THE LEAN EXPERIENCE AT NEWCASTLE HOSPITALS CELLULAR PATHOLOGY DEPARTMENT Background For around 12 years, Newcastle Hospitals Royal Victoria Infirmary (RVI) cellular pathology department has been working to develop and continually improve its staff and services, streamlining the processes used to assess the 54,000 requests they receive each year. With increasing patient demand, specialty shortages, a need for quicker diagnostics and a number of pathology sites in the area working in silos, it was decided to merge departments across the city. This initially resulted in bigger NOT better! Leading to the adoption of a lean philosophy. This example explains why the RVI cellular pathology department has become a visiting hot spot for colleagues, pathologists and other service users from all over the world and why the team there won a prestigious Chief Scientific Officer Outstanding Service Innovators award, which celebrates projects which make a difference to patient lives. Led by David Evans, laboratory manager and Terry Coaker, histology operations manager, the department has reduced sample turnaround times by more than half, made significant financial savings, effectively used skill-mix, has incredibly low sickness levels and typically retains its workforce until retirement age. Sound too good to be true it s not. Why did we go lean? The NHS, as we know, is changing in line with continual improvement of standards and an increase in patient expectations. Combine this with technological advances and you have both the desire and ability to streamline processes and provide faster patient diagnosis. Modernising Scientific Careers, developments in the private sector, various government drivers and cost improvement targets combined with patient demographics, require cellular pathology to work differently and adapt to these modern day demands and expectations. 1
CASE STUDY At the start of this journey, in a nutshell, the department was struggling. Processes were clunky, samples were taking too long and backlogs were becoming a normality. Staff were becoming more and more stressed and motivation among them was low. How we did it David Evans identified the problems and began to sow the seeds of change. The department decided to use an all hands on deck approach and stopped doing tasks that weren t necessary. We had to become quite selfish and say no to work or support that wasn t our core business. Anyone who could put a lab coat on did and it was decided to focus on completing samples each day to prevent any backlog if we needed to use overtime we did. Standardisation across the board was key we needed clear processes and we needed to stick to them. Staff engagement from the outset was very important. Throughout both the cultural and process changes made, as you would expect in any large organisation, there was uncertainty and elements of resistance among staff. However with effective communication, when lean processes and tools were introduced, staff felt more involved and motivated. Staff started to realise the benefits, both in terms of their work, outputs and stress levels. Key to this was commitment to the change from the top. Staff needed to see that this wasn t another passing phase but a very real commitment to service improvement. It became evident that 9am to 5pm Monday to Friday working was no longer meeting process demand. So staff were given the opportunity to change their working hours, if desired, with some starting early in the morning to enable processes to be carried out first thing, and 6.15pm finishes to ensure the completion of reporting. Saturday morning working was also adopted. It is important to note that any changes to working arrangements was completely voluntary and if staff wanted to remain working the hours/patterns they were used to, they could. Many new starters however are contracted to start at 7:30am. We also introduced Annual Management Review (AMR) meetings where the department s past performance is assessed and future threats and opportunities considered. Senior managers give short presentations using no more than three slides which highlight within three key points. What went well? What didn t go well? What will you change? A key outcome of the AMR was the production of the department s annual objectives. These are disseminated widely and are included in staff appraisals. This exercise provided a clear strategy and direction for the staff in the department as well as reinforcing the commitment to continuous improvement from the very top. A review was undertaken of the number and the effectiveness of meetings held in the department. The number of meetings was reduced and restructured with the daily huddle as the bed rock. Rules were introduced to make sure that meetings were short but effective. A monthly Gemba Meeting was introduced which saw 2
the most senior staff meet with section leaders at their performance display boards, discussing the section performance. This highly visible meeting ensured staff recognised the commitment of senior staff to the performance of every section within the department. A quarterly board meeting reviews progress of the department s annual objectives set at the AMR. This re-vamped meetings structure ensures that all staff are focused on the department s strategy, its goals and its values. It provides a two-way exchange of information and ideas as well as encouraging staff to come forward with ideas. Many changes were made with the most significant broken down into the following categories. The barriers As with any large organisation the main barrier has been communication, and with a relatively small international staffing group (at present) the relevance of the programme was sometimes missed. However, once the induction day was advertised we received a lot of interest. Releasing staff to attend workshops presented some problems. After discussions with managers, it was agreed that a 90 minute session once a week for ten weeks was manageable. Staff also showed some reluctance at the beginning, especially