NHSCANCER NHS Improvement DiagnosticsDIAGNOSTICSHEARTLUNGSTROKENHS Improvement - DiagnosticsService improvement in blood sciencesHow to improve quality, delivery andefficiency for laboratory providers andtheir customersJanuary 2013Clinical excellence in partnership“with process excellence”
Matching your capacity and demandsupports improved turnaround timesand improves staff morale.
Service improvement in blood sciences: How to improve quality,delivery and efficiency for laboratory providers and their customersContents1. Foreword 62. Executive summary 73. Introduction 104. Waste 145. Sites 156. Start with the end in mind 167. Pre pre-analytical stage 17 Pathology transport reconfiguration 18 Chesterfield Royal Hospital NHS Foundation Trust Introduction of coloured transport bags in pathology 20 Chesterfield Royal Hospital NHS Foundation Trust Decreasing the rejection rate for transfusion blood samples 22 Taunton and Somerset NHS Foundation Trust Emergency department diagnostics improvement 23 Derby Hospitals NHS Foundation Trust Haematology clinic changes to support patient experience and improve flow 25 Chesterfield Royal Hospital NHS Foundation Trust Streamlining day surgery admission to improve group and screen result turnaround 29 Taunton and Somerset NHS Foundation Trust8. Pre-analytical stage 31 How Lean improvement enabled us to save time and money in blood transfusion 32 Taunton and Somerset NHS Foundation Trust Reduced checking at booking-in improves detection of defects 34 Taunton and Somerset NHS Foundation Trust Reducing turnaround times for urgent samples 36 Derby Hospitals NHS Foundation Trust Using data to manage staffing levels within blood sciences pre-analytical section 39 Chesterfield Royal Hospital NHS Foundation Trust Using visual management to improve communication and ways of working 42 Chesterfield Royal Hospital NHS Foundation Trust Using standard work and 5S in specimen reception to create a standardised, clean 44 and safe work environment allowing staff to perform optimally Chesterfield Royal Hospital NHS Foundation Trust Pathology outpatient process improvements 46 Derby Hospitals NHS Foundation Trust Blood sciences pre- analytics pathway improvements 48 Chesterfield Royal Hospital NHS Foundation Trust Using data and team problem solving to improve sample TAT 52 Bolton NHS Foundation Trust
59. Analytical stage 54 Changed priorities in the laboratory to deal with samples from same day surgical 55 admission patients – analyser set-up and method of validation Taunton and Somerset NHS Foundation Trust Reducing the turnaround times for haematology clinic by reducing the time taken 57 from a result being available to authorising a result that requires a peripheral blood film Chesterfield Royal Hospital NHS Foundation Trust 5S of cold room at Derby 59 Derby Hospitals NHS Foundation Trust Demonstrating how Lean work cells deliver faster turnaround times, higher 61 productivity and efficiency, increased flexibility, improved space utilisation and improved quality Path Links Crossing disciplinary boundaries improves transfusion safety for day surgery patients 64 Taunton and Somerset NHS Foundation Trust Positive clinical benefits of improvement work in a transfusion laboratory: 66 a clinician’s view Taunton and Somerset NHS Foundation Trust The relationship between patient flow, patient safety, labour cost and the 67 contribution of laboratory sciences to appropriate patient care The Health Foundation, South Warwickshire NHS Foundation Trust10. Post-analytical stage 71 Implementation of a visual system to improve patient turnaround time in A&E 72 Bolton NHS Foundation Trust Customer engagement and use of data to reduce defects 74 Bolton NHS Foundation Trust Card viewer access for outpatient departments and health centres 76 Bolton NHS Foundation Trust Reducing paper reports from laboratory medicine 77 Bolton NHS Foundation Trust11. Post post-analytical stage 78 Using data and customer engagement to identify and eliminate defects 79 Bolton NHS Foundation Trust Joint problem solving to reduce total patient turnaround time in A&E 82 Bolton NHS Foundation Trust Introduction of a new test code which removed the need for extra courier pick-ups 88 Bolton NHS Foundation Trust Seminar sessions for the orthopaedic department at a walk-in centre 90 Bolton NHS Foundation Trust12. End with the start in mind 9313. Contacts 9514. References and additional information 96
6 Foreword Foreword Pathology services lie at the heart of healthcare services. The vision for the NHS pathology services puts patients first by providing services which are: • clinically excellent; • responsive to users; • cost effective; and • integrated. Two thousand and twelve/thirteen is the second year of the Quality, Innovation, Productivity, Prevention (QIPP) challenge and this document demonstrates how clinical teams have taken up this challenge to improve services for patients and users of the service. In addition, the NHS Operating Framework 2012/13 highlights five domains, of which four are important for blood sciences. • Domain 1: the reducing of premature mortality from the major causes of death. Blood sciences services have a significant role in providing effective screening for cardiovascular, respiratory and liver disease. • Domain 2: requires improvements in health-related quality of life for people with long-term conditions , such as diabetes. By using innovative approaches to service delivery, blood sciences has a significant role to play in the monitoring of patients with long-term conditions. • Domain 3: involves support for helping people to recover from episodes of ill health or following injury. Blood sciences services have a significant role in providing timely results for emergency admissions for acute conditions. • Domain 4: obliges all NHS organisations to actively seek out, respond positively and improve services in line with patient feedback. The sites have demonstrated the need to focus on and measure the whole end-to- end patient pathway highlighted in the Lord Carter review¹, demonstrating the importance of user engagement, the impact this can have on appropriate testing and the need for user education in correct sample taking. The need for clinical and managerial leadership is fundamental to achieving continuous sustainable improvement and the integration of pathology services within clinical pathways. The robust approach to improvement undertaken can be demonstrated in all eight descriptors of the new NHS Change Model launched by the NHS Commissioning Board. The Department of Health (DH) Pathology Programme is very pleased to support the work of NHS Improvement to demonstrate how these improvements can be achieved using Lean methodology. We commend this guide to all commissioners and providers of blood sciences services. Dr Ian Barnes Mr David Hamer National Clinical Director for Pathology National Clinical Lead for Blood Sciences Department of Health NHS Improvement
