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

NHS
NHS Improvement

CANCER

DIAGNOSTICS
NHS Cervical Screening Programme (NHSCSP)

Cytology improvement guide -
HEART
achieving a 14 day turnaround
time in cytology
Clinical excellence in partnership
“
LUNG

STROKE
with process excellence”

Cytology improvement guide - achieving a 14 day turnaround time in cytology 3

Contents
1. Foreword 5 Motion
Case study 6
2. Executive summary 6 Moving the fridge reduces walking.
Case study 7
3. Introduction 7 Sample collection trips reduced.
Why Lean as the methodology of choice?
Automating inefficient processes
4. Phase 1 pilot sites 8 Waiting
5. Learning for future improvement 9 Case study 8
Changing quality control procedures.
6. Understanding where you are 10
Overproduction
What to measure and how to collect it?
Case study 9
• Baseline data – ‘Go see’.
Slide matching.
• Data requirements.
• SPC charts. Over-processing
• Skyline plots. Case study 10
Removal of date stamping.
7. Self assessment 12 Case study 11
Score the current status of your service.
Removing the day book.
8. How to begin 13 Case study 12
Team make-up, the wider team, executive Adjusting download times to the
support and involving users. primary care support services.

9. Establish the measures 14 Defects
Identifying and measuring factors which Case study 13
impact overall turnaround time. Zero tolerance of defects.
Case study 14
10. Just-do-its – recommended Improving mapping tables.
immediate activities 15
Skills utilisation
• Primary care.
Case study 15
• Laboratory.
Expanding roles in prep room.
• Results agency.
Case study 16
Case study 1 Abnormal pathway changes.
Reducing batching in the screening room.
12. A3 thinking 39
Case study 2 What it is and how to produce an A3?
Introduction of multiple downloads.
Case study 17
Case study 3 Using A3s for problem solving.
Reducing manual-matching and first
class post. 13. Root cause analysis 41
Techniques to determine the true cause
11. The nine wastes 22 of a problem.
Transport
Case study 4 Case study 18
Specific bags sent straight to laboratory. Using data for root cause analysis.

Inventory
Case study 5
Reducing the backlog.

www.improvement.nhs.uk

4 Cytology improvement guide - achieving a 14 day turnaround time in cytology

14. Visual management 44 20. Capacity and demand 60
What is it and how is it used? Do we have sufficient capacity to
meet the demand?
Case study 19
Use of visual management to support Case study 28
a zero tolerance of defects. Using capacity and demand information.
Case study 20 Case study 29
Introduction of yellow stickers for the 100 day plan.
abnormal pathway.
Case study 30
15. Value, value stream mapping, Cost avoidance.
flow and pull 47
21. Communication 67
Improving flow, introducing pull, eliminating
The importance of good two way
non-value adding steps, simplifying processes,
communication.
combining steps, re-sequencing.
Case study 31
Case study 21
Understanding communication issues.
Removing duplicate checks.
Case study 22 22. Leadership, engagement
Establishing work cells. and sustainability 69
How leadership style affects staff
Case study 23 engagement.
Standard work and flow at late delivery times.
Case study 32
Case study 24 Sustainability - managing a surge in demand.
Abnormal pathway changes.
Case study 33
Case study 25 Sticking to Lean principles.
Changing work patterns.
23. Customer experience 74
16. Future state mapping 54 What do the users really want?
How do you get there and action
Case study 34
planning?
Colposcopy service improvements.
17. 5S to improve safety and morale 55
25. NHS Improvement contact details 76
Case study 26
5s in the screening room, office and stores. 26. Websites and useful reading 77

18. Standard work 57
The best way to perform each
process step.
Case study 27
Standard work in screening.
19. Takt time 59
What it is and how it can be used to
level the workload.



1. Foreword
The NHS Cervical Screening Programme (NHSCSP) is undoubtedly a
major success. Over the past two decades the NHSCSP has led to
many cancers being prevented and has led to significant reductions
in the death rate from cervical cancer in this country. It has been
established that cervical screening saves around 4,500 lives every
year in England.

Professor Mike Richards CBE
Much of the success of the NHSCSP can be attributed to having
National Cancer Director effective call and recall systems and quality assurance schemes.
The introduction of liquid based cytology over the past few years
(2003-2008) has led to significant reductions in the number of
‘inadequate’ tests (from around 9.5% to 2.5%). This means that
around 400,000 fewer women need to be re-screened each year.

However, we know that we can and we must do better. In many
parts of the country women are having to wait far too long to
receive their test results. By December 2010, all cervical screening
Professor Julietta Patnick CBE services have to ensure that women receive their results within two
Director NHS Cancer Screening
Programme weeks of the test being done.

Pilot sites working with NHS Improvement have demonstrated that the 14 day standard for
cervical cytology can be achieved and that this brings benefits both for the patient and for the
NHS in terms of potential cost savings.

This guide shows how the 14 day standards can be achieved. We commend it to all
commissioners and providers of cervical screening services.

Professor Mike Richards CBE Professor Julietta Patnick CBE
National Cancer Director Director NHS Cancer Screening Programme



2. Executive summary
The publication of the Cancer Reform Strategy Productivity: Eliminating non value added
(Nov 2007) made a promise to ‘ensure that all steps, ensuring appropriate utilisation of
women receive the results of their screening workforce, demonstrating the capacity required
tests within two weeks by 2010’. based on the demand, and ensuring technology
is used effectively.
The Scharr report (Feb 2006) highlighted that
with minimal investment it was possible to Key learning has demonstrated success is
deliver the service to 50-66% of women within achieved through:
seven days with the remainder receiving their
result within 14 days. Strong and proactive clinical and
managerial leadership: To encourage, drive,
In 2006 the Review of Pathology Services in motivate and empower staff.
England by Lord Carter endorsed Lean as the
method of choice for improving processes in Collection and analysis of appropriate data:
pathology services. Working in partnership with To understand the current end to end pathway.
the National Cancer Screening Programme, NHS
Improvement supported10 pilot sites to test the Walking the pathway: Go to see the problem
Lean methodology to demonstrate how to first hand.
deliver a two week service.
Executive support: To provide active support
The approach involved bringing multi-disciplinary and remove barriers.
teams from primary care, laboratories and recall
agencies together to work collaboratively on the Empowered staff: Who own the problem,
whole pathway. Staff were trained in Lean find the solutions and ‘stop to fix’.
methodology, applied the learning, redesigned
their own service and delivered significant This guide provides clinical teams with the basic
improvements. tools to make changes to their processes, and is
supported by tried and tested case studies from
Over 500,000 women will have benefited from across the whole pathway.
the improvements in:

Turnaround times: 100% of women receiving
their result within 14 days (for most sites) and
over 80% of women receiving results within
seven days for five out of ten sites.

