Continuous improvement in cytology - sustaining and accelerating improvement

HEART

LUNG

CANCER

DIAGNOSTICS

NHS Cervical Screening Programme (NHSCSP)

Continuous improvement in cytology:sustaining and accelerating improvement

STROKE

Clinical excellence in partnershipwith process excellence“

”

NHSNHS Improvement

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1. Foreword

2. Executive summary

3. Introduction

4. Site overview

5. Phase one sustainabilityRoot cause analysis• Case study 1 – Root cause analysis ofsamples breaching 14 day TAT

• Case study 2 – Addressing delaysfrom primary care

6. Phase two accelerated implementationAchieving the cultural shift• Case study 3 – Cytology LeanManagement system

7. Learning for the futureFocus on the whole end to end pathwaySmall batch sizesKeep samples movingFirst in, first out• Case study 4 – Communication toimprove the pathway

8. Ideal pathwayVoice of the customer• Case study 5 – Continuous improvementto a four day pathway

• Case study 6 – Voice of the customer

9. Primary CareUse of Open Exeter produced HMR101• Case study 7 – Changing to OpenExeter HMR101

Right first time• Case study 8 – Right first timeTransport• Case study 9 – A3 thinking fortransport problems

10. Laboratory• Case study 10 – Removing the waste ofover processing at specimen reception

• Case study 11 – Creating a work cell forspecimen reception and booking in

• Case study 12 – Achieving ‘first in, first out’according to date test taken

• Case study 13 – Stop to fix – removing thewaste of waiting

• Case study 14 – Productivity improvement inscreening – removal of key strokes

• Case study 15 – Removing the waste of overprocessing – code checking

• Case study 16 – Simplifying manual logs –removing the waste of over processing

• Case study 17 – Removing the wastesof over processing and motion

• Case study 18 – Reducing timespent slide filing

• Case study 19 – Implementing a ‘pull’ basedscheduling system to reduce backlogs

• Case study 20 – Electronic 100% file checkreplaces manual 10% one

11. Recall agency• Case study 21 – Removal of invalid data slips

12. Key mechanisms for changeEngagement• Case study 22 – Improving communicationand teamwork

Daily huddles• Case study 23 – Sustaining huddlesVisual management• Case study 24 – Visual management• Case study 25 – Visual management forprocessing blood stained samples

13. Information to support the processStatistical process controlCSSE Enquiries – Open ExeterUnderstanding long and short term demand

14. Measures

15. Cytology Self Assessment Tool

16. Consolidation of services• Case study 26 – Consolidation of cytologylaboratories

• Case study 27 – Consolidation of theprimary care screening service

17. Appendices

18. Acknowledgements

19. Contacts

Contents

www.improvement.nhs.uk

Continuous improvement in cytology: sustaining and accelerating improvement

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In November 2009, following a period of testing changes across the

complete cytology pathway, NHS Improvement published the

‘Cytology Improvement Guide’, which documents the learning from

the phase 1 national cytology pilot sites,

Since then the 14 day standard for cervical cytology has been

confirmed as a tier one vital sign in the Revision to the Operating

framework for the NHS in England 2010/11(June 2010)

The new white paper ‘Liberating the NHS’ sets out plans to ensure

the patient is at the heart of everything we do, and has a focus on

clinical outcomes. It also recognizes that the NHS scores relatively

poorly on being responsive to the patients it services. Too often

patients are expected to fit around services, rather than the other

way around.

The work of the Cytology Improvement Programme has

demonstrated that simple changes to the process can deliver

improvements in quality, safety, and productivity, to deliver an

equitable service for all women, while ensuring they are at the

heart of the process.

This document builds on the learning from phase 1, demonstrates the importance of

sustainability, and demonstrates how implementing what we know works can accelerate the pace

of change.

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

4 Continuous improvement in cytology: sustaining and accelerating improvement


1. Foreword

Professor Mike Richards CBENational Cancer Director

Professor Julietta Patnick CBEDirector NHS Cancer ScreeningProgramme

5Continuous improvement in cytology: sustaining and accelerating improvement


Following the initial success of the 10 phase onepilot sites to ‘ensure that all women receive theresults of the screening tests within two weeksby 2010’, the next challenge was that ofsustainability.

These pilot sites have continued to embed theirimprovements throughout all stages of thepathway, developing a culture of continuousimprovement in their daily work.

All have found sustainability challenging withadditional learning being developed through therigour of root cause analysis of those samplesfalling outside 14 days.

Their learning was, ‘never assume you knowwhat the problem is’. Detailed analysisdemonstrated the importance of data, ratherthan hunch or assumption.

In phase two, six pilot sites were challenged to:• Test the learning from phase one using theCytology Improvement Guide (November2009)

• Accelerate the pace of implementation

Phase two further evidenced the importance ofthe following four key changes identified inphase one:• Focus on the whole end to end pathway• Adopt small batch sizes• Keep samples moving• Establish first in first out.

The key mechanisms required to achieve thisalso hold true:• Empowered staff• Daily meetings• Visual management techniques• Information to support the process.

In addition it is important to:• Baseline any backlog and establish aplan for removal

• Ensure Executive support to remove blockages• Perform root cause analysis to identify the trueproblem

• Understand the challenge of consolidationof services.

2. Executive summaryTeams have also been trained to understand thecost of poor quality (defects) and reduce andeliminate the causes in a way that supports theinterests of women and the cytology service.

Improvements made are aligned to the Quality,Innovation, Productivity and Prevention (QIPP)strategy.

Quality• A ‘right first time’ approach• Guaranteed and predictable results

Innovation• Robust problem solving using A3 thinking• Visual management

Productivity• Removal of duplication• Reduction and elimination of waste• Reductions in overtime and outsourcing• Appropriate use of skill mix

Prevention• Timely referral to colposcopy and treatment

This programme of work has demonstratedbenefits to over one million women.

Improvements in quality and productivityhave been published by NHS Evidencewww.evidence.nhs.uk in both the‘Recommended’ and ‘Long Term Conditions’sections.

This document is designed to be used inconjunction with the first Cytology ImprovementGuide - Achieving a 14 day turnaround time incytology (November 2009), Cytology SelfAssessment Tool (refer to page 56) and ourBringing Lean to Life document. All of thesedocuments can be found on our website at:www.improvement.nhs.uk/diagnostics



Phase one identified issues across each step ofthe pathway

3. Introduction

The key components to close the gap betweenthese problems and the ideal pathway aredetailed in the phase one publication.

An assessment of the steps within the cytologyend to end pathway reveals there is just 5.5hours of true value added steps from the‘customer’ point of view.

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Whilst the work with the pilot sites has focusedon the 14 day turnaround time, teams have alsobeen testing whether a seven day turnaround isachievable and sustainable, as highlighted in theScHARR Report (2006).

Primary Care

• Training of smear takers• Inconsistent use of NHSnumbers/patient ID parameters

• Transport - deliverytimes/routes

• Samples left at surgery• Incorrect info/demographics• Illegible forms• Multiple request form formats• Missing/wrong smear takercodes

• 25% out of scope samples

PATHWAYPROBLEMS

Laboratory

• Data entry issues• Writing on forms• Double look-up/printingfrom Open Exeter

• Skill mix/staffing• Processor reliability• Over printing labels• Matching forms/slides• Returned samples/cards• Excessive checks• Backlogs• Staff morale• Sending out processing/screening to other labs

Recall Agency

• Results issued weekly• Large volume of manualmatching

• Manual enveloping/leaflets• Variable postage• ‘Abnormals’ sent out by GP• Route to colposcopy (nodirect referral)

• Manual checking ofelectronic data

• Print jobs not believed• IT issues• Variable out of areaprocesses

Figure 1: Identified issues across each step of the pathway



The following sites were selected by the NationalCancer Screening Programme to work with NHSImprovement to pilot changes and test thelearning to deliver improvements in the cytologypathway.

There are NHS Improvement sites in eachStrategic Health Authority. Contact with thesesites is recommended to spread their learning.

A table of site data is available in theappendices.

4. Site overview

Phase 1 and Phase 2Cytology Pilot Sites

Phase 1 Cytology Pilot Sites


Leeds PCT and The Leeds Teaching Hospitals NHS Trust

Hull Royal Infirmary and Hull and East Ridings PCTs

Pennine Acute Hospitals NHS Trust

Norfolk and Waveney Cellular Pathology Network (Norfolkand Norwich University Hospital NHS Foundation Trust

West Anglia Pathology Cytology Laboratory(Cambridge University Hospitals NHS Foundation Trust,Addenbrookes Hospital and Anglia Support Partnership)

Barts and The London NHS Trust

Somerset and West Dorset Cervical Screening Service(Taunton and Somerset Hospitals NHS Trust)

Ashford and St Peter’s Hospitals NHS Trust

North West London NHS Trust (Northwick Park Hospital)

Central Manchester University Hospital NHS Foundation Trust

Newcastle upon Tyne Hospitals NHS Foundation Trust

Sheffield Teaching Hospitals NHS Foundation Trust

Derby Hospitals NHS Foundation Trust

University Hospitals Coventry and Warwick NHS Trust

Heart of England NHS Foundation Trust

Winchester & Eastleigh Healthcare NHS Trust

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One of the greatest challenges to improvementis sustainability. An improvement implementedtoday and gone tomorrow is not animprovement.

The presence of certain factors is crucial not onlyto ensure sustainability but to foster a culture ofcontinuous improvement.

The following were identified by the PathologyService Improvement Team in 2006 in thedocument ‘Learning from Pathology ServiceImprovement Pilot Sites and ImprovementExamples.’

5. Phase one: Sustainability

These elements are consistent with redesign inother clinical services including the CancerServices Collaborative and are not unique topathology.

The work of the phase two sites has continuedto evidence the importance of strength in all theareas identified above.

Root cause analysisApproximately 24 months after the phase onesites began their improvement work they wereasked to undertake a root cause analysis (RCA)of all samples falling outside 14 days.

The detailed analysis demonstrated the followingroot causes:

• Delays transferring samples from primarycare to the laboratory. This was the greatestcause and was essentially due to samplesbeing held over in primary care. All practicesconcerned have daily transport available. Theproblems are being addressed by identifyingthe practices and reinforcing training andcommunication

• Annual leave, restricted year end leavecarry over and Easter Bank Holiday. Thesecan be addressed by appropriate staff planningand operational management

• Missing data and information/zerotolerance of defects. Recommendations areto audit non-compliance, training andcommunication. Case studies are availableat: www.improvement.nhs.uk

• Surge in demand one year on from JadeGoody’s death. Repeat recall tests followingthe 2009 surge in abnormal results

• Recall agency delays – out of area• HPV – processing delays from externalproviders. Additional issues were causedduring the air travel restrictions due to volcanicash which prevented delivery of consumables.

Root cause analysis has prompted these sites, inpartnership with their PCTs, to take proactivesteps to eliminate these issues through:

• Identification of practices responsible• Ongoing training and reinforcement ofstandard work

• Demand and capacity planning to ensureappropriate staffing levels.

Phase one sustainability is reflected in figure 3on the next page.

Figure 2: Factors for achieving sustainableimprovements



Figure 3: Phase one cytology - percentage in 14 day turnaround



SummaryRoot cause analysis reveals the causesfor samples which have breached the14 day turnaround time.

Understanding the problemAnalysis of turnaround times identifiedtests taking longer than 14 days fromsample taken to anticipated delivery ofthe result letter.

Failure to sustain the 100% 14 dayturnaround time for all samples hasalmost always been due to delay byGP practices sending samples to thelaboratory.

• The problem was identified instatistical process control graphs

• Key dates for each sample wereextracted - sample date, receiptdate, registration date, screeningdate and date the file was sent tocall/recall

• Call/recall supplied a list oflaboratory numbers with the datethe letter was printed

• The laboratory extract and call/recalllists were cross linked in an AccessDatabase to provide acomprehensive data file for thewhole pathway.

The waste identified was that ofwaiting.

How the changes wereimplemented• Data for outlier tests was sent toPCT leads and the sampletaker

• The sample taker visited the GPpractices where the delay in sendingthe sample to the laboratory wasthe reason for the breach.

Root cause analysis of samples breaching 14 day TATBarts and The London NHS Trust

Measureable outcomes and impactSince October 2009, 74 tests havebeen delayed by practices failing todeliver samples in a timely manner.Root cause analysis and direct contactwith practices has reduced the numberof tests delayed from:• 19 in October 2009• 9 in April 2010.

Of 173 practice addresses:• 31 practices were delaying samplesbetween October and December2009

• 10 practices were delaying samplesbetween January and April 2010.

Ideas tested which were successfulVisiting practices was the idea of thecancer screening nurse and has provedto be the most effective approach.

Ideas tested which wereunsuccessfulInitial email lists sent to PCT leadswithout explicit instructions toundertake a root cause analysis werenot successful.

How will this be sustained andwhat is the potential for the future/additional learning?Whilst the feed back processes havereduced the number of practicescausing delays, there are still a fewpractices who continue to delaysamples.

A continued collaborative approachbetween the laboratory and PCT leadsis needed to continue to identify andreduce these delays.

