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NHSCANCER                                                 NHS ImprovementDIAGNOSTICSHEART              NHS Cervical Screen...
Continuous improvement in cytology: sustaining and accelerating improvement      3Contents1. Foreword                     ...
4    Continuous improvement in cytology: sustaining and accelerating improvement           1. Foreword           In Novemb...
Continuous improvement in cytology: sustaining and accelerating improvement    52. Executive summaryFollowing the initial ...
6    Continuous improvement in cytology: sustaining and accelerating improvement           3. Introduction           Phase...
Continuous improvement in cytology: sustaining and accelerating improvement                    74. Site overviewThe follow...
8    Continuous improvement in cytology: sustaining and accelerating improvement           5. Phase one: Sustainability   ...
Continuous improvement in cytology: sustaining and accelerating improvement   9Figure 3: Phase one cytology - percentage i...
10   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 1     Root cause analysis ...
Continuous improvement in cytology: sustaining and accelerating improvement                 11Case study 2Addressing delay...
12   Continuous improvement in cytology: sustaining and accelerating improvement           6. Phase two: Accelerated imple...
Continuous improvement in cytology: sustaining and accelerating improvement   13Achieving the cultural shift“The most impo...
14   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 3     Newcastle Cytology L...
Continuous improvement in cytology: sustaining and accelerating improvement          15Proposed counter measures(What will...
16   Continuous improvement in cytology: sustaining and accelerating improvement           7. Learning for the future     ...
Continuous improvement in cytology: sustaining and accelerating improvement          17Case study 4Communication to improv...
18   Continuous improvement in cytology: sustaining and accelerating improvement     Mean time for ‘sample taken to     re...
Continuous improvement in cytology: sustaining and accelerating improvement                                     198. Ideal...
20   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 5     Continuous improveme...
Continuous improvement in cytology: sustaining and accelerating improvement   21Table 3: Four day pathway                 ...
22   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 6     Voice of the custome...
Continuous improvement in cytology: sustaining and accelerating improvement        239. Primary careTo achieve a 14 or sev...
24   Continuous improvement in cytology: sustaining and accelerating improvement           2. Implement a non-acceptance p...
Continuous improvement in cytology: sustaining and accelerating improvement                       25Case study 7Changing t...
26   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 8     Right first time    ...
Continuous improvement in cytology: sustaining and accelerating improvement               27                              ...
28   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 9     A3 thinking for tran...
Continuous improvement in cytology: sustaining and accelerating improvement   29Women will benefit from knowing theresult ...
30   Continuous improvement in cytology: sustaining and accelerating improvement           10. Laboratory           Within...
Continuous improvement in cytology: sustaining and accelerating improvement          31Case study 10Removing the waste of ...
32   Continuous improvement in cytology: sustaining and accelerating improvement     Case study 11     Creating a work cel...
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
Continuous improvement in cytology - sustaining and accelerating improvement
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Continuous improvement in cytology - sustaining and accelerating improvement

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The Cancer Reform Strategy made a promise that all women would receive their screening results within two weeks by 2010, the next challenge was sustainability. This publication demonstrates how the pilot sites have continued to embed their improvements throughout the cytology pathway. It includes practical examples in reducing turnaround times, improving quality, safety and productivity (Oct 2010)

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Continuous improvement in cytology - sustaining and accelerating improvement

  1. 1. NHSCANCER NHS ImprovementDIAGNOSTICSHEART NHS Cervical Screening Programme (NHSCSP) Continuous improvement in cytology:LUNG sustaining and accelerating improvement Clinical excellence in partnership “STROKE with process excellence ”
  2. 2. Continuous improvement in cytology: sustaining and accelerating improvement 3Contents1. Foreword 4 • Case study 13 – Stop to fix – removing the 34 waste of waiting2. Executive summary 5 • Case study 14 – Productivity improvement in 35 screening – removal of key strokes3. Introduction 6 • Case study 15 – Removing the waste of over 36 processing – code checking4. Site overview 7 • Case study 16 – Simplifying manual logs – 37 removing the waste of over processing5. Phase one sustainability 8 • Case study 17 – Removing the wastes 38Root cause analysis of over processing and motion• Case study 1 – Root cause analysis of 10 • Case study 18 – Reducing time 39 samples breaching 14 day TAT spent slide filing• Case study 2 – Addressing delays 11 • Case study 19 – Implementing a ‘pull’ based 40 from primary care scheduling system to reduce backlogs • Case study 20 – Electronic 100% file check 426. Phase two accelerated implementation 12 replaces manual 10% oneAchieving the cultural shift• Case study 3 – Cytology Lean 14 11. Recall agency 43 Management system • Case study 21 – Removal of invalid data slips 447. Learning for the future 16 12. Key mechanisms for change 45Focus on the whole end to end pathway EngagementSmall batch sizes • Case study 22 – Improving communication 46Keep samples moving and teamworkFirst in, first out Daily huddles• Case study 4 – Communication to 17 • Case study 23 – Sustaining huddles 50 improve the pathway Visual management • Case study 24 – Visual management 528. Ideal pathway 19 • Case study 25 – Visual management for 53Voice of the customer processing blood stained samples• Case study 5 – Continuous improvement 20 to a four day pathway 13. Information to support the process 54• Case study 6 – Voice of the customer 22 Statistical process control CSSE Enquiries – Open Exeter9. Primary Care 23 Understanding long and short term demandUse of Open Exeter produced HMR101• Case study 7 – Changing to Open 25 14. Measures 55 Exeter HMR101Right first time 15. Cytology Self Assessment Tool 56• Case study 8 – Right first time 26Transport 16. Consolidation of services 57• Case study 9 – A3 thinking for 28 • Case study 26 – Consolidation of cytology 58 transport problems laboratories • Case study 27 – Consolidation of the 6010. Laboratory 30 primary care screening service• Case study 10 – Removing the waste of 31 over processing at specimen reception 17. Appendices 62• Case study 11 – Creating a work cell for 32 specimen reception and booking in 18. Acknowledgements 63• Case study 12 – Achieving ‘first in, first out’ 33 according to date test taken 19. Contacts 64 www.improvement.nhs.uk
  3. 3. 4 Continuous improvement in cytology: sustaining and accelerating improvement 1. Foreword In November 2009, following a period of testing changes across the complete cytology pathway, NHS Improvement published the ‘Cytology Improvement Guide’, which documents the learning from the phase 1 national cytology pilot sites, Since then the 14 day standard for cervical cytology has been confirmed as a tier one vital sign in the Revision to the Operating framework for the NHS in England 2010/11(June 2010) Professor Mike Richards CBE National Cancer Director The new white paper ‘Liberating the NHS’ sets out plans to ensure the patient is at the heart of everything we do, and has a focus on clinical outcomes. It also recognizes that the NHS scores relatively poorly on being responsive to the patients it services. Too often patients are expected to fit around services, rather than the other way around. The work of the Cytology Improvement Programme has demonstrated that simple changes to the process can deliver Professor Julietta Patnick CBE improvements in quality, safety, and productivity, to deliver an Director NHS Cancer Screening Programme equitable service for all women, while ensuring they are at the heart of the process. This document builds on the learning from phase 1, demonstrates the importance of sustainability, and demonstrates how implementing what we know works can accelerate the pace of change. Professor Julietta Patnick CBE Professor Mike Richards CBE Director NHS Cancer Screening Programme National Cancer Directorwww.improvement.nhs.uk