as the initiative was new. We therefore presented the model as one of support, emphasising how the trust understands the difficulties and challenges faced by new overseas staff, and how it can be used as a tool for coping with the increased demands of appraisal and revalidation where communication is an element. Process changes Visual control boards which clearly outline who does what and when, recorded to allow trend analysis. Daily huddle meetings in each section of the department and weekly huddle reviews to discuss key priorities, issues and progress where the entire team gathers round the visual boards. Assessments of work stations and equipment using spaghetti diagrams to indicate how much time each day is spent walking (and wasted) from bench to equipment and so forth. Continuous flow streams where all appropriately qualified staff take personal responsibility to progress a sample onto the next stage of the process if they see it is ready team working. Identification of waste including correction, overproduction, transport, movement, waiting, inventory, inappropriate processing and people waste. Each of these were looked at in detail to determine what could be changed to save time and simplify processes. 3
CASE STUDY Batch size reduction to improve work flow. Just in time and Point of use to ensure the correct level of stock is maintained without the need for stock cupboards again reducing the time spent by staff to fill shelves. Clever little markers (Kanban) which indicate when stock needs to be ordered. End-to-end connectivity. We dispelled the notion that our responsibility for the service began and ended at the lab door. Engagement with users of the service both upstream and downstream has led to significant improvements in the quality of data submitted and the distribution of reports. This has been a major factor in reducing wasted time and turnaround of reports. Technological changes New techniques and equipment to minimise labelling errors. The use of bar codes on cassette samples has led to 0 per cent of transcription errors over the last three years. Use of digital dictation and voice recognition in macro and micro reporting. Productivity, staffing and outputs Turnaround times for patient samples used to be in the region of 17 days, they are now generally completed in just over four days. Staff turnover is 4.3 per cent, below the trust average of 10.1 per cent. The latest sickness absence rates are 1.5 per cent, whereas the trust average is 3.85 per cent. Development of the support workforce has led to 10 band 6/7 having been replaced with band 4 healthcare science associates. The department created three advanced biomedical practitioner posts who work on histology dissection and who are also involved in the Royal College of Pathologists reporting pilot. It also boasts a new research unit, helping to develop biomedical research and visibility in the health service. Despite a 10 per cent increase in histology requests, the lean transformation has not only absorbed the increase in activity, but also improved the speed of reporting. Use of voice recognition technology has significantly reduced the need for audio typing. A horizon scanning group was formed to review the latest developments and how they can be incorporated into the service improvement agenda. 4
Top tips for other organisations constantly look towards improvement hold an annual management review and set clear objectives and strategy for the organisation regularly review progress of those objectives disseminate objectives widely and include them in annual appraisals have clear leadership which is visibly committed to the principles of continuous improvement have visual display boards and regular huddle meetings encourage/empower staff to address issues and foster innovation through encouragement to those with ideas (even if they aren t very good!) use incidents/complaints as a driver for improvement through the use of root cause analysis use reflective learning as a tool for preventing recurrence of mistakes highlight success both of individuals and of teams challenge unhelpful attitudes and behaviour strive for constant improvement ensuring people are aware of the priorities and targets have mega huddles across departments to ensure cross department working reduce batch size and work in smaller units (do samples as you go, don t let them build up) engage positively with users engage positively with staff to get working patterns that best suit the service 5
CASE STUDY The organisation The RVI has been providing healthcare to communities in Newcastle and the North East for over 250 years. It provides services which are among the safest and most advanced in the country. From broken bones in the emergency department to tropical fevers in the infectious diseases unit, from brain conditions to problems with a child s immune system, it provides a full range of modern healthcare services. Services range from emergency medicine, from our pioneering burns unit to our innovative dermatology unit, the sole provider in the region of the leading edge Mohs micrographic surgery for skin cancer. Several departments are officially designated regional centres of expertise. Some enjoy international reputations, like our neurosciences centre, which treats people with illnesses affecting the nervous system, including the brain and the spinal cord. Patients come not only from Newcastle and across northern England but, for some pioneering treatments, from all over the UK and abroad. The cellular pathology department is the largest of its kind in the northern region and has over 30 consultant pathologists. The department consequently receives referred cases from across the northern region and beyond. For further information contact Terry Coaker, Cellular Pathology, terry.coaker@nhs.net Contact us NHS Employers 2 Brewery Wharf Kendell Street Leeds LS10 1JR Published May 2014 NHS Employers 2014. www.nhsemployers.org enquiries@nhsemployers.org @nhsemployers NHS Employers www.youtube.com/nhsemployers 6