ContactGeoffrey [email protected]

Case study 1



SummarySamples that have taken five days ormore to get to the laboratory arequickly identified and processed. Aletter is sent to the woman’s GP torequest that they investigate the causeof the delay. An incident report formis completed when the 14 dayturnaround has been breached.

Understanding the problemThe laboratory monitors how well thespecimen transport system isperforming by checking the ‘datetaken’ on all samples as they arrive inthe preparation room. During Apriland May 2010, specimens more than14 days old when they arrived wereinvestigated.

The team started by telephoning thesample takers to understand the causeof the delay. This information wascollated in incident report forms thatwere passed on to the qualitymanager.

A transport problem was suspectedhowever the root cause was thatsamples were spending prolongedperiods stored in the GP surgeriesbefore they entered the transportsystem.

Addressing delays from primary careAshford and St Peter’s Hospitals NHS Trust

How the changes wereimplementedThe initial approach was to telephonesurgeries whose samples were overduebut the sample takers (usually practicenurses) were hard to contact and notalways able to help.

A letter template was then preparedthat could be quickly completed andsent to the woman’s GP. The letterand a copy of the request form aresent to the GP whenever a samplearrives that is over five days old.

All overdue specimens that arrive inthe laboratory are processed urgentlyand sent for immediate screening.Negatives are reported straight awayby the screening room staff whileabnormals are passed to theconsultant clinical cytologist forimmediate reporting. The aim is tohave the result leave the laboratorywithin 24 hours of the samples arrival.

Measurable outcomes and impactDelayed samples are identified,processed and resulted within 24hours of their arrival in the laboratory.The causes of the delays are beinginvestigated via letters sent to thewoman’s GPs (see table 1 below)

So far the explanations offered havevaried but sample takers are beingfocused on getting samples to the labpromptly.

Ideas tested which were successful• Identifying delayed tests as soon asthey arrive in the laboratory

• Rapid processing and reporting ofdelayed tests

• Contacting the GP by letter torequest an explanation for the delay.

Ideas tested which wereunsuccessfulTelephone calls to sample takerswhose samples had arrived too late toachieve the 14 day target had a poorsuccess rate due to availability ofsample takers

How this improvement benefitspatientsThis process is intended to improve theoverall reliability of the screeningprogramme by ensuring that smeartakers understand the importance ofsending samples to the lab promptly.

How will this be sustained andwhat is the potential for the future/additional learning?This process will continue to helpidentify any weaknesses in sampletaker procedures and to pick up anyproblems with the specimen collectionand transport system.

ContactSteve [email protected]

Case study 2

Date sampletaken

16/03/2010

23/03/2010

29/04/2010

12/05/2010

20/05/2010

26/05/2010

Date of arrivalin laboratory

23/04/2010

12/04/2010

07/05/2010

17/05/2010

02/06/2010

02/06/2010

Time indays

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Reason given for delay

Surgery unable to explain delay

Three samples sent to another laboratory by a new practice nurse, returned toGP and then sent to correct lab

No explanation for delay but promised to send future samples ASAP.

Sample taken Wednesday but GP too busy to fill in a request form until Friday

Six specimens locked in fridge by a new practice nurse, discovered days laterand sent to lab

Delayed by staff illness followed by a bank holiday, measures put in place toprevent a recurrence

Table 1: Causes of delays



Phase two of the Cytology 14 Day TurnaroundTime Programme was established to test thelearning from phase one for repeatability andscalability.

The additional challenge was to accelerate theachievement of this vital sign to six months.

The changes made in phase one were proved toresult in the elimination of waste and reductionin turnaround times.

The progress towards a 14 day turnaround bythe phase two sites within the acceleratedtimescale has varied due to a number of factors:

• Baseline starting position against 14 days• Backlogs that existed at the start of theprogramme

• Staffing capacity insufficient to meet demandon the service

• Absence of senior management to supportoperational service delivery

• Lack of technology.

The A3 document on page 14 shares theNewcastle Cytology team’s assessment of theircurrent position and plans to continue to embedLean as their management system.

6. Phase two: Accelerated implementation



Achieving the cultural shift

The most important factors for success arepatience, a focus on long-term rather thanshort-term results, reinvestment in people,product and plant, and an unforgivingcommitment to quality.

“

”I am personally quite pleased that we areconsistently turning around material within14 days. But I am far more pleased withhow much safer we are now than 15months ago and how much more staffengagement we have. These are the realmeasures of success to my mind .

“

”Dr Simon Knowles, National Clinical Lead, Cytology Service Improvement

Robert B McCurry, former executive VP, Toyota Motor Sales

Newcastle Cytology Lean Management System A3Newcastle upon Tyne Hospitals NHS Foundation Trust

Case study 3



Define the problem/opportunity:(Why are you talking about it? What are you trying to solve/improve?)

The Newcastle Cytology Lean team want to ensure an embedded Lean Management system. The aspiration is for a longterm, sustained philosophy of daily problem solving and on going improvement beyond the support of NHS Improvement.

Current Condition:(What happens now? Be visual – value stream map, graphs, facts and measurements etc)

• The principles and tools of Lean methodology have been introduced.• Most of the ‘just do its’ detailed in the Cytology Improvement Guide (NHS Improvement 2009) have been implementedand tools applied to the process to smooth and level flow.

• Establishing a culture of daily problem solving is required by coaching the team in Lean principles and establishingtransparency in performance and process issues across all areas of the lab (including specimen reception, the office andscreening rooms).

Performance against plan as of May 10 = 61%

Goal:(State the specific SMART target(s). State in measurable or identifiable terms)

To be a Lean exemplar site by meeting the criteria set by NHS Improvement:

• 100%TAT within 14 days • Engaged staff• 50% TAT within seven days • Lean culture• All staff think Lean • Daily meetings/problem solving• Good measures • Evidence of 5S• All staff talk Lean • Leadership• Good visual management • Standard work• Clear evidence of how Lean has been used

Gap analysis:

75% of staff received Lean awareness training, with six members of the team being on the core Lean group.Even with daily huddles and completed process production documentation in each area, the team recognises that morework is required to achieve a Lean culture.

Responsible:

Team members:

Gynaecology Cytology % TAT and activity: Performance against target

Mr David Evans - [email protected]

Cytology Team



Proposed counter measures(What will it look like? Be visual i.e. future state value stream map)

Within the next four months, the daily focus of the team will be on performance against the 14 and seven day turnaroundtimes - levelling workload across the laboratory so that work flows to takt with no backlog.

By October, all areas of the lab will be operating without: overproducing, waiting, and defects; and with minimal motionwithin and between processes; and any areas of overprocessing identified and plans in place to remove it.

An experimental approach to problem solving and potential countermeasures will be in place using the PDSA cycle.

Action Plan

Action – What, Why, How? Who? When? Progress Status(i.e. completed, in progress)

Team Huddle every day All Daily In Progress

Establishment of 3 Cs (Concern, Cause andCountermeasures) DE/CB Daily TBC

Root Cause Analysis of SPCs CB Weekly TBC

Visually monitor Goal vs Actual at each step All Hourly TBC

Agree Report out date DE Aug 10 In Progress

Raise Transport issues – no tracking, no servicelevel agreement , review of scheduled pick ups,audit of pick up times – with Transport sub –group DE Aug 10 In progress

Instigate a ‘name and shame’ policy forpersistent offenders of ‘zero tolerance’ policy CB July 10 In Progress

Raise issue of uneven rate of smear taking atlocal and national level DE Aug 10 In progress

Increase downloads to FHSA on Friday CB July 10 In progress

Results and Measures

Criteria set by NHS Improvement will be met, evidenced and assessed as achieved.

Next steps

Share with exec sponsor – Invite to report out in late August , Early September 2010



The four key changes identified in phase onehave been further evidenced as critical tosuccess

1. Focus on the whole end to end pathwayEach core project team contained membershipfrom the PCT(s), laboratory and results agencies.Within the laboratory, each staff group/functionwas represented.

Every member of the core team was asked to‘go see’ the whole pathway. Value streammapping techniques brought what they sawtogether to visualise the whole pathway andhighlight where samples and reports werewaiting.

The multiple organisations involved in providingthe cervical screening service then workedtogether to identify improvements.

Starting with the point at which the sample istaken, laboratories have worked collaborativelywith their PCT screening leads to raiseawareness of their 14 day turnaround projectswithin the primary care community. Sampletaker introductory and update training eventshave been held during which project contenthas been communicated and received verypositively.

2. Small batch sizesTeams in phase two have further evidenced thevalue of small batches in keeping samples andreports flowing through the pathway.

7. Learning for the future3. Keep samples movingThe principle of ‘today’s work today’ can befacilitated by ensuring

• Samples are sent from primary care daily –even if there is only one

• Flow of samples, using pull systems wherenecessary

• Multiple (or optimal) daily downloads to theresults agency with letters sent same day.

4. First in, First out (FIFO)Whilst the vital sign requirement is to deliverresults to women within 14 days of their test,sites have also tested their capability to deliverwithin seven days as highlighted by the ScHARRreport (February 2006)

Sustaining a seven day turnaround for themajority of samples provides some flexibility tomanage peaks in demand, unexpected resourcechallenges and removes the need to operateseparate ‘urgent’ work streams.

SummaryTwo way communication betweenprimary care and the laboratory is vitalin ensuring the 14 day turnaroundtimes are achieved.

Understanding the problemSPC charts were used to identifydelays along the processing pathway –outliers show where delays areoccurring (see figure 4):

Root cause analysis of the outliersidentified what was causing delays inprimary care:• Sample batching within practices• Lack of daily courier collections• Overnight delays due to couriertransfers at other hospitals

• Inaccurate completion of cytologyrequest forms which were returnedto senders for correction.

How the changes wereimplementedVarious methods of communicationwere used to highlight delays andimplement changes:• Newsletters sent by cytologylaboratory to inform primary care ofthe improvement work beingundertaken, emphasising theimportance of completing therequest form accurately and askingthat samples are not batched

• Letters sent from PCT screeningcommissioners outlining policy forout of scope samples. Clearmessage that these samples wouldnot be processed by the laboratory

• Telephone calls by PCT leads topractices and clinics to re-confirmcourier frequencies and times. Callsmade to practices that werebatching samples

Communication to improve the pathwayDerby Hospitals NHS Foundation Trust

• E mail correspondence by PCTs tosample takers providing feedback onprogress of the improvement project

• Face to face discussions atintroductory and update sampletaker courses and practice nurseforums. Opportunities for sampletaker feedback and commentsencouraged

• Workshops held to pilot the use ofpre-populated Open Exeter HMR101forms

Case study 4



Figure 4: Sample taken to received in lab - Baseline data (August 2009)

Figure 5: Sample taken to received in lab (May 2010)

Measurable outcomes and impact• Number of outliers reducedfollowing communication andimplementation of changes (seefigure 5 below).

• 213 sample takers attendedmeetings and courses from Nov2009 - May 2010

• Example of form filling guidancecommunicated to sample takers atupdate courses.



Mean time for ‘sample taken toreceipt in lab’ decreased during the sixmonth project:• from 2.22 days to 1.37 days

Ideas tested which were successful• Transportation changes - followingroot cause analysis the courierservice changed from pick up at alocal community hospital to threeindividual practices

• Primary care participation - OpenExeter Workshop piloted and 10 GPpractices now have Open Exeteraccess. Comments and suggestionsto be incorporated into full PCTrollout in 2010

• Right First Time – communicationwith sample takers resulted in thisapproach.

Ideas tested which wereunsuccessfulA zero tolerance policy was consideredincluding the disposal of samples. PCTcommissioners were concerned thatwomen would be disadvantagedhence the development of a ‘right firsttime’ approach encouraged throughcommunication.

How this improvement benefitswomenCommunicating information to sampletakers has improved turnaround times.Quicker results for women reducesanxiety.

How will this be sustained andwhat is the potential for the future/additional learning?• Continued monitoring ofinformation will ensure outliers areidentified and investigated

• Ongoing communication withprimary care will ensure messagesare relayed and feedback received

• Closer links with primary care haveresulted from this project.

ContactAlison [email protected]

Top tips for sample takers

• Ensure the form is fullycompleted and the vial islabelled correctly

• Screw lids on securely• If two brushes are used, putboth in one pot but ensure thatthis is clearly indicated on theform

• Date of last test is given• Correct reason for smear isstated.



Reduction and elimination of waste from typicalcytology pathways has resulted in thedevelopment of this ideal pathway model.

The following case studies build on thosepublished in the first cytology learningdocument and further evidence the value ofrecommended improvements.

8. Ideal pathwayVoice of the customerThe programme has focused on achieving a14 day turnaround time that ensures whererequired women are referred to the appropriatecancer pathway in a timely manner.

Further opportunities should be sought tounderstand the voice of the customer assupported in the case study from Newcastle.

Primary Care

• Use of electronic prepopulated HMR101 and ordercomms

• Request form and vialidentification and labellingright first time

• Daily transport for samplecollection

RECOMMENDED

ACTIONS

Laboratory

• Sample receipt, dataentry, process and reportin one to three days

• Samples received,booked in, processed andauthorised right first time

• Small batch sizes (sixsamples)

• First in first out (FIFO)• Report abnormals daily

Recall Agency

• Multiple daily downloads• Results transferred and postedright first time

• Daily posting of results

Figure 6: The ideal pathay

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1-3 DAYS 1-3 DAYS 1-2 DAYS 1 DAY



SummaryContinuous improvement hascreated a four day end to endpathway for some women.