  4. 4. Continuous improvement in cytology: sustaining and accelerating improvement 52. Executive summaryFollowing the initial success of the 10 phase one Teams have also been trained to understand thepilot sites to ‘ensure that all women receive the cost of poor quality (defects) and reduce andresults of the screening tests within two weeks eliminate the causes in a way that supports theby 2010’, the next challenge was that of interests of women and the cytology service.sustainability. Improvements made are aligned to the Quality,These pilot sites have continued to embed their Innovation, Productivity and Prevention (QIPP)improvements throughout all stages of the strategy.pathway, developing a culture of continuousimprovement in their daily work. Quality • A ‘right first time’ approachAll have found sustainability challenging with • Guaranteed and predictable resultsadditional learning being developed through therigour of root cause analysis of those samples Innovationfalling outside 14 days. • Robust problem solving using A3 thinking • Visual managementTheir learning was, ‘never assume you knowwhat the problem is’. Detailed analysis Productivitydemonstrated the importance of data, rather • Removal of duplicationthan hunch or assumption. • Reduction and elimination of waste • Reductions in overtime and outsourcingIn phase two, six pilot sites were challenged to: • Appropriate use of skill mix• Test the learning from phase one using the Cytology Improvement Guide (November Prevention 2009) • Timely referral to colposcopy and treatment• Accelerate the pace of implementation This programme of work has demonstratedPhase two further evidenced the importance of benefits to over one million women.the following four key changes identified inphase one: Improvements in quality and productivity• Focus on the whole end to end pathway have been published by NHS Evidence• Adopt small batch sizes www.evidence.nhs.uk in both the• Keep samples moving ‘Recommended’ and ‘Long Term Conditions’• Establish first in first out. sections.The key mechanisms required to achieve this This document is designed to be used inalso hold true: conjunction with the first Cytology Improvement• Empowered staff Guide - Achieving a 14 day turnaround time in• Daily meetings cytology (November 2009), Cytology Self• Visual management techniques Assessment Tool (refer to page 56) and our• Information to support the process. Bringing Lean to Life document. All of these documents can be found on our website at:In addition it is important to: www.improvement.nhs.uk/diagnostics• Baseline any backlog and establish a plan for removal• Ensure Executive support to remove blockages• Perform root cause analysis to identify the true problem• Understand the challenge of consolidation of services. www.improvement.nhs.uk
  5. 5. 6 Continuous improvement in cytology: sustaining and accelerating improvement 3. Introduction Phase one identified issues across each step of the pathway Figure 1: Identified issues across each step of the pathway Result with Woman Sample Receipt Sample Taken Result Issue Data Entry Authorise Process Report Primary Care Laboratory Recall Agency • Training of smear takers • Data entry issues • Results issued weekly • Inconsistent use of NHS • Writing on forms • Large volume of manual numbers/patient ID parameters • Double look-up/printing matching PATHWAY PROBLEMS • Transport - delivery from Open Exeter • Manual enveloping/leaflets times/routes • Skill mix/staffing • Variable postage • Samples left at surgery • Processor reliability • ‘Abnormals’ sent out by GP • Incorrect info/demographics • Over printing labels • Route to colposcopy (no • Illegible forms • Matching forms/slides direct referral) • Multiple request form formats • Returned samples/cards • Manual checking of • Missing/wrong smear taker • Excessive checks electronic data codes • Backlogs • Print jobs not believed • 25% out of scope samples • Staff morale • IT issues • Sending out processing/ • Variable out of area screening to other labs processes The key components to close the gap between Whilst the work with the pilot sites has focused these problems and the ideal pathway are on the 14 day turnaround time, teams have also detailed in the phase one publication. been testing whether a seven day turnaround is achievable and sustainable, as highlighted in the An assessment of the steps within the cytology ScHARR Report (2006). end to end pathway reveals there is just 5.5 hours of true value added steps from the ‘customer’ point of view.www.improvement.nhs.uk
  6. 6. Continuous improvement in cytology: sustaining and accelerating improvement 74. Site overviewThe following sites were selected by the NationalCancer Screening Programme to work with NHSImprovement to pilot changes and test thelearning to deliver improvements in the cytologypathway.There are NHS Improvement sites in eachStrategic Health Authority. Contact with thesesites is recommended to spread their learning.A table of site data is available in theappendices.Phase 1 and Phase 2Cytology Pilot Sites Phase 1 Cytology Pilot Sites Phase 2 Cytology Pilot Sites 11Phase 1 Cytology Pilot Sites1 Leeds PCT and The Leeds Teaching Hospitals NHS Trust2 Hull Royal Infirmary and Hull and East Ridings PCTs3 Pennine Acute Hospitals NHS Trust4 Norfolk and Waveney Cellular Pathology Network (Norfolk and Norwich University Hospital NHS Foundation Trust5 West Anglia Pathology Cytology Laboratory 1 2 (Cambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital and Anglia Support Partnership) 36 Barts and The London NHS Trust 10 127 Somerset and West Dorset Cervical Screening Service (Taunton and Somerset Hospitals NHS Trust)8 Ashford and St Peter’s Hospitals NHS Trust9 North West London NHS Trust (Northwick Park Hospital) 1310 Central Manchester University Hospital NHS Foundation Trust 4Phase 2 Cytology Pilot Sites 15 1411 Newcastle upon Tyne Hospitals NHS Foundation Trust 512 Sheffield Teaching Hospitals NHS Foundation Trust13 Derby Hospitals NHS Foundation Trust14 University Hospitals Coventry and Warwick NHS Trust15 Heart of England NHS Foundation Trust16 Winchester & Eastleigh Healthcare NHS Trust 9 6 8 7 16 www.improvement.nhs.uk
  7. 7. 8 Continuous improvement in cytology: sustaining and accelerating improvement 5. Phase one: Sustainability One of the greatest challenges to improvement Root cause analysis is sustainability. An improvement implemented Approximately 24 months after the phase one today and gone tomorrow is not an sites began their improvement work they were improvement. asked to undertake a root cause analysis (RCA) of all samples falling outside 14 days. The presence of certain factors is crucial not only to ensure sustainability but to foster a culture of The detailed analysis demonstrated the following continuous improvement. root causes: The following were identified by the Pathology • Delays transferring samples from primary Service Improvement Team in 2006 in the care to the laboratory. This was the greatest document ‘Learning from Pathology Service cause and was essentially due to samples Improvement Pilot Sites and Improvement being held over in primary care. All practices Examples.’ concerned have daily transport available. The problems are being addressed by identifying the practices and reinforcing training and communication Figure 2: Factors for achieving sustainable improvements • Annual leave, restricted year end leave carry over and Easter Bank Holiday. These can be addressed by appropriate staff planning and operational management • Missing data and information/zero tolerance of defects. Recommendations are to audit non-compliance, training and communication. Case studies are available at: www.improvement.nhs.uk • Surge in demand one year on from Jade Goody’s death. Repeat recall tests following the 2009 surge in abnormal results • Recall agency delays – out of area • HPV – processing delays from external providers. Additional issues were caused during the air travel restrictions due to volcanic ash which prevented delivery of consumables. Root cause analysis has prompted these sites, in partnership with their PCTs, to take proactive steps to eliminate these issues through: These elements are consistent with redesign in • Identification of practices responsible other clinical services including the Cancer • Ongoing training and reinforcement of Services Collaborative and are not unique to standard work pathology. • Demand and capacity planning to ensure appropriate staffing levels. The work of the phase two sites has continued to evidence the importance of strength in all the Phase one sustainability is reflected in figure 3 areas identified above. on the next page.www.improvement.nhs.uk