Executive summary 7Executive summaryIn 2006, the Review of PathologyServices in England by Lord Carterendorsed Lean as the method ofchoice for improving processes. .Working in partnership with the DHPathology Programme, NHSImprovement has supported anumber of blood sciences teams, tolearn how Lean methodology canenable the service to achieveimprovements to support the QIPPtransformation programme.Multidisciplinary teams workedcollaboratively to test and implementchanges that deliver improvementsfor patients, staff and users of theservice.In 250 NHS laboratories in England, Productivity A review of current guidance500 million biochemistry and 130 • reducing inappropriate demand by including Royal College of Pathology,million haematology tests(2) are ensuring users are educated to Keele Benchmarking, Clinicalcarried out per year. Ninety five request the appropriate test Pathology Accreditation (CPA) andpercent of all clinical pathways rely correctly the Lord Carter Review of Pathologyon a patient having access to • matching capacity to demand, and Services 2006/2008 identified a lackefficient, timely and cost-effective ensuring the appropriate use of of consistent approach toservices. staff skills measurement of the blood science • removing waste from process flows specimen pathway. The recent RoyalAs a result the impact on patients is to increase productivity and timely College of Pathology keysignificant, with improvements in: delivery, reduce cost and space performance indicators (KPIs) have requirements. now been specified as the time ofQuality and safety collection, to completion and• working with service users to Lessons learned confirmation of the test result achieve ‘right first time’ - Three important lessons have been available to the requestor. Similarly, addressing errors in sample learned in piloting and prototyping they have identified the need to labelling and requests; Lean thinking in blood sciences. measure the blood sample for A&E as follows.Innovation 1. Lack of a consistent standard• using Lean techniques to improve and approach to end- to-end Baseline. Percentage of core the flow of samples and reduce sample pathway measurement. investigations, i.e. renal function, liver turnaround times (TATs), function tests and full blood counts introducing technology to aid Working with a variety of clinical from A&E completed within one hour timely clinical decision making; and teams has shown an inconsistent of receipt, including out–of- hours. approach to the end- to- end sample This standard will move to one hour pathway measurement. A similar from sample collection by April 2015. finding was made during the Challenge. Eighty five per cent by microbiology improvement April 2012 increasing to 90% by programme. April 2014.
8 Executive summary Recommendation Measure end-to-end sample pathway Following recent changes towards outcome based healthcare and new and timely KPIs from the Royal College of Pathology, we recommend the blood sample specimen pathway should be measured from the time the sample is taken, until a result is available for the clinician to act on. Key measures across the pathway include: • date and time the specimen is taken; • date and time the specimen arrives in the lab; and • date and time the result is available to the clinical user. Pathology teams should collect this data and educate patients and users to provide details of sample timings. 2. Process and wider system changes are required to support end to end pathway measurement The recent document ‘First steps in It is vital to study the whole end- to- Much of the pre-analytical phase is improving phlebotomy: the challenge end pathway, as this will highlight the currently invisible to the laboratory to improve quality, productivity and importance effective pathology and pathology laboratory information patient experience’ (May 2011) services are as an enabler of systems (LIMS) and processes do not demonstrates the delays in each redesign, rather than a burdensome support measurement of the end- to- stage of the blood sample pathway. If cost centre. end pathway. Teams have been pathology teams are to support required to resort to lengthy manual significant changes in clinical Recommendation data collection or local adaptation of pathways to deliver: Pathology LIMS providers are information systems to demonstrate • reductions in admissions for commissioned / required to basic end- to -end sample pathway. emergency care; support the changing landscape • reductions in length of stay; to allow a patient- focussed • redesign of outpatient services; and approach to information across • innovative approaches to the patient pathway. supporting long term conditions. Pathology teams should collect this data and educate users to provide details of ‘sample taken’ timings.
Executive summary 93. Face-to-face user engagement Key elements to bring about 4. Establish ‘first in, first out’is essential to enable laboratories change • No prioritisation of specimens.to engage and educate users to Learning from other improvementensure: initiatives in pathology services has 5. Appropriate testing• appropriate testing to defined and confirmed the five key elements likely • Work with users to design agreed protocols, reducing to bring about substantial protocols and systems to support inappropriate demand; improvements in the pathway. appropriate test requesting.• education of users to get the best • Develop acceptance policies that from blood sciences wealth of 1. Focus on the whole end to specify information and data knowledge; end pathway quality requirements.• a ‘right first time’ approach to high • Ensure all staff in the pathway quality specimen collection, request understand up and downstream This learning guide provides blood and specimen labelling, to improve processes and how their own work sciences teams with the basic tools to safety and eliminate the impacts others. make changes to their processes, opportunity for error; and • Use whole pathway data (from along with insight into how• transportation of the sample is sample taken to result available) to colleagues have used these tools frequent, rapid and ensures the understand how samples, forms across the whole patient pathway. shortest turnaround times to and results flow and identify facilitate rapid clinical decision bottlenecks and waiting. making, with pathology services taking an active role in the 2. Adopt small batch sizes management of all transport • Throughout the entire pathway - provision. waiting to ‘fill’ equipment causes samples (and therefore patients) toRecommendation wait.Blood sciences works inpartnership with users to provide 3. Keep specimens movingvisible access to agreed protocols Daily throughout the day, withfor tests and to educate users. multiple deliveries from source ofA ‘right first time’ approach is specimen.encouraged and endorsed by • Pull work through the laboratory.commissioners, clinical teams and • Continuous authorisation ofusers to ensure safety and efficiency. results.
