Cytology improvement guide: achieving a 14 day turnaround time in cytology


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This guide highlights the findings and improvements from the pilot sites who tested how the 14 day standards can be achieved using Lean methodology.This practical guide is supported by tried and tested case studies across the whole patient pathway which NHS staff involved in the screening pathway can adopt and adapt to meet their local setting. (Nov 2009)

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Cytology improvement guide: achieving a 14 day turnaround time in cytology

  1. 1. NHS NHS ImprovementCANCERDIAGNOSTICS NHS Cervical Screening Programme (NHSCSP) Cytology improvement guide -HEART achieving a 14 day turnaround time in cytology Clinical excellence in partnership “LUNGSTROKE with process excellence”
  2. 2. Cytology improvement guide - achieving a 14 day turnaround time in cytology 3Contents1. Foreword 5 Motion Case study 62. Executive summary 6 Moving the fridge reduces walking. Case study 73. Introduction 7 Sample collection trips reduced.Why Lean as the methodology of choice? Automating inefficient processes4. Phase 1 pilot sites 8 Waiting5. Learning for future improvement 9 Case study 8 Changing quality control procedures.6. Understanding where you are 10 OverproductionWhat to measure and how to collect it? Case study 9• Baseline data – ‘Go see’. Slide matching.• Data requirements.• SPC charts. Over-processing• Skyline plots. Case study 10 Removal of date stamping.7. Self assessment 12 Case study 11Score the current status of your service. Removing the day book.8. How to begin 13 Case study 12Team make-up, the wider team, executive Adjusting download times to thesupport and involving users. primary care support services.9. Establish the measures 14 DefectsIdentifying and measuring factors which Case study 13impact overall turnaround time. Zero tolerance of defects. Case study 1410. Just-do-its – recommended Improving mapping tables.immediate activities 15 Skills utilisation• Primary care. Case study 15• Laboratory. Expanding roles in prep room.• Results agency. Case study 16Case study 1 Abnormal pathway changes.Reducing batching in the screening room. 12. A3 thinking 39Case study 2 What it is and how to produce an A3?Introduction of multiple downloads. Case study 17Case study 3 Using A3s for problem solving.Reducing manual-matching and firstclass post. 13. Root cause analysis 41 Techniques to determine the true cause11. The nine wastes 22 of a problem.TransportCase study 4 Case study 18Specific bags sent straight to laboratory. Using data for root cause analysis.InventoryCase study 5Reducing the backlog.
  3. 3. 4 Cytology improvement guide - achieving a 14 day turnaround time in cytology 14. Visual management 44 20. Capacity and demand 60 What is it and how is it used? Do we have sufficient capacity to meet the demand? Case study 19 Use of visual management to support Case study 28 a zero tolerance of defects. Using capacity and demand information. Case study 20 Case study 29 Introduction of yellow stickers for the 100 day plan. abnormal pathway. Case study 30 15. Value, value stream mapping, Cost avoidance. flow and pull 47 21. Communication 67 Improving flow, introducing pull, eliminating The importance of good two way non-value adding steps, simplifying processes, communication. combining steps, re-sequencing. Case study 31 Case study 21 Understanding communication issues. Removing duplicate checks. Case study 22 22. Leadership, engagement Establishing work cells. and sustainability 69 How leadership style affects staff Case study 23 engagement. Standard work and flow at late delivery times. Case study 32 Case study 24 Sustainability - managing a surge in demand. Abnormal pathway changes. Case study 33 Case study 25 Sticking to Lean principles. Changing work patterns. 23. Customer experience 74 16. Future state mapping 54 What do the users really want? How do you get there and action Case study 34 planning? Colposcopy service improvements. 17. 5S to improve safety and morale 55 25. NHS Improvement contact details 76 Case study 26 5s in the screening room, office and stores. 26. Websites and useful reading 77 18. Standard work 57 The best way to perform each process step. Case study 27 Standard work in screening. 19. Takt time 59 What it is and how it can be used to level the
  4. 4. Cytology improvement guide - achieving a 14 day turnaround time in cytology 51. Foreword The NHS Cervical Screening Programme (NHSCSP) is undoubtedly a major success. Over the past two decades the NHSCSP has led to many cancers being prevented and has led to significant reductions in the death rate from cervical cancer in this country. It has been established that cervical screening saves around 4,500 lives every year in England.Professor Mike Richards CBE Much of the success of the NHSCSP can be attributed to havingNational Cancer Director effective call and recall systems and quality assurance schemes. The introduction of liquid based cytology over the past few years (2003-2008) has led to significant reductions in the number of ‘inadequate’ tests (from around 9.5% to 2.5%). This means that around 400,000 fewer women need to be re-screened each year. However, we know that we can and we must do better. In many parts of the country women are having to wait far too long to receive their test results. By December 2010, all cervical screeningProfessor Julietta Patnick CBE services have to ensure that women receive their results within twoDirector NHS Cancer ScreeningProgramme weeks of the test being done.Pilot sites working with NHS Improvement have demonstrated that the 14 day standard forcervical cytology can be achieved and that this brings benefits both for the patient and for theNHS in terms of potential cost savings.This guide shows how the 14 day standards can be achieved. We commend it to allcommissioners and providers of cervical screening services.Professor Mike Richards CBE Professor Julietta Patnick CBENational Cancer Director Director NHS Cancer Screening Programme
  5. 5. 6 Cytology improvement guide - achieving a 14 day turnaround time in cytology 2. Executive summary The publication of the Cancer Reform Strategy Productivity: Eliminating non value added (Nov 2007) made a promise to ‘ensure that all steps, ensuring appropriate utilisation of women receive the results of their screening workforce, demonstrating the capacity required tests within two weeks by 2010’. based on the demand, and ensuring technology is used effectively. The Scharr report (Feb 2006) highlighted that with minimal investment it was possible to Key learning has demonstrated success is deliver the service to 50-66% of women within achieved through: seven days with the remainder receiving their result within 14 days. Strong and proactive clinical and managerial leadership: To encourage, drive, In 2006 the Review of Pathology Services in motivate and empower staff. England by Lord Carter endorsed Lean as the method of choice for improving processes in Collection and analysis of appropriate data: pathology services. Working in partnership with To understand the current end to end pathway. the National Cancer Screening Programme, NHS Improvement supported10 pilot sites to test the Walking the pathway: Go to see the problem Lean methodology to demonstrate how to first hand. deliver a two week service. Executive support: To provide active support The approach involved bringing multi-disciplinary and remove barriers. teams from primary care, laboratories and recall agencies together to work collaboratively on the Empowered staff: Who own the problem, whole pathway. Staff were trained in Lean find the solutions and ‘stop to fix’. methodology, applied the learning, redesigned their own service and delivered significant This guide provides clinical teams with the basic improvements. tools to make changes to their processes, and is supported by tried and tested case studies from Over 500,000 women will have benefited from across the whole pathway. the improvements in: Turnaround times: 100% of women receiving their result within 14 days (for most sites) and over 80% of women receiving results within seven days for five out of ten sites. Quality and safety: Implementing a zero tolerance of defects in request forms and sample labelling to reduce errors. Innovation: Using simple visual management techniques to improve flow, safety and
