Service improvement in blood sciences

NHSNHS Improvement

Diagnostics

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

Service improvement in blood sciencesNHS Improvement - Diagnostics

January 2013

How to improve quality, delivery andefficiency for laboratory providers andtheir customers

Clinical excellence in partnershipwith process excellence”“

Matching your capacity and demandsupports improved turnaround timesand improves staff morale.

1. Foreword

2. Executive summary

3. Introduction

4. Waste

5. Sites

6. Start with the end in mind

7. Pre pre-analytical stagePathology transport reconfigurationChesterfield Royal Hospital NHS Foundation TrustIntroduction of coloured transport bags in pathologyChesterfield Royal Hospital NHS Foundation TrustDecreasing the rejection rate for transfusion blood samplesTaunton and Somerset NHS Foundation TrustEmergency department diagnostics improvementDerby Hospitals NHS Foundation TrustHaematology clinic changes to support patient experience and improve flowChesterfield Royal Hospital NHS Foundation TrustStreamlining day surgery admission to improve group and screen result turnaroundTaunton and Somerset NHS Foundation Trust

8. Pre-analytical stageHow Lean improvement enabled us to save time and money in blood transfusionTaunton and Somerset NHS Foundation TrustReduced checking at booking-in improves detection of defectsTaunton and Somerset NHS Foundation TrustReducing turnaround times for urgent samplesDerby Hospitals NHS Foundation TrustUsing data to manage staffing levels within blood sciences pre-analytical sectionChesterfield Royal Hospital NHS Foundation TrustUsing visual management to improve communication and ways of workingChesterfield Royal Hospital NHS Foundation TrustUsing standard work and 5S in specimen reception to create a standardised, clean and safe work environment allowing staff to perform optimallyChesterfield Royal Hospital NHS Foundation TrustPathology outpatient process improvementsDerby Hospitals NHS Foundation TrustBlood sciences pre- analytics pathway improvementsChesterfield Royal Hospital NHS Foundation TrustUsing data and team problem solving to improve sample TATBolton NHS Foundation Trust

Contents

Service improvement in blood sciences: How to improve quality,delivery and efficiency for laboratory providers and their customers

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9. Analytical stageChanged priorities in the laboratory to deal with samples from same day surgical admission patients – analyser set-up and method of validationTaunton and Somerset NHS Foundation TrustReducing the turnaround times for haematology clinic by reducing the time taken from a result being available to authorising a result that requires a peripheral blood filmChesterfield Royal Hospital NHS Foundation Trust5S of cold room at DerbyDerby Hospitals NHS Foundation TrustDemonstrating how Lean work cells deliver faster turnaround times, higher productivity and efficiency, increased flexibility, improved space utilisation and improved qualityPath LinksCrossing disciplinary boundaries improves transfusion safety for day surgery patientsTaunton and Somerset NHS Foundation TrustPositive clinical benefits of improvement work in a transfusion laboratory: a clinician’s viewTaunton and Somerset NHS Foundation TrustThe relationship between patient flow, patient safety, labour cost and the contribution of laboratory sciences to appropriate patient careThe Health Foundation, South Warwickshire NHS Foundation Trust

10. Post-analytical stageImplementation of a visual system to improve patient turnaround time in A&EBolton NHS Foundation TrustCustomer engagement and use of data to reduce defectsBolton NHS Foundation TrustCard viewer access for outpatient departments and health centresBolton NHS Foundation TrustReducing paper reports from laboratory medicineBolton NHS Foundation Trust

11. Post post-analytical stageUsing data and customer engagement to identify and eliminate defectsBolton NHS Foundation TrustJoint problem solving to reduce total patient turnaround time in A&EBolton NHS Foundation TrustIntroduction of a new test code which removed the need for extra courier pick-upsBolton NHS Foundation TrustSeminar sessions for the orthopaedic department at a walk-in centreBolton NHS Foundation Trust

12. End with the start in mind

13. Contacts

14. References and additional information

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Foreword6

Pathology services lie at the heart of healthcare services. The vision for the NHS pathology services puts patients first by providing services which are:• clinically excellent;• responsive to users;• cost effective; and• integrated.

Two thousand and twelve/thirteen is the second year of the Quality, Innovation, Productivity, Prevention (QIPP)challenge and this document demonstrates how clinical teams have taken up this challenge to improve services for patients and users of the service.

In addition, the NHS Operating Framework 2012/13 highlights five domains, of which four are important for blood sciences.• Domain 1: the reducing of premature mortality from the major causes of death. Blood sciences services have a significant role in providing effective screening for cardiovascular, respiratory and liver disease.

• Domain 2: requires improvements in health-related quality of life for people with long-term conditions , such as diabetes. By using innovative approaches to service delivery, blood sciences has a significant role to play in the monitoring of patients with long-term conditions.

• Domain 3: involves support for helping people to recover from episodes of ill health or following injury. Blood sciences services have a significant role in providing timely results for emergency admissions for acute conditions.

• Domain 4: obliges all NHS organisations to actively seek out, respond positively and improve services in line with patient feedback.

The sites have demonstrated the need to focus on and measure the whole end-to- end patient pathway highlightedin the Lord Carter review¹, demonstrating the importance of user engagement, the impact this can have onappropriate testing and the need for user education in correct sample taking. The need for clinical and managerialleadership is fundamental to achieving continuous sustainable improvement and the integration of pathologyservices within clinical pathways.

The robust approach to improvement undertaken can be demonstrated in all eight descriptors of the new NHSChange Model launched by the NHS Commissioning Board.

The Department of Health (DH) Pathology Programme is very pleased to support the work of NHS Improvement todemonstrate how these improvements can be achieved using Lean methodology. We commend this guide to all commissioners and providers of blood sciences services.

Dr Ian Barnes Mr David HamerNational Clinical Director for Pathology National Clinical Lead for Blood SciencesDepartment of Health NHS Improvement

Foreword

7Executive summary

In 2006, the Review of PathologyServices in England by Lord Carterendorsed Lean as the method ofchoice for improving processes. . Working in partnership with the DHPathology Programme, NHSImprovement has supported anumber of blood sciences teams, tolearn how Lean methodology canenable the service to achieveimprovements to support the QIPPtransformation programme. Multidisciplinary teams workedcollaboratively to test and implementchanges that deliver improvementsfor patients, staff and users of theservice.

In 250 NHS laboratories in England,500 million biochemistry and 130million haematology tests(2) arecarried out per year. Ninety fivepercent of all clinical pathways relyon a patient having access toefficient, timely and cost-effectiveservices.

As a result the impact on patients issignificant, with improvements in:

Quality and safety • working with service users to achieve ‘right first time’ - addressing errors in sample labelling and requests;

Innovation • using Lean techniques to improve the flow of samples and reduce turnaround times (TATs), introducing technology to aid timely clinical decision making; and

Executive summary

Productivity • reducing inappropriate demand by ensuring users are educated to request the appropriate test correctly

• matching capacity to demand, and ensuring the appropriate use of staff skills

• removing waste from process flowsto increase productivity and timely delivery, reduce cost and space requirements.

Lessons learnedThree important lessons have beenlearned in piloting and prototypingLean thinking in blood sciences.

1. Lack of a consistent standardand approach to end- to-endsample pathway measurement.

Working with a variety of clinicalteams has shown an inconsistentapproach to the end- to- end samplepathway measurement. A similarfinding was made during themicrobiology improvementprogramme.

A review of current guidanceincluding Royal College of Pathology,Keele Benchmarking, ClinicalPathology Accreditation (CPA) andthe Lord Carter Review of PathologyServices 2006/2008 identified a lackof consistent approach tomeasurement of the blood sciencespecimen pathway. The recent RoyalCollege of Pathology keyperformance indicators (KPIs) havenow been specified as the time ofcollection, to completion andconfirmation of the test resultavailable to the requestor. Similarly,they have identified the need tomeasure the blood sample for A&E as follows.

Baseline. Percentage of coreinvestigations, i.e. renal function, liverfunction tests and full blood countsfrom A&E completed within one hourof receipt, including out–of- hours.This standard will move to one hourfrom sample collection by April 2015.Challenge. Eighty five per cent byApril 2012 increasing to 90% byApril 2014.

Executive summary8

RecommendationMeasure end-to-end sample pathwayFollowing recent changes towardsoutcome based healthcare and newand timely KPIs from the RoyalCollege of Pathology, we recommendthe blood sample specimen pathwayshould be measured from the timethe sample is taken, until a result isavailable for the clinician to act on.

Key measures across the pathwayinclude:• date and time the specimen is taken;

• date and time the specimen arrives in the lab; and

• date and time the result is availableto the clinical user.

Pathology teams should collect thisdata and educate patients and usersto provide details of sample timings.

2. Process and wider systemchanges are required to supportend to end pathwaymeasurementMuch of the pre-analytical phase iscurrently invisible to the laboratoryand pathology laboratory informationsystems (LIMS) and processes do notsupport measurement of the end- to-end pathway. Teams have beenrequired to resort to lengthy manualdata collection or local adaptation ofinformation systems to demonstratebasic end- to -end sample pathway.

The recent document ‘First steps inimproving phlebotomy: the challengeto improve quality, productivity andpatient experience’ (May 2011)demonstrates the delays in eachstage of the blood sample pathway. Ifpathology teams are to supportsignificant changes in clinicalpathways to deliver:• reductions in admissions for emergency care;

• reductions in length of stay; • redesign of outpatient services; and • innovative approaches to supporting long term conditions.

It is vital to study the whole end- to-end pathway, as this will highlight theimportance effective pathologyservices are as an enabler ofredesign, rather than a burdensomecost centre.

RecommendationPathology LIMS providers arecommissioned / required tosupport the changing landscapeto allow a patient- focussedapproach to information acrossthe patient pathway. Pathology teams should collect thisdata and educate users to providedetails of ‘sample taken’ timings.

9Executive summary

3. Face-to-face user engagementis essential to enable laboratoriesto engage and educate users toensure:• appropriate testing to defined and agreed protocols, reducing inappropriate demand;

• education of users to get the best from blood sciences wealth of knowledge;

• a ‘right first time’ approach to highquality specimen collection, requestand specimen labelling, to improve safety and eliminate the opportunity for error; and

• transportation of the sample is frequent, rapid and ensures the shortest turnaround times to facilitate rapid clinical decision making, with pathology services taking an active role in the management of all transport provision.

RecommendationBlood sciences works inpartnership with users to providevisible access to agreed protocolsfor tests and to educate users.A ‘right first time’ approach isencouraged and endorsed bycommissioners, clinical teams andusers to ensure safety and efficiency.

Key elements to bring aboutchangeLearning from other improvementinitiatives in pathology services hasconfirmed the five key elements likelyto bring about substantialimprovements in the pathway.

1. Focus on the whole end to end pathway• Ensure all staff in the pathway understand up and downstream processes and how their own work impacts others.

• Use whole pathway data (from sample taken to result available) to understand how samples, forms and results flow and identify bottlenecks and waiting.

2. Adopt small batch sizes• Throughout the entire pathway - waiting to ‘fill’ equipment causes samples (and therefore patients) to wait.

3. Keep specimens movingDaily throughout the day, withmultiple deliveries from source ofspecimen.• Pull work through the laboratory.• Continuous authorisation of results.

4. Establish ‘first in, first out’• No prioritisation of specimens.

5. Appropriate testing• Work with users to design protocols and systems to support appropriate test requesting.

• Develop acceptance policies that specify information and data quality requirements.

This learning guide provides bloodsciences teams with the basic tools tomake changes to their processes,along with insight into howcolleagues have used these toolsacross the whole patient pathway.

Introduction10

Pathology services are faced withincreasing demand and pressure toreduce costs whilst improving andmaintaining clinical safety andquality. Traditional cost cuttingmethods including staff reductionfail to deliver the required savingsbecause fewer staff are left withthe same processes.

A Lean management systemdelivers reductions in error ratesand waiting times, together withincreases in productivity.Application by healthcareorganisations across the world hasimproved outcomes for patientsand reduced the cost of care at thesame time.

NHS Improvement has worked withmultiple teams across pathologydisciplines to evidence the value ofLean methodology.

Application of Lean tools enablesimprovement of isolated processesbut the impact of one-offimprovement efforts of this naturecan be short lived. It is only whenclinical leadership and operationalmanagement changes sufficientlythat an organisational culture ofcontinuous improvement can beachieved.

The NHS Commissioning Board hasrecently launched the NHS ChangeModel.

The model brings together familiarelements of any successful changeprogramme and is designed to ensurethe NHS can meet the challenge ofthe pace and scale of changerequired to meet future financialconstraints and improvements inquality.

Introduction

The key to the Change Model is notthe individual components butensuring all are addressed equally aspart of any improvement effort.

“By doing that, we’llamplify and reinforce ourability to drive change.We’ll take the skills we’vealready got, and takethem to the next level inbeing able to makethings happen.”

• Our shared purpose: patient experience is at the heart of what we do and drives change.

• Leadership for change: to create transformational change.

• Engagement to mobilise: understanding, recognising and valuing individuals’ contributions.

• System drivers: QIPP, CQinns, NHS Operating Framework.

• Transparent measurement: measurement for improvement andpatient outcomes.

• Rigorous delivery: project management, PDCA cycles and measurement of benefits.

• Improvement methodology: Lean, capacity and demand, value and process mapping.

• Spread of innovation: using shared learning via multi-media techniques.

Ourshared

purpose

Leadershipfor change Spread of

innovation

Engagementto mobilise

Systemdrivers

Improvementmethodology

Rigorousdelivery

Transparentmeasurement

The NHS Change Model

11Introduction

The programme of improvementpredates this model. However, it can be demonstrated that NHSImprovement’s approach insupporting clinical teams hasaddressed each of the eightelements of the model which shouldbe at the centre of any improvementeffort whether localised to a singledepartment or at national scale.

Lean management is not simply an’improvement methodology’ asdescribed in the Change Model. Leanaddresses all areas and providesteams with a checklist for continuousquality improvement.

Exemplar programme and ShingoassessmentThe majority of the case studies inthis document come fromlaboratories that are part of the NHSImprovement pathology exemplarsite programme commissioned by theDH Pathology Programme Board. Theaim of the programme is to establishand support a network of pathologylaboratory exemplar sites who willdemonstrate continuous qualityimprovement (CQI) in clinical, processand business excellence.

Site assessments All pathology disciplines within theexemplar sites will carry out self-assessments supported by NHSImprovement, based on theinternational Shingo Standards forBusiness Excellence. The assessmentswill be made against criteriademonstrating:

• leadership and cultural enablers;• continuous quality improvement;• organisational alignment; • understanding the needs of customers; and

• business results.

www.shingoprize.org/model-guidelines.html

Leadership for changeLeadership is behaviour –

“What we do as leadersis more important thanwhat we say.”

Sir Nigel Crisp

One element of the new NHSChange Model is Leadership forchange. The narrative supportingthis asks, “do all our leaders have theskills to create transformationalchange?”

Lean is the term popularised byWomack and Jones to describe amanagement system derived fromthe Toyota production system (TPS)that has been adapted andsuccessfully applied nationally andinternationally to a wide variety ofindustries including healthcare forover 20 years.

Why, when it seems so simple doLean initiatives often fail to sustain?

John Toussaint, CEO Thedacare,Wisconsin, USA, a healthcareorganisation that slashed errors andimproved patients outcomes, raisedstaff morale and saved $27m in costswith no lays offs, sums it up asfollows:

“In the end the enemy ofour improvement effortswas us. Leadership wastreating eachimprovement initiative astime limited, a finiteproject conducted by afew members of staff orconsultants.Improvements endedwhen a project was overbecause nobody was incharge of sustainingchange and measuringresults.”

Introduction12

Finding change agents Achieving a culture shift starts with asmall team working collaborativelywith their department colleagues andusers to improve identified areas ofthe process.

Identify a credible and respectedproject lead to head up this team.Look for a clinician or manager withthe drive and enthusiasm to steerchanges across the patient pathway.

Project team members should bedrawn from across the entirepathway:• clinical colleagues who will actively commit to the improvement effort;

• laboratory representatives for each job grade;

• administrative /office staff representative;

• porters/ transport staff; and• user involvement – member of a patient group and a high volume user – from primary care, ward or clinic.

Core team members mustunderstand the process within theirstage of the pathway and be:• able to contribute ideas/information on the process;

• able to influence the decision making process;

• prepared to test and implement changes across the pathway; and

• committed to attend all team meetings, activities and work required between meetings.

Escalation planningAn executive sponsor is essential toprovide proactive support and accessto relevant support services such asestates and transport, HR, financeand IT teams. They may be calledupon to escalate key issues.

“In order to changeoutcomes, leaders atThedacare needed tochange”(3)

Continuous improvement can, andwill, only occur if the people whoactually do the work are activelyengaged and understand Lean andtheir leaders change.

Literature evidences that there arekey behaviours that leaders andmanagers need to adopt in order todevelop a sustainable Leanmanagement system.

Developing a Lean cultureCulture change takes time andrequires leadership. A great manymodels and theories exist to guidethose wishing to develop their ownleadership capability and approach.

Key steps to influencing the creationof a lean culture include:• find change agents;• get Lean knowledge;• seize crisis;• map the value stream;• remove waste;• continuous improvement; and• sustain.

A Lean culture could be described asone where managers at every levelgo to the workplace and coach theirstaff in plan, do, check, act (PDCA)problem solving. A continuousprocess that is part of ‘the way weoperate here’.

13Introduction

Engagement of your staffWhat is engagement?Another element of the new NHSChange Model is engagement tomobilise – are we engaging andmobilising the right people?There is no single answer but themesof commitment, involvement,communication and energy are clear.

“Employees who workwith passion and feel aprofound connection totheir organisation. Theydrive innovation andmove the organisationforward.”

Meere(4)

“Employee engagementis about translatingemployee potential intoemployee performanceand business outcomes.”

Melcrum(5)

It is well-established that change isdifficult for most people. It is theresponsibility of leaders to listen andunderstand individual perspectivesand concerns creating anenvironment of open and honestcommunication.

How engaged are we?An engagement surveying tool hasbeen developed and is available atwww.improvement.nhs.uk/improvementsystem to enablemeasurement and to motivateleaders at all levels to take action onresults and improve their ownleadership capability.

The 10 questions are based on thework of the Gallup organization,Marcus Buckingham and CurtCoffman published in First, Break allthe Rules.

CommunicationEstablishing the framework for, andmaintaining, good two waycommunication is critical to thesuccess and sustainability of anyimprovement activity.

Daily meeting - huddlesAn important mechanism forengaging staff is huddling.A huddle is a daily, short and snappyface to face gathering of a team,preferably standing around aperformance board that addressesthe following.

1. Focus – on key goals andresponsibilities for the day.2. Clarity – clear, relevant and timelyinformation to help staff performtheir daily roles. 3. Commitment – listen and act onstaff views, ideas, and concerns andto feedback progress.

When huddles are first introducedthey may feel strange anduncomfortable for some people.Participation is likely to come fromthe same small group of individualsand so other mechanisms for elicitinginput and views from the whole teamcan be used to support efforts tocreate an environment where all arecomfortable to speak up.

Suggestions boxes / boardsProvide an outlet for staff to makeanonymous comments, niggles andsuggestions. Share comments at thedaily huddles and provide either aninstant response or agree a timescalefor investigation and feedback.

1-2-1sSpeak privately with individualswhere necessary to make it knownthat their views and concerns areimportant. Ask their permission toraise their issues at daily huddles forfurther discussion.

After a period of time (which will bedifferent for each team depending onthe starting point) use of suggestionboxes and boards should diminish asthe daily huddle becomes the focusfor raising, discussing and resolvingissues.

Daily meetings can (and should) be aformal part of department operationsand minuted accordingly. The needfor formal laboratory meetings willreduce and may be eliminatedaltogether.

More supporting information isavailable at:www.improvement.nhs.uk/improvementsystem

Waste14

Waste

Every process has waste. Thefoundation of Lean is the relentlesspursuit and elimination of waste in all work activities.

When we look at a process as a timeline of activities, material (samplesand consumables) and information(request cards and reports) whetherin a value stream map or a processsequence chart, we see a significantpercentage of waste. Usually inexcess of 90% of a sample journey istaken up by wasteful, non-valueadding activity.

Some steps in the current process willbe pure waste (see below), otherwaste may be necessary within thecurrent way of working. For example,in many blood sciences laboratories,the need to centrifuge samples ortransport samples to, or between,laboratories is currently necessarywaste.

Improvement initiatives should focuson eliminating the pure waste andreducing the necessary waste.

A simple mnemonic exists to aidrecall of the nine wastes.

T TRANSPORT

INVENTORY

MOTION

AUTOMATING

WAITING

OVER-PRODUCTION

OVER-PROCESSESING

DEFECTS

SKILLS UTILISATION

I

M

A

W

O

O

D

S

Material or information that is movedunnecessarily or repeatedly e.g. Unnecessarymovement of samples between work areasor laboratories.

Excess levels of stock in cupboards / storerooms; batches of specimens waiting tomove to next step in process.

Unnecessary walking, moving, bending orstretching e.g. equipment placed in wronglocation, unnecessary key strokes.

Where technology is substituted tocompensate for a poor process. For exampleanalytical track systems which are purchasedwithout the right process being agreed,tested and established. In some casesresulting in ‘urgents’ being taken off the‘track’ because it’s too slow.

Waiting for specimens, equipment, and staff.Samples waiting to move to the next stageof the process.

Producing something before it is required, ormore than is required e.g. unnecessary orinappropriate tests; batching specimens,tests and information; ‘just in case’ bloodtubes drawn from patients, but not used.