10 Introduction Leadership Introduction for change Spread of innovation Pathology services are faced with increasing demand and pressure to Engagement reduce costs whilst improving and to mobilise maintaining clinical safety and quality. Traditional cost cutting Our methods including staff reduction fail to deliver the required savings shared Improvement methodology because fewer staff are left with the same processes. purpose A Lean management system delivers reductions in error rates System and waiting times, together with drivers increases in productivity. Rigorous Application by healthcare delivery organisations across the world has improved outcomes for patients and reduced the cost of care at the Transparent same time. measurement NHS Improvement has worked with multiple teams across pathology disciplines to evidence the value of Lean methodology. The NHS Change Model Application of Lean tools enables improvement of isolated processes but the impact of one-off The key to the Change Model is not • Our shared purpose: patient improvement efforts of this nature the individual components but experience is at the heart of what can be short lived. It is only when ensuring all are addressed equally as we do and drives change. clinical leadership and operational part of any improvement effort. • Leadership for change: to create management changes sufficiently transformational change. that an organisational culture of “By doing that, we’ll • Engagement to mobilise: continuous improvement can be understanding, recognising and achieved. amplify and reinforce our valuing individuals’ contributions. ability to drive change. • System drivers: QIPP, CQinns, NHS The NHS Commissioning Board has Operating Framework. recently launched the NHS Change We’ll take the skills we’ve • Transparent measurement: Model. already got, and take measurement for improvement and patient outcomes. The model brings together familiar them to the next level in • Rigorous delivery: project elements of any successful change being able to make management, PDCA cycles and programme and is designed to ensure measurement of benefits. the NHS can meet the challenge of things happen.” • Improvement methodology: Lean, the pace and scale of change capacity and demand, value and required to meet future financial process mapping. constraints and improvements in • Spread of innovation: using shared quality. learning via multi-media techniques.
Introduction 11The programme of improvementpredates this model. However, itcan be demonstrated that NHSImprovement’s approach insupporting clinical teams hasaddressed each of the eightelements of the model which shouldbe at the centre of any improvementeffort whether localised to a singledepartment or at national scale.Lean management is not simply an’improvement methodology’ asdescribed in the Change Model. Leanaddresses all areas and providesteams with a checklist for continuousquality improvement.Exemplar programme and ShingoassessmentThe majority of the case studies inthis document come from Leadership for change John Toussaint, CEO Thedacare,laboratories that are part of the NHS Leadership is behaviour – Wisconsin, USA, a healthcareImprovement pathology exemplar organisation that slashed errors andsite programme commissioned by the “What we do as leaders improved patients outcomes, raisedDH Pathology Programme Board. The staff morale and saved $27m in costsaim of the programme is to establish is more important than with no lays offs, sums it up asand support a network of pathology what we say.” follows:laboratory exemplar sites who willdemonstrate continuous qualityimprovement (CQI) in clinical, process Sir Nigel Crisp “In the end the enemy ofand business excellence. One element of the new NHS our improvement effortsSite assessments Change Model is Leadership for was us. Leadership was change. The narrative supportingAll pathology disciplines within the this asks, “do all our leaders have the treating eachexemplar sites will carry out self- skills to create transformational improvement initiative asassessments supported by NHS change?”Improvement, based on the time limited, a finiteinternational Shingo Standards for Lean is the term popularised by project conducted by aBusiness Excellence. The assessments Womack and Jones to describe awill be made against criteria management system derived from few members of staff ordemonstrating: the Toyota production system (TPS) consultants. that has been adapted and• leadership and cultural enablers; successfully applied nationally and Improvements ended• continuous quality improvement; internationally to a wide variety of when a project was over• organisational alignment; industries including healthcare for• understanding the needs of over 20 years. because nobody was in customers; and charge of sustaining• business results. Why, when it seems so simple do Lean initiatives often fail to sustain? change and measuringwww.shingoprize.org/model- results.”guidelines.html
12 Introduction “In order to change outcomes, leaders at Thedacare needed to change”(3) Continuous improvement can, and will, only occur if the people who actually do the work are actively engaged and understand Lean and their leaders change. Literature evidences that there are key behaviours that leaders and managers need to adopt in order to develop a sustainable Lean management system. Developing a Lean culture Culture change takes time and requires leadership. A great many models and theories exist to guide those wishing to develop their own Finding change agents Core team members must leadership capability and approach. Achieving a culture shift starts with a understand the process within their small team working collaboratively stage of the pathway and be: Key steps to influencing the creation with their department colleagues and • able to contribute of a lean culture include: users to improve identified areas of ideas/information on the process; • find change agents; the process. • able to influence the decision • get Lean knowledge; • seize crisis; making process; Identify a credible and respected • prepared to test and implement • map the value stream; project lead to head up this team. changes across the pathway; and • remove waste; Look for a clinician or manager with • committed to attend all team • continuous improvement; and the drive and enthusiasm to steer meetings, activities and work • sustain. changes across the patient pathway. required between meetings. A Lean culture could be described as Project team members should be Escalation planning one where managers at every level drawn from across the entire An executive sponsor is essential to go to the workplace and coach their pathway: provide proactive support and access staff in plan, do, check, act (PDCA) • clinical colleagues who will actively to relevant support services such as problem solving. A continuous commit to the improvement effort; estates and transport, HR, finance process that is part of ‘the way we • laboratory representatives for each and IT teams. They may be called operate here’. job grade; upon to escalate key issues. • administrative /office staff representative; • porters/ transport staff; and • user involvement – member of a patient group and a high volume user – from primary care, ward or clinic.
Introduction 13Engagement of your staff How engaged are we? Suggestions boxes / boardsWhat is engagement? An engagement surveying tool has Provide an outlet for staff to makeAnother element of the new NHS been developed and is available at anonymous comments, niggles andChange Model is engagement to www.improvement.nhs.uk/ suggestions. Share comments at themobilise – are we engaging and improvementsystem to enable daily huddles and provide either anmobilising the right people? measurement and to motivate instant response or agree a timescaleThere is no single answer but themes leaders at all levels to take action on for investigation and feedback.of commitment, involvement, results and improve their owncommunication and energy leadership capability. 1-2-1sare clear. Speak privately with individuals The 10 questions are based on the where necessary to make it known“Employees who work work of the Gallup organization, that their views and concerns are Marcus Buckingham and Curt important. Ask their permission towith passion and feel a Coffman published in First, Break all raise their issues at daily huddles forprofound connection to the Rules. further discussion.their organisation. They Communication After a period of time (which will bedrive innovation and Establishing the framework for, and different for each team depending on maintaining, good two way the starting point) use of suggestionmove the organisation communication is critical to the boxes and boards should diminish asforward.” success and sustainability of any the daily huddle becomes the focus improvement activity. for raising, discussing and resolvingMeere(4) issues. Daily meeting - huddles“Employee engagement An important mechanism for Daily meetings can (and should) be a engaging staff is huddling. formal part of department operationsis about translating A huddle is a daily, short and snappy and minuted accordingly. The needemployee potential into face to face gathering of a team, for formal laboratory meetings will preferably standing around a reduce and may be eliminatedemployee performance performance board that addresses altogether.and business outcomes.” the following. More supporting information isMelcrum(5) 1. Focus – on key goals and available at: responsibilities for the day. www.improvement.nhs.ukIt is well-established that change is 2. Clarity – clear, relevant and timely /improvementsystemdifficult for most people. It is the information to help staff performresponsibility of leaders to listen and their daily roles.understand individual perspectives 3. Commitment – listen and act onand concerns creating an staff views, ideas, and concerns andenvironment of open and honest to feedback progress.communication. When huddles are first introduced they may feel strange and uncomfortable for some people. Participation is likely to come from the same small group of individuals and so other mechanisms for eliciting input and views from the whole team can be used to support efforts to create an environment where all are comfortable to speak up.