  8. 8. Continuous improvement in cytology: sustaining and accelerating improvement 9Figure 3: Phase one cytology - percentage in 14 day turnaround www.improvement.nhs.uk
  9. 9. 10 Continuous improvement in cytology: sustaining and accelerating improvement Case study 1 Root cause analysis of samples breaching 14 day TAT Barts and The London NHS Trust Summary Measureable outcomes and impact Root cause analysis reveals the causes Since October 2009, 74 tests have for samples which have breached the been delayed by practices failing to 14 day turnaround time. deliver samples in a timely manner. Root cause analysis and direct contact Understanding the problem with practices has reduced the number Analysis of turnaround times identified of tests delayed from: tests taking longer than 14 days from • 19 in October 2009 sample taken to anticipated delivery of • 9 in April 2010. the result letter. Of 173 practice addresses: Failure to sustain the 100% 14 day • 31 practices were delaying samples turnaround time for all samples has between October and December almost always been due to delay by 2009 GP practices sending samples to the • 10 practices were delaying samples laboratory. between January and April 2010. • The problem was identified in Ideas tested which were successful statistical process control graphs Visiting practices was the idea of the • Key dates for each sample were cancer screening nurse and has proved extracted - sample date, receipt to be the most effective approach. date, registration date, screening date and date the file was sent to Ideas tested which were call/recall unsuccessful • Call/recall supplied a list of Initial email lists sent to PCT leads laboratory numbers with the date without explicit instructions to the letter was printed undertake a root cause analysis were • The laboratory extract and call/recall not successful. lists were cross linked in an Access Database to provide a How will this be sustained and comprehensive data file for the what is the potential for the future whole pathway. /additional learning? Whilst the feed back processes have The waste identified was that of reduced the number of practices waiting. causing delays, there are still a few practices who continue to delay How the changes were samples. implemented • Data for outlier tests was sent to A continued collaborative approach PCT leads and the sample between the laboratory and PCT leads taker is needed to continue to identify and • The sample taker visited the GP reduce these delays. practices where the delay in sending the sample to the laboratory was Contact the reason for the breach. Geoffrey Curran geoffrey.curran@bartsandthelondon.nhs.ukwww.improvement.nhs.uk
  10. 10. Continuous improvement in cytology: sustaining and accelerating improvement 11Case study 2Addressing delays from primary careAshford and St Peter’s Hospitals NHS TrustSummary How the changes were Ideas tested which were successfulSamples that have taken five days or implemented • Identifying delayed tests as soon asmore to get to the laboratory are The initial approach was to telephone they arrive in the laboratoryquickly identified and processed. A surgeries whose samples were overdue • Rapid processing and reporting ofletter is sent to the woman’s GP to but the sample takers (usually practice delayed testsrequest that they investigate the cause nurses) were hard to contact and not • Contacting the GP by letter toof the delay. An incident report form always able to help. request an explanation for the delay.is completed when the 14 dayturnaround has been breached. A letter template was then prepared Ideas tested which were that could be quickly completed and unsuccessfulUnderstanding the problem sent to the woman’s GP. The letter Telephone calls to sample takersThe laboratory monitors how well the and a copy of the request form are whose samples had arrived too late tospecimen transport system is sent to the GP whenever a sample achieve the 14 day target had a poorperforming by checking the ‘date arrives that is over five days old. success rate due to availability oftaken’ on all samples as they arrive in sample takersthe preparation room. During Apriland May 2010, specimens more than All overdue specimens that arrive in How this improvement benefits14 days old when they arrived were the laboratory are processed urgently patientsinvestigated. and sent for immediate screening. This process is intended to improve the Negatives are reported straight away overall reliability of the screeningThe team started by telephoning the by the screening room staff while programme by ensuring that smearsample takers to understand the cause abnormals are passed to the takers understand the importance ofof the delay. This information was consultant clinical cytologist for sending samples to the lab promptly.collated in incident report forms that immediate reporting. The aim is towere passed on to the quality have the result leave the laboratory How will this be sustained andmanager. within 24 hours of the samples arrival. what is the potential for the future /additional learning?A transport problem was suspected Measurable outcomes and impact This process will continue to helphowever the root cause was that Delayed samples are identified, identify any weaknesses in samplesamples were spending prolonged processed and resulted within 24 taker procedures and to pick up anyperiods stored in the GP surgeries hours of their arrival in the laboratory. problems with the specimen collectionbefore they entered the transport The causes of the delays are being and transport system.system. investigated via letters sent to the woman’s GPs (see table 1 below) Contact Steve Blackman So far the explanations offered have steve.blackman@asph.nhs.uk varied but sample takers are being focused on getting samples to the lab promptly.Table 1: Causes of delays Date sample Date of arrival Time in Reason given for delay taken in laboratory days 16/03/2010 23/04/2010 37 Surgery unable to explain delay 23/03/2010 12/04/2010 20 Three samples sent to another laboratory by a new practice nurse, returned to GP and then sent to correct lab 29/04/2010 07/05/2010 8 No explanation for delay but promised to send future samples ASAP. 12/05/2010 17/05/2010 5 Sample taken Wednesday but GP too busy to fill in a request form until Friday 20/05/2010 02/06/2010 12 Six specimens locked in fridge by a new practice nurse, discovered days later and sent to lab 26/05/2010 02/06/2010 7 Delayed by staff illness followed by a bank holiday, measures put in place to prevent a recurrence www.improvement.nhs.uk
  11. 11. 12 Continuous improvement in cytology: sustaining and accelerating improvement 6. Phase two: Accelerated implementation Phase two of the Cytology 14 Day Turnaround Time Programme was established to test the learning from phase one for repeatability and scalability. The additional challenge was to accelerate the achievement of this vital sign to six months. The changes made in phase one were proved to result in the elimination of waste and reduction in turnaround times. The progress towards a 14 day turnaround by the phase two sites within the accelerated timescale has varied due to a number of factors: • Baseline starting position against 14 days • Backlogs that existed at the start of the programme • Staffing capacity insufficient to meet demand on the service • Absence of senior management to support operational service delivery • Lack of technology. The A3 document on page 14 shares the Newcastle Cytology team’s assessment of their current position and plans to continue to embed Lean as their management system.www.improvement.nhs.uk
