CYTOGENETICISTS IN DISGUISE

Lucy PlattsNE London Regional Cytogenetics Laboratory

Great Ormond Street HospitalACC Spring Conference 2008

31st March to 2nd April Liverpool

Content of presentation

• Importance of booking in and problems

• GOS 2010

• Management concepts

• Outcomes

• Lessons learnt

Importance of booking in• Booking in a key stage affecting patient care

• Increasing complexity

• If booking in is wrong, everything else tends to go wrong!

Problems recognised

• Confusing, stressful, time consuming

• Time pressure, unpredictable

• Need to:-o eliminate failure to test incidentso reduce corrections at report authorisationo increase role clarity

• Transformation project, as part of GOS 2010

GOS 2010

• more efficient by focusing on quality

• GOS 2010 aims to:-o Make things better for patients while improving

financial positiono Make world-class and pioneering work standardo Encourage staff to work better with each other

transformation no waste-no waits-no harm

•Lab joined this hospital-wide initiative

•New operating system rather than patches

Management concepts

• Pragmatic approach

• Used variety of methodologies and techniques:-

o Lean Six Sigma o Multidisciplinary teamo Process mapping, analysis and redesigno PDSA cycleso 5S system

Multidisciplinary team

• Key to Lean Six sigma

• Team of 9, including 2 section heads, scientists, technologist, secretary, improvement facilitator

• Cover variety of roles

• Would have been helpful to have internal supplier – porter, referring clinician

Process mapping, analysis and redesign

• Process map – understand problems and how complicated process is – overview

• Once have map, need to analyse – number of steps and handovers, problems and complaints

• Then redesign process

Cytogenetics – Complete ‘booking-in’ of blood sample process

FIS

H te

am

lead

erA

naly

stC

heck

Lis

t Dut

y S

cien

tist

Sec

reta

ryD

uty

Sci

entis

tT

echn

olog

ist

Update database with patient

details. Print tube labels

Print ‘send out’ sheet and put in

tray

Repeatedly check ‘booking-in’ office

for card arrival

Telephone to confirm test, if

required

Return cards to ‘booking-in’ office

A

Take copy of micro-array cards

to office

Print rapid FISH test

sheet/label

Check details and countersign FISH test sheet

Countersign FISH test sheet

C

D

Bottleneck

Take copy of micro-array cards

to office

FISH, HoD or HoS book in EDTA and

print DNA extraction sheet

Bottleneck

Cell suspension send out?

N

Print ‘send out’ sheet and put in

trayC

No Value

How it worked for us

• Process mapping was fun

• Demonstrated high level of confusion

• Solve problems – indication codes, samples received in error

• Design ideal system

PDSA cycles

• Can test ideas using PDSA cyclesPlan Do StudyAct

Our use of PDSA cycles

• Found hard to use

• Felt constrained by need for accurate SOP in place at all times

• Weekly changes – gradual adjustments

• Need to measure impact of change

• Problems with time delay for measurement and lack of baseline measurements

5S system

Sort – keep only what is neededSet in order – arrange items so easy to findSweep and shine – clean and tidy working

environment

5S system

Sort – keep only what is neededSet in order – arrange items so easy to findSweep and shine – clean and tidy working environment

Standardise – maintain first 3 S’s

Sustain – continuously improve

• Thorough review of SOP

Sweep and shine!

5S system

SortSet in orderSweep and shineStandardiseSustain

• Thorough review of SOP

• Printing of send out documentation

• Still receive old request cards

• Sustain improvements

Outcomes

• No booking in incidents that led to failure to test

• Reduced number of corrections made at report authorisation

% samples with one or more errors at reporting during baseline period

15%

85%

With Changes

No Changes

% samples with one or more errors at reporting during trial period

8%

92%

With changes

No changes

Outcomes

• No booking in incidents that lead to failure to test• Reduced number of corrections made at report authorisation

• Less role confusion

• Solve problemso Request card handovers reduced from 3 to 1

Cytogenetics – Complete ‘booking-in’ of blood sample process – New

Ch

eck

Lis

t D

uty

S

cie

ntis

tS

ecr

eta

ryB

loo

d S

ect

ion

H

ea

d/

Te

am

L

ea

de

rD

uty

Sci

en

tist

Te

chn

olo

gis

t

Unpack sample and card

Record blood volume and date

taken on sticker and attach to the card

Discuss problem case with blood section head or

team leader

Check paperwork and tube details match. Record

differences

Prioritise