NHS Improvement - Diagnostics Service Improvement Guide

NHS
CANCER
NHS Improvement
Diagnostics

DIAGNOSTICS

HEART

LUNG

STROKE

NHS Improvement - Diagnostics
Service improvement in blood sciences
How to improve quality, delivery and
efficiency for laboratory providers and
their customers
January 2013

Clinical excellence in partnership
“
with process excellence”

Matching your capacity and demand
supports improved turnaround times
and improves staff morale.

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

Contents
1. Foreword 6

2. Executive summary 7

3. Introduction 10

4. Waste 14

5. Sites 15

6. Start with the end in mind 16

7. Pre pre-analytical stage 17
Pathology transport reconfiguration 18
Chesterfield Royal Hospital NHS Foundation Trust
Introduction of coloured transport bags in pathology 20
Decreasing the rejection rate for transfusion blood samples 22
Taunton and Somerset NHS Foundation Trust
Emergency department diagnostics improvement 23
Derby Hospitals NHS Foundation Trust
Haematology clinic changes to support patient experience and improve flow 25
Streamlining day surgery admission to improve group and screen result turnaround 29

8. Pre-analytical stage 31
How Lean improvement enabled us to save time and money in blood transfusion 32
Reduced checking at booking-in improves detection of defects 34
Reducing turnaround times for urgent samples 36
Using data to manage staffing levels within blood sciences pre-analytical section 39
Using visual management to improve communication and ways of working 42
Using standard work and 5S in specimen reception to create a standardised, clean 44
and safe work environment allowing staff to perform optimally
Pathology outpatient process improvements 46
Blood sciences pre- analytics pathway improvements 48
Using data and team problem solving to improve sample TAT 52
Bolton NHS Foundation Trust

5

9. Analytical stage 54
Changed priorities in the laboratory to deal with samples from same day surgical 55
admission patients – analyser set-up and method of validation
Reducing the turnaround times for haematology clinic by reducing the time taken 57
from a result being available to authorising a result that requires a peripheral blood film
5S of cold room at Derby 59
Demonstrating how Lean work cells deliver faster turnaround times, higher 61
productivity and efficiency, increased flexibility, improved space utilisation and
improved quality
Path Links
Crossing disciplinary boundaries improves transfusion safety for day surgery patients 64
Positive clinical benefits of improvement work in a transfusion laboratory: 66
a clinician’s view
The relationship between patient flow, patient safety, labour cost and the 67
contribution of laboratory sciences to appropriate patient care
The Health Foundation, South Warwickshire NHS Foundation Trust

10. Post-analytical stage 71
Implementation of a visual system to improve patient turnaround time in A&E 72
Customer engagement and use of data to reduce defects 74
Card viewer access for outpatient departments and health centres 76
Reducing paper reports from laboratory medicine 77

11. Post post-analytical stage 78
Using data and customer engagement to identify and eliminate defects 79
Joint problem solving to reduce total patient turnaround time in A&E 82
Introduction of a new test code which removed the need for extra courier pick-ups 88
Seminar sessions for the orthopaedic department at a walk-in centre 90

12. End with the start in mind 93

13. Contacts 95

14. References and additional information 96

6 Foreword

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

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

In addition, the NHS Operating Framework 2012/13 highlights five domains, of which four are important
for blood sciences.
• Domain 1: the reducing of premature mortality from the major causes of death. Blood sciences services have a
significant role in providing effective screening for cardiovascular, respiratory and liver disease.
• Domain 2: requires improvements in health-related quality of life for people with long-term conditions , such as
diabetes. By using innovative approaches to service delivery, blood sciences has a significant role to play in the
monitoring of patients with long-term conditions.
• Domain 3: involves support for helping people to recover from episodes of ill health or following injury. Blood
sciences services have a significant role in providing timely results for emergency admissions for acute conditions.
• Domain 4: obliges all NHS organisations to actively seek out, respond positively and improve services in line with
patient feedback.

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

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

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

Dr Ian Barnes Mr David Hamer
National Clinical Director for Pathology National Clinical Lead for Blood Sciences
Department of Health NHS Improvement

Executive summary 7

Executive summary
In 2006, the Review of Pathology
Services in England by Lord Carter
endorsed Lean as the method of
choice for improving processes. .
Working in partnership with the DH
Pathology Programme, NHS
Improvement has supported a
number of blood sciences teams, to
learn how Lean methodology can
enable the service to achieve
improvements to support the QIPP
transformation programme.
Multidisciplinary teams worked
collaboratively to test and implement
changes that deliver improvements
for patients, staff and users of the
service.

In 250 NHS laboratories in England, Productivity A review of current guidance
500 million biochemistry and 130 • reducing inappropriate demand by including Royal College of Pathology,
million haematology tests(2) are ensuring users are educated to Keele Benchmarking, Clinical
carried out per year. Ninety five request the appropriate test Pathology Accreditation (CPA) and
percent of all clinical pathways rely correctly the Lord Carter Review of Pathology
on a patient having access to • matching capacity to demand, and Services 2006/2008 identified a lack
efficient, timely and cost-effective ensuring the appropriate use of of consistent approach to
services. staff skills measurement of the blood science
• removing waste from process flows specimen pathway. The recent Royal
As a result the impact on patients is to increase productivity and timely College of Pathology key
significant, with improvements in: delivery, reduce cost and space performance indicators (KPIs) have
requirements. now been specified as the time of
Quality and safety collection, to completion and
• working with service users to Lessons learned confirmation of the test result
achieve ‘right first time’ - Three important lessons have been available to the requestor. Similarly,
addressing errors in sample learned in piloting and prototyping they have identified the need to
labelling and requests; Lean thinking in blood sciences. measure the blood sample for A&E
as follows.
Innovation 1. Lack of a consistent standard
• using Lean techniques to improve and approach to end- to-end Baseline. Percentage of core
the flow of samples and reduce sample pathway measurement. investigations, i.e. renal function, liver
turnaround times (TATs), function tests and full blood counts
introducing technology to aid Working with a variety of clinical from A&E completed within one hour
timely clinical decision making; and teams has shown an inconsistent of receipt, including out–of- hours.
approach to the end- to- end sample This standard will move to one hour
pathway measurement. A similar from sample collection by April 2015.
finding was made during the Challenge. Eighty five per cent by
microbiology improvement April 2012 increasing to 90% by
programme. April 2014.

