The “Lean” Experience and The “Lean” Experience and ongoing Workforce ongoing Workforce

Considerations.Considerations.Carmarthenshire DivisionCarmarthenshire Division

Hywel Dda NHS TrustHywel Dda NHS Trust

PartnershipPartnership

Project funded by NLIAH. Project funded by NLIAH.

Knowledge Management and Transfer Knowledge Management and Transfer (KM&T) (KM&T)

KM&T project lead – Dave HodgkinsonKM&T project lead – Dave Hodgkinson

NLIAH project lead – Claire LloydNLIAH project lead – Claire Lloyd

Project OverviewProject Overview

Pilot site – West Wales General Pilot site – West Wales General Scope – to introduce “Lean Thinking” service Scope – to introduce “Lean Thinking” service

improvement methodology improvement methodology AimsAims to identify and implement improvements in to identify and implement improvements in

the specimen pathway.the specimen pathway. to include collection and delivery of the to include collection and delivery of the

specimen to receptionspecimen to reception

Project ObjectivesProject Objectives

Improve the efficiency and quality of service Improve the efficiency and quality of service delivery within specimen reception.delivery within specimen reception.

Remove waste from processes.Remove waste from processes.

Introduce a “one piece flow and pull system”Introduce a “one piece flow and pull system”

Staff engagement.Staff engagement.

Project deliverablesProject deliverables

To “level” specimen delivery to reduce peaks To “level” specimen delivery to reduce peaks and errors.and errors.

Improvement of >25% in “turnaround time” Improvement of >25% in “turnaround time” from receipt to electronic authorisation of from receipt to electronic authorisation of result.result.

Improvement of >40% in processing time and Improvement of >40% in processing time and subsequent throughput (specimen/hour).subsequent throughput (specimen/hour).

Project deliverablesProject deliverables

Increased team work and better utilisation of Increased team work and better utilisation of resources through :resources through :

1. Clear definition and communication of roles / 1. Clear definition and communication of roles / staff empowermentstaff empowerment

2. Introduction of key metric measurement, 2. Introduction of key metric measurement, visual management and reporting processesvisual management and reporting processes

3. Undertake a high level operation review of 3. Undertake a high level operation review of twin pathology site at Llanellitwin pathology site at Llanelli

Day One Day One

Introductory meeting Introductory meeting

KM&T overview of “Lean principles” KM&T overview of “Lean principles”

Ice breakerIce breaker

Brainstorming sessionBrainstorming session

Brainstorming – examples (46)Brainstorming – examples (46) Aim to get ward specimens back by 10amAim to get ward specimens back by 10am Segregate general pathology enquiries from processing workSegregate general pathology enquiries from processing work Look at current racking of samples in receptionLook at current racking of samples in reception Segregate NPHS samples at source e.g. GP surgerySegregate NPHS samples at source e.g. GP surgery Stop printing hard copy pathology reportsStop printing hard copy pathology reports Reduce errors in specimen collection and labellingReduce errors in specimen collection and labelling Use MLA to transport specimens from surgeries – lease vanUse MLA to transport specimens from surgeries – lease van Review postal processReview postal process MLA to go with phlebotomist to Cardigan Hospital to number and MLA to go with phlebotomist to Cardigan Hospital to number and

data entry samples at sourcedata entry samples at source Train staff to use new sample archiving systemTrain staff to use new sample archiving system When phlebotomist goes out to a surgery , suggest they bring back all When phlebotomist goes out to a surgery , suggest they bring back all

samples not just the ones they have takensamples not just the ones they have taken

Key issuesKey issues

GP samples delivered late afternoon due to GP samples delivered late afternoon due to outlying geography and lack of dedicated outlying geography and lack of dedicated transport systems.transport systems.

Ward samples delivered late in the morning.Ward samples delivered late in the morning. Insufficient numbers of MLA’s to process the Insufficient numbers of MLA’s to process the

work in reception.work in reception. Backlog of samples at data entry, centrifuge Backlog of samples at data entry, centrifuge

and authorisation at 17:00 hours.and authorisation at 17:00 hours.