Understanding the problemBy the end of the phase one projectthe team had achieved:

• 98% of results received by womenwithin 14 days

• 58% of results received by womenwithin seven days.

The data suggested that with furtherimprovement the turnaround timecould be reduced further.

Continuous improvement to a four day pathwayThe Leeds Teaching Hospitals NHS Trust

How the changes wereimplemented• The seven day pathway wasanalysed to determine thenecessary measures to improve toa four day pathway (see table 2below)

• Assumed one day for first class post• To enable the woman to receive aresult by day 4, only samples thatwere authorised before the11.30am download on day 3could meet this goal

• To facilitate screening/authorisation of results by11.30am on day 3, samples mustbe processed on day 2

• Processing of samples would needto occur no later than day 2

• Samples must be registered bylunchtime on day 2

• Samples must be received by thelaboratory no later than themorning of day 2, but ideallyreceived the same day as taken.

Case study 5

Day 1

Samplestaken andsomereceived inlab.

Table 2: Seven day pathway

Seven Day Pathway

Day 2

Rest ofsamplesreceived inlab.Registeredand somesamplesprocessed.

Day 3

Rest of samplesprocessed.Slides pre-screened.Some screened forend of daydownload.

Day 4

Day three resultsin post.Remainingsamples pre-screened andscreened.

Day 5

Day threeresultsreceived bywoman.

Day 6

Day fourresultsreceived bywoman.

Day 7

Sunday(day of rest!)



Measurable outcomes and impactBy June 2010:• 98% of results were received bywomen within seven days

• 47% of results were received bywomen within four days.

Phone calls received from practiceswhose patients had commented onthe speed of their result.

Ideas tested which weresuccessful• Smaller batches of slides per tray(from eight to six)

• Hourly scheduled deliveries to/from each area

• One co-ordinated transfer of workthroughout the department ateach delivery.

Ideas tested which wereunsuccessfulReducing batches of forms forregistration from 12 to six resulted informs being registered and sent tolab out of numerical sequencemaking processing of samples verydifficult.

How this improvement benefitswomen• Additional 40% of women nowreceive their result within sevendays

• 47% of women now receive theirresult within four days.

How will this be sustained andwhat is the potential for the future/additional learning?• Work with transport services andpractices to:• increase % of samples receivedin lab on day taken

•spread the delivery of samplesmore evenly throughout the day

• Daily scheduling of work requests(when/volume) and actions tocorrects missed plans.

ContactHazel [email protected]

Day 1

Samplestaken andmajorityreceived inLab. Someregistered

Table 3: Four day pathway

Four Day Pathway

Day 2

Rest of samples receivedin lab. Remainingregistered and allsamples processed.Some slides pre-screened/screened.

Day 3

Remaining slidespre-screened/screened by11.10amdownload. Resultsletters issued.

Day 4

Resultsreceived bywoman



SummaryWomen were advised in a letter fromthe recall agency that they couldexpect a result within eight to tenweeks. When they received a resultwithin considerably less time somebecame concerned and telephoned.

The wording of the letter was changedto reflect current performance and thenumber of phone calls was reducedsignificantly.

Understanding the problemIt was identified from the volume oftelephone calls received within thedepartment that women wereconfused by the wording in theirinvitation letters which stated that aresult would be received within eightto ten weeks.

Prior to the 14 day turnaroundprogramme, eight to ten weeks wasthe length of time it took for results toreach women in the area.

This was identified as the ‘waste ofdefects’ in a staff daily huddle. Theteam were spending time answeringcalls and reassuring women who hadreceived their results much earlier thanthey expected.

How the changes wereimplementedThe invitation letter was changed tostate that the woman would receiveher result letter within three weeks ofthe test date.

Voice of the customerNewcastle upon Tyne Hospitals NHS Foundation Trust

Measurable outcomes and impact• 99% reduction in telephone callsfrom patients

• Staff time saving of approximatelytwo hours per week

• Improved patient experience.

How this improvement benefitswomenThis saving in staff time is being usedon value add processes and womenare more accurately informed.

How will this be sustained andwhat is the potential for the future/additional learning?As turnaround times continue toimprove the letter will be furtherupdated to ensure women areaccurately informed.

ContactDavid [email protected]

Case study 6



To achieve a 14 or seven day turnaround time,the focus within primary care needs to be ongetting the sample and request form right firsttime and ensuring that it is on the next availabletransport run.

Use of Open Exeter produced HMR101Moving to the use of electronic pre-populatedHMR101 request forms from the Open Exetersystem:• Improves patient safety – forms are pre-populated with demographics and screeninghistories. Risks associated with misreadinghandwritten forms are removed.

• Saves sample takers time completing blankforms

• Saves laboratory time deciphering handwriting• Saves laboratory time looking for informationlocated differently on multiple form types.

9. Primary careUse of electronic requestingWhere available, use of electronic requesting forevery sample:• Ensures correct demographics are recorded• Samples do not need to be returned forcorrection or clarification

• Removes the risk associated with handwritinginterpretation

Right first timeLearning in phase two has highlighted the needto consider the approach taken with two of the‘just do it’ recommendations contained in thefirst Cytology Improvement Guide -

1. Enforce a policy for refusing ‘out ofscope’ samples and ensure GPs and sampletakers know the correct pathway forsymptomatic women. The aim of this is tostop inappropriate testing and to ensureappropriate interventions or referrals are made inline with Cancer Screening Policy.

Figure 7: Example of a ‘right first time’ visual aid

Age

<25

25-49

49-64

65>

Frequency of screening

N/A

3 yearly

5 yearly

N/A

Unacceptable samples

Under 24 years 6 months and not scheduled for a test

Less than 30 months since previous routine negative

Less than 54 months since previous routine negative

65 years and over with previous consecutive routinenegative tests in last ten years

As from 1 April 2010Laboratories will not processthe following samples

DON’TFORGET

Cervical screening - implementing good practice

Screening starts at 25

Screening ends at 64



2. Implement a non-acceptance policy forincorrect forms/vials. The main aim of this isto ensure quality and safety that guarantees theright sample is reported to the right woman.The additional time required for staff to dealwith omissions, errors, logging returns,telephoning surgeries etc is eliminated.

These recommendations are aimed at achievinga service where every test is completed correctlyand sent immediately to the laboratory in acorrectly labelled vial with a fully completedstandardised request form. Every sample shouldbe ‘right first time’.

Following the experience of a number of sites,there are some further recommendations tosupport implementation.

• Measure defects - Identify how manysamples and forms are received that cannot bebooked in and processed without the need to:• search for information (wrong form)• look up information (missing codes)• telephone the sample taker (missinginformation)

• return for correction (not recommended) ordispose of sample (when woman’s identitycompromised only).

In phase two up to 47% of all samples andforms had either an error or an omission. Notall of these errors compromised the identify ofthe woman but all required additional work andwere in Lean terms considered ‘defects’.

It is important to establish a rigorous process toachieving a ‘right first time’ approach including:

• Root cause analysis – understand why theseerrors have occurred

• Engage stakeholders – communicate yourfindings to all relevant stakeholders including(but not limited to) GPs, sample takers,screening leads, PCTs, QARC

• Agree a collaborative approach across thewhole pathway – agree what the standardis, communicate frequently using all availableavenues

• Consider how errors will be handled andby whom – agree where responsibility forerrors sits and how they will be addressed.What action will be taken by PCTs to ensuresample takers deliver ‘right first time’ samplesevery time?

• Establish a timescale for training andimplementation – communicate this widely.

NHS CSP guidance is that ANY sample receivedwhere the woman’s identity or safety iscompromised should be disposed of. Where asample taker fails to indicate whether the cervixhas been visualized the sample should bereported as inadequate by default.

Other errors or omissions should be agreed uponeither locally or regionally. A whole pathwayapproach involving all stakeholders is thereforeessential.

The case studies demonstrate the differentapproaches that have been taken to achieveright first time and include the learning fromeach site concerned.

TransportA percentage of the turnaround time forsamples is taken up with transportation to thelaboratory.

It is essential that every sample taken is sent viathe next available transport van which should beat least daily. Samples should not be batched orheld within surgeries or clinics.



SummaryBy early July 2010, three months afterrequesting sample takers use OpenExeter HMR101:

• The booking in backlog of 5,000forms had been reduced to zero

• Both screeners and clerical staff findthe new form much easier to use

• Reduction in the number ofincorrect reports put on thecomputer by the screeners.

Turnaround time from collection toreporting has improved dramatically:• November 2009: 7.1% in 14 days• July 2010: 92.2% in 14 days.

Understanding the problemIn April 2009, the Cervical CytologyServices at Warwick, George Eliot andUniversity Hospitals Coventry andWarwick (UHCW) merged into one labon the UHCW site in Coventry. Thethree laboratories had over 20 years ofcervical cytology history on theirrespective databases and each used adifferent computer system. Althougha decision was made that the historicdata would be transferred to thenewly merged lab at UHCW, this hadnot happened by the time of themerger and has still not beencompleted 18 months later.

Screeners in the newly merged lab didnot have the sample history for anyWarwickshire women (40,000 womena year) and each case had to belooked up on Open Exeter and thehistory manually written on therequest form and entered onto theUHCW computer system.

The laboratory received multipleformats of forms:• Single copy HMR101 forms• UHCW’s own designed HMR101form

• Old style green multi-copy HMR101forms

• Open Exeter A4 PDF one previoussample displayed

• Open Exeter A5 PDF (2003) twoprevious samples displayed.

Changing to Open Exeter HMR101University Hospitals Coventry and Warwick NHS Trust

• Each form had information indifferent places which wasconfusing for booking in andscreening staff who had to searchfor information

• Booking in a single sample includingthe look up on Open Exeter andwriting the history on the form wastaking an average of two minutes22 seconds

• Where screeners did not have thecomplete history or missedinformation on the multiple formformats, errors were made in therecall management. These were notpicked up until the data wasdownloaded to the recall agencycreating unnecessary work for asenior member of the laboratoryteam who corrected the error

• By the summer of 2009, thelaboratory had a backlog of 5,000samples awaiting booking in.

How the changes wereimplementedVery early on after the merger the Laband the PCT decided that all Coventryand Warwickshire surgeries would beencouraged to use Open Exeter andmove to pre-printed Open ExeterHMR101 forms (version A5 PDR 2009)which have all the cervical cytologyhistory printed on them:• The recall team drove the changeprogramme by writing to allpractices, setting up user access andvisiting all practices to providetraining

• An intensive education and trainingprogramme was initiated by the PCTin the summer of 2009 toencourage surgeries to use OpenExeter and the laboratory introduceda non-acceptance policy for the useof anything other than the pre-printed HMR101 forms in April2010.

Measurable outcomes and impactBy May 2010, the use of Open ExeterHMR101 forms had dramaticallyincreased.• 11% in May 2009• 92.35% in May 2010.

Time taken to book in each sampledropped from:• 144 seconds in May 2009• 52 seconds in May 2010.

The laboratory deals withapproximately 70,000 samples per yearmeaning a time saving 1,789 hoursper year.

How does this improvementbenefits womenThe removal of waste from the processhas contributed to a reduction in theend to end turnaround for all women


Case study 7

160

140

120

100

80

60

40

20

0Non Open Exeter HMR FormAverage booking in time x 1

Non Open Exeter Pre-PrintedAverage booking in time x 1

144seconds

52seconds

Seco

nd

s

Figure 8: University Hospitals Coventry and Warwick NHS Trust - Booking intimes: Old style HMR 101 forms vs Open Exeter printed HMR 101

SummaryAchieving right first time for allsamples requires a plannedcollaborative approach involving andengaging all key stakeholders.

Understanding the problemThe scale of the perceived problemwas confirmed with a data collectionexercise to identify the type andvolume of errors as well as the stafftime to deal with them.

A simple table was used at booking into identify errors. Process sequencecharts were used to understand theprocesses staff were required to followto deal with errors (see figure 9).

How the changes wereimplemented• ‘Out of scope’ samples were definedlocally as those from women underthe age of 24.5 years as they arecalled before their 25th birthday.

• Incorrect forms were defined asspecimens received with anythingother than an Open Exeterdownloaded HMR101 A5 size form

• Defects were defined in twocategories:• Serious defects where thewoman’s safety may becompromised including unlabelledvials or significant mismatches ofinformation between form andvial

• Minor defects where necessaryinformation for the smooth flowof the sample through thelaboratory is missing and requiresextra work on the part of thelaboratory. This can includemissing practice codes, missing orincorrect sample taker PINs, lackof test date, failure to confirmthat the cervix was visualised orthat a 360 degree sweep wastaken

• A policy was devised and a copysent out by the PCTs to all practices,Genito-Urinary Medicine (GUM) andFamily Planning clinics together witha visual management aid to formfilling and vial labelling

Right first timeUniversity Hospitals Coventry and Warwick NHS Trust

• In between notification of theimpending policy and itsimplementation, sample takerswould receive a notification where asample was ‘defective’ in some wayso that they could correct theirprocess to prevent a reoccurrence

• Sample taker training was providedby the PCT to assist with accessingand completing the requiredHMR101 form.