Quality and safety: Implementing a zero
tolerance of defects in request forms and sample
labelling to reduce errors.

Innovation: Using simple visual management
techniques to improve flow, safety and
productivity.



3. Introduction
As the 14 day target is of national importance,
there will naturally be a great deal of interest in
how Lean methodology has been used to
support the aims of the Cancer Reform Strategy.
ACT PLAN
What changes Objective
Over the past four years NHS Improvement has are to be made? Questions and
Next cycle predictions (why)
worked with a number of pathology teams to Plan to carry out the
test and prove the value of Lean methodology. cycle (who, what,
where and when)
Clinical teams have been extremely successful
and the methodology is being widely adopted in STUDY DO
many pathology laboratories and other clinical Complete the
analysis of the data
Carry out the plan
Document problems
settings across the country. Compare data to
predictions
and unexpected
observations
Summarise what Begin analysis
was learned of the data
The methodology and approach was further
endorsed by Lord Carter in the ‘Report of the
Review of NHS Pathology Services in England’
in 2006/2008.

Pilot site teams were trained to:
• Understand and identify waste. Spreading and sharing the learning
• Apply Lean principles to improve flow. Networking amongst clinical teams involved in
• Use PDSA cycles (plan, do, study, act) to test the pilot, facilitated a collaborative approach to
out ideas to ensure changes make the achieving improvements and to spreading
improvement required before implementation innovation and success.
(sometimes known as PDCA - plan, do,
check, act). A buddy system for close locality sites was set
• Use data to demonstrate the impact of up to support the sharing of best practice along
improvement. with a series of training and development
• Understand how people respond to change; workshops and shared learning events.
• Use statistical process control charts (SPC)
and root cause analysis. In addition, a number of regional learning events
• Understand communication methods and were conducted by pilot site teams, supported
work as part of a team. by NHS Improvement National Improvement
Leads to spread some of the learning to non-
To further support and embed the improvement pilot sites.
methodology within the local environment and
create local ownership, an overview of Lean This document contains case studies from
methodology was provided for all staff involved the phase one pilot sites to help illustrate
in the pathway. the changes made. Further case studies
can be found on the website at:
The training, combined with clinical lead www.improvement.nhs.uk/diagnostics
commitment, are essential to the sustainability
of achieved and ongoing improvement.



4. Phase one pilot sites
The following sites were selected by the National The phase one pilot sites are:
Cancer Screening programme to take part as
phase one pilot sites. One of the criteria for Leeds PCT and The Leeds Teaching
joining the programme as a pilot site was to Hospitals NHS Trust
become exemplar sites, prepared to share Lead: Dr Simon Balmer
learning with other teams.
Hull Royal Infirmary and Hull and
Clinical teams will benefit from visiting the East Riding PCTs
following phase one sites, where they will Lead: Ms Kathleen Young
observe Lean methodology as part of everyday
working and learn how the targets have been Pennine Acute Hospitals NHS Trust
achieved. Lead: Mr Tom Wilson

The criteria for inclusion as an exemplar site are: Norfolk and Waveney Cellular Pathology
Network (Norfolk and Norwich University
• Delivery against 14/7 day target Hospital NHS Foundation Trust)
(min. 95% and 50%). Lead: Dr Xenia Tyler
• Clear evidence of Lean methodology
including: West Anglia Pathology Cytology Laboratory
• Visual management (Cambridge University Hospitals NHS
• Standard work Foundation Trust, Addenbrookes Hospital
• A3 problem solving and Anglia Support Partnership)
• Stop to fix problems via daily meetings Lead: Ms Roseanna Bignell
• 5S.
• Evidence of all staff committed to continuous Barts and The London NHS Trust
improvement and Lean methodology. Lead: Mr Geoffrey Curran
• Evidence of sustainability and committed
leadership. Somerset and West Dorset Cervical
Screening Service (Taunton and Somerset
Hospitals NHS Trust)
Lead: Dr Simon Knowles

Ashford and St Peter’s Hospitals NHS Trust
Lead: Mr Behdad Shambayati

North West London NHS Trust (Northwick
Park Hospital)
Lead: Dr Tanya Levine

Central Manchester University Hospital
NHS Foundation Trust
Lead: Dr Mina Desai



5. Learning for future improvement
The purpose of this document is to share the The key mechanisms required to achieve these
learning from phase one pilot sites. changes are:
It makes recommendations for change through
evidence based case studies and encourages 1. Empowered staff who can:
teams to adopt the learning, adapt within their • see the waste and remove it;
own service, and visit exemplar sites to discuss • test changes through PDSA cycles;
improvements made, challenges faced and • have information to say how we are doing;
pitfalls to avoid. • use suggestion boards to have ideas actioned.

The four key changes have been identified 2. Daily meetings established to:
which will bring about substantial reductions in • stop and fix problems;
end-to-end waiting times for the cervical • encourage a culture of daily problem solving.
cytology pathway are:
3. Visual management techniques to:
1. Focus on the whole end to end pathway: • display performance data;
• link all staff across the pathway; • promote standard work;
• use whole pathway data to understand where • ensure safe working practices.
samples and reports are waiting.
4. Information to support the process:
2. Adopt small batch sizes: • turn real time data in to information to
• throughout the entire pathway, including the manage the process;
prep room, lab, screening room, data entry as • ensure visibility of efforts;
well as primary care and the call/recall agency. • identify problems and establish mechanisms
to solve problem;
3. Keep samples moving: • encourage root cause analysis.
• daily delivery from primary care;
• pull work through the lab; To accelerate the pace of change to reduce
• multiple daily downloads; turnaround times, defects and rework and
• daily issue of reports. improve quality, safety and productivity, teams
should consider applying:
4. Establish first in, first out:
• no prioritisation of samples; • Just do its – tried and tested, proven to
• todays work today. reduce turnaround times – adopt as many as
you can;
and consider the;
• Human dimensions of change – the
importance of engaging all staff.