  6. 6. Cytology improvement guide - achieving a 14 day turnaround time in cytology 73. IntroductionAs the 14 day target is of national importance,there will naturally be a great deal of interest inhow Lean methodology has been used tosupport the aims of the Cancer Reform Strategy. ACT PLAN What changes ObjectiveOver the past four years NHS Improvement has are to be made? Questions and Next cycle predictions (why)worked with a number of pathology teams to Plan to carry out thetest and prove the value of Lean methodology. cycle (who, what, where and when)Clinical teams have been extremely successfuland the methodology is being widely adopted in STUDY DOmany pathology laboratories and other clinical Complete the analysis of the data Carry out the plan Document problemssettings across the country. Compare data to predictions and unexpected observations Summarise what Begin analysis was learned of the dataThe methodology and approach was furtherendorsed by Lord Carter in the ‘Report of theReview of NHS Pathology Services in England’in 2006/2008.Pilot site teams were trained to:• Understand and identify waste. Spreading and sharing the learning• Apply Lean principles to improve flow. Networking amongst clinical teams involved in• Use PDSA cycles (plan, do, study, act) to test the pilot, facilitated a collaborative approach to out ideas to ensure changes make the achieving improvements and to spreading improvement required before implementation innovation and success. (sometimes known as PDCA - plan, do, check, act). A buddy system for close locality sites was set• Use data to demonstrate the impact of up to support the sharing of best practice along improvement. with a series of training and development• Understand how people respond to change; workshops and shared learning events.• Use statistical process control charts (SPC) and root cause analysis. In addition, a number of regional learning events• Understand communication methods and were conducted by pilot site teams, supported work as part of a team. by NHS Improvement National Improvement Leads to spread some of the learning to non-To further support and embed the improvement pilot sites.methodology within the local environment andcreate local ownership, an overview of Lean This document contains case studies frommethodology was provided for all staff involved the phase one pilot sites to help illustratein the pathway. the changes made. Further case studies can be found on the website at:The training, combined with clinical lead, are essential to the sustainabilityof achieved and ongoing improvement.
  7. 7. 8 Cytology improvement guide - achieving a 14 day turnaround time in cytology 4. Phase one pilot sites The following sites were selected by the National The phase one pilot sites are: Cancer Screening programme to take part as phase one pilot sites. One of the criteria for Leeds PCT and The Leeds Teaching joining the programme as a pilot site was to Hospitals NHS Trust become exemplar sites, prepared to share Lead: Dr Simon Balmer learning with other teams. Hull Royal Infirmary and Hull and Clinical teams will benefit from visiting the East Riding PCTs following phase one sites, where they will Lead: Ms Kathleen Young observe Lean methodology as part of everyday working and learn how the targets have been Pennine Acute Hospitals NHS Trust achieved. Lead: Mr Tom Wilson The criteria for inclusion as an exemplar site are: Norfolk and Waveney Cellular Pathology Network (Norfolk and Norwich University • Delivery against 14/7 day target Hospital NHS Foundation Trust) (min. 95% and 50%). Lead: Dr Xenia Tyler • Clear evidence of Lean methodology including: West Anglia Pathology Cytology Laboratory • Visual management (Cambridge University Hospitals NHS • Standard work Foundation Trust, Addenbrookes Hospital • A3 problem solving and Anglia Support Partnership) • Stop to fix problems via daily meetings Lead: Ms Roseanna Bignell • 5S. • Evidence of all staff committed to continuous Barts and The London NHS Trust improvement and Lean methodology. Lead: Mr Geoffrey Curran • Evidence of sustainability and committed leadership. Somerset and West Dorset Cervical Screening Service (Taunton and Somerset Hospitals NHS Trust) Lead: Dr Simon Knowles Ashford and St Peter’s Hospitals NHS Trust Lead: Mr Behdad Shambayati North West London NHS Trust (Northwick Park Hospital) Lead: Dr Tanya Levine Central Manchester University Hospital NHS Foundation Trust Lead: Dr Mina
  8. 8. Cytology improvement guide - achieving a 14 day turnaround time in cytology 95. Learning for future improvementThe purpose of this document is to share the The key mechanisms required to achieve theselearning from phase one pilot sites. changes are:It makes recommendations for change throughevidence based case studies and encourages 1. Empowered staff who can:teams to adopt the learning, adapt within their • see the waste and remove it;own service, and visit exemplar sites to discuss • test changes through PDSA cycles;improvements made, challenges faced and • have information to say how we are doing;pitfalls to avoid. • use suggestion boards to have ideas actioned.The four key changes have been identified 2. Daily meetings established to:which will bring about substantial reductions in • stop and fix problems;end-to-end waiting times for the cervical • encourage a culture of daily problem solving.cytology pathway are: 3. Visual management techniques to:1. Focus on the whole end to end pathway: • display performance data;• link all staff across the pathway; • promote standard work;• use whole pathway data to understand where • ensure safe working practices. samples and reports are waiting. 4. Information to support the process:2. Adopt small batch sizes: • turn real time data in to information to• throughout the entire pathway, including the manage the process; prep room, lab, screening room, data entry as • ensure visibility of efforts; well as primary care and the call/recall agency. • identify problems and establish mechanisms to solve problem;3. Keep samples moving: • encourage root cause analysis.• daily delivery from primary care;• pull work through the lab; To accelerate the pace of change to reduce• multiple daily downloads; turnaround times, defects and rework and• daily issue of reports. improve quality, safety and productivity, teams should consider applying:4. Establish first in, first out:• no prioritisation of samples; • Just do its – tried and tested, proven to• todays work today. reduce turnaround times – adopt as many as you can; and consider the; • Human dimensions of change – the importance of engaging all staff. An engagement survey tool is available on the NHS Improvement website. Whilst this process will not be easy, the rewards are great!