• Sample takers were also sent theNHS Clinical Practice Guidance forthe Assessment of Young Womenaged 20 -24 with Abnormal VaginalBleeding.

• Sample takers received a reminderthree weeks after the originalnotification and then again oneweek before the plannedimplementation of the policy

• Hospital clinics were notifiedinternally by the project lead.

Following a significant challenge froma small number of GPs advice wassought from the Trust Solicitor andMedical Defence Union.

• On their advice the policy wasamended to confirm that sampleswould only be disposed of wherethe woman’s identity or safety iscompromised or where the sample isout of scope as previously defined.

Case study 8



• The remainder of samples arereported but additional commentaryis added to the report highlightingthe errors to the sample taker.

• Errors are reported on a monthlybasis to the PCTs.

• The laboratory has chosen tocontinue to report samples wherecervix visualized and/or 360 degreesweep is not confirmed. A note isadded to the report that thisinformation was missing from therequest form and it is theresponsibility of the sample taker todecide whether to recall thewoman. This decision was made onthe basis that the 10% of samplesmissing this information beingreported as inadequate wouldrequire additional screening resourcethat is not available

• All samples are electronicallyrecorded on the lab system ratherthan in a manual log as this enablesaccurate and fast analysis of anyerrors.

Measurable outcomes and impactErrors have fallen dramatically acrossall categories and time spentmanaging errors has fallen accordingly.

The time taken to book in a samplehas been reduced by 50%.

50

45

40

35

30

25

20

15

10

5

0NHS No. DOB GP name Sender code EMP Unregistered PIN Non OE forms

November 944 forms March 1417 forms

April 2297 forms May 9812 forms

First Name Address GP address Test date Reason for test CX seen/360 OE format

Perc

enta

ge

Figure 9: University Hospitals Coventry and Warwick NHS Trust - Requestform percentage defects (Nov 2009, March, April, May 2010)



Ideas tested which wereunsuccessful• Problems occurred early duringimplementation as ‘out of scope’,‘incorrect/forms and vials’ and‘defects’ was not clearly definedwithin national guidance and couldnot initially be agreed with GPslocally

• The term ‘zero tolerance’ was notliked by many and was felt to have‘policing’ connotations. Thisimpacted on successful engagementwith the intention of the policywhich was to ensure samples wereright first time.

• If a ‘defective’ sample is sent backto the sample taker or held on tountil more information is obtainedto be able to process it wait time isadded and achievement of the 14day turnaround is compromised.The laboratory initially decided withthe support of their two PCTs todiscard such samples.

Figure 10: University Hospitals Coventry and Warwick NHS Trust -Example of a pre-printed HMR101 request form using Open Exeter

How this improvement benefitswomenSample taker attention has beendrawn to the importance of correctdata and process to ensure a qualitysample as well as a good experiencefor the woman. Time savings haveenabled the laboratory to continue toreduce their backlog and turnaroundtimes.

How will this be sustained andwhat is the potential for the future/additional learning?Continued reporting of errors back tothe source will enable sample takers toimprove their processes to prevent areoccurrence.


Summary• The laboratory receives samplesfrom three primary care trusts (PCTs)across NHS North of Tyne

• The percentage of samples receivedwithin three days increased from73% to 97%.

Understanding the problemDelays in samples reaching thelaboratory were evident across allthree PCTs although the majority ofdelayed samples were generatedwithin one which serves ageographically large, sparselypopulated area. The transport pathwaywas carefully mapped in order toexplore this further. Key problemsidentified included:• Potential batching of samples atprovider clinics and surgeries

• Complex transport routes withmultiple hand offs

• Lack of segregation of cervicalcytology specimens from othersamples during transportation

• Failure to deliver samples directly tothe laboratory.

A3 thinking for transport problemsNewcastle upon Tyne Hospitals NHS Foundation Trust

How the changes wereimplemented• A multidisciplinary group includingrepresentatives from the laboratory,estates, primary care, public healthand commissioning was establishedto understand the problems intransporting specimens to thelaboratory

• A turnaround time of three days orless was set for samples reachingthe laboratory from provider clinics

• Actual transport times were auditedover a one week period on twoseparate occasions. Where outlierswere identified the responsiblesample takers were contacteddirectly in order to exploreunderlying issues.

Measurable outcomes and impact:After excluding any returned samples,the proportion of samples reaching thelaboratory within three days increasedon average from 73% to 97% (seetable 4 below).

The laboratory now receives two dailybatches of samples from the collectionpoint enabling processing to startearlier in the day.

Case study 9

Ideas tested which were successful• Introduction of pink specimen bagsto allow separation of cervicalcytology specimens from otherscollected by couriers

• Delivery of samples directly to thecytology laboratory reception ratherthan via the post room

• Provision of an additional courierrun from one of the intermediarycollection centres to ensure a moreconstant flow of specimens

• Development of a communicationsplan engaging local leaders as figureheads to ensure dissemination ofkey messages to stakeholders.

Ideas tested which wereunsuccessfulIt was suggested that it might be moreefficient for the more remote practicesto send samples in via the post ratherthan have them picked up by courier.We ran a pilot scheme butunfortunately it proved to be veryunpopular with the GP practices.

How this improvement benefitswomenReducing transport time makescompliance with the 14 dayturnaround more achievable andsustainable.



Table 4: Newcastle upon Tyne Hospitals NHS Trust - Proportion of samples reaching the laboratory within three days

Transport Provider Count

North Tyneside (Northumbria)

North Tyneside

Newcastle

TOTAL

423

269

462

1154

Averagetransporttime (days)

No. of cases- to or <3 days

% of cases- to or <3 days

No. of cases> 3 days

% of cases> 3 days

1.93

1.59

0.97

1.46

408

261

451

1120

96.45

97.03

97.62

97.05

15

8

11

34

3.55

2.97

2.38

2.95



Women will benefit from knowing theresult of their test sooner reducinganxiety and, if required faster referralto the cancer pathways.

How will this be sustained andwhat is the potential for the future/additional learning?A number of additional challengeshave been identified which will beaddressed in the future. These includethe development of a robust trackingsystem for individual specimens toidentify and monitor delays at differentstages throughout the pathway.

Evidence from this project is currentlybeing used to:• Highlight the need for furtherimprovement of the wholepathology transport infrastructure

• Undertake detailed analysis ofroutes, schedules etc

• Accompany drivers to understandsome of the difficulties faced incollecting samples.

The return journey of send backsamples needs to be mapped toensure their speedy return to thepractice.

ContactDavid [email protected]



Within the laboratory, teams have focused onkeeping samples moving from the point of entryat specimen reception through to the time theresult is transferred to the recall agency.

This has been made possible by reducing andeliminating the waste, using visual management,5S and standard work.

10. Laboratory



SummaryThe removal of a step at specimenreception has removed over one houra week for a workload of 34,000 andwill save three hours on a workload of96,000 following consolidation.

Understanding the problemThe core team looked objectively athow samples were received, checkedand labelled in the reception area.

• Samples are received and detailschecked on the vial to ensure thatthey match details on the requestform

• Each sample is given a uniquenumber and the label is applied tothe form and vial

• Each vial has the number written onits top as well as having the samplenumber label on the body of thevial.

The core team recognized this as awaste of over processing.

Removing the waste of over processingat specimen receptionSheffield Teaching Hospitals NHS Foundation Trust

How the changes wereimplementedThe core team recognized that theycould see no benefit from writing thenumber on the vial lid. This was apractice that has always beenundertaken but the need had neverbeen questioned.

It was agreed at the daily huddle thatthe number would no longer bewritten on the vial top.

Measurable outcomes and impact• Six seconds have been saved perspecimen by not labelling the vialtop with the laboratory number

• Taking into account the increasedworkload of 96,000, 160 hours peryear are saved equating to threehours per week.

Ideas tested which were successfulThe idea came from the core team asthey were doing a walk round of thework flow through the preparationarea. It was also felt that thenumbering was difficult to see andprovided no added value to theservice.

How this improvement benefitspatientsThe time saved will be investedelsewhere in the lab on value addactivities.

How will this be sustained andwhat is the potential for the future/additional learning?There will continue to be periodicalreviews around the department toassess the value of each step of theprocess.

ContactKay [email protected]

Case study 10

SummarySpecimen reception has beenrelocated and combined with thebooking in function removing thewastes of motion, transport, waitingand over processing.

Understanding the problemWhen the equipment was installed forLBC processing, specimen receptionwas relocated to a distant locationwithin the histology laboratory wherespace happened to be available withinthe cut up area.

The workspace was cramped and outof sight of the rest of the cytologyteam. It was located at the furthestpoint from the processing room andadmin office and samples weretherefore being transported.

How the changes wereimplemented• Following discussion with thelaboratory team, it was agreed thatthe admin office would become awork cell as a PDSA (plan, do, study,act)

• The desks are covered withdisposable non-absorbent paper tomake them suitable and staffmembers wear disposable plasticaprons to adhere to PPE procedures

• Samples are handled one at a time -unpacked from the plastic bag,checked, labelled and booked in

• Staff work in batches of 24 whichmatches the Surepath equipmentcapacity

• Forms and pots move into theprocessing room together and aredivided into two batches of 12when they come off the coverslipper.

Creating a work cell for specimenreception and booking inWinchester and Eastleigh NHS Trust

Measurable outcomes and impactBy combining the previously separateprocesses into a single work cell,samples are opened, checked andbooked in one at a time. 73 secondsper sample has been saved whichequates to 781 hours per year.

How this improvement benefitswomenTime savings have been reinvested intovalue add process steps contributingto a reduction in the turnaround time.

How will this be sustained andwhat is the potential for the future/additional learning?The work cell is to be madepermanent but will move into anadjacent office space where theflooring is due for replacement.Appropriate flooring will be laid andthe function moved as the currentlocation has recently been carpeted.

ContactCraig [email protected]

Case study 11





SummaryHaving removed priority workstreamsduring phase 1, the laboratory hasidentified a further improvementopportunity that relies on identifying,tracking and ultimately screeningsamples that are nearing 14 daysturnaround time.

These samples were often spreadthroughout the waiting work and hadto be pulled out and prioritised forscreening ahead of the rest of theworkload.

Changing to working in date sampletaken order was accepted as the mostappropriate way to ensure true first in,first out.

The department continues to meet the14 day TAT and planning thedeployment of staff has been easier.

Understanding the problem• A department workload increasecoincided with a staff shortage inboth the admin and screening teams

• Some screening staff also do dataentry and it was becoming difficultto assess where to deploy staff tohave the greatest impact onmaintaining performance

• The Cyres IT system is used toidentify those cases that requirereporting to ensure the 14 dayturnaround is met. However, casesnot yet booked onto the LaboratoryInformation Management System(LIMS) were not identified bythis monitoring

• Due to a developing backlog, up to150 cases were being identified thatrequired pulling through to meet theturnaround time but these would bespread throughout the workloadwaiting to be screened. This meantthat a priority work stream was ineffect being reintroduced.

How the changes wereimplemented• Staff suggested a PDSA (plan, do,study, act) to sort cases at an earlierstage into the order of the date thesample was taken

Achieving first in, first out according to date test takenCambridge University Hospitals NHS Foundation Trust, Addenbrookes Hospital

• Two different methods wereproposed:1.At the unpacking stage sort thesamples into ‘date taken’ orderwhere possible. Then labelsamples keeping them in ‘datetaken’ batches

2.Sort the request forms afterlabelling into ‘date taken’ order.Forms to be kept in ‘date sampletaken’ order in batches of 10where possible. Slides kept innumerical order. Screener matchesslides with each batch of requestforms as they take them

• Daily huddles were used to discussand monitor the PDSA. Times wererecorded before and after thechanges1.Unpacking in the previous wayversus unpacking and sorting intodate taken order

2.Time taken to sort forms in theadmin office versus time taken tomatch forms and slides.

Measurable outcomes and impactBoth options resulted in samples beingreported in order of the date thesample was taken.

• Option 1 - took slightly less timeper sample but due to the currenttimings of the deliveries and currentstaff available to complete this taskindividuals were working past theirfinish time of 5pm

• Option 2 - was successful butintroduced a level of complexity thattook staff time to get used to. Therewere concerns about mismatchesbetween forms and slides and timetaken to pick up the cases increased.There was an additional impact onfiling as batches were not innumerical order.

Ideas tested which were successfulOption 1 - will be implemented oncea reconfiguration of existing vacantposts enables appointment andtraining of Band 2 Biomedical supportworkers for the prep room and dataentry.

Option 1 - helps ensure the oldestsamples are processed, stained andavailable for screening first.

Ideas tested which wereunsuccessfulThe option 2 approach meant theforms available did not consistentlymatch up to the slides that wereavailable. This could be managed byadding additional sorting complexitiesbut this places additional pressures onthe data entry staff and is not Lean!

