READER INFORMATION

Policy Estates
HR/Workforce Performance
Management IM & T
Planning Finance
Clinical Partnership Working
Document Purpose Best Practice Guidance
ROCR Ref: Gateway Ref: 6884
Title Learning from Pathology Service Improvement Pilot Sites
and Improvement Examples
Author Pathology Service Improvement Team
Publication date 14 August 2006
Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs,
Medical Directors, PCT PEC Chairs, GPs, Pathology
Departments
Circulation List Service Improvement Leads
Description As referred to in the Carter review “Learning from the
Pathology Service Improvement Pilot Sites” clearly
demonstrates that achievements can be done rapidly, for
little or no cost. The improvements outlined in the
document show immediate results to motivate others to
accelerate the pace of change and demonstrate
significant efficiency gains.
Cross Ref Modernising Pathology Services (DH 2004)
Superseded Docs N/A
Action Required N/A
Timing N/A
Contact Details Pathology Service Improvement Team
3rd Floor, St John’s House House,
East Street, Leicester,
LE1 6NB

Tel: 0116 222 5113
Web: www.pathologyimprovement.nhs.uk

“ I think this project has
given us the opportunity
to scrutinise and improve
parts of the pathology
service. Seeking the views
on what the service means
to practices and surgery
staff has been carried out
too infrequently.”
PCT Service Development Facilitator

Learning from Pathology Service Improvement Pilot Sites and Improvement Examples

Contents
Foreword 6

1 Executive summary 7

2 Introduction – Why Service Improvement? 8

3 Background to project 9

4 Pilot sites 10

5 Developing the learning 11

6 Involving patients and developing user engagement 12

Key findings from patients 12
• Patient Line of Sight (PLS) methodology 13
Partnership Pathology Services - Frimley Park Hospital NHS Trust
and Royal Surrey County Hospital NHS Trust
• Establishing patient focus groups and user forums 14
Calderdale and Huddersfield NHS Trust
• Using patient views to improve anticoagulation services 15
North East London Strategic Health Authority

7 Process improvement 16

Improving flow, eliminating waste 16

• Understanding the impact of delays in transport 17
Coventry and Warwickshire Pathology Network
• Transport issues affecting patients attending 18
hospital for phlebotomy services
Blackpool, Fylde and Wyre Hospitals NHS Trust
• Removing non value adding steps 19
• Improving flow in specimen reception 21
• Reducing steps and hand offs in specimen reception 22
• Reducing waiting times for patients by implementing 23
Point of Care Testing (POCT)
• Identifying waste in pathology pathway 24
• Using 5S to remove waste in specimen reception 25

4 www.pathologyimprovement.nhs.uk


8 Understanding demand, utilising capacity 26

Demand management
• Understanding variation in demand for diabetic screening tests 27
• Reducing unnecessary/duplicate requests 28
for thyroid function testing (TSH)
• Reducing inappropriate testing for thrombolytic patients 29
• Reducing inappropriate urine requests in microbiology 30
Royal Devon and Exeter NHS Foundation Trust

Optimising staff skills and utilisation
• Improving staff utilisation to match demand 31
• Understanding service demand and staff capacity 33
• Improving clinical Information on immunology requests 34
to release staff capacity
• Introducing BMS cut up to release Consultant Histopathologist time 35

Maximising technology
• Introduction of Point of Care Testing (POCT) to reduce 36
turnaround times in A&E
• Introducing histology robotics to maximize available skill mix 37
• Introducing automated liquid based cytology to reduce waiting 38
times for cervical screening results

9 Learning for future improvement teams 39

10 Building for sustainable change 41

11 References, resources, information, acknowledgements 43
and further reading

www.pathologyimprovement.nhs.uk 5


Foreword
Pathology service improvement has played a key role in the Department of Health’s
Modernising Pathology Programme. The National Pathology Service Improvement
Team has helped to raise the profile of pathology and provided practical support
across the NHS to put in place key improvements in laboratories.

The Team’s work with the six pilot sites funded by DH to implement the tools and
techniques of pathology service improvement in laboratories has developed vital
learning for other pathology services. Their work - set out in this report - shows
that service improvement in pathology delivers effective change and supports an
improved service for patients and benefits for staff.

Pathology has an important role to play in delivering improved choice and a more
convenient health service for patients. The practical learning in this report is a key
tool in bringing that about.

Dr Ian Barnes
National Clinical Lead for Pathology, Department of Health



1. Executive summary
The pathology service improvement pilot sites set out on a journey to test service improvement and Lean
principles across the whole patient pathway. The pilots were funded by the Department of Health to test
improvements over a period of 12 months starting in April 2005.

The key principles of the work were to compress time, reduce turnaround times, reduce the steps that add
‘no value’ to the patient, maximise staff skills and use technology effectively. The focus was to meet the
needs of patients and clinical users.

