The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Simon Rattenbury

Head of Laboratory Service

Microbiology

Seven Day Services supporting

Improved Outcomes in Prevention

and Early Diagnosis 4th March

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

RFH Founded in 1828 Royal Charter 1837

Clinical Instruction for Women

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• ~600 beds Reduced from 1200.

• 700,000 patients a year from all over the world.

• Employ around 4,600 people and have a turnover of about £450m.

• Major A&E.

• All branches of surgery and medicine

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

What am I Going to Cover

• Scientists / Pathology & its Role

• What was the need & why consider 24/7?

• What was the clinical need?

• The outline planning of the 24/7 case?

• What the key points/take home message?

• What did it deliver / measure success today?

(time, Money, efficiency etc)

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Why 24/7 Why Microbiology

• Patients aren't ill 9 to 5:

– Better patient outcomes

– Fit with patients care pathways

– Antibiotic Stewardship

– The new system of working was developed over

several years. It involved changes to staff roles,

training and contractual arrangements and was a

major restructuring exercise

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

The 63 heroes who saved our son: Revealed in the heart-tugging story of a critically ill baby and the astonishing army of NHS staff needed to save one life

To save one life: 7 doctors, 9 consultants, 18 nurses, 5

support staff, 22 scientists, 1 professor and 1 receptionist

6

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Pathology Challenge

• Organise services around the patient/users,

– not disciplines, staff groups, hospital labs

• Transform structures and practices

Reduce variability

Provide evidence of progress

• No change is not an option

• Take ownership and drive the agenda

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Vision of 24/7

Providing an

integrated service

end to end

Increasing productivity

& delivering continuous

improvement

Providing quality

services at

competitive prices

Pathology

Services enabling

better NHS care

Better patient outcomes

& commitment to a

quality 24/7

A Department

employees are proud

to be part of

Providing a Service for the

Future

Delivering “end-to-end” Pathology

Service

Transforming the

existing path

operating model

Developing

scientific & clinical

knowledge

Target Markets:

Core pathology services in chosen geographies

Specialist reference services nationally & internationally

Innovation R&D

PATIENT

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Improvement Cycle

User

Satisfaction

Pathology

Modernisation

Pathology Service

Improvement

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Current Service Provision

Departments philosophy

Molecular Rapid Microbiology

• Chlamydia/GC

• TB

• MRSA

• Enteric Panel Real time

• 16s RNA sequencing

• Fungal 18ITs Sequencing

• Typical & Atypical respiratory

• C difficile toxin

• MALDI ToF

Patient

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

The Past

• Staff turnover………..high

• Staff cover at weekend and out of hours was

on a voluntary rather than a contractual basis.

• Reliance on high cost locum staff and high

turnover meant the training and staff

experience was variable and at times services

had to be withdrawn due to lack of staff

available to perform the work

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

The Past

• 2000 all new contracts were changed to 24/7

working including bank holidays

• Staff titles were changed to ‘Health Care

Scientists’ in an attempt to remove glass

ceilings and introduce equality and to gain

greater job satisfaction

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

The Past• Two on call systems were in operation (routine and

High Secure Pathology Unit) plus additional staffing for

– Blood cultures

– MRSA

– C difficile

– Resistant Gram negative screening

• Shift Rota was complex and time consuming

• Required at least 2 .5 days to prepare but was not EWTD compliant

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

The Past

• 2004 Introduction of more support grades and

Health Care Scientists

• Band re-profile 6 to 5

• AP

• MLA

• No A&C grades

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Staff grade 07/08 08/09 2011/13

8 6 5 5

7 BS 10 13 8

7 CS 6 4 4

6 BS 15 13 14

5 BS 0 0 3

4 AP 2 2 6

3 MLA 1 1 2

2 MLA 2 8 8

A&C 4 3 3 0

A&C 2 2 0 0

Totals 50 49 47

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Year 06/07 07/08 08/09 11/12 12/13

approx

Workload 250,000 300,000 350,000 500,000 600,000

Staffing 50 50 49 47 47

Workload & Staffing

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• Major change

• Negative and some positive impacts on staff

• Time, effort and strong communication to

work through the issues with staff.

• Major concern for staff was reduction in pay;

managed by providing pay protection for up to

one year, variable lengths

Introduction of 24/7

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• The benefits to staff

– self roster

– working hours 37.5hrs

– Improved staff safety.

• New ways of working and career development

– new roles to emerge e.g. the associate practitioner role.