  9. 9. 10 Cytology improvement guide - achieving a 14 day turnaround time in cytology 6. Understanding where you are Measuring the end-to-end pathway Recommendations include: At the launch stage of a project, it is important • Date/time primary screened to create an understanding of what is actually • Date/time rapid review performed happening, as distinct from what ‘should be’ or • Date/time report authorised is thought to be happening. Identifying the • Date recall agency received info (down current situation should include the whole electronic link), journey of the samples – not just in-laboratory • Date letter was issued. processes. A sample data collection spreadsheet can be The best way to do this is to ‘go see’. This found on the NHS Improvement website. means to physically walk the whole pathway and produce a photographic record of the Note: it may be appropriate to record measures process. It is recommended that this is done by for all test results (abnormal, negative, the whole core team to ensure objectivity. incomplete) separately so these can be monitored individually. The pathway should then be graphically represented as a current state value stream map. What type of data and how much? Measurements taken as part of value stream We recommend you collect data on at least 750 mapping will provide the baseline against which consecutively numbered specimens taken in the the impact of any changes to the process can be same week to provide a statistically valid compared. baseline TAT. Every task undertaken while processing samples Calculating and monitoring TAT - Using will have an impact on achieving the 14 day statistical process control (SPC) turnaround time (TAT) and should therefore be By collecting data from samples at the three key included in baseline measurement. TAT is stages within the pathway, variations in defined as the time the sample was taken to delay/wait times and other sources of waste can expected date of delivery of the result letter to be detected, corrected and tracked to assess the woman. how/if these are reduced over time as a result of improvement changes. Data requirements SPC charts provide a graphical representation of To capture a clear and accurate TAT measure, the time it takes to process a particular sample data should be collected for all three key stages and an overall view of the variation in the of the cytology pathway: process. 1. Date sample taken to date sample received in Statistical control limits are calculated from the the laboratory specimen reception. data input and are displayed on the chart along 2. Date specimen received in specimen with process average (mean) and its variation reception to date report authorised and sent about that mean. If there is evidence of unusual to the recall agency. variation or ‘special cause’ (outlier) detected, 3. Date report received in the recall agency to then this ‘special cause’ should be investigated date result received by woman (calculated by using a root cause analysis technique (see by adding one day to the date letter issued section 13). for first class postage or three days for second class). SPC tools can be accessed via the NHS Improvement reporting system or NHS To determine the impact of changes made in the Improvement excel data template. To find out laboratory or other specific parts of the pathway, more about SPC and the types of ‘run rules’ that additional timings should be captured and are used to indicate out-of-statistical control statistical process control (SPC) charts produced situations please refer to the website or NHS to evidence achieved improvements. Improvement publication ‘Bringing Lean to Life - Making Processes Flow in Healthcare.’
  10. 10. Cytology improvement guide - achieving a 14 day turnaround time in cytology 11 Special Cause Variation process is ʻout of controlʼ Special Cause Variation process is ʻout of controlʼYour individual project can be set up on the NHS The query covers date sample taken through toImprovement reporting system and this will date added to recall system. It shows patientenable you to track the project, add project identity to enable root cause analysis for samplesdocumentation and upload improvement stories. that have taken longer than 14 days for analysisFurther information on how to use the NHS and result return. An additional field ofImprovement System can be obtained via ‘expected date of delivery’ is due to be added the query shortly so full end-to-end TAT can be produced.Other important data for your baselineTurnaround times This query can be run by all recall agencies for% achieved in 14 days any specified time period, allowing analysis of data on daily, weekly or monthly cycles. The% achieved in 7 days data can be sent to laboratories via secureQuality and safety (defects) transfer (or can be run without patient% samples/forms with inaccurate/illegible/ identifiers) and together with laboratoryincomplete information sample data can be used as an alternative to SPC charts.% referrals returned to requester% reports authorised and sent to recall agency Instructions on how to run this query can bewhich required manual matching found at: www.improvement.nhs/uk/ diagnosticsEngagementOverall engagement scores at start of project In addition, each individual laboratory can runand various additional points throughout the this query through CYRES. It should bechange process. remembered that this will only show from date sample received to date results sent to recallSkyline plots agency. Ensuring a 14 day end-to-end TAT willThe East of England Screening QA Reference require all samples to be within 10 and 12 daysCentre (QARC) has developed a cervical depending on time taken by recall to sendscreening system enquiry that recall centres can letters out.use to perform a patient based search that willshow TATs in a bar chart.