An engagement survey tool is available on the
NHS Improvement website.

Whilst this process will not be easy,
the rewards are great!



6. Understanding where you are
Measuring the end-to-end pathway Recommendations include:
At the launch stage of a project, it is important • Date/time primary screened
to create an understanding of what is actually • Date/time rapid review performed
happening, as distinct from what ‘should be’ or • Date/time report authorised
is thought to be happening. Identifying the • Date recall agency received info (down
current situation should include the whole electronic link),
journey of the samples – not just in-laboratory • Date letter was issued.
processes.
A sample data collection spreadsheet can be
The best way to do this is to ‘go see’. This found on the NHS Improvement website.
means to physically walk the whole pathway
and produce a photographic record of the Note: it may be appropriate to record measures
process. It is recommended that this is done by for all test results (abnormal, negative,
the whole core team to ensure objectivity. incomplete) separately so these can be
monitored individually.
The pathway should then be graphically
represented as a current state value stream map. What type of data and how much?
Measurements taken as part of value stream We recommend you collect data on at least 750
mapping will provide the baseline against which consecutively numbered specimens taken in the
the impact of any changes to the process can be same week to provide a statistically valid
compared. baseline TAT.

Every task undertaken while processing samples Calculating and monitoring TAT - Using
will have an impact on achieving the 14 day statistical process control (SPC)
turnaround time (TAT) and should therefore be By collecting data from samples at the three key
included in baseline measurement. TAT is stages within the pathway, variations in
defined as the time the sample was taken to delay/wait times and other sources of waste can
expected date of delivery of the result letter to be detected, corrected and tracked to assess
the woman. how/if these are reduced over time as a result of
improvement changes.
Data requirements SPC charts provide a graphical representation of
To capture a clear and accurate TAT measure, the time it takes to process a particular sample
data should be collected for all three key stages and an overall view of the variation in the
of the cytology pathway: process.
1. Date sample taken to date sample received in Statistical control limits are calculated from the
the laboratory specimen reception. data input and are displayed on the chart along
2. Date specimen received in specimen with process average (mean) and its variation
reception to date report authorised and sent about that mean. If there is evidence of unusual
to the recall agency. variation or ‘special cause’ (outlier) detected,
3. Date report received in the recall agency to then this ‘special cause’ should be investigated
date result received by woman (calculated by using a root cause analysis technique (see
by adding one day to the date letter issued section 13).
for first class postage or three days for
second class). SPC tools can be accessed via the NHS
Improvement reporting system or NHS
To determine the impact of changes made in the Improvement excel data template. To find out
laboratory or other specific parts of the pathway, more about SPC and the types of ‘run rules’ that
additional timings should be captured and are used to indicate out-of-statistical control
statistical process control (SPC) charts produced situations please refer to the website or NHS
to evidence achieved improvements. Improvement publication ‘Bringing Lean to Life -
Making Processes Flow in Healthcare.’



Special Cause
Variation process
is ʻout of controlʼ

Special Cause
Variation process is
ʻout of controlʼ

Your individual project can be set up on the NHS The query covers date sample taken through to
Improvement reporting system and this will date added to recall system. It shows patient
enable you to track the project, add project identity to enable root cause analysis for samples
documentation and upload improvement stories. that have taken longer than 14 days for analysis
Further information on how to use the NHS and result return. An additional field of
Improvement System can be obtained via ‘expected date of delivery’ is due to be added to
support@improvement.nhs.uk the query shortly so full end-to-end TAT can be
produced.
Other important data for your baseline
Turnaround times This query can be run by all recall agencies for
% achieved in 14 days any specified time period, allowing analysis of
data on daily, weekly or monthly cycles. The
% achieved in 7 days
data can be sent to laboratories via secure
Quality and safety (defects) transfer (or can be run without patient
% samples/forms with inaccurate/illegible/ identifiers) and together with laboratory
incomplete information sample data can be used as an alternative
to SPC charts.
% referrals returned to requester
% reports authorised and sent to recall agency Instructions on how to run this query can be
which required manual matching found at: www.improvement.nhs/uk/
diagnostics
Engagement
Overall engagement scores at start of project In addition, each individual laboratory can run
and various additional points throughout the this query through CYRES. It should be
change process. remembered that this will only show from date
sample received to date results sent to recall
Skyline plots agency. Ensuring a 14 day end-to-end TAT will
The East of England Screening QA Reference require all samples to be within 10 and 12 days
Centre (QARC) has developed a cervical depending on time taken by recall to send
screening system enquiry that recall centres can letters out.
use to perform a patient based search that will
show TATs in a bar chart.



7. Self assessment
The Endoscopy Global Rating Scale (GRS) and
Radiology Service Improvement Assessment Tool
(RSIAT) were developed by the Endoscopy and
Radiology service improvement teams
respectively and have been used widely since
2004 to benchmark these diagnostic services
and provide teams with a focus for
improvements. They have been designed to
allow clinical teams to see which areas they
need to concentrate on to achieve the cancer
waiting times targets.

Whilst such a tool for cytology is currently still
under development, the questions, and answers
teams provide, can help to steer the focus of
improvement in the direction that will create the
most benefit to the screening programme.