The learning demonstrates that:
• achievements can be made rapidly, for little or no cost, demonstrating immediate results that motivate
others to accelerate the pace of change, and deliver significant efficiency gains

Examples in this document include:

• releasing 1.5 hours per week of non productive time by reduced staff motion
• 50% reduction in average sample processing times, by reducing batching of specimens and
introducing one piece flow
• 50% reduction in phone calls in specimen reception
• 36% increase in number of samples labelled per hour
• 66% reduction in processing times in histopathology
• releasing 2.5 consultant sessions per week in histopathology
• 100% of patients seen in 20 minutes by introducing Point of Care Testing (POCT)

Service improvement should not be seen as a one off improvement initiative that ticks a box to satisfy
objectives. Equally it must not be something that is ‘done to’ teams, where those with improvement skills
walk away without leaving a ‘legacy of learning’ to support continuous improvement. The improvement
philosophy needs to be part of the organisational culture, that gives pathology staff:

• skills they can use in their everyday working life
• an opportunity to learn by doing
• the ability to continually look to improve flow by removing waste
• a patient focused approach to service provision

Whilst Lean Improvement is the methodology of choice for pathology, it will not replace the need for
organisations to focus on a sound implementation strategy based around the key success factors of:

• effective clinical leadership and executive support
• involvement of ALL pathology staff
• investment in dedicated time out, to reap huge rewards

We hope you find the examples of improvement and learning useful.

Ann Eason Lesley Wright
National Manager Associate Director
Pathology Service Improvement Diagnostics



2. Introduction
Why service improvement? Service improvement tools and Protected time out
techniques as rigorously applied by
the pathology service improvement Equally important, is the opportunity
The DH publication, Modernising
pilot sites have resulted in: to provide sufficient protected time
Pathology Services (Feb 2004),
out to give staff the opportunity to
recognises the role service
• patient focused pathology service test and implement change.
improvement and redesign has to
provision Sacrifices made in quality time out is
play in providing modern pathology
• lean processes that ensure clinical a small investment that needs to be
services. Such services should be
excellence is supported by process made, compared to the potential
responsive to the challenges posed
excellence gains that can be made to reap the
by new scientific and technical
• timely and reliable services rewards for the future.
developments, changing practice
• appropriate utilisation of staff
and patient expectations. Finally, we cannot solve the
• increased cost effectiveness
• improved efficiency and service problems by looking at data alone
The core principles of service
flexibility and theorising about a solution. We
improvement are to:
• optimised use of capacity need to fully understand the actual
• ensure the patient is at the heart
situation, identify the root cause and
of the service
implement the correct solution.
• streamline processes by eliminating Key factors for successful
non-value adding steps service improvement
• utilise staff skills appropriately
• maximise the use of technology Leadership and strategic
support
The pathology service consists of a
series of processes essential to Experience from all previous service
provide value for patients and clinical improvement initiatives has taught
users. To maximise value and us that success is dependent upon
eliminate waste, it is important to strong effective leadership and
fully understand the process. Value strategic support. The commitment
must flow across the entire pathway, must start at the top of the
ensuring the needs of patients and organisation and involve a whole
users are met. system redesign. This is also true for
pathology. The process of improving
To ensure patients flow through the
pathology services cannot be
system, whilst receiving quality and
achieved by the purchase of
timely care, it is essential pathology
technological solutions alone.
services are fully integrated,
Strong commitment, inspiring and
performing the appropriate test, at
motivating leadership are crucial to
the right time, in the most
support effective initiatives that build
appropriate location to ensure results
and create sustainable change.
influence clinical decision making.
Leaders must be prepared to
challenge the culture of their
organisation encouraging staff to
behave differently, test ideas for
change and believe in newly created
processes thus gradually allowing
the service to evolve.



3. Background to project
Pathology teams in England were
given the opportunity to bid for
funding to become one of six pilots,
to test service improvement
techniques.
Successful sites were expected to:
• map each pathology discipline
• develop and implement an
action plan
• demonstrate reduced turnaround
times, from decision to test to
result
• measure capacity and demand at
key points across the pathway
ensuring optimum use of
pathology services
• develop clear protocols and
systems to ensure effective
management of demand
• evaluate patient choice in
pathology to improve certainty for
patients who wish to use
pathology services
• review the use of technology in
improving pathology services
• evaluate the role of point of care
testing in provision of local
pathology services
• demonstrate changes in skill mix
• share learning nationally
• submit monthly progress report
and present progress to the
National Pathology Oversight
Group on a regular basis
Project commenced April 2005 for a
period of 12 months



4. Pilot sites
Blackpool, Fylde and Wyre Royal Devon and Exeter
Hospitals NHS Trust NHS Foundation Trust
Whinney Heys Road, Blackpool, Pathology Department, Royal Devon
Lancashire. FY3 8NR and Exeter Hospital, Room A213,
Barrack Road, Exeter, Devon
Calderdale & Huddersfield EX2 2DW
NHS Trust
Huddersfield Royal Infirmary, Acre The sites chosen to be pilots cover a
Street, Lindley, Huddersfield wide and diverse range of service
HD3 3EA providers:

Coventry & Warwickshire • Foundation Trust
Pathology Network • District General Hospital with large
University Hospitals Coventry & fluctuations in summer population
Warwickshire NHS Trust • Dual Site Trust
South Warwickshire Acute NHS Trust • Pathology network of hospitals
George Eliot Acute NHS Trust including a University Teaching
Department of Pathology, Walsgrave Hospital
Hospital, Clifford Bridge Road, • SHA wide pathology service
Coventry CV2 2DX approach for services in primary
care
Partnership Pathology Services -
A joint venture between Frimley Whilst all the sites were very
Park Hospital NHS Trust and different in size, structure and
Royal Surrey County Hospital location, each identified similar
NHS Trust issues and all utilised the same tools
c/o Frimley Park Hospital NHS Trust, and techniques to make the
Portsmouth Road, Frimley, necessary improvements.
Camberley, Surrey GU16 7UJ

North East London Strategic
Health Authority (SHA)
Eneurin Bevan House,
81 Commercial Road,
London E1 1RD
Including:
Whipps Cross University Hospital
Barking and Havering and Redbridge
Hospitals NHS Trust
Homerton University Hospital NHS
Foundation Trust
Newham University Hospital
NHS Trust
Barts and the London NHS Trust



5. Developing the learning
Each site participated in a series of Expert input was provided by the following:
four workshops, the focus of which
was to provide time to: • NHS Pathology Service Improvement Team

• understand the application of Lesley Wright
service improvement tools, Associate Director, Diagnostics
techniques and lean methodology Ann Eason
• share experiences, network, adopt National Pathology Manager
and adapt service improvement
ideas • Dr Ian Barnes
DH Pathology Lead
Key aspects of the workshops were:
• Mitzi Blennerhassett
• the role of leadership/ownership Patient Representative
• effective communication
• Deirdre Feehan
• introduction to Lean techniques
DH Pathology Modernisation Programme
• mapping techniques
• capacity and demand • Mike Hallworth
• measurement for improvement Royal Shrewsbury Hospital
• promoting new ways of working –
skills escalator • Professor Sue Hill
• patient involvement Chief Scientific Officer – Skills Escalator
• managing demand
• Ian Maidment
• user involvement
Patient Information Manager –
• sustainability and spread
Cancer Services Collaborative ‘Improvement Partnership’ (CSC’IP’)
• Dr Stuart Smellie
Bishop Auckland General Hospital
• Paul Whalley
Lecturer Warwick University

Additional support and input included:
• project manager development programme
• conference calls
• site visits



6. Involving patients and developing
user engagement
The importance of understanding Several methods exist for gathering • long waits to have blood taken –
patient needs came to the fore with patient views, each have different varying from 10 minutes to 4
the DH publication ‘Creating a benefits and can be used to gain hours
patient-led NHS’ (March 2005). and provide information: • long waits for results to be
Three key aspects were highlighted: available
• questionnaires • lack of privacy and dignity when
• people have a far greater range of • surveys (360 degree) giving personal information to
choices and information • question and answer sessions staff
• there are stronger standards and • 1:1 interviews • poor access to phlebotomy
safeguards for patients • posters services
• NHS organisations are better at • newsletters
understanding patients and their • compliments and complaints
needs, use new and different • utilisation of Patient and Public
methodologies to do so and have Information Groups and PALS
better and more regular sources of
information about preferences See Chapter 11 - References,
and satisfaction resources, useful information,
acknowledgements and further
Patient and public involvement can reading.
be a long and complex subject; it is
particularly challenging for some
Key findings from patients
pathology disciplines where there is
little, if any, direct contact with
Findings from each of the sites were
patients.
remarkably similar:
As providers of a service we cannot
• patients were often unaware of
assume to know what our patients
the reason for the test being
consider to be a good or bad
performed and the implication of
service. Patient satisfaction is based
the results
on meeting or exceeding patient
• staff often gave conflicting
requirements, and we need to
information about the need to fast
engage with them to understand
before particular tests
their needs.
• car parking charges, difficulty
finding a space, abuse of disabled
spaces
• lack of access to the service in the
early morning/late evening and
weekends for patients who work



Patient Line of Site (PLS) methodology
Partnership Pathology Services - Frimley Park Hospital NHS Trust and Royal Surrey County Hospital NHS Trust