  12. 12. Continuous improvement in cytology: sustaining and accelerating improvement 13Achieving the cultural shift“The most important factors for success arepatience, a focus on long-term rather thanshort-term results, reinvestment in people,product and plant, and an unforgivingcommitment to quality. ”Robert B McCurry, former executive VP, Toyota Motor Sales“I am personally quite pleased that we areconsistently turning around material within14 days. But I am far more pleased withhow much safer we are now than 15months ago and how much more staffengagement we have. These are the realmeasures of success to my mind .Dr Simon Knowles, National Clinical Lead, Cytology Service Improvement ” www.improvement.nhs.uk
  13. 13. 14 Continuous improvement in cytology: sustaining and accelerating improvement Case study 3 Newcastle Cytology Lean Management System A3 Newcastle upon Tyne Hospitals NHS Foundation Trust Define the problem/opportunity: (Why are you talking about it? What are you trying to solve/improve?) The Newcastle Cytology Lean team want to ensure an embedded Lean Management system. The aspiration is for a long term, sustained philosophy of daily problem solving and on going improvement beyond the support of NHS Improvement. Current Condition: (What happens now? Be visual – value stream map, graphs, facts and measurements etc) • The principles and tools of Lean methodology have been introduced. • Most of the ‘just do its’ detailed in the Cytology Improvement Guide (NHS Improvement 2009) have been implemented and tools applied to the process to smooth and level flow. • Establishing a culture of daily problem solving is required by coaching the team in Lean principles and establishing transparency in performance and process issues across all areas of the lab (including specimen reception, the office and screening rooms). Performance against plan as of May 10 = 61% Gynaecology Cytology % TAT and activity: Performance against target Goal: (State the specific SMART target(s). State in measurable or identifiable terms) To be a Lean exemplar site by meeting the criteria set by NHS Improvement: • 100%TAT within 14 days • Engaged staff • 50% TAT within seven days • Lean culture • All staff think Lean • Daily meetings/problem solving • Good measures • Evidence of 5S • All staff talk Lean • Leadership • Good visual management • Standard work • Clear evidence of how Lean has been used Gap analysis: 75% of staff received Lean awareness training, with six members of the team being on the core Lean group. Even with daily huddles and completed process production documentation in each area, the team recognises that more work is required to achieve a Lean culture. Responsible: Mr David Evans - david.evans@nuth.nhs.uk Team members: Cytology Teamwww.improvement.nhs.uk
  14. 14. Continuous improvement in cytology: sustaining and accelerating improvement 15Proposed counter measures(What will it look like? Be visual i.e. future state value stream map)Within the next four months, the daily focus of the team will be on performance against the 14 and seven day turnaroundtimes - levelling workload across the laboratory so that work flows to takt with no backlog.By October, all areas of the lab will be operating without: overproducing, waiting, and defects; and with minimal motionwithin and between processes; and any areas of overprocessing identified and plans in place to remove it.An experimental approach to problem solving and potential countermeasures will be in place using the PDSA cycle.Action PlanAction – What, Why, How? Who? When? Progress Status (i.e. completed, in progress)Team Huddle every day All Daily In ProgressEstablishment of 3 Cs (Concern, Cause andCountermeasures) DE/CB Daily TBCRoot Cause Analysis of SPCs CB Weekly TBCVisually monitor Goal vs Actual at each step All Hourly TBCAgree Report out date DE Aug 10 In ProgressRaise Transport issues – no tracking, no servicelevel agreement , review of scheduled pick ups,audit of pick up times – with Transport sub –group DE Aug 10 In progressInstigate a ‘name and shame’ policy forpersistent offenders of ‘zero tolerance’ policy CB July 10 In ProgressRaise issue of uneven rate of smear taking atlocal and national level DE Aug 10 In progressIncrease downloads to FHSA on Friday CB July 10 In progressResults and MeasuresCriteria set by NHS Improvement will be met, evidenced and assessed as achieved.Next stepsShare with exec sponsor – Invite to report out in late August , Early September 2010 www.improvement.nhs.uk
  15. 15. 16 Continuous improvement in cytology: sustaining and accelerating improvement 7. Learning for the future The four key changes identified in phase one 3. Keep samples moving have been further evidenced as critical to The principle of ‘today’s work today’ can be success facilitated by ensuring 1. Focus on the whole end to end pathway • Samples are sent from primary care daily – Each core project team contained membership even if there is only one from the PCT(s), laboratory and results agencies. • Flow of samples, using pull systems where Within the laboratory, each staff group/function necessary was represented. • Multiple (or optimal) daily downloads to the results agency with letters sent same day. Every member of the core team was asked to ‘go see’ the whole pathway. Value stream 4. First in, First out (FIFO) mapping techniques brought what they saw Whilst the vital sign requirement is to deliver together to visualise the whole pathway and results to women within 14 days of their test, highlight where samples and reports were sites have also tested their capability to deliver waiting. within seven days as highlighted by the ScHARR report (February 2006) The multiple organisations involved in providing the cervical screening service then worked Sustaining a seven day turnaround for the together to identify improvements. majority of samples provides some flexibility to manage peaks in demand, unexpected resource Starting with the point at which the sample is challenges and removes the need to operate taken, laboratories have worked collaboratively separate ‘urgent’ work streams. with their PCT screening leads to raise awareness of their 14 day turnaround projects within the primary care community. Sample taker introductory and update training events have been held during which project content has been communicated and received very positively. 2. Small batch sizes Teams in phase two have further evidenced the value of small batches in keeping samples and reports flowing through the pathway.www.improvement.nhs.uk
  16. 16. Continuous improvement in cytology: sustaining and accelerating improvement 17Case study 4Communication to improve the pathwayDerby Hospitals NHS Foundation TrustSummaryTwo way communication between Figure 4: Sample taken to received in lab - Baseline data (August 2009)primary care and the laboratory is vitalin ensuring the 14 day turnaroundtimes are achieved.Understanding the problemSPC charts were used to identifydelays along the processing pathway –outliers show where delays areoccurring (see figure 4):Root cause analysis of the outliersidentified what was causing delays inprimary care:• Sample batching within practices• Lack of daily courier collections• Overnight delays due to courier transfers at other hospitals• Inaccurate completion of cytology request forms which were returned • E mail correspondence by PCTs to Measurable outcomes and impact to senders for correction. sample takers providing feedback on • Number of outliers reduced progress of the improvement project following communication andHow the changes were • Face to face discussions at implementation of changes (seeimplemented introductory and update sample figure 5 below).Various methods of communication taker courses and practice nurse • 213 sample takers attendedwere used to highlight delays and forums. Opportunities for sample meetings and courses from Novimplement changes: taker feedback and comments 2009 - May 2010• Newsletters sent by cytology encouraged • Example of form filling guidance laboratory to inform primary care of • Workshops held to pilot the use of communicated to sample takers at the improvement work being pre-populated Open Exeter HMR101 update courses. undertaken, emphasising the forms importance of completing the request form accurately and asking that samples are not batched• Letters sent from PCT screening Figure 5: Sample taken to received in lab (May 2010) commissioners outlining policy for out of scope samples. Clear message that these samples would not be processed by the laboratory• Telephone calls by PCT leads to practices and clinics to re-confirm courier frequencies and times. Calls made to practices that were batching samples www.improvement.nhs.uk