• Continuity of staffing

– Provide better quality services and reduce the pressures that

had previously been experienced

Introduction of 24/7

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• Addition of three bands 5

• Gradual introduction of band 4 to be trained as

Associate Practitioners.

• Budget

– Funding for pay protection was required Overall

the remaining staffing changes were managed

within the existing budget by re-profiling the skill

mix.

Introduction of 24/7

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• Unions

• Consultation

• Committee

• Staff questions

• HR A4C pay rates

• Reserve lists

• Multidisciplinary HSPU training

• Three monthly and weekly rota

• Went live 1st Aug 2009

Challenges

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Challenges• Terms and conditions

• Working practices - consultants

• - technical

• Culture - professional

• - Management» - “siteism”

• Corporate identity

• Changing job roles

• Ownership / territory

• Takeover mentality

• Disaffected staff

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Staff View

STAFF

FOCUS

HEALTH AND SAFETY

LOW SICKNESS RATES

CPD

A4C/KSF

TRAINING

INDUCTION

RECRUITMENT AND

RETENTION

WORKING

CONDITIONS

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

What’s Needed

• Management Support

• Resources

• Team Building

• Organisational / Personal Development

• Vision / Plan

• Leadership

• Resolve

• Time

• Stability

• Communication

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

In Transition: Key Objectives

• Keep the system safe in transition

• Drive sustainable innovation and service excellence

• Modernise planning to deliver a patient centred approach that embraces patient pathways

• Enable service transformation– Move general services closer to patients’ homes– Centralise specialist services to leverage

expertise and drive economies of scale– Integrate across health and social care

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• Have clear and measurable goals and realistic timeframes when planning the changes.

• Engage staff early in the change process and gain as much agreement with the project goals as possible.

• Ensure that all meetings have minutes taken and they are distributed to all staff

• Ensure negotiations with staff are reasonable and managed well

• Skill changes provide positive training and development opportunities for all staff and enable flexible rosters

Top Tips

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

• Develop key baseline measures and track the measures to demonstrate the improvements to all stakeholders…Win/Win

• Be prepared to modify original plans where possible so that staff are involved and are part of the decision making

• Allowing staff to design the shift and rosters system worked well

• Recognition of staff in their staff review

Top Tips

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Types

of Shift

Time Staff numbers

HCS MLA

Early 8.00 am to 4.30 pm 1 1

Core 9.00 am to 5.30 pm 15 7

Late 11.30 am to 8.00pm 2 2

Nights 8.00pm to 8.00am

7.30pm to 7.30am

1

1

0

0

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Night Person Night Person 2

19:30 Hand over Hand over

20:30 Blood Cultures Start final put up of all left

21:30 over samples

22:30 Fluids Help with follow up

23:30 "

00:30 Follow up of both benches

Lunch

01:30 Urines

Lunch "

02:30 Any urgent samples PLUS "

03:30 Help on urines "

04:30 " "

05:30 Make sure all samples "

06:30 are booked in plus blood "

07:30 cultures put on analyses "

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital MICROBIOLOGY WEEKEND ROTA (Prepared by ABhamra)

Sections Sat 21.04.12 Sun 22.04.12 SECTION

LEADER

RECEPTION

Sat only sorted

Taufiq am –please note reception / spa done

on night shift + tristel

® kumar (V) >2

Taufiq am –please note reception / spa done

on night shift + tristel

® kumar >1

SPA

Urines Put up Komal < 1 pm

Taufiq pm;♣♣♣♣Sarah>4

Taufiq pm

♣♣♣♣Sarah

Waste collection / autoclave ® kumar (V) (minimal) priority<2 ® kumar ( minimal) <1

Stool Put up

&CDT( 12.30)

Michelle + Stool Put up ( priority for CDT)

+ Sub SF/APW/Acetamide

+ OCP Prep / Crypto stain

+ Send TDM levels @ 10 am and 3 pm

♦♦♦♦Michelle + Stool Put up ( priority for CDT)

+ Sub SF/APW/Acetamide

+ OCP Prep / Crypto stain

+ Send TDM levels @ 10 am and 3 pm

BLOOD CULTURES

+ report TDM

+ GUM

Maria ( No Maldi) + IQC Oxidase / Nephelometer

+ GC Screen / Read & record AST

+Sub ATCC Ctrls

+ Report TDM

Maria( No Maldi) + IQC Oxidase / Nephelometer

+ GC Screen / Read & record AST

Sub ATCC Ctrls (if applicable)

+ Report TDM

FLUIDS NW+FU

RESPIRATORY NW+FU

Includes reporting on Sunday

RESPIRATORY NW Putup

*Owen( No Maldi)