8 Executive summary

Recommendation
Measure end-to-end
sample pathway
Following recent changes towards
outcome based healthcare and new
and timely KPIs from the Royal
College of Pathology, we recommend
the blood sample specimen pathway
should be measured from the time
the sample is taken, until a result is
available for the clinician to act on.

Key measures across the pathway
include:
• date and time the specimen is
taken;
• date and time the specimen arrives
in the lab; and
• date and time the result is available
to the clinical user.

Pathology teams should collect this
data and educate patients and users
to provide details of sample timings.

2. Process and wider system
changes are required to support
end to end pathway
measurement The recent document ‘First steps in It is vital to study the whole end- to-
Much of the pre-analytical phase is improving phlebotomy: the challenge end pathway, as this will highlight the
currently invisible to the laboratory to improve quality, productivity and importance effective pathology
and pathology laboratory information patient experience’ (May 2011) services are as an enabler of
systems (LIMS) and processes do not demonstrates the delays in each redesign, rather than a burdensome
support measurement of the end- to- stage of the blood sample pathway. If cost centre.
end pathway. Teams have been pathology teams are to support
required to resort to lengthy manual significant changes in clinical Recommendation
data collection or local adaptation of pathways to deliver: Pathology LIMS providers are
information systems to demonstrate • reductions in admissions for commissioned / required to
basic end- to -end sample pathway. emergency care; support the changing landscape
• reductions in length of stay; to allow a patient- focussed
• redesign of outpatient services; and approach to information across
• innovative approaches to the patient pathway.
supporting long term conditions. Pathology teams should collect this
data and educate users to provide
details of ‘sample taken’ timings.

Executive summary 9

3. Face-to-face user engagement Key elements to bring about 4. Establish ‘first in, first out’
is essential to enable laboratories change • No prioritisation of specimens.
to engage and educate users to Learning from other improvement
ensure: initiatives in pathology services has 5. Appropriate testing
• appropriate testing to defined and confirmed the five key elements likely • Work with users to design
agreed protocols, reducing to bring about substantial protocols and systems to support
inappropriate demand; improvements in the pathway. appropriate test requesting.
• education of users to get the best • Develop acceptance policies that
from blood sciences wealth of 1. Focus on the whole end to specify information and data
knowledge; end pathway quality requirements.
• a ‘right first time’ approach to high • Ensure all staff in the pathway
quality specimen collection, request understand up and downstream This learning guide provides blood
and specimen labelling, to improve processes and how their own work sciences teams with the basic tools to
safety and eliminate the impacts others. make changes to their processes,
opportunity for error; and • Use whole pathway data (from along with insight into how
• transportation of the sample is sample taken to result available) to colleagues have used these tools
frequent, rapid and ensures the understand how samples, forms across the whole patient pathway.
shortest turnaround times to and results flow and identify
facilitate rapid clinical decision bottlenecks and waiting.
making, with pathology services
taking an active role in the 2. Adopt small batch sizes
management of all transport • Throughout the entire pathway -
provision. waiting to ‘fill’ equipment causes
samples (and therefore patients) to
Recommendation wait.
Blood sciences works in
partnership with users to provide 3. Keep specimens moving
visible access to agreed protocols Daily throughout the day, with
for tests and to educate users. multiple deliveries from source of
A ‘right first time’ approach is specimen.
encouraged and endorsed by • Pull work through the laboratory.
commissioners, clinical teams and • Continuous authorisation of
users to ensure safety and efficiency. results.

10 Introduction

Leadership
Introduction for change Spread of
innovation

Pathology services are faced with
increasing demand and pressure to Engagement
reduce costs whilst improving and to mobilise
maintaining clinical safety and
quality. Traditional cost cutting Our
methods including staff reduction
fail to deliver the required savings shared Improvement
methodology
because fewer staff are left with
the same processes. purpose
A Lean management system
delivers reductions in error rates
System
and waiting times, together with drivers
increases in productivity. Rigorous
Application by healthcare delivery
organisations across the world has
improved outcomes for patients
and reduced the cost of care at the Transparent
same time.
measurement
NHS Improvement has worked with
multiple teams across pathology
disciplines to evidence the value of
Lean methodology.
The NHS Change Model
Application of Lean tools enables
improvement of isolated processes
but the impact of one-off The key to the Change Model is not • Our shared purpose: patient
improvement efforts of this nature the individual components but experience is at the heart of what
can be short lived. It is only when ensuring all are addressed equally as we do and drives change.
clinical leadership and operational part of any improvement effort. • Leadership for change: to create
management changes sufficiently transformational change.
that an organisational culture of “By doing that, we’ll • Engagement to mobilise:
continuous improvement can be understanding, recognising and
achieved. amplify and reinforce our valuing individuals’ contributions.
ability to drive change. • System drivers: QIPP, CQinns, NHS
The NHS Commissioning Board has Operating Framework.
recently launched the NHS Change We’ll take the skills we’ve • Transparent measurement:
Model. already got, and take measurement for improvement and
patient outcomes.
The model brings together familiar them to the next level in • Rigorous delivery: project
elements of any successful change being able to make management, PDCA cycles and
programme and is designed to ensure measurement of benefits.
the NHS can meet the challenge of things happen.” • Improvement methodology: Lean,
the pace and scale of change capacity and demand, value and
required to meet future financial process mapping.
constraints and improvements in • Spread of innovation: using shared
quality. learning via multi-media
techniques.

Introduction 11

The programme of improvement
predates this model. However, it
can be demonstrated that NHS
Improvement’s approach in
supporting clinical teams has
addressed each of the eight
elements of the model which should
be at the centre of any improvement
effort whether localised to a single
department or at national scale.

Lean management is not simply an
’improvement methodology’ as
described in the Change Model. Lean
addresses all areas and provides
teams with a checklist for continuous
quality improvement.