Additional visuals had to beintroduced to support the process ofslide matching but it was agreed thatthis approach was overall addingwaste back into the process.

How this improvement benefitswomenThe department is consistentlymeeting the 14 day TAT, despite theincrease in workload

How will this be sustained andwhat is the potential for the future/additional learning?The laboratory will progress withimplementing option 1 once the staffconfiguration is correct. This willensure the department stays on trackwith 14 day TAT and also help identifypotential non-achievement muchfaster allowing the department torespond quickly and proactively ratherthan reactively.

Workflow will be more efficient andpressure on staff reduced.

The department is planning to recruitmore Band 2 staff to man the preproom until 5.30 pm rather than 5pmas at present.

ContactRoseanna [email protected]

Case study 12

SummaryWhile undergoing lean training thebatching of clerical queries wasidentified as a waste of waiting.

A ‘stop and fix’ approach wasimplemented followed by theintroduction of a rota and all staffunderwent IT refresher training.

Understanding the problem• Waste identification sheetshighlighted that potential clericalerrors were a concern. For examplemismatches between form andcomputer system

• The waste of waiting was alsoidentified by screening staff who feltthey were not receiving a promptresponse to clerical errors picked outat screening

• The relevant forms were beingbatched in a basket and only beingdealt with when a member of theclerical team was available. This wasdelaying reports for up to one week

• A focus group session with theclerical team revealed a lack ofclarity with regard to roles andresponsibilities and also highlightedthe need for refresher training.

How the changes wereimplemented• IT refresher training implemented forall staff

• The creation of a ‘stop and fix’policy, where one person isresponsible for resolving queriesimmediately as they arise wassuggested by staff

• The idea was discussed and agreedat a huddle

• A visual rota was introduced to givedirection to the clerical staff andscreeners showing who wasresponsible for ‘stop and fix’.

Stop to fix - removing the waste of waitingDerby Hospitals NHS Foundation Trust

Measurable outcomes and impact• The visible rota has eliminated thebatching of forms and simplified theprocess

• Clerical staff know who is on ‘stopand fix’ duty and that personexpects to be interrupted

• Screening staff know who to ask toamend errors.

There is now no delay of work waitingto be processed and screened. Anaudit confirmed a reduction in waitingtime to three minutes per sample.

Clerical staff are satisfied with the newrota. They have commented that theyfeel under less pressure to completelarge batches of queries at one time.This has resulted in improvedteamwork and boosted team morale.

Ideas tested which were successfulIT refresher training was provided forall members of staff which improvedconfidence in the use of the computersystem.

Screening staff were encouraged tocorrect mistakes themselves andultimately log them.

Case study 13

Ideas tested which wereunsuccessfulInitially the ‘stop and fix’ rota was notsupported by a visual aid. This meantthat the clerical staff were still unsurewho was responsible for carrying outthe task each day.

How this improvement benefitswomenThe introduction of the ‘stop and fix’rota had the effect of reducing batchsizes and waiting times, enhancedwork flow and ultimately led to areduced TAT.

How will this be sustained andwhat is the potential for the future/additional learning?If a member of the clerical team isabsent the rest of the team adapt therota on a daily basis as necessary.

Daily ‘huddles’ are used as a forum todiscuss other clerical problems as theyarise.






SummaryIntroducing the use of hot keys byscreeners has saved time, removingthe waste of over processing.

Understanding the problem• Entering a negative report andmanagement previously required16 key strokes

• Using hot keys can reduce thenumber of key strokes to as little astwo.

How the changes wereimplemented• A member of the laboratory teamasked his colleagues at a dailyhuddle how many of them wereaware of and used hot keys forreporting

• Whilst a small number of peoplewere familiar with them the majoritywere not and it was agreed thateveryone would receive 1-2-1tuition

• It took a couple of weeks to get tothe stage where everyone knewhow to hot key a report.

Productivity improvement in screening -removal of key strokesPennine Acute Hospitals NHS Trust

Measurable outcomes and impactThe time to enter results andcomments onto the computer systemhas reduced from 20 seconds to fourseconds per case.

The estimated annual time saving is225 hours based on approximately200 cases per day.

Ideas tested which wereunsuccessfulNot every staff member wascomfortable with changing theirprocess. They preferred the way theyhad always typed reports.

The time savings were explained andthe majority of the team are nowcomfortable with the faster reportingprocess. Whilst a few people havecontinued with the old process, theirreporting speed is acceptable.

How this improvement benefitswomenA further small change has been madewhich has contributed to reducing theend to end turnaround time.

How will this be sustained andwhat is the potential for the future/additional learning?The system has further hot keycapabilities beyond cytology reportingwhich will be exploited as much aspossible to save time elsewhere in thepathology service.

ContactRichard [email protected]

Case study 14

You can use Shift& Function Key

You can use otherkeyboard keys

SummaryRemoval of an unnecessary checkingstep in the screening room has savedfive hours of senior time per weekwith no detriment to quality.

Understanding the problemThe value stream map and staffsuggestions identified the codechecking of forms as a waste ofwaiting. Forms were batched and leftwaiting for the management code tobe checked by the next availablesenior member of staff.

Ideally this check should have beencarried out three times a day.However, occasionally this would onlybe completed once a day and the waitcould range from one hour to sixhours.

It was also identified following thespaghetti mapping exercise of thescreening room that the code checkingtable was situated in the wrongposition. This caused disruption forcolleagues nearest the table duringtheir screening time.

How the changes wereimplementedThe initial change was to move thelocation of the task to make waitingwork more visible to seniors andreduce disruption in the screeningroom.

When this proved to be unsuccessful,further discussion examined thepurpose of the check and it wasagreed that it should be part of therapid reviewer’s tasks.

Measurable outcomes and impact• An audit was completed detailingthe amount of time spent by asenior member of staff to carry outthis process. The time saving wasone hour per day, the equivalent tofive hours per week or 260 hoursper year. This time has been utilisedfor other value add duties

• Work flow improved in thescreening room and the batching offorms for result entry was removed

Removing the waste of overprocessing - code checkingDerby Hospitals NHS Foundation Trust

• The invalid returns have notincreased since stopping the codechecking by senior members of staff.

Ideas tested which wereunsuccessful• Following discussion at a dailyhuddle, it was agreed that therelocation of the checking station toa more central location within theroom was a good idea. It wasthought that this would serve as amore visual indicator for thesenior staff

• To illustrate the impact of thechange, another spaghetti map wascompleted. This demonstrated thatstaff movement remained the samebut disruption was reduced

• The relocation proved to be aninadequate visual reminder to thesenior team

• Further discussions lead to the roleof code checking becoming theresponsibility of the screenerperforming the rapid review.

Case study 15

How this improvement benefitswomen:As the recall management of thewomen is now part of the rapidscreeners routine, work continuallyflows throughout the day. Quality isnot affected and TAT has improved byone day.

How will this be sustained andwhat is the potential for the future/additional learning?This will be sustained by the continualmonitoring of invalid returns.




Spaghetti Map of Screening Room

Spaghetti map of screening room after moving the code checking table



Simplifying manual logs - removing thewaste of over processingDerby Hospitals NHS Foundation Trust

Case study 16

SummaryAt the start of the lean project, elevenhandwritten log books were in use bylaboratory and screening staff. Afterdiscussion with the team it wasdecided to either remove, combine orsimplify them.

Handwritten logs were replaced withelectronic versions using a simplecoded key that saved time, duplicationand maintained flow of work.

Understanding the problemIt was highlighted in staff feedbackand whilst gathering data for the valuestream map that numeroushandwritten log books were in use

It was evident that this was the wasteof over processing. Some of theinformation collected was duplicatedand some of it was never analysed.

How the changes wereimplementedIn order to decide whether any of thelog books could be eliminated,combined, simplified an initialdiscussion during a huddle focused onwhich log books were unnecessaryand could be removed immediately.

11 books were reduced to eight withinone week.

Combination and simplification ofcertain log books was discussed indetail with the relevant staff thatmade use of them. A decision wasmade to retain some logs whilst otherswere combined and put onto theserver accessible by all staff.

Measurable outcomes and impactBy combining and simplifying logbooks approximately five hours permonth has been saved.

Ideas tested which were successfulRemaining log books were combinedand converted into an electronicversion. To make this version moreuser friendly a coded key was added.

Less information was therefore neededto be input by members of staff. Allmembers of the team have full accessto the shared server.

How this improvement benefitswomenTime saved has been reinvested invalue add tasks contributing to areduction in the turnaround time.

Table 5: Logs used and time taken to complete

Name of log Frequency of use

High Risk Samples

Screeners Day Book

Practice Nurse Visits

Specimen Reception Queries

Clerical Errors

Sendbacks

Specimen Receipt

Semen Analysis

Consumables

Machine Breakdown

Reprep

X3 per month

X1 per day

X2 per month

X5 per day

X5 per day

X3 per day

X5 per day

X3 per week

X1 per month

X1 per month

X2 per week

2 mins

1 min

2 mins

2 mins

2 mins

2 mins

1 min

1 min

1 min

3 mins

1 min

6 mins

30 mins

4 mins

10 mins

10 mins

6 mins

5 mins

3 mins

1 min

3 mins

2 mins

Removed

Removed

Removed

Combined

Combined

Retained

Simplified

Retained

Retained

Retained

Retained

Time to complete Total time Outcome


SummaryPrevious history slides are no longerretrieved prior to passing abnormalslides to the checking stage saving72 hours of screener time andremoving 93 km of walking per year.

Understanding the problemFollowing the completion of a valuestream map and process sequencecharts for the screening process, thecore team questioned the process stepof pulling all previous slides for anywoman whose sample is beingreferred for checking:

• Screeners would check previoushistories, walk to the local slide filingstore opposite the screening room,then along the corridor to thearchive filing room, often returningto their PC to check if the woman’sname had changed if the slidescould not all be found

• Several people, including consultantpathologists, were asked why theseslides were being pulled out. Noone could say for sure – thecheckers were not looking at themand the pathologists also confirmedthat they did not need them.

How the changes wereimplementedHaving checked with all stakeholdersand after discussion at the huddle, theprocess step was removed.

Removing the wastes of over processing and motionWinchester and Eastleigh NHS Trust

Measurable outcomes and impactRemoval of the step has savedscreeners 72 hours and 93 km peryear. There is a further saving in there-filing time which has not beenquantified.

How this improvement benefitswomenScreeners’ time has been reinvested invalue add work of screeningcontributing to a reduction of theturnaround time.


Case study 17





SummaryThe process of filing has beensimplified preventing the accumulationof trays of slides. Time spent filing hasreduced as have filing errors.

Understanding the problem• One of the factors affecting the flowof work through the lab was theslide filing process. Trays of reportedslides would accumulate in the filingroom in no particular order

• The process of filing by office staffwas inefficient as the slides were notnecessarily in numerical order andwere being separated into normaland abnormal

• If a slide needed to be retrievedbefore it had been filed, additionaltime could be wasted searchingthrough the pile awaiting filing

• Filing was being done by office staffonce or twice a week and wastaking about four hours.

• The slides would be filed in twoseparate files ‘normal’ and‘abnormal’.

How the changes wereimplementedAgreement was reached within theteam to file all the slides together.

A further PDSA was performed by twoof the screening staff. They assessedimpact on screening time of self-filingand in view of its success; all screenersare now filing their own slides.

Reducing time spent slide filingNorfolk and Norwich University Hospital NHS Foundation Trust

Measurable outcomes and impact• Immediate filing of screened slides,taking one minute per tray;releasing approximately four hoursof office staff time per week

• Because the slides are in numericalorder, fewer filing errors occur

• Filing all slides together is simplerand makes slide retrieval easier.

How this improvement benefitswomenWasteful steps have been eliminated,releasing time to concentrate on valueadd activities to help reduce TAT.

How this improvement benefitsthe organisationIdentification of wasteful steps in theprocess and the use of PDSA testingcycles is now regularly used by thecytology staff to assess impact ofchanges made to ensure they havemade an improvement.

ContactDr Xenia [email protected]

Case study 18

SummaryA pull based scheduling system fordeliveries allows work to flow througheach department preventing build-upof work at any stage of the process.

Understanding the problem• Work was piling up in differentareas creating bottlenecks

• Work in progress figures werecollated on a weekly basis in eacharea, and a chart was producedidentifying how much work waspending in each section.

The waste of waiting was identifiedfrom the figures with over-processingin some areas.

How the changes wereimplemented• Daily workload targets are calculatedbased upon the previous day’sdeliveries (demand) and requiredprocessing time (capacity)

• Decided upon hourly scheduling fortransfer of work across all areas asthis correlates to analyzer processingcycle-time

• Each department has its own dailyprocessing schedule board

• Slide tray batch sizes were reducedfrom eight to six to facilitate timelydeliveries and better distribution ofwork

• Transfer of work was scheduled sotimes were coordinated to allow onestaff member (water spider) to bothcollect and deliver to alldepartments. This is performed bytrainees on a daily rota

• Required ‘buffer’ work quantities areincorporated into daily schedules toaccount for known staff resourceshortfalls which cannot be covered

• Reasons are logged when deliveriesare late or not in the plannedquantity

• The next scheduled delivery is usedto re-balance earlier shortfalls involumes of delivered work.