  11. 11. 12 Cytology improvement guide - achieving a 14 day turnaround time in cytology 7. Self assessment The Endoscopy Global Rating Scale (GRS) and Radiology Service Improvement Assessment Tool (RSIAT) were developed by the Endoscopy and Radiology service improvement teams respectively and have been used widely since 2004 to benchmark these diagnostic services and provide teams with a focus for improvements. They have been designed to allow clinical teams to see which areas they need to concentrate on to achieve the cancer waiting times targets. Whilst such a tool for cytology is currently still under development, the questions, and answers teams provide, can help to steer the focus of improvement in the direction that will create the most benefit to the screening programme. The questionnaire can be found on the NHS Improvement website at:
  12. 12. Cytology improvement guide - achieving a 14 day turnaround time in cytology 138. How to beginTeam guidance Wider team membership/steering groupFirstly, identify a credible and respected project It is recognised there will be a wider team oflead to head up the team. This could be a individuals who are key stakeholders across theclinician or manager with the drive and pathway who will provide managerial andenthusiasm to steer changes across the strategic support but may not be a member ofwhole pathway. N.B. full screening programme the core team for training.pathway includes colposcopy and histology: Executive support An executive team sponsor should be identifiedProject team members should be drawn to provide proactive support and access tofrom across the entire pathway: relevant support services such as estates,• Clinical /managerial lead who must provide transport, HR, finance and IT teams. They may active support and leadership to the core team be called upon to escalate key issues.• Primary care – (e.g. PCT lead, practice manager) should be able to contribute to Protected time out discussions such as organisation of transport This is essential to allow thinking time for the for same day sample delivery core team and any members of staff planning a• Laboratory – (e.g. MLA, BMS, AP, screener) plan, do, study, act (PDSA) cycle and may have must represent and understand specimen to be facilitated by the departmental manger or reception processes and the laboratory LBC executive lead and screening process (you may wish to co- opt a laboratory manager and/or Communication plan histopathologist onto the core team/wider It has been widely recognised from the phase team or steering group) one pilot sites that the establishment of a• Results issue agency – should be able to communication plan is essential and a central contribute to discussions and influence / lead information board should be positioned to changes to the results issue process inform all staff of project activity and progress.• User involvement – member of an existing gynaecology patient group or suitable Training location/work room equivalent, likely to be a wider team member Space will be required for the core team to• Colposcopy – a member from this area may be work. An area should be identified where local co–opted onto the wider team / steering training can take place and where teams will group. have space to work on projects and store information work sheets/maps with easy accessCore team members must: to these items on a regular basis.• Understand the process within their stage of the pathway• Be able to contribute ideas/information on the process• Be able to influence the decision making process• Be prepared to test and implement changes across the pathway• Be committed to attend all team meetings, conference calls and sharing events.
  13. 13. 14 Cytology improvement guide - achieving a 14 day turnaround time in cytology 9. Establish the measures Identifying and measuring factors which impact overall turnaround time In addition to the global measure of turnaround times (TAT), quality, safety and staff engagement, there will be other local measures and quality indicators that can be used to asses the impact of the project. These should be focussed around: Safety - reducing avoidable harm and creating confidence that the result is accurate e.g. no errors in sample taking, request cards, data input or results letters. Customer experience - understanding of the result with relevant and timely information e.g., information at time of test and with result letters. Effectiveness of care - good quality outcomes e.g. no unplanned staff/machine/system downtime and each result produced within PCT tariff. Some examples of additional measures: • Patient satisfaction rating; • % processor/system utilisation; • % staff availability; • % inadequate/re-prep samples; • % machine/system re-runs; • % of samples with insufficient cells; • % staff absence; • Stock level replenishment; • Number of unplanned shutdowns v. target; • Department productivity v.
  14. 14. Cytology improvement guide - achieving a 14 day turnaround time in cytology 1510. Just-do-its (JDIs) - recommended immediate activitiesThis section is designed to help teams make structured way, guided by the core project teamsome very quick changes. These have been and project lead. Measures should be in placetested and proven to make a significant to track improvements.difference to turnaround times. To support the JDIs, the case studiesMost are simple, quick to do, with very little demonstrate how sites have implemented someeffort required. of these simple changes evidencing the improvements achieved.All parts of the pathway are covered. Changesshould be implemented in a planned and Primary Care Action Why? 1 Enforce a policy for refusing ‘out of scope’ Stop inappropriate sample testing and samples and ensure GPs and sample takers inappropriate samples being tested when a know the correct pathway for symptomatic more suitable test/intervention is required. patients. 2 Send samples to laboratory daily, even if there To ensure timely testing. is only one! 3 Ensure appropriate staff are trained in use of To enable the correct information to be put ‘Open Exeter’ and are able to use the system to onto the request form regarding the last its full capability. cytology results etc. 4 Always use pre-populated HMR101 forms or To ensure correct demographics are recorded. print offs from the primary care system. Samples are not returned for correction or because hand writing is illegible. 5 Where available – use electronic requesting for To ensure correct demographics are recorded. every sample. Samples are not returned for correction or because hand writing is illegible. Laboratory Action Why? 1 Reduce batch sizes to a maximum of 20 in the Although instinct tells us batching ‘feels’ prep room. quicker, this will immediately reduce your TAT. Use SPC to evidence the gains. 2 Reduce batch size to 10 or less in screening Although instinct tells us batching ‘feels’ room and office area. quicker, this will immediately reduce your TAT. Use SPC to evidence the gains. 3 Reduce batch size for consultants to a Although instinct tells us batching ‘feels’ maximum of four. quicker, this will immediately reduce your TAT. Use SPC to evidence the gains. 4 Implement a non-acceptance policy for Eliminates time spent by staff dealing with incorrect forms/vials. omissions and mistakes, logging returns, telephoning surgeries etc.