Exemplar programme and Shingo
assessment
The majority of the case studies in
this document come from Leadership for change John Toussaint, CEO Thedacare,
laboratories that are part of the NHS Leadership is behaviour – Wisconsin, USA, a healthcare
Improvement pathology exemplar organisation that slashed errors and
site programme commissioned by the “What we do as leaders improved patients outcomes, raised
DH Pathology Programme Board. The staff morale and saved $27m in costs
aim of the programme is to establish is more important than with no lays offs, sums it up as
and support a network of pathology what we say.” follows:
laboratory exemplar sites who will
demonstrate continuous quality
improvement (CQI) in clinical, process
Sir Nigel Crisp “In the end the enemy of
and business excellence. One element of the new NHS our improvement efforts
Site assessments
Change Model is Leadership for was us. Leadership was
change. The narrative supporting
All pathology disciplines within the this asks, “do all our leaders have the treating each
exemplar sites will carry out self- skills to create transformational improvement initiative as
assessments supported by NHS change?”
Improvement, based on the time limited, a finite
international Shingo Standards for Lean is the term popularised by project conducted by a
Business Excellence. The assessments Womack and Jones to describe a
will be made against criteria management system derived from
few members of staff or
demonstrating: the Toyota production system (TPS) consultants.
that has been adapted and
• leadership and cultural enablers; successfully applied nationally and
Improvements ended
• continuous quality improvement; internationally to a wide variety of when a project was over
• organisational alignment; industries including healthcare for
• understanding the needs of over 20 years.
because nobody was in
customers; and charge of sustaining
• business results. Why, when it seems so simple do
Lean initiatives often fail to sustain?
change and measuring
www.shingoprize.org/model- results.”
guidelines.html

12 Introduction

“In order to change
outcomes, leaders at
Thedacare needed to
change”(3)
Continuous improvement can, and
will, only occur if the people who
actually do the work are actively
engaged and understand Lean and
their leaders change.

Literature evidences that there are
key behaviours that leaders and
managers need to adopt in order to
develop a sustainable Lean
management system.

Developing a Lean culture
Culture change takes time and
requires leadership. A great many
models and theories exist to guide
those wishing to develop their own
Finding change agents Core team members must
leadership capability and approach.
Achieving a culture shift starts with a understand the process within their
small team working collaboratively stage of the pathway and be:
Key steps to influencing the creation
with their department colleagues and • able to contribute
of a lean culture include:
users to improve identified areas of ideas/information on the process;
• find change agents;
the process. • able to influence the decision
• get Lean knowledge;
• seize crisis; making process;
Identify a credible and respected • prepared to test and implement
• map the value stream;
project lead to head up this team. changes across the pathway; and
• remove waste;
Look for a clinician or manager with • committed to attend all team
• continuous improvement; and
the drive and enthusiasm to steer meetings, activities and work
• sustain.
changes across the patient pathway. required between meetings.
A Lean culture could be described as
Project team members should be Escalation planning
one where managers at every level
drawn from across the entire An executive sponsor is essential to
go to the workplace and coach their
pathway: provide proactive support and access
staff in plan, do, check, act (PDCA)
• clinical colleagues who will actively to relevant support services such as
problem solving. A continuous
commit to the improvement effort; estates and transport, HR, finance
process that is part of ‘the way we
• laboratory representatives for each and IT teams. They may be called
operate here’.
job grade; upon to escalate key issues.
• administrative /office staff
representative;
• porters/ transport staff; and
• user involvement – member of a
patient group and a high volume
user – from primary care, ward or
clinic.

Introduction 13

Engagement of your staff How engaged are we? Suggestions boxes / boards
What is engagement? An engagement surveying tool has Provide an outlet for staff to make
Another element of the new NHS been developed and is available at anonymous comments, niggles and
Change Model is engagement to www.improvement.nhs.uk/ suggestions. Share comments at the
mobilise – are we engaging and improvementsystem to enable daily huddles and provide either an
mobilising the right people? measurement and to motivate instant response or agree a timescale
There is no single answer but themes leaders at all levels to take action on for investigation and feedback.
of commitment, involvement, results and improve their own
communication and energy leadership capability. 1-2-1s
are clear. Speak privately with individuals
The 10 questions are based on the where necessary to make it known
“Employees who work work of the Gallup organization, that their views and concerns are
Marcus Buckingham and Curt important. Ask their permission to
with passion and feel a Coffman published in First, Break all raise their issues at daily huddles for
profound connection to the Rules. further discussion.

their organisation. They Communication After a period of time (which will be
drive innovation and Establishing the framework for, and different for each team depending on
maintaining, good two way the starting point) use of suggestion
move the organisation communication is critical to the boxes and boards should diminish as
forward.” success and sustainability of any the daily huddle becomes the focus
improvement activity. for raising, discussing and resolving
Meere(4) issues.
Daily meeting - huddles
“Employee engagement An important mechanism for Daily meetings can (and should) be a
engaging staff is huddling. formal part of department operations
is about translating A huddle is a daily, short and snappy and minuted accordingly. The need
employee potential into face to face gathering of a team, for formal laboratory meetings will
preferably standing around a reduce and may be eliminated
employee performance performance board that addresses altogether.
and business outcomes.” the following.
More supporting information is
Melcrum(5) 1. Focus – on key goals and available at:
responsibilities for the day. www.improvement.nhs.uk
It is well-established that change is 2. Clarity – clear, relevant and timely /improvementsystem
difficult for most people. It is the information to help staff perform
responsibility of leaders to listen and their daily roles.
understand individual perspectives 3. Commitment – listen and act on
and concerns creating an staff views, ideas, and concerns and
environment of open and honest to feedback progress.
communication.
When huddles are first introduced
they may feel strange and
uncomfortable for some people.
Participation is likely to come from
the same small group of individuals
and so other mechanisms for eliciting
input and views from the whole team
can be used to support efforts to
create an environment where all are
comfortable to speak up.