Understanding the problem “When I come to see Dr X, he gets Learning points from patients
annoyed if my results aren’t ready for using PLS methodology
The aims of this project were to: him, so when I got here I checked at • the pathology pathway for patients
• take the patient line of sight and reception and they told me they were starts with getting an appointment
identify how the change of ready. Although it wasn’t my fault that • costs associated with travelling to
technology will have a direct impact he didn’t get them that one time, I do the hospital to have a test done are
on the experience for the following feel slightly anxious because he said it a burden for many patients
groups of patients: was a wasted appointment and I’d • the amount of effort patients go
• a GP patient (diabetic) have to come back.” through to give what can be a
• community hospital patient unique specimen
(diabetic) Retesting – the patient bears • for patients with chronic long term
• emergency medical admission the burden illness, their preferences may not
(chest pain) It is easy to overlook the pain and coincide with those of their health
• elective surgery admission discomfort patients experience when care practitioners
(prostate) providing specimens. If for some • patients are generally not aware of
• evaluate the pathology model of reason the specimen is unsuitable, the technical turnaround time for
centralised and de-centralised inappropriate or of poor quality and their tests
pathology and evaluate the benefits therefore cannot be tested, the patient • patients are most aware of issues at
to both patients and clinical users bears the burden of having a repeat test. the beginning and the end of the
• produce a development plan for the pathology pathway
next five years based on learning “I used to have 6 samples taken with no • although patients were generally
from this project anaesthetic but now I have a local. This
happy with the service they received,
time they knocked me out as I had to
most pathology staff felt they had
Findings have 30 tests.”
become isolated from the patients
Overheads incurred by patients “The sample taking procedure hurt but I they serve
Pathology tends to discount or ignore was given cream to help the pain.”
Learning points about using the
overheads borne by the patient. “I had to have the test done but I had methodology
Financial costs to patients and carers in heard a lot of things like it hurt and the • plan and arrange story collection
the course of giving a sample can be embarrassment of something pushed up early
substantial. there. I just wanted to get it over with.” • choose interviewers with good
Inflated turnaround times interpersonal skills
“Although I haven’t been told the actual
Most patients do not know the • consider role play, the story
results of my blood test my GP gave me
technical turnaround times or what the impression that everything was fine,
collection technique, recruitment of
the required standards are and are with my ECG as well, but that they patients and feedback to staff
currently not sensitive to this issue. would perform these extra tests as “belt • easier to collect stories in general
and braces” so I am here just to make clinic waiting areas especially those
“Usually have blood taken at GP sure” directly controlled by pathology
surgery, told result will be back in 8 to • use an electronic template for story
10 days time. I will be called if there is “I have had 4-5 blood tests in the last transcription
anything wrong. No news is good month and I think the last one was just
news. GP’s don’t notify you if the that the locum Dr wanted to do it again Contact: Dr Ian Fry
result is normal.” himself to make sure nothing was Partnership Pathology Services,
wrong.”
Frimley Park Hospital
Preciousness of sample christine.bannister@fph-tr.nhs.uk
For patients, providing the sample is
their experience of pathology. A
patient will only become aware of the
mechanics if something goes wrong.



Establishing patient focus groups and user forums

Involving patients Benefits of focus group result being available to the referer in
secondary and primary care. Questions
The team preferred to talk directly to The focus group has given the were asked about the process and the
patients rather than get their views pathology department food for issues for them as users of the service.
through a survey / questionnaire as it thought, they have
was felt that this would provide high been, and are determined to make As a result of this engagement a user
quality and meaningful information. changes from the comments made. group including A&E, ICU, Medical
Further work is ongoing in the primary Assessment, and CCU and laboratory
• recruiting patients by directly care setting, this is seen to be the one staff has been established.
approaching them in phlebotomy area that patients had
clinic was difficult the most concerns with. Table 1 illustrates the examples of
• recruiting patients by sending a patient and user comments and
letter to a random sample of Involving users subsequent action taken.
patients who had attended
phlebotomy clinic was more Engaging users proved much easier. Contact: Dr Huw Griffiths
successful Users were invited to join the process Calderdale and Huddersfield NHS Trust
• interviews were conducted over the mapping session which started from huw.griffiths@cht.nhs.uk
phone and a patient focus group the point of referral through to the
established

Questions asked fell into 3 categories: Table 1

• information provided about the test Patient/User Comments Action
• access to pathology
• results I don’t know what happens to my Poster developed – checked with patients
blood once it has been taken. – put up in phlebotomy department.
Comments from patients
The Phlebotomist did not wash his / Alcogel installed in all cubicles and staff
“ I ring my GP for the test results and I her hands before taking my blood. asked to wash hands between each patient
am told its OK but I don’t really know and to do so in front of the patient.
what this means, it would be better if
you got a little bit more detail” I have to wait to have my blood Poster developed and displayed showing
taken. busy times and quiet times.
“I had tests undertaken for food
allergies but was not told of the result, On one site patients arriving in Q matic system is being purchased on
I can only presume that the test was phlebotomy are asked to take a both hospital sites. Patients will take a
normal” numbered card. Concerns were disposable ticket from dispenser.
expressed that these cards are
Issues for patients reused but probably not cleaned
thus posing a health risk.
• patients did not know what test they
were having or why A& E staff reported having IT staff informed and issues addressed for
• hygiene issues in phlebotomy login/passwords issues with individuals.
• patient having to wait a long time pathology reporting system.
in phlebotomy clinic
A & E requested a paper copy of A&E staff introduced to a “latest results”
results printed out in A &E as they screen which does not time out enabling
became available. Staff felt they did them to see at a glance when results are
not have time to keep checking the available. IT department trained staff on
computer to see if results were best way to use the screen.
available.



