1. The “Lean” Experience and ongoing Workforce Considerations. Carmarthenshire Division Hywel Dda NHS Trust

2. Partnership Project funded by NLIAH. Project funded by NLIAH. Knowledge Management and Transfer (KM&T) Knowledge Management and Transfer (KM&T) KM&T project lead – Dave Hodgkinson KM&T project lead – Dave Hodgkinson NLIAH project lead – Claire Lloyd NLIAH project lead – Claire Lloyd

3. Project Overview Pilot site – West Wales General Pilot site – West Wales General Scope – to introduce “Lean Thinking” service improvement methodology Scope – to introduce “Lean Thinking” service improvement methodology Aims Aims to identify and implement improvements in the specimen pathway. to identify and implement improvements in the specimen pathway. to include collection and delivery of the specimen to reception to include collection and delivery of the specimen to reception

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

5. Project deliverables To “level” specimen delivery to reduce peaks and errors. To “level” specimen delivery to reduce peaks and errors. Improvement of >25% in “turnaround time” from receipt to electronic authorisation of result. Improvement of >25% in “turnaround time” from receipt to electronic authorisation of result. Improvement of >40% in processing time and subsequent throughput (specimen/hour). Improvement of >40% in processing time and subsequent throughput (specimen/hour).

6. Project deliverables Increased team work and better utilisation of resources through : Increased team work and better utilisation of resources through : 1. Clear definition and communication of roles / staff empowerment 2. Introduction of key metric measurement, visual management and reporting processes 3. Undertake a high level operation review of twin pathology site at Llanelli

7. Day One Introductory meeting Introductory meeting KM&T overview of “Lean principles” KM&T overview of “Lean principles” Ice breaker Ice breaker Brainstorming session Brainstorming session

8. Brainstorming – examples (46) Aim to get ward specimens back by 10am Aim to get ward specimens back by 10am Segregate general pathology enquiries from processing work Segregate general pathology enquiries from processing work Look at current racking of samples in reception Look at current racking of samples in reception Segregate NPHS samples at source e.g. GP surgery Segregate NPHS samples at source e.g. GP surgery Stop printing hard copy pathology reports Stop printing hard copy pathology reports Reduce errors in specimen collection and labelling Reduce errors in specimen collection and labelling Use MLA to transport specimens from surgeries – lease van Use MLA to transport specimens from surgeries – lease van Review postal process Review postal process MLA to go with phlebotomist to Cardigan Hospital to number and data entry samples at source MLA to go with phlebotomist to Cardigan Hospital to number and data entry samples at source Train staff to use new sample archiving system Train staff to use new sample archiving system When phlebotomist goes out to a surgery, suggest they bring back all samples not just the ones they have taken When phlebotomist goes out to a surgery, suggest they bring back all samples not just the ones they have taken

9. Key issues GP samples delivered late afternoon due to outlying geography and lack of dedicated transport systems. GP samples delivered late afternoon due to outlying geography and lack of dedicated transport systems. Ward samples delivered late in the morning. Ward samples delivered late in the morning. Insufficient numbers of MLA’s to process the work in reception. Insufficient numbers of MLA’s to process the work in reception. Backlog of samples at data entry, centrifuge and authorisation at 17:00 hours. Backlog of samples at data entry, centrifuge and authorisation at 17:00 hours.

10. Value Stream mapping Key observations: Key observations: The samples were batched in quantities of 40 The samples were batched in quantities of 40 The average time to number a request form was 40 secs The average time to number a request form was 40 secs The average time to data enter a request form was 35 secs The average time to data enter a request form was 35 secs The centrifuge cycle was 6 minutes The centrifuge cycle was 6 minutes Average time to verify a request was 8 secs Average time to verify a request was 8 secs Number sample Data entry sample Spin sample Verify sample Load analyser Electronic results

11. Batch size of 40 Batch size of 40 Number sample Data entry sample Spin sample Verify sample Load analyser Electronic results 27 min23 min 6 Min5.5 min25 min Specimen reception Bio 2 Bio 1 Assuming no interruptions during each process 27 + 23 + 6 + 5.5 +25 = 86.5 min

12. Samples to be pulled every 15 mins Samples to be pulled every 15 mins Number sample Data entry sample Spin sample Verify sample Load analyser Electronic results 15 min13 min 6 Min2 min25 min Specimen reception Bio 2 Bio 1 Assuming no interruptions during each process 15 + 13 + 6 + 2 +25 = 61 min (25% reduction in TAT)

13. New system Reducing the batch size from 40 to 24 Reducing the batch size from 40 to 24 Moving from fixed lot variable time to fixed time variable lot improved efficiency Moving from fixed lot variable time to fixed time variable lot improved efficiency For example : For example : During non peak periods it may take up to 2 hours between receipting the 1 st sample to the 40 th sample, resulting in TAT > 2.5 hours During non peak periods it may take up to 2 hours between receipting the 1 st sample to the 40 th sample, resulting in TAT > 2.5 hours If samples are centrifuged every 15 minutes the TAT would be a constant 61 mins If samples are centrifuged every 15 minutes the TAT would be a constant 61 mins