The questionnaire can be found on the
NHS Improvement website at:
www.improvement.nhs.uk/diagnostics



8. How to begin
Team guidance Wider team membership/steering group
Firstly, identify a credible and respected project It is recognised there will be a wider team of
lead to head up the team. This could be a individuals who are key stakeholders across the
clinician or manager with the drive and pathway who will provide managerial and
enthusiasm to steer changes across the strategic support but may not be a member of
whole pathway. N.B. full screening programme the core team for training.
pathway includes colposcopy and histology:
Executive support
An executive team sponsor should be identified
Project team members should be drawn to provide proactive support and access to
from across the entire pathway: relevant support services such as estates,
• Clinical /managerial lead who must provide transport, HR, finance and IT teams. They may
active support and leadership to the core team be called upon to escalate key issues.
• Primary care – (e.g. PCT lead, practice
manager) should be able to contribute to Protected time out
discussions such as organisation of transport This is essential to allow thinking time for the
for same day sample delivery core team and any members of staff planning a
• Laboratory – (e.g. MLA, BMS, AP, screener) plan, do, study, act (PDSA) cycle and may have
must represent and understand specimen to be facilitated by the departmental manger or
reception processes and the laboratory LBC executive lead
and screening process (you may wish to co-
opt a laboratory manager and/or Communication plan
histopathologist onto the core team/wider It has been widely recognised from the phase
team or steering group) one pilot sites that the establishment of a
• Results issue agency – should be able to communication plan is essential and a central
contribute to discussions and influence / lead information board should be positioned to
changes to the results issue process inform all staff of project activity and progress.
• User involvement – member of an existing
gynaecology patient group or suitable Training location/work room
equivalent, likely to be a wider team member Space will be required for the core team to
• Colposcopy – a member from this area may be work. An area should be identified where local
co–opted onto the wider team / steering training can take place and where teams will
group. have space to work on projects and store
information work sheets/maps with easy access
Core team members must: to these items on a regular basis.
• Understand the process within their stage of
the pathway
• Be able to contribute ideas/information on the
process
• Be able to influence the decision making
process
• Be prepared to test and implement changes
across the pathway
• Be committed to attend all team meetings,
conference calls and sharing events.



9. Establish the measures
Identifying and measuring factors which
impact overall turnaround time
In addition to the global measure of
turnaround times (TAT), quality, safety and staff
engagement, there will be other local measures
and quality indicators that can be used to asses
the impact of the project.

These should be focussed around:

Safety - reducing avoidable harm and creating
confidence that the result is accurate e.g. no
errors in sample taking, request cards, data input
or results letters.

Customer experience - understanding of the
result with relevant and timely information e.g.,
information at time of test and with result
letters.

Effectiveness of care - good quality outcomes
e.g. no unplanned staff/machine/system
downtime and each result produced within
PCT tariff.

Some examples of additional measures:

• Patient satisfaction rating;
• % processor/system utilisation;
• % staff availability;
• % inadequate/re-prep samples;
• % machine/system re-runs;
• % of samples with insufficient cells;
• % staff absence;
• Stock level replenishment;
• Number of unplanned shutdowns v. target;
• Department productivity v. target.



10. Just-do-its (JDIs) - recommended immediate activities
This section is designed to help teams make structured way, guided by the core project team
some very quick changes. These have been and project lead. Measures should be in place
tested and proven to make a significant to track improvements.
difference to turnaround times.
To support the JDIs, the case studies
Most are simple, quick to do, with very little demonstrate how sites have implemented some
effort required. of these simple changes evidencing the
improvements achieved.
All parts of the pathway are covered. Changes
should be implemented in a planned and

Primary Care
Action Why?
1 Enforce a policy for refusing ‘out of scope’ Stop inappropriate sample testing and
samples and ensure GPs and sample takers inappropriate samples being tested when a
know the correct pathway for symptomatic more suitable test/intervention is required.
patients.
2 Send samples to laboratory daily, even if there To ensure timely testing.
is only one!
3 Ensure appropriate staff are trained in use of To enable the correct information to be put
‘Open Exeter’ and are able to use the system to onto the request form regarding the last
its full capability. cytology results etc.
4 Always use pre-populated HMR101 forms or To ensure correct demographics are recorded.
print offs from the primary care system. Samples are not returned for correction or
because hand writing is illegible.
5 Where available – use electronic requesting for To ensure correct demographics are recorded.
every sample. Samples are not returned for correction or
because hand writing is illegible.

Laboratory
Action Why?
1 Reduce batch sizes to a maximum of 20 in the Although instinct tells us batching ‘feels’
prep room. quicker, this will immediately reduce your TAT.
Use SPC to evidence the gains.
2 Reduce batch size to 10 or less in screening Although instinct tells us batching ‘feels’
room and office area. quicker, this will immediately reduce your TAT.
3 Reduce batch size for consultants to a Although instinct tells us batching ‘feels’
maximum of four. quicker, this will immediately reduce your TAT.
4 Implement a non-acceptance policy for Eliminates time spent by staff dealing with
incorrect forms/vials. omissions and mistakes, logging returns,
telephoning surgeries etc.



Laboratory (continued)
Action Why?
5 Implement ‘quiet time’ in the screening room This will improve the quality of concentration
during an agreed period each day (no and productivity of the screeners.
answering e-mails, remove the fax machine,
mobile phones set to silent).
6 Introduce a staff ideas and information board. Important to engage staff in identifying issues
and solutions. Essential to provide a feedback
loop explaining what is happening with
suggestions made.
7 Initiate five minute daily meetings (huddles) Encourages ‘stop to fix it’ culture and improves
with all staff around the information board. engagement. Staff know what is expected of
them and how the team is progressing
8 Introduce visual management showing Improves productivity. Progress is visible and
numbers of slides/samples in (demand) and motivating.
numbers out (screened) daily.
9 Stop over labelling or writing patient names on Will remove an extra step and improve safety
slides. which could be compromised by potential
labelling errors.
10 Stop the process of slide matching in the prep Saves staff time and frees up space. Reduces
room. Ensure all slides and forms are kept in TAT.
numerical order in the same batch sizes. When
required, screeners collect one tray of slides
and the corresponding batch of request forms
before screening.
11 Implement standard work in screening - Prevents slides waiting overnight or over
screening one tray of ‘primary’ followed by one weekends for rapid review. Saves BMS time
tray of ‘rapids’. allocating slides.
12 Promote the use of pre-populated Prevents defects / mistakes on forms.
HMR101/primary care system forms or order
comms.
13 Set up multiple daily electronic downloads to If sent weekly – could save up to save seven
the recall centre – at least twice daily if IT days off TAT.
systems allow. Check what can be done – If sending download daily - Will save one day
don’t assume it isn’t possible! for half your screening output each day.



