Porters Value Chain Analysis Samples by eto51410

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									                     Lean - a Step Forward ?




                     Cellular Pathology, Royal Victoria Infirmary
                                    Terry Coaker
20th November 2009
         Introduction
           Review
           Why look at the pre and post
            examination phase?
           The future
           Examples of our experiences
           Personal opinions
           Presented on behalf of the team at
            Newcastle Hospitals

20th November 2009
                       Lean Methods
                            Continuous Improvement Toolbox

                                                                         Performance
                           Pull Systems        Work Cells      TPM
                                                                         Measurement
              Lean Tools




                              Setup        Quality at                           Batch Size
                                                            Continuous Flow
                            Reduction     the Source                            Reduction

                           Standardized Work                Teams               POUS

                            Visual
                                        Value Stream Mapping        5S System    Layout
                           Controls




20th November 2009
       Cellular Pathology, RVI, Newcastle
             1981: RVI 9,700 requests per annum
             1995: NGH acute services
             1996: NGH histology
             1997: Dental Hospital – oral pathology
             2002: Freeman histology; muscle & nerve;
                    cytology decant
             2005: Histopathology decant – 42,000 pa
             2008: Neuropathology decant
             2009: move to new building (planned 2004)



20th November 2009
                     Spaghetti diagrams
                     Band 2 embedding




29th November 2007
                     Spaghetti diagrams
                     Band 6 microtomy




29th November 2007
                     Spaghetti diagrams
                          Cells




29th November 2007
          Pre- and post examination process
               Lord Carter of Coles - Review of Pathology Services
               DoH
               Royal College of Pathologists
               IBMS
               “It has been a long standing source of frustration to
                laboratory professionals that inefficiencies in the
                sample collection and result transmission/delivery
                systems reflect negatively upon the diagnostic and
                interpretive service and the recognition of this
                through the report is reassuring”



20th November 2009
                     Pre-examination process
           The challenge:

                Improving Outcomes Guidance –
                 Haematopathology
                 http://www.nice.org.uk/nicemedia/pdf/NICE_HAEMATOLOGICAL_
                 CSG.pdf




20th November 2009
     Cytology 14 day TAT
     http://clinicalcytology.co.uk/resources/p
     df/14dayturnaround.pdf


     Cytology
     Improvement Guide
     http://system.improvement.nhs.uk/I
     mprovementSystem/ViewDocument
     .aspx?path=Cardiac%2FNational%2
     FWebsite%2FDiagnostics%2FCytol
     ogy_14day_TAT.pdf




20th November 2009
                 Pre-examination process
           The problem: Attitude
            Immediately the biopsy is in the pot, it
             becomes labs responsibility and now
             I‟m waiting for the report
            Delivery of samples to the laboratory is
             not seen as core business by the
             laboratory


20th November 2009
                Pre-examination process
           The problem:
            Lack of knowledge and awareness
            Boundaries: organisational,
             geographical, professional
            Lack of control
            Lack of authority
            No / Less funding – Prof Ian Cumming



20th November 2009
       60 G.P‟s in Newcastle
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20th November 2009
                      Hermes
                      The Messenger God
                      Protector of thieves & liars
                      Guide to the Underworld




20th November 2009
                     Pre-Examination Process
                        Personal delivery
                        Air tube            Mis-direction
                        Porters             Multiple hand-offs
                        Couriers            Cytology in Northumberland
                           Local
                                             Ramsay NHS Treatment
                           National           Centre, Cobalt
                        Post
                        Digital images


20th November 2009
                     Post




                       Received: 17:45   14th October 2009
20th November 2009
                     Problems with improvements
                     Courier service
                      Last collection 15:30
                      Later run at 16:30 would catch
                       additional work the same day
                      Clinic batched all specimens for new
                       later pickup
                      All samples received too late for same
                       day processing


20th November 2009
                     Problems with improvements
                     Courier service
                        Discovered that theatres at another
                         hospital were getting samples to the lab
                         for the 16:30 collection.
                         Unfortunately, transport were picking
                         up at 16:10!