Using patient views to improve anticoagulation services

Understanding the problem Changes implemented • clinical staff given more time to
concentrate on patient care rather
Provision for anticoagulation was Issues such as poor flow and waste than administration
inadequate in North East London. were addressed.
The following issues were identified: Measurable outcomes
Changing the process and
• lack of direct patient involvement introduction of point of care testing Figure 2 demonstrates the impact of
• little or no patient choice of time, had a number of benefits: the improvements made.
location and type of encounter
• unnecessary steps in the process • shorter waits for patients
• limited flexibility and • ability to provide patient choice
responsiveness
• poor understanding of the cost /
Figure 1 - Patient views of clinic waiting areas
benefits of alternative methods of
providing the service
• conditions in the waiting area
were poor. Patient surveys
confirmed this

Patient comments about waiting
room conditions.
Figure 1 demonstrates that 81% of
patients felt the conditions weren’t
as good as they could be.

Contact: Karen Ward
Figure 2 - Patients views of the anticoagulation service after
Project Manager,
the introduction of POCT
North East London Pathology
Network.
100
abeo@ukonline.co.uk
90
80
70
60
50
40
30
20
10
0 venous
excellent
above excellent
good poct
below average
poct venous poor



7. Process improvement
Improving flow, Access to results
Eliminating Waste -
eliminating waste Surveys of pathology users 5S approach
demonstrated significant delays and
Establishing an effective flow of difficulty in accessing pathology 5S is a Lean technique that
work through the pathology process results. Although departments report provides pathology teams with
is crucial to ensure rapid turnaround electronically, many users do not the first step to develop stability
times. Techniques such as value have relevant access to the IT and promote flow by removing
stream, process and spaghetti systems. Many clinical areas i.e. obvious waste in a standardised
mapping illustrate non value adding wards or outpatient clinics have no and sustained approach.
steps and demonstrate poor flow. or too few terminals. Hard copy
These techniques point to the areas reports are subject to delays Sort (seiri) – sort through items
where changes and improvements associated with processing and and keep only what is needed.
need to be made. At each point of transporting to the appropriate Dispose of anything that is not
the pathway there are barriers to location. Many inpatients have been needed
flow. discharged when the paper report
arrives on the ward. Straighten (seiton) – organise
Access to phlebotomy and label a place for everything.
Waste in pathology “a place for everything and
Work with patients at each site
uncovered delays to phlebotomy To improve flow we need to everything in its place”
services. These ranged between 1 eliminate waste, i.e. actions
day and 4 weeks. On reaching the undertaken that do not add any Shine (seiso) – clean it
clinic patients experienced delays in value to the final result.
waiting for phlebotomy. Standardise (seiketsu) –
Waste can be classified as: create procedures to maintain
Transport the first 3S
• over production
• waiting – patients and staff
Delays caused by both internal and Sustain (shitsuke) – make it
• transport
external transportation of specimens mainstream, use regular audits
• motion
can be particularly dramatic. to stay disciplined. Continually
• defects
improve.
• inventory
Specimen reception
• customer time
Implementing this technique
Here the impact of delayed and • intellect and skills
in isolation will not improve
batched transport systems is a (case study example, see page 23)
process flow, but will start to
frequent occurrence. highlight associated
problems.
Validation of results
Significant delays can occur at
validation of results and is most
often associated with manual
validation.



Understanding the impact of delays in transport

Understanding the problem Figure 3 demonstrates variation and
delays in transportation from primary
Work was undertaken to identify the care.
true extent of transport delays, both
external and internal on pathology
services. Figure 3 - Time lag for GP phlebotomy samples

Learning
80
5 hours delay
In order to reduce the time it takes 70
from the patient having a test to 60
receiving the results, it is necessary
50
Quantity

to analyse this data. Pathology
services must take a lead to use this 40
data to influence transport provision, 30
highlighting the impact on
20
turnaround times and imbalance of
workload flow and staff capacity. 10
0
8.00 8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00
8.30 9.00 9.30 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 17.30

Time in 30 minute intervals

Sample taken Sample arrived in lab

Contact: Steve Smith
steve.smith@uhcw.nhs.uk



Transport issues affecting patients attending hospital
for phlebotomy services

Figure 4 demonstrates how patients
use transport to attend for Figure 4 - Patients use of transport to attend pathology tests
pathology tests.
350
Findings
300
• 317 (72%) patients used the car 250
to attend – this has a significant
Quantity

impact on already overstretched 200
car parking facilities 150
• average journey time to hospital
was 35 minutes 100

50
Figure 5 shows the number of
patients attending hospital based 0
phlebotomy services each week. Car Public Walked Patient Taxi Other
Transport Transport
Of patients attending for
phlebotomy::
• 172 (38%) patients were asked to • 24 patients (5.3%) were requested This information has been presented
attend by their GP to attend by the Admissions & to local primary care trusts to
• 269 (59%) patients were Discharge Lounge influence future service provision.
requested to attend from within • 212 (47%) patients attended the
the hospital site for no other reason than Contact: Wendy Lewis-Cordwell
• 148 (33%) from outpatients phlebotomy Blackpool, Fylde and Wyre
Hospitals NHS Trust
wendy.lewis-cordwell@bfwhospitals.nhs.uk
Figure 5 - Patients attending hospital based
phlebotomy services each week

200
180
160
140
120
Quantity

100
80
60
40
20
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Removing non value adding steps