Duplication of data e.g. Dual data entry,repeat testing, additional steps and checksthat add no value to the process.

Errors, omissions, anything not right firsttime e.g. Poorly labelled specimens andrequests, insufficient or illegible information.

Unused employee skills e.g. Highly qualifiedstaff performing inappropriate tasks; staffideas not being considered.

Type of waste Laboratory examples

(inefficient processes)

Waste costs money and adds time

15Sites

Sites

This document shares learning from anumber of clinical teams from threesites who have been working withNHS Improvement and three siteswho have independently undertakena Lean improvement journey.

NHS Improvement sites

Derby Hospitals NHS FoundationTrust, Royal Derby HospitalBeginning in November 2011, theDerby blood sciences team have beendeveloping a Lean culture whichstarted in specimen reception andsubsequently spread into the bloodsciences laboratory and the A&Edepartment.

Chesterfield Royal Hospital NHSFoundation Trust Beginning in October 2011, theChesterfield blood sciences teamhave been developing a Lean culturewhich started in specimen receptionand subsequently spread into theblood sciences laboratory, thespecimen transport system and thehaematology clinics.

Taunton and Somerset NHSFoundation Trust, Musgrove ParkHospitalThe blood transfusion team atTaunton have been developing a Leanculture which has spread from thecytology laboratory and specimenreception functions to the surgicaladmissions lounge and operatingtheatres.

Working with blood sciences teamsacross these sites to further evidencethe value of Lean thinking, NHSImprovement provided training in theuse of Lean thinking to support staffto redesign the way services aredelivered, to achieve processexcellence to support the clinicalexcellence within the laboratory andin turn improve the user’sexperience.

The approach required localownership and leadership if theimprovement was to be sustained,underpinned by the training of allmembers of the team in Leanmethodology.

Clinical teams were encouraged tovisit other exemplar sites to observeLean methodology as part ofeveryday working and understandhow improvements have beenachieved.

Independent sitesThese sites were selected to reflectthe importance of a long termsustainable approach toimprovement, where the learningnever ends, and the service isconstantly looking to pursueperfection.

Bolton NHS Foundation Trust,Royal Bolton HospitalThe team at the Royal Bolton Hospitalstarted their Lean journey in bloodsciences in 2005-6. They haveprovided support to the NHSImprovement sites through hostingexemplar site visits. Recognition oftheir sustainable efforts was achievedin the HSJ Award for Efficiency inSeptember 2012.

Northern Lincolnshire and GooleHospitals NHS Foundation Trust Path Links is a single managedClinical Pathology Network operatingacross Lincolnshire. Formed in 2001from the amalgamation of NHSservices in Boston, Grantham,Grimsby, Lincoln, and Scunthorpe,Path Links is a directorate within thediagnostics and therapeutics division.

Standardisation of blood sciencescommenced in 2009 culminating inthe successful implementation of pre-analytic and analytical lean work cellssupported by multi-discipline trainedstaff. The introduction of standardwork and A3 SOPs has resulted inimproved quality, increasedproductivity and reduced costs.

South Warwickshire NHSFoundation TrustThe South Warwickshire team waspart of a hospital wide approach toimprovement sponsored as a threeyear work programme by ‘The HealthFoundation’ to examine therelationship between emergencypatient flow, mortality and cost.

Sites and leads

Derby Hospitals NHSFoundation Trust

Chesterfield Royal Hospital NHS Foundation Trust

Taunton and Somerset NHSFoundation Trust

Bolton NHS Foundation Trust

North Lincolnshire and GooleHospitals NHS Foundation Trust(Path Links)

Laboratory Lead: David SimpsonClinical Lead: Dr Nigel Lawson

Laboratory Lead: Christine AingerClinical Lead: Roger Start

Laboratory Lead: Matt BarnettClinical Lead: Dr Sarah Allford

Laboratory Lead: David HamerClinical Lead: Gilbert Wieringa

Laboratory Lead: Martin Fottles,Continuous Improvement ManagerClinical Lead: Dr David Clark

Start with the end in mind16

The often-asked question inimprovement work is, ‘where do we start’?

There is no simple answer, it dependson what are your biggest issues;what is your burning platform?

How will you know what these are? Sometimes this is obvious, fromknown failings in your systems, orimperatives set by your executives orcommissioners. However, withoutthree fundamentals in place you areunlikely to be in a position to applythe right improvements in the rightplaces. These three fundamentals are:

• looking at the end-to-end processes in your service (from decision to test to provision of interpreted result);

• collecting data to inform exactly what is happening as a baseline and understand what needs to improve; and

• engaging with the customer (patients and their clinical teams) tounderstand their needs and what value you can add to them (the true ‘end in mind’).

In the following chapter and casestudies, you will see how thesefundamentals have helped drive andfocus the improvement work at allthe sites who have contributed to thislearning document.

Start with the end in mind

Since the publication of the secondCarter Report, there has been agrowing emphasis on Pathologyservices taking responsibility formanaging the end-to-end journey(i.e. from collection of sample todelivery of interpreted result,including transport and logistics –Carter Report 2008). This documenthas been constructed around the keystages in this end to end journey asfollows:

• Pre-pre analytical: clinician decision to test to sample delivery.

• Pre analytical: sample receipt to available to test.

• Analytical: availability to test to result available to view.

• Post-analytical: result available withcomments added to result, delivered and viewed.

• Post post -analytical: result interpretation and follow up testing.

There are opportunities for laboratoryservices to add value at each stage ofthis pathway.

Some of the Lean tools available lendthemselves to a particular part of thepathway, others are equally asvaluable across several or all parts ofthe pathway.

Similarly some of the case studiesoverlap the pathway sections and forease of inclusion we have tended toinclude case studies under the stagein which the journey starts.

All continuous quality improvementinitiatives should deliverimprovements in one or more keyareas, namely:

• quality e.g. reduced defects;• timeliness/delivery e.g.

improved turnaround times;• cost/value for money e.g.

removal of waste, reduction in inventory; and

• morale/staff experience/patientexperience e.g. reduced overburdening for staff, reduced waits for patients.

It is indicated before each case studywhich improvement parameter(s)they deliver by highlighting theappropriate box, together with theheadlines from the case study.

COST ORVALUE FOR

MONEY

MORALE,STAFF ORPATIENT

EXPERIENCE

TIMELINESSAND

DELIVERY

QUALITYAND

SAFETY

17. Pre pre-analytical stage

The start of the journeyThe clinician has a clinical questionand they require diagnostic input tohelp answer that question. Thelaboratory can influence and addvalue at this stage in a variety ofways, including advising on:• what to test for;• how to test;• when to test;• where to test; and• who performs the test.

Laboratory staff can educate clinicalstaff to understand the safest andmost effective way to collect, labeland despatch the required samples.

This may include providingphlebotomy services; assisting inimplementation of electronic orderingsystems; providing sample collectionand transport services/systems.

Pre pre-analytical stage

All of these opportunities to addvalue are dependent on:• laboratory staff engaging with theircustomers;

• listening to their requirements;• helping them solve their problems;• understanding what the customer values from the services on offer; and

• ensuring that value is delivered as efficiently and effectively as possible with minimum wasteful/non value adding steps.

The concepts highlighted in the casestudies in this section include:• user engagement;• use of order sets; and• communicating with users.

The tools illustrated include:• value stream mapping;• current and future state models;• identifying non value adding steps;• reducing defects; and• ‘go and see’.

PRE PRE-ANALYTICAL

CLINICAL QUESTION

GENERATE REQUEST

COLLECT THE SAMPLE

TRANSPORT THE SAMPLE

18


Pathology transport reconfiguration

SummaryThe trust’s transport serviceintroduced an ‘interceptor’ van,which has enabled samples to bedelivered to the laboratory morefrequently throughout the day,smoothing the flow to the laboratoryand reducing the number ofspecimens by 61% between 12:45and 1:15pm (the main lunch period).

Understanding the problemThe pathology transport service atChesterfield Royal Hospital providesa delivery and collection service ofinternal mail, pharmacy supplies andpathology samples to a mixture ofGP practices, community hospitalsand clinics. The service operates byemploying eight part time and onefull time van driver. At present theservice has five vans and does anaverage of 190 calls per day over fivevan schedules, which are split intomorning and afternoon runs.

A detailed audit of the bloodsciences pre-analytics processidentified two major peaks ofworkload arriving from GP andcommunity locations, so thepathology transport serviceexamined how they could contributeto improving the flow of workarriving into the laboratory.

The data collection revealed thenumber of samples arriving intopathology, along with number ofsamples on each van by the hour.

800

700

600

500

400

300

200

100

0

Tota

l nu

mb

er o

f sa

mp

les

186 214

330

686

110

546

335309

9am-10am 10am-11am 11am-12pm 12pm-1pm 1m-2pm 2pm-3pm 3pm-5pm 4m-5pm

Time

Data collection of when samplesarrived at the laboratory andestablishment of interceptor vanensured smaller batches of workwhich were delivered more often.

COST ORVALUE FOR

MONEY


EXPERIENCE

TIMELINESSAND

DELIVERY

QUALITYAND

SAFETY

500

450

400

350

300

250

200

150

100

50

0

Tota

l nu

mb

er o

f sa

mp

les

A B C D E

96

182 186

250

468

224

315

379351

381

Morning Afternoon

Total number of samples on pathology vans on 4 January 2012

Number of samples arriving by pathology van byschedule - January 2012

Key learningData collection of when samplesarrived at the laboratory andestablishment of interceptor vanensured smaller batches of workdelivered more often.

How this improvement benefitspatientsSamples arriving earlier in the day insmaller batches means that moresamples are received and processedon the day they were collected fromthe patient, so results are availablesooner.

ContactJoanne Dodsworth, Operational Services Co-ordinatorEmail:[email protected]

19

How the changes wereimplementedA team of representatives from thepathology transport service,pathology general and bloodsciences departments produced avalue stream map and process mapsof the service to identify key areasfor potential improvement. Three groups within the teamdiscussed the issues and the aims ofthis session were identified as:

• reduce the ‘peaks’ of samples being delivered to the laboratory; and

• resolution of community pharmacyissues such as controlled drugs, incomplete paperwork, and accessto the department.

An interceptor van was introducedto meet other van drivers at specificpoints along their routes, collectingsamples and returning back to thelaboratory more frequentlythroughout the day. The impact ofthis was monitored after severalweeks by repeating the hourly audit of samples arriving in thedepartment and comparing this tothe baseline data originally collected.

Measurable improvements and impactThe data analysis shows the impactof the introduction of the interceptorvan with a significant amount ofwork now being received earlierfrom the morning and afternooncollections, with 32% less samplesreceived in the morning and 1%increase in the afternoon on re-auditwhen compared to the baselinedata.

Positive feed-back from the samplehandling staff was received. They felt that the introduction of theinterceptor van meant that sampleswere arriving more often in smallerbatches.

Community pharmacyAfter discussions and e-mails withcommunity pharmacy the van drivershave noticed that the time waitingto access the pharmacy departmenthad reduced so that the length oftime waiting for controlled drugs hasalso reduced. The situation ismonitored through the departmentalmeetings.

All community pharmacy issues hadbeen resolved.

11.30-11.45

12.00-12.15

12.30-12.45

12.45-1.00

1.00-1.15

3.30-3.45

4.00-4.15

4.15-4.30

4.30-4.45

-800 -600 -400 -200 0 200 400 600 800

Before interceptor van After interceptor van

Daily deliveries

20


Introduction of coloured transport bags in pathologySummaryThe pathology departmentintroduced coloured transport bags,currently in use for 40% of GP userswith the remaining GP surgeriesusing the coloured bags by the endof 2012.

Understanding the problemThe pathology transport service atChesterfield Royal Hospital providesa delivery and collection service ofinternal mail, pharmacy supplies to amixture of GP practices, communityhospitals and clinics and pathologysamples are delivered to pathologyreception from these sites. The data collection identified thesample types arriving in pathologyreception.

• Multiple sample/mail collection points in practices/hospitals.

• Samples not ready for collection (bags not sealed).

• Van drivers queuing in-line with patients.

• No notification if surgeries closed for training etc. (therefore no collection required).

• Samples stored in un-manned areas.

• Incorrect sample storage (fridge/ room temperature).

• Many items collected are inappropriate items of mail, e.g. mobile phones.

How the changes wereimplementedA team of representatives from thepathology transport service,pathology general and bloodsciences departments identified keypilot sites to roll out the newcoloured transport bags. Initial meetings took place with sixGP practices.

This identified a ‘go-live’ date for thetrial of the new bags as 12 March2012, and it was recommended thatthe van drivers report anyconcerns/issues. The main focus onthis session was to review what thetransport service will accept withrespect to collections/deliveries.

Some users had also raised concernsover the changes to the new samplebiohazard bag, a guide was also sentout to help address issues.

The core team produced a guidancenotice from the operational servicesco-ordinator, along with a coveringletter, which was sent out to all usersof the transport service in April2012.

Measurable improvements and impact• Samples are now placed in the coloured sample bags, sealed and placed at the collection point.

• Inappropriate items of mail have reduced.

• Communication of surgery closures has improved.

Key learningThe introduction of a simple visualmanagement system has improvedthe communication with GPpractices and improved sampleintegrity.

How this improvement benefitspatientsSample integrity has improved assamples are stored appropriately andat the correct storage temperature.

ContactJoanne Dodsworth, Operational Services Co-ordinatorEmail:[email protected]

A simple visual management systemhas improved communicationsbetween the laboratory and GPpractices.

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1200

1000

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0

Tota

l nu

mb

er o

f sa

mp

les

Blood Urine Stool Swab Cytology Histology Nail clip Sputem Other

11001021

152188

13 1298 55 37 30 1 0 4 4 10 5 1 1

Morning Afternoon

Number and types of samples arriving by pathologyvan by schedule - 4 January 2012

21

Examples of new pathology transport sample bags

22

Taunton and Somerset NHS Foundation Trust

Decreasing the rejection rate fortransfusion blood samplesSummaryThe rejection of blood transfusionsamples due to the poor completionof the transfusion request formcaused delays in transfusionprocesses. Introduction of a newrequest form in two clinical areasreduced rejection rates from 15% to 1.8%.

Understanding the problemOne of the causes for delay in theavailability of group and antibodyscreen results for patients going totheatre was the number of samplesthat were rejected by the laboratorystaff due to the form beingcompleted incorrectly, increasing theworkload for clinical staff andcausing dissatisfied patients whomay have to be re-bled, or have theirsurgery delayed (especially if they arefirst on the operating list).

In September 2011, 15% of allrejected samples came from thesurgical admission lounge (SAL) and15% came from A&E. Other clinicalareas also were found to have highrejection rates. The analysis of thecauses for rejection indicated thatthe two main issues related to thedate of birth missing from the formand the form not being signed bythe doctor.

How the changes wereimplementedDiscussions were held with clinicians,including the anaesthetists andnursing staff to find out what werethe key obstacles preventing theforms from being completedcorrectly. This led to a redesigning of the blood transfusion requestform to allow the use of anaddressograph label which

contained the correct patient detailsand removing the requirement for adoctor to sign the request form.

The form was piloted for twomonths in two clinical areas, thehaematology ward as they are highusers and A&E department becauseof the high rejection rate. The SALwas not used as although they had ahigh rejection rate, only four staff onthe ward perform the phlebotomy.

Measurable improvements and impactIn the two months prior to the pilotover 15% of the rejected samplescame from the A&E Department.Overall rejection rates for Februaryand March were:• 6% for all samples; and• A&E – 10%.

During the pilot period 110 formswere completed. Only two formswere rejected.

Key learningEngagement with users andsubsequent redesign of the requestform has allowed the clinical andlaboratory staff to focus on thecritical information that is requiredwhen requesting blood componentsand transfusion related blood tests.

How this improvement benefitspatients• The reduction in the number of samples rejected means less repeating of samples and therefore less re-bleeding of patients.

• For those patients awaiting a blood transfusion, there is less likelihood of delay, especially for patients first on the operation list. This is also especially important forthose patients who need regular monthly blood transfusions.

How will this be sustained andwhat is the potential for thefuture?The next slep in the process is to roleout the new form across the wholeof the trust. This will be supportedby an implementation plan to ensurethat all relevant staff are aware ofthe changes.

Rejection rates will be monitored bythe transfusion staff and fedback tothe clincial areas with the highestrejection rates.

ContactAlison Western,Transfusion PractitionerEmail: [email protected]

Engagement with users andsubsequent redesign of the requestform has allowed the clinical andlaboratory staff to focus on the criticalinformation required.

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Derby Hospitals NHS Foundation Trust

Emergency department diagnosticsimprovementSummaryA thirteen per cent improvement inthe number of samples authorisedwithin one hour of collection as aresult of a clinical support workertrial, and the reduction of bloodtransport times by up to 15 minutesdue to re-prioritisation of pneumaticchute station.

Understanding the problemThe requirements set by the RoyalCollege of Pathologists, states thatby 2015, 90% of samples taken inthe emergency department(A&E)must have results available withinone hour from receipt in thelaboratory. Since the responsibilityfor achievement of this goal isshared between staff in thepathology laboratories and A&E, oneof the keys to understanding theissue fully, was to ’go and see’ whatactually took place in eachdepartment.

As a result of the ‘go and see’activity, the phlebotomy was seen to be delayed in triage due to thenature of the workload faced byspecialist nurses in A&E , since theyhave to respond more urgently topatient needs. There was often asubstantial discrepancy between’collection’ time as recorded on thecomputer system (when requestforms were printed) and actual timethe blood was taken, resulting inincorrectly recorded TATs.

Two of the laboratory staff went toA&E to observe the processes. Theyrecorded the times samples wererequested, the times samples weretaken, when the samples wereplaced in the pneumatic chute,arrived in the laboratory, were

booked in and when the resultswere authorised. It became apparentfrom these observations that thepneumatic chute sometimes heldpods filled with samples for up to 20minutes prior to sending them to thelaboratory.

Teams of staff from both thepathology laboratory and A&E metwith each other to discuss theproblems faced by each departmentwhen taking and processing blood,in an effort to help identify issueswhich could be solved quickly, andfor the most mutual gain. Bothteams gave tours of their respectivedepartments to each other, to helpgain some understanding of thepracticality of working in each area.

On observation of the workloadfaced by the specialist nursesworking in A&E, it was clear thatasking more of them, even for theimprovement of their processes,would be very difficult to implementand sustain.

Enquiries were made with theestates department, who areresponsible for the pneumatic chutesystem, to find out if there was anyway of reducing the time pods werewaiting to be sent to the laboratoryfrom A&E.

The importance of 'go and see' andunderstanding the end-to-endpathway reduces turnaround times,and improves communicationbetween departments.

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How the changes wereimplemented• Meetings were held between pathology and A&E staff. Some long standing issues on both sides were discussed, allowing a greater depth of understanding of the challenges each group must overcome on a daily basis. Bridges were built, allowing improved communication and an increased feeling of team spirit and empathybetween the two departments.

• One Plan, Do, Study, Act (PDSA) trial was carried out to determine the effectiveness of a clinical support worker in the emergency department to carry out all phlebotomy duties.

• It was discovered that the ’priority’setting on the pneumatic chute in the emergency department had been lost two years previously and no one had noticed. This was reinstated and reduced the maximum time pods were waiting to be sent from A&E to the laboratory from 20 minutes to five minutes.

Measurable improvements and impact• Pod priorities reinstated after being lost two years previously .

• 25% improvement in mean collection to receipt time during trial week.

• Average sample collection to receipt time improved from 75.75 to 57.07 minutes during trial week.

• 76% reduction in average moving range overall, showing a reductionin variability of sample transport times from A&E. Possibly attributable to increased awareness among staff.

• 13% improvement in number of samples collected and authorised within one hour.

• Average time from pods waiting tobe sent from A&E to the lab improved from 9.25 to 3.5 minutes or 62%.

• Formal and informal meeting and ’go and see’ activities improved vital communication betweenA&Eand the laboratory, with one advanced nurse practitioner stating: “Just knowing who to talkto about certain issues makes any problems that arise much easier toresolve quickly.”

• Phone calls reduced from A&E to the laboratory from six per day to six a week.

• The clinical support worker trial was perceived to reduce A&E specialist nurse workload. Although not formerly measured, staff simply said it meant they had one less thing to worry about.

Key learning• Properly defining the issue to be resolved and collecting relevant data in a consistent way is absolutely fundamental to the success of any improvement project.

• Leadership is the key. Without investing the time required to make and sustain effective improvement, nothing can change.

• Following the clinical support worker trial in A&E, no post has been put in place to make this permanent due to funding. All benefits must be weighed against their cost for improvement to be truly effective.

How this improvement benefitspatientsThis reduction in time taken totransport samples to the laboratorymeans faster results, fastertreatment and ultimately, fasterdischarge. Should the trial ever bemade a permanent post, thereduced workload on the A&Especialist nurses would allow moretime to provide patient focussedcare, rather than being focussed onturnaround times and targets.

ContactTom Kennedy, Specialist MedicalLaboratory AssistantEmail: [email protected]

Clinical Support Worker Trial

25


Haematology clinic changes to supportpatient experience and improve flowSummaryBy using the principles of ‘go-see’and ‘ask why’, haematology clinicchanges have improved the timetaken for samples to arrive in thelaboratory. These activities havegenerated multiple suggestions forfurther changes to improve thepatient experience of clinics.