  15. 15. 16 Cytology improvement guide - achieving a 14 day turnaround time in cytology Laboratory (continued) Action Why? 5 Implement ‘quiet time’ in the screening room This will improve the quality of concentration during an agreed period each day (no and productivity of the screeners. answering e-mails, remove the fax machine, mobile phones set to silent). 6 Introduce a staff ideas and information board. Important to engage staff in identifying issues and solutions. Essential to provide a feedback loop explaining what is happening with suggestions made. 7 Initiate five minute daily meetings (huddles) Encourages ‘stop to fix it’ culture and improves with all staff around the information board. engagement. Staff know what is expected of them and how the team is progressing 8 Introduce visual management showing Improves productivity. Progress is visible and numbers of slides/samples in (demand) and motivating. numbers out (screened) daily. 9 Stop over labelling or writing patient names on Will remove an extra step and improve safety slides. which could be compromised by potential labelling errors. 10 Stop the process of slide matching in the prep Saves staff time and frees up space. Reduces room. Ensure all slides and forms are kept in TAT. numerical order in the same batch sizes. When required, screeners collect one tray of slides and the corresponding batch of request forms before screening. 11 Implement standard work in screening - Prevents slides waiting overnight or over screening one tray of ‘primary’ followed by one weekends for rapid review. Saves BMS time tray of ‘rapids’. allocating slides. 12 Promote the use of pre-populated Prevents defects / mistakes on forms. HMR101/primary care system forms or order comms. 13 Set up multiple daily electronic downloads to If sent weekly – could save up to save seven the recall centre – at least twice daily if IT days off TAT. systems allow. Check what can be done – If sending download daily - Will save one day don’t assume it isn’t possible! for half your screening output each
  16. 16. Cytology improvement guide - achieving a 14 day turnaround time in cytology 17Recall agency Action Why?1 Implement first class post for all results letters. Can save between two to seven days on TAT.2 Post results letters every day, Monday to Friday. Will save a minimum of five days on TAT.3 Remove the lab and recall telephone number Prevents unnecessary phone calls to the from results letter, add NHS Direct telephone laboratory and recall centre who then have to number. refer back to the GP.4 Receive numerous electronic daily downloads Will save one day for half the screening output from the laboratory – at least twice daily. each day.5 Contact all recall agencies you forward results 14 day target is: Date sample taken to to, ensure they are aware of their role in expected date of delivery of result to woman. delivering 14 day target. A result to the wrong recall agency, will need time to send to correct agency – the clock is still ticking.All areas Action Why?1 Initiate monthly meetings with the laboratory, To improve communication and resolve any recall agency, commissioners, primary care cross boundary issues. representative etc.2 Send out monthly reports and newsletters To improve communication, promote your communicating current TAT, achievements, project and the national target and manage issues etc. customer expectations.
  17. 17. 18 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 1Reducing batching in the screening roomNorth West London NHS TrustSummary Effect of reduced batching of slides on length of timeChanges made in cytology screening taken from booking in to primary screenroom to reduce waste caused by batchprocessing through the screeningprocess.Understanding the problemThe need to reduce the length of timespent waiting for something tohappen:• Watching the progress a case made during its journey through the cytology screening room identified numerous occasions where the case would simply sit and wait amongst a batch until the next stage of the process could take place.• Backlogs were seen with slides waiting to be primary screened, rapid reviewed, checked and How the changes were • The move to reduce the batch size reviewed by the pathologist. implemented down further to 5 slides per tray• Slides were done in batches of 20 • Batch sizes of slides reduced to 10 resulted in a further 20% as this was the number of spaces per tray. reduction in primary screen to available on the slide tray. • Policy imposed that a screener verification TAT.• Screeners would not always take a completing a tray of primary • The effect these changes have tray of rapid review after completing screening must then take a tray of made can be clearly seen on the a tray of primary screening which rapid review. SPC chart below which displays would result in an increased number • Cases to be reported on computer the length of time taken from the of cases awaiting rapid review. immediately after screening. booking in of the case to the time• Some screeners would put their • No work to be left on desk at end it is primary screened. results on the computer only after of working day. Any uncompleted • The reduction of batch sizes has they had completed a tray of slides screening must be returned to the had the effect of pulling the work and not immediately after screening pool of work. through the department. the case. • Checkers to be more pro active in • The reporting rates for abnormality• It was common practice for a doing checking to prevent build has remained constant during this screener to leave an uncompleted up cases. time. tray of work on their desk where it • Work requiring pathologist review would remain until they returned to to be allocated to named Ideas tested which were successful work. pathologist Improvements in turnaround time• Data recorded included the date • Eight months after the above were seen wherever batching was and time when each stage of the changes were implemented the reduced or eliminated. process took place. This data was batch size of slides per tray were How this improvement benefits extracted from the computer by use reduced from 10 to five. women of a specially written computer Improved TAT without reduction in programme and then manipulated Measurable outcomes and impact quality. in Excel and analysed using SPC • Since the implementation of the charts. A numerical assessment as to reduced batching procedures within How will this be sustained/ what the backlog was at the various the screening room there have been potential for the future/ stages of the process was also kept. marked reductions in the length of additional learning?• Slides requiring checking or time cases take from when they are Reduced batch size has become the pathologist review were allowed booked in to being verified. normal practice within the department. to build up. • Changes instigated at the time of Further reductions in batch size may• The principle type of waste reducing the number of slides per be tried but we are not sure this will identified was waiting. tray from 20 to 10 resulted in a one produce further reductions in TAT. day reduction in primary screen to Contact verification TAT. David Smith Email:
  18. 18. Cytology improvement guide - achieving a 14 day turnaround time in cytology 19Case study 2Introduction of multiple downloadsThe Leeds Teaching Hospitals NHS TrustSummary • Agreed volumes of work, calculated Ideas tested which were successful32% of result letters are received by from demand and capacity analysis are • Lean methodology discourageswomen a day sooner than before with a collected at agreed times throughout batching. The idea was to reduce thefurther 8% being received three days each day from the laboratory to the batch size of results sent to call/recallsooner. office for registration, from the office enabling them to process the resultsTotal waiting days saved 58,800 to the prep lab for processing, and and send out the result letters the from the prep lab to the screening same day.Understanding the problem room for sending the expected • The multiple files involved restrictFuture state planning identified that in number of authorised reports in each call/recall from getting all reportedorder to improve turnaround times, daily electronic link to call/recall. authorisations dispatched as results onresult letters need to be issued on the This maximises the number of letters the same day.same day that the results are authorised dispatched on the same day that theyby the laboratory. were reported from the screening How this improvement benefits room. womenResults of cervical cytology samples were • Clearly marked, standardised On current workload figures this changedownloaded to the screening agency collection points for work completed means that over 33,600 women per yearonce a day late in the evening, are used to ensure each department will receive their cervical cytology resultsirrespective of the time the result was knows where and when to pull a day earlier than previously and 8,400authorised on the laboratory computer completed items into their area. The will receive results three days earlier.system. time of day and volume of workNo result letters were issued the same pulled is indicated through the use of How will this be sustained/day as the authorised reports, and some red/green kanban cards acting as potential for the future/letters were being delayed by up to trigger signals which alert additional learning?three days. departments to what work is ready • Standard operating procedures have and in what volume as compared to been updated to reflect the changesHow the changes were implemented the timetable. implemented.Changing to two downloads per day • This occurs three times per day with a • Daily problem solving at five minutewould initially ensure up to 50% of visual management system in place to meetings to level out any deviationsresults available to be posted out a day clearly show when deliveries are made from the planned timetable to ensureearlier. but can be increased/decreased at the target number of result letters is• To ensure a continuous flow of anytime to reflect fluctuations in dispatched. samples ready for reporting, a pull demand and 20 capacity. • Further enhancements to visual system has been set up across the • Deviations from the norm are management controls and prep lab, office, screening room and monitored daily, discussed at huddles communication will ensure that a call/recall agency. and counter measures put in place if standard minimum level of work• When the future state map was required. outstanding in each area supports flow developed to optimise workflow, the • Team members attend each others through all steps in the process. team recognised that the pace of huddles with a weekly scheduling • Further root-cause analysis and PDSA work through each department would review taking place at the Monday problem solving sessions will take be determined by the recall agency. huddle which involves all areas. place to evaluate whether changes to• A timetable was drawn up to ensure the Exeter system will enable the that the required number of samples Measurable outcomes and impact laboratory to send results to call/recall and forms are processed in a planned • On average 41% of results reported in real time. schedule throughout each working each day are now sent to call/recall at day. Visual management is in place to 11.30 am and these result letters are Contact ensure the schedule is adhered to. all posted out the same day. Hazel Eager • 38% of result letters are received by Email: the patient a day sooner than before. • A further 8% of result letters are received three days sooner.