Recall agency
Action Why?
1 Implement first class post for all results letters. Can save between two to seven days on TAT.
2 Post results letters every day, Monday to Friday. Will save a minimum of five days on TAT.
3 Remove the lab and recall telephone number Prevents unnecessary phone calls to the
from results letter, add NHS Direct telephone laboratory and recall centre who then have to
number. refer back to the GP.
4 Receive numerous electronic daily downloads Will save one day for half the screening output
from the laboratory – at least twice daily. each day.
5 Contact all recall agencies you forward results 14 day target is: Date sample taken to
to, ensure they are aware of their role in expected date of delivery of result to woman.
delivering 14 day target. A result to the wrong recall agency, will need
time to send to correct agency – the clock is
still ticking.

All areas
Action Why?
1 Initiate monthly meetings with the laboratory, To improve communication and resolve any
recall agency, commissioners, primary care cross boundary issues.
representative etc.
2 Send out monthly reports and newsletters To improve communication, promote your
communicating current TAT, achievements, project and the national target and manage
issues etc. customer expectations.



Case study 1

Reducing batching in the screening room
North West London NHS Trust

Summary
Effect of reduced batching of slides on length of time
Changes made in cytology screening taken from booking in to primary screen
room to reduce waste caused by batch
processing through the screening
process.

Understanding the problem
The need to reduce the length of time
spent waiting for something to
happen:
• Watching the progress a case made
during its journey through the
cytology screening room identified
numerous occasions where the case
would simply sit and wait amongst a
batch until the next stage of the
process could take place.
• Backlogs were seen with slides
waiting to be primary screened,
rapid reviewed, checked and How the changes were • The move to reduce the batch size
reviewed by the pathologist. implemented down further to 5 slides per tray
• Slides were done in batches of 20 • Batch sizes of slides reduced to 10 resulted in a further 20%
as this was the number of spaces per tray. reduction in primary screen to
available on the slide tray. • Policy imposed that a screener verification TAT.
• Screeners would not always take a completing a tray of primary • The effect these changes have
tray of rapid review after completing screening must then take a tray of made can be clearly seen on the
a tray of primary screening which rapid review. SPC chart below which displays
would result in an increased number • Cases to be reported on computer the length of time taken from the
of cases awaiting rapid review. immediately after screening. booking in of the case to the time
• Some screeners would put their • No work to be left on desk at end it is primary screened.
results on the computer only after of working day. Any uncompleted • The reduction of batch sizes has
they had completed a tray of slides screening must be returned to the had the effect of pulling the work
and not immediately after screening pool of work. through the department.
the case. • Checkers to be more pro active in • The reporting rates for abnormality
• It was common practice for a doing checking to prevent build has remained constant during this
screener to leave an uncompleted up cases. time.
tray of work on their desk where it • Work requiring pathologist review
would remain until they returned to to be allocated to named Ideas tested which were successful
work. pathologist Improvements in turnaround time
• Data recorded included the date • Eight months after the above were seen wherever batching was
and time when each stage of the changes were implemented the reduced or eliminated.
process took place. This data was batch size of slides per tray were How this improvement benefits
extracted from the computer by use reduced from 10 to five. women
of a specially written computer
Improved TAT without reduction in
programme and then manipulated Measurable outcomes and impact quality.
in Excel and analysed using SPC • Since the implementation of the
charts. A numerical assessment as to reduced batching procedures within How will this be sustained/
what the backlog was at the various the screening room there have been potential for the future/
stages of the process was also kept. marked reductions in the length of additional learning?
• Slides requiring checking or time cases take from when they are Reduced batch size has become the
pathologist review were allowed booked in to being verified. normal practice within the department.
to build up. • Changes instigated at the time of Further reductions in batch size may
• The principle type of waste reducing the number of slides per be tried but we are not sure this will
identified was waiting. tray from 20 to 10 resulted in a one produce further reductions in TAT.
day reduction in primary screen to
Contact
verification TAT.
David Smith
Email: David.SmithB@nwlh.nhs.uk



Case study 2

Introduction of multiple downloads
The Leeds Teaching Hospitals NHS Trust

Summary • Agreed volumes of work, calculated Ideas tested which were successful
32% of result letters are received by from demand and capacity analysis are • Lean methodology discourages
women a day sooner than before with a collected at agreed times throughout batching. The idea was to reduce the
further 8% being received three days each day from the laboratory to the batch size of results sent to call/recall
sooner. office for registration, from the office enabling them to process the results
Total waiting days saved 58,800 to the prep lab for processing, and and send out the result letters the
from the prep lab to the screening same day.
Understanding the problem room for sending the expected • The multiple files involved restrict
Future state planning identified that in number of authorised reports in each call/recall from getting all reported
order to improve turnaround times, daily electronic link to call/recall. authorisations dispatched as results on
result letters need to be issued on the This maximises the number of letters the same day.
same day that the results are authorised dispatched on the same day that they
by the laboratory. were reported from the screening How this improvement benefits
room. women
Results of cervical cytology samples were
• Clearly marked, standardised On current workload figures this change
downloaded to the screening agency
collection points for work completed means that over 33,600 women per year
once a day late in the evening,
are used to ensure each department will receive their cervical cytology results
irrespective of the time the result was
knows where and when to pull a day earlier than previously and 8,400
authorised on the laboratory computer
completed items into their area. The will receive results three days earlier.
system.
time of day and volume of work
No result letters were issued the same pulled is indicated through the use of How will this be sustained/
day as the authorised reports, and some red/green kanban cards acting as potential for the future/
letters were being delayed by up to trigger signals which alert additional learning?
three days. departments to what work is ready • Standard operating procedures have
and in what volume as compared to been updated to reflect the changes
How the changes were implemented the timetable. implemented.
Changing to two downloads per day • This occurs three times per day with a • Daily problem solving at five minute
would initially ensure up to 50% of visual management system in place to meetings to level out any deviations
results available to be posted out a day clearly show when deliveries are made from the planned timetable to ensure
earlier. but can be increased/decreased at the target number of result letters is
• To ensure a continuous flow of anytime to reflect fluctuations in dispatched.
samples ready for reporting, a pull demand and 20 capacity. • Further enhancements to visual
system has been set up across the • Deviations from the norm are management controls and
prep lab, office, screening room and monitored daily, discussed at huddles communication will ensure that a
call/recall agency. and counter measures put in place if standard minimum level of work
• When the future state map was required. outstanding in each area supports flow
developed to optimise workflow, the • Team members attend each others through all steps in the process.
team recognised that the pace of huddles with a weekly scheduling • Further root-cause analysis and PDSA
work through each department would review taking place at the Monday problem solving sessions will take
be determined by the recall agency. huddle which involves all areas. place to evaluate whether changes to
• A timetable was drawn up to ensure the Exeter system will enable the
that the required number of samples Measurable outcomes and impact laboratory to send results to call/recall
and forms are processed in a planned • On average 41% of results reported in real time.
schedule throughout each working each day are now sent to call/recall at
day. Visual management is in place to 11.30 am and these result letters are Contact
ensure the schedule is adhered to. all posted out the same day. Hazel Eager
• 38% of result letters are received by Email: Hazel.Eager@Leedsth.nhs.uk
the patient a day sooner than before.
• A further 8% of result letters are
received three days sooner.