Understanding the problemHaematology clinics for patients witha wide range of malignant and non-malignant haematological conditionsheld on Monday and Friday haveapprox. 35 patients booked in toeach clinic. Many of the patientsattend this clinic on a regular basisand many require chemotherapyand/or blood transfusion supportand so require recent blood testresults to enable the clinicians tomake treatment decisions and so themedical staff do not have aconsultation with the patient untilthis result is available. A fewpatients who attend the clinic havetheir blood sample taken sometimein the week before theirappointment either at the hospitalphlebotomy clinic or in thecommunity. The majority of patientshave their blood sample taken onthe day they attend clinic and thenwait for the result to be availablebefore having their consultation withthe doctor, nurse or pharmacist.

The clinics are very busy and tend tooverrun on a regular basis with somepatients waiting a long time to beseen. The perception of the clinicstaff was that waiting for bloodresults delayed patient consultationsin clinic.

A ‘go see’ exercise to understandhow patients flow through clinic andhow the samples flow through thelab was completed in April 2012.The service manager, consultanthaematologist, phlebotomy teamleader and lab staff all visited theclinic.

Pre-lab (phlebotomy, transport to lab) • Patients don’t attend at their allocated appointment times. Some patients requiring blood tests come earlier than their appointment time, others attend at their appointment time. Patients not requiring blood tend to arrive at their appointment time.

• Phlebotomists have a list of patients attending clinic and checkon notes which ones will be requiring blood tests on the day. Phlebotomy staff call patients in the order on the list, but do not know if the patient has arrived.

• Blood is taken and then transported down the corridor to send to the lab via the air tube.

• Patient notes are put in a box for the consultant when the patient has booked in and gone to have bloods taken.

Lab (booking in, processing,authorising)• Requests are collected from the air-tube and identified by yellow paper.

• They are processed as urgent.• If a blood-film is required, results are not authorised.

Post result (consultation andfollow up organisation)• Unauthorised results cannot be seen by all clinic staff (medical staff and some nursing staff can see unauthorised results). Until authorised, the results do not go across to the result viewing systemaccessed by all staff in the Trust.

• Notes for patients who are ready to be seen by consultant are put into a box in the clinic. Consultants collect notes from the front of the box and taken back to their consultation room.

• Consultants check that all results are available and that they are ableto see the patient. If results are available, the patient is called in tothe consultation room. If results are not available, the consultant has to either chase results from the lab or put notes back and pick another patient to see.

• During consultation, the consultant makes arrangements for follow up appointments and treatment for the patient.

It is important to differentiatebetween what is thought to happen ina process and the reality of whatactually happens. Don’t try to solveevery problem at the same time.

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Within each of the previous steps inthe pathway, lots of issues wereidentified. Ideas for improvementswere suggested during abrainstorming session and alsopicked up during discussions at teammeetings.

Base line data was collected at eachstep of the patient pathway throughclinic to identify the problem areas.The figures showed that theautomated testing process withinthe lab was very quick and themedian time taken was 8 minutesfrom the sample being booked in toa result being available, thisaccounted for 16% of the totalturnaround time.

The turnaround times for each stageof the process showed that the mainareas to focus on improving shouldbe:• Time taken from the patient arriving to the request being booked in to the lab (pre-result -53% of total turnaround time).

• The time taken between the result being available and this being authorised (post result - 8% of turnaround time but a maximum value of over two hours).

How the changes wereimplementedOn 6 June 2012, the haematologyclinic re-located from Suite 1 on aMonday and Friday due to re-organisation of clinic space in theTrust. This move forced someimmediate changes in the pathway.The nursing staff for suite 4 are notthe same members of staff whoworked in suite 1. They did notknow how the clinic had run in suite1 and were very keen to suggestimmediate changes.

1. Change of route taken to get to lab:Suite 4 is not connected to the airtube network so the samples have tobe hand delivered to the laboratory.Although Suite 4 is next door toPathology the route to drop off thesamples meant walking out of Suite4 along the corridor and then in toPathology reception. The sampleswere then dropped at pathologyreception and taken by the receptionstaff to sample handling. The totaldistance from the blood taking roomto sample handling is approximately30meters one way (blue line on floorplan). This change had the potentialto significantly increase the timefrom sample being taken to beingbooked in. It was noted thatadjacent to the waiting room in suite4 there is a door which leads in to astairwell which then leads on to the

fire door in to the blood sciences lab.It was suggested that this route wasused to deliver samples directly in tosample handling. The total distancefrom the blood taking room to thesample handling bench would bereduced to 9 metres (red line onfloor plan). Additionally, this reducedtravelling distance enabled deliveryof samples to the lab in flow ratherthan in batch as had been thecustom.

This suggestion raised several healthand safety issues but followingdiscussion with the pathologyhealth and safety lead, measureswere put in place which wereaccepted by the pathology clinicalgovernance committee. Asphlebotomists are classed asmembers of laboratory staff they areaware of the precautions they needto take in the laboratory, they wearappropriate clinical uniform andcarry hand gel to apply when goingin and out of the laboratory.

27

2. Numbering system forphlebotomy introduced:From the ‘go-see’ observations itwas clear that the phlebotomistneeded to know that a patient hadarrived and needed a blood test.The clinic staff and phlebotomistcame up with the idea of a numbersystem, which works by the clinicstaff giving any patient who requiresa blood test a number when theycheck in to the clinic. Thephlebotomist calls the numbers outand the patients go in to thephlebotomy room.

Measurable improvements andimpactThe numbering system has allowedpatients to be bled in the order inwhich they are booked in the clinic,a first in first out system, which hasenabled samples to be dealt with inflow.

The whole pathway was re-measured on 18 June 2012. Abreakdown of the data showed thatthe time from sample being taken tobeing booked in had decreased froma median of 17 minutes in April to11 minutes in June 2012. This was adirect result of the change of theroute the samples took whichenabled flow rather than batchdelivery of the samples. On average100 patients are bled in the clinicsper week. So these improvementshave removed 10 hours of patientwaiting time per week.

Key learning• The importance of ‘go see’ to follow the pathway. This helps everyone involved in the process understand how the work they do impacts on others.

• The perception that one part of the pathway was slowing the rest down is not always true. A combination of issues results in delays.

• Data collection is difficult and it is important to have a standardised way of collecting this. This was particularly an issue as each part of the pathway is completed by a different member of staff and in different locations.

• Ideas should not be discounted immediately because “we have tried that before” or “health and safety would never allow it”.

• Lots of areas for improvement are highlighted when you examine a process. It is important not to try to solve all of the problems immediately, but to plan changes in a structured fashion.

How this improvement benefitspatientsAt the moment the doctors have noway of knowing when results areavailable without looking up eachpatient individually. If the patientsrequiring a blood test were asked toattend 45 minutes before theirconsultation time they could becalled in to the consultation at theirspecified time. This is because thelab could guarantee that a result willbe available within 45 minutes andthe consultant would be confident aresult would be available when theycalled in the patient.

The patient would know that thetime of their consultation would bethe time they are actually seen. Thisconsistency will also mean that thedoctors do not waste time checkingwhether results are availablemeaning that they can actuallyspend more time seeing the patient.This should result in a better qualityconsultation for the patient.

How will this be sustained andwhat is the potential for thefuture?• Continue to gather data to gain a better understanding of the wait times on various clinic days.

• Ensure that each step of the process is as efficient as it can be by drilling down to examine ways to improve. Some of the data collected suggests that the phlebotomist is not delivering every sample as soon as it is taken and will take 2 or 3 at the same time. The effect on the overall turnaround time for the sample needs to be measured to see if thisdoes actually have a significant negative impact.

• Continue to work with the staff in clinic to make sure that any small changes in procedure are noted and the effect on the running of the clinic is acknowledged. Exploreimplementing a more visual systemin clinic to show where a patient isin the process.

28

• Work has already begun examining the scheduling of patients. Currently around 68%of patients come earlier than their allocated appointment times, some of these are overbooked in to the early slots and others attendearly as they think they will be seen earlier. The plan is to ask the patients who require blood test onthe day to attend 45 minutes before their allocated consultation time. The data collected shows that this will be sufficient time for their sample to be collected, delivered to the lab and processed.There is some work to be done in the lab to guarantee that the result will be authorised in 45 minutes. This is because a lot of the patients will have abnormal results due to the nature of their condition and these abnormal results would usually require a blood film to be checked. The BMS and consultants are working together to look at changing the film criteria for clinic patients. Once this has been agreed the roll out of the new clinic slot timings and the 45 minute rule can begin.

• Ongoing work with consultants and clinic staff is underway to streamline the very end of the process when the patient needs tobe booked for further follow up ortreatment. The way these appointments are booked is quite confusing currently with a lot of the consultation time being taken up with filling in paperwork and making phone calls. To release this time so the consultant can give the patients a better quality consultation, standard work will be developed to ensure that these tasks can be done by other members of clinic staff. .

ContactHelen Cooke, Clerical Co-ordinatorEmail: [email protected]

29


Streamlining day surgery admission to improvegroup and screen result turnaroundSummaryThe risk of patients commencingsurgery without appropriatetransfusion cover has reduced fromgreater than 45% to consistently lessthan 10% by examining the pre-analytical pathway, changing thestaffing at patient admission toimprove phlebotomy provision andstandardising this step.

Understanding the problemIncreasing numbers of patients areundergoing surgery via a same dayadmission pathway in which theatrelists commence within one hour offirst admission. In excess of 45% ofpatients had surgery commencewithout a valid group and antibodyscreen due to failures in the patientadmission process (patientphlebotomy was not prioritised).These patients therefore were notassured of appropriate transfusioncover during the procedure.

How the changes wereimplementedA ’go and see’ exercise (or GEMBAwalk) highlighted a lack ofstandardisation in the patientadmission process. A value streammap was constructed of the patientadmission process, phlebotomy andsample journey to receipt in thetransfusion laboratory. This mappingtask highlighted a number of non-value added steps which wereexamined and removed, and theadmissions process was standardisedwith a specific phlebotomy stepincorporated early in the process toensure samples were taken and sentto the lab prior to surgerycommencing.

The mapping also emphasised thatstaffing levels on the surgicaladmission ward failed to match thepatient workload, particularly forearly patient admissions. Staffinglevels were amended to reflect thepatient workload; a member of staffwas given a specific phlebotomy rolefirstly as a trial, and then onceproven as a permanent position.

Measurable improvements andimpact• Steps in the patient admission andsample delivery process were reduced from six to three.

• Hand offs in the sample delivery process were reduced from five to two.

• The introduction of standard work defined expectations of the surgical admission and laboratory staff with clear timelines to provide samples in order to assure result turnaround prior to the commencement of theatre lists.

• The trial of a specific phlebotomy role on the surgical admission ward provided sufficient evidence for a business case for a permanent role to be recruited.

• The introduction of these actions has resulted in a significant reduction in the number of patients commencing surgery without a valid group and screen result.

The power of ‘go and see’ andengaging with customers.

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Percentage of occurences where group and screen results werenot available when surgery commenced on day admissionsurgery patients via S.A.L

50%

0%June

JulyAug

SeptOct

NovDec

JanFeb

MarApr

MayJune

July

% knife to skin breaches (all data)

30

Key learning• A multidisciplinary approach is central to finding the solution.

• Consider the pre-analytical factors that can impede on result turnaround before you even receive the sample in the laboratory.

• The use of lean improvement methodology and the information gathered to demonstrate success can be a vital tool to inform business cases.

How this improvement benefitspatients• A streamlined patient admission process improves the patient experience.

• The risk of patients commencing surgery without appropriate transfusion cover has reduced from greater than 45% to consistently less than 10%.

How will this be sustained andwhat is the potential for thefuture?• Monthly data continues to be gathered to review the efficiency of the process and highlight any areas in the patient admission and pre-analytical process that may impact on result turnaround.

• The lessons learnt can be applied to many other clinical areas including orthopaedic day surgery admissions and haematology day case transfusions.

• A similar approach to understand the pre-analytical process outside of the lab could also be used to streamline critical processes such as major trauma admissions wherethe right sample from the right patient at the right time can improve patient outcomes.

ContactMatthew Barnett, AdvancedPractitioner, Blood TransfusionEmail: [email protected]

A key stage in all laboratories and forall disciplines.

The sample reception stage is oftenchosen as the starting point forimprovement initiatives due to itsvital positioning in the value stream.Getting this stage wrong has adetrimental knock on effect to all thefollowing stages.

This stage typically covers:• sample receipt;• sorting;• checking;• numbering;• registering in the laboratory computer;

• preparation (centrifugation if required);

• sorting;• racking; and • distributing to appropriate laboratories and analysers.

The laboratory adds value at thisstage by:• ensuring all samples flow through the reception area in small batch sizes;

• with the minimum of non-value adding steps;

• as quickly as possible;• identifying errors in sample, labelling and requests; and

• working with users to minimise andeliminate these errors.

Pre-analytical stage

The concepts highlighted in the casestudies in this section include:• user engagement; • use of order sets;• communicating with users;• matching staff numbers to workload;

• adopting single sample flow streams;

• reducing unnecessary checks; and• role enhancement.

The tools illustrated include:• visual management of flow;• Takt time analysis;• ‘stranger’ and ‘water strider’ roles;• defect analysis;• Pareto analysis;• reducing hand offs; and• daily huddles.

PRE-ANALYTICAL

RECEIVE

CHECK & NUMBER

REGISTER INCOMPUTER

PREPARE(SPIN ETC.)

31. Pre-analytical stage

SORT & DISTRIBUTE

32


How lean improvement enabled us to save timeand money in blood transfusionSummaryIntroducing a simple visual aid andrecording blood wasted has resultedin approx. £12,000 p.a. saving byreducing time expired bloodreturned.

Understanding the problemBlood was being wasted due toreaching the time expiry date. BMSstaff were not noticing when unitswere nearing expiry and thereforenot using these as a priority.It was recognised that there was aneed to free up time for transfusionstaff to be able to come up with aneffective solution to prevent this typeof blood wastage.

It became obvious when staff werepassing each other in the corridordoing the same job (checking forsamples), that time was beingwasted by both AssociatePractitioner and BMS staff going tospecimen reception to look forsamples.

How the changes wereimplementedA specimen collection log wascreated at half hourly intervals. Thismade it clear when the sampleswere arriving and so a schedule wascreated and included in thespecimen reception standard worklist to prompt the member of staff toonly collect samples at the set timeswhen work came in.

This organisation of time meant thatin between collection of samples theAssociate Practitioner and seniorBMS staff could devote time tocreating a visual aid for the bloodfridge to make it obvious to BMSstaff when a blood unit is nearingexpiry and prompt them to use themwherever possible before expiry.

This took the form of coloured cardsin front of each blood type stored inthe stock fridge; each card is red onthe front and fluorescent on thereverse – when the reverse side isshowing it is immediately apparentthat there is blood to be used assoon as possible.

In order for staff to be more awareof wastage, a poster fixed to thestock fridge door displays thewastage figures for each month.

An extremely simple visualmanagement system using colouredcard has saved the trust thousands ofpounds. Reducing waste can savetime that can be used to concentrateon solutions to other problems in abid for continuous improvement.

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Measurable improvements and impact• Time saved on the specimen reception bench equating to approximately two hours per weekas a result of removing the waste of walking to pick up specimens that are not there. This equates to a saving of £1,300 per annum.

• Monies saved by less wastage of blood units equating to approximately £12,000 per annum.

Key learning• An extremely simple visual management system using coloured card has saved thousandsof pounds.

• Reducing waste can save time thatcan be used to concentrate on solutions to other problems in a bid for continuous improvement

How this improvement benefitspatients• Samples are now being collected regularly and put on the analyser without waiting for batches, meaning less waiting time for results.

• Ensuring less blood wastage has had an enormous impact financially for the trust and in addition the blood donor’s time and effort are not being wasted.

How will this be sustained andwhat is the potential for thefuture?The card system will stay in place inthe stock fridge enabling the bloodstock wastage to remain at minimallevels. By continuing to utilise thespecimen collection log, theAssociate Practitioner has time toexamine other lab processes andassist in improving these, as well asincorporating additional duties intotheir work, such as loadinganalysers.

ContactAnna Baker, Associate Practitioner BMSEmail: [email protected]

Cost of blood wasatge due to time expiry

£1,600

£1,400

£1,200

£1,000

£800

£600

£400

£200

£0

Lean Improvement Event - July 2011

May11Jun11

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May12 Jul12Jun12

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Reduced checking at booking-in improvesdetection of defectsSummaryBy only checking transfusion samplesonce prior to analysis the laboratoryimproved detection of samplerejects. This had the effect ofreducing turn-around-time (TAT) forall samples. The two-check processresulted in 2.8% of samples beingrejected whereas the one-checkprocess resulted in an average of5.5% of samples being rejected,showing a 51% improvement indetection of defects. The number ofsamples which should have beenrejected but were missed by thechecking procedure was reducedfrom 4.9% to 1.7% in the one-stepprocess, a 69% improvement.

Understanding the problemIt was practice in the laboratory tohave a staff member (Band 3/Band 4grade) numbering transfusionsamples and booking them into thecomputer system from the requestform. Post centrifugation a secondstaff member (Band 5-Band7) wouldthen check the sample against thecomputer system prior to analysis. Afinal check for errors occurred on the‘crossmatch’ bench prior to bloodbeing issued for transfusion (the final3rd check). The two-check pre-analytical process resulted insignificant delays within thelaboratory and despite it being inplace there were still occasions whenthe 3rd check picked up adiscrepancy resulting in the samplebeing unsuitable for the provision ofcrossmatched blood. This had anegative impact on patient care as afurther sample was then requested.

In addition ownership of thechecking process was poor, withreliance on the ‘second-checker’ todetect defects when that staffmember was actually busy elsewherein the laboratory, and an in-builtassumption that the other personwas responsible for detectingdefects.

How the changes wereimplementedA3 thinking was used to plan a newspecimen reception process. A trialwas conducted and an auditundertaken of defect detection preand post change. Following the trial,a bench card incorporating visualaids was written to inform staff ofthe new one-check procedure andall staff were trained in the newstandard work process. Followinggo-live the success of the newprocess was audited by checking allsamples from one day per week fornine weeks to ensure theimprovements were sustained.

Measurable improvements and impact• Delay between booking in and start of analysis reduced from mean of 22 minutes with two-check process to eight minutes with one-check process.

• Reduced motion of samples around laboratory and hand-off to‘second check’ person.Approximately 30 seconds of BMS time saved per sample, equating to one hour of BMS time saved per day.

• Reduced motion of samples between racks. Samples loaded directly into centrifuge, and from there directly into analyser racks byone staff member (Band 4).

• Increased detection of samples failing sample acceptance policy (correct rejects) compared to base-line two-check process measurements (51% improvement)• The two-check process resulted in 2.8% of samples being rejected whereas the one-check process resulted in an average of5.5% samples being rejected.

• Reduction in defects being missed (69% improvement)• Reduced from 4.9% to 1.7% in the one-step process.

Over the 10 weeks, there were 0.6to 3.3% samples which wereerroneously processed with the one-check process and 3.3 to 7.2%correctly identified rejects.

A thorough one-check system, withclear ownership of responsibility, ismore effective at detecting samplerejects than multiple check system.

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Key learningA thorough one-check system, withclear ownership of responsibility, ismore effective at detecting samplerejects than a two check system.

How this improvement benefitspatients• Removal of second check has beena major component in the reduction of TAT for all samples. Prior to the change in procedure the median TAT for acute samples was 115 minutes, TAT for those samples is now 74 minutes.

• One hour of BMS time generated per day ensuring qualified staff areavailable for more complex work.

• Reduced occasions of defects being missed and subsequently being detected when blood is required for cross-match.

How will this be sustained andwhat is the potential for thefuture?Following audit the one-checkprocess was incorporated into bloodtransfusion specimen receptionstandard operating procedures. Thisprocess has the potential to be rolledout to other areas of blood sciences.

ContactSandra Harlow, Transfusion BMSEmail: [email protected]

Sample defects and quality defect data

10

8

6

4

2

0Two Step Process

Average

Perc

enta

ge

2.8

4.9

One Step ProcessAverage

5.5

1.6

Missed rejects goingfurther into the process

Correctly identifiedrejects

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Reducing turnaround times for urgent samples

SummaryTurnaround times (TATs) for urgentsamples reduced by 10% and animprovement in collection toreceived times from 82.7 to 74.8minutes.

Understanding the problemThe Royal College of PathologistsKey Performance Indicator for 2015states clear guidelines for A&E bloodturnaround times. On 1 Oct 2011,the laboratory was completing 75%of urea requests within one hourfrom receipt in the lab, which is10% below the recommended KPI.Average TATs from collection toauthorisation were 108 minutes.

The multidisciplinary team consistingof staff working across thepathology laboratory spent two daysmapping out the current state of theprocesses, highlighting handovers,and spaghetti mapping, as well asidentifying the key areas wherechange could be implemented easilyand efficiently, and that wouldprovide the most improvement.

The team determined that:• samples were being delayed due to batching on the ‘urgent’ desk, as all urgent samples were being placed in a red basket, in no particular order, and simply being numbered as they were picked out;

• extra steps existed in the process where needless double checking was taking place; and

• the staff responsible for numbering the urgent samples were being distracted with samples that required extra work to process (which could take up to20 minutes) and so preventing the flow of work.

There was a perception that errorswere a large problem, representing awaste of effort and adding to theworkload. A manual count wasundertaken to measure the numberof internal errors received in theautomated lab, which ideally wouldhave been picked up in reception.

Visual management was consideredas an effective way of helping peoplework in a more consistent way.

Baselines were collected, somemanually using a stop watch andnoting down how long each steptook. The hospital data analysts werealso asked to provide regularmeasures of TATs and specimencounts.

The establishment of an exceptionsbench allows improved flow tomajority of samples. Removing flowstoppers (strangers) allows themajority of samples (runners) tocontinue to flow, thus eliminatingwaiting and queues forming for thebulk of the work.