  19. 19. 20 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 3Reducing manual matching and first class postAnglia Support PartnershipSummaryOver 17000 result letters are issuedeach month by Anglia SupportPartnership call/recall service.Approx. 2000 women are nowreceiving result letters two to threedays sooner than they would havethis time last year after reducing thenumber of non hit query cases from15% to 5%.A further two days has additionallybeen saved following theintroduction of the use of first classmail.Understanding the problem Visual management techniquesThe reduction of mismatchedreports, caused by typingdiscrepancies, booking in errors(laboratories) and out of area results demonstrate the resource savings • Introduced standard workingwas targeted as a major source of that could be made if outsourced procedures in general processesdelayed result letters. In July 2008 letter production was used. across all three agencies.between 15 and 20% of resultsreceived were mismatch/non hits How the changes were Measurable outcomes and impactcaused by invalid senders, out of implemented • The audit of costs of thearea, sender with end date in the • Visited mailing bureau, to review folding/inserting machine showedpast, incorrect source type, incorrect full pathway and undertook a that savings in excess of £7000management of women. These postal audit to assess the per year could be realised bydefects needed to be reduced so difference in delivery times switching to a mailing bureauwomen received their result letters in between the first class and assuming fully operationala more timely fashion. business class service. equipment. The time savings • Migrated whole Anglia Support would be greater when taking intoThe postal service was taking too Partnership (ASP) call/recall service account equipment failures andlong with many result letters taking to the mailing bureau. the time this had previously addedthree days from dispatch to receipt • Engaged with laboratories to on to woman. review all senders and established • The postal audit showed that if practice codes as senders, checked first class post was used a furtherThere was manual distribution and all postcodes correctly mapped. two days could be removed fromdispatch of result letters in Norfolk, • Previously, result files were the time taken for the woman towhich caused delays due to processed throughout day then receive her letter.unreliable equipment often with two 8am next morning results letters • The non-hit/defect rate hasday breakdowns. Staff were having generated. Now the results letters reduced from 15% to 5% onto watch the equipment to deal with are generated immediately and average (see table 1).regular issues. don’t wait until the next day. • The graph on the rightSome systematic data collection was • Enabled remote access, from their demonstrates that the averageundertaken to assess the range of own desktop, for all staff across time from result received by recall‘non hits’ using visual management ASP to the Cambridgeshire, to letter received by woman hastechniques. Norfolk and Suffolk systems to reduced from five days to 1.57 enable result input and cross- days since October 2008.A postal audit was performed to working across the three agencies. • Staff comments include: ‘Theassess delivery times. • Established practice nurse and visual management of lab-link filesAn audit of costs and time for the administrative training sessions for is great because it gives an instantprocess of ‘in house’ dispatch of primary care staff on general picture of the service’. ‘The use ofletters, assessing the use of call/recall, Open Exeter and the mailing bureau is great as I nofolding/inserting machine, time spent common queries. longer have to sit and watch theand local costs, was undertaken as • Introduced visual management to folding machine whirring through’.part of a business case that would capture all lab-link
  20. 20. Cytology improvement guide - achieving a 14 day turnaround time in cytology 21 ‘This course has meant I’ll have Table 1: fewer telephone queries in future’. Before changes were made ‘I now have a far greater understanding of call/recall and what it all means’. Ideas tested which were unsuccessful • The first attempt at the postal After changes were made audit was unsuccessful. Inclement weather meant post could not be delivered. • The initial implementation of using mailing bureau in Norfolk was problematic because there was not enough testing done before going live. How this improvement benefits West Anglia - Oct 08, Jan 09 and Jul 09 data - result patients received by recall to letter received by women On average, 17,282 women are receiving their result letters two days earlier and on average 1.5 days after the result was authorised in the laboratories. How will this be sustained/ potential for the future/ additional learning? • The introduction of improved communication between all programme providers (call/recall, labs, primary care) will be sustained as no-one wants to return to the old ways of working. • More time is available to developIdeas tested which were originally. Although results can be further service improvements.successful input at any of the three agencies Staff are being used appropriately• Mapping/checking of all postcodes results currently have to be to do the job they are best at and enabled results to be sent to the generated from each office, but standardised working has been correct agency in the first place, this is under review to make the introduced to improve accuracy causing fewer ‘non hits’. appropriate changes so result between the lab and call/recall.• Mapping/checking all sender codes letters can be run from any of the • Potential for the future – NNUH to ensure accurate booking in of three agencies. lab should develop electronic links samples in the laboratories, • The decision to move to first class with more than two agencies to reduced sender queries and ‘non mail meant that women received enable the results to be sent to the hits’ when the results were result letters quicker. correct call/recall agency based on received. • Following the visit to the mailing patients postcode although this is• Running the CP/result letter bureau and a greater not currently possible due to production job after all lab-link understanding of the business funding issues preventing progress. files and queries had been resolved needs from both sides, meant that result letters were sent communications between the Contact the same day they were received bureau and call/recall improved Claire Robinson and processed. resulting in an improved service. Email:• Remote access to all three ‘Exeter • Feedback from the primary care systems’ meant immediate manual admin training sessions was very entry of results where it had been positive with comments such as sent to the wrong agency