Value Stream mappingValue Stream mapping

Key observations:Key observations: The samples were batched in quantities of 40The samples were batched in quantities of 40 The average time to number a request form was 40 secsThe average time to number a request form was 40 secs The average time to data enter a request form was 35 secsThe average time to data enter a request form was 35 secs The centrifuge cycle was 6 minutesThe centrifuge cycle was 6 minutes Average time to verify a request was 8 secsAverage time to verify a request was 8 secs

Number sample

Data entry sample

Spin sample

Verify sample

Load analyser

Electronic results

Batch size of 40Batch size of 40

Number sample

Data entry sample

Spin sample

Verify sample

Load analyser

Electronic results

27 min 23 min

6 Min 5.5 min 25 min

Specimen reception

Bio 2 Bio 1

Assuming no interruptions during each process

27 + 23 + 6 + 5.5 +25 = 86.5 min

Samples to be pulled every 15 minsSamples to be pulled every 15 mins

Number sample

Data entry sample

Spin sample

Verify sample

Load analyser

Electronic results

15 min 13 min

6 Min 2 min 25 min

Specimen reception

Bio 2 Bio 1

Assuming no interruptions during each process

15 + 13 + 6 + 2 +25 = 61 min (25% reduction in TAT)

New systemNew system

Reducing the batch size from 40 to 24Reducing the batch size from 40 to 24 Moving from fixed lot variable time to fixed Moving from fixed lot variable time to fixed

time variable lot improved efficiencytime variable lot improved efficiency For example :For example : During non peak periods it may take up to 2 During non peak periods it may take up to 2

hours between receipting the 1hours between receipting the 1stst sample to the sample to the 4040thth sample, resulting in TAT > 2.5 hours sample, resulting in TAT > 2.5 hours

If samples are centrifuged every 15 minutes If samples are centrifuged every 15 minutes the TAT would be a constant 61 minsthe TAT would be a constant 61 mins

Alignment of processesAlignment of processes Alignment of the request form numbering and data entry Alignment of the request form numbering and data entry

process could save an additional 23% on TATprocess could save an additional 23% on TAT If they run almost simultaneously, it ensures that when If they run almost simultaneously, it ensures that when

samples have been centrifuged, all request forms will have samples have been centrifuged, all request forms will have been entered in the database, resulting in no delays when been entered in the database, resulting in no delays when verifyingverifying

(Original) Numbering Process Data entry Process (New process) Numbering Process Data Entry Process

Start 12 samples 24 samples

30 minutes

23 minutes

InterruptionsInterruptions

Every interruption encountered resulted in Every interruption encountered resulted in stopping either the data entry or the stopping either the data entry or the numbering processnumbering process

105 requests per hour – no interruptions105 requests per hour – no interruptions

This dropped to 45- 70 per hour due to This dropped to 45- 70 per hour due to interruptionsinterruptions

Staffing requirementsStaffing requirements

8.00am- 12:00 ( 2 staff)8.00am- 12:00 ( 2 staff) 12:00 -14:00 (4 staff)12:00 -14:00 (4 staff) 14:00 – onwards (6 14:00 – onwards (6

staff)staff) Remove interruptions Remove interruptions

and 4 staff should cope and 4 staff should cope with the throughputwith the throughput

T yp ical d em an d fo r req u est card s in S p ec im en R ecep tio n

34

56

74

58

169

76

237

108

4160 60 60 60 60 60 60 60 60 60

120 120 120 120 120 120 120 120 120 120

0

50

100

150

200

250

Req Card s

1 n u m & D ata en try

2 n u m & D ata en try

Staff role definitionStaff role definition

NumbererNumberer Data entryData entry Post functionPost function Float roleFloat role Send awaysSend aways Biochem 2 – centrifugation, verification, load Biochem 2 – centrifugation, verification, load

analyseranalyser

Floating RoleFloating Role

Handle all interruptions Handle all interruptions Process “urgent specimens” Process “urgent specimens” Sorts samplesSorts samples Transport samples to centrifuge Transport samples to centrifuge Transfer samples to and from dumb waiterTransfer samples to and from dumb waiter Ensure staff who are numbering and Ensure staff who are numbering and

undertaking data entry are synchronisedundertaking data entry are synchronised

Benefits identifiedBenefits identified Reduction of double handling of samples by Reduction of double handling of samples by

racking directly into centrifuge pods (saving racking directly into centrifuge pods (saving £1700 per year)£1700 per year)