14 Waste

Waste
Every process has waste. The
foundation of Lean is the relentless Type of waste Laboratory examples
pursuit and elimination of waste in
all work activities. T TRANSPORT Material or information that is moved
unnecessarily or repeatedly e.g. Unnecessary
When we look at a process as a time movement of samples between work areas
line of activities, material (samples or laboratories.
and consumables) and information
(request cards and reports) whether I INVENTORY Excess levels of stock in cupboards / store
in a value stream map or a process rooms; batches of specimens waiting to
sequence chart, we see a significant move to next step in process.
percentage of waste. Usually in
excess of 90% of a sample journey is M MOTION Unnecessary walking, moving, bending or
taken up by wasteful, non-value stretching e.g. equipment placed in wrong
adding activity. location, unnecessary key strokes.

Some steps in the current process will A AUTOMATING Where technology is substituted to
be pure waste (see below), other (inefficient processes) compensate for a poor process. For example
waste may be necessary within the analytical track systems which are purchased
current way of working. For example, without the right process being agreed,
in many blood sciences laboratories, tested and established. In some cases
the need to centrifuge samples or resulting in ‘urgents’ being taken off the
transport samples to, or between, ‘track’ because it’s too slow.
laboratories is currently necessary
waste. W WAITING Waiting for specimens, equipment, and staff.
Samples waiting to move to the next stage
Improvement initiatives should focus of the process.
on eliminating the pure waste and
reducing the necessary waste. O OVER-PRODUCTION Producing something before it is required, or
more than is required e.g. unnecessary or
A simple mnemonic exists to aid inappropriate tests; batching specimens,
recall of the nine wastes. tests and information; ‘just in case’ blood
tubes drawn from patients, but not used.

O OVER-PROCESSESING Duplication of data e.g. Dual data entry,
repeat testing, additional steps and checks
that add no value to the process.

D DEFECTS Errors, omissions, anything not right first
time e.g. Poorly labelled specimens and
requests, insufficient or illegible information.

S SKILLS UTILISATION Unused employee skills e.g. Highly qualified
staff performing inappropriate tasks; staff
ideas not being considered.

Waste costs money and adds time

Sites 15

Sites
This document shares learning from a The approach required local Northern Lincolnshire and Goole
number of clinical teams from three ownership and leadership if the Hospitals NHS Foundation Trust
sites who have been working with improvement was to be sustained, Path Links is a single managed
NHS Improvement and three sites underpinned by the training of all Clinical Pathology Network operating
who have independently undertaken members of the team in Lean across Lincolnshire. Formed in 2001
a Lean improvement journey. methodology. from the amalgamation of NHS
services in Boston, Grantham,
NHS Improvement sites Clinical teams were encouraged to Grimsby, Lincoln, and Scunthorpe,
visit other exemplar sites to observe Path Links is a directorate within the
Derby Hospitals NHS Foundation Lean methodology as part of diagnostics and therapeutics division.
Trust, Royal Derby Hospital everyday working and understand
Beginning in November 2011, the how improvements have been Standardisation of blood sciences
Derby blood sciences team have been achieved. commenced in 2009 culminating in
developing a Lean culture which the successful implementation of pre-
started in specimen reception and Independent sites analytic and analytical lean work cells
subsequently spread into the blood These sites were selected to reflect supported by multi-discipline trained
sciences laboratory and the A&E the importance of a long term staff. The introduction of standard
department. sustainable approach to work and A3 SOPs has resulted in
improvement, where the learning improved quality, increased
Chesterfield Royal Hospital NHS never ends, and the service is productivity and reduced costs.
Foundation Trust constantly looking to pursue
Beginning in October 2011, the perfection. South Warwickshire NHS
Chesterfield blood sciences team Foundation Trust
have been developing a Lean culture Bolton NHS Foundation Trust, The South Warwickshire team was
which started in specimen reception Royal Bolton Hospital part of a hospital wide approach to
and subsequently spread into the The team at the Royal Bolton Hospital improvement sponsored as a three
blood sciences laboratory, the started their Lean journey in blood year work programme by ‘The Health
specimen transport system and the sciences in 2005-6. They have Foundation’ to examine the
haematology clinics. provided support to the NHS relationship between emergency
Improvement sites through hosting patient flow, mortality and cost.
Taunton and Somerset NHS exemplar site visits. Recognition of
Foundation Trust, Musgrove Park their sustainable efforts was achieved
Hospital in the HSJ Award for Efficiency in
The blood transfusion team at September 2012.
Taunton have been developing a Lean
culture which has spread from the
cytology laboratory and specimen Sites and leads
reception functions to the surgical
admissions lounge and operating Derby Hospitals NHS Laboratory Lead: David Simpson
theatres. Foundation Trust Clinical Lead: Dr Nigel Lawson

Chesterfield Royal Hospital Laboratory Lead: Christine Ainger
Working with blood sciences teams
NHS Foundation Trust Clinical Lead: Roger Start
across these sites to further evidence
the value of Lean thinking, NHS Taunton and Somerset NHS Laboratory Lead: Matt Barnett
Improvement provided training in the Foundation Trust Clinical Lead: Dr Sarah Allford
use of Lean thinking to support staff
to redesign the way services are Bolton NHS Foundation Trust Laboratory Lead: David Hamer
delivered, to achieve process Clinical Lead: Gilbert Wieringa
excellence to support the clinical
excellence within the laboratory and North Lincolnshire and Goole Laboratory Lead: Martin Fottles,
in turn improve the user’s Hospitals NHS Foundation Trust Continuous Improvement Manager
experience. (Path Links) Clinical Lead: Dr David Clark