  21. 21. 22 Cytology improvement guide - achieving a 14 day turnaround time in cytology 11. The nine wastes The key to adding value is to remove waste. So, Overproduction what is waste? Producing something before it is required, or more than is required e.g. unnecessary / There are nine forms of waste and these can be inappropriate tests, batching samples, tests and easily remembered with the mnemonic – information TIM A WOODS Over-processing Duplication of data or repeat testing due to defects e.g. dual data entry, additional steps Transport and checks Material or information that is moved unnecessarily or repeatedly e.g. unnecessary Defects movement of samples. Errors, omissions, anything not right first time e.g. poorly labelled specimens and requests, Inventory insufficient or illegible information. Excess levels of stock in cupboards and store rooms e.g. specimens waiting to move to next Skills utilisation step in process, or people waiting for tests and Unused employee skills e.g. highly qualified staff results. performing inappropriate tasks Motion WASTE COSTS MONEY AND ADDS TIME Unnecessary walking, moving, bending or stretching e.g. equipment placed in wrong The following case studies illustrate how the location, unnecessary key strokes. sites have removed waste from their systems to improve turnaround times. Automating Where technology is substituted to compensate for a poor inefficient process/processes “ No worker, particularly in healthcare where the well-being and safety of Waiting another human comprises the core Waiting for samples, equipment, staff, of the work, appreciates having his appointments or results e.g. patients waiting for test and results, staff waiting for other or her time wasted.” staff, equipment or information. Cindy Jimmerson A3 Problem Solving for
  22. 22. Cytology improvement guide - achieving a 14 day turnaround time in cytology 23Case study 4Specific bags sent straight to laboratoryNorth West London NHS TrustSummary How the changes were How this improvement benefitsReorganisation of the way cervical implemented patientscytology samples are collected from • Core team members discussed the • By implementing the use ofGP surgeries and delivered directly to issues identified with the staff dedicated cervical cytology samplethe cytology department has resulted members responsible for this bags which are delivered directly toin a reduction in the TAT of between process. the cytology department has meant0.1 and 2.5 days for approximately • Clear separation of cytology a reduction in the TAT of between90% of women. MLA staff are also specimens from other types of 0.1 and 2.5 days for approximatelysaving approximately 50 minutes per pathology samples was identified as 90% of through no longer walking to and a way to make sorting easier.from pathology reception to collect • Large pink specimen collection bags How will this be sustained /the specimens. This equates to a were purchased and distributed to potential for the future/saving of approximately nine days or all sample taker practices and clinics. additional learning?110 miles a year. • Sample takers were instructed by • The practice of separating cervical letter and at meetings to use the cytology samples from other pink collection bags exclusively for pathology samples and having themUnderstanding the problem cytology work. delivered directly to the department• During their ‘walk the process’, the • Cytology samples contained in pink has worked well since its core team observed large volumes of sample bags could easily be seen introduction and has now become pathology specimens being delivered amongst the rest of pathology the normal practice. in large specimen transport bags to specimens which made the sorting • The successful use of dedicated main pathology reception. out process much quicker and cervical cytology specimen bags has• Specimens were sorted by one efficient. been noted by other pathology member of reception staff into • Drivers were later instructed to keep departments and is likely to lead to appropriate boxes for the different pink bagged samples separate from the introduction of dedicated pathology disciplines. The process other pathology specimens during specimen collection bags in other was laborious and occasional collection and asked to deliver them pathology disciplines. mistakes occurred as it was not straight to the cytology department. always clear to the person doing the Contact sorting which discipline the Measurable outcomes and impact David Smith specimen belonged to. • 90% of cervical cytology samples Email:• Pathology reception is located on delivered directly to cytology the opposite side of the hospital to department resulting in a reduction the cytology lab. An MLA from of between 0.1 – 2.5 days in the cytology spent up to 15 minutes TAT for these specimens. walking back and forth to collect • MLA staff saved approximately 50 specimens. On arrival, the staff minutes walking time per day. This member usually waited until all equates to a saving of approximately specimens were sorted in case any nine days and 110 miles a year, cytology work was in the bags allowing more effective and recently delivered. This was done up productive use of MLA time around to five times a day five days a week. the department.• Waiting and transport waste were • MLA staff are happier. clearly identified by core team members.