14 Waste Waste Every process has waste. The foundation of Lean is the relentless Type of waste Laboratory examples pursuit and elimination of waste in all work activities. T TRANSPORT Material or information that is moved unnecessarily or repeatedly e.g. Unnecessary When we look at a process as a time movement of samples between work areas line of activities, material (samples or laboratories. and consumables) and information (request cards and reports) whether I INVENTORY Excess levels of stock in cupboards / store in a value stream map or a process rooms; batches of specimens waiting to sequence chart, we see a significant move to next step in process. percentage of waste. Usually in excess of 90% of a sample journey is M MOTION Unnecessary walking, moving, bending or taken up by wasteful, non-value stretching e.g. equipment placed in wrong adding activity. location, unnecessary key strokes. Some steps in the current process will A AUTOMATING Where technology is substituted to be pure waste (see below), other (inefficient processes) compensate for a poor process. For example waste may be necessary within the analytical track systems which are purchased current way of working. For example, without the right process being agreed, in many blood sciences laboratories, tested and established. In some cases the need to centrifuge samples or resulting in ‘urgents’ being taken off the transport samples to, or between, ‘track’ because it’s too slow. laboratories is currently necessary waste. W WAITING Waiting for specimens, equipment, and staff. Samples waiting to move to the next stage Improvement initiatives should focus of the process. on eliminating the pure waste and reducing the necessary waste. O OVER-PRODUCTION Producing something before it is required, or more than is required e.g. unnecessary or A simple mnemonic exists to aid inappropriate tests; batching specimens, recall of the nine wastes. tests and information; ‘just in case’ blood tubes drawn from patients, but not used. O OVER-PROCESSESING Duplication of data e.g. Dual data entry, repeat testing, additional steps and checks that add no value to the process. D DEFECTS Errors, omissions, anything not right first time e.g. Poorly labelled specimens and requests, insufficient or illegible information. S SKILLS UTILISATION Unused employee skills e.g. Highly qualified staff performing inappropriate tasks; staff ideas not being considered. Waste costs money and adds time
Sites 15SitesThis document shares learning from a The approach required local Northern Lincolnshire and Goolenumber of clinical teams from three ownership and leadership if the Hospitals NHS Foundation Trustsites who have been working with improvement was to be sustained, Path Links is a single managedNHS Improvement and three sites underpinned by the training of all Clinical Pathology Network operatingwho have independently undertaken members of the team in Lean across Lincolnshire. Formed in 2001a Lean improvement journey. methodology. from the amalgamation of NHS services in Boston, Grantham,NHS Improvement sites Clinical teams were encouraged to Grimsby, Lincoln, and Scunthorpe, visit other exemplar sites to observe Path Links is a directorate within theDerby Hospitals NHS Foundation Lean methodology as part of diagnostics and therapeutics division.Trust, Royal Derby Hospital everyday working and understandBeginning in November 2011, the how improvements have been Standardisation of blood sciencesDerby blood sciences team have been achieved. commenced in 2009 culminating indeveloping a Lean culture which the successful implementation of pre-started in specimen reception and Independent sites analytic and analytical lean work cellssubsequently spread into the blood These sites were selected to reflect supported by multi-discipline trainedsciences laboratory and the A&E the importance of a long term staff. The introduction of standarddepartment. sustainable approach to work and A3 SOPs has resulted in improvement, where the learning improved quality, increasedChesterfield Royal Hospital NHS never ends, and the service is productivity and reduced costs.Foundation Trust constantly looking to pursueBeginning in October 2011, the perfection. South Warwickshire NHSChesterfield blood sciences team Foundation Trusthave been developing a Lean culture Bolton NHS Foundation Trust, The South Warwickshire team waswhich started in specimen reception Royal Bolton Hospital part of a hospital wide approach toand subsequently spread into the The team at the Royal Bolton Hospital improvement sponsored as a threeblood sciences laboratory, the started their Lean journey in blood year work programme by ‘The Healthspecimen transport system and the sciences in 2005-6. They have Foundation’ to examine thehaematology clinics. provided support to the NHS relationship between emergency Improvement sites through hosting patient flow, mortality and cost.Taunton and Somerset NHS exemplar site visits. Recognition ofFoundation Trust, Musgrove Park their sustainable efforts was achievedHospital in the HSJ Award for Efficiency inThe blood transfusion team at September 2012.Taunton have been developing a Leanculture which has spread from thecytology laboratory and specimen Sites and leadsreception functions to the surgicaladmissions lounge and operating Derby Hospitals NHS Laboratory Lead: David Simpsontheatres. Foundation Trust Clinical Lead: Dr Nigel Lawson Chesterfield Royal Hospital Laboratory Lead: Christine AingerWorking with blood sciences teams NHS Foundation Trust Clinical Lead: Roger Startacross these sites to further evidencethe value of Lean thinking, NHS Taunton and Somerset NHS Laboratory Lead: Matt BarnettImprovement provided training in the Foundation Trust Clinical Lead: Dr Sarah Allforduse of Lean thinking to support staffto redesign the way services are Bolton NHS Foundation Trust Laboratory Lead: David Hamerdelivered, to achieve process Clinical Lead: Gilbert Wieringaexcellence to support the clinicalexcellence within the laboratory and North Lincolnshire and Goole Laboratory Lead: Martin Fottles,in turn improve the user’s Hospitals NHS Foundation Trust Continuous Improvement Managerexperience. (Path Links) Clinical Lead: Dr David Clark
16 Start with the end in mind Start with the end in mind The often-asked question in Since the publication of the second Similarly some of the case studies improvement work is, ‘where do Carter Report, there has been a overlap the pathway sections and for we start’? growing emphasis on Pathology ease of inclusion we have tended to services taking responsibility for include case studies under the stage There is no simple answer, it depends managing the end-to-end journey in which the journey starts. on what are your biggest issues; (i.e. from collection of sample to what is your burning platform? delivery of interpreted result, All continuous quality improvement including transport and logistics – initiatives should deliver How will you know what Carter Report 2008). This document improvements in one or more key these are? has been constructed around the key areas, namely: Sometimes this is obvious, from stages in this end to end journey as known failings in your systems, or follows: • quality e.g. reduced defects; imperatives set by your executives or • timeliness/delivery e.g. commissioners. However, without • Pre-pre analytical: clinician decision improved turnaround times; three fundamentals in place you are to test to sample delivery. • cost/value