImprovementPathology Service Improvement Team3rd FloorSt John’s HouseEast StreetLeicesterLE1 6NBTelephone: 0116 222 5113Fax: 0116 222 5101www.pathologyimprovement.nhs.uk NHS Cancer Services Collaborative ‘Improvement Partnership’CSCIP015 August 2006