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C. Timeliness in pathology ensures an appropriate level ofpatient care

i) KPI: A&E blood sciences turnaround timesBaseline: Percentage of core investigations i.e. renal function, liver function

tests and full blood counts from A&E completed within one hour of receipt, including out of hours.

Challenge: 85% by April 2012 increasing to 90% by April 2014. The standardwill move to one hour from sample collection by April 2015.

Frequency: To report, as at the 30 May and 30 November, the percentage of renal function, liver function tests and full blood counts requested by A&E completed and available to the requestor within one hour of receipt including out of hours. Exception reports to be completed and reported for all A&E blood sciences requests whichare not reported within one hour of receipt.

Guidance: www.dh.gov.uk/en/Healthcare/Urgentandemergencycare/

Taken from Key Performance Indicators in Pathology, RoyalCollege of Pathologists (2011)

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How the changes wereimplemented• A separate workbench was created to deal with all the ‘exceptions’ to normal workflow, allowing non-defective urgent work to flow without interruption.

• Black specimen bags were introduced to allow emergency department samples to be identified as a priority.

• A simple addition to a box on the urgent desk has allowed staff to deal with samples in a true first-in first-out flow.

• The urgent work desk was put under scrutiny using 5s and scoredbefore and after changes to measure success.

• Highly visual standard work sheets were produced and introduced to staff for several tasks within the department.

• Reception staff were trained to front-load urgent work onto the analysers in the laboratory to remove the check/loading step from the BMS work flow.

• A dashboard was set up in reception detailing the number of samples received the previous day and current events of the lean project. This was used to ensure reception staff felt part of the process of improvement, and to increase ownership.

• A morale (or engagement) questionnaire was completed by staff to gauge the general mood of the department.

Measurable improvements and impact• An overall reduction in average turnaround time of just over 10%.

• An improvement in collection to received times from 82.7 to 74.8 minutes.

• 1.9 days saved per month on introduction of the ‘exceptions’ bench (data collected over five month period)

• A reduction in the 90th percentile from 118 to 109 minutes from collection to authorisation.

• No improvement in sample transport times seen from emergency department to the lab.

• Staff morale re-measured (see below).

The first morale questionnaires gavean indication that most of the staffwere either happy or content, withonly 13% returning the unhappyresponse, whereas the secondmeasurement had a higher responserate, but showed that 31% of staffwere unhappy.

On further analysis of the second setof data, each group was looked atseparately to gain a betterunderstanding of the feelings of thestaff.

All response groups felt things weregetting better overall, including theunhappy responders.

The cause highlighted as a majorreason for unhappiness amongst thestaff was closely linked to people’sfeelings about being heard, with73% of unhappy responders statingthat they felt they were not listenedto.

An interesting pattern that emergedshowed that people’s level of prideover the work they do is closely tiedto their happiness overall, with 36%of unhappy responders stating theyfelt no pride over their work.

Days saved per month on introduction of the ‘exceptions’ bench

82.7

71.676.7 73.1 75.8 74.8 76.5 74.8

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Key learning• Reliable and trusted data is essential. This should be collected in the same way throughout the process. Without this any staff involved may be deprived of the feeling of achievement, morale may decline and future projects would be hard to launch.

• Commitment by senior leadership.Staff must be made available totake part in the project (lack of progress displayed in some areas of the project disheartened the team, made further improvements seem less valuable and lowered the energy and motivation of all staff involved).

• It was also observed that a deciding factor for the success of an improvement project is communication. Staff involvement is vital and regular communications concerning any changes in the lab can help minimise the amount of disruptiondramatic changes can cause. This is supported by the second moralequestionnaire, which highlighted that the least happy staff felt they were not being listened to and felt no pride over their work.

How this improvement benefitspatientsThe overall improvement inturnaround times provides patientswith results faster. This meanspatients who are admitted to thehospital via the emergencydepartment can be assessed fasterand treatment plans can be put inplace earlier. The introduction of theexceptions bench removesdisruptions to workflow ensuringthat ward patients requiring urgentblood results will receive their resultssooner and to a much morepredictable timescale.

How will this be sustained andwhat is the potential for thefuture?• This improvement will be sustainedusing continued data monitoring and vigilance from the staff, as well as by passing down the lessons learned as future improvements are underway.

• Involvement in this project has enabled staff to articulate ideas forimprovements that they may have had a long time earlier.

• The journey taken by the team on this project has not been easy or without its challenging moments. However, one manager said, “it has become clear that the time investment is worthwhile in the long run”.

• The lessons learned in developing more structured and robust improvement techniques have proved to be extremely valuable. More projects have already been undertaken utilising the 5S technique to make the lab a wastefree environment and changes to the flow for outpatient and GP work through the reception area.

• There has also been interest from some of the haematology consultants to examine their processes.

• Through the learning achieved in this project some staff have become key players in the improvement process. This will lead to further improvements for patients and service users.

ContactTom Kennedy, Specialist MedicalLaboratory AssistantEmail: [email protected]

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Using data to manage staffing levels withinblood sciences pre-analytical sectionSummaryVolumes of work delivered to thesample handling area, staffavailability in the area, delivery vanarrivals and TATs were monitored.The data collected was discussed atthe staff ‘huddle’ (daily five minutemeeting) and MLA staff numbersthroughout the day now ensure thatthere are always sufficient staffavailable to deal with the workloadwithin core hours and to reducesample waiting time to a consistentminimum. Before Lean wasimplemented 16% of work wasoutstanding after 5pm whilst postlean figures show only 8% of workwas outstanding after 5pm – a 50%improvement. An increase in activityof 10% has been absorbed by thedepartment without any increase instaffing.

Understanding the problemApproximately 40% of workreceived in the sample handling areais from within the hospital and 60%from GP surgeries/communityhospitals.

The MLA staffing in the bloodsciences department consists of 17staff, with eight full time equivalents(FTEs) with a variety of shifts overseven days. The remaining nine staffwork part time hours, each having adifferent work pattern Monday –Friday (9am – 7pm). Three of thesepart time staff are on temporarycontracts.

The work areas the MLA staff cover • Sample handling – this includes reception, sorting, bar-coding of specimens and the subsequent entry into the laboratory information system. There is also a‘runner’ role (pre- analytical problem solver).

• Separating area – where work to be analysed at other hospitals is collected, sorted and sent.

• Referred office – for data entry of specimens referred to other hospitals and results received here and phone line 9am – 1pm.

• Traceability in blood bank.• Urine separation/phone line.

Work arrives in sample handling fromthe following areas:• routine work from ward taken by phlebotomist arriving between 9am and midday;

• work from OPD arriving throughoutthe day until approximately 5pm;

• urgent work from within the hospital received at all times; and

• work from GP surgeries and community hospitals. These come transported by five vans twice a dayand arrive during the lunch time

Matching your capacity and demandsupports improved TAT and improvesstaff morale.

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Number of samples entering sample handling and being barcodedon an hour by hour basis during a working week

900

800

700

600

500

400

300

200

100

0

Nu

mb

er o

f sa

mp

les

Time period8-9am 10-11am 12-1pm 2-3pm 4-5pm 6-7pm 8-9pm

Monday Tuesday Wednesday Thursday Friday

period (11.30pm - 1.15pm) and later afternoon (3.30pm - 4.40pm).

To better understand the workloadlevels throughout the week and staffavailability, the following measureswere undertaken.

1.Monitoring the amount of work being dealt with in the sample handling area every hour (from 8am - 9pm) for a full week by using a table to record the bar-code numbers that had been reached at each hour. This audit was performed four times over eight months. From this data the time at which work flow ‘peaked’ within the department was realised and the number of samples dealt with on a daily basiswas recorded, see graph below.

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2. A spread sheet recording staff availability on a day by day (Monday – Friday) and hour by hour (8am – 9pm) basis.

3.A turnaround time (TAT) audit from the time the sample arrived in the laboratory to the time at which it was booked. These TATs were performed randomly on specimens throughout the working day, over a number of days in order to get a true representation.

4.The number of specimen bags andthe time of arrival by the delivery vans over a sample number of days were recorded.

How the changes wereimplementedFrom the audit of work beinghandled, the busiest days thatrequired maximum staff wereidentified and this enabled the daysand the hours on which thetemporary staff were required towork to be implementedaccordingly. See graph above forsample received on a daily basis.

This same audit showed how workfrom the early afternoon van loadswere not always being cleared before the late afternoon vansreturned. This coincided with theafternoon break times. It wasevident that staff needed to taketheir breaks according to how muchwork was still to be completed at3pm (the time at which breaks start).

This information was taken to theMLA ‘huddle’ and it was recognisedand agreed by staff that thenumbers going to break had to bedependent upon workloadoutstanding. It was agreed that thedecision as to how many staff wererequired to stay to complete work at3pm would rest with the ‘runner’role.

Measurable improvements and impactDuring this time the van timeschanged and interceptor vans wereintroduced to allow smaller batchesof work to enter the departmentthroughout the day to improve flow,reference ‘Transport case study’.

These interceptor vans arrived in thelaboratory at approximately12.10pm, 12.40pm (the lunchtimeperiod when most MLA staff are atbreak) and 3.30pm. The next TATaudit showed that the average timesfor the period 11.30am – 1.30pmwas approximately two hours 30minutes which compared poorly tothe average TAT of approximately 50minutes at other times.

An audit of the number of bags ofspecimens arriving in the lab showedthat before interceptor vans it was720 arriving between 12.45pm -1.30pm whilst after interceptor vanswere introduced this number of bagshad been spread evenly at 11.30am,12.30pm and 1.30pm.

Turnaround times (minutes) arrival to booked in

180

160

140

120

100

80

60

40

20

0

Min

ute

s

DateAug11 Sep11 Oct11 No11 Dec11 Jan12 Feb12 Mar12 Apr12 May12 Jun12

162

96

77

58

106

TAT (mins) arrival to booked in

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These two audits together withstaffing numbers over the lunchhour showed there needed to be achange in numbers of staff havingbreaks at this time. This data wastaken to the staff huddle fordiscussion where it was decided thatstaffing numbers should be dictatedby the amount of work present atthe time of lunch break – thisdecision to be taken by the runner.

Key learningBy using data to evidence problemsand engaging staff in findingsolutions, the section is able toensure that all samples arriving inthe laboratory are capable of maintaining shorter sample waitingtimes. Pre Lean the average a timefor samples being received to beingbooked in was one hour fiveminutes, Post Lean this time hasbeen reduced to a median time of32 minutes.

From daily data collected thedepartment has seen the averageamount of workload per dayincrease by approximately 10%. Thisincreased activity has been absorbedinto the system without the need forextra staffing and completion timesfor booking in work remainsconsistently within core workinghours.

How this improvement benefitspatientsAs specimens will be available to theanalytical platform sooner, samplequality will be enhanced and resultswill be available for the requestingdoctor sooner. Any abnormal resultswill be available earlier and can beacted upon more quickly.

How will this be sustained andwhat is the potential for thefuture?To monitor improvements ordeterioration of TAT regularly, theaudits will be performed weekly andthe average TATs recorded on graphsas visual management for staffdiscussion. This will allow staff toidentify problems quickly and makechanges to maintain the TATs.

ContactElizabeth Galley, BMS Team Manager – Pre-analyticsand Point of CareEmail: [email protected]

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Using visual management to improvecommunication and an improved way of workingSummaryVisual management has been usedto encourage working to standardpractice, identify defects, recogniseflow stoppers and visualise work inprogress. This has made our livesand the lives of patients safer.

Understanding the problemThe problem that was encounteredin the laboratory before visualmanagement was introduced wasthat many of the staff within thedepartment did not know what washappening and when. This became aproblem as much of the work wasbeing repeated or missed due to alack of communication betweenstaff. When this was drawn to ourattention, it was decided visualmanagement changes were to beintroduced to the laboratory toimprove our way of working andcommunication.

How the changes wereimplementedStandard work visualmanagementSample handling has three workstations and they are now all set outexactly the same. Each station isclearly labelled with what equipmentshould be stored where and thismakes visibly clear when something,which is needed at the bench toperform the task, is missing. It helpskeep clutter and unnecessaryinventory, such as personalpossessions, out of sample handling.

Visual foldersThe folders in the laboratory are allclearly marked with tape. If a bookor folder goes missing or is placed inthe incorrect position then it is visibleat a quick glance which reduceswasted time in searching for thecorrect information.

Analyser status boardThis analyser status board ispositioned in the laboratory wherethe majority of staff have easy accessto it. A green card indicates that theequipment is working. An orangecard means that the equipmentrequires maintenance, for example aQC is in progress, but will berestored to full working order quicklywhereas a red card indicates that theequipment is not working andrequires further investigation i.e. avisit from an engineer.

Huddleboard and huddle clocksThe laboratory ‘huddle’ board is anexample of communication visualmanagement.

The board is used by all staff levelsand is the main focus for all issuesraised, keeping staff up to date withany improvements made and issuesaffecting how work is performed.Data such as turnaround times andthe amount of samples which areprocessed each day is displayed. A short daily meeting (usually 10minutes) is used to raise issues fromthe previous day. The volume of workprocessed and the time the work wasfinished the previous day are loggedon a graph on the huddle board so

The analyser status board has provenvery useful as all staff are able toquickly identify the status of eachanalyser and recognise flow stoppers.This enables work to continue in flowby identifying the defects beforehandand all staff are aware of any issues.

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the staff can see how theirperformance is improving and howwell they are dealing with theworkload.

Placed around the laboratory are‘huddle clocks’. These clearly statewhat time the next huddle meetingis due to start so all staff are awarewhat time to attend. The times arechanged to allow staff on differentshift patterns the opportunity toattend the ‘huddle’. A differentteam member leads the huddle eachday and this is also displayed.

Analyser status cardsEach analyser in chemistry has astatus card visible on the top of theanalyser. It is positioned on the lidwhere the samples are directlyloaded.

One side of the card is green,indicating the analyser is in fullworking order and in use. The otherside is red – which indicates theanalyser is currently unusable. Staffalso find the cards useful to writenotes regarding issues or messagesfor shift workers.

Measurable improvements and impactA morale questionnaire wasdesigned and distributed to the pre-analytics team prior to theimplementation of the pilot in orderto monitor staff engagement duringthe initial changes and as part of anongoing process. The morale /engagement scores improved withstaff satisfaction increasing from67% to 90% over a six monthperiod despite the 10% workloadincrease.

Staff satisfaction scorePre-changes 67%First day of pilot 79%2 weeks post changes 83%6 months post 90%

It can be argued that theimprovement in communication, aswell as other factors, within thelaboratory has improved staffsatifaction.

Key learningThe analyser status board has provenvery useful as all staff are able toquickly identify the status of eachanalyser and recognise flowstoppers. This enables work tocontinue in flow by identifying thedefects beforehand and all staff areaware of any issues.

Leah Egley (Medical LaboratoryAssistant) said: “All levels of staff areaware which analysers are workingat a quick glance at the status board.This helps the MLAs as we knowwithout asking if we are going toget our aliquots back for referredtests or not.”

Beth Lane (Associate Practitioner)said: “The analyser status cards are a huge help when working inchemistry. All the staff working inthe department know which

analysers are ok to use. Notes canalso be written on the cards so ifthere is an issue, you do not need tokeep passing messages on. This isparticularly useful for shift workers.”

How this improvement benefitspatientsSince visual management has beenintroduced to the laboratory, thework flows better. All staff knowwhat is happening and when. Thusreducing the risk of processing errorswhich would have a negative impacton patient safety.

How will this be sustained andwhat is the potential for thefuture?The visual management in thelaboratory will be sustained using a5S assessment sheet in each workarea. This assessment will be carriedout periodically, and is designed tohighlight any areas that are notsustaining so they can be acted onquickly.

An information board is currentlybeing designed for the samplehandling and separating area toinform MLA staff what jobs needperforming on each day. Each taskwill be on a red magnetic card torepresent that the task has not beenperformed yet. When the task iscomplete the card will be turnedover to show a green card. It ishoped that a row of green cards willgive staff a sense of job satisfaction.

The chemistry department arealready using analyser statuscards/dots and this will beintroduced in haematology.

ContactCathryn Boyer, Associate PractitionerEmail:[email protected]

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Using ‘standard work’ and 5S in specimen reception to create a standardised, clean and safe workenvironment allowing staff to perform optimally

SummaryAdopting the methodology of 5S (sort, set, shine, standardise andsustain) as everyday practice hasimproved staff morale and focus byremoving unnecessary equipmentand distractions from key areas.Working practices have also beencondensed to a generic anduniversally accepted way of workingwhich has become ‘standard work’.

Understanding the problem‘Sample handling’ is the mainreception point in the laboratorywith all specimens passing throughthis area and had become untidywith no agreed layout. The areascored badly on the 5S audit with a score of only 24%.

The ‘booking-in’ room was hecticand untidy – PCs were badly placedwith tangled wires, the walls werecovered by many unnecessary andout-of-date notices and reminders tostaff, and the shelves and workbenches held many piles of irrelevantpaperwork and dictionaries, withreference books strewn throughoutthe room.

A short assessment sheet outlineseach principle and highlightsproblems which may have anadverse effect on productivity(directly or not).

It was clear from the initial 5Sscoring of the ‘sample handling’ and‘booking-in’ areas that both wouldrequire a significant amount of timeto organise and clean.

As they deal with the highestthroughput of specimens and stafftraffic, it was decided that twomembers of staff familiar with theinner workings of the area woulddedicate some time outside of coreworking hours in order to cause theleast amount of disruption to thelaboratory.

How the changes wereimplementedBooking-in room - Cleaning beganwith the room being cleared of allunnecessary paperwork and notices.The notices and reminders were thencondensed and made into a booklet-style terminal handbook which couldbe centrally controlled and updatedto ensure the information containedwithin was current and correct.

The PC units were removedindividually, cleaned andreconnected neatly. Each PC unitalong with its associated peripheralsand plugs was given a uniquecolour-code allowing easyidentification of the power source.

The terminal used for scanning paperforms into a digital image waslocated in the corner of the room butwas needed by all staff causing abottle-neck effect at busy times. ThisPC and scanner were moved to acentral location allowing easy accessto the unit without encroaching onthe other booking in terminals.Reference books were moved to acentral location on a shelf accessibleby all staff.

Sample handling room - The areawas cleared and cleaned and, afterconsulting staff, each barcodelabelling station was marked out withelectrical tape and clear printed labelsto create a generic layout providingeach team member with theequipment required to perform theirrole. Files stored in the area weremarked with sloping electrical tapewhich, when aligned in the correctorder, show at a glance that all filesare present and stored where thestaff would expect to find them.

Clearly defined and visible to all staff, standard work and 5S of sample handling and booking in hasunderpinned the changes made to thespecimen reception and added to theimprovement in result turnaroundtimes.

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In the specimen reception handlingprocess it was also important to findan agreed upon and uniform way ofworking. This was achieved bycreating standard work documents.

Each document details a clearlydefined method for each task to beperformed, ensuring that theoutcome of the task will be reliedupon to always be the same. Thedocuments define team roles,ensuring duties are fairly distributed,and resources are not under-utilisedor wasted ensuring staff worktogether as a well structured andefficient team. The staff membersand/or teams that are expected towork in each location and theduration of time to be spent there,as well as step-by-step guides forvarious stages of the booking-inprocess are also detailed. Followingthe standard work has ensured theconsistent and efficient flow ofspecimens passed to the laboratoryareas for processing.

Measurable improvements and impactAs a marker for the improvementsmade in the booking-in room, the 5Saudit was repeated and scored 68%as opposed to 24% previously. Following the changes in the samplehandling room, the 5S audit showeda greatly improved score of 80%.

Staff morale has been measuredthroughout the implementation ofthe new standard work and 5S rollout by means of a ‘How did it gotoday?’ staff questionnaire. Prior toany changes, staff morale amongstthe MLA and AP roles was gaugedto be at 67% satisfaction. Thisimproved to 79.5% satisfaction onthe first day of the pilot, rising to82.5% two weeks after thechanges. Staff have also commentedthat the specimen reception area isnow a much calmer environment,communication between teammembers has been improved andproblems are resolved quicklywithout having an adverse effect onthe work flow.

Key learningClearly defined and visible to allstaff, the standard work hasunderpinned the changes made tothe specimen reception and addedto the improvement in resultturnaround times. So far theturnaround time from sample arrivalto data entry has been reduced by40%, whilst maintaining an errorrate of 0.06%. The overallturnaround time from sample receiptto result available has been reducedby 36%.

How this improvement benefitspatientsImproving the specimen turn-around-times and therefore thequality and timeliness of resultsprovided to clinicians and patients.

How will this be sustained andwhat is the potential for thefuture?A plan is now in place to carry out5S audit at monthly intervals for allthe areas targeted so far. After aperiod of time the interval will bereduced to weekly intervals and theresults displayed on the wall so as toengage all staff with the importanceof this methodology which will bethe foundation to a well organisedand efficient laboratory.

As a consequence of the visualimprovements in sample handlingand the booking-in room, areas suchas the cold storage room and themain work bench in haematologyhave also been audited, cleared,organised and cleaned. A 5S auditfile has been created for thecollation of all 5S scoring across thelab. The file sits in a central locationand contains the 5S scores and aplotted graph for each locationshowing improving and/orworsening results.

ContactJaimie Hancock,Email:[email protected]

Before and after view of a PCin the booking-in room

Examples of the receptionarea before and after the 5Sactivity

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Pathology outpatient process improvements

SummaryAverage time for outpatient samplesfrom receipt to analyser reducedfrom three hours 21 minutes to onehour 37 minutes, a reduction of51.74%. Average samples left overat the end of the day reduced from973.75 to 50.8, a reduction of94.8%. This was due to theimplementation of standard workand a change to late shift staffinglevels.