20th November 2009
                     National Patient Safety Agency
                       Reduce avoidable harm
                      UN Surgical Safety (read out loud) checklist
                      Have the specimens been labelled?
                        (including patient name)
                     “ Incorrect labelling of pathological specimens
                        is potentially disastrous for a patient and has
                        been shown to be a frequent source of
                        laboratory error.”



20th November 2009
                     Tracking
                      Sign a book
                      Electronic tracking
                      Order communications results and
                       reporting
                      UPMC Cerner Millenium




20th November 2009
                     Private sector
                        On-line courier booking
                        On-line requests, orders and test
                         reports
                        Provide containers, packaging and
                         ease of dispatch
                        Autofax, e-mail, electronic links
                        A dedicated national courier
                         infrastructure
                        Quest “A fleet of dedicated aircraft”


20th November 2009
                     Developing the BMS Role
                        Undertake value chain analysis of the pre
                         examination pathway. Are we receiving the
                         specimens as soon as possible? If not why
                         not? How could it be improved?
                        Regular auditing of the pre examination
                         pathway
                        Share our expertise with users on
                         standardisation, protocols and accreditation
                         to eliminate error


20th November 2009
                     Key goals
                      Explain and educate
                      Right first time
                      Eliminate error
                      Reduce patient risk
                      Find bottlenecks and waits
                      Reduce turnaround time




20th November 2009
         Visit your users
          Follow requests from source
          Discuss your service
          Listen, understand their requirements
           Explain the laboratory requirements
           e.g. Specimen Acceptance Policy
          Agree and set standards, monitor performance




20th November 2009
               CPA
                E4 Specimen Transportation

                Specimen transportation systems need to
                ensure the timely arrival of specimens at the
                correct destination…




20th November 2009
                 The Roman Way- direct route




20th November 2009
    Hexham -
    Newcastle =19 miles

    Hexham -
    North Tyneside -
    Newcastle =37 miles




20th November 2009
                     The Relay Race




20th November 2009
  Berwick on Tweed
  to
  Newcastle Upon Tyne
  = 53 miles




20th November 2009
                     Cobalt NHS Treatment Centre
                     Ramsay Health Care, Unilabs
                             Request           Patient at
                             slides for           GP
                                MDT

                                                     Biopsy at
                     Copy report to                  Treatment
                     Dermatology,                      Centre
                         RVI
                                      Histology
                                      at Unilabs

20th November 2009
                         Haematopathology, June 2009
                                                                                              Does post and samples
                                                                                            come on the same delivery
               N Tyneside                                                                   does it get delivered to Path
               lab by 9.30                                                                     reception / post room
                                                                                                                                      Sample &
                                             Courier                                                                              paperwork placed                     Timeline ?
                                                                               ?                                                    in KW Ducket
                                          (N Tyneside)


                                                                                                                      In department
               N Tyneside
         post room for daily pick                                                  Specimen reception
                 up 1.30                    RVI Post Room                                                                   Taken by lab staff
                                                                                    (allocated number
                                                                                                                                                                         Reassess slides                                      Lab staff pick up the
                                                                                                                                                                        (complete request        Lab staff pick up request   request and the block
              Post room system?                                                                        Goes between the two areas                                       for cyto chemistry)                                       back to lab
                                                                                                             for processing


                                                                                 General office
                                                                               (open post, record                                 Sample and
              Royal Mail                            Timeline ?
                                                                                contents, assign                               paperwork in CB &
          delivery (all other                                                                                                                                     Timeline ?
          samples referrals                                                        Pathologist)   *                             GM Duckets (Dr
                                                                                                                                 Residences)



                                                                                                       Identify which are the key points and
                                                                                                         the time between them / where do
                                                                                                                                                                                 Reassess as needed
                         Electronically
                           available
                                                                                                           things wait ...for how long     *


                                              Pathologist access                                                     General office pick                                                                    Request & Block in
                                                                                    Report available                                                            Report issued                               immuno chemistry
                   Sent to print cue               system &                                                           off dictation and
                                                                                      for dictation                                                           (Digital Dictation)
                                               authorises report                                                      type hard copy



                                                                                                          Block returned to lab to await return to referrer


                                            Copy 2 returned with block later
                                                      to referrer