for money e.g. unlikely to be in a position to apply • Pre analytical: sample receipt to removal of waste, reduction in the right improvements in the right available to test. inventory; and places. These three fundamentals are: • Analytical: availability to test to • morale/staff experience/patient result available to view. experience e.g. reduced • looking at the end-to-end • Post-analytical: result available with overburdening for staff, processes in your service (from comments added to result, reduced waits for patients. decision to test to provision of delivered and viewed. interpreted result); • Post post -analytical: result It is indicated before each case study • collecting data to inform exactly interpretation and follow up which improvement parameter(s) what is happening as a baseline testing. they deliver by highlighting the and understand what needs to appropriate box, together with the improve; and There are opportunities for laboratory headlines from the case study. • engaging with the customer services to add value at each stage of (patients and their clinical teams) to this pathway. understand their needs and what MORALE, value you can add to them (the Some of the Lean tools available lend COST OR STAFF OR true ‘end in mind’). themselves to a particular part of the VALUE FOR PATIENT pathway, others are equally as MONEY EXPERIENCE In the following chapter and case valuable across several or all parts of studies, you will see how these the pathway. fundamentals have helped drive and focus the improvement work at all TIMELINESS QUALITY the sites who have contributed to this AND AND learning document. DELIVERY SAFETY
. Pre pre-analytical stage 17Pre pre-analytical stageThe start of the journey All of these opportunities to addThe clinician has a clinical question value are dependent on: PRE PRE-ANALYTICALand they require diagnostic input to • laboratory staff engaging with theirhelp answer that question. The customers;laboratory can influence and add • listening to their requirements;value at this stage in a variety of • helping them solve their problems;ways, including advising on: • understanding what the customer• what to test for; values from the services on offer;• how to test; and CLINICAL QUESTION• when to test; • ensuring that value is delivered as• where to test; and efficiently and effectively as• who performs the test. possible with minimum wasteful/non value adding steps.Laboratory staff can educate clinicalstaff to understand the safest and The concepts highlighted in the casemost effective way to collect, label studies in this section include: GENERATE REQUESTand despatch the required samples. • user engagement; • use of order sets; andThis may include providing • communicating with users.phlebotomy services; assisting inimplementation of electronic ordering The tools illustrated include:systems; providing sample collection • value stream mapping;and transport services/systems. • current and future state models; COLLECT THE SAMPLE • identifying non value adding steps; • reducing defects; and • ‘go and see’. TRANSPORT THE SAMPLE
18 MORALE, COST OR TIMELINESS QUALITY STAFF OR VALUE FOR AND AND PATIENT MONEY DELIVERY SAFETY EXPERIENCE Chesterfield Royal Hospital NHS Foundation Trust Pathology transport reconfiguration Summary The trust’s transport service Data collection of when samples introduced an ‘interceptor’ van, which has enabled samples to be arrived at the laboratory and delivered to the laboratory more establishment of interceptor van frequently throughout the day, smoothing the flow to the laboratory ensured smaller batches of work and reducing the number of specimens by 61% between 12:45 which were delivered more often. and 1:15pm (the main lunch period). Understanding the problem The pathology transport service at Total number of samples on pathology vans on 4 January 2012 Chesterfield Royal Hospital provides a delivery and collection service of 800 internal mail, pharmacy supplies and 700 Total number of samples pathology samples to a mixture of 686 600 GP practices, community hospitals and clinics. The service operates by 500 546 employing eight part time and one 400 full time van driver. At present the service has five vans and does an 300 330 335 309 average of 190 calls per day over five 200 214 186 van schedules, which are split into 100 morning and afternoon runs. 110 0 9am-10am 10am-11am 11am-12pm 12pm-1pm 1m-2pm 2pm-3pm 3pm-5pm 4m-5pm A detailed audit of the blood Time sciences pre-analytics process identified two major peaks of workload arriving from GP and community locations, so the pathology transport service Number of samples arriving by pathology van by examined how they could contribute schedule - January 2012 to improving the flow of work arriving into the laboratory. 500 450 468 Total number of samples The data collection revealed the 400 number of samples arriving into 350 379 381 pathology, along with number of 351 300 315 samples on each van by the hour. 250 250 200 224 182 186 150 100 96 50 0 A B C D E Morning Afternoon
19How the changes wereimplemented Daily deliveriesA team of representatives from the Before interceptor van After interceptor vanpathology transport service,pathology general and blood 11.30-11.45sciences departments produced avalue stream map and process maps 12.00-12.15of the service to identify key areas 12.30-12.45for potential improvement.Three groups within the team 12.45-1.00discussed the issues and the aims of 1.00-1.15this session were identified as: 3.30-3.45• reduce the ‘peaks’ of samples 4.00-4.15 being delivered to the laboratory; and 4.15-4.30• resolution of community pharmacy 4.30-4.45 issues such as controlled drugs, incomplete paperwork, and access -800 -600 -400 -200 0 200 400 600 800 to the department.An interceptor van was introducedto meet other van drivers at specificpoints along their routes, collecting Positive feed-back from the sample Key learningsamples and returning back to the handling staff was received. They Data collection of when sampleslaboratory more frequently felt that the introduction of the arrived at the laboratory andthroughout the day. The impact of interceptor van meant that samples establishment of interceptor vanthis was monitored after several were arriving more often in smaller ensured smaller batches of workweeks by repeating the hourly batches. delivered more often.audit of samples arriving in thedepartment and comparing this to Community pharmacy How this improvement benefitsthe baseline data originally After discussions and e-mails with patientscollected. community pharmacy the van drivers Samples arriving earlier in the day in have noticed that the time waiting smaller batches means that moreMeasurable improvements to access the pharmacy department samples are received and processedand impact had reduced so that the length of on the day they were collected fromThe data analysis shows the impact time waiting for controlled drugs has the patient, so results are availableof the introduction of the interceptor also reduced. The situation is sooner.van with a significant amount of monitored through the departmentalwork now being received earlier meetings. Contactfrom the morning and afternoon Joanne Dodsworth,collections, with 32% less samples All community pharmacy issues had Operational Services Co-ordinatorreceived in the morning and 1% been resolved. Email:increase in the afternoon on re-audit email@example.com compared to the baseline nhs.ukdata.