Case study 3

Reducing manual matching and first class post
Anglia Support Partnership

Summary
Over 17000 result letters are issued
each month by Anglia Support
Partnership call/recall service.
Approx. 2000 women are now
receiving result letters two to three
days sooner than they would have
this time last year after reducing the
number of non hit query cases from
15% to 5%.
A further two days has additionally
been saved following the
introduction of the use of first class
mail.

Understanding the problem Visual management techniques
The reduction of mismatched
reports, caused by typing
discrepancies, booking in errors
(laboratories) and out of area results demonstrate the resource savings • Introduced standard working
was targeted as a major source of that could be made if outsourced procedures in general processes
delayed result letters. In July 2008 letter production was used. across all three agencies.
between 15 and 20% of results
received were mismatch/non hits How the changes were Measurable outcomes and impact
caused by invalid senders, out of implemented • The audit of costs of the
area, sender with end date in the • Visited mailing bureau, to review folding/inserting machine showed
past, incorrect source type, incorrect full pathway and undertook a that savings in excess of £7000
management of women. These postal audit to assess the per year could be realised by
defects needed to be reduced so difference in delivery times switching to a mailing bureau
women received their result letters in between the first class and assuming fully operational
a more timely fashion. business class service. equipment. The time savings
• Migrated whole Anglia Support would be greater when taking into
The postal service was taking too Partnership (ASP) call/recall service account equipment failures and
long with many result letters taking to the mailing bureau. the time this had previously added
three days from dispatch to receipt • Engaged with laboratories to on to TAT.
by woman. review all senders and established • The postal audit showed that if
practice codes as senders, checked first class post was used a further
There was manual distribution and
all postcodes correctly mapped. two days could be removed from
dispatch of result letters in Norfolk,
• Previously, result files were the time taken for the woman to
which caused delays due to
processed throughout day then receive her letter.
unreliable equipment often with two
8am next morning results letters • The non-hit/defect rate has
day breakdowns. Staff were having
generated. Now the results letters reduced from 15% to 5% on
to watch the equipment to deal with
are generated immediately and average (see table 1).
regular issues.
don’t wait until the next day. • The graph on the right
Some systematic data collection was • Enabled remote access, from their demonstrates that the average
undertaken to assess the range of own desktop, for all staff across time from result received by recall
‘non hits’ using visual management ASP to the Cambridgeshire, to letter received by woman has
techniques. Norfolk and Suffolk systems to reduced from five days to 1.57
enable result input and cross- days since October 2008.
A postal audit was performed to
working across the three agencies. • Staff comments include: ‘The
assess delivery times.
• Established practice nurse and visual management of lab-link files
An audit of costs and time for the administrative training sessions for is great because it gives an instant
process of ‘in house’ dispatch of primary care staff on general picture of the service’. ‘The use of
letters, assessing the use of call/recall, Open Exeter and the mailing bureau is great as I no
folding/inserting machine, time spent common queries. longer have to sit and watch the
and local costs, was undertaken as • Introduced visual management to folding machine whirring through’.
part of a business case that would capture all lab-link activity.



‘This course has meant I’ll have
Table 1:
fewer telephone queries in future’.
Before changes were made ‘I now have a far greater
understanding of call/recall and
what it all means’.

Ideas tested which were
unsuccessful
• The first attempt at the postal
After changes were made audit was unsuccessful. Inclement
weather meant post could not be
delivered.
• The initial implementation of using
mailing bureau in Norfolk was
problematic because there was not
enough testing done before going
live.

How this improvement benefits
West Anglia - Oct 08, Jan 09 and Jul 09 data - result patients
received by recall to letter received by women On average, 17,282 women are
receiving their result letters two days
earlier and on average 1.5 days after
the result was authorised in the
laboratories.

How will this be sustained/
potential for the future/
additional learning?
• The introduction of improved
communication between all
programme providers (call/recall,
labs, primary care) will be
sustained as no-one wants to
return to the old ways of working.
• More time is available to develop
Ideas tested which were originally. Although results can be further service improvements.
successful input at any of the three agencies Staff are being used appropriately
• Mapping/checking of all postcodes results currently have to be to do the job they are best at and
enabled results to be sent to the generated from each office, but standardised working has been
correct agency in the first place, this is under review to make the introduced to improve accuracy
causing fewer ‘non hits’. appropriate changes so result between the lab and call/recall.
• Mapping/checking all sender codes letters can be run from any of the • Potential for the future – NNUH
to ensure accurate booking in of three agencies. lab should develop electronic links
samples in the laboratories, • The decision to move to first class with more than two agencies to
reduced sender queries and ‘non mail meant that women received enable the results to be sent to the
hits’ when the results were result letters quicker. correct call/recall agency based on
received. • Following the visit to the mailing patients postcode although this is
• Running the CP/result letter bureau and a greater not currently possible due to
production job after all lab-link understanding of the business funding issues preventing progress.
files and queries had been resolved needs from both sides,
meant that result letters were sent communications between the Contact
the same day they were received bureau and call/recall improved Claire Robinson
and processed. resulting in an improved service. Email:
• Remote access to all three ‘Exeter • Feedback from the primary care Claire.Robinson@suffolkpct.nhs.uk
systems’ meant immediate manual admin training sessions was very
entry of results where it had been positive with comments such as
sent to the wrong agency