16 Start with the end in mind

Start with the end in mind
The often-asked question in Since the publication of the second Similarly some of the case studies
improvement work is, ‘where do Carter Report, there has been a overlap the pathway sections and for
we start’? growing emphasis on Pathology ease of inclusion we have tended to
services taking responsibility for include case studies under the stage
There is no simple answer, it depends managing the end-to-end journey in which the journey starts.
on what are your biggest issues; (i.e. from collection of sample to
what is your burning platform? delivery of interpreted result, All continuous quality improvement
including transport and logistics – initiatives should deliver
How will you know what Carter Report 2008). This document improvements in one or more key
these are? has been constructed around the key areas, namely:
Sometimes this is obvious, from stages in this end to end journey as
known failings in your systems, or follows: • quality e.g. reduced defects;
imperatives set by your executives or • timeliness/delivery e.g.
commissioners. However, without • Pre-pre analytical: clinician decision improved turnaround times;
three fundamentals in place you are to test to sample delivery. • cost/value for money e.g.
unlikely to be in a position to apply • Pre analytical: sample receipt to removal of waste, reduction in
the right improvements in the right available to test. inventory; and
places. These three fundamentals are: • Analytical: availability to test to • morale/staff experience/patient
result available to view. experience e.g. reduced
• looking at the end-to-end • Post-analytical: result available with overburdening for staff,
processes in your service (from comments added to result, reduced waits for patients.
decision to test to provision of delivered and viewed.
interpreted result); • Post post -analytical: result It is indicated before each case study
• collecting data to inform exactly interpretation and follow up which improvement parameter(s)
what is happening as a baseline testing. they deliver by highlighting the
and understand what needs to appropriate box, together with the
improve; and There are opportunities for laboratory headlines from the case study.
• engaging with the customer services to add value at each stage of
(patients and their clinical teams) to this pathway.
understand their needs and what MORALE,
value you can add to them (the Some of the Lean tools available lend COST OR
STAFF OR
true ‘end in mind’). themselves to a particular part of the VALUE FOR
PATIENT
pathway, others are equally as MONEY
EXPERIENCE
In the following chapter and case valuable across several or all parts of
studies, you will see how these the pathway.
fundamentals have helped drive and
focus the improvement work at all TIMELINESS QUALITY
the sites who have contributed to this AND AND
learning document. DELIVERY SAFETY

. Pre pre-analytical stage 17

Pre pre-analytical stage
The start of the journey All of these opportunities to add
The clinician has a clinical question value are dependent on:
PRE PRE-ANALYTICAL
and they require diagnostic input to • laboratory staff engaging with their
help answer that question. The customers;
laboratory can influence and add • listening to their requirements;
value at this stage in a variety of • helping them solve their problems;
ways, including advising on: • understanding what the customer
• what to test for; values from the services on offer;
• how to test; and CLINICAL QUESTION
• when to test; • ensuring that value is delivered as
• where to test; and efficiently and effectively as
• who performs the test. possible with minimum
wasteful/non value adding steps.
Laboratory staff can educate clinical
staff to understand the safest and The concepts highlighted in the case
most effective way to collect, label studies in this section include: GENERATE REQUEST
and despatch the required samples. • user engagement;
• use of order sets; and
This may include providing • communicating with users.
phlebotomy services; assisting in
implementation of electronic ordering The tools illustrated include:
systems; providing sample collection • value stream mapping;
and transport services/systems. • current and future state models; COLLECT THE SAMPLE
• identifying non value adding steps;
• reducing defects; and
• ‘go and see’.

TRANSPORT THE SAMPLE

18

MORALE,
COST OR TIMELINESS QUALITY
STAFF OR
VALUE FOR AND AND
PATIENT
MONEY DELIVERY SAFETY
EXPERIENCE

Pathology transport reconfiguration
Summary
The trust’s transport service
Data collection of when samples
introduced an ‘interceptor’ van,
which has enabled samples to be
arrived at the laboratory and
delivered to the laboratory more establishment of interceptor van
frequently throughout the day,
smoothing the flow to the laboratory ensured smaller batches of work
and reducing the number of
specimens by 61% between 12:45 which were delivered more often.
and 1:15pm (the main lunch period).

Understanding the problem
The pathology transport service at Total number of samples on pathology vans on 4 January 2012
Chesterfield Royal Hospital provides
a delivery and collection service of 800
internal mail, pharmacy supplies and 700
Total number of samples

pathology samples to a mixture of 686
600
GP practices, community hospitals
and clinics. The service operates by 500 546

employing eight part time and one 400
full time van driver. At present the
service has five vans and does an 300 330 335
309
average of 190 calls per day over five 200
214
186
van schedules, which are split into
100
morning and afternoon runs. 110

0
9am-10am 10am-11am 11am-12pm 12pm-1pm 1m-2pm 2pm-3pm 3pm-5pm 4m-5pm
A detailed audit of the blood Time
sciences pre-analytics process
identified two major peaks of
workload arriving from GP and
community locations, so the
pathology transport service Number of samples arriving by pathology van by
examined how they could contribute schedule - January 2012
to improving the flow of work
arriving into the laboratory. 500
450 468

The data collection revealed the 400
number of samples arriving into 350 379 381
pathology, along with number of 351
300 315
samples on each van by the hour.
250
250
200 224
182 186
150
100
96
50
0
A B C D E
Morning Afternoon

19

How the changes were
implemented Daily deliveries
A team of representatives from the
Before interceptor van After interceptor van
pathology transport service,
pathology general and blood 11.30-11.45
sciences departments produced a
value stream map and process maps 12.00-12.15
of the service to identify key areas 12.30-12.45
for potential improvement.
Three groups within the team 12.45-1.00
discussed the issues and the aims of 1.00-1.15
this session were identified as:
3.30-3.45
• reduce the ‘peaks’ of samples
4.00-4.15
being delivered to the
laboratory; and 4.15-4.30
• resolution of community pharmacy
4.30-4.45
issues such as controlled drugs,
incomplete paperwork, and access -800 -600 -400 -200 0 200 400 600 800
to the department.

An interceptor van was introduced
to meet other van drivers at specific
points along their routes, collecting Positive feed-back from the sample Key learning
samples and returning back to the handling staff was received. They Data collection of when samples
laboratory more frequently felt that the introduction of the arrived at the laboratory and
throughout the day. The impact of interceptor van meant that samples establishment of interceptor van
this was monitored after several were arriving more often in smaller ensured smaller batches of work
weeks by repeating the hourly batches. delivered more often.
audit of samples arriving in the
department and comparing this to Community pharmacy How this improvement benefits
the baseline data originally After discussions and e-mails with patients
collected. community pharmacy the van drivers Samples arriving earlier in the day in
have noticed that the time waiting smaller batches means that more
Measurable improvements to access the pharmacy department samples are received and processed
and impact had reduced so that the length of on the day they were collected from
The data analysis shows the impact time waiting for controlled drugs has the patient, so results are available
of the introduction of the interceptor also reduced. The situation is sooner.
van with a significant amount of monitored through the departmental
work now being received earlier meetings. Contact
from the morning and afternoon Joanne Dodsworth,
collections, with 32% less samples All community pharmacy issues had Operational Services Co-ordinator
received in the morning and 1% been resolved. Email:
increase in the afternoon on re-audit joanne.dodsworth@chesterfieldroyal.
when compared to the baseline nhs.uk
data.