20 MORALE, COST OR TIMELINESS QUALITY STAFF OR VALUE FOR AND AND PATIENT MONEY DELIVERY SAFETY EXPERIENCE Chesterfield Royal Hospital NHS Foundation Trust Introduction of coloured transport bags in pathology Summary The pathology department A simple visual management system introduced coloured transport bags, currently in use for 40% of GP users has improved communications with the remaining GP surgeries between the laboratory and GP using the coloured bags by the end of 2012. practices. Understanding the problem The pathology transport service at Chesterfield Royal Hospital provides Number and types of samples arriving by pathology a delivery and collection service of van by schedule - 4 January 2012 internal mail, pharmacy supplies to a 1200 Total number of samples mixture of GP practices, community 1100 1021 1000 hospitals and clinics and pathology Morning Afternoon samples are delivered to pathology 800 reception from these sites. 600 The data collection identified the 400 sample types arriving in pathology 200 188 reception. 152 13 98 55 37 30 10 12 1 0 4 4 5 1 1 0 Blood Urine Stool Swab Cytology Histology Nail clip Sputem Other • Multiple sample/mail collection points in practices/hospitals. • Samples not ready for collection (bags not sealed). This identified a ‘go-live’ date for the • Inappropriate items of mail have • Van drivers queuing in-line with trial of the new bags as 12 March reduced. patients. 2012, and it was recommended that • Communication of surgery • No notification if surgeries closed the van drivers report any closures has improved. for training etc. (therefore no concerns/issues. The main focus on collection required). this session was to review what the Key learning • Samples stored in un-manned transport service will accept with The introduction of a simple visual areas. respect to collections/deliveries. management system has improved • Incorrect sample storage (fridge/ the communication with GP room temperature). Some users had also raised concerns practices and improved sample • Many items collected are over the changes to the new sample integrity. inappropriate items of mail, e.g. biohazard bag, a guide was also sent mobile phones. out to help address issues. How this improvement benefits patients How the changes were The core team produced a guidance Sample integrity has improved as implemented notice from the operational services samples are stored appropriately and A team of representatives from the co-ordinator, along with a covering at the correct storage temperature. pathology transport service, letter, which was sent out to all users pathology general and blood of the transport service in April Contact sciences departments identified key 2012. Joanne Dodsworth, pilot sites to roll out the new Operational Services Co-ordinator coloured transport bags. Measurable improvements Email: Initial meetings took place with six and impact joanne.dodsworth@chesterfieldroyal. GP practices. • Samples are now placed in the nhs.uk coloured sample bags, sealed and placed at the collection point.
21Examples of new pathology transport sample bags
22 MORALE, COST OR TIMELINESS QUALITY STAFF OR VALUE FOR AND AND PATIENT MONEY DELIVERY SAFETY EXPERIENCE Taunton and Somerset NHS Foundation Trust Decreasing the rejection rate for transfusion blood samples Summary The rejection of blood transfusion Engagement with users and samples due to the poor completion of the transfusion request form subsequent redesign of the request caused delays in transfusion form has allowed the clinical and processes. Introduction of a new request form in two clinical areas laboratory staff to focus on the critical reduced rejection rates from 15% to 1.8%. information required. Understanding the problem One of the causes for delay in the availability of group and antibody contained the correct patient details How this improvement benefits screen results for patients going to and removing the requirement for a patients theatre was the number of samples doctor to sign the request form. • The reduction in the number of that were rejected by the laboratory samples rejected means less staff due to the form being The form was piloted for two repeating of samples and completed incorrectly, increasing the months in two clinical areas, the therefore less re-bleeding of workload for clinical staff and haematology ward as they are high patients. causing dissatisfied patients who users and A&E department because • For those patients awaiting a may have to be re-bled, or have their of the high rejection rate. The SAL blood transfusion, there is less surgery delayed (especially if they are was not used as although they had a likelihood of delay, especially for first on the operating list). high rejection rate, only four staff on patients first on the operation list. the ward perform the phlebotomy. This is also especially important for In September 2011, 15% of all those patients who need regular rejected samples came from the Measurable improvements monthly blood transfusions. surgical admission lounge (SAL) and and impact 15% came from A&E. Other clinical In the two months prior to the pilot How will this be sustained and areas also were found to have high over 15% of the rejected samples what is the potential for the rejection rates. The analysis of the came from the A&E Department. future? causes for rejection indicated that Overall rejection rates for February The next slep in the process is to role the two main issues related to the and March were: out the new form across the whole date of birth missing from the form • 6% for all samples; and of the trust. This will be supported and the form not being signed by • A&E – 10%. by an implementation plan to ensure the doctor. that all relevant staff are aware of During the pilot period 110 forms the changes. How the changes were were completed. Only two forms implemented were rejected. Rejection rates will be monitored by Discussions were held with clinicians, the transfusion staff and fedback to including the anaesthetists and Key learning the clincial areas with the highest nursing staff to find out what were Engagement with users and rejection rates. the key obstacles preventing the subsequent redesign of the request forms from being completed form has allowed the clinical and Contact correctly. This led to a redesigning laboratory staff to focus on the Alison Western, of the blood transfusion request critical information that is required Transfusion Practitioner form to allow the use of an when requesting blood components Email: firstname.lastname@example.org addressograph label which and transfusion related blood tests.