Figure 6 demonstrates the pre-
analytical process map. Figure 6 - Pre-analytical process map
Reception Services Pre-analytical Phase - Current
Understanding the problem
Reception

Receive
Mapping the service demonstrates: (reception desk,
WardPod)
• non value adding activity
• lack of multi skilled staff
• work spread across a wide area Receive (Pods,
Sort and Check, label Match form
CSR

A&E, ward,
prioritise & spin to sample
(see figure 6) Haem/Onc)

• significant delays caused by
prioritisation, leading to wide
Transport

Sample to Form, CSR Form office Sample
variance in turn around times (TAT) CSR to office to CSR to lab

encouraging requesters to flag
samples as urgent
~Office

• inconsistent flow of samples to the PID

analysers creating backlogs
• capacity of staff did not match
Laboratory

workload demands
Analysis
• unnecessary movement due to
(see figure 8)
• layout of the rooms
• position of necessary equipment
• interruptions by telephone Figure 7 demonstrates pre-analytic process
enquiries averaging 2.3hrs map (post implementation)
per day
• impact of incorrectly labelled
samples Figure 7 - Pre-analytical process map (post-implementation)
• delays caused by large batches Reception Services Pre-analytical Phase - New
and prioritisation increasing
turnaround times by 59 minutes
Reception

Receive
(reception desk,
WardPod)

Receive (Pods,
Sort and Check, label
CSR

A&E, ward, PID
prioritise & spin
Haem/Onc)
Transport

Sample to Sample
CSR to lab
~Office
Laboratory

Analysis



Changes implemented
• layout of equipment and work
area reconfigured. (See figure 9)
(See case study on page 21)
• non value adding steps were
removed
• over processing waste reduced
• number of handoffs reduced
• batching minimised
• unnecessary travel eliminated

Measurable outcomes

Table 2

Measurable outcomes Pre-Implementation Post-Implementation

Sample processing time 59 min 26 min

Number of steps in the 11 8
process.
Figure 7

Staff movement 2,000 mtrs /day 474 mtrs /day
Figure 9

Number of work areas 3 2

Contact: Wendy Lewis-Cordwell
Blackpool, Fylde and Wyre
Hospitals NHS Trust.



Improving flow in specimen reception

Understanding the problem Figure 8 - Original spaghetti map of central specimen reception
The movements of one member of staff during a 10 minute period
Lack of flow in specimen reception
resulting in unnecessary
transportation of staff and
specimens.

Spaghetti map findings
• one member of staff walks
1.2 miles each day
• 5 staff walk a total of 6 miles
each day
• at 4 miles per hour, this equals
1.5 hours working time
• an operator can prepare 48
samples for analysis in this time
• this is a cost equivalent to £2200 -
£2900 per annum

Changes implemented
• reconfigured layout
• individual workstations
Figure 9 - Reconfigured layout spaghetti map of central specimen reception
standardised
• equipment repositioned to support
workflow
• specimens processed in smaller
batches
• each batch of samples are labelled
checked and loaded into the
centrifuge by a single operative

Measurable outcomes
• see table on page 20

Hospitals NHS Trust



Reducing steps and handoffs in specimen reception

Understanding the problem Number of steps and handoffs before and after process change
• analysis of the process identified Figure 10 - Amount of samples Figure 11 - Number of steps and
unnecessary steps and handoffs. unpacked by one MLA and numbered handoffs before and after process
Simplification of the process by another MLA in an hour change
allowed the team to make better 150
use of resources and increase 140
130 141 12
efficiency and productivity in 120 11 12
125
specimen reception 110 10
100 9
90 8 9
Changes implemented
Amount

Number
80 7
70 6
Changes were made to the usual 60 5
working practice. One Medical 50 4
4
40 3
Laboratory Assistant (MLA) would 30 2 3
deal with the numbering and 20 1
unpacking to decrease the number 10 0
Steps Handoffs
0
of steps and handoffs. Operator 1 Operator 2
Name
Before After

Measurable outcomes
• increase productivity
(see figure 10) Additional audits were undertaken to assess the impact
• fewer steps and handoffs
(see figure 11) Figure 12 - Number of phone calls Figure 13 - Impact of change in reducing
• reduce time spent on non-value before and after process change in time spent dealing with problems in
adding activities specimen reception specimen reception (mins)
(see figures 12 and 13)
100 250

Contact: Dr Ian Fry 90

Partnership Pathology Services. 80 200

christine.bannister@fph-tr.nhs.uk 70
Number of calls

60 150
Minutes

50
40 100
30
20 50
10
0 0
Before After Before After



Reducing waiting times for patients by
implementing Point of Care Testing (POCT)

Understanding the problem Measurable outcomes
• excessive waiting times in
anticoagulation clinics (up to
Figure 14 - Waiting times for patients before and
120 mins)
after the introduction of POCT
• patients waiting in cramped and
poor conditions 100
• staff over whelmed and 90
undertaking unnecessary non 80
Percentage of patients

clinical duties Before change After change
70

Changes implemented 60
50
• improved waiting areas provided
40
• point of care testing implemented
• provision to be made in primary 30
and secondary care settings 20
10
Contact: Karen Ward
0
Project Manager, 10 to 20 20 to 30 30 to 60 60 to 120 >120
North East London Pathology Waiting times - minutes
Network.
abeo@ukonline.co.uk