Implementing a ‘pull’ based schedulingsystem to reduce backlogsThe Leeds Teaching Hospitals NHS Trust

Measurable outcomes and impact• Reduction in steps – one persondelivers scheduled work to eachdepartment in one delivery run(66% reduction in motion)

• Over and under processingreduced by daily scheduled flow ofwork

• Bottlenecks in work floweliminated as required staffresource can be allocated to whereand when needed as a result ofmulti-skilling across tasks and depts

Case study 19

• On Time In Full (OTIF)deliveries/quantities trackeddaily – current schedule efficiencytarget of 80% exceeded across alldepartments

• Reduction in waiting time waste– areas never have to wait morethan one hour before work isdelivered, corresponding toreduction in TATs for results

• Eight scheduled daily deliveries –optimize throughput of in-progresswork.



Date

04/01/2010

11/01/2010

18/01/2010

25/01/2010

01/02/2010

08/02/2010

15/02/2010

22/02/2010

01/03/2010

08/03/2010

15/03/2010

22/03/2010

29/03/2010

05/04/2010

12/04/2010

19/04/2010

26/04/2010

Table 6: Work pending at each stage

To register

156

24

156

192

372

516

430

288

156

48

276

228

228

418

228

36

78

To process

36

48

96

132

84

132

144

156

144

132

108

108

84

144

48

120

120

To screen

68

128

288

300

232

248

264

276

300

288

272

304

392

280

392

248

168

Total

260

200

540

624

688

896

838

720

600

468

656

640

704

842

668

404

366



IIdeas tested which wereunsuccessful• Initially reduced batches of forms forregistration from 12 to six. However,forms were being registered andsent to the lab out of numericalsequence as not all staff memberswere working to the standardprocess and processing times

How this improvement benefitswomenIncreased work throughput from dailyscheduling has contributed toreduction in TAT average:October 2009 = 9 daysJune 2010 = 4.6 days

How will this be sustained andwhat is the potential for the future/additional learning?• Constant monitoring of thescheduling system allows changes inbatch size and frequency ofdeliveries to be altered in line withworkload demands

• Daily ‘end-of-day’ meeting involvingeach department to agree next daywork schedule and balanceresourcing to meet this. All loggedissues that prevented scheduleadherence are reviewed withcountermeasures, owners andcompletion tracked on 3Cs board

• Three ‘bite sized’ pieces of workdelivered through the day meansmaximum waiting time neverexceeds one hour in any section,allowing any problems in particularareas to be highlighted quickly andprompt action to be implemented.


SummaryThe introduction of an electronic100% file check between the resultsagency and laboratory results file hasreduced time spent manually checkingfiles.

It also ensures that all errors aredetected rather than a proportion ofpossible errors in performing only a10% manual check.

The changes exceed the minimumQuality Assurance Reference Centre(QARC) requirements.

Understanding the problem• The QARC recommends a 10%check of the file which is sent fromlaboratory to call recall

• The 10% check at Barts and TheLondon NHS Trust was infrequentand, when completed, a member ofstaff manually checked one in tenlaboratory numbers with theinformation against Open Exeter

• The team did not have fullconfidence in the 10% check as itdidn’t check every patient on thefile. They wanted to improve qualityand safety by checking 100% of theresults and recall code in each file.

How the changes wereimplemented• The team also wanted the check tobe computerised rather than manual

• The call recall centre were asked todownload the laboratory number,result and recall code into an Excelspreadsheet and send the file to thelaboratory

• The laboratory extracted the sameinformation from their laboratorysystem (WinPath) and both sets ofinformation were downloaded intoMicrosoft Access and cross linked

• A simple sort of the data in Accessclearly shows any discrepanciesbetween the two sets ofinformation.

Electronic 100% file check replaces a manual 10% oneBarts and The London NHS Trust

Measurable outcomes and impact• An infrequent manual file check of10% increased to a regular 100%electronic file check• From one day for the data managerto check 10% of the file

• Now 30 minutes to check 100% ofthe file

• Safety and quality have bothincreased

• Since the new system has beenintroduced mismatches between thetwo systems are being intercepted.Before the system was introducedthere was a 90% chance that thesecases would not have been detected.

How this improvement benefitswomenThis initiative has an impact on allwomen as all results and recall codesare verified.

How will this be sustained and whatis the potential for the future/additional learning?The new process will be sustained as itis simple to carry out and can becompleted in a timely manner.


Case study 20





For the final stage of the pathway, laboratoriesand recall agencies have focused on:

• Multiple daily downloads (where possible)• Results transferred and posted right first time• Daily posting of results.

11. Recall agency



SummaryWomen are receiving their result lettersooner as a result of the creation of anelectronic process to obtain correctmanagement information.

Understanding the problemOnce the download of results sentfrom the laboratory has beenprocessed at recall, manual rejects areprinted. A number of rejects arecaused by incorrect patientmanagement decisions with regardsthe required recall. These invalid dataslips were being posted to thelaboratory.

On receipt the laboratory wouldcorrect the information which wouldthen wait to be sent with the nextelectronic download.

The process was delaying the resultletter to the woman by up to a week.

How the changes wereimplemented• The recall agency now telephonesthe laboratory and agrees thenecessary correction

• The laboratory continues to producethe required letters to the resultsagency and GP to complete theaudit trail but this no longer delaysthe result letter production

• A letter is now issued to the womanon the same day that the originalresult is received.

Measurable outcomes and impactUp to seven days removed from theturnaround time for approximately120 women each year.

Removal of invalid data slipsWinchester and Eastleigh NHS Trust

Ideas tested which were successfulThis change was part of a review ofthe optimum time to download resultsto the recall agency. Overnightprocessing requirements limited theoptions and prevent twice dailydownloads.

The laboratory and recall agencyagreed to change the download timeto 4pm daily. This allows time toconfirm a successful download beforethe laboratory closes and maximisesthe number of results that run throughthe overnight processing in the recallsystem. The recall agency completesthe matching process by 9:30am thefollowing day when all letters areissued.

How this improvement benefitswomenAll women are now having their letterposted to them 24 hours after thelaboratory reports the result.


Case study 21



The aim of the survey is to encourage andsupport a culture of open and honest feedbackwithin the work area which will help motivateleaders at all levels to take action on results andimprove their own leadership capability.

It is essential to recognise that surveying inisolation using these questions may eventuallylead to a reduction in engagement. Resultsshould be shared with all staff, verbatimcomments carefully considered and timededicated to planning visible action to addressissues impacting on engagement.

The questions in the survey are:1. I am clear what my duties and

responsibilities are2. I have everything I need to do my job3. I understand the Trust vision and objectives

and know how my job contributes to them4. There is a good fit between the job I do and

my skills and abilities5. I can identify and implement improvements

in my work and the work environment6. I receive regular feedback on my

performance7. I get the help and support I need from my

manager8. At work my opinions seem to count9. As a team, I feel we are committed to doing

our best10. There are opportunities to grow and

develop.

An online toolkit is available at:www.improvement.nhs.uk/diagnostics/ToolsandTemplates/tabid/95/Default.aspx along withfurther useful information and reading.

To ensure ownership and sustainability ofimprovements in the process, it is essential toprovide all staff involved in delivering the servicewith an understanding of the principles of Leanmethodology. This enables them to contributeto suggestions for improvements and tounderstand the rationale for changes that arebeing made to their work place and routine.

Test staff suggestions for change using the Plan,Do, Study, Act cycle described in the CytologyImprovement Guide (Nov 2009).

• Understand who your stakeholders are andengage them early, including executive, clinicaland managerial leads

• Decide how and to whom you will escalateany issues that have the potential to blockimprovements

• Communicate progress regularly to yourstakeholders and service users.

EngagementIt is well acknowledged that change is difficultfor most people. Lean is about a permanentshift to a continuous improvement culture withinwhich everyone feels able to identify problems,solutions and opportunities for improvement.

Leadership is the key to how successfully teamscan make this transition. An engagementsurveying tool has been developed during phasetwo to both measure and to guide managersthrough working with the feedback.

The question set is based on the work of theGallup Organization and Marcus Buckinghamand Curt Coffman published in First, Break allthe Rules.

12. Key mechanisms for change

SummaryIt was clear from the start of the leanprocess that communication is the keyelement to achieving successfulchange and the core team recognisedfrom staff suggestions that this was anarea for improvement.

Following the recommendations fromthe phase one pilot sites, all staff weretrained in Lean principles to ensure fullengagement. They were positivelyencouraged to make suggestions andtake part in discussions as well asoffering feedback and solutions forpotential problems.

Understanding the problemStaff suggestions and the engagementsurvey identified communication as anarea that needed further development.

Although a structure for teammeetings was in place it was notalways adhered to. The team had littleopportunity to raise issues. The surveyhighlighted that staff were becomingdespondent and losing confidence intheir ability to put forward concernsand new ideas.

It became clear that at the beginningof the NHS Improvement process thatcolleagues felt changes were beingimplemented too quickly and withoutconsultation of the wider team.

Staff requested that they receive timelyand appropriate feedback in thefuture.

How the changes wereimplementedImmediate measures were put in placeas a direct result of the successful JustDo It’s (JDI’s ) learned from phase onepilot sites:

• Daily huddles – an opportunity forall members of the team to attendan open discussion where ideaswere encouraged

Improving communication and teamworkDerby Hospitals NHS Foundation Trust

• Staff suggestions – ideas could beput forward anonymously byaccessing a designated area on theserver. There was also a post box forhandwritten suggestions. Theoption to approach a member of thecore team with concerns and ideaswas positively encouraged

• Communications board – membersof the wider team were invited toparticipate in the creation of anideas and information board whichcovered mainly work related issuesbut also social events

• Small focus groups were organizedfor colleagues within their peergroups. Without members of themanagement team present, staff feltconfident enough to air theirproblems and even agree onsolutions as a team.

Case study 22

Measurable outcomes and impactThe second engagement survey carriedout showed less neutral responses.Staff had been encouraged to giveopinions rather than a neutral answerwherever they felt they could and thisresulted in more red areas.

The overall response was more positiveas staff felt more comfortable to givehonest answers and the managementteam have greater clarity of the issuesimpacting staff and the possiblesolutions (see figure 11).

As a direct result of positive inputduring a clerical focus group meetinga visual management tool was agreedon. This consisted of an action/trackerchart detailing issues raised andfeedback received.



Information Board



Figure 11: Lean Cytology Project - Engagement Survey 2

Visual management was alsointroduced in the laboratory in theform of daily/weekly/monthly checklists. This has served as a visualreminder for timely, sharedreplenishment of stock by all teammembers.

Some jobs were not being completeddue to a lack of communication.Stock replenishment now has a visualreminder /check list so stock isreplenished before it runs out.

Ideas tested which were successfulThe focus groups resulted in stafffeeling empowered to raise concernsand test their own solutions withintheir own team.

The communications board provedsuccessful pathology wide promotinginterest from all areas.

How this improvement benefitswomenIncreased engagement, versatility andadaptability of staff who are workingbetter as a team, ensuring animprovement in the quality of theprocesses. This results in more rightfirst time and a continual flow ofwork.

How will this be sustained andwhat is the potential for the future/additional learning?• Regular huddles will continue• Maintain the staff suggestions folderon the server

• Continue with the focus groups notlead by line managers with a view toincorporating a two waycommunication pathway

• Communications board continuallyupdated by all members of theteam.


DOING IT

• Doing it daily• Fair process• KPI results deliveredweekly

• Daily focus on keygoals

• Comms discussed &made meaningful

• Opportunity to raiseissues

• Huddles continued inabsence of themanager

DOING IT WELL

• Staff engaged &contributing

• Issues discussed &feedback

• Blockages identifies &acted upon

• Actively seeking inputfrom the whole team

• Focus on goals & howto achieve them

• Volunteers to ownissues

• Shared air time• Structure changesregularly to keephuddle fresh

• Staff are asking forhuddles

• Less email traffic

Figure 12: Great huddles



Daily huddlesA further mechanism for engaging staff is‘huddling’.

A huddle is a DAILY, short and snappygathering of a team led face to face by theteam’s manager. Taking no more than 15minutes each day, they should be conducted in ahigh involvement style.

There are three key elements to include in everyhuddle:

1. Focus – on key goals and responsibilities forthe day

2. Clarity – clear, relevant and timely informationto help staff perform their daily roles

3. Commitment – to listen and act on staffviews, ideas, concerns and to feed backprogress.

More supporting information is available at:www.improvement.nhs.uk/diagnostics

Decision making in a huddle – Fair processMany people think that in order to be fair, aprocess must be either consensual ordemocratic. Not so. Although a fair processgives every idea a chance, it is the merit of theidea – not the agreement of all involved – thatdrives the decision making

What constitutes a fair process? There arethree principles

1. Engagement – getting individualsinvolved in decisions by asking for theiropinions and allowing them to refute themerits of one another’s assumptions andideas. Not only does this sharpen everyone’sthinking, it communicates management’s respectfor their people’s ideas which, in turn, generatesa higher level of commitment from thoseinvolved.