Reduction in hours required for the post Reduction in hours required for the post function (reduced from 3 X daily to 2X daily) function (reduced from 3 X daily to 2X daily) also paperless pilot for GP surgeries (saving also paperless pilot for GP surgeries (saving £4900 per year staff time and £1000 per year £4900 per year staff time and £1000 per year consumables)consumables)

Increases in TAT of 8% but could increase to Increases in TAT of 8% but could increase to 25% if Bio 2 role could be resourced all day25% if Bio 2 role could be resourced all day

Benefits (continued)Benefits (continued)

Increase of throughput from 60 requests per Increase of throughput from 60 requests per hour to 105 requests per hour with the hour to 105 requests per hour with the introduction of the “float role” (75% increase)introduction of the “float role” (75% increase)

Levelling of sample delivery time by Levelling of sample delivery time by phlebotomists collecting samples from phlebotomists collecting samples from surgeries on the way back to WWGHsurgeries on the way back to WWGH

All samples numbered and data entered by All samples numbered and data entered by 17:00 hours consistently17:00 hours consistently

Next StagesNext Stages

Identify workforce requirements.Identify workforce requirements. Consideration of other strands which might Consideration of other strands which might

affect the project work.affect the project work. Wider implications affecting service provision.Wider implications affecting service provision. Legacy of the project and workforce Legacy of the project and workforce

implications.implications.

Workforce Requirements.Workforce Requirements.

Roles identified within the project.Roles identified within the project.Reception based roles.Reception based roles. ““Floater” role.Floater” role. Data Entry role.Data Entry role.Laboratory/Multiskilled roles.Laboratory/Multiskilled roles. Reception/PhlebotomyReception/Phlebotomy Reception/LaboratoryReception/Laboratory Consideration of Bands for these roles.Consideration of Bands for these roles.

Wider implications to Service Wider implications to Service Provision.Provision.

TRRR/WCP/LIMS and TRRR/WCP/LIMS and other IT considerationsother IT considerations

National harmonisation National harmonisation of codes and ranges.of codes and ranges.

POCT. On Wards and in POCT. On Wards and in the Community.the Community.

Laboratory Design.Laboratory Design.

What service do we design What service do we design for?for?

Blood Sciences Blood Sciences Staff Budgeting Staff Budgeting

implicationsimplications Accreditation. - NetworksAccreditation. - Networks

Other Strands to considerOther Strands to consider

TRRR and Welsh Clinical Portal.TRRR and Welsh Clinical Portal.

Skeleton requesting/ Sample storage Skeleton requesting/ Sample storage verification checking.verification checking.

?Departmental reorganisation.?Departmental reorganisation. Accreditation.Accreditation. Sister site Prince Philip Hospital.Sister site Prince Philip Hospital.

Lean “Ideal Service provision”??Lean “Ideal Service provision”??

1.1. Primary care: Direct requesting of work for Pathology. Provision of Primary care: Direct requesting of work for Pathology. Provision of Community based Phlebotomy & POCT. Networked specimen Community based Phlebotomy & POCT. Networked specimen preparation and transport to department – On site Pathology advice preparation and transport to department – On site Pathology advice available.available.

2.2. Secondary care: Direct requesting for Pathology work.Secondary care: Direct requesting for Pathology work.

3.3. Centralised Pathology reception, covering sample distribution, Centralised Pathology reception, covering sample distribution, receipting and verification of specimens. Centralised centrifugation and receipting and verification of specimens. Centralised centrifugation and sample preparation to loading of Blood sciences based Automation area sample preparation to loading of Blood sciences based Automation area allowing maximum relevant robotics with Chemistry and Haematology allowing maximum relevant robotics with Chemistry and Haematology areas for specialist work. Centralised SAS work.areas for specialist work. Centralised SAS work.

4.4. Specialist Chemistry and Haematology validation of results.Specialist Chemistry and Haematology validation of results.

5.5. Electronic delivery of results to all users.Electronic delivery of results to all users.

Project Legacy and Workforce implications.Project Legacy and Workforce implications.

Blood sciences considerations.Blood sciences considerations. Staff budgeting.Staff budgeting. Networking, both for Service provision and Networking, both for Service provision and

Accreditation.Accreditation. Role redesign.Role redesign.

In the department. In the department. In the Community.In the Community. Associate practitioner.Associate practitioner. Role of qualified staff.Role of qualified staff.