*Owen

Komal >2pm

*Owen( No Maldi)

Rizalea ( V)

Rizalea( V)

MRSA CULTURE & PCR Mohammed

+ CDT PCR if required

Mohammed

+ CDT PCR if required

HVS

Kanti 9-1

Read the NW only and complete the FU

CLOSED

RNOH & MALDI ♣♣♣♣Sarah<4 ( RNOH Maldi only) ♣♣♣♣Sarah( RNOH Maldi only/ SPA

URINES NIGHT Jasim CLOSED

WOUNDS/ E.N.T/ACIN

NIGHT NIGHT

ENTERICS Komal only to Screen for Salm/

Shi < 11-45

Komal start to finish + reporting

SEROLOGY CLOSED CLOSED

VIPER CLOSED CLOSED

Computing CLOSED Owen

Night staff Lucy

• Wounds / ENT

• Leave reporting for Sun night if

necessary

Jasim: urine start to finish

Paul

• Night duties

• Read TVs/BVs and Record + Sub LIMs

• Help Lucy with + reporting

Lucy

• Wounds / ENT

• Leave FU on bench with instruction

Jasim

• Night duties

• Help Lucy with FU + reporting

• Read TVs/BVs and Record + Sub LIMs

HSPU Day

Night

Maria

Jasim

Maria

Lucy

Sickness Andrew Andrew

Early

Late

No colour= Core

Night

Over time /

Xtra hours

Team

leader:

Owen

Please ensure

relevant plates

for closed

sections are

placed in the

fridge

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

MICROBIOLOGY WEEKLY ROTA (Ed 23 March 2012) Rota Prepared by:A.Bhamra

Sections / Section-leaders Monday 23/04/12 Tuesday24/04/12 Wednesday 25/04/12 Thursday26/04/12 Friday 27/04/12

Deputy Rota Maker + weekly overdues Rajita Monica am Victoria Rajita Rajita Rajita Chris , Angela

Judith Shaila

Fitzroy 8-9

Chris Angela

Judith Shaila

Fitzroy 8-9

Chris AngelaJudith

Shaila, θAudrey pm

Fitzroy 8-9

Yonas Angela

Judith Andrew

Fitzroy 8-9;Rita

Chris Angela

Judith Andrew

Fitzroy 8-9 Rita

: SL Rajita

Victoria 0n tuesday

Ward Duties Jenny closed Yonas closed Yonas

URINE/ GU MED : Section leader Owen

rine Phx + Urine NW +AP

Urine NW & FU +Microscopy

•Maferim<11.30

Temitayo

Saroj ♥Komal>4.30

•Maferim<11.30

Temitayo

Saroj γRizalea<4.30

•Maferim<11.30

Temitayo

Dr Lakshi

Saroj♥ Komal>4.30

Temitayo

Dr Lakshi

Saroj⊗Kanti >4.30

Temitayo

Dr Lakshi

Saroj ⊗Kanti >4.30

HVS+ GC+ settle plate < 4

+ MALDI SPOTTING GC ONLY

Alan Vicky Alan Alan Alan

SWAB CULTURE: Section leader Kanti

read / report Kanti, ♥Komal Kanti ♥Komal Kanti, ♥Komal ⊗Kanti,Komal ⊗Kanti,Komal

follow-up < 3 Kanti, ♥Komal Kanti ♥Komal ♦Vicky >11 ♦Vicky >11 ♦Vicky >11

up (SPA) ↓Samer >10 Andrew

•Maferim>11.30

Dr Anna pm

JennyChika>4.30

•Maferim>11.30

↓Samer >10 Andrew

♦Vicky <11 Jenny

•Maferim>11.30

Andrew↓Samer >10

♦Vicky <11

↓Samer >10

Shaila°Mod >2

♦Vicky <11

↓Samer >10

Shaila°Mod >2 HAI : Section leader Gemma

(am/pm)

+ MALDI SPOTTING culture) +transferx2 runs

Kumar/ωMonica brief

ωMonica am

Kumar

θAudrey am/2 pm

Kumar

θAudrey am/2 pm

Kumar

θAudrey am/2 pm

Kumar

θAudrey am/2 pm MYCOLOGY: Section leader Rebecca

Shanti ♠Shanti koh Dr Daniel=dopsx2 * Rebecca/Shanti

↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10

(Tues & Fri)