2. Explanation –helping everyoneaffectedunderstand thereasons for thefinancialdecisions. Givingexplanation helpspeople see howtheir own opinionshave been takeninto considerationand builds theirtrust inmanagement’sintentions.

3. Expectationclarity – makingexplicit the newrules of the gameonce the decisionhas beenreached. What

are the new requirements? Who will beresponsible for what? How will individuals beevaluated? It matters less what the newexpectations are than that they are clearlycommunicated and understood.

ACHIEVINGPERFORMANCE

RESULTS

• Strong correlationbetween huddles andimplementedimprovements

• Increased KPIperformance

• Evidence of strengthbased management

• Evidence of stretchtargets



Fair process profoundly influences attitudes andbehaviours critical to high performance. It buildstrust and unlocks ideas. With it, managers canachieve even the most painful and difficult goalswhile gaining voluntary cooperation of thepeople affected. Without fair process, evenoutcomes that people might favour can bedifficult to achieve.

Consider this exampleFaced with sharply decreasing domestic demand,an elevator company brought in consultants tohelp devise a plan for shifting to a more efficientmanufacturing process. The plan itself wassound; it gave employees greater autonomy andplaced a high priority on preserving jobs. Butthe process of developing the plan keptemployees in the dark. The need to cutmanufacturing costs was never explained,employees were never introduced to theconsultants who suddenly appeared one day,and the final decisions were simply presented -without employees having had a chance to offerinput. Not surprisingly performance plummetedand employees trust in managementevaporated.

Think about your huddles. Are you practicingthe ‘3 Es’ every day? Do your team just seethem as ‘time away from the bench’ whilst youtell them what they need to know before going‘back to work’, or are you having a two waydiscussion?

Remember, fair process doesn’t mean thatdecisions are made on the basis of voting or‘who shouts loudest’.

It is sometimes easy to assume that people areonly concerned with what is best for them.There is evidence that when the process isperceived to be fair, most people will acceptoutcomes that are not wholly in their favour.People realise that compromises and sacrificesare necessary.

Taken from Fair Process: Managing in the KnowledgeEconomy by W.Chan Kim and Renee Mauborgne - a HarvardBusiness Review On Point Publication (March 2000)

SummaryA daily meeting was introduced duringphase one of the 14 day turn aroundproject. In phase two the approachand information given at the meetinghas been altered.

How the changes wereimplemented• Procurement of a white board todisplay the rota for the week

• Visual management used to identifythe roles of each staff member foreach day including screening,checking, practical work,supervision, annual leave or trainingcourses

• Daily laboratory targets are indicatedon the board

• Individual screening targets, in termsof numbers of trays to be screened,were set for each screener takinginto account the daily laboratorytarget and the duties of the screener

• The supervisor, who is responsiblefor the work flow for the day leadsthe huddle

• Problems are identified andcorrected straight away.

Measurable outcomes and impactThe laboratory contribution to the 14day turn around has been maintainedwith the process from reception toscreening remaining steady at twodays.

The supervisor is more empoweredand engaged in delivering the targets.

Ideas tested which were successfulThe huddle has been led by thelaboratory manager or the servicemanager.

A section on the notice board called‘need to know’ was successful inensuring that the huddle chair and allstaff were made aware of importantissues such as training events ofexternal quality assurance assessments.

Sustaining huddlesBarts and The London NHS Trust

Ideas tested which wereunsuccessfulAllowing staff to remain at their desks,some distance away from the noticeboard, was not successful as some staffwere not engaged in the meeting.

It is important that everyone standstogether, away from workstations toensure all are engaged and involved inthe huddle as it is a short timeframewithin which to listen andcommunicate.

How will this be sustained and whatis the potential for the future/additional learning?The daily huddle has helped to improvework flow and correct problems in atimely manner. More regular meetingsin histology with reception MLAs hasbeen discussed.


Case study 23





Visual ManagementA gallery of visual management is available at:www.improvement.nhs.uk/diagnostics

SummaryVisual management provides an ‘at aglance’ means of observing whichtasks have been completed and whichare outstanding.

Understanding the problem• Lack of communication between alldepartments regarding levels ofwork in progress

• Necessary to ask numerouscolleagues to establish current workstate

• Core and support tasks e.g.equipment checks, dealing withdeliveries, were missed due toassumptions that someone else hadalready completed them

• Wastes of waiting and motionexperienced due to constant needfor staff members to chase/checkwhether work had been completed

• Visual management for ‘everythingin its place’ already implementedand aiding efficiency. Thishighlighted the use of additionalvisual cues to act as prompts fortask completion.

Visual managementThe Leeds Teaching Hospitals NHS Trust

How the changes wereimplemented• Task lists were compiled for eacharea with supporting staff memberrotas identifying who is designatedto perform the tasks

• Daily (am/pm) and weekly dutieswere identified and charts drawnwith red/green tags to indicatewhether task was pending orcompleted

Case study 24

• Visual prompts were sited in workareas to promote standard workingpractices.



• Visual charts used as triggers toinitiate actions if tasks notcompleted

• Daily ‘late-afternoon’ all-departmentseniors meeting used to verify allplanned daily activities were eithercomplete or ‘on-track.’

Measurable outcomes and impact• Visual task lists provide platform tocommunicate crucial info quickly.

• Triggers necessary actions at giventimes throughout the day

• Required duties completed atallotted am/pm times on daily task list

• Reduces waste in form of time takenfor verbal communications withnumerous staff members 127 hoursper year

• All staff can see current state of playat any given time

• Staff morale improved as nofrustrations due to lack ofcommunication

• Standard working practice put intooperation.

Ideas tested which were successful• The use of visual management is asuccess

• Use of red/green tags on task chartsboth serve as ‘at-a-glance’completion and early-warningmonitoring of potential delays

• Visual prompts in work areas remindstaff to take action i.e. to filter stainsbecause they were placed at pointof use (on equipment).

Ideas tested which were unsuccessfulPositioning of visual management wasnot at point-of-use initially. Staff didnot observe notices so they weremoved to more appropriate positions(e.g. on stainer lid).

How this improvement benefitswomenContinuous improvements in efficiencythrough removal of waste reduce TAT’sfor results.

How will this be sustained andwhat is the potential for the future/additional learning?• Visual management can be adaptedto fit the needs of a changingworkplace:•Agreed changes to howoften (or when through the day)tasks are performed can bereflected visually and immediatelyon daily task boards

•Extra tasks can equally be added ascan creation of new visual cueswhen standard tasks are changed.

High quality of work maintainedthrough recording changes on SOPsensuring all (not just some) staffmembers now complete routine tasksat allotted times.


Tasks completed

Tasks notcompleted (actionrequired)

SummaryImproved process for identifyingbloodstained Liquid Based Cytology(LBC) vials at the reception stage andreduction of previous delays inprocessing such samples.

Understanding the problemNot all bloodstained vials were beingsent for processing with acetic acid toremove the blood at the initialreception stage. Many bloodstainedsamples were processed as routinesamples on the T3000 machine andrequired later reprocessing with aceticacid.

• Large number of samples that weresent back for reprocessing – five orsix per day

• These samples were being tracked intwo ways. A visual alert wasattached to reprocessed work as itthen required fast tracking throughthe rest of the laboratory. A list ofincomplete work from thelaboratory computer system wasalso used to keep a track on theprogress of delayed samples

• The wastes identified were defects(and subsequent reworking), overprocessing (double tracking), waitingand motion (of staff completing therework and tracking the samples).

How the changes wereimplemented• Photographs of bloodstainedsamples were taken and made intoa laminated visual managementsheet to be used at reception

Visual management for processing blood stained samplesBarts and The London NHS Trust

• The visual management sheetshowed which samples could beroutinely processed on the T3000machine and which samples neededto be treated with acetic acid

• The request forms from samplestreated with acetic acid were taggedwith a blue flag as these were outof step with the routine workmaking them easy to identify andensuring that the samples werescreened in order (first in first out).

Measurable outcomes and impactThe number of samples sent back forreprocessing has reduced to one ortwo per day. Based on a reduction ofreprocessed work of four samples perday the yearly consumable savingsequate to £3,243.93 per year.

The turn around for previously re-processed bloodstained samples hasimproved by one to two days.

By processing the acetic acid treatedsamples on the T3000 machine(previously done on a T2000) one hourof MLA time has been saved per day.

Ideas tested which wereunsuccessfulInitially the reprocessed samples wereprocessed on the T2000. This was amanual process and meant that oneMLA was tied to the machine for anhour per day.

How will this be sustained andwhat is the potential for the future/additional learning?The changes have becomestandard procedure for dealing withbloodstained samples at specimenreception.


Case study 25



Data should be used to evidence the performanceof each process across the whole pathway.

Statistical Process ControlStatistical process control and pathway analysertools are available on the NHS Improvement systemat www.improvement.nhs.uk/improvementsystem

Cervical Screening Statistical Enquiry(CSSE) - Open ExeterA CSSE produces a ‘skyline’ plot of turnarounddata from the date of test to the expected date ofdelivery of the letter.

Cyres is available at all recall agencies and in somelaboratories.

13. Information to support the processInstructions for running this report can be foundat: www.improvement.nhs.uk/diagnostics

Understanding short and long term demandLaboratories should monitor the pattern ofdemand to ensure operational resource planningmatches peaks and troughs.

Recall agencies can inform the laboratory of thenumber of women invited for screening eachmonth. Known response rates and delays can beapplied to predict short term workloads.

PCTs are in a position to advise laboratories onlonger term population forecasts that should drivesuccession planning.



Figure 13: Examples of a Cervical Screening Statistical Enquiry skyline plots

As detailed in the first Cytology ImprovementGuide:

• Section 6, ‘Understanding where you are’, and• Section 9, ‘Establish the measures’,

Suitable measures need to be identified and agreedat the start of any improvement project in order toassess the impact of changes being tested. As aminimum, these should consist of the globalmeasures outlined below, with additional sub-measures being identified locally.

14. Measures



Delivery

• 100% of resultswithin 14 days

• 50% of resultswithin 7 days

Safety/quality

• 100% defect freerequest cards(defect free tobe agreed atlocal level)

• 100%appropriate andwithin scopetesting

• Reduced defectswithin thesystem (eg dataentry errors, nonhits at recall

Efficiency/effectiveness/cost

• Time saved byreducing waste

• Reduction inovertime

• Cost avoidanceby bringing workin-house

• Productivitysavings fromdemand andcapacitymonitoring

Team developmentand leadership

• Engagementsurvey %improvement

• 100% staffattended Leanawarenesstraining

• Reduction instaff sickness

Responsive topatients andusers

• TAT sharedwith 100%of users

Global measureSub-measure/potential local measure

Figure 14: Example of suitable measures identified and agreed at the start of an improvement project



As outlined in the first Cytology ImprovementGuide, a simple web-based tool has beendeveloped to help with identifying improvementareas across the whole pathway.

The tool enables assessment of the process flow,communication across the pathway, staffengagement and development, prevention ofdefects, sample taker training; and provides:

• A graphical representation of what the servicelooks like

• An overall percentage score for how the serviceis performing

• Percentage scores across all sections of thepathway to show areas of strength andweakness

• Recommendations from other teams anddirection on where to look for help

• Print out of the score and graph• An opportunity to compare the service withpeers (anonymously).

Access the tool at:www.improvement.nhs.uk/cytology/assessmenttool

15. Cytology Self Assessment Tool

Figure 15: Cytology Self Assessment Tool



In February 2006, the University of Sheffield,School of Health and Related Research (ScHARR)report made five key recommendations including‘merging workload from smaller laboratories’which would result in potential savings.

During phase one and phase two, a number ofchanges to service provision have beencommissioned which have impacted on a numberof the pilot sites, including:

• Central Manchester University HospitalNHS Foundation Trust

• Anglia Support Partnership• West Anglia Pathology Cytology Laboratory• Sheffield Teaching Hospitals NHSFoundation Trust

• East Midlands Screening Services.

During the period of consolidation it is importantto stick to the key principles established from theoriginal improvement activity.

Full case studies will be developed postconsolidation to demonstrate the benefits andlearning and will be available at:www.improvement.nhs.uk/diagnostics

16. Consolidation of services



SummaryConsolidation of Addenbrookes, WestSuffolk and Hinchingbrooke CytologyLaboratories into a single site in2004/5, coupled with being an NHSImprovement phase one pilot site in2008/9, provides flexibility to managefluctuation in demand and ensure70,000 women locally receive apredictable service delivering the 14day turnaround vital sign.

Understanding the problemAddenbrookes, West Suffolk andHinchingbrooke Cytology laboratoriesunderwent a review of thesustainability of their services.Difficulties in meeting turnaroundtimes and recruiting staff, coupledwith space restrictions, fluctuatingworkloads and the need to convert toLiquid Based Cytology (LBC) led to thePCTs and laboratories agreeing tomerge the three sites and build a newfacility. West Anglia PathologyServices Cytology Laboratory wascreated.

How the changes wereimplementedA whole end to end pathwaycollaborative approach was adoptedwith all PCTs, laboratories and recallagencies involved. A consolidationplan was established which detailedworkforce planning, transport,technical and operational delivery,premises and equipment, IT and newtechnology.