Figure 15 - Rate of introduction of new methods

350
Number of patients tested per week

Venous POCT Self Community
300

250

200

150

100

50

0
Aug Sep Oct Nov Dec Jan Feb Mar

Month in 2005



Identifying waste in the pathology pathway

Table 3

Type of Waste Examples

Waiting Patient waits to attend phlebotomy or clinic
i.e. waiting for samples or equipment Patient waits at clinic
Waiting for specimens to arrive
Delays to booking
Waiting for analysis
Waiting for machines to finish
Delays to validation
Waiting for results to be released out of hours
Requester awaiting results
Patient waits for results

Transportation Patients travelling to secondary care when request was made in primary care
i.e. unnecessary movement of specimens Samples travelling from GP practices to the lab
equipment or reagent due to poor layout. Location of the pathology service

Motion Twisting to access equipment
i.e. unnecessary movements made by Bending to reach poorly located reagents or kit
staff as a result of poor ergonomic design Performing unnecessary key strokes when recording information on IT system

Inventory Over ordering of stock
i.e. stock reagent or work in progress Large batches of reagent made
Specimens in progress awaiting next process step

Overproduction Unnecessary test requests
i.e. too much or too soon Sorting and resorting of specimen
Unnecessary barcodes or labels
More specimens taken from the patient than required
Re entry and duplication of data
Batches of specimens awaiting next processing step

Defects Haemolysed samples
Specimen received with insufficient details
Wrong sample type
Result not available as required

Intellect and skills Clinical staff performing admin
Scientists performing non scientist duties

Customer time Patients attending appointment where results are not available
Staff phoning for results or information that should be accessible elsewhere

As a result of identifying this waste an action plan was established to systematically remove this waste and improve flow.

Contact: Dr Huw Griffiths
huw.griffiths@cht.nhs.uk



Using 5S to remove waste in specimen reception

Area cluttered, hindering effective
flow and standard working for staff.
5S implemented to identify items
that could be:
• moved to a more appropriate
location
• discarded

Changes implemented
• waste removed
• standard workstations developed
• improved utilisation of space

Measurable outcomes
• space released in data entry room
and specimen reception
• work areas tidier and more
organised
• effective way of changing practice,
taking 11 2 days of effort including
works department to remove
cabinets
• working conditions improved
• teamwork improved
• staff appreciated additional space
and organised area
• generated interest in the service
improvement programme

Contact: Dr Ian Fry
Partnership Pathology Services.
christine.bannister@fph-tr.nhs.uk



8. Understanding demand, utilising capacity
Demand management “Being trained to carry out factory “Automation can provide a more
V Leiden testing in Haematology. efficient way of doing the wrong
Demand for pathology services has Using the molecular has been very thing.”
increased considerably over the past beneficial to me, enabling me
few years. Data demonstrates that to learn and practice new techniques Reengineering the Corporation
clinical chemistry laboratories saw as well as supporting my personal
an increase in workload of 15-30% development and improving the “Automation can actually cost the
between 2000/2001 and services.” lab more money if the overall
2002/2003. This has increased process is not first considered.”
Trainee Clinical Scientist,
further as a result of key NHS Advance
Haematology
reforms such as the Quality and
Outcomes Framework. In addition Developing a truly patient focused
Utilising technology
the Healthcare Commission (2005) service will depend upon the
highlighted a number of common To cope with the increasing successful combination of:
problems including: workload it has been necessary to
invest in new technology. • streamlining the processes
• an estimated 25% of common • utilising skills of staff
Experience world wide has shown
tests are duplicated and have no • maximising the use of technology
that this investment should not be
additional impact on patient care
made without prior consideration
• many requests are illegible, contain
and understanding of the pathology
insufficient clinical information,
process.
causing significant delays and
rework
• poor contact with clinical users –
20 - 25% of ward managers Figure 16 - Relationship between process, workforce and technology
reported that delayed access to to ensure the patient is at the heart of the service
pathology results had a significant
impact on care or discharge of PROCESS
patients at least once per week

Optimising staff skills
Pathology services are facing issues
of an ageing workforce and
difficulties in recruiting new staff.
To lessen the impact we need to
optimise staff skills and utilisation.
PATIENT FOCUSED
SERVICE

WORKFORCE TECHNOLOGY



Understanding variation in demand
for diabetic screening tests

Figure 17 - HbA1c requests per thousand patients for
Demand data was collected and Blackpool PCT (April - June 2005)
analysed from the primary care users
of the pathology service. The data 30

highlighted significant differences in 26
No. of requests per 1000 patients

25 25
requesting patterns of individual 24
23
registered at each practice

22
surgeries.
20 19
18
17 17 17
Learning 16 16 16 16 16
15 15 15
14

Further investigation highlighted that 11 11
10
nursing staff were not requesting 10
according to protocols developed by
the PCT.
The data has been used to influence 0
P81159

P81072

P81714

P81066

P81081

P81052

P81042

P81172

P81063

P81043

P81054

P81162

P81722

P81004

P81681

P81115

P81684

P81074

P81016

P81629

P81706

P81754

P81713
future requesting patterns and to
improve usage of the pathology
GP Practice
service by GP practices.