  17. 17. 18 Continuous improvement in cytology: sustaining and accelerating improvement Mean time for ‘sample taken to receipt in lab’ decreased during the six Top tips for sample takers month project: • Ensure the form is fully • from 2.22 days to 1.37 days completed and the vial is labelled correctly Ideas tested which were successful • Screw lids on securely • Transportation changes - following • If two brushes are used, put root cause analysis the courier both in one pot but ensure that service changed from pick up at a this is clearly indicated on the local community hospital to three form individual practices • Date of last test is given • Correct reason for smear is • Primary care participation - Open stated. Exeter Workshop piloted and 10 GP practices now have Open Exeter access. Comments and suggestions to be incorporated into full PCT rollout in 2010 • Right First Time – communication with sample takers resulted in this approach. Ideas tested which were unsuccessful A zero tolerance policy was considered including the disposal of samples. PCT commissioners were concerned that women would be disadvantaged hence the development of a ‘right first time’ approach encouraged through communication. How this improvement benefits women Communicating information to sample takers has improved turnaround times. Quicker results for women reduces anxiety. How will this be sustained and what is the potential for the future /additional learning? • Continued monitoring of information will ensure outliers are identified and investigated • Ongoing communication with primary care will ensure messages are relayed and feedback received • Closer links with primary care have resulted from this project. Contact Alison Cropper alison.cropper@derbyhospitals.nhs.ukwww.improvement.nhs.uk
  18. 18. Continuous improvement in cytology: sustaining and accelerating improvement 198. Ideal pathwayReduction and elimination of waste from typical Voice of the customercytology pathways has resulted in the The programme has focused on achieving adevelopment of this ideal pathway model. 14 day turnaround time that ensures where required women are referred to the appropriateThe following case studies build on those cancer pathway in a timely manner.published in the first cytology learningdocument and further evidence the value of Further opportunities should be sought torecommended improvements. understand the voice of the customer as supported in the case study from Newcastle. Figure 6: The ideal pathay Result with Woman Sample Receipt Sample Taken Result Issue Data Entry Authorise Process Report 1-3 DAYS 1-3 DAYS 1-2 DAYS 1 DAY Primary Care Laboratory Recall Agency RECOMMENDED ACTIONS • Use of electronic pre • Sample receipt, data • Multiple daily downloads populated HMR101 and order entry, process and report • Results transferred and posted comms in one to three days right first time • Request form and vial • Samples received, • Daily posting of results identification and labelling booked in, processed and right first time authorised right first time • Daily transport for sample • Small batch sizes (six collection samples) • First in first out (FIFO) • Report abnormals daily www.improvement.nhs.uk
  19. 19. 20 Continuous improvement in cytology: sustaining and accelerating improvement Case study 5 Continuous improvement to a four day pathway The Leeds Teaching Hospitals NHS Trust Summary How the changes were • Processing of samples would need Continuous improvement has implemented to occur no later than day 2 created a four day end to end • The seven day pathway was • Samples must be registered by pathway for some women. analysed to determine the lunchtime on day 2 necessary measures to improve to • Samples must be received by the Understanding the problem a four day pathway (see table 2 laboratory no later than the By the end of the phase one project below) morning of day 2, but ideally the team had achieved: • Assumed one day for first class post received the same day as taken. • To enable the woman to receive a • 98% of results received by women result by day 4, only samples that within 14 days were authorised before the • 58% of results received by women 11.30am download on day 3 within seven days. could meet this goal • To facilitate screening/ The data suggested that with further authorisation of results by improvement the turnaround time 11.30am on day 3, samples must could be reduced further. be processed on day 2 Table 2: Seven day pathway Seven Day Pathway Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Samples Rest of Rest of samples Day three results Day three Day four Sunday taken and samples processed. in post. results results (day of rest!) some received in Slides pre-screened. Remaining received by received by received in lab. Some screened for samples pre- woman. woman. lab. Registered end of day screened and and some download. screened. samples processed.www.improvement.nhs.uk
  20. 20. Continuous improvement in cytology: sustaining and accelerating improvement 21Table 3: Four day pathway Four Day Pathway Day 1 Day 2 Day 3 Day 4 Samples Rest of samples received Remaining slides Results taken and in lab. Remaining pre-screened/ received by majority registered and all screened by woman received in samples processed. 11.10am Lab. Some Some slides pre- download. Results registered screened/screened. letters issued.Measurable outcomes and impact How will this be sustained andBy June 2010: what is the potential for the future• 98% of results were received by /additional learning? women within seven days • Work with transport services and• 47% of results were received by practices to: women within four days. • increase % of samples received in lab on day takenPhone calls received from practices • spread the delivery of sampleswhose patients had commented on more evenly throughout the daythe speed of their result. • Daily scheduling of work requests (when/volume) and actions toIdeas tested which were corrects missed plans.successful• Smaller batches of slides per tray Contact (from eight to six) Hazel Eager• Hourly scheduled deliveries to/ hazel.eager@leedsth.nhs.uk from each area• One co-ordinated transfer of work throughout the department at each delivery.Ideas tested which wereunsuccessfulReducing batches of forms forregistration from 12 to six resulted informs being registered and sent tolab out of numerical sequencemaking processing of samples verydifficult.How this improvement benefitswomen• Additional 40% of women now receive their result within seven days• 47% of women now receive their result within four days. www.improvement.nhs.uk