Understanding the problemIssues regarding the lengthyturnaround times of outpatientchemistry samples led the team toinvestigate all stages of theoutpatient process. The first problemwe encountered came wheninvestigating the arrival times ofsamples into the laboratory. It wasknown that we received around40% of our total outpatientworkload before 1pm and that ourstaffing did not match that demand.Boxes of work were left unattendeduntil staff on later shifts arrived.

The fact that the outpatient/GP workwas not getting started until after1pm raised an issue with chemistryregarding the MPA. It was knownthat the MPA hit saturation point ataround 4pm under current workingconditions and this led to theanalyser being strained and unableto cope with the demand andsubsequently causing a backlog ofsamples. This inevitably led tosamples being queued for aconsiderable amount of time andinevitably refrigerated overnight.

Under the previous workingmethods it was found thatnumbered outpatient samples werewaiting up to two hours 20 minutesto be booked onto the computersystem before they could beanalysed, this was due to thenumbered samples being queued forthe clerical staff members.

It was found that some samples,known as exceptions, interruptedthe work flow, samples which hadspecial requirements or errorsrequired a staff member to delay theprocesses of their current batch ofsamples in order to process theexception.

How the changes wereimplementedThe shift staffing was changed; one11 till 7 shift and one 12 till 8 shiftwere brought down to twodedicated outpatient nine to fiveshifts. The staff members on theseshifts would solely focus onprocessing outpatient samples forthe whole duration of the workingday.

Standard work was introduced foroutpatient processing, this includeda staff member numbering and thenbooking in their own samples toachieve real time processing on theirown standardised workstation.

Outpatient exceptions passed toexceptions bench (exceptions benchpreviously introduced as part ofUrgent/ED Lean project).

Reduce carve out; treating all routinework as a single flow reduces TAT insample handling.

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Number samples refrigeratedovernight

119510506001050

Beforechanges

9409466

Afterchanges

47

Measurable improvements and impact• 94.8% reduction in samples left over at the end of the day.

• Average time for outpatient samples from receipt to analyser reduced by 51.74%.

• Reduced the waiting time between numbering to booking infrom two hours 11 minutes, to 12 minutes.

Ideas tested which weresuccessful • Shift staffing changes enabled the department to begin outpatient processing much earlier, consequentially leading to a same day completion of the majority of outpatient processing and removed the need to regularly refrigerate samples overnight.

• Standard work with real time processing removed the waste from the process and provided a faster more efficient work flow.

• Integrating the outpatient exceptions onto the previously created dedicated exceptions bench, meant that any more than average time consuming samples were removed from the work flow.

OPD processing: time taken fromnumbering to bookingBefore 131 minsAfter standard work 12 mins

Key learningDuring the course of this project theteam learned the following:• standard work is essential;• investing the time to sustain improvements is paramount;

• trialling changes and adjustments provide valuable data and information on potential improvements; and

• involving everybody as part of the project is important to generate new ideas, constructive communication and a team ethic.

How this improvement benefits patientsThe large reduction in samples beingrefrigerated overnight means a veryhigh percentage of outpatient andGP requests will have resultsavailable on the same day.

ContactGareth Moss, MLA SupervisorEmail: [email protected]

250

200

150

100

50

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Date20 April 2012 23 April 2012

168

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Average time (mins) from receipt to booking - Before improvements

140

120

100

80

60

40

20

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Date28/05/2012 29/05/2012 30/05/2012 31/05/2012 01/06/2012

112

127

92 81

73

Average time (mins) from receipt to booking - Before improvements

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Blood sciences pre-analytics pathway improvements

SummaryImproving the flow of samplesthrough sample handling hasreduced the overall sampleturnaround times by 36%, improvedstaff engagement to 90% andincreased workload capacity (10%increase in workload). There has alsobeen a change in the culture of thedepartment, staff are engaged andempowered to make changes andsee this as an on-going process ofcontinuous improvement rather thana single event to fix a problem.

Understanding the problemThe blood sciences department isthe central reception area for all thepathology disciplines, pre-sorting thesamples for blood sciences,microbiology, histopathology andcytology. The samples for thecombined blood sciencesdepartment are split for each sectionresulting in four workstreams.Demand varies significantly, with themajority of samples arriving in thelaboratory at lunchtime and lateafternoon resulting in bottlenecksthroughout the department andputting pressure on the whole of the blood science team during thelate shift.

Morale within the sample handlingteam was low with staff feelingoverburdened despite previousreviews of the workflow and staffinglevels. Medical laboratory assistantsin the sample handling sectionregularly required assistance fromother staff groups to clear thebacklog of work creating deficienciesin other areas of the department.

Order-comms (electronic) requestingwas in the process of being rolledout across the trust and in primarycare but an initial review of theturnaround times for these requestshad not indicated a significantimprovement. A review of thebaseline data indicated the order-comms requests were taking longerfrom time of arrival in department totime entered onto the laboratorysystem than other request types. Anaudit of the data entry time for eachtype of request was carried out andindicated order-comms requestsreduced the data entry time by 45%.Only by observing the processfirsthand was it possible tounderstand the contradictory data.The requests were still in a minorityand were being treated as a separateworkflow with the majority of theteam ignoring the ‘new anddifferent’ requests.

Initial baseline data was collecteddetailing workload per hour of day,route of arrival and turnaround timesthroughout the process. The datawas used to identify key areas forimprovement and a means ofmonitoring the impact of anychanges.

How the changes wereimplementedRepresentatives from all grades ofstaff within blood sciences,phlebotomy team leader andoperational services manager tookpart in the initial lean awarenesstraining and became the ‘core team’formulating the new way of workingand communicating the changes tothe rest of the team. Input from the phlebotomy teamleader and operational services co-ordinator allowed key constraintsregarding sample collection anddelivery to the laboratory to beconsidered leading to a review of thetransport service. Involving staffassociated with all parts of the pre-analytic and analytical pathwayensured the potential impacts ofchanges to the sample handlingprocess were evaluated across therest of the laboratory. A3 thinkingwas used to identify and fullyinvestigate key problem areas beforeimplementing further changes.

Involving the staff in the decisionsand empowering them to continue todevelop the department has led to amuch more engaged and receptiveworkforce. Introduction of 'huddles'enables daily communication toidentify and solve problems.

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Using the ‘go and see’ principle thecore team produced a value streammap of the pre-analytics process,providing a visual aid to identify themain steps in the process, batchsizes, cycle times and associatedwastes. The initial focus was toreduce the time interval betweensamples arriving in the departmentand being available for analysis. Byvisualising the process andconsidering from a ‘customer’s’ viewwhether each step in the currentprocess added value, the team wereable to re-evaluate the samplehandling process.

The value stream map (VSM) allowedthe team to examine which stepsand wasted activity could beremoved to produce a futuristic‘perfect world’ and to plan a ‘futurestate’ which would form the basis ofthe pilot for the new way ofworking.

Spaghetti maps and handoff charts were used to compare themovement of staff, samples andrequest forms in the existing andfuture states.

At the end of the initial two daysession, the team agreed to pilot theproposed ‘future state’ andexplained the proposed changes tothe rest of the sample handlingteam.

Key changes• Introduction of clearly defined standard work to ensure all staff understood their role.

• New roles for the medical laboratory assistants.

MLAs were split into two teams, oneto sort and barcode the samples, theother to enter the demographic dataonto the laboratory system anddeliver the samples to the analyticalsections. Dividing the staff in thisway ensured all the data entry teamhad their own terminal and did notwaste time logging in after eachsession. Sample handling was lesscrowded, allowing standardisedworkstations to ensure everything

required to perform the task isreadily available. 5S audits wereintroduced to ensure theworkstations remained fit forpurpose.

• A problem solver ‘runner’ role wasdefined to ensure the flow of samples through the department by dealing with problem samples ‘flow stoppers’ and urgent work arriving via the pneumatic air-tube. • Giving the ‘runner’ role the responsibility for dealing with urgent samples ensured this work had priority even when thebulk of the work from primary care arrived.

50

The future state removed andcombined a number of stepsreducing the total number of processsteps by 33%, cycle time by 15%and handoffs by 50%.

• Separate pre-sort stage removed and first in first out principles usedto process the work in flow.

• Initial check and barcode of samples combined into one step.

• Reduction of batch sizes from thirty samples to fifteen.

• Combined workflows halved the number of work streams and ensured order-comms requests were processed ‘in flow’.

• Request forms removed from the process post data entry.

• A3 problem solving technique used to investigate the impact of removing request forms from the haematology section which had previously been used as a trigger for further action.

• Visual management introduced so staff could at a glance identify andunderstand problems throughout the sample pathway.

• A questionnaire was produced andused to monitor staff morale and engagement.

The core team produced a teamcharter to work by: “working as ateam we will provide a quality,accurate and reliable process toenable the delivery of a timely andefficient patient focussed service.”

A later review of the transportservice to reduce the peaks of workarriving from primary care led to theintroduction of an ‘interceptor’ vanwhich met the other vans at setpoints along their routes. Thisallowed samples from primary careto be delivered to the laboratorythroughout the day and smooth theflow of work to the department. Theintroduction of colour codedtransport bags further reduced theworkload demand on the samplehandling team and reduced samplewaiting times for other departments.GP surgeries and communitylocations were asked to pre-sortspecimens for the separatepathology departments enablingsamples to be taken directly to therelevant laboratory. Communicationand engagement with the GPsurgeries and community serviceswas vital to the success of theimplementation of this system.

Communication was improved withthe introduction of short dailymeetings, or ‘huddles’, ensuring allthe team are updated of changes,workload, issues and problemsallowing all staff to be involved inthe discussions and potentialsolutions.

Members of the core team attended‘huddles’ in other departments toupdate on changes to samplehandling and potential impact ontheir department and workflows.This allowed the changes to progressquickly, captured potential issuesearly and encouraged greaterinteraction between the differentstaff groups.

Measurable improvements and impactThe overall aim was to improve theworkflow and turn-around times ofsamples arriving in blood sciencesand develop a standardisedapproach irrespective of the type ofrequest, route of arrival or analyticaldepartment.

One of the main drivers for changewas to improve the morale of thesample handling team. Moralescores from the staff questionnaireimproved by 23% over a six monthperiod.

As part of the capacity and demandmanagement, the number ofsamples arriving in the department isdiscussed at the daily meeting‘huddle’. Since the implementationof the new process there has been a10.2% increase in the number ofsamples processed which has beenaccommodated without increasingstaffing levels, a cost avoidance of£28,000 based on the currentestablishment. Error rates of 0.06%at data entry have been maintainedconfirming quality has not beencompromised due to the increasedworkload.

To date there is a 36% reduction inTAT from time of sample arrival totime of data entry. A steady

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improvement was noted initially butone set of data indicated there hadbeen a negative effect, withturnaround times 10% worse thanthe baseline. Detailed analysis of theturnaround times per hour of theday highlighted that the problemareas occurred at shift changes andbreak times. These now coincidedwith the earlier arrival of the primarycare work via the interceptor van.The data was reviewed with the pre-analytics team who were proactive insuggesting further changes toworking times to accommodate thechanges in the workflow. The latestoverall turnaround time dataindicates a 36% reduction in theturnaround time from receipt ofsample to result available.

Key learning• The power of ‘go and see’ and notmaking assumptions when producing the value stream map or reviewing the data.

• The importance of robust data to monitor the impact of the changesand review problem areas.

• Involving the staff in the decisions and empowering them to continue to develop the department has led to a much more engaged and receptive workforce. Staff are now much more pro-active in providing potential solutions than just identifying a problem.

• Giving staff time out of the routinework of the department to implement the changes has been avaluable investment.

• Communication is vital, daily ‘huddles’ take place in every department in pathology enabling the rapid communication of changes and assessment of impacton other areas.

• Sharing the learning and reviewingthe changes which have taken place in other areas of pathology. This has been facilitated by the introduction of a monthly directorate ‘lean lunch’ attended by the clinical director and general manager, providing a forum for all staff to informally exchange ideas. Successes in one department have since been implemented in others without having to ‘re-invent the wheel’.

• Going out to talk to the users before implementing changes suchas the new transport bags has led to greater engagement and provided a network of key contacts.

How this improvement benefits patientsConsistent reduction in sampleturnaround times allows for earlierdiagnosis and treatment of patients.

How will this be sustained andwhat is the potential for thefuture?• The potential impact of this improvement will be discussed with service users to determine how this might affect their patient management.

• To standardise the process further and ensure turnaround times are maintained the department has started to calculate the ‘takt time’ for each task. This will allow the sample handling team to react appropriately to changes in workload demand.

• Work has already started with other departments to improve the patient pathway. Recently the department and phlebotomy service have processes mapped haematology clinics and are working with the haematology team to reduce the waiting time for patients.

ContactChristine Ainger, Service Manager,Blood Sciences DepartmentEmail:[email protected]

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Using data and team problem solving toimprove sample TATSummaryAttention to metrics and daily teamproblem solving have led to earlyidentification of a defect and a 20%improvement in achieving an internaltarget.

Understanding the problemThe specimen reception teamnoticed from their InfoCentremetrics that they were failing tosustain their turnaround target timefrom sample receipt, to whenavailable for analysis. Thisobservation was recorded on theteam’s continuous improvementsheet for discussion at the next dailymeeting. At the team meeting theroot cause was provisionallyidentified (using the five whys) as thechecking process for order commsrequests for which there had recentlybeen a significant increase. The teamagreed to devise a rapid experimentto try an alternative process.

How the changes wereimplementedA member of the team was assignedthe task of devising and monitoringthe experiment. Feedback at asubsequent daily meeting withexamination of the metrics indicatedthat the new way of working wasreducing the turnaround time and infact the team was now exceedingtheir target. It was agreed that newstandard work would be written sothat the new process became thenew standard.

Measurable improvements and impact1.This is an internal target which had been deliberately set to be challenging in order to drive further improvements in this part of the process. A defect was identified from metrics. TAT in specimen reception has fallen from80% success rate to 60%.

2.Defect recorded on the continuousimprovement sheet for discussion at daily meeting.

3.Team apply the five whys root cause analysis and agree countermeasure.

4.Rapid experiment devised with fullinvolvement of the team and revised

5.Metrics indicate that the new process is improving the TAT. New standard work agreed and written.

6.Continued monitoring of metrics indicates that countermeasure has been successful. TAT success rate now above original.

Daily team meetings and theapplication of simple problem solvingtools can have a significant impact onimproving performance.

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Turnaround time metrics Rapid experiment

Continuous improvement sheet Root cause analysis(5 whys)

Defectcorrected

Rapidexperiment

Rootcause

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Key learning• Data is vital to understanding and improving performance.

• Daily team meetings and the application of simple problem solving tools can have a significantimpact on improving performance.

• Ownership of the problem, its analysis and implementation of solutions by the team responsible for the work is key to sustained improvement.

How this improvement benefits patientsThe new process has increased thesuccess rate for achieving shortenedTATs for samples. This contributes toan overall reduced TAT for bloodrequests, improving the timelinessthat clinical teams receive testresults.

How will this be sustained andwhat is the potential for thefuture?This improvement will be sustainedby the production of revisedstandard work for the new process.All staff were, and continue to be,involved in identifying, analysing andsolving the problem and monitoringthe solution at their daily meetings(huddles).

ContactJanet Ashworth, Specimen Reception ManagerEmail:[email protected]

A key stage in all laboratories and forall disciplines.

The stage in which actual analysis ofthe sample occurs. Be it fullyautomated, semi-automated ormanual testing the key steps are:• receiving the sample;• performing the analysis; • performing the appropriate QC and QA;

• technically validating the results;• clinically validating the results including delta checking; and

• the addition of appropriate interpretive commentsbefore releasing the results for distribution to the user.

The laboratory adds value at thisstage by:• ensuring that all samples flow through the testing area, preferably, in small batch sizes, with the minimum of non-value adding steps as quickly as possible;

• performing appropriate QC and QAto ensure accuracy of test results;

• identifying errors in testingand working with colleagues and suppliers to minimise these errors; and

• performing clinical validation with interpretive comments.

Analytical stage

The concepts highlighted in the casestudies in this section include:• user engagement;• communicating with users; and• co-location of resources.

The tools illustrated include:• visual management;• Takt time analysis; • ‘stranger’ and ‘waterstrider’ roles;• daily huddles;• root cause analysis; and• Pareto analysis.

ANALYTICAL

RECEIVE

TEST & QC/QA

TECHNICALVALIDATION

CLINICALVALIDATION

Analytical stage54

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Changed priorities in the laboratory to deal withsamples from same day surgical admission patients -analyser set-up and method of validation

SummaryLean principles and a three day ‘Leanevent’ with multidisciplinaryrepresentation including the coretransfusion team and staff from thesurgical admissions lounge was usedto map the value stream from pre-assessment to theatre admission andhighlight areas of waste forimprovement. Implemented changesreduced turnaround times by anaverage of 28 minutes and helped toimprove workflow on particularlybusy mornings by having a secondanalyser available before 08:00am.

Understanding the problemThe number of same day surgicaladmissions at Musgrove ParkHospital has increased dramaticallydue to increasing bed pressureswithin the hospital. This has led to areduction in the time available toprocess transfusion samples and aperception that laboratory practicedelayed theatre start times. Auditshowed that during the first week ofJune 2011 none of the group andsave requests received from thesurgical admissions lounge hadresults available at 09:00am and16% of these patients went totheatre before the results werevalidated and viewable by thesurgical team. Value stream mappingshowed significant delay in the post-analysis stage of sample processing.Results were waiting for an averageof 28 minutes before being manuallyexported to the laboratory computersystem (LIMS).

Root cause analysis identified severalreasons for this:• distraction of the on-call BMS withother duties;

• analyser set-up between 08:00am and 09:00am; and

• general lack of awareness of the importance of the post-analysis phase.

Similarly, rejected samples weretaking an average of 64.5 minutes to validate because of thedisproportionate amount of effortinvolved in validating singlespecimens, coupled with a lack ofunderstanding with regards to theimportance of validating resultspromptly.

Measurable improvements and impact• Implementation of the auto-validation of sample rejects reduced the validation time of this unique subset of samples from an average of 64.5 minutes to zero. Similarly, auto-approval and export of ‘normal’ results on the emergency analyser has decreased the mean time from results being available on the analyser to export to the LIMS from 28 minutes to zero.

Value stream and process mapping isa very valuable tool and can help toidentify waste and key areas forimprovement within the process.Small changes can have a significantimpact on turnaround times andimprove patient safety.

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Both these small changes have had ahuge impact on the turn-aroundtimes for group and save sampleswithin the laboratory. They havealso saved approximately ten tofifteen minutes of Band 6 time per day. • The impact of changing the analyser set-up time is harder to quantify, however, it has had a double benefit. • There is now a second analyser available from 08:00am to help deal with large influxes of urgent work at this busy time.

• The on-call BMS is now less distracted between 08:00am and 09:00am and better able to concentrate on processing the urgent pre-operative bloods.

Key learning• It is important to differentiate between what is thought to happen in a process and the realityof what actually happens.

• Value stream and process mappingis a very valuable tool and can helpto identify waste and key areas forimprovement within the process.

• Where waste is observed, current practice should be challenged and potential alternative methods sought.

• A small change can have a significant impact on turn-around times and improve patient safety.

How this improvement benefitspatientsThis improvement benefits allpatients requiring an urgent groupand save, particularly those admittedfor same day surgery. Thepercentage knife to skin breacheshas shown to have improved from16% to a consistent 0%, thusimproving patient safety in theatre.In addition, auto-validation ofsample rejects promptly informs theclinical team of any problems so thata fresh sample can be taken as soonas possible.

How will this be sustained andwhat is the potential for thefuture?Most of these changes are self-sustaining: once implemented, thereduction in waiting time ismaintained through a standardised(automated) process. However, aswork-pressures increase for the on-call BMS at this busy time thepotential for distraction increasesand it may be necessary to changethe work patterns within thelaboratory to keep pace withcustomer needs and expectations.There is potential to implementauto-export of results on the batchanalyser as well as the emergencyanalyser, however, this is lessstraightforward and has yet to betaken forward.

ContactNicolette Heydon, Senior Transfusion BMSEmail: [email protected]

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Reducing the turnaround times for haematologyclinic by reducing the time taken from a result beingavailable to authorising a result that requires aperipheral blood film

SummaryThe goal is for haematology clinicspecimen results that require a filmto be authorised as soon as resultedrather than wait for film commentsso the result is available to theclinicians to action drug dosing. Thiswill reduce turnaround times by upto three hours.

Understanding the problemFollowing analysis of how clinicsamples are processed, it was foundthat there was an area forimprovement from the time taken toauthorise these clinic samples oncethe result had become available.Upon inspection it became apparentthat over 90% of clinic samples wereauthorised quickly within a suitabletime frame however approximately8% of clinic samples required ablood film to be looked at. This cantake up to three hours depending onstaffing levels, leaving the resultunauthorised and greatly increasingthe mean turnaround time forauthorisation of results. This is aproblem for the patient as pharmacycannot access unauthorised results,yet they need the result to dose thepatient. This leads to a delay intreating the patient and thusincreasing time spent in the hospitalfor their clinic appointment.

How the changes wereimplementedA suggested change was potentiallyauthorising all clinic resultscompletely so pharmacy cancontinue with patient care whilst theblood film is waiting to be analysed.

This information was then fed backto the haematology biomedicalscientist team, who were given theopportunity to raise any issues theymay have with the suggestions.