11. The nine wastes
The key to adding value is to remove waste. So, Overproduction
what is waste? Producing something before it is required, or
more than is required e.g. unnecessary /
There are nine forms of waste and these can be inappropriate tests, batching samples, tests and
easily remembered with the mnemonic – information

TIM A WOODS Over-processing
Duplication of data or repeat testing due to
defects e.g. dual data entry, additional steps
Transport and checks
Material or information that is moved
unnecessarily or repeatedly e.g. unnecessary Defects
movement of samples. Errors, omissions, anything not right first time
e.g. poorly labelled specimens and requests,
Inventory insufficient or illegible information.
Excess levels of stock in cupboards and store
rooms e.g. specimens waiting to move to next Skills utilisation
step in process, or people waiting for tests and Unused employee skills e.g. highly qualified staff
results. performing inappropriate tasks

Motion WASTE COSTS MONEY AND ADDS TIME
Unnecessary walking, moving, bending or
stretching e.g. equipment placed in wrong The following case studies illustrate how the
location, unnecessary key strokes. sites have removed waste from their systems to
improve turnaround times.
Automating
Where technology is substituted to
compensate for a poor inefficient
process/processes
“ No worker, particularly in healthcare
where the well-being and safety of
Waiting another human comprises the core
Waiting for samples, equipment, staff,
of the work, appreciates having his
appointments or results e.g. patients waiting
for test and results, staff waiting for other or her time wasted.”
staff, equipment or information. Cindy Jimmerson
A3 Problem Solving for Healthcare.



Case study 4

Specific bags sent straight to laboratory
North West London NHS Trust

Summary How the changes were How this improvement benefits
Reorganisation of the way cervical implemented patients
cytology samples are collected from • Core team members discussed the • By implementing the use of
GP surgeries and delivered directly to issues identified with the staff dedicated cervical cytology sample
the cytology department has resulted members responsible for this bags which are delivered directly to
in a reduction in the TAT of between process. the cytology department has meant
0.1 and 2.5 days for approximately • Clear separation of cytology a reduction in the TAT of between
90% of women. MLA staff are also specimens from other types of 0.1 and 2.5 days for approximately
saving approximately 50 minutes per pathology samples was identified as 90% of women.
day through no longer walking to and a way to make sorting easier.
from pathology reception to collect • Large pink specimen collection bags How will this be sustained /
the specimens. This equates to a were purchased and distributed to potential for the future/
saving of approximately nine days or all sample taker practices and clinics. additional learning?
110 miles a year. • Sample takers were instructed by • The practice of separating cervical
letter and at meetings to use the cytology samples from other
pink collection bags exclusively for pathology samples and having them
Understanding the problem cytology work. delivered directly to the department
• During their ‘walk the process’, the • Cytology samples contained in pink has worked well since its
core team observed large volumes of sample bags could easily be seen introduction and has now become
pathology specimens being delivered amongst the rest of pathology the normal practice.
in large specimen transport bags to specimens which made the sorting • The successful use of dedicated
main pathology reception. out process much quicker and cervical cytology specimen bags has
• Specimens were sorted by one efficient. been noted by other pathology
member of reception staff into • Drivers were later instructed to keep departments and is likely to lead to
appropriate boxes for the different pink bagged samples separate from the introduction of dedicated
pathology disciplines. The process other pathology specimens during specimen collection bags in other
was laborious and occasional collection and asked to deliver them pathology disciplines.
mistakes occurred as it was not straight to the cytology department.
always clear to the person doing the Contact
sorting which discipline the Measurable outcomes and impact David Smith
specimen belonged to. • 90% of cervical cytology samples Email: David.SmithB@nwlh.nhs.uk
• Pathology reception is located on delivered directly to cytology
the opposite side of the hospital to department resulting in a reduction
the cytology lab. An MLA from of between 0.1 – 2.5 days in the
cytology spent up to 15 minutes TAT for these specimens.
walking back and forth to collect • MLA staff saved approximately 50
specimens. On arrival, the staff minutes walking time per day. This
member usually waited until all equates to a saving of approximately
specimens were sorted in case any nine days and 110 miles a year,
cytology work was in the bags allowing more effective and
recently delivered. This was done up productive use of MLA time around
to five times a day five days a week. the department.
• Waiting and transport waste were • MLA staff are happier.
clearly identified by core team
members.



Case study 5

Reducing the backlog
Norfolk and Norwich University Hospital NHS Foundation Trust

Summary • Stopped checking of previous
The Norwich laboratory processes and computer system and adding
screens over 60,000 samples per year numbers by office staff, as it was
and is pilot site for HPV testing. By not used anymore.
applying Lean methodology to remove • Stopped writing management advice
waste and improve the flow of work on green forms.
we were able to: • Stopped ‘special attention’ stamping
• Remove the backlog of screening of abnormal results.
samples.
• Take in-house additional screening Measurable outcomes and impact:
whilst coping with a 48% increase By February 2009 the lab had data to
in demand (February 2009). demonstrate:
• Still achieve 97% meeting the 14 • 10.5 days average receipt in the lab
day TAT by July 2009. to issue TAT with a range 2-22
days maximum.
Understanding the problem • Backlog reduced from 4,000 to 655
In October 2008 the lab faced the by (February 2009).
following situation:
• A backlog of over 4,000 samples An increase in demand in February
with some being set out for 2009 took the backlog back to over
screening to another site. 5,000 by the first week in May 2009.
• 24 day average for receipt to
authorisation turnaround times (TAT) By continuing with the changes
with a range of 2-44 days. already made and introducing others
by August 2009 the lab could
SPC charts provided the evidence to demonstrate:
demonstrate the waiting at each step • Backlog of less than 500 by August
of the pathway. 2009, representing only two days
work.
To achieve the goal of 100% in 14 • 7.4 days average receipt to lab
days changes had to be made across issues TAT with a range of 2-16
the whole pathway, with the support days (July 2009).
of a multidisciplinary team of staff • All work is now screened in-house
representing the whole pathway. and the lab is in a position for other
work.
How the changes were
implemented
Using the Lean tools gained from Norfolk and Waveney - Receipt to authorise
national events and on-site training,
small changes were made to the
process and SPC charts were used to
measure the benefits.