  21. 21. 22 Continuous improvement in cytology: sustaining and accelerating improvement Case study 6 Voice of the customer Newcastle upon Tyne Hospitals NHS Foundation Trust Summary Measurable outcomes and impact Women were advised in a letter from • 99% reduction in telephone calls the recall agency that they could from patients expect a result within eight to ten • Staff time saving of approximately weeks. When they received a result two hours per week within considerably less time some • Improved patient experience. became concerned and telephoned. How this improvement benefits The wording of the letter was changed women to reflect current performance and the This saving in staff time is being used number of phone calls was reduced on value add processes and women significantly. are more accurately informed. Understanding the problem How will this be sustained and It was identified from the volume of what is the potential for the future telephone calls received within the /additional learning? department that women were As turnaround times continue to confused by the wording in their improve the letter will be further invitation letters which stated that a updated to ensure women are result would be received within eight accurately informed. to ten weeks. Contact Prior to the 14 day turnaround David Evans programme, eight to ten weeks was david.evans@nuth.nhs.uk the length of time it took for results to reach women in the area. This was identified as the ‘waste of defects’ in a staff daily huddle. The team were spending time answering calls and reassuring women who had received their results much earlier than they expected. How the changes were implemented The invitation letter was changed to state that the woman would receive her result letter within three weeks of the test date.www.improvement.nhs.uk
  22. 22. Continuous improvement in cytology: sustaining and accelerating improvement 239. Primary careTo achieve a 14 or seven day turnaround time, Use of electronic requestingthe focus within primary care needs to be on Where available, use of electronic requesting forgetting the sample and request form right first every sample:time and ensuring that it is on the next available • Ensures correct demographics are recordedtransport run. • Samples do not need to be returned for correction or clarificationUse of Open Exeter produced HMR101 • Removes the risk associated with handwritingMoving to the use of electronic pre-populated interpretationHMR101 request forms from the Open Exetersystem: Right first time• Improves patient safety – forms are pre- Learning in phase two has highlighted the need populated with demographics and screening to consider the approach taken with two of the histories. Risks associated with misreading ‘just do it’ recommendations contained in the handwritten forms are removed. first Cytology Improvement Guide -• Saves sample takers time completing blank forms 1. Enforce a policy for refusing ‘out of• Saves laboratory time deciphering handwriting scope’ samples and ensure GPs and sample• Saves laboratory time looking for information takers know the correct pathway for located differently on multiple form types. symptomatic women. The aim of this is to stop inappropriate testing and to ensure appropriate interventions or referrals are made in line with Cancer Screening Policy. Figure 7: Example of a ‘right first time’ visual aid Cervical screening - implementing good practice DON’T As from 1 April 2010 FORGET Laboratories will not process the following samples Age Frequency of screening Unacceptable samples <25 N/A Under 24 years 6 months and not scheduled for a test Screening starts at 25 25-49 3 yearly Less than 30 months since previous routine negative 49-64 5 yearly Less than 54 months since previous routine negative Screening ends at 64 65> N/A 65 years and over with previous consecutive routine negative tests in last ten years www.improvement.nhs.uk
  23. 23. 24 Continuous improvement in cytology: sustaining and accelerating improvement 2. Implement a non-acceptance policy for • Agree a collaborative approach across the incorrect forms/vials. The main aim of this is whole pathway – agree what the standard to ensure quality and safety that guarantees the is, communicate frequently using all available right sample is reported to the right woman. avenues The additional time required for staff to deal • Consider how errors will be handled and with omissions, errors, logging returns, by whom – agree where responsibility for telephoning surgeries etc is eliminated. errors sits and how they will be addressed. What action will be taken by PCTs to ensure These recommendations are aimed at achieving sample takers deliver ‘right first time’ samples a service where every test is completed correctly every time? and sent immediately to the laboratory in a • Establish a timescale for training and correctly labelled vial with a fully completed implementation – communicate this widely. standardised request form. Every sample should be ‘right first time’. NHS CSP guidance is that ANY sample received where the woman’s identity or safety is Following the experience of a number of sites, compromised should be disposed of. Where a there are some further recommendations to sample taker fails to indicate whether the cervix support implementation. has been visualized the sample should be reported as inadequate by default. • Measure defects - Identify how many samples and forms are received that cannot be Other errors or omissions should be agreed upon booked in and processed without the need to: either locally or regionally. A whole pathway • search for information (wrong form) approach involving all stakeholders is therefore • look up information (missing codes) essential. • telephone the sample taker (missing information) The case studies demonstrate the different • return for correction (not recommended) or approaches that have been taken to achieve dispose of sample (when woman’s identity right first time and include the learning from compromised only). each site concerned. In phase two up to 47% of all samples and Transport forms had either an error or an omission. Not A percentage of the turnaround time for all of these errors compromised the identify of samples is taken up with transportation to the the woman but all required additional work and laboratory. were in Lean terms considered ‘defects’. It is essential that every sample taken is sent via It is important to establish a rigorous process to the next available transport van which should be achieving a ‘right first time’ approach including: at least daily. Samples should not be batched or held within surgeries or clinics. • Root cause analysis – understand why these errors have occurred • Engage stakeholders – communicate your findings to all relevant stakeholders including (but not limited to) GPs, sample takers, screening leads, PCTs, QARCwww.improvement.nhs.uk
  24. 24. Continuous improvement in cytology: sustaining and accelerating improvement 25Case study 7Changing to Open Exeter HMR101University Hospitals Coventry and Warwick NHS TrustSummaryBy early July 2010, three months after Figure 8: University Hospitals Coventry and Warwick NHS Trust - Booking inrequesting sample takers use Open times: Old style HMR 101 forms vs Open Exeter printed HMR 101 160Exeter HMR101: 140 144• The booking in backlog of 5,000 120 seconds forms had been reduced to zero Seconds 100• Both screeners and clerical staff find the new form much easier to use 80• Reduction in the number of 60 incorrect reports put on the 52 40 computer by the screeners. seconds 20Turnaround time from collection to 0reporting has improved dramatically: Non Open Exeter HMR Form Average booking in time x 1 Non Open Exeter Pre-Printed Average booking in time x 1• November 2009: 7.1% in 14 days• July 2010: 92.2% in 14 days.Understanding the problem • Each form had information in • An intensive education and trainingIn April 2009, the Cervical Cytology different places which was programme was initiated by the PCTServices at Warwick, George Eliot and confusing for booking in and in the summer of 2009 toUniversity Hospitals Coventry and screening staff who had to search encourage surgeries to use OpenWarwick (UHCW) merged into one lab for information Exeter and the laboratory introducedon the UHCW site in Coventry. The • Booking in a single sample including a non-acceptance policy for the usethree laboratories had over 20 years of the look up on Open Exeter and of anything other than the pre-cervical cytology history on their writing the history on the form was printed HMR101 forms in Aprilrespective databases and each used a taking an average of two minutes 2010.different computer system. Although 22 secondsa decision was made that the historic • Where screeners did not have the Measurable outcomes and impactdata would be transferred to the complete history or missed By May 2010, the use of Open Exeternewly merged lab at UHCW, this had information on the multiple form HMR101 forms had