Potential issues included:• a comment is needed to make other departments aware that the result is subject to film review;

• a post-film comment is needed to confirm it is an amended report;

• there was concern over paper reporting (would there be two different paper reports in the patients notes or is it all electronic and does the second electronic result override the first?);

• concern over results changing post film – e.g. if metamyelocytes were detected on the film and a manual white blood cell differential performed lowering the neutrophil count slightly, is this of any significance?

Reduce the waste of over processingby only processing haematology filmsas necessary rather than 'just in case'.

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Resulted toauthorised

Arrival toauthorised

+13 hours

Delays to results being authorised because blood films being generated ‘just in case’

Box plot (showing 10th and 90th percintile and median) forhaematology clinic FBCs

58

• a turnaround time would need to be agreed for samples that neededa film before the result could be released, e.g. unexpectedly low platelet counts; and

• there was concern that if a film did not get written down on the ‘further action list’, then the film would be missed as it would be authorised and therefore would not get picked up on the work file.

A meeting was then held to discussthese points and determine thesignificance. It was decided that thefollowing comment would be addedto any authorised clinic resultneeding film review.

‘This is an interim report awaitingfilm review. Do not action resultswithout first consulting a consultanthaematologist.’

It was then suggested that once thefilm had been analysed, thiscomment should be removed and areplacement comment added.

‘Please note this is an amendedreport following film review.’

It was decided that this shouldinclude patients with no white bloodcell differential, the logic being thatfor some patients only a plateletcount or a haemoglobin level issufficient for dosing. A turnaroundtime will be agreed for patientswithout a differential where thedifferential is needed prior to dosing.

If there is concern over a resultpotentially changing post filmanalysis, (for example anunexpectedly low platelet count),then these results will not beauthorised until a film has beenanalysed to confirm the validity ofthe result. This information wasthen emailed to the service managerwho, along with the consultanthaematologist, discussed the issue atthe consultants meeting. Animplementation date has yet to bedecided and a standard operatingprocedure (SOP) needs to be inplace.

Measurable improvements and impactIt is expected that once this changeis implemented, the turnaroundtimes in the laboratory for clinicpatients will be reduced. More datawill be collected postimplementation to produce evidenceto this effect.

Key learningReduce the waste of over processingby only processing haematologyfilms as necessary rather than 'just incase'

How this improvement benefitspatientsReducing the time taken to authoriseclinic results contributes towardsreducing the overall turnaround timethat a patient spends on site for theirappointment. This is beneficial to thepatient as it enables them toprogress through the clinic process ina more efficient and practicalmanner, thus enhancing theirhospital experience.

How will this be sustained andwhat is the potential for thefuture?The changes will be sustained by thecontinued support of thehaematology biomedical scientiststoward the new process. Potentialadjustments to the system toimprove include the addition of asuppressed flag that does not delaythe authorisation of results butallows the haematology BMSs todetect any missed samples requiringa film.

ContactSarah Fraser, Haematology BMSEmail:[email protected]

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5S of cold room at Derby

SummaryA transformation of the cold room inthe main biochemistry laboratorywithin just a day improved thequality of service, work efficiencyand productivity and also gave jobsatisfaction.

Understanding the problemThe cold room in the mainbiochemistry laboratory is used byalmost every member of staff as thisis used to store reagents, calibrators,QC material, washes etc. Staffmembers working nights weregetting extremely frustrated as themess in the cold room was:

• awful and unbearable;• tight spaced - items on the floor, so lots of clutter;

• lot of different unnecessary items including waste and trolleys;

• no waste bin;• not enough reagents, QC material,washes, calibrators etc. as space was limited;

• no set order, difficult to locate anything, very untidy; and

• dangerous!!!

Staff members had to go to themain cold room in the corridor tocollect reagents in the middle of thenight and scan every item. Thismeant that they were spendingaround half an hour minimum timeaway from the laboratory which waseffecting the one hour turnaroundtime of the urgent samples fromA&E. This is non-value added timeand has a big impact financially onthe trust, especially a Band 6 or 7 ifyou work out the salary per hourthey could be saving time and doingsomething more effective.

How the changes wereimplementedStaff members split into five teams,each group was given an importanttask and together we managed tosort everything out.

Team 1 took everything out of the cold room.Team 2 checked the dates of all the stock and gave expired items to team 3.Team 3 separated all the expired,unwanted and items that needed togo back to the main cold room. Theyalso calculated the financial loss dueto the expired stock.Team 4 assembled new shelves togo into the cold room.Team 5 analysed the teams ensuringeveryone was working according toplan.

The floor was cleaned in the coldroom using a dustpan and brush,new shelves were added, decisionswere made regarding what wasneeded and the quantity with the useof a checklist, everything wasrearranged and organised inalphabetical order by labelling theshelves. One by one all the itemswere put back into the cold room,with the reagents and calibrators thatare used the most at the front andless frequently used reagents towardsthe back of the cold room. Reagentswere labelled alphabetically andplaced in trays. A waste bin was alsoplaced in the cold room.

Staff were made aware of theimportance of the 5S cold roomproject in a meeting and the impactthis may have if we do not worktogether as a team. Following thislaminated sheets were placed on thedoor with pictures showing how thecold room is expected to look at alltimes.

A one day 5S can improve safety, savemoney and engage staff to realisesmall changes can have a big impact.

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Items that had expired orwere of no use

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Measurable outcomes andimpactThe result is that the cold room ismuch safer, very well organised,much cleaner and items are easier tolocate. This has facilitated goodwork flow and good productiveworking.

Staff members appear to be moreenergetic as they are not as tiredphysically and feel so much better. Afew colleagues have shown theirappreciation which means it isworking and definitely feels good.

“Thank you for sorting outthe cold room, you havedone a great job. I’m sorelieved I don’t have to go tothe main cold room to collectreagents anymore.

I managed to load reagentson in just 5 minutes - nightsare so much better now.”

Sheri Scott, BMS

Ideas tested which weresuccessfulThe cold room is assessed everyFriday by using a 5S scoring sheet tomake sure we are maintainingconsistency.

‘’In order to ensure the coldroom contains sufficientamount of reagents etc.,Dave Megson or Cliff visitthe main laboratory coldroom every day around thesame time and restock theshelves. This has beenworking great for us so far asthere are enough reagents atall times.’’

Key learning‘’When you sit and reflect itmakes you realise that a lotcan change in just one day.The cold room wastransformed with a fewhours of hard work! Thisreally shows that nothing isimpossible, also as this is justthe beginning, in order tomaintain this it is absolutelyvital that everyone workstogether as a team.’’

How this improvement benefits patientsStaff members will not be wastingany more time collecting reagentsfrom the main stores, which meansthey have more time to concentrateon patient samples, ensuringsamples are processed andauthorised within the turn-aroundtimes. Patients will receive results alot more quickly and thereforetreatment will be done sooner ifnecessary.

ContactShabana Asghar, Chemistry BMSEmail: [email protected]

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Path Links

Demonstrating how Lean work cells deliver fasterturnaround times, higher productivity and efficiency,increased flexibility, improved space utilisation andimproved quality

SummaryThe adoption of Lean principles andmethodologies provides significantimprovement opportunities for theclinical laboratory. Not least toaddress the challenges of improvingquality, increasing productivity andreducing costs, Lean provides asystematic and analytical approachto achieving optimised workprocesses, laboratory design, layoutconfiguration, and appropriateequipment choice.

Understanding the problemBased on perceived needs andbenefits rather than an objectiveunderstanding and analysis ofprocess, the blood scienceslaboratory commissioned foursystems for pre-analyticalautomation (purchase price£800,000, revenue costs £80,000per year).

Several departments began a Leanprocess analysis, using value streammapping (VSM), future statemapping, waste identification andexamination of laboratory layout toscrutinise batching and sample flow.This demonstrated that the pre-analytical equipment contributed tounnecessary delays and bottlenecks,proving less efficient than anoptimised manual Lean process.

Further analysis of the layout andspace utilisation of the laboratoryenvironment revealed aconfiguration that hinderedworkflow and productivity.

Wastes identified• Transportation - Excessive travel of samples and staff >1.6km EVERY hour (£8k p.a.). Urgent pathway only, routine pathway operated independently contributing to further delays.

• Inventory - multiple work in progress (WIP) areas, excess equipment.

• Motion - poor workstation layouts.

• Waiting - variable time frames up to four hours.

• Over processing/production -multiple checking adding delays.

• Defects - increased opportunity for error due to complexity of process.

• Skill - poor/underutilisation of staff skill.

How the changes wereimplementedUsing a rapid improvement or Kaizenevent, the work cell philosophy hasbeen applied to the pre-analyticalprocess, where, a single operatorundertakes all pre-analytical functionsin a single process from de-bagging,sample and request checking, bar-coding, data entry, sample rackingand centrifugation.

Lean work cells are designed toeliminate waste, improve flow andhelp optimise material, people andinformation flows. Communication isenhanced, because operators workcloser to each other and, throughimproved visual control, operators cansee and manage the entire process.

Through achieving and maintainingefficient continuous work flows, Leanwork cells deliver shorter cycle times(turnaround times), higherproductivity and efficiency, increasedflexibility, improved space utilisation,and improved quality.

Automating a poor process onlyserves to automate waste and willoften lead to higher expenditure thanis required.

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The experience from manufacturingindustry is that a u-shaped Leanwork cell provides an optimumconfiguration, minimising walkingdistance and allowing differentcombinations of work tasks to beundertaken by the cell operator. Thelaboratory layout of the work cell isstandardised so that each work cellis identical. Samples are processedone at a time achieving ‘single pieceflow’ on a ‘first in first out’ basis.Problem samples are taken out ofthe process so as not to interrupt thework flow.

The entire process is designed tooptimise throughput and eliminateopportunity for error.The analytical work cell bringstogether automated systems; in thiscase, haematology, clinicalbiochemistry/immunoassay andcoagulation. Efficiency gains areachieved as a single operator canmanage the work cell.

Measurable outcomes andimpactThe development and deployment ofpre-analytical work cells has led todramatic improvements to laboratoryefficiency and productivity. Hospitalinpatient turnaround times haveimproved by 40% and medianturnaround times for emergencydepartment requests down to 14minutes for haematology (CBC) and29 minutes for chemistry(U&E/Troponin I). The completion ofroutine daily work has been reducedby over two hours releasing two FTEpreviously required for the eveningwork period.

A further benefit of work cells is thatthey are scalable to match variableworkload activity throughout theday. During quiet periods only asingle work cell will be operationalincreasing to maximum deploymentat peak times. The data shows thatthe throughput of each pre-analytical work cell is 60 requests perhour for manual data entry and 240for electronic order requests. At peaktimes, utilising three work cells toensure smooth and continuous flow,a rate of delivery of between 45 -180 samples to the analytical workcells is achievable every 15 minutes.

Importantly, the analytical capacityof the analysers is not exceeded withboth systems running at 75% oftotal capacity throughout the period.

The benefits of work cells include:• no wait points, with a single point of entry for all samples;

• maximises staff resource;• full line of site between functional groups (from pre-analytical to reporting);

• releases estate for further development;

• co-location of blood transfusion to support out of hours BMS/BMA working; and

• manual laboratory testing co-located.

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Key learning• Although improving quality, increasing staff productivity, and reducing costs are challenges typically driving clinical laboratories towards higher levels of automation as a solution, this does not always bring the predicted benefits.

• Lean is not an alternative to automation per se, but rather as a methodology that may be used to guide the appropriate choice of equipment and its utilisation in thelaboratory.

• Automating a poor process only serves to automate waste and will often lead to higher expenditure than is required.

How this improvement benefitspatientsBy improving TATs, and makingresults available to clinicians morequickly, will ultimately mean a betterservice for patients.

How will this be sustained andwhat is the potential for thefuture?In Path Links laboratories, Lean isbeing applied to all work processesacross the pre-analytical, analyticaland post-analytical phases to achievea total Lean laboratory solution. Thelean tools being used include:• value stream mapping;• layout evaluation;• work cell analysis;• achievement of continuous flow; and

• batch size reduction.

ContactMartin Fottles, Path LinksContinuous Improvement ManagerEmail: [email protected]

Mick Chomyn, Path Links AssistantGeneral ManagerEmail: [email protected]

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Crossing disciplinary boundaries improvestransfusion safety for day surgery patientsSummaryBy engaging a multi-disciplinaryteam to examine the whole pathwayand make improvements, the end-to-end TAT for day-case patients hasdecreased by 62% and theoccurrence of surgery commencingwithout a group and screen resulthas reduced from 45% to zero.

Understanding the problemForty five per cent of day casesurgery patients were undergoingsurgery without the availability of avalid group and screen result toassure safe transfusion cover fortheir procedure. A number of causeswithin the patient admission,phlebotomy and analytical processwere found to be at the root of theproblem. A thorough review of theentire patient pathway highlightedsurgical teams consistently failed tocheck for the presence of validresults prior to commencing surgery.Forty seven per cent of test resultswere never reviewed prior to thecommencement of surgery.

How the changes wereimplementedInitially, a GEMBA walk (a ‘go see’activity designed to see what ishappening where the work is done)allowed everyone to understand theprocess and identify issues at a valuestream level. Key metrics includingpatient admission times, samplecollection/delivery times andanalytical processing times werethen identified and measured.Subsequently a three day rapidimprovement event withrepresentation from all disciplinesinvolved in the day surgery patientpathway was held. The entire patientprocess from admission to theavailability of a group and screen

result was mapped and acollaborative approach was soughtto reduce the non-value added stepsin the process in order to ensurepatients had a valid group andscreen result prior to thecommencement of surgery:

• Expectations of all those involved in the process were identified and understood.

• The phlebotomy process was identified and incorporated into a specific stage of the patient admission process.

• Sample delivery and reception processes were defined.

Measurable improvements and impactAwareness of the need to check forvalid results prior to surgery hasimproved in clinical areas and a morerobust mechanism to ensure resultsare reviewed is being sought:

• Total steps in the entire process were reduced by 31% with non-value added steps reduced by 38%.

• The flow time of the admission to result provision process was reduced by 65%.

• Hand-offs, which can introduce risk and delays into a process, were reduced by 56%.

• Staff distance travelled was reduced overall by 42%.

• Initial trial of day admission phlebotomy process culminated in the employment of a care assistantwith a designated role of phlebotomy.

• The multidisciplinary approach has reduced the occurrence of surgery commencing without a group and screen result from 45% to zero.

• Laboratory staff feel empowered to suggest change and a culture ofcontinuous improvement has developed within the laboratory.

Any improvement effort shouldalways include the key stakeholdersin the pathway.

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% knife to skin breaches (all data)

Percentage of occurences where group and screen results were notavailable when surgery commenced on day admission surgerypatients admitted via S.A.L.

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Since the rapid improvement eventin July 2011, reductions inturnaround time for all group andscreen results has been observed(see the graph on the right).

Pre event turnaround times of 158minutes for non-acute work has nowreduced to 100 minutes since theintroduction of Lean methodology,representing a 62% improvement.Overall improvement in G&S TATs is66%.

Key learning• The laboratory-clinical interface is central to finding a solution to what can be perceived as an isolated/internal problem.

• A rapid improvement event with appropriate representations can resolve issues for all disciplines andfocus a common goal.

• The use of lean methodology markedly reduces unnecessary steps in a process which can impact directly on patient safety.

How this improvement benefits patientsForty five per cent of surgerycommencing without a valid groupand screen result has reduced tozero. A vast improvement in patientsafety has been observed withimproved understanding andresponsibility of clinical teams toensure surgery is appropriatelycovered for transfusion.

How will this be sustained andwhat is the potential for thefuture?Specific data measures are in placeto permit continuous monitoring.Any breaches of result availability atthe time of surgery commencementare investigated as defects and root-cause analysis performed in order tocontinually improve the service.

ContactMatthew Barnett, AdvancedPractitioner, Blood TransfusionEmail: [email protected]

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Positive clinical benefits of improvement work ina transfusion laboratory: a clinician’s viewSummaryImprovement work in the transfusionlaboratory has resulted inunexpected clinical benefits. Anaudit of transfusion rates inorthopaedic surgery has led to pilotof pre-operative correction ofanaemia. An audit of transfusionrates in laparoscopic surgery ischallenging the practice of takingroutine G&S.

Understanding the problemThe transfusion laboratory teamrecognised that surgery wassometimes delayed as G&S resultswere unavailable. To understandcurrent practice anaesthetic andsurgical colleagues were invited to atransfusion event. This forumallowed the establishment of regularmeetings between the transfusionteam, consultant haematologist andanaesthetic colleagues.

How the changes wereimplementedIt was recognised that there was nouniform practice for e.g.management of pre-operativesurgery, or where G&S results arerequired for a range of other surgicalprocedures. Consequently, anunderstanding of current practicewas needed to drive these changesand as data was needed to supportthis several audits were undertakenby medical trainees.

Measurable improvements and impactAn audit of transfusion rates inorthopaedic surgery demonstratedtransfusion rates of 42% in patientswith pre-operative anaemiacompared to 10% in the non-anaemic group. A joint workingparty (haematology andanaesthetics) has written guidelinesfor the correction of pre-operativeanaemia and a pilot is in progress,employing logic rules in thelaboratory and parenteral irontherapy in the clinical areas. Ifsuccessful this will be adopted by allsurgical specialties. A survey oftransfusion rates in laparoscopicsurgery confirmed transfusion ratesof less than 1%. If unnecessarytransfusion testing is stopped thiswould result in annual savings inexcess of £10,000. There is now aneffective clinical interface betweenthe transfusion service and userswith quarterly meetings betweenhaematology and anaestheticcolleagues.

Key learningEstablishing effective communicationwith clinicians has allowed clearidentification of common goals andefficient team working. Data is vitalto inform clinical teams and to drivechange.

How this improvement benefits patientsOverall clinical care is improved andis more cohesive. Patients avoidunnecessary blood tests andtransfusions.

How will this be sustained andwhat is the potential for thefuture?Meetings are timetabled to continueon a quarterly basis. Future projectsinclude critical assessment oftransfusion sampling rates inperipartum setting.

ContactDr Sarah Allford,Consultant HaematologistEmail: [email protected]

Establishing effective communicationwith clinicians has allowed clearidentification of common goals andefficient team working. Data is vital toinform clinical teams and to drivechange.

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The Health Foundation, South Warwickshire NHS Foundation Trust

The relationship between patient flow, patient safety, labour cost and the contribution oflaboratory sciences to appropriate patient care

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By collecting appropriate data todemonstrate the system performance(SPC), simple laboratory changes canreduce sample TAT.

SummaryBy collecting appropriate data todemonstrate the systemperformance, simple laboratorychanges based on Takt time andmaintaining a ‘trickle’ flow ofsamples has ensured 80% to 100%of U&E results are available to theward rounds by 10:30am. The trustwas also given a ‘highlycommended’ in the Patient SafetyAwards March 2011, in the category‘Patient Safety in Diagnosis’.

Understanding the problemDelays getting samples to laboratory due to:• phlebotomists starting at 09:00, then batching and prioritising work;

• transport: batching and prioritisingwork; and

• delays within the laboratory: big machines requiring large batches, necessitating prioritisation of workand samples, leading to uncertainty and delays for requestors.

Delays getting results back to requester due to:• no visibility of when results are available – the queue is ‘hidden’ inside computers;

• blood results are not back until after the ward round has finished so the results wait until the following day’s ward round. As a consequence clinical decisions are made for acutely ill patients on blood results that are 24 hours outof date; and

• day-time to night-time to day-timestaff handovers make the problem worse.

Delays are at non-value adding booking-in and waiting for verification in the laboratory.

Inpatient monitoring: • alerted by patient safety incidents (silent haemorrhage in one patientand two hypo-natraemic patients unwittingly put on drips); and.

• observing ward rounds - all clinical decisions are made on blood tests which were at least 24 hours out of date.

Samples arrive into thelaboratory from multiple sources: • emergency: A&E, assessment units, emergency from wards and ITU/CCU;

• inpatient morning monitoring bloods from wards;

• outpatients; and• GPs.

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Demand profile by half hourly time buckets (NB this is a record ofnumber of samples booked in as can be seen by the impact oflunchtime on the numbers booked in).

68

• The A&E and assessment units have an air-tube to the laboratory, but the wards do not.

• The requests are left until the end of the morning ward round (a fourhour delay). By this time the phlebotomists have left the wards,so unless the doctors take the samples, the requests are left on a peg behind the nurses’ station for the following morning phlebotomy round (24 hour delay).

• The hospital’s routine round robin transport trolley round picks up all samples, post, drugs etc. and has a cycle time of one and a half hours to get a sample from ward to laboratory.

• The result remains unopened on the computer system until the following evening round or consultant morning round (a 12 hour delay) when a different juniordoctor or consultant reviews the patient.

• There is a 20 minute delay while batches of samples are sorted and prioritised before being logged into the LIS.

• Minimum centrifuge and analyser time for a basic chemistry is 27 minutes (but only for a very urgentrequest that involves the doctor phoning the laboratory technician).

• There is a batching process every half an hour for the laboratory scientist to verify results before they are released to the IT system and ICE (where the ward staff can view results). By this time the doctor and (very probably) the patient have moved on.

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RSA

Where do the delays occur in the laboratory process?

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Process map and impact of flow into laboratory

69

• There was no time series monitoring of turnaround times (either as actual cycle times or as apercentage against the clinician’s desired target of one hour). Instead the three laboratories in the network were compared monthly against an arbitrary targetof only the 85% of A&E samples TAT in one hour. None of the laboratories achieved this unacceptable target as far as the clinicians were concerned. However one laboratory was ‘praised’ as being the ‘best’ in the network despite there being no statistically significant difference between laboratories.