14. Alignment of processes Alignment of the request form numbering and data entry process could save an additional 23% on TAT Alignment of the request form numbering and data entry process could save an additional 23% on TAT If they run almost simultaneously, it ensures that when samples have been centrifuged, all request forms will have been entered in the database, resulting in no delays when verifying If they run almost simultaneously, it ensures that when samples have been centrifuged, all request forms will have been entered in the database, resulting in no delays when verifying

15. Interruptions Every interruption encountered resulted in stopping either the data entry or the numbering process Every interruption encountered resulted in stopping either the data entry or the numbering process 105 requests per hour – no interruptions 105 requests per hour – no interruptions This dropped to 45- 70 per hour due to interruptions This dropped to 45- 70 per hour due to interruptions

16. Staffing 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 staff) 14:00 – onwards (6 staff) Remove interruptions and 4 staff should cope with the throughput Remove interruptions and 4 staff should cope with the throughput

17. Staff role definition Numberer Numberer Data entry Data entry Post function Post function Float role Float role Send aways Send aways Biochem 2 – centrifugation, verification, load analyser Biochem 2 – centrifugation, verification, load analyser

18. Floating Role Handle all interruptions Handle all interruptions Process “urgent specimens” Process “urgent specimens” Sorts samples Sorts samples Transport samples to centrifuge Transport samples to centrifuge Transfer samples to and from dumb waiter Transfer samples to and from dumb waiter Ensure staff who are numbering and undertaking data entry are synchronised Ensure staff who are numbering and undertaking data entry are synchronised

19. Benefits identified Reduction of double handling of samples by racking directly into centrifuge pods (saving £1700 per year) Reduction of double handling of samples by racking directly into centrifuge pods (saving £1700 per year) Reduction in hours required for the post function (reduced from 3 X daily to 2X daily) also paperless pilot for GP surgeries (saving £4900 per year staff time and £1000 per year consumables) Reduction in hours required for the post function (reduced from 3 X daily to 2X daily) also paperless pilot for GP surgeries (saving £4900 per year staff time and £1000 per year consumables) Increases in TAT of 8% but could increase to 25% if Bio 2 role could be resourced all day Increases in TAT of 8% but could increase to 25% if Bio 2 role could be resourced all day

20. Benefits (continued) Increase of throughput from 60 requests per hour to 105 requests per hour with the introduction of the “float role” (75% increase) Increase of throughput from 60 requests per hour to 105 requests per hour with the introduction of the “float role” (75% increase) Levelling of sample delivery time by phlebotomists collecting samples from surgeries on the way back to WWGH Levelling of sample delivery time by phlebotomists collecting samples from surgeries on the way back to WWGH All samples numbered and data entered by 17:00 hours consistently All samples numbered and data entered by 17:00 hours consistently

21. Next Stages Identify workforce requirements. Identify workforce requirements. Consideration of other strands which might affect the project work. Consideration of other strands which might affect the project work. Wider implications affecting service provision. Wider implications affecting service provision. Legacy of the project and workforce implications. Legacy of the project and workforce implications.

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

23. Wider implications to Service Provision. TRRR/WCP/LIMS and other IT considerations TRRR/WCP/LIMS and other IT considerations National harmonisation of codes and ranges. National harmonisation of codes and ranges. POCT. On Wards and in the Community. POCT. On Wards and in the Community. Laboratory Design. Laboratory Design. What service do we design for? What service do we design for? Blood Sciences Blood Sciences Staff Budgeting implications Staff Budgeting implications Accreditation. - Networks Accreditation. - Networks

24. Other Strands to consider TRRR and Welsh Clinical Portal. TRRR and Welsh Clinical Portal. Skeleton requesting/ Sample storage verification checking. Skeleton requesting/ Sample storage verification checking. ?Departmental reorganisation. ?Departmental reorganisation. Accreditation. Accreditation. Sister site Prince Philip Hospital. Sister site Prince Philip Hospital.

25. Lean “Ideal Service provision”?? 1. Primary care: Direct requesting of work for Pathology. Provision of Community based Phlebotomy & POCT. Networked specimen preparation and transport to department – On site Pathology advice available. 2. Secondary care: Direct requesting for Pathology work. 3. Centralised Pathology reception, covering sample distribution, receipting and verification of specimens. Centralised centrifugation and sample preparation to loading of Blood sciences based Automation area allowing maximum relevant robotics with Chemistry and Haematology areas for specialist work. Centralised SAS work. 4. Specialist Chemistry and Haematology validation of results. 5. Electronic delivery of results to all users.

26. Project Legacy and Workforce implications. Blood sciences considerations. Blood sciences considerations. Staff budgeting. Staff budgeting. Networking, both for Service provision and Accreditation. Networking, both for Service provision and 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.