dramaticallynot happened by the time of the formats, errors were made in the increased.merger and has still not been recall management. These were not • 11% in May 2009completed 18 months later. picked up until the data was • 92.35% in May 2010. downloaded to the recall agencyScreeners in the newly merged lab did creating unnecessary work for a Time taken to book in each samplenot have the sample history for any senior member of the laboratory dropped from:Warwickshire women (40,000 women team who corrected the error • 144 seconds in May 2009a year) and each case had to be • By the summer of 2009, the • 52 seconds in May 2010.looked up on Open Exeter and the laboratory had a backlog of 5,000history manually written on the samples awaiting booking in. The laboratory deals withrequest form and entered onto the approximately 70,000 samples per yearUHCW computer system. How the changes were meaning a time saving 1,789 hours implemented per year.The laboratory received multiple Very early on after the merger the Labformats of forms: and the PCT decided that all Coventry How does this improvement• Single copy HMR101 forms and Warwickshire surgeries would be benefits women• UHCW’s own designed HMR101 encouraged to use Open Exeter and The removal of waste from the process form move to pre-printed Open Exeter has contributed to a reduction in the• Old style green multi-copy HMR101 HMR101 forms (version A5 PDR 2009) end to end turnaround for all women forms which have all the cervical cytology• Open Exeter A4 PDF one previous history printed on them: Contact sample displayed • The recall team drove the change Steve Ferryman• Open Exeter A5 PDF (2003) two programme by writing to all steve.ferryman@uhcw.nhs.uk previous samples displayed. practices, setting up user access and visiting all practices to provide training www.improvement.nhs.uk
  25. 25. 26 Continuous improvement in cytology: sustaining and accelerating improvement Case study 8 Right first time University Hospitals Coventry and Warwick NHS Trust Summary Achieving right first time for all Figure 9: University Hospitals Coventry and Warwick NHS Trust - Request samples requires a planned form percentage defects (Nov 2009, March, April, May 2010) collaborative approach involving and 50 engaging all key stakeholders. 45 November 944 forms March 1417 forms 40 Understanding the problem April 2297 forms May 9812 forms 35 The scale of the perceived problem Percentage was confirmed with a data collection 30 exercise to identify the type and 25 volume of errors as well as the staff 20 time to deal with them. 15 10 A simple table was used at booking in 5 to identify errors. Process sequence 0 charts were used to understand the NHS No. First Name DOB Address GP name Sender code GP address Test date EMP Unregistered PIN Reason for test Non OE forms CX seen/360 OE format processes staff were required to follow to deal with errors (see figure 9). How the changes were implemented • In between notification of the • The remainder of samples are • ‘Out of scope’ samples were defined impending policy and its reported but additional commentary locally as those from women under implementation, sample takers is added to the report highlighting the age of 24.5 years as they are would receive a notification where a the errors to the sample taker. called before their 25th birthday. sample was ‘defective’ in some way • Errors are reported on a monthly • Incorrect forms were defined as so that they could correct their basis to the PCTs. specimens received with anything process to prevent a reoccurrence • The laboratory has chosen to other than an Open Exeter • Sample taker training was provided continue to report samples where downloaded HMR101 A5 size form by the PCT to assist with accessing cervix visualized and/or 360 degree • Defects were defined in two and completing the required sweep is not confirmed. A note is categories: HMR101 form. added to the report that this • Serious defects where the • Sample takers were also sent the information was missing from the woman’s safety may be NHS Clinical Practice Guidance for request form and it is the compromised including unlabelled the Assessment of Young Women responsibility of the sample taker to vials or significant mismatches of aged 20 -24 with Abnormal Vaginal decide whether to recall the information between form and Bleeding. woman. This decision was made on vial • Sample takers received a reminder the basis that the 10% of samples • Minor defects where necessary three weeks after the original missing this information being information for the smooth flow notification and then again one reported as inadequate would of the sample through the week before the planned require additional screening resource laboratory is missing and requires implementation of the policy that is not available extra work on the part of the • Hospital clinics were notified • All samples are electronically laboratory. This can include internally by the project lead. recorded on the lab system rather missing practice codes, missing or than in a manual log as this enables incorrect sample taker PINs, lack Following a significant challenge from accurate and fast analysis of any of test date, failure to confirm a small number of GPs advice was errors. that the cervix was visualised or sought from the Trust Solicitor and that a 360 degree sweep was Medical Defence Union. Measurable outcomes and impact taken Errors have fallen dramatically across • A policy was devised and a copy • On their advice the policy was all categories and time spent sent out by the PCTs to all practices, amended to confirm that samples managing errors has fallen accordingly. Genito-Urinary Medicine (GUM) and would only be disposed of where Family Planning clinics together with the woman’s identity or safety is The time taken to book in a sample a visual management aid to form compromised or where the sample is has been reduced by 50%. filling and vial labelling out of scope as previously defined.www.improvement.nhs.uk
  26. 26. Continuous improvement in cytology: sustaining and accelerating improvement 27 How this improvement benefits Figure 10: University Hospitals Coventry and Warwick NHS Trust - women Example of a pre-printed HMR101 request form using Open Exeter Sample taker attention has been drawn to the importance of correct data and process to ensure a quality sample as well as a good experience for the woman. Time savings have enabled the laboratory to continue to reduce their backlog and turnaround times. How will this be sustained and what is the potential for the future /additional learning? Continued reporting of errors back to the source will enable sample takers to improve their processes to prevent a reoccurrence. Contact Steve Ferryman steve.ferryman@uhcw.nhs.ukIdeas tested which were • If a ‘defective’ sample is sent backunsuccessful to the sample taker or held on to• Problems occurred early during until more information is obtained implementation as ‘out of scope’, to be able to process it wait time is ‘incorrect/forms and vials’ and added and achievement of the 14 ‘defects’ was not clearly defined day turnaround is compromised. within national guidance and could The laboratory initially decided with not initially be agreed with GPs the support of their two PCTs to locally discard such samples.• The term ‘zero tolerance’ was not liked by many and was felt to have ‘policing’ connotations. This impacted on successful engagement with the intention of the policy which was to ensure samples were right first time. www.improvement.nhs.uk