• Despite improvements in laboratory turnaround time, this does not show in data collected in this format.

How the changes wereimplementedGetting ward samples to thelaboratory earlier • Phlebotomists started earlier at 08:00 before the ward rounds at 09:00

• Two ‘hot-socks’ porters employed from 08:15 to 10:15 to run between each ward and the laboratory so that smaller more frequent batches arrived in the laboratory every few minutes, enabling a constant trickle-flow into the laboratory.

• Emergency blood samples: alertingthe junior doctors to the clinical impact of delayed emergency samples and training them to achieve one-piece flow by putting samples in the air-tube.

Inside the laboratorya.Change in the laboratory staff rotas so one technician arrived earlier at 08:15 to help the night technician start processing the ward samples before leaving at 09:00.

b.Takt time calculated to work out the number of staff needed each hour.

Maximum rate of production i.e. atmaximum demand in afternoon =one sample every 24 seconds: thismust be met throughout thelaboratory. This means, one sampleinto the laboratory every 24 seconds,and one result (in-full) out every 24seconds.

To enable production to Takt.• Booking in: • one blood sample every 24 seconds; and

• cycle time (task time) for booking-in = 1 minute, therefore 3 laboratory staff required at booking- in at peak time.

• Centrifuge:• 10 minute cycle; and• three centrifuges: so one centrifuge has to be started every 3.33 minutes.

Lesson: Do not wait to fill the large centrifuge! The same overall centrifuge capacity is required but made up of several smaller batch quantity centrifuges.

• Remove the RSA (tube top remover track). This causes a delayof 20 minutes to process one centrifuge load of 32 samples and irregular batching onto the analysers. Lesson: ‘One piece flow’ onto the two analysers is required.

• Laboratory scientist ‘hot verifying’ so there is no batching.

The laboratory team plotted thesame data used for the DRAT butas a time series. TAT measured inthis way (statistical processcontrol chart) is used to ensurethe process is ‘in-control’, as wellas to show the step change in theprocess when the phlebotomy/transport and laboratorybottlenecks were addressed.

Measurable improvements and impact• Despite electronic systems, manualdata collection is required to collect the end to end process time. However, when this data was collected and charts produced, laboratory staff could relate the changes in process performance to changes in the collection of samples and the laboratory, e.g. phlebotomy or laboratory staff sickness, taking the RSA machine out of the process. This gave them confidence:a) that they could achieve a far higher level of performance despite an increase in demand;

b) which changes did or didn’t improve the process; and

c) the fact that their data backed up their real life experience of working in the laboratory. The delusion of ‘best service’ and therefore that everything was okcould no longer survive.

70

• SPC enables managers to see when the process is statistically out-of-control and not capable of producing the one hour turnaround time.

• At the start, less than 10% results were back to the requester on the morning the blood was taken. Now 80% to 100% of U&E resultsare available to the ward rounds by 10:30am.

• Highly Commended in the National Patient Safety Awards March 2011 for ‘Patient Safety in Diagnosis’.

How will this be sustained andwhat is the potential for thefuture?• More work needs to be done to ensure 100% samples from whatever source have a TAT <1 hour.

• Employing and training more phlebotomists and laboratory technicians to take blood.

• Laboratory staff to monitor laboratory turnaround and use improvement science (lean, theory of constraints, SPC) to continuously improve performance.

• Mobile hand held devices to alert doctors when a result is available at the bedside e.g. VitalPac

• Regular feedback to doctors and laboratory staff on the impact of doctor behaviour and laboratory performance on patient care. This should include praise when very ill patients have their samples collected by the phlebotomists andporters; the abnormal result is spotted by laboratory staff and treated quickly by doctors on the same morning.

How this improvement benefitspatients“I now know if the blood resultisn’t back for the ward roundthere is something wrong andwe need to revisit the patient atthe end of the round”.Quote from a consultant physician

Key learning• Stop carve-out (prioritisation) and do this hour’s work this hour.

• Change the financial paradigm (a policy constraint): the pathology network is working to the economies of scale paradigm and the local laboratory is learning to work to the ‘economies of flow’ paradigm (Theory of Constraints).

Which is more costly to thetaxpayer? • One hour of phlebotomist time or four extra days length of stay with a misguided clinical decision and all the potential for litigation or anunexplained death.

• The blood collection, processing and review delays for one patient meant that a 38 hour length of stay turned into eight day length of stay.

Learning for the laboratory• Implications for technology investments from ‘economies of scale’ to ‘economies of flow’.

• Implications for job design and team work.

• IT and LIS not capable of tracking a sample from booking in to verification.It is very difficult for laboratory staff to get their data tounderstand their process capability.

• Comparative mind-set - comparisons of laboratories to each other, but with no idea of each laboratories individual process capability.

• Arbitrary ratios and targets set by the network are not good enough for patients or users.

ContactKate Silvester, BSc MBA FRCOphth(coach for ‘Flow Cost Qualityprogramme’ sponsored by TheHealth Foundation between April2009 and March 2012) Email: [email protected]

In this stage the results are madeavailable and delivered to the user.Paper copies of results and/orelectronic copies of results areprepared and distributed.

The reports themselves should:• convey the results;• highlight abnormal findings; and• carry clear interpretations and comments.

The laboratory adds value at thisstage by:• ensuring that results have been released in a timely fashion; and

• reports are delivered to the correct requestor• in their preferred format• as quickly as possible• with clear interpretations • with comments which have beenagreed with the users.

Post-analytical stage

The concepts highlighted in the casestudies in this section include:• user engagement;• communicating with users;• providing predictability of result availability against timescales agreed with the users; and

• providing signals to alert result availability.

The tools illustrated include:• visual management of result availability;

• root cause analysis; and• Pareto analysis.

POST-ANALYTICAL

RESULTS AVAILABLE

DELIVER REPORT

71.Post-analytical stage

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Implementation of a visual system to improvepatient turnaround times in A&ESummaryWorking together with staff in A&Eto identify delays in patientpathways, a simple visual tool wasintroduced which reduced theaverage time from laboratory resultsavailable to results viewed by 90%.This contributed to reducing theoverall patient waiting time in theA&E department and helped reducebreaches of the four hour target.

Understanding the problemAs a result of previous initiativesbetween the laboratory and the A&Edepartment, an agreement had beenreached regarding time targets foreach part of the patient pathwaythrough the A&E department.

Analysis of turnaround dataindicated that the average time fromresults available to results viewedwas 110 minutes.

Observation of the processes in A&Eindicated that the problem for staffwas that they had no way ofknowing whether a sample hadarrived in the laboratory or whetherthe results were available.

Consequently they wasted aconsiderable amount of time makingenquiries on the laboratorycomputer system. These enquirieshad to fit in around their patientcare duties. Delays in viewing resultsfor a particular patient wereregularly caused by the member ofstaff being busy with anotherpatient.

A simple visual indicator of bloodsamples received in the laboratoryand availability of test results wasrequired in the A&E department.

How the changes wereimplementedA rapid experiment was run using avariant of a computer-based systemdeveloped by laboratory staff, whichwas used to monitor the flow ofsamples through the laboratories. Amodification of this system, namedMonSTA (monitor of shortturnaround), was deployed in theA&E department. A computer screenwas set up at the nursing station inthe major treatment area. This was

linked to the laboratory computersystem using the MonSTA software.As samples were booked into thelaboratory system, they appeared onthe top half of the screen, displayingpatient name, hospital number, timein laboratory and tests requested.The background colour for eachrequest changed from green to redgradually over time, giving animmediate visual indication of howlong the sample had been waiting tobe processed.

Making results information visual to A&E reduced time from resultsavailable to results viewed from 110minutes to 10 minutes.

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FromPatient arrivalBlood takenBooked into lab systemResults availableResult viewed in AE

ToBloods takenBooked into lab systemResult availableResult viewed in AEPatient discharged from AE

Target (mins)6020601090

The targets

Emergency Department (A&E) screen

73

On completion of testing, thepatient information moved to thelower half of the screen, a clearvisual indication that results werenow available.

During the rapid experiment,laboratory staff worked with A&Estaff to assess the best location forthe screen and to train A&E staff inusing the system. After just a fewdays, time from results available toresults viewed was reduced from amaximum of 110 minutes to 38minutes.

It was therefore agreed with A&E toinstall a permanent connection tothe MonSTA system. This has nowresulted in an maximum time fromresults available to results viewed of10 minutes

Measurable improvements and impactMaximum time from results availableto results viewed was reduced from110 mins to 10 minutes

Key learning• Data is vital to understanding and improving performance.

• Engaging with the customer and understanding their issues leads toservice improvement.

• The value of working as a problemsolving team with service users.

• The value of going to the Gemba to see what is actually happening.

How this improvement benefits patientsPatient results are viewed in a moretimely manner.

Clinical staff are not taken awayfrom their patients to make repeatedenquiries on the laboratorycomputer system.

How will this be sustained andwhat is the potential for thefuture?The communication channelsestablished with A&E staff duringthis and other related initiatives willhelp sustain the improvement andinform potential for furtherimprovements.

The laboratory continues to analysedata relating to patient flow throughA&E and monitor the time targetsfor each part of the pathway. Thisanalysis is shared with the A&Edepartment staff on a weekly basis.

In the future it is envisaged that theMonSTA system may be able to beintegrated with the standard bedmanagement system (ExtraMed) inthe hospital, so that all wards anddepartments will be able to monitorthe progress of their requests to thelaboratory.

ContactSteve Sawley, ChemistryLaboratory ManagerEmail: [email protected]

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Customer engagement and use of data to reduce defectsSummaryPareto analysis of data input andengagement of the customer haveenabled a reduction in defects inspecimen reception data entry.

Understanding the problemThe specimen reception teamcontinuously monitors their accuracyat manual data entry of laboratoryrequests and maintains a very highstandard of accuracy (>99.7%).

However, they noticed from the datathat there had been no improvementfor some time (graph 1). At a dailymeeting (huddle) it was agreed thatmore analysis of the data wasrequired and a member of the teamwas assigned to do the analysis.Simple Pareto analysis (80/20 rule)showed that the majority of errorswere with antenatal samples (graph2) and further Pareto analysisshowed that the issue was withmissed serology tests (graph 3).

The request form had been originallydesigned for machine opticalcharacter reading, but thetechnology had failed and staff hadto manually read and input data. Theserology tests tick box area of theform contains a large number ofoptions and the antenatal serviceselected different patterns of testsfor different patients. Hence theopportunity for error when manuallyinputting data. It was not possible toamend the form in the short term.This information was fed back to theteam at their daily meeting and anaction agreed.

It is important to openly discussdefects if they are to be effectivelyeliminated.

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Labcentre request booking accuracy rate

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How the changes wereimplementedThe action agreed was for thesection manager to visit theantenatal clinic, talk to the staff andget a better understanding of theirrequesting requirements. Thereturned out to be a small number ofpredictable variations in the testprofiles requested. This resulted inan agreement with the antenatalnurses to enter an agreed code onthe request form rather than tickboxes. This code was alsoprogrammed into the laboratorycomputer. Entry of this codeautomatically requested theappropriate tests. This was fed backto the staff at their daily meetingand standard work was rewritten toinclude this new requesting system.Examination of the metrics followingthe changes showed that the errorshad been eliminated.

Measurable improvements and impact• The opportunity for requesting errors due to missed tests has been eliminated for antenatal patients.

• The need for repeat clinic appointments for the missed tests has been eliminated.

• The same system of coding requests for complex serology requesting patterns is being followed up with other customer groups.

• Microbiology colleagues are now involved, advising on the most appropriate combinations of serology test for various patient pathways.

• This approach has also simplified the task of data entry.

Key learning• Repeated cycles of Pareto analysis assist with root cause analysis and enable the biggest problems to be quickly identified.


• It is important to openly discuss defects if they are to be effectively eliminated.

How this improvement benefits patientsTests are no longer missed, thusreducing the need for repeat testingand the inconvenience and worrythat this can cause patients.

How will this be sustained andwhat is the potential for thefuture?• New standard work has been agreed and written for the data entry staff.

• The team will continue to monitor defects as part of their daily meetings.

• This system of coding requests is being rolled out to other areas with similar issues.

ContactJanet Ashworth, SpecimenReception ManagerEmail:[email protected]

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Card viewer access for outpatient departmentsand health centresSummaryPaediatric consultants were havingdifficulties viewing results of bloodtests which had been referred tooutside laboratories.

Paper copies of results were oftennot available to them due to thelocations in which they saw theirpatients.

A simple system to enable them toview scanned copies of the reportselectronically was introduced.

Understanding the problemSome tests cannot be performed inour laboratories and so are sentaway to external referencelaboratories.

These laboratories send the resultsback as paper copies rather thanelectronically. Thus the results arenot held in our computer system.Only an audit trail of date samplereceived, date sent away and dateresult received is kept in our system.

The problem for the consultants wasthat with the existing system theycould not view the test resultselectronically and often the paperresult was not in the notes or hadbeen sent to another consultant whohad actually requested the tests.Hence the consultant would have tocontact the external laboratory byphone to ask for the results. Orpossibly request repeat tests. Thistook valuable time and causeddelays to the patients and could leadto the clinic over running.

Engage with customers to understandtheir issues to jointly arrive atsolutions.

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How the changes wereimplementedStaff from the laboratory visitedseveral consultant paediatricians toget a fuller understanding of theproblems raised. As a consequence acompromise solution was agreedwhereby the consultants could viewan image of the report.Paper reports from externallaboratories are routinely scannedinto a database for future referencein our laboratory. With the help ofIT colleagues we had access to thiscard scanner database madeavailable to outpatient clinics andhealth centres where paediatricclinics take place. Standard work foraccessing the reports via theconsultants’ desktop computers waswritten and shared with clinic staff.

Measurable improvements and impact• Consultants can now see and discuss the test results during the patient’s clinic appointment. The need for repeat testing is removed as is duplication of tests that may have already been requested by another consultant/GP.

• The consultants do not have to waste time phoning external laboratories for the results.

Key learning• Engaging with customers to understand their issues and jointly arrive at solutions.

How this improvement benefits patients• Patient test results are available during their consultation.

• The need for repeat testing and repeat appointments is reduced.

How will this be sustained andwhat is the potential for thefuture?• Frequent contact with the users to discuss how the system is working.Investigating any problems reported with the system.

• It is planned to roll out the system to all user areas in primary and secondary care.


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Reducing paper reports fromlaboratory medicineSummaryAs part of the value stream map bythe patient care team in theadministration and support servicesarea of laboratory medicine, it wasidentified that unnecessary paperreports were being printed.

Analysis of metrics and discussionswith customers enabled those areasonly requiring electronic reports tobe identified. Paper reporting wasthen discontinued for these areaswith concomitant savings in paperusage and staff time.

Understanding the problemPaper reports were originally printedfor each request. Electronic orderinghas been introduced in the hospitaland in GP surgeries and a trustdecision was made that electronicreports would replace paper reportswherever possible. However someareas using electronic ordering werestill receiving paper reports.

How the changes wereimplementedThe patient care team collectedmetrics of which areas were gettingpaper reports and informed thecomputer manager. He checked thecomputer settings and amendedthem if necessary. The team alsovisited wards and departments in thehospital and community to discuss ifthey still needed paper reports.

Do not assume that because it hasalways been done that way it is theright way.

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Measurable improvements and impactThe number of paper reports printedwas reduced by 1,600 per day,giving a saving of around £5,000 perannum on paper alone. Staff time was also saved as therewas no longer a requirement to sortand distribute these paper reports.This has been calculated to be savingin the region of 1,200 hours per yearor 0.6wte. This allows the patientcare team to spend more timeperforming patient facing duties.

Key learning• Collect metrics and talk to the customer.

• Do not assume that because it hasalways been done that way it is the right way.

How this improvement benefits patients• Paper reports could take 24 hours to reach the requestor but electronic reports are instant.

• The patient care team have more time to spend focusing on patient issues.

How will this be sustained andwhat is the potential for thefuture?Patient care staff continue tohighlight issues to the computermanager as more areas begin to useelectronic ordering. Eventually theonly paper reports that need to beprinted will be those for the very rareexamples of a GP surgery orcommunity clinic with no access toelectronic reports.

ContactBarbara Colman, Admin andSupport Services ManagerEmail:[email protected]

In the final stage, the user hasreceived the test results but requiresadvice on:• interpretation and follow up testing;

• what further tests to perform; and• with what frequency.

The laboratory adds value at thisstage by:• ensuring availability of advice for result interpretation and follow up testing;

• ease of access to this advice; and• round the clock access to this advice.

Post post-analytical stage

The concepts highlighted in the casestudies in this section include:• user engagement;• use of investigation guides;• communicating with users; and• joint problem solving.

The tools illustrated include:• Pareto analysis;• A3 problem solving; and• visual management.

POST POST-ANALYTICAL

RESULTS INTERPRETATION

ADVISE ON FOLLOW UP

Post post-analytical stage78

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Using data and customer engagement to identify and eliminate defectsSummaryPareto analysis of requesting defectsand engagement of the customerhave enabled the elimination of‘missing sample’ defects in A&E.

Understanding the problemAs a result of previous initiativesbetween the laboratory and A&Edepartment, an agreement had beenreached on sets of tests to berequested dependent on thepatient’s presenting complaint (ordersets). Codes for these ‘order sets’had been agreed which greatlysimplified the data entry task in thelaboratory. However, it had beenobserved from defect metrics in thelaboratory that the system did notalways work.

The data was analysed using Paretoanalysis (80/20 rule). The mostcommon defect was shown to bethat a required sample was missingwhen the request arrived in the lab(1). Further Pareto analysis indicatedthat this was predominantly theyellow (oxalate) tube required forblood glucose testing (2).

Historically, the purpose of theyellow tube was to stabilise thesample to offset deterioration in thecase of delay in testing. Thelaboratory team decided to removethe requirement for the yellow tubeas the time from sample collection totesting was now so short due toother improvements that had beenmade in sample turnaround. Hence,the standard clotted blood tube,which was routinely sent for allpatients covered by the order setagreement, could be used for theglucose test.

Repeated cycles of Pareto analysisassist with root cause analysis andenable the biggest problems to bequickly identified.

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How the changes wereimplemented• The changes were agreed with theA&E staff.

• Standard work was rewritten in the laboratory for testing glucose using the clotted blood tubes.

• The order sets were amended to reflect this change (3).

Blood Investigation GuideConsider the need for any blood test or ECG at all.More than one test group may apply.

Royal Bolton HospitalNHS Foundation Trust

NHS 3

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Measurable improvements and impact• Defects due to no yellow tube being received were completely eliminated.

• The costs associated with supplying the yellow tubes were eliminated.

• Fewer blood samples were required to be collected from patients.

Key learning• Repeated cycles of Pareto analysis assist with root cause analysis and enable the biggest problems to be quickly identified.


• It is important to openly discuss defects if they are to be effectively eliminated.

• Challenge the current paradigm - just because we have always done it that way does not mean that wecannot change.

How this improvement benefitspatients• Fewer blood samples are required.• The need for repeat testing has been eliminated along with the inconvenience and worry that this can cause patients.

• The risk of a vital test result being not available or delayed has been removed.

How will this be sustained andwhat is the potential for thefuture?• New standard work has been agreed and written for the laboratory.

• The amended order sets have beenagreed with A&E staff.

• The team will continue to monitor defects as part of their daily meetings.

• This system of order sets is being rolled out to other areas with similar issues.


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Joint problem solving to reduce totalpatient turnaround times in A&ESummaryThe project was initiated using theBolton Improving Care System (BICS)with the aim of improving patientexperience in the A&E department,reducing anxiety and delays intreatment due to diagnostic delaysand poor handovers of information.

A key aim was to ensure the timelyand accurate diagnosis for patientsin the A&E department by improvingthe flow from arrival in thedepartment, to diagnosis as a resultof blood results being available. Amultidisciplinary team comprising ofstaff from the A&E department,laboratory medicine, and ward staffacting as ‘fresh eyes’ was assembled.

The team established base linemeasures, and set a target forimprovement. The solutionsimplemented by the team have hada direct impact on the reduction inpatient harm by creating a cleardiagnostic pathway, with

Use root cause analysis to fullyunderstand and solve problems.The value of working as a problemsolving team with service users.

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standardised tests through a ‘blood investigation guide’. This,along with the development of asystem which allows clinicians to seeimmediately when results areavailable, has resulted in the safetyand reliability of the system beingimproved. Interventions have beensustained for nearly three years nowand further improvements continueto be made by the team to improvepatient care.

Understanding the problemThe trust has an improvement planaimed at improving pathways forurgent care patients. The emergency

department have been identifyingareas of the overall process causing delays to patient care.Although not the major contributorto breaches of the four hour A&Etarget (1), it was considered thatthere were opportunities to improvethe pathway for blood samples. Thelaboratories have a good history ofimprovement and so a joint problemsolving team was established.

The purpose of the team was toidentify further improvements toreduce the ‘flow times’ from decisionto take bloods to decision made as aresult of blood results being available.

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1. One month analysis of reasons stated for A&E patients breaching four hours(presumed delays in blood results highlighted in red)

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Improving the handover ofinformation to support patient careis also a key objective for the SaferClinical Systems Programme.

At the outset it was agreed thatimprovements were required in thefollowing key areas:• reducing the flow time between decision bloods required to decision based on blood results;

• agreeing standards for where in the pathway the sample should betaken to ensure no delays for the patient;

• agreeing a test menu for key pathways reducing the risk of over/under investigating; and

• designing visual management triggers in A&E for knowing when blood results are on the system reducing delays and staff frustration.