Hospitals NHS Trust.



Reducing unnecessary/duplicate requests for
thyroid function testing

Monitoring of Thyroid Stimulating Table 4
Hormone (TSH) requests
demonstrated an increasing number Month TSH requests Number rejected Percentage rejected
of duplicate tests. After discussions
between the pathology department Oct 9006 371 3.96
and endocrinologist it was decided
to reject TSH requests made Nov 8796 313 3.44
within one week of a previous
request. Dec 6927 251 3.50

Jan 9247 300 3.24
Changes implemented
Feb 8725 257 2.95
Initially tests were rejected when a
previous result had been given
Mar 9664 414 4.28
within 7 days; this was then
extended to 2 weeks. Apr 8853 310 3.50

May 9597 372 3.88




Reducing inappropriate testing for thrombolytic patients

Significant thrombolytic (D-Dimer) Significant reductions in the number
requests were felt to be of requests for D-Dimer were seen.
inappropriate. (See figure 18).
Changes implemented
Figure 18 - Changes in D-Dimer request patterns
• the pathology network redesigned
the request form for use within
the A&E department 500
• profiles of tests for specific 450
conditions were agreed with 400
clinical teams
• staff now indicate a possible 350

diagnosis (eg chest pain) when 300
Tests

requesting pathology tests 250
• requests for D-Dimer tests are only
200
accepted if a Wells score is
appropriate. 150
100
50
0
Oct 2005 Nov 2005 Dec 2005 Jan 2006

Admissions Unit, St Cross A&E Hospital of St Cross
Emergency Department Observation Ward WGH

Coventry and Warwickshire
Pathology Network



Reducing inappropriate urine requests in microbiology

Figure 19 - Algorithm for urine dipstick testing
It was felt that a significant number
of urine requests were inappropriate,
Reason for
leading to unnecessary workload urine dipstick
and delays to results for patients.

Symptoms of infection eg Routine urinalysis
Changes implemented eg new admission,
frequency, dysuria, fever, groin
pain, unexplained confusion diabetic
Trust and community users of the OR
pathology service were willing to Pre op screening
eg urology, orthopaedics
engage in this piece of work,
particularly after a visit to the Record results and if
positive make available
laboratory to see the intensive to trained nurse or
Protein
nature of processing urine Blood
One or more tests doctor
negative positive, send MSU
specimens. LE for culture
Nitrite
After meetings with users a new Do not send a urine for
urine testing protocol was developed culture unless there is a
specific indication
and has been distributed within the No need to send urine
RD&E Trust. A separate algorithm is for culture unless doctor
specifically requesting
being developed for community
users. The urine request form is
undergoing redesign to support
users to provide sufficient
information to the laboratory, and
this can be used with the 2D Contact: Mike Burden
barcode system already successful Royal Devon and Exeter
in clinical chemistry. NHS Foundation Trust.
mike.burden@rdehc-tr.swest.nhs.uk
Measurable outcomes
• A reduction in urines received by
the lab. This will be regularly
audited to ascertain success of
algorithm



Improving staff utilisation to match demand

Figure 20 demonstrates the
mismatch of staff capacity against Figure 20 - PID staff demand chart
the demand on the service. This
causes significant delay in simple
160 5
processing. Staff Forms
4.5
140
Changes implemented 4
120
3.5
• administrative and technical staff
Number of PIDs

100 3
are combined into one team
• batch sizes have been reduced to a 80 2.5

maximum of 16 in boxes 60
2
numbered in order of arrival 1.5
(first in - first out) 40
1
• each batch of samples is checked, 20 0.5
labelled and loaded into the
0 0
centrifuge by a single operative 10.00 10.30 11.00 11.30 12.00 12.30 13.00 13.30 14.00 14.30 15.00 15.30 16.00 16.30 17.00 17.30 18.00 18.30 19.00

• whilst samples are in the Time of day

centrifuge the operator inputs
patient and test data. On
completion samples are taken to
Measurable outcomes
the laboratory to be loaded on to
the analysers
• standard workstations established, Table 5 - Sample processing time, number of stages in the process
with each station housing its own
centrifuge and PC Measurable outcomes Pre-implementation Post implementation
• the number of workstations
increased to 11 with one Sample processing time 59 min 26 min
dedicated to ‘urgent’ samples
• samples that cannot be processed Number of steps in the process. 11 8
immediately are placed in a Figure 7
“problem box” to be dealt with by
Staff movement 2,000 m/d 474 m/d
another operator Figure 9
• all causes of problem samples are
identified, reviewed, and protocols Number of work areas 3 2
developed to deal with problems
• each day one operator is
designated to deal with difficult (See case study on pages 19/20)
requests and phone calls
• staff working hours and rosters
modified to meet demand


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