23 MORALE, COST OR TIMELINESS QUALITY STAFF OR VALUE FOR AND AND PATIENT MONEY DELIVERY SAFETY EXPERIENCEDerby Hospitals NHS Foundation TrustEmergency department diagnosticsimprovementSummaryA thirteen per cent improvement in The importance of go and see andthe number of samples authorisedwithin one hour of collection as a understanding the end-to-endresult of a clinical support worker pathway reduces turnaround times,trial, and the reduction of bloodtransport times by up to 15 minutes and improves communicationdue to re-prioritisation of pneumaticchute station. between departments.Understanding the problemThe requirements set by the RoyalCollege of Pathologists, states thatby 2015, 90% of samples taken inthe emergency department(A&E)must have results available withinone hour from receipt in thelaboratory. Since the responsibilityfor achievement of this goal isshared between staff in thepathology laboratories and A&E, oneof the keys to understanding theissue fully, was to ’go and see’ whatactually took place in eachdepartment.As a result of the ‘go and see’ booked in and when the results On observation of the workloadactivity, the phlebotomy was seen were authorised. It became apparent faced by the specialist nursesto be delayed in triage due to the from these observations that the working in A&E, it was clear thatnature of the workload faced by pneumatic chute sometimes held asking more of them, even for thespecialist nurses in A&E , since they pods filled with samples for up to 20 improvement of their processes,have to respond more urgently to minutes prior to sending them to the would be very difficult to implementpatient needs. There was often a laboratory. and sustain.substantial discrepancy between’collection’ time as recorded on the Teams of staff from both the Enquiries were made with thecomputer system (when request pathology laboratory and A&E met estates department, who areforms were printed) and actual time with each other to discuss the responsible for the pneumatic chutethe blood was taken, resulting in problems faced by each department system, to find out if there was anyincorrectly recorded TATs. when taking and processing blood, way of reducing the time pods were in an effort to help identify issues waiting to be sent to the laboratoryTwo of the laboratory staff went to which could be solved quickly, and from A&E.A&E to observe the processes. They for the most mutual gain. Bothrecorded the times samples were teams gave tours of their respectiverequested, the times samples were departments to each other, to helptaken, when the samples were gain some understanding of theplaced in the pneumatic chute, practicality of working in each area.arrived in the laboratory, were
24 Clinical Support Worker Trial How the changes were implemented • Meetings were held between pathology and A&E staff. Some long standing issues on both sides were discussed, allowing a greater depth of understanding of the challenges each group must overcome on a daily basis. Bridges were built, allowing improved communication and an increased feeling of team spirit and empathy between the two departments. • One Plan, Do, Study, Act (PDSA) trial was carried out to determine • 13% improvement in number of • Leadership is the key. Without the effectiveness of a clinical samples collected and authorised investing the time required to support worker in the emergency within one hour. make and sustain effective department to carry out all • Average time from pods waiting to improvement, nothing can phlebotomy duties. be sent from A&E to the lab change. • It was discovered that the ’priority’ improved from 9.25 to 3.5 • Following the clinical support setting on the pneumatic chute in minutes or 62%. worker trial in A&E, no post has the emergency department had • Formal and informal meeting and been put in place to make this been lost two years previously and ’go and see’ activities improved permanent due to funding. All no one had noticed. This was vital communication betweenA&E benefits must be weighed against reinstated and reduced the and the laboratory, with one their cost for improvement to be maximum time pods were waiting advanced nurse practitioner truly effective. to be sent from A&E to the stating: “Just knowing who to talk laboratory from 20 minutes to five to about certain issues makes any How this improvement benefits minutes. problems that arise much easier to patients resolve quickly.” This reduction in time taken to Measurable improvements • Phone calls reduced from A&E to transport samples to the laboratory and impact the laboratory from six per day to means faster results, faster • Pod priorities reinstated after six a week. treatment and ultimately, faster being lost two years previously . • The clinical support worker trial discharge. Should the trial ever be • 25% improvement in mean was perceived to reduce A&E made a permanent post, the collection to receipt time during specialist nurse workload. reduced workload on the A&E trial week. Although not formerly measured, specialist nurses would allow more • Average sample collection to staff simply said it meant they had time to provide patient focussed receipt time improved from 75.75 one less thing to worry about. care, rather than being focussed on to 57.07 minutes during trial turnaround times and targets. week. Key learning • 76% reduction in average moving • Properly defining the issue to be Contact range overall, showing a reduction resolved and collecting relevant Tom Kennedy, Specialist Medical in variability of sample transport data in a consistent way is Laboratory Assistant times from A&E. Possibly absolutely fundamental to the Email: email@example.com attributable to increased success of any improvement awareness among staff. project.
25 MORALE, COST OR TIMELINESS QUALITY STAFF OR VALUE FOR AND AND PATIENT MONEY DELIVERY SAFETY EXPERIENCEChesterfield Royal Hospital NHS Foundation TrustHaematology clinic changes to supportpatient experience and improve flowSummaryBy using the principles of ‘go-see’ It is important to differentiateand ‘ask why’, haematology clinicchanges have improved the time between what is thought to happen intaken for samples to arrive in the a process and the reality of whatlaboratory. These activities havegenerated multiple suggestions for actually happens. Don’t try to solvefurther changes to improve thepatient experience of clinics. every problem at the same time.Understanding the problemHaematology clinics for patients witha wide range of malignant and non- A ‘go see’ exercise to understand Lab (booking in, processing,malignant haematological conditions how patients flow through clinic and authorising)held on Monday and Friday have how the samples flow through the • Requests are collected from theapprox. 35 patients booked in to lab was completed in April 2012. air-tube and identified by yelloweach clinic. Many of the patients The service manager, consultant paper.attend this clinic on a regular basis haematologist, phlebotomy team • They are processed as urgent.and many require chemotherapy leader and lab staff all visited the • If a blood-film is required, resultsand/or blood transfusion support clinic. are not authorised.and so require recent blood testresults to enable the clinicians to Pre-lab (phlebotomy, transport Post result (consultation andmake treatment decisions and so the to lab) follow up organisation)medical staff do not have a • Patients don’t attend at their • Unauthorised results cannot beconsultation with the patient until allocated appointment times. seen by all clinic staff (medicalthis result is available. A few Some patients requiring blood staff and some nursing staff canpatients who attend the clinic have tests come earlier than their see unauthorised results). Untiltheir blood sample taken sometime appointment time, others attend authorised, the results do not goin the week before their at their appointment time. across to the result viewing systemappointment either at the hospital Patients not requiring blood tend accessed by all staff in the Trust.phlebotomy clinic or in the to arrive at their appointment • Notes for patients who are readycommunity. The majority of patients time. to be seen by consultant are put inhave their blood sample taken on • Phlebotomists have a list of to a box in the clinic. Consultantsthe day they attend clinic and then patients attending clinic and check collect notes from the front of thewait for the result to be available on notes which ones will be box and taken back to theirbefore having their consultation with requiring blood tests on the day. consultation room.the doctor, nurse or pharmacist. Phlebotomy staff call patients in • Consultants check that all results the order on the list, but do not are available and that they are ableThe clinics are very busy and tend to know if the patient has arrived. to see the patient. If results areoverrun on a regular basis with some • Blood is taken and then available, the patient is called in topatients waiting a long time to be transported down the corridor to the consultation room. If resultsseen. The perception of the clinic send to the lab via the air tube. are not available, the consultantstaff was that waiting for blood • Patient notes are put in a box for has to either chase results fromresults delayed patient consultations the consultant when the patient the lab or put notes back and pickin clinic. has booked in and gone to have another patient to see. bloods taken. • During consultation, the consultant makes arrangements for follow up appointments and treatment for the patient.