Initially a rapid improvement event(RIE) was run over a period of oneweek. A team comprising A&E staff,laboratory staff and ‘fresh eyes’ fromoutside both departments wasassembled. Using an A3 problemsolving approach, the followingissues were identified.

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2. Pareto analysis of presumed delays in blood results (major causes highlighted in green)

Analysis of presumed delays in blood results indicated that the twomain causes were actually samples not taken at the start of thepatient journey and delay to see a doctor.

Problem

Turnaround time – currentlyonly turnaround time ismeasured once the samplehits the lab. Staff in A&E are not aware of currentturnaround time.

Delays exist across thepathway in taking bloodsamples, getting to POD (airtube), being booked in tolaboratory medicine, resultsavailable to viewing.

No ‘test menu’ based onpresenting condition meansdelay in requesting bloodsand add on tests requestedwhich causes delays to thepathway in both pathologyand A&E.

No visual trigger when blood results are available - leads to delays in accessing results.

Scale of the problem

Turnaround time ‘average’47 minutes but variationexists dependant on time ofday. Flow time 228 minutes– bloods taken to resultsviewed.

Breaches relating to bloods during Oct = 51.

85 add-ons over three day period each taking between 10 mins and one hour to sort.

Delay of 110 minutes onaverage between resultsbeing available and viewing.

Root cause

No visual management. No formal communicationfeedback loop between departments.

Limited standard work.

Never been considered as part of the pathway.No standard work.

No system either manualor electronic to supportvisual management ofthe process.

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How the changes were implementedThe following potential solutions were identified.

Measurable improvements and impact• The multidisciplinary team developed a ‘blood investigation guide’ (test menu) with accompanying standard work for emergency department and laboratory medicine. This allows nurses or doctors to order a standard battery of tests based on a patient’s presenting condition at the initial assessment.

• Laboratory medicine’s existing computerised MonSTA system wasdeveloped for use in the emergency department to enable the visual management and monitoring of blood results. The system also provides turnaround times in ‘real-time’ allowing improved communications with patients about when results will beavailable and highlighting problems as they occur (see case study - Implementation of a visual system to improve patient turnaround times in A&E).

• The pod system (pneumatic air tube system for transporting bloodsamples) was improved to improveefficiency for the emergency department and reduce risk of delays in transportation to the lab and the risk of running out of pods. Standard work has been put in place across the whole hospital to reduce the traffic to laboratory medicine during A&E department peak times. Additional pods were also put intothe department to avoid risk of running out.

Solutions

Measure ‘flow time’ – arrival to viewing bloods.

Develop ‘test menu’ or ‘order set’based on presenting condition – thiswill simplify requesting, simplifybooking in in the lab and reduce theneed for add-ons• A&E complete code e.g. Abdo pain = AP.

• Lab med then input code and correct test sets are processed.

Agree where in the pathway bloods are taken ‘first contact’ and documentstandard work – link to gateway design for A&E.

Develop MonSTA system currently usedin laboratory for A&E - to indicateblood sample in the department,turnaround times and results available.

Set up feedback loop to improvecommunications and act on potentialrisks during handover of information.

Implementation

A&E to focus on speed of gettingbloods into the POD (air tube system).Labs to focus on arrival to booking on.

Put in place in RIE week.

Designed in RIE week.

Put in place in RIE week.

Laboratories aim to study variation inturnaround times (i.e. % seen in onehour).Laboratories to analyse end to endturnaround data weekly and feedbackto A&E staff.

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Outcome measures and processmeasures were chosen to monitorprogress and allow prompt correctiveaction if required. Key measureswere as follows.• A 74% reduction in time from blood tests being taken to results being read has been measured as a result of interventions, enabling earlier diagnosis and decision making.

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Blood Investigation GuideConsider the need for any blood test or ECG at all. More than one test group may apply.

Royal Bolton HospitalNHS Foundation Trust

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• There has been a better than 90%reduction in breaches of the four hour target relating to ‘waiting forbloods’ since implementation.

• Process measure put in place to indicate compliance of medical staff with correctly completing samples, and following the ‘blood investigation guide’. This is measured daily and fed back via the link staff in both departments for corrective action. Main reasons for errors undergo Pareto analysis to support reducing the risk of errors on request forms. The reduction and logging of add-on tests is also analysed – each add on test is electronically tagged.

• Time taken to view results once processed by emergency department staff as a result of theMONSTA visual management system reduced from a maximum of 110 minutes to a maximum of 10 minutes.

• Establishing the robust communication mechanisms has ensured greater feedback betweenthe two geographically separated teams. This has enabled joint problem solving and corrective action to further benefit the patient’s journey. Accordingly an agreement was reached regarding time targets for each part of the patient pathway through the A&E department.

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Key learning• The value of data and a structured approach to problem solving (A3), especially when working with complex systems.

• The value of ‘fresh eyes’ when mapping a process.

• The value in engaging with customers and going and seeing their issues.

• Building relationships with customers and problem solving together brings significant short and long term benefits. Prior to this work relationships between laboratory medicine and A&E department had been strained. Joint working enabled each to see problems from the other’s perspective and consequently relationships and mutual trust have improved.

How this improvement benefits patients• The team involved staff from departments across the trust to ensure that the changes were designed and led by the people doing the job, and ‘fresh eyes’ where also part of the team.

• Patients were asked about the impact of not getting results and delayed diagnosis and the majorityadvised that they felt that anything to speed up the process and also ensure accurate and safe diagnosis would reduce anxiety at the stressful point in their pathway.

• All interventions are enabling earlier diagnosis and decision making. The solutions implemented (interventions) by theteam have had a direct impact on the reduction in patient harm by creating and documenting a clear diagnostic pathway.

FromPatient arrivalBlood takenBooked into lab systemResults availableResult viewed in AE

ToBloods takenBooked into lab systemResult availableResult viewed in AEPatient discharged from AE

Target (mins)6020601090

The targets

How will this be sustained andwhat is the potential for thefuture?• Robust feedback mechanisms were established with named links from both laboratory medicine andA&E department to build team relationships; ensure two-way feedback to improve handovers of information; document and support problem solving and continuous improvement.

• Analysis of every sample is now in place to pick up and feedback errors on a daily basis. Problem solving and root cause analysis are standard for all breaches of pathway targets.


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Introduction of a new test code which removedthe need for extra courier pick-upsSummaryGPs were holding extra clinics in theevening after the laboratory courierhad picked up their blood samples.Consequently blood samples takenat these clinics were not received inthe laboratory until the next day.Thisresulted in erroneous potassiumresults and requests for repeattesting. The GP surgeries wereasking for extra sample pick up runsin the evenings otherwise they hadto make repeat appointments fortheir patients.

By engaging with the GPs andunderstanding what theirrequirements were, it was possibleto introduce an amended testingprofile which did not includepotassium and hence removed theneed for a later pick up or repeatappointments. This also removed18,000 unnecessary tests along withan associated cost of around £6,600per year.

Understanding the problemGPs are increasingly finding the needto hold late clinics either as extraclinics due to service demand or tosuit patient needs.

If the patient requires a blood test,then either the sample is taken andstored overnight in the surgery orthe patient has to make anotherappointment for phlebotomy at atime when transport to thelaboratory is available.

Do not make assumptions about whatthe customer requires. Talk to themand find out.

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In the first case, if potassium hasbeen requested, the sample will notbe viable for testing on the next day.In the second case, both the patientand the surgery are inconveniencedby the need for an extraappointment.

Hence more and more GP practiceswere requesting later and later pickup of samples. Introducing theselater pickups would have significantstaffing implications for both thelaboratory and courier services.

How the changes wereimplementedSpecimen reception staff opened adialogue with the GPs requesting theextra pick up runs. In conversations itwas established that, more oftenthan not, the clinic sessions were forprimary prevention screening andthe test result the GPs wereinterested in was the eGFR and notthe potassium or sodium result. Theyhad assumed these tests(electrolytes) had to be requested toget an eGFR result. In fact only acreatinine result is required tocalculate the eGFR. Consequently, aspecific request group and code(BBHC) was established to coverthese primary prevention screens,which did not include potassium.

The tests included were urea,creatinine (with a calculated eGFR),lipids and HbA1c. All of these testscan be performed on uncentrifgedsamples stored in a fridge overnightwithout affecting the result.

The GPs were asked to write thiscode (BBHC) on the request form(there was no need to tick any otherboxes). When laboratory staff inputthis code into the laboratory systemit expands to request the agreedtests.

Measurable improvements and impact• The establishing and use of this request code has simplified both requesting for the GPs and requestentry in the laboratory.

• It has prevented errors at booking in and the GPs get all the tests firsttime.

• As samples can be stored in the fridge overnight there is no need for a late pick up or to make an extra appointment for the patient.

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• There has also been a cost reduction due to the elimination ofunnecessary tests and a reduction in the need for repeat samples. Approximately 6,000 patient requests per year are received for this primary prevention screen. Thus 18,000 unnecessary tests have been removed along with an associated cost of around £6,600 per year. Just as importantly, none of these 6,000 patients should require a repeat appointment for bloods to be taken or repeat tests performed.

Key learning• Understanding and responding to customer needs.

• Do not make assumptions about what the customer requires. Talk to them and find out.

• No need for repeat testing due to deteriorated samples.

How this improvement benefits patients• No longer having to have bloods repeated.

• No need to make an extra appointment for samples to be taken.

How will this be sustained andwhat is the potential for thefuture?• Frequent contact with users.• Constant monitoring of data to identify and root cause any defectsin the system.

• Expand the use of similar test groups throughout the laboratory for all our users.


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Seminar sessions for the orthopaedicdepartment at a walk-in centreSummaryWhen members of the laboratoryteam were having discussions withthe orthopaedic department at awalk-in centre regarding receivingpaper reports, it was highlightedthat changes and improvements inlaboratory medicine were not alwayspassed on to all areas.

Understanding the problemThe orthopaedic staff did not alwaysreceive information regardingupdates from laboratory medicineand the staff were concerned thatthey did not always know the correcttests to request. They wereconcerned that this meant somepatients might be bled more thanonce and this would also cost morefor the department.

How the changes wereimplementedThe laboratory medicine teamarranged for consultanthaematologists and biochemists topresent seminars for the orthopaedicstaff regarding which tests torequest and also update them onrecent improvements in laboratorymedicine services.

Measurable improvements and impactImprovements in this area aredifficult to measure and quantitate.However, we know from continuedcontact with walk-in centre staff thatthey value the education sessionsand the newsletter.

We make assumptions about what ourcustomers know about our services,how to access them and how to usethem. To fully understand their issuesand promote our services, we need tomake personal contact.

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They also feel that the likelihood ofinappropriate or repeat testing hasbeen minimised by delivery of thesesessions. We are currentlydeveloping a method of auditingand/or measuring improvements inthis area.

Key learning• We need to make even more effort to talk to all our customers.

• We make assumptions about whatour customers know about our services; how to access them and how to use them. To fully understand their issues and promote our services, we need to make personal contact.

How this improvement benefits patientsThe correct tests will be requestedwhich may help earlier diagnosis andless repeat testing will be needed.Improvements and additions to ourservices can be properly accessed bythe patient’s clinical team.

How will this be sustained andwhat is the potential for thefuture?Laboratory medicine now produces anewsletter which providesinformation about all issues andimprovements. It is distributed to allwards and departments throughoutthe hospital and community.

A laboratory medicinemultidisciplinary team now has aregular slot on GP governancetraining sessions to convey serviceimprovements and answer questionsrelating to the use of services,selection of tests etc.


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The laboratory medicine newsletter received a Highly Commended Awardin Excellence in Communication section of the annual Trust StaffAchievement Awards 2012

Any improvement effort shouldalways include the key stakeholdersin the pathway.

93End with the start in mind

The overarching messages in thisbooklet are simple and obvious atfirst sight. However, they are so oftenoverlooked to the detriment of theimprovement journey.

As the reader can see from the waythis booklet is laid out, the first stepis the need to consider the wholepathway from vein to brain; orneedle to notes; or brain to brain, orend to end … whichever descriptionyou choose. It is about being involvedin; taking control of; influencing;adding value to; and managing thewhole process from decision to testto delivery of interpreted result.

In this work, the journey has beenbroken down into the arbitrary butoften cited stages of pre-pre; pre-;analytical; post-; and post post-analytical. Due to time limitations ofthe improvement work undertakenwith the various sites, most of thecase studies contained in thisdocument are concerned with theearlier part of the pathway. This is thesensible place to start yourimprovement journey.

What comes next for those of us whohave been on improvement journeysfor some time, is a fundamentalfeature of every improvement event… data.

As W. Edwards Deming said, “… Ingod we trust... all others must bringdata”.

End with the start in mind

You need data (sometimes referredto as metrics) to:• understand exactly where you are now;

• set a target for improvement; and• monitor your progress towards your target.

How else will you know what to door whether you are achieving yourgoal? Sounds simple really, butproblems related to data areencountered regularly. This is in termsof what data to collect; how tocollect it; how to analyse andinterpret it, and how to share it.Data can give you clarity on wherethe real problem is, often not whereeverybody assumed it was.

It will give you a clearerunderstanding of what your biggestissues are (your burning platform as itis often referred to). This will helpfocus you on where you need to startor focus your improvement activities.Here are a few lessons NHSImprovement and the blood sciencesteams have learned along the way.

• Do not get too hung up on the absolute accuracy of the data. Sometimes you have to admit that it is not perfect but does show the trend or the area of biggest concern.

• Analyse the data using the 80/20 rule (Pareto analysis), such that youfocus on the 80%. Endeavour to mine into the 80% to find root causes and then again analyse these using the same 80/20 rule. This will enable you to focus on thecauses of the biggest issues rather than dissipating your energy trying to solve all the problems at once.

• The requirement for computer systems to collect the data for you can be over exaggerated. It is very convenient if this can be done, but all too often you cannot access precisely what you want from the computer in the format you want it. You may be dependent on external IT or Informatics staff to interrogate your computer and your priorities might not match theirs.

• It is OK to use manually collected data, even if it is just a snapshot of a situation. You know enough about your own systems to get a feel for how much such data you need to get a good handle on an issue.

• It is important to develop sufficient maturity to realise that it is acceptable if the data indicates poor performance. That is a very valuable insight which will now enable you to improve. If you do not know where the problems are or which we tackle first, how will you ever improve your services in an efficient and focussed way?

• Related to this point, is the need todevelop the maturity and confidence to share this data with your staff and even your customers. Identifying and admitting there is a problem, without apportioning blame - remember it is the process that causes the problems and generatesthe waste, not the people - is fundamental to being able to improve your processes and services.

End with the start in mind94

Finally, this brings us to the very coreof why our services exist - to solveour customers’ problems. Whilst theterm ‘customer’ is not popular with alot of healthcare staff and we wouldsuggest that when you read the term‘customer’, you should interpret thisas the patient and the clinical teamswho care for them. The termcustomer is used only in the interestof being concise.

Engaging with the customerthroughout the whole pathway is keyto successful continuousimprovement. If you do not knowwhat the customer wants or valuesfrom your service, how will you beable to deliver the best service? If thecustomer does not know what youcan deliver or what is the mosteffective way to use your servicesthen you will be missing lots ofopportunities to improve customerexperience.

Only by engaging with the customercan you hope to really understandtheir requirements; demands on theirservices; pressures on their resources,and limitations of their understandingof your services.

There are many ways to engage andhear the voice of the customer.It may be through:• analysing results of user surveys;• conducting face to face or telephone interviews;

• from comments cards;• from requirements in customer specifications and contracts; and

• complaints (a very important sourceof understanding whether your basic services are delivering to the customer needs).

During the improvement work whichis reported in the case studies in thisbooklet, it was re-affirmed that thefundamental premise, that the mosteffective way to engage, is to ‘go andsee’. Laboratory staff visiting theircustomers and walking through thepatient pathways, and clinical staffvisiting and walking through thelaboratory pathways, proved to be avery powerful tool for engagementand understanding.

Two important points to rememberwhen setting out to listen to andanalyse the voices of your customersare: • you need to identify all your different customers; and

• you need to understand they may each have different needs and values.

By understanding customer value andhaving the data to identify what isreally happening in your processesand what needs to be improved, youare now better placed to add value ateach stage of the journey. Fromselection of the right test to solve thecurrent clinical problem, to where toperform the test in the patientpathway, and who should performthe test using what technology. Fromhow to make the request and collectand deliver the sample to the site oftesting, to the analysis of the samplewith appropriate QC/QA andcomparison with previous results.From generation of the report withappropriate comments, to delivery ofthe final report by the mostappropriate method, and to theclinical interpretation of the resultand advice on what to do next. Andto do all this within agreed andrelevant turnaround times.

95Contacts

NHS Improvement Team

DirectorLesley Wright Email: [email protected]

National Improvement LeadsPeter Gray Email: [email protected] Hodgkinson Email: [email protected] Horobin Email: [email protected] Peachey Email: [email protected] Smee Email: [email protected] Marley Email: [email protected] Taylor Email: [email protected]

Senior AnalystIan Snelling Email: [email protected]

Diagnostics Team PAsAnabelaDeGouveia Email: [email protected]: 0116 222 5122Tina Eatough Email: [email protected]: 0116 222 5128

Information & Systems Development ManagerMaggie Herbert Email: [email protected]

National Clinical Leads - Pathology Service ImprovementMr David Hamer Email: [email protected] David Clark Email: [email protected] Saimah Arif Email: [email protected]

National Improvement Associate - MicrobiologyMr Kevin McLachlan Email: [email protected]

Contacts

References

(1) Report of the Review of Pathology services in England by Lord Carter ; Sep 2005 & Dec 2008

(2) ClinBiochem Review- Feb 2008; 29 (1):3-10(3) On the Mend: Revolutionizing Healthcare to Save

Lives and Transform the Industry- John Toussaint, Roger A. Gerard; 2010

(4) High Cost of Disengaged Employees- Meere, M; December 2005

(5) Building High Performance People and Organsations - Melcrum Publishing Gallup; 2005

References and additional information

Additional information

NHS Improvement Diagnosticswww.improvement.nhs.uk/diagnostics

For access to:• pathology case studies.• pathology how to guides for histopathology, microbiology, phlebotomy and cytology.

• Bringing Lean to life.• First steps toward quality improvement: A simple guideto improving services.

NHS Improvement Systemwww.improvement.nhs.uk/improvementsystem

For access to:• free statistical process control charts (SPC), capacity and demand and process sequence tools; and

• webinars covering Lean topics.

Contact: [email protected] for yourpassword.

The Lean Enterprise Academywww.leanuk.org

Useful reading – LeanA3 Problem Solving for HealthcareCindy JimmersonISBN 978-1-56327-358-2Demonstrates how to use A3 to problem solving.Contains practical examples from USA healthcare that can be easily translated to UK.

Value Stream Mapping for Healthcare Made EasyCindy JimmersonISBN 978-1-4200-7852-7Demonstrates why value stream maps are a fundamentalcomponent in applying Lean.

On the MendJohn Toussaint, MD and Roger A.Gerard, PhDISBN 978-1-934109-27-4The story of a whole hospital improvement programmeat Theadare, Wisconsin, where they achieved $23 millionsavings, improved quality and safety, without the loss ofany jobs. It identifies the critical role of leadership andhow leaders need to change.

References and additional information96

Lean Healthcare – Improving the Patient’sExperienceDavid FillinghamISBN 978 -1- 904235-56-9Written by CEO of Bolton NHS Trust as an account of hisexperience of the long term perspective of using Lean tosupport whole healthcare.

The Gold MineFreddy and Michael BalléISBN 978-0974322568Comprehensively introduces all the Lean tools by meansof a vivid personal story showing how hearts and mindsare won over.

The Toyota Way Jeffrey K. LikerISBN 978-0071392310Explains Toyota’s unique approach to Lean management– the 14 principles that drive their quality and efficiencyobsessed culture.

Learning to SeeMike Rother and John ShookISBN 0-9667843-0-8An easy to read practical workbook for creating a valuestream map to evidence waste in a process.

Managing to LearnJohn ShookISBN 978-1-934109-20-5How A3 enables an organisation to identify, frame, actand review progress on problems, projects and proposals.

Making Hospitals WorkMarc Baker and Ian Taylor with Alan MitchellA Lean action workbook from the Lean EnterpriseAcademy.

First Break All the RulesMarcus Buckingham and Curt CoffmanISBN 1-4165-0266-1What the world’s greatest managers do differently.

The Toyota Way to Lean LeadershipJeffrey K. Liker and Gary L.ConvisISBN 978-0-07-178078-0

Lean ThinkingJames P. Womack and Daniel T. JonesISBN 978-0-7432-3164-0

The Heart of ChangeJohn P. Kotterand and Dan S. CohenISBN 10: 1-57851-254-9

97References and additional information

98

HEART

LUNG

CANCER

DIAGNOSTICS

STROKE

NHSNHS Improvement

©NHS Improvement 2011 |All Rights Reserved

Publication Ref: IM

P/diagnostics005 - January 2013

NHS ImprovementNHS Improvement’s strength and expertise lies in practical service improvement. It has over adecade of experience in clinical patient pathway redesign in cancer, diagnostics, heart, lungand stroke and demonstrates some of the most leading edge improvement work in Englandwhich supports improved patient experience and outcomes.

Working closely with the Department of Health, trusts, clinical networks, other health sector

partners, professional bodies and charities, over the past year it has tested, implemented,

sustained and spread quantifiable improvements with over 250 sites across the country as

well as providing an improvement tool to over 2,000 GP practices.

NHS Improvement

3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101

www.improvement.nhs.uk

Delivering tomorrow’simprovement agenda for the NHS

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