20

MORALE,
STAFF OR
VALUE FOR AND AND
PATIENT
EXPERIENCE

Introduction of coloured transport
bags in pathology
Summary
The pathology department
A simple visual management system
introduced coloured transport bags,
currently in use for 40% of GP users
has improved communications
with the remaining GP surgeries between the laboratory and GP
using the coloured bags by the end
of 2012. practices.
The pathology transport service at
Chesterfield Royal Hospital provides Number and types of samples arriving by pathology
a delivery and collection service of van by schedule - 4 January 2012
internal mail, pharmacy supplies to a
1200

mixture of GP practices, community 1100
1021
1000
hospitals and clinics and pathology Morning Afternoon
samples are delivered to pathology 800
reception from these sites. 600
The data collection identified the
400
sample types arriving in pathology
200 188
reception. 152
13
98 55 37 30 10
12 1 0 4 4 5 1 1
0
Blood Urine Stool Swab Cytology Histology Nail clip Sputem Other
• Multiple sample/mail collection
points in practices/hospitals.
• Samples not ready for collection
(bags not sealed). This identified a ‘go-live’ date for the • Inappropriate items of mail have
• Van drivers queuing in-line with trial of the new bags as 12 March reduced.
patients. 2012, and it was recommended that • Communication of surgery
• No notification if surgeries closed the van drivers report any closures has improved.
for training etc. (therefore no concerns/issues. The main focus on
collection required). this session was to review what the Key learning
• Samples stored in un-manned transport service will accept with The introduction of a simple visual
areas. respect to collections/deliveries. management system has improved
• Incorrect sample storage (fridge/ the communication with GP
room temperature). Some users had also raised concerns practices and improved sample
• Many items collected are over the changes to the new sample integrity.
inappropriate items of mail, e.g. biohazard bag, a guide was also sent
mobile phones. out to help address issues. How this improvement benefits
patients
How the changes were The core team produced a guidance Sample integrity has improved as
implemented notice from the operational services samples are stored appropriately and
A team of representatives from the co-ordinator, along with a covering at the correct storage temperature.
pathology transport service, letter, which was sent out to all users
pathology general and blood of the transport service in April Contact
sciences departments identified key 2012. Joanne Dodsworth,
pilot sites to roll out the new Operational Services Co-ordinator
coloured transport bags. Measurable improvements Email:
Initial meetings took place with six and impact joanne.dodsworth@chesterfieldroyal.
GP practices. • Samples are now placed in the nhs.uk
coloured sample bags, sealed and
placed at the collection point.

21

Examples of new pathology transport sample bags

22

MORALE,
STAFF OR
VALUE FOR AND AND
PATIENT
EXPERIENCE

Decreasing the rejection rate for
transfusion blood samples
Summary
The rejection of blood transfusion
Engagement with users and
samples due to the poor completion
of the transfusion request form
subsequent redesign of the request
caused delays in transfusion form has allowed the clinical and
processes. Introduction of a new
request form in two clinical areas laboratory staff to focus on the critical
reduced rejection rates from 15%
to 1.8%. information required.
One of the causes for delay in the
availability of group and antibody contained the correct patient details How this improvement benefits
screen results for patients going to and removing the requirement for a patients
theatre was the number of samples doctor to sign the request form. • The reduction in the number of
that were rejected by the laboratory samples rejected means less
staff due to the form being The form was piloted for two repeating of samples and
completed incorrectly, increasing the months in two clinical areas, the therefore less re-bleeding of
workload for clinical staff and haematology ward as they are high patients.
causing dissatisfied patients who users and A&E department because • For those patients awaiting a
may have to be re-bled, or have their of the high rejection rate. The SAL blood transfusion, there is less
surgery delayed (especially if they are was not used as although they had a likelihood of delay, especially for
first on the operating list). high rejection rate, only four staff on patients first on the operation list.
the ward perform the phlebotomy. This is also especially important for
In September 2011, 15% of all those patients who need regular
rejected samples came from the Measurable improvements monthly blood transfusions.
surgical admission lounge (SAL) and and impact
15% came from A&E. Other clinical In the two months prior to the pilot How will this be sustained and
areas also were found to have high over 15% of the rejected samples what is the potential for the
rejection rates. The analysis of the came from the A&E Department. future?
causes for rejection indicated that Overall rejection rates for February The next slep in the process is to role
the two main issues related to the and March were: out the new form across the whole
date of birth missing from the form • 6% for all samples; and of the trust. This will be supported
and the form not being signed by • A&E – 10%. by an implementation plan to ensure
the doctor. that all relevant staff are aware of
During the pilot period 110 forms the changes.
How the changes were were completed. Only two forms
implemented were rejected. Rejection rates will be monitored by
Discussions were held with clinicians, the transfusion staff and fedback to
including the anaesthetists and Key learning the clincial areas with the highest
nursing staff to find out what were Engagement with users and rejection rates.
the key obstacles preventing the subsequent redesign of the request
forms from being completed form has allowed the clinical and Contact
correctly. This led to a redesigning laboratory staff to focus on the Alison Western,
of the blood transfusion request critical information that is required Transfusion Practitioner
form to allow the use of an when requesting blood components Email: alison.western@tst.nhs.uk
addressograph label which and transfusion related blood tests.

23

MORALE,
STAFF OR
VALUE FOR AND AND
PATIENT
EXPERIENCE

Emergency department diagnostics
improvement
Summary
A thirteen per cent improvement in
The importance of 'go and see' and
the number of samples authorised
within one hour of collection as a
understanding the end-to-end
result of a clinical support worker pathway reduces turnaround times,
trial, and the reduction of blood
transport times by up to 15 minutes and improves communication
due to re-prioritisation of pneumatic
chute station. between departments.
The requirements set by the Royal
College of Pathologists, states that
by 2015, 90% of samples taken in
the emergency department(A&E)
must have results available within
one hour from receipt in the
laboratory. Since the responsibility
for achievement of this goal is
shared between staff in the
pathology laboratories and A&E, one
of the keys to understanding the
issue fully, was to ’go and see’ what
actually took place in each
department.