26 Within each of the previous steps in the pathway, lots of issues were identified. Ideas for improvements were suggested during a brainstorming session and also picked up during discussions at team meetings. Base line data was collected at each step of the patient pathway through clinic to identify the problem areas. The figures showed that the automated testing process within the lab was very quick and the median time taken was 8 minutes from the sample being booked in to a result being available, this accounted for 16% of the total turnaround time. This suggestion raised several health The turnaround times for each stage and safety issues but following of the process showed that the main discussion with the pathology areas to focus on improving should health and safety lead, measures be: were put in place which were • Time taken from the patient accepted by the pathology clinical arriving to the request being governance committee. As booked in to the lab (pre-result - phlebotomists are classed as 1. Change of route taken to members of laboratory staff they are 53% of total turnaround time). get to lab: aware of the precautions they need • The time taken between the result Suite 4 is not connected to the air to take in the laboratory, they wear being available and this being tube network so the samples have to appropriate clinical uniform and authorised (post result - 8% of be hand delivered to the laboratory. carry hand gel to apply when going turnaround time but a maximum Although Suite 4 is next door to in and out of the laboratory. value of over two hours). Pathology the route to drop off the samples meant walking out of Suite How the changes were 4 along the corridor and then in to implemented Pathology reception. The samples On 6 June 2012, the haematology were then dropped at pathology clinic re-located from Suite 1 on a reception and taken by the reception fire door in to the blood sciences lab. Monday and Friday due to re- staff to sample handling. The total It was suggested that this route was organisation of clinic space in the distance from the blood taking room used to deliver samples directly in to Trust. This move forced some to sample handling is approximately sample handling. The total distance immediate changes in the pathway. 30meters one way (blue line on floor from the blood taking room to the The nursing staff for suite 4 are not plan). This change had the potential sample handling bench would be the same members of staff who to significantly increase the time reduced to 9 metres (red line on worked in suite 1. They did not from sample being taken to being floor plan). Additionally, this reduced know how the clinic had run in suite booked in. It was noted that travelling distance enabled delivery 1 and were very keen to suggest adjacent to the waiting room in suite of samples to the lab in flow rather immediate changes. 4 there is a door which leads in to a than in batch as had been the stairwell which then leads on to the custom.
272. Numbering system for Key learning The patient would know that thephlebotomy introduced: • The importance of ‘go see’ to time of their consultation would beFrom the ‘go-see’ observations it follow the pathway. This helps the time they are actually seen. Thiswas clear that the phlebotomist everyone involved in the process consistency will also mean that theneeded to know that a patient had understand how the work they do doctors do not waste time checkingarrived and needed a blood test. impacts on others. whether results are availableThe clinic staff and phlebotomist • The perception that one part of meaning that they can actuallycame up with the idea of a number the pathway was slowing the rest spend more time seeing the patient.system, which works by the clinic down is not always true. A This should result in a better qualitystaff giving any patient who requires combination of issues results in consultation for the patient.a blood test a number when they delays.check in to the clinic. The • Data collection is difficult and it is How will this be sustained andphlebotomist calls the numbers out important to have a standardised what is the potential for theand the patients go in to the way of collecting this. This was future?phlebotomy room. particularly an issue as each part • Continue to gather data to gain a of the pathway is completed by a better understanding of the waitMeasurable improvements and different member of staff and in times on various clinic days.impact different locations. • Ensure that each step of theThe numbering system has allowed • Ideas should not be discounted process is as efficient as it can bepatients to be bled in the order in immediately because “we have by drilling down to examine wayswhich they are booked in the clinic, tried that before” or “health and to improve. Some of the dataa first in first out system, which has safety would never allow it”. collected suggests that theenabled samples to be dealt with in • Lots of areas for improvement are phlebotomist is not deliveringflow. highlighted when you examine a every sample as soon as it is taken process. It is important not to try and will take 2 or 3 at the sameThe whole pathway was to solve all of the problems time. The effect on the overallre-measured on 18 June 2012. A immediately, but to plan changes turnaround time for the samplebreakdown of the data showed that in a structured fashion. needs to be measured to see if thisthe time from sample being taken to does actually have a significantbeing booked in had decreased from How this improvement benefits negative impact.a median of 17 minutes in April to patients • Continue to work with the staff in11 minutes in June 2012. This was a At the moment the doctors have no clinic to make sure that any smalldirect result of the change of the way of knowing when results are changes in procedure are notedroute the samples took which available without looking up each and the effect on the running ofenabled flow rather than batch patient individually. If the patients the clinic is acknowledged. Exploredelivery of the samples. On average requiring a blood test were asked to implementing a more visual system100 patients are bled in the clinics attend 45 minutes before their in clinic to show where a patient isper week. So these improvements consultation time they could be in the process.have removed 10 hours of patient called in to the consultation at theirwaiting time per week. specified time. This is because the lab could guarantee that a result will be available within 45 minutes and the consultant would be confident a result would be available when they called in the patient.