Staff consultation (four meetings) tookplace during the preparation processat each location so that staff couldraise concerns. There was anopportunity to visit the unit prior tothe move and meet staff from thedifferent sites. A decorationcommittee was formed withrepresentation from the different sitesto choose desks, layouts and colourschemes giving input into the workingenvironment.

Consolidation of cytology laboratoriesWest Anglia Pathology Services Cytology Laboratory

Case study 26

Key changes implementedthroughout consolidation• Staff suggested and voted on thenew department’s mission statement

• Feedback to practice managers andsamples takers regarding turnaroundtimes and importance of right firsttime samples

• Suitable transport links establishedto ensure timely transfer of samplesto laboratory

• Preparation for and management ofdifferent laboratory systems

• Staff communication groupsestablished

• A staff suggestions box and boardwas created

• Daily demand and capacity planning.Using NHS Cancer ScreeningProgramme (NHSCSP) guidance, adaily target of 25 slides per screenerwas set with monthly performancetracking and feedback to screeners

• Team target established to sign outmore cases than received (to reducebacklog) with weekly monitoring ofthe outstanding cases

• Appointment of Consultant BMS tosupport abnormal pathway

• Changes made to routine/contractedhours and overtime restrictions.More slides screened within routinehours, reducing £/slide rate

• Review of standard operatingprocedures in line with new ways ofworking

• Changes made to priority workstream making more cases routineand improving overall TAT.

Following the success of theconsolidation, West Anglia PathologyServices Cytology Laboratory wasselected as an NHS Improvementphase one pilot site. The principal aimwas to identify practical ways tofurther reduce turnaround times andimprove quality, safety and productivityin line with the Cancer ReformStrategy commitment that all womenwill receive their screening tests resultswithin two weeks by 2010.

Changes implemented during thepilot project• Improved visual managementthroughout lab

• Small batch sizes for processing andscreening

• Target date established• Daily lab briefings• Improved communication/suggestions board

• ‘Pat on the back’ board to feedbackcompliments received

• Removal of priority workstream• Removal of waste, introduction ofmore standard working, 5S.

For further details, refer to theCytology Improvement Guide(November 2009) at:www.improvement.nhs.uk/diagnostics– case studies 8, 21, 23, 26 and 31.

Changes implemented to sustainthe 14 day TAT• Work sorted into date taken orderfrom point of receipt.

Measurable outcomes and impactKey outcomes• 2005 TAT (pre-consolidation): 12%results within 14 days

• 2007 TAT: 31% results within 14days

• 2008 TAT: 95% results within 14days, 6% within seven days

• 2010 TAT: 100% results within 14days, >90% within seven days

• Overtime ceased• Ideal workforce structure establishedusing BSCC guidelines

• Business continuity strategy in placeincluding demand and capacityplanning.



Ideas tested which were successfulPrior to consolidation all staff involvedwere invited to visit the temporary andnew premises and meet newcolleagues.

• Post consolidation, daily huddleshave allowed for two waycommunications and ensured anyquestions or concerns can be raisedand acted upon in a timely manner

• Regular cytology updates vianewsletters, website and at sampletaker training events have ensuredservice progress and improvementsare communicated to all involved

• Adequate provision of computersystems (LIMS and individual PCs)has ensured all staff can performtheir daily duties as and whenrequired

• Assessing and adjusting daily/weeklycapacity plans to meet demandensures predictable turnaroundtimes can be achieved.

Ideas tested which wereunsuccessfulCommunication could have beenbetter during the consolidationprocess. This is key to a successful,smooth changeover.

How this improvement benefitspatients70,000 women locally receive apredictable service delivering the14 day turnaround vital sign.

How will this be sustained andwhat is the potential for the future/additional learning?Root cause analysis of 14 dayturnaround breaches will continue tobe performed and countermeasureswill be tested accordingly.

Cyres database will continue to beused to integrate colposcopy and labinformation, which improves failsafeand quality management.

Should a similar consolidation activityoccur in the future, lean principles willbe applied by value stream mappingthe current service(s) with all staff anddeveloping the future state servicewith minimal waste. Workingenvironments would be set up to keepsamples flowing throughout thepathway.

ContactRoseanna [email protected]

SummaryConsolidation of East Anglia FamilyHealth Service (FHS) functions into asingle regional support service, coupledwith being an NHS Improvement phaseone pilot site in 2008/9, ensures over150,000 women locally receive aguaranteed and predictable call/recallservice in line with the 14 dayturnaround vital sign.

Understanding the problemIn 2007, a review of the FHS primarycare service functions in Norfolk, Suffolkand Cambridgeshire was undertakenand it was decided to create a singleregional service, run by Anglia SupportPartnership, covering five PCTs.

With this, four key challenges arose forthe cervical screening service:1. Integrate three ways of working intoa single standardised structure.2.Maintain communication channelswith PCTs, primary care andlaboratories.

3. Ensure women are recalled on timeand result letters are postedpromptly.4. Complete the 14 day turnaroundtime project with NHS Improvement.

The plan was to move to a single servicewhich would still operate out of thethree offices, followed later by a moveto two offices in January 2010. As aresult, staff from the three primary careservices offices felt apprehensive andwere concerned about their future.

How the changes wereimplementedA detailed changeover plan was createdwhich included workforce planning,technical and operational delivery,premises and equipment.

Regular face-to-face primary careservices staff consultation briefings wereconducted for all three offices, usingstandard agendas and positioningstatements. At every opportunity, staffwere reassured that they would not beasked to work harder or faster, butsimply work differently. They were given

Consolidation of the primary care screening serviceAnglia Support Partnership

Case study 27

recognition for their efforts in deliveringsafe and reliable services and were askedto continue with this.

Three staffing structures were integratedinto a single structure and three versionsof job descriptions were reviewed andstandardised to ensure that tasks wouldbe completed in the same way,regardless of location. All staff weretrained to the same new standards.

Communication with PCTs wasstandardised to ensure that consistentmessages were provided and GPpractices were informed of the newregional service plans and their newcontact details.

At the same time, IT and telephonysystems were reviewed and improved.Remote access was installed so that thethree FHS databases could be shared.With dedicated informatics support,thorough testing was carried out prior tothe office changes to ensure there wouldbe no interruption to service.

Through involvement with the NHSImprovement 14 day turnaround timeproject, the following changes were alsomade:• Review of postage andimplementation of first class post

• Improved dispatch timing for resultletters

• Improved automatic hit rate on lablink files

• Enhanced use of Open Exeter inrelation to data collection/programme monitoring, particularlythe Cervical Screening StatisticalEnquiry (CSSE) which generatesskyline plots (see next section).

Measurable outcomes and impactA single regional primary care supportservice has been established, operatingfrom two locations, ensuring thatwomen are recalled on time and resultletters are posted promptly. Through theuse of the CSSE application, weeklyskyline plots can be generated whichallows for real time monitoring of the 14day vital sign (see graphs on page 61)

Positive feedback from PCTs and primarycare has been received since the move totwo offices in January 2010. There hasbeen no interruption to services and thechangeover was completed within 24 hours.

Ideas tested which were successfulRegular communication with all staffand stakeholders involved has ensuredsmooth changeovers with nointerruption to services.

By creating standardised job descriptionsand training all staff to the same newstandards, a more flexible workforce hasbeen created that can respond todemand changes such as the increaseduptake of cervical screening testsfollowing the news of the terminalillness and death of Jade Goody.

Adequate provision of IT systems hasensured that all staff can perform theirdaily duties as and when required.

Ideas tested which were unsuccessfulAlthough all ideas tested weresuccessful, one point of caution wouldbe the time allocated to arrange ITchanges such as security settings,remote access and integrated telephonysystems. Ensure you dedicate sufficienttime for these activities and link in withIT support at the earliest opportunity.

How this improvement benefitspatientsOver 150,000 women locally receive apredictable call/recall service in line withthe 14 day turnaround vital sign.

How will this be sustained andwhat is the potential for the future/additional learning?The CSSE application has recently beenupdated and allows the ‘anticipated dateof delivery’ to be extracted and includedin the skyline plot. The full end to endturnaround time can now be monitoredwith ease (see section 13, Information toSupport the Process, for further details).

ContactClaire [email protected]





West Anglia TAT December 2009 – Sample taken to call/recall input

NNUH TAT December 2008 – Sample taken to call/recall input

West Anglia TAT December 2008 – Sample taken to call/recall input

NNUH TAT December 2008 – Sample taken to call/recall input

Figure 16: Skyline plots showing real time monitoring of the 14 day vital sign



Pilot Site

Leeds PCT and The LeedsTeaching Hospitals NHS Trust

Hull Royal Infirmary and Hulland East Ridings PCTs

Pennine Acute HospitalsNHS Trust

Norfolk and Waveney CellularPathology Network (Norfolkand Norwich University HospitalNHS Foundation Trust

West Anglia PathologyCytology Laboratory(Cambridge UniversityHospitals NHS Foundation Trust,Addenbrookes Hospital andAnglia Support Partnership)

Barts and The LondonNHS Trust

Somerset and West DorsetCervical Screening Service(Taunton and SomersetHospitals NHS Trust)

Ashford and St Peter’sHospitals NHS Trust

North West London NHS Trust(Northwick Park Hospital)

Central Manchester UniversityHospital NHS Foundation Trust

Newcastle upon Tyne HospitalsNHS Foundation Trust

Sheffield Teaching HospitalsNHS Foundation Trust

Derby Hospitals NHSFoundation Trust

University Hospitals Coventryand Warwick NHS Trust

Heart of England NHSFoundation Trust

Winchester & EastleighHealthcare NHS Trust

Phase

One

Two

SHA

Yorkshire &the Humber


North West

East ofEngland

East ofEngland

London

South West

South EastCoast

London

North West

North East


EastMidlands

WestMidlands

WestMidlands

SouthCentral

Annualvolume

99,000

65,000

45,500

66,000

70,000

65,000

50,000

35,900

60,000

102,900

59,000

100,000

59,000

70,000

45,000

38,500

LabProcessor

Surepath

Surepath

Surepath

Thinprep

Thinprep

Thinprep

Thinprep

Thinprep

Thinprep

Surepath &Thinprep

Surepath

Surepath

Surepath

Thinprep

Thinprep

Surepath

Lead Contact& Email

Mrs Hazel [email protected]

Ms Susan [email protected]

Mr Richard [email protected]

Dr Xenia [email protected]

Ms Roseanna [email protected]

Mr Geoffrey [email protected]

Dr Simon [email protected]

Mr Behdad [email protected]

Dr Tanya [email protected]

Ms Yvonne [email protected]

Mr David [email protected]

Mrs Kay [email protected]

Mrs Alison [email protected]

Dr Steve [email protected]

Dr Bruce [email protected]

Mr Craig [email protected]

No.

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17. Appendix

Total Samples: 1,030,800



18. AcknowledgementsOur thanks go to all the phase one and phase twopilot sites who have tested and implemented changesand diligently produced the case studies for others tobenefit from their pioneering efforts.



NHS Improvement Team

Lesley [email protected]

Simon KnowlesNational Clinical Lead for [email protected]

Jamie BallochNational Improvement [email protected]

Peter GrayNational Improvement [email protected]

Amy HodgkinsonNational Improvement [email protected]

Suzanne HorobinNational Improvement [email protected]

Alan LewitzkyNational Improvement [email protected]

Susie PeacheyNational Improvement [email protected]

Carole SmeeNational Improvement [email protected]

Lisa SmithNational Improvement [email protected]

19. Contact detailsIan SnellingSenior [email protected]

Ana DeGouveiaDiagnostics Team [email protected]: 0116 222 5122 or 0116 222 1423

Maggie HerbertInformation & Systems Development [email protected]





Policy EstatesHR / Workforce CommissioningManagement IM & TPlanning / Performance FinanceClinical Social Care / Partnership Working

Document Purpose Best Practice Guidance

Gateway Reference ?????

Title Continuous improvement in cytology: sustaining andaccelerating improvement

Author NHS Improvement

Publication Date 5 October 2010

Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs,Medical Directors, Directors of Nursing, Directors ofFinance, Allied Health Professionals, GPs, ServiceImprovement Personnel

Circulation List

Description The Cancer Reform Strategy made a promise that allwomen would receive their screening test results withintwo weeks by 2010, the next challenge wassustainability. This publication demonstrates how thepilot sites have continued to embed their improvementsthroughout the cytology pathway. It includes practicalexamples in reducing turnaround times, improvingquality, safety and productivity.

Cross Ref Cytology improvement guide: achieving a 14 dayturnaround time in cytology

Superseded Docs N/A

Action Required N/A

Timing

Contact Details NHS Improvement3rd Floor, St John’s House,East Street, Leicester LE1 6NB

Tel: 0116 222 5184


For Recipient’s Use

DH INFORMATION READER BOX

NHSNHS Improvement

©NHS Improvement 2010 | All Rights ReservedPublication Ref: IMP/comms001 - September 2010

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5184 | Fax: 0116 222 5101


NHS Improvement

With over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensurevalue for money to improve the efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart, lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

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Continuous improvement in cytology - sustaining and accelerating improvement

Documents

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