  27. 27. 28 Continuous improvement in cytology: sustaining and accelerating improvement Case study 9 A3 thinking for transport problems Newcastle upon Tyne Hospitals NHS Foundation Trust Summary How the changes were Ideas tested which were successful • The laboratory receives samples implemented • Introduction of pink specimen bags from three primary care trusts (PCTs) • A multidisciplinary group including to allow separation of cervical across NHS North of Tyne representatives from the laboratory, cytology specimens from others • The percentage of samples received estates, primary care, public health collected by couriers within three days increased from and commissioning was established • Delivery of samples directly to the 73% to 97%. to understand the problems in cytology laboratory reception rather transporting specimens to the than via the post room Understanding the problem laboratory • Provision of an additional courier Delays in samples reaching the • A turnaround time of three days or run from one of the intermediary laboratory were evident across all less was set for samples reaching collection centres to ensure a more three PCTs although the majority of the laboratory from provider clinics constant flow of specimens delayed samples were generated • Actual transport times were audited • Development of a communications within one which serves a over a one week period on two plan engaging local leaders as figure geographically large, sparsely separate occasions. Where outliers heads to ensure dissemination of populated area. The transport pathway were identified the responsible key messages to stakeholders. was carefully mapped in order to sample takers were contacted explore this further. Key problems directly in order to explore Ideas tested which were identified included: underlying issues. unsuccessful • Potential batching of samples at It was suggested that it might be more provider clinics and surgeries Measurable outcomes and impact: efficient for the more remote practices • Complex transport routes with After excluding any returned samples, to send samples in via the post rather multiple hand offs the proportion of samples reaching the than have them picked up by courier. • Lack of segregation of cervical laboratory within three days increased We ran a pilot scheme but cytology specimens from other on average from 73% to 97% (see unfortunately it proved to be very samples during transportation table 4 below). unpopular with the GP practices. • Failure to deliver samples directly to the laboratory. The laboratory now receives two daily How this improvement benefits batches of samples from the collection women point enabling processing to start Reducing transport time makes earlier in the day. compliance with the 14 day turnaround more achievable and sustainable. Table 4: Newcastle upon Tyne Hospitals NHS Trust - Proportion of samples reaching the laboratory within three days Transport Provider Count Average No. of cases % of cases No. of cases % of cases transport - to or < - to or < > 3 days > 3 days time (days) 3 days 3 days North Tyneside (Northumbria) 423 1.93 408 96.45 15 3.55 North Tyneside 269 1.59 261 97.03 8 2.97 Newcastle 462 0.97 451 97.62 11 2.38 TOTAL 1154 1.46 1120 97.05 34 2.95www.improvement.nhs.uk
  28. 28. Continuous improvement in cytology: sustaining and accelerating improvement 29Women will benefit from knowing theresult of their test sooner reducinganxiety and, if required faster referralto the cancer pathways.How will this be sustained andwhat is the potential for the future/additional learning?A number of additional challengeshave been identified which will beaddressed in the future. These includethe development of a robust trackingsystem for individual specimens toidentify and monitor delays at differentstages throughout the pathway.Evidence from this project is currentlybeing used to:• Highlight the need for further improvement of the whole pathology transport infrastructure• Undertake detailed analysis of routes, schedules etc• Accompany drivers to understand some of the difficulties faced in collecting samples.The return journey of send backsamples needs to be mapped toensure their speedy return to thepractice.ContactDavid Evansdavid.evans@nuth.nhs.uk www.improvement.nhs.uk
  29. 29. 30 Continuous improvement in cytology: sustaining and accelerating improvement 10. Laboratory Within the laboratory, teams have focused on keeping samples moving from the point of entry at specimen reception through to the time the result is transferred to the recall agency. This has been made possible by reducing and eliminating the waste, using visual management, 5S and standard work.www.improvement.nhs.uk
  30. 30. Continuous improvement in cytology: sustaining and accelerating improvement 31Case study 10Removing the waste of over processingat specimen receptionSheffield Teaching Hospitals NHS Foundation TrustSummary How the changes were How will this be sustained andThe removal of a step at specimen implemented what is the potential for the futurereception has removed over one hour The core team recognized that they /additional learning?a week for a workload of 34,000 and could see no benefit from writing the There will continue to be periodicalwill save three hours on a workload of number on the vial lid. This was a reviews around the department to96,000 following consolidation. practice that has always been assess the value of each step of the undertaken but the need had never process.Understanding the problem been questioned.The core team looked objectively at Contacthow samples were received, checked It was agreed at the daily huddle that Kay Ellisand labelled in the reception area. the number would no longer be kay.ellis@sth.nhs.uk written on the vial top.• Samples are received and details checked on the vial to ensure that Measurable outcomes and impact they match details on the request • Six seconds have been saved per form specimen by not labelling the vial• Each sample is given a unique top with the laboratory number number and the label is applied to • Taking into account the increased the form and vial workload of 96,000, 160 hours per• Each vial has the number written on year are saved equating to three its top as well as having the sample hours per week. number label on the body of the vial. Ideas tested which were successful The idea came from the core team asThe core team recognized this as a they were doing a walk round of thewaste of over processing. work flow through the preparation area. It was also felt that the numbering was difficult to see and provided no added value to the service. How this improvement benefits patients The time saved will be invested elsewhere in the lab on value add activities. www.improvement.nhs.uk
  31. 31. 32 Continuous improvement in cytology: sustaining and accelerating improvement Case study 11 Creating a work cell for specimen reception and booking in Winchester and Eastleigh NHS Trust Summary Measurable outcomes and impact Specimen reception has been By combining the previously separate relocated and combined with the processes into a single work cell, booking in function removing the samples are opened, checked and wastes of motion, transport, waiting booked in one at a time. 73 seconds and over processing. per sample has been saved which equates to 781 hours per year. Understanding the problem When the equipment was installed for How this improvement benefits LBC processing, specimen reception women was relocated to a distant location Time savings have been reinvested into within the histology laboratory where value add process steps contributing space happened to be available within to a reduction in the turnaround time. the cut up area. How will this be sustained and The workspace was cramped and out what is the potential for the future of sight of the rest of the cytology /additional learning? team. It was located at the furthest The work cell is to be made point from the processing room and permanent but will move into an admin office and samples were adjacent office space where the therefore being transported. flooring is due for replacement. Appropriate flooring will be laid and How the changes were the function moved as the current implemented location has recently been carpeted. • Following discussion with the laboratory team, it was agreed that Contact the admin office would become a Craig Roberts work cell as a PDSA (plan, do, study, craig.roberts@wehct.nhs.uk act) • The desks are covered with disposable non-absorbent paper to make them suitable and staff members wear disposable plastic aprons to adhere to PPE procedures • Samples are handled one at a time - unpacked from the plastic bag, checked, labelled and booked in • Staff work in batches of 24 which matches the Surepath equipment capacity • Forms and pots move into the processing room together and are divided into two batches of 12 when they come off the cover slipper.www.improvement.nhs.uk

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