                    General Office
                    generate print
                        runs
                                                                                             Mail out from RVI                                 Referring post                                 Referring
                                                                                                                              ?                                              ?
                                                                                                post room                                       room receipt                                  Consultant
                                            Copy 1 to referrer hard
                                            copy collected for post
                                                  room RVI




20th November 2009
                     The Roadrunner




20th November 2009
                Haematopathology, June 2009




20th November 2009
                               Haematopathology, July 2009
                ? Days                                                      ? days                                                           ? Days                                       ? Days

       N Tyneside
       lab by 9.30


         Courier
                                        ?                                                                              Sample & paperwork
      (N Tyneside)                                                                              In Department                                                                           1 – 3 cycles.
                                                                                                                       placed in KW Ducket
                                                                Dropped off at                                                                                                   Number of ICC / ISH cycles
                                                              Specimen Reception                                                                                                 and time to report depends
                                                                    (SR)                                                                                                         on complexity and workload
       N Tyneside
     post room for                   RVI Post Room                                            Taken by lab staff             DOCTORS
    daily pick up 1.30                                                                                                      RESIDENCE
                                                                                                                                                           Pathologist                       Lab staff / KW / CB /
                                                                                                                       Sample and paperwork
                                                                                                                                                      Assess / Reassess slides                 GM pick up the
                                                                                                                      in CB & GM Duckets (Dr
                                                                              Given priority Returned to SR for         Residences) specific
                                                                                                                                                       (complete request for                request and the block
                                                                                              Accession No &                                                    ICC)                             back to lab
                                                                                                                      delivery times to Drs res
        Royal Mail                                                                            booking into iLab
                                                                                                                         except after 14:00
    delivery (all other
    samples referrals
                                                              General office (open
                                                              post, record contents,         0-60 mins
                                                               assign Pathologist)
                                                                                                                                                                                             Request & Block in
           ? NHS net support                                                                                                                                                                 immuno chemistry
              Anglia ICE
              Web Server
                                                                                                      When lab work complete and assessment
                                                                  Allocated to
                                                                Lymphoma team
        Electronically available
                                                                spreadsheet for
          (within Trust only)
                                                                   invoicing
                                                                                                                                                                                      ISH performed        ICC performed

     Automatically sent to print
                                                                        Report entered by
                cue                                 Pathologist
                                                                        Pathologist using
     Before 11:00 – same day                     authorises report
                                                                        voice recognition
       After 11:00 –next day


                                            Paperwork returned to office
                                             to await return to referrer


                                                Copy 2 to referrer -
                                                returned with block
                                                       later
                                                    BATCHED


                                                Copy 1 to referrer
                                                                                                                                                             Referring
      General Office generate                 hard copy collected for                  Mail out from RVI                Referring post
                                   ? time                                  ? time                                 ?                               ?         Consultant
            print runs                          post room RVI at                          post room                      room receipt
                                                                                                                                                            Pathologist
                                                      13:30



                                                    Copy 3 to                              Referring
                                               Haematology clinician        faxed       Haematologist                                    ?
                                                   IF KNOWN                            IF REQUESTED




20th November 2009
                     Post Examination Phase
                      Hard copy report
                      LIMS
                      Anglia ICE
                      Dedicated server „Backlogs‟
                                        „Medical Solutions‟




20th November 2009
                     Problems with improvements
                     Hard copy report delivery
                      Portering services very supportive of
                       delivery of hard copy reports to
                       clinicians outside normal working
                       hours
                      No letterboxes, therefore no secure
                       place to leave reports



20th November 2009
                 The future
                      Divert funding from efficiency gains
                      Order Communications,
                       Results and Reporting
                      Networked logistics
                      Chain of custody -Tracking
                      Teamwork, education and awareness
                      Assume nothing, be resolute



20th November 2009
        Why do we do this?
   “Not only did the results come through
    much quicker than she had
    anticipated… Despite what she still
    needs to go through the relief in the
    household was palpable. I feel many
    days of worry have been saved… you
    are to be thanked for running such a
    tight and efficient department, it‟s much
    appreciated”

20th November 2009
                        Lean management
                           Thankyou




                     Cellular Pathology, Royal Victoria Infirmary
                                    Terry Coaker
20th November 2009

								
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