The changes implemented
included:
• Stopped re-screening of abnormal
samples if they had already been
seen by checker screening trainees
work.
• Removal of excess checking of ‘open
exeter’, to stop over-processing.
• No hard copy reports were printed
for some GPs (who requested no
paper copy) eliminating over-
processing.



Norwich backlog data
How will this be sustained/
potential for the future/
6000 additional learning?
By reducing the backlog staff have
5000
seen several benefits including:
Number of slides waiting

• Screening staff comment that they
4000
no longer feel under pressure to do
more all the time.
3000
• Clerical staff have freed up time by
2000
reducing non-value adding activities
to enable them to concentrate on
1000 the parts of their job that add value
to the process.
0 • There is now the potential for taking
in work from other laboratories in
0

1

k9 1
k1 /12

2
k1 /01

1
02

02

k2 /03

k2 /03

k2 /03

04

k3 /04

05

k3 /05

k3 /06

06

k4 /07

07

8
0
W 7 /1

W 0 /1

W /1

W 2/1

k1 /0

/0
W 3/1

W 02/

W 16/

W 13/

W 11/

W 22/

W 20/
24

8

5

W 19

W 02

W 16

W 30

W 27

W 25

W 08

W 06

03
the area still struggling with
2

1

2
1

3
k3

k5

k7

1
k1

5

7

9

1

3

5

7

9

1

3

5

7

9

1

3
k1

k1

k2

k2

k3

k3

k4
W

W

W

backlogs as a result of the increased
demand.

Contact
Ideas tested which were successful • Introduced bar-code readers in
Carol Taylor
• Stopped linking of old Sunquest. screening to eliminate the over-
Email: CAROL.TAYLOR@nnuh.nhs.uk
reports, saving approximately one labelling of slides with patients
hour/person/day. name which has released office
• Bell to alert porter, office staff time time, saved money on labels/printing
saved approximately one hour per and prevented slides waiting before
day. going through for screening.
• Accepting pre-printed HMR forms • Lab introduced letter informing
saves time on phone calls and stops sample senders of out of scope
sample processing delays. samples to reduce inappropriate
• Call/recall centre advising lab of demand.
wrong recall by email and phone • PCT core team member re-enforced
call. Changes made and re-sent non-acceptance of out-of scope
electronically. This has removed samples by letter in GP magazines
paper, cut down TAT by 24 hours and by writing to GPs separately.
and saved lab staff time.
• Each screener now has their own PC How this improvement benefits
to enter results etc, so eliminating patients
the waste of waiting to use a piece Over 60,000 women in the Norwich
of equipment. area can now expect to receive their
• Day books were eliminated (over results within 14 days of the sample
processing) saving time for more being taken.
screening and allowing the screening
of five extra slides per day per
screener.
• Screeners doing their own slide filing
has released ½ a days time in the
office.
• Infection information is now circled
and not written on forms, again
removing the waste of
overproduction.



Case study 6

Moving the fridge reduces walking
The Leeds Teaching Hospitals NHS Trust

Summary then back across the room to the Three of these changes released time
Waste of motion reduced. 123.7 miles coverslipper. A bowl was placed in the sample preparation area. A
of walking per year has been removed, between the prepstain and the timetable has now been devised that
equivalent to 8.25 working days of coverslipper for this purpose. enables 12 runs per day (576 samples)
capacity now available for other Area 4 to be processed daily which meets the
duties. Rapid pre-screening results were current demand and enables samples
entered onto the computer in the to be processed on the same day or
Understanding the problem cytology office and the forms then the day following receipt in the
• The core team walked the pathway returned to the screening room. These laboratory.
from the time a cervical cytology are now entered onto the computer in
sample was received at specimen the screening room The time saved in area 4 (pre-
reception to the time the result screening) releases time for the
letter was sent out by the screening Measurable outcomes and impact office staff to register samples.
agency and produced a value stream • Area 1 (stock room). A saving of
map. 16,048 yards/year (38% decrease How will this be sustained/
• During the walk, two initial areas of in time). potential for the future/
waste which could be reduced were • Area 2 (fridge). A saving of 76,365 additional learning?
identified - distance from fridge to yards/year (100% decrease in The building housing the current
lab and distance from stock room to time). accommodation is to be closed.
lab. • Area 3 (bowl). A saving of 79,685
• Process sequence charts were yards/year (4% decrease in time). Lessons learned from the service
produced detailing all steps of the • Area 4 (pre-screening). A saving of improvement journey will inform
process. 45,653 yards/year (15.5% planning the layout of the new
• The time taken and distance decrease in time). accommodation. Awareness of waste
travelled at each step of the process • A total saving of 217,751 yards or due to travelling time has been raised,
was recorded. 123.7 miles per year, the and the team will aim to minimise
• By looking at the process sequence equivalent of 4.72 marathons travelling distances further in their
charts we identified two more areas • At a walking pace of two miles per new accommodation.
in the lab where waste in the form hour these changes have released
of motion could be reduced - 8.25 working days of capacity for Standard operating procedures have
distance from prepstain machine to other duties i.e. more processing been updated to reflect the changes
sink and distance from screening time to help achieve our targets. implemented.
room to office for prescreening
sheets. How this improvement benefits Contact
patients Hazel Eager
How the changes were These savings will help to improve the Email: Hazel.Eager@Leedsth.nhs.uk
implemented turnaround time of all cervical cytology
Area 1 samples.
The gynaecology consumables
stockroom was moved to a room
nearer to the preparation laboratory. Distances travelled per day pre and post changes
Area 2 500
Samples waiting processing were 450 432
stored in a cold room in the specimen Pre change
400
Distance in metres

reception area which was 69 metres Post change
from the laboratory. A refrigerator 350
was placed in a room adjacent to the 300 276
preparation laboratory. Samples were 250
stored there until the backlog of 200 174
samples to be processed was removed 154
and storage was no longer required. 150
100 94
Area 3
At the end of processing on the 50 36
0 9
prepstain machines, trays of samples 0
were carried to the sink across the Area 1 Area 2 Area 3 Area 4
room to tip off the excess alcohol Area of laboratory


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

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

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