(Mon & Thu) Rebecca/Shanti+koh Rebecca/Shanti+koh

BLOOD / FLUID: Section leader : Monica Victoria 0n Tuesday pm

+ MALDI SPOTTING Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi Fluids + MALDI SPOTTING Harry Emma Monica am /Dr Anna

am Victoria ♠Shanti +koh

Emma

Anna Emma Anna Emma

<2 Sini /Mohammed Sini /Mohammed Sini/ Mohammed+caf °Mohammed °Mohammed

Main Lab cover 1-2 Kanti/Komal Purnima/Gemma Harry Sirilaksmi Anna Sirilaksmi Rajita Audrey

RESPIRATORY / TB: Section leader Kanti

+ MALDI SPOTTING Manpreet Manpreet Manpreetam Victoria Manpreet ManpreetDr Anna am RNOH Tissues + MALDI SPOTTING Anna /Rachel Anna Rachel Rajita Rachel Rajita Rachel Rajita Rachel

Xpert-CepheidPCR) Rizalea/Chika+ind -AL γRizalea&Chika<4.3 Rizalea Chika Harry Chika Harry Chika ENTERICS / IQC: Section leader : Purnima Gemma ( Wed)

+ CDT/HP transfer 4-4.15 Purnima Gemma Purnima Gemma Gemma Purnima Gemma Purnima Gemma

H.pylori prep only( Mon & Thu) ◊ Michelle ◊ Michelle

Stool/CDT /OCP prep &CDT assay ◊ Michelle Yonas Michelle ◊ Michelle Michelle IQC am (all day Wednesday) Ω Rajita am till 7pm θAudrey pm Harry θAudrey pm θAudrey pm

SEROLOGY: Section leader Rajita( Purnima on Tuesday)

/ TDM (if closed) Rita Rita Rita Night(Paul) Night(Sini)

MLA Serology prep + send aways

i DS2 on Mon/Thu only

Fitzroy 9 -4.30Kristine

+H.Pylori DS2

Fitzroy9 -4.30

Kristine

Fitzroy 9 -4.30

Kristine

Fitzroy9 -4.3Kristine

+H.Pylori DS2

Fitzroy 9 -4.30

Kristine

MOLECULAR (VIPER): Section leader Victoria( Mon-Wed),Gemma( Thu-Fri)

Chlamydia Viper / CDT & HPYL via DS2 Night( Sarah) Night( Sarah) Night( Sarah) Jenny Jenny

CT/GC Transfer results Night( Sarah) Night( Sarah) Night( Sarah) Night( Lucy) Night( Lucy)

MOLECULAR (Other): Section leader Victoria( Mon-Wed),Gemma( Thu-Fri)

Molecular (16s & others) / Atypical PCR ↑Damion Kevin ↑Damion Kevin Damion Kevin Damion Kevin Damion Kevin am

( half day 2 staff ) Anna Rob Rizalea Rob Rizalea Rob

Other Activities + R&D Rebecca=maldi sort

ΩRajita 7pm =Audit

writMonica pm =caf sort

Victoria =Eucast plan

Monica am =caf sort

+dops for Dr Daniel-

see Amrat

Monica =caf sort

Maria pm= audit ‘f’ std

Sini= audit –see mk

Abh= Rota

Rebecca/♣Owen maldi sort ,Abh= Rota

Monica =strep phx

Maria till 7= audit

: ↑ Damion =CoSurv Owen↑Damion pm Owen ICE+CoSurv Owen/Maria am ♣Owen +CoSurv MEDIA / WASH-UP: Section leader Adrain

Media stock Tues / delivery Weds Taufiq Taufiq Taufiq Taufiq Taufiq

Registrars office /Enquiries Kelly, Valeria Kelly, Valeria Kelly, Valeria Kelly, Valeria Kelly, Valeria SR,Abh,Mk am,AL Abh Mk AL Abh,Mk am AL SR,Mk AL Mk AL

Lucy Sarah Paul Sarah Paul Sarah Paul Lucy Sini Lucy

LEAVE (Med) = Medical (S) = Study (E) = Emergency (O) = off duty due to 24/7

(L) = Annual / Time-In-Lieu Leave

(MP) = M/Paternity (MT) = Meeting Francis @georgeds,Fenella rfh –virology,

Catherine r&d @ rfh,Ingrid@Barts,Manar @

Over time Kristine Mon 9-

Thu/Fri 9-11.30,Judith tue 9-

L:Yonas,Dallas,Audrey

GinaPaulO:TomMaria,

Owen,Jasim , Mk pm

S:VickyRob MP AntheaMT:Michelle/Ab

ccrp1-2,Sini & Abh

12.15-12.30, Sam/Abh

12-12.15

L:Dallas, Gina

O:,Michelle,

Tom,Lucy,Maria,

Jasim Rajita MP: AntheaSHarry,Manar

Alan,EmmaSamantha

RobMT:Yonas/Abh

ccrp 12-1,Monica

pm,SR,AL10.30-11

L:Dallas,Gina,

RebeccaO:TomLucy,

Purnima,Jasim,

MK pm,Monica pm S: Maria, Manpreet

pm MP: Anthea

MT:SR

L:Dallas,Gina, O:

Maferima,Tom,Sarah

Victoria,Jasim, MP:

Anthea MT:Monica 10-11.30 & 1-2

L:Dallas,Gina,Jasim

Kevin pm, SR,Chika

O: Maferima,Tom,

Sarah,Victoria,Paul, MP: Anthea

S: Manpreet pm

Night Training Late shift Early HCS 1.5hrs Dr Rita Oladele: observer from ECCMID in dept for I month

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Sections / Section-leaders Monday 23/04/12 Tuesday24/04/12 Wednesday 25/04/12

Thursday26/04/12 Friday 27/04/12

Deputy Rota Maker + weekly overdues Rajita Monica am Victoria Rajita Rajita Rajita

RECEPTION: SL RajitaMonica am Victoria 0n tuesday

Ward Duties

Chris , Angela Judith ShailaFitzroy 8-9

Chris AngelaJudith ShailaFitzroy 8-9

Chris AngelaJudith Shaila, θAudrey pm

Fitzroy 8-9

Yonas AngelaJudith AndrewFitzroy 8-9;Rita

Chris AngelaJudith AndrewFitzroy 8-9 Rita

Jenny closed Yonas closed Yonas

URINE/ GU MED : Section leader Owen

Urine Phx + Urine NW +APUrine NW & FU +Microscopy

•Maferim<11.30 Temitayo

Saroj ♥Komal>4.30

•Maferim<11.30 Temitayo

Saroj γRizalea<4.30

•Maferim<11.30 Temitayo

Dr Lakshi

Saroj♥ Komal>4.30

TemitayoDr LakshiSaroj⊗Kanti >4.30

Temitayo Dr LakshiSaroj ⊗Kanti >4.30

GU MED HVS+ GC+ settle plate < 4 + MALDI SPOTTING GC ONLY

Alan Vicky Alan Alan Alan

SWAB CULTURE: Section leader Kanti

Wounds / Ent read / report Kanti, ♥Komal Kanti ♥Komal Kanti, ♥Komal ⊗Kanti,Komal ⊗Kanti,Komal

Wounds / Ent follow-up < 3 Kanti, ♥Komal Kanti ♥Komal ♦Vicky >11 ♦Vicky >11 ♦Vicky >11

Swab put-up (SPA) ↓Samer >10 Andrew

•Maferim>11.30Dr Anna pm

JennyChika>4.30•Maferim>11.30↓Samer >10 Andrew

♦Vicky <11 Jenny

•Maferim>11.30Andrew↓Samer >10

♦Vicky <11↓Samer >10Shaila°Mod >2

♦Vicky <11↓Samer >10Shaila°Mod >2

HAI : Section leader Gemma

ACP MRSA (am/pm)+ MALDI SPOTTING

HAI (MRSA culture) +transferx2 runs

Kumar/ωMonica briefωMonica am

KumarθAudrey am/2 pm

KumarθAudrey am/2 pm

KumarθAudrey am/2 pm

KumarθAudrey am/2 pm

MYCOLOGY: Section leader Rebecca

Mycology (Tues & Fri)MLA 1 HPLC (Mon & Thu)

Shanti ♠Shanti koh Dr Daniel=dopsx2 * Rebecca/Shanti

↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10

Rebecca/Shanti+koh Rebecca/Shanti+koh

BLOOD / FLUID: Section leader : Monica Victoria 0n Tuesday pm

Blood culture + MALDI SPOTTING Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi

Fluids + MALDI SPOTTING Harry Emma Monica am /Dr Anna am Victoria

♠Shanti +kohEmma

Anna Emma Anna Emma

MALDI LAB <2 Sini /Mohammed Sini /Mohammed Sini/ Mohammed+caf °Mohammed °Mohammed

The Royal National

Throat, Nose and

Ear Hospital

The Royal Free

Hospital

Summary

• To ensure that workforce planning, training, &

education drive sustainable innovations

• To deliver a capable and flexible workforce

now and in the future.

• An aim to improve the quality of care and the

experience of patients and staff at all levels

and enable them to embrace change and

improvement.”