  23. 23. 24 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 5Reducing the backlogNorfolk and Norwich University Hospital NHS Foundation TrustSummary • Stopped checking of previousThe Norwich laboratory processes and computer system and addingscreens over 60,000 samples per year numbers by office staff, as it wasand is pilot site for HPV testing. By not used anymore.applying Lean methodology to remove • Stopped writing management advicewaste and improve the flow of work on green forms.we were able to: • Stopped ‘special attention’ stamping• Remove the backlog of screening of abnormal results. samples.• Take in-house additional screening Measurable outcomes and impact: whilst coping with a 48% increase By February 2009 the lab had data to in demand (February 2009). demonstrate:• Still achieve 97% meeting the 14 • 10.5 days average receipt in the lab day TAT by July 2009. to issue TAT with a range 2-22 days maximum.Understanding the problem • Backlog reduced from 4,000 to 655In October 2008 the lab faced the by (February 2009).following situation:• A backlog of over 4,000 samples An increase in demand in February with some being set out for 2009 took the backlog back to over screening to another site. 5,000 by the first week in May 2009.• 24 day average for receipt to authorisation turnaround times (TAT) By continuing with the changes with a range of 2-44 days. already made and introducing others by August 2009 the lab couldSPC charts provided the evidence to demonstrate:demonstrate the waiting at each step • Backlog of less than 500 by Augustof the pathway. 2009, representing only two days work.To achieve the goal of 100% in 14 • 7.4 days average receipt to labdays changes had to be made across issues TAT with a range of 2-16the whole pathway, with the support days (July 2009).of a multidisciplinary team of staff • All work is now screened in-houserepresenting the whole pathway. and the lab is in a position for other work.How the changes wereimplementedUsing the Lean tools gained from Norfolk and Waveney - Receipt to authorisenational events and on-site training,small changes were made to theprocess and SPC charts were used tomeasure the benefits.The changes implementedincluded:• Stopped re-screening of abnormal samples if they had already been seen by checker screening trainees work.• Removal of excess checking of ‘open exeter’, to stop over-processing.• No hard copy reports were printed for some GPs (who requested no paper copy) eliminating over-
  24. 24. Cytology improvement guide - achieving a 14 day turnaround time in cytology 25 Norwich backlog data How will this be sustained/ potential for the future/ 6000 additional learning? By reducing the backlog staff have 5000 seen several benefits including: Number of slides waiting • Screening staff comment that they 4000 no longer feel under pressure to do more all the time. 3000 • Clerical staff have freed up time by 2000 reducing non-value adding activities to enable them to concentrate on 1000 the parts of their job that add value to the process. 0 • There is now the potential for taking in work from other laboratories in 0 1 k9 1 k1 /12 2 k1 /01 1 02 02 k2 /03 k2 /03 k2 /03 04 k3 /04 05 k3 /05 k3 /06 06 k4 /07 07 8 0 W 7 /1 W 0 /1 W /1 W 2/1 k1 /0 /0 W 3/1 W 02/ W 16/ W 13/ W 11/ W 22/ W 20/ 24 8 5 W 19 W 02 W 16 W 30 W 27 W 25 W 08 W 06 03 the area still struggling with 2 1 2 1 3 k3 k5 k7 1 k1 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 k1 k1 k2 k2 k3 k3 k4 W W W backlogs as a result of the increased demand. ContactIdeas tested which were successful • Introduced bar-code readers in Carol Taylor• Stopped linking of old Sunquest. screening to eliminate the over- Email: reports, saving approximately one labelling of slides with patients hour/person/day. name which has released office• Bell to alert porter, office staff time time, saved money on labels/printing saved approximately one hour per and prevented slides waiting before day. going through for screening.• Accepting pre-printed HMR forms • Lab introduced letter informing saves time on phone calls and stops sample senders of out of scope sample processing delays. samples to reduce inappropriate• Call/recall centre advising lab of demand. wrong recall by email and phone • PCT core team member re-enforced call. Changes made and re-sent non-acceptance of out-of scope electronically. This has removed samples by letter in GP magazines paper, cut down TAT by 24 hours and by writing to GPs separately. and saved lab staff time.• Each screener now has their own PC How this improvement benefits to enter results etc, so eliminating patients the waste of waiting to use a piece Over 60,000 women in the Norwich of equipment. area can now expect to receive their• Day books were eliminated (over results within 14 days of the sample processing) saving time for more being taken. screening and allowing the screening of five extra slides per day per screener.• Screeners doing their own slide filing has released ½ a days time in the office.• Infection information is now circled and not written on forms, again removing the waste of overproduction.
  25. 25. 26 Cytology improvement guide - achieving a 14 day turnaround time in cytologyCase study 6Moving the fridge reduces walkingThe Leeds Teaching Hospitals NHS TrustSummary then back across the room to the Three of these changes released timeWaste of motion reduced. 123.7 miles coverslipper. A bowl was placed in the sample preparation area. Aof walking per year has been removed, between the prepstain and the timetable has now been devised thatequivalent to 8.25 working days of coverslipper for this purpose. enables 12 runs per day (576 samples)capacity now available for other Area 4 to be processed daily which meets theduties. Rapid pre-screening results were current demand and enables samples entered onto the computer in the to be processed on the same day orUnderstanding the problem cytology office and the forms then the day following receipt in the• The core team walked the pathway returned to the screening room. These laboratory. from the time a cervical cytology are now entered onto the computer in sample was received at specimen the screening room The time saved in area 4 (pre- reception to the time the result screening) releases time for the letter was sent out by the screening Measurable outcomes and impact office staff to register samples. agency and produced a value stream • Area 1 (stock room). A saving of map. 16,048 yards/year (38% decrease How will this be sustained/• During the walk, two initial areas of in time). potential for the future/ waste which could be reduced were • Area 2 (fridge). A saving of 76,365 additional learning? identified - distance from fridge to yards/year (100% decrease in The building housing the current lab and distance from stock room to time). accommodation is to be closed. lab. • Area 3 (bowl). A saving of 79,685• Process sequence charts were yards/year (4% decrease in time). Lessons learned from the service produced detailing all steps of the • Area 4 (pre-screening). A saving of improvement journey will inform process. 45,653 yards/year (15.5% planning the layout of the new• The time taken and distance decrease in time). accommodation. Awareness of waste travelled at each step of the process • A total saving of 217,751 yards or due to travelling time has been raised, was recorded. 123.7 miles per year, the and the team will aim to minimise• By looking at the process sequence equivalent of 4.72 marathons travelling distances further in their charts we identified two more areas • At a walking pace of two miles per new accommodation. in the lab where waste in the form hour these changes have released of motion could be reduced - 8.25 working days of capacity for Standard operating procedures have distance from prepstain machine to other duties i.e. more processing been updated to reflect the changes sink and distance from screening time to help achieve our targets. implemented. room to office for prescreening sheets. How this improvement benefits Contact patients Hazel EagerHow the changes were These savings will help to improve the Email: Hazel.Eager@Leedsth.nhs.ukimplemented turnaround time of all cervical cytologyArea 1 samples.The gynaecology consumablesstockroom was moved to a roomnearer to the preparation laboratory. Distances travelled per day pre and post changesArea 2 500Samples waiting processing were 450 432stored in a cold room in the specimen Pre change 400 Distance in metresreception area which was 69 metres Post changefrom the laboratory. A refrigerator 350was placed in a room adjacent to the 300 276preparation laboratory. Samples were 250stored there until the backlog of 200 174samples to be processed was removed 154and storage was no longer required. 150 100 94Area 3At the end of processing on the 50 36 0 9prepstain machines, trays of samples 0were carried to the sink across the Area 1 Area 2 Area 3 Area 4room to tip off the excess alcohol Area of