As a result of the ‘go and see’ booked in and when the results On observation of the workload
activity, the phlebotomy was seen were authorised. It became apparent faced by the specialist nurses
to be delayed in triage due to the from these observations that the working in A&E, it was clear that
nature of the workload faced by pneumatic chute sometimes held asking more of them, even for the
specialist nurses in A&E , since they pods filled with samples for up to 20 improvement of their processes,
have to respond more urgently to minutes prior to sending them to the would be very difficult to implement
patient needs. There was often a laboratory. and sustain.
substantial discrepancy between
’collection’ time as recorded on the Teams of staff from both the Enquiries were made with the
computer system (when request pathology laboratory and A&E met estates department, who are
forms were printed) and actual time with each other to discuss the responsible for the pneumatic chute
the blood was taken, resulting in problems faced by each department system, to find out if there was any
incorrectly recorded TATs. when taking and processing blood, way of reducing the time pods were
in an effort to help identify issues waiting to be sent to the laboratory
Two of the laboratory staff went to which could be solved quickly, and from A&E.
A&E to observe the processes. They for the most mutual gain. Both
recorded the times samples were teams gave tours of their respective
requested, the times samples were departments to each other, to help
taken, when the samples were gain some understanding of the
placed in the pneumatic chute, practicality of working in each area.
arrived in the laboratory, were

24

Clinical Support Worker Trial

implemented
• Meetings were held between
pathology and A&E staff. Some
long standing issues on both sides
were discussed, allowing a greater
depth of understanding of the
challenges each group must
overcome on a daily basis. Bridges
were built, allowing improved
communication and an increased
feeling of team spirit and empathy
between the two departments.
• One Plan, Do, Study, Act (PDSA)
trial was carried out to determine • 13% improvement in number of • Leadership is the key. Without
the effectiveness of a clinical samples collected and authorised investing the time required to
support worker in the emergency within one hour. make and sustain effective
department to carry out all • Average time from pods waiting to improvement, nothing can
phlebotomy duties. be sent from A&E to the lab change.
• It was discovered that the ’priority’ improved from 9.25 to 3.5 • Following the clinical support
setting on the pneumatic chute in minutes or 62%. worker trial in A&E, no post has
the emergency department had • Formal and informal meeting and been put in place to make this
been lost two years previously and ’go and see’ activities improved permanent due to funding. All
no one had noticed. This was vital communication betweenA&E benefits must be weighed against
reinstated and reduced the and the laboratory, with one their cost for improvement to be
maximum time pods were waiting advanced nurse practitioner truly effective.
to be sent from A&E to the stating: “Just knowing who to talk
laboratory from 20 minutes to five to about certain issues makes any How this improvement benefits
minutes. problems that arise much easier to patients
resolve quickly.” This reduction in time taken to
Measurable improvements • Phone calls reduced from A&E to transport samples to the laboratory
and impact the laboratory from six per day to means faster results, faster
• Pod priorities reinstated after six a week. treatment and ultimately, faster
being lost two years previously . • The clinical support worker trial discharge. Should the trial ever be
• 25% improvement in mean was perceived to reduce A&E made a permanent post, the
collection to receipt time during specialist nurse workload. reduced workload on the A&E
trial week. Although not formerly measured, specialist nurses would allow more
• Average sample collection to staff simply said it meant they had time to provide patient focussed
receipt time improved from 75.75 one less thing to worry about. care, rather than being focussed on
to 57.07 minutes during trial turnaround times and targets.
week. Key learning
• 76% reduction in average moving • Properly defining the issue to be Contact
range overall, showing a reduction resolved and collecting relevant Tom Kennedy, Specialist Medical
in variability of sample transport data in a consistent way is Laboratory Assistant
times from A&E. Possibly absolutely fundamental to the Email: tom.kennedy@nhs.net
attributable to increased success of any improvement
awareness among staff. project.

25

MORALE,
STAFF OR
VALUE FOR AND AND
PATIENT
EXPERIENCE

Haematology clinic changes to support
patient experience and improve flow
Summary
By using the principles of ‘go-see’
It is important to differentiate
and ‘ask why’, haematology clinic
changes have improved the time
between what is thought to happen in
taken for samples to arrive in the a process and the reality of what
laboratory. These activities have
generated multiple suggestions for actually happens. Don’t try to solve
further changes to improve the
patient experience of clinics. every problem at the same time.
Haematology clinics for patients with
a wide range of malignant and non- A ‘go see’ exercise to understand Lab (booking in, processing,
malignant haematological conditions how patients flow through clinic and authorising)
held on Monday and Friday have how the samples flow through the • Requests are collected from the
approx. 35 patients booked in to lab was completed in April 2012. air-tube and identified by yellow
each clinic. Many of the patients The service manager, consultant paper.
attend this clinic on a regular basis haematologist, phlebotomy team • They are processed as urgent.
and many require chemotherapy leader and lab staff all visited the • If a blood-film is required, results
and/or blood transfusion support clinic. are not authorised.
and so require recent blood test
results to enable the clinicians to Pre-lab (phlebotomy, transport Post result (consultation and
make treatment decisions and so the to lab) follow up organisation)
medical staff do not have a • Patients don’t attend at their • Unauthorised results cannot be
consultation with the patient until allocated appointment times. seen by all clinic staff (medical
this result is available. A few Some patients requiring blood staff and some nursing staff can
patients who attend the clinic have tests come earlier than their see unauthorised results). Until
their blood sample taken sometime appointment time, others attend authorised, the results do not go
in the week before their at their appointment time. across to the result viewing system
appointment either at the hospital Patients not requiring blood tend accessed by all staff in the Trust.
phlebotomy clinic or in the to arrive at their appointment • Notes for patients who are ready
community. The majority of patients time. to be seen by consultant are put in
have their blood sample taken on • Phlebotomists have a list of to a box in the clinic. Consultants
the day they attend clinic and then patients attending clinic and check collect notes from the front of the
wait for the result to be available on notes which ones will be box and taken back to their
before having their consultation with requiring blood tests on the day. consultation room.
the doctor, nurse or pharmacist. Phlebotomy staff call patients in • Consultants check that all results
the order on the list, but do not are available and that they are able
The clinics are very busy and tend to know if the patient has arrived. to see the patient. If results are
overrun on a regular basis with some • Blood is taken and then available, the patient is called in to
patients waiting a long time to be transported down the corridor to the consultation room. If results
seen. The perception of the clinic send to the lab via the air tube. are not available, the consultant
staff was that waiting for blood • Patient notes are put in a box for has to either chase results from
results delayed patient consultations the consultant when the patient the lab or put notes back and pick
in clinic. has booked in and gone to have another patient to see.
bloods taken. • During consultation, the
consultant makes arrangements
for follow up appointments and
treatment for the patient.

