LEAN WORKING

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LEAN WORKING

• TVCS meeting
• Princess Alexandra Hospital
• 16th June 2009

David Smith - London Cytology Training
School Northwick Park Hospital
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Cancer Reform Strategy

• Minimising the time taken to get results back to
  women, aiming to inform women of the result of
  their cervical screening test within 2 weeks of
  it being taken
• 100 women receiving result letter within 14 days
  of sample collection
• 50 women receiving result letter within 7 days
  of sample collection

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Turnaround times

• Mean TAT approximately 29 days
• Approximately 2 hours touch time
• 28.9 days waste

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Apply lean methodologies to working practice
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What is lean?

• Management philosophy
• Perfected by Toyota by 1970

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Implementation of Lean benefits

• Improved quality and safety
• Fewer mistakes, accidents and errors,
  resulting in better care
• Improved service experience
• Improved delivery/ timeliness
• Better work gets done sooner (meets
  targets)
• Improved throughput (more income)
• The same people, using the same equipment,
  find they are capable of achieving more
• Accelerated momentum
• Stable working environment with clear,
  standardised
• procedures creates foundations for
  constant improvement
• Value for money lower costs, less waste
• Improved staff morale

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Lean principles

• Key areas of system
• Improving flow (pull)
• Increase value for user / customer
• Get rid of waste
• Get it right first time
• Continually improve
• Customer at heart of the process
• Driver for quality and safety

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Lean principles

• NHS Improvements team
• One of 10 centres to work at developing new ways
  of working

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Lean tools

• Process mapping
• Value stream mapping
• Future stream mapping
• Spaghetti mapping

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5S

• Sort Clearing the work area
• Set in Order Designating locations
• Shine Cleanliness workplace appearance
• Standardise All doing things the same way
• Sustain Ingraining the 5Ss into the culture

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Lean tools

• A3s
• TAKT time
• Root cause analysis
• 5 Whys analysis
• Visual management

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Lean Overview

• Specify VALUE from the customer viewpoint
• Identify the VALUE STREAM remove waste
• Make Value FLOW
• Initiate PULL in line with customer demand
• Pursue PERFECTION in quality quantity by
  continuous improvement

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Start of Lean project

• Core Team
• Primary care
• PCT
• Laboratory
• Executive sponsorship

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LEAN Methodology

• Looking at all steps in the process
• Implementation and monitoring of small changes to
  eliminate waste and simplify the process.

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Data collection

• Need to measure everything
• Collection to receipt in Lab TAT
• Receipt to verification of result TAT
• PCT to woman receiving result letter TAT
• End to end TAT
• Baseline data

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Baseline data

• 1 7 September 2008
• Collection to receipt 1.36 days
• Receipt to verification 18.9 days
• PCT to woman 8 days
• End to End 28.26 days
• Statistical Process Control (SPC) Chart

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Statistical Process Control (SPC) Chart

• Excellent visualisation tool for measuring and
  identifying variation and have been used to
  monitor the impact of changes made to the
  turnaround times (TAT) for cervical cytology
  specimens

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Points that lie outside the control limits should
be investigated with a view to make the process
more stable or predictable.
Upper process limit
Mean
Point where change made
Lower process limit
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Number of cases 1082 Mean 28.26 Shortest 9
days Longest 61 days
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Collection to receipt in Lab TAT data
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North West London Hospitals NHS Trust

• 54,000 cervical samples per year
• 3 PCTs
• Brent
• Harrow
• Hillingdon

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Problems identified

• Delays in pick up from surgery
• Delays in Pathology Reception

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Delays in pick up from surgery

• Communication with surgery
• More frequent pick up from surgery
• Communication with primary care staff

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Specimen Transport

• Hospital transport
• GP NPH Path Reception Lab

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The solution

• Put cytology in different coloured bags to help
  separate from rest of Pathology samples

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Pathology Reception

• Easier to identify cytology cases
• Reduced sort out time

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Collection of samples from Pathology Reception

• 10 minutes five times a day
• Approximately 9 days a year
• Over 110 miles a year

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Delivery of Cytology specimens

• Separation of cytology samples from other
  pathology samples
• Direct delivery of samples to cytology
• Estimated improvement of 0.1 2.5 days in
  collection to receipt in lab TAT

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Receipt to Verification TAT data
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Number 1082 Mean 18.9 days Shortest
1 Longest 51 days
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Process

• Walked the process
• Delays identified at all stages

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Gynae Reception

• Variable batches of work
• Separate urgent / fast track cases
• Large piles of slides awaiting booked in request
  forms
• No MLA staff at end of the day

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Gynae Reception

• Stop separating urgent / fast track cases from
  routine
• Time taken to sort out batch reduced by up to 1
  hr
• Request forms put in bundles of 10
• Matching up of slides with forms easier
• Vacant MLA post filled
• Specimens received late in afternoon sorted
• Increased use of pre-printed request form

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Booking in

• Biggest problem
• Insufficient staff
• Inefficient use of available staff
• Inaccurate information on request form
• Hard to decipher information on request form
• Large number of phone enquiries
• Method used for booking in varied

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Booking in

• Adjusted rota
• Enabled all booking in staff to access NSTS
• Attempted to standardise booking in methods
• Stopped putting printed specimen label on back of
  request form
• Increased use of pre-printed request form
• Daily meeting

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Sept mean 8.7 days June mean 1 day
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Screening Room

• Large backlog
• Batches of 20 slides
• Batch reporting
• Work left on desk
• Rapid review delayed
• Delays in Pathologist reporting
• Delays with HPV tested cases

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Changes made

• Reduce number of slides per tray to 10
• No batch reporting
• Tray of primary screening followed by tray of
  rapid review
• No outstanding work to be left on desk at end of
  day
• Cases queued to named Pathologist
• Daily meetings and e-mail

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Sept mean 1.87 days June mean 0.58 days 1.29
days improvement
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PCT to Woman TAT data
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What used to happen

• Electronic file sent daily to BH PCT and
  Hillingdon PCT
• Letters printed once a week
• Letters sent out 2nd class post

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Changes made

• Result letters printed every day Monday to Friday
• Results sent out 1st class post

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Still to do

• Investigate and improve TAT for cases that dont
  get loaded into Exeter system automatically
• Process of forwarding on to additional PCTs
• Send result file twice a day to PCTs

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Pre-printed request form

• Majority of request forms completed by hand
• Majority of defects encounter in sorting out
  and booking in related to use of hand written
  forms
• Number of surgeries printing their own form

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Pre-printed request forms

• Need to standardise form
• Open Exeter
• A5 pre-populated form distributed by PCT to
  womans GP
• Template loaded on GP system and printed as
  required

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End to End TAT data
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June Mean 1.41 days Shortest 0.5 days Longest
8 days
September Mean 1.36 days Shortest 0.5
days Longest 25 days
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June Mean 2..95 days Shortest 1 day Longest
11days
September Mean 18.9 days Shortest 1
day Longest 51 days
Mean improvement 15.95 days
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September Mean 8 days Shortest 0.5
days Longest 8 days
June Mean 2.91 days Shortest 2 days Longest
9 days
Mean improvement 5.19 days
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June Mean 7.27 days Shortest 3 days Longest
16 days
September Mean 28.26 days Shortest 9
days Longest 61 days
Mean improvement 20.99 days
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• If you always do what you always did,
• you will always get, what you always have!
• by NHS Improvement

THANK YOU