26

Within each of the previous steps in
the pathway, lots of issues were
identified. Ideas for improvements
were suggested during a
brainstorming session and also
picked up during discussions at team
meetings.

Base line data was collected at each
step of the patient pathway through
clinic to identify the problem areas.
The figures showed that the
automated testing process within
the lab was very quick and the
median time taken was 8 minutes
from the sample being booked in to
a result being available, this
accounted for 16% of the total
turnaround time.
This suggestion raised several health
The turnaround times for each stage and safety issues but following
of the process showed that the main discussion with the pathology
areas to focus on improving should health and safety lead, measures
be: were put in place which were
• Time taken from the patient accepted by the pathology clinical
arriving to the request being governance committee. As
booked in to the lab (pre-result - phlebotomists are classed as
1. Change of route taken to members of laboratory staff they are
53% of total turnaround time).
get to lab: aware of the precautions they need
• The time taken between the result
Suite 4 is not connected to the air to take in the laboratory, they wear
being available and this being
tube network so the samples have to appropriate clinical uniform and
authorised (post result - 8% of
be hand delivered to the laboratory. carry hand gel to apply when going
turnaround time but a maximum
Although Suite 4 is next door to in and out of the laboratory.
value of over two hours).
Pathology the route to drop off the
samples meant walking out of Suite
4 along the corridor and then in to
implemented
Pathology reception. The samples
On 6 June 2012, the haematology
were then dropped at pathology
clinic re-located from Suite 1 on a
reception and taken by the reception fire door in to the blood sciences lab.
Monday and Friday due to re-
staff to sample handling. The total It was suggested that this route was
organisation of clinic space in the
distance from the blood taking room used to deliver samples directly in to
Trust. This move forced some
to sample handling is approximately sample handling. The total distance
immediate changes in the pathway.
30meters one way (blue line on floor from the blood taking room to the
The nursing staff for suite 4 are not
plan). This change had the potential sample handling bench would be
the same members of staff who
to significantly increase the time reduced to 9 metres (red line on
worked in suite 1. They did not
from sample being taken to being floor plan). Additionally, this reduced
know how the clinic had run in suite
booked in. It was noted that travelling distance enabled delivery
1 and were very keen to suggest
adjacent to the waiting room in suite of samples to the lab in flow rather
immediate changes.
4 there is a door which leads in to a than in batch as had been the
stairwell which then leads on to the custom.

27

2. Numbering system for Key learning The patient would know that the
phlebotomy introduced: • The importance of ‘go see’ to time of their consultation would be
From the ‘go-see’ observations it follow the pathway. This helps the time they are actually seen. This
was clear that the phlebotomist everyone involved in the process consistency will also mean that the
needed to know that a patient had understand how the work they do doctors do not waste time checking
arrived and needed a blood test. impacts on others. whether results are available
The clinic staff and phlebotomist • The perception that one part of meaning that they can actually
came up with the idea of a number the pathway was slowing the rest spend more time seeing the patient.
system, which works by the clinic down is not always true. A This should result in a better quality
staff giving any patient who requires combination of issues results in consultation for the patient.
a blood test a number when they delays.
check in to the clinic. The • Data collection is difficult and it is How will this be sustained and
phlebotomist calls the numbers out important to have a standardised what is the potential for the
and the patients go in to the way of collecting this. This was future?
phlebotomy room. particularly an issue as each part • Continue to gather data to gain a
of the pathway is completed by a better understanding of the wait
Measurable improvements and different member of staff and in times on various clinic days.
impact different locations. • Ensure that each step of the
The numbering system has allowed • Ideas should not be discounted process is as efficient as it can be
patients to be bled in the order in immediately because “we have by drilling down to examine ways
which they are booked in the clinic, tried that before” or “health and to improve. Some of the data
a first in first out system, which has safety would never allow it”. collected suggests that the
enabled samples to be dealt with in • Lots of areas for improvement are phlebotomist is not delivering
flow. highlighted when you examine a every sample as soon as it is taken
process. It is important not to try and will take 2 or 3 at the same
The whole pathway was to solve all of the problems time. The effect on the overall
re-measured on 18 June 2012. A immediately, but to plan changes turnaround time for the sample
breakdown of the data showed that in a structured fashion. needs to be measured to see if this
the time from sample being taken to does actually have a significant
being booked in had decreased from How this improvement benefits negative impact.
a median of 17 minutes in April to patients • Continue to work with the staff in
11 minutes in June 2012. This was a At the moment the doctors have no clinic to make sure that any small
direct result of the change of the way of knowing when results are changes in procedure are noted
route the samples took which available without looking up each and the effect on the running of
enabled flow rather than batch patient individually. If the patients the clinic is acknowledged. Explore
delivery of the samples. On average requiring a blood test were asked to implementing a more visual system
100 patients are bled in the clinics attend 45 minutes before their in clinic to show where a patient is
per week. So these improvements consultation time they could be in the process.
have removed 10 hours of patient called in to the consultation at their
waiting time per week. specified time. This is because the
lab could guarantee that a result will
be available within 45 minutes and
the consultant would be confident a
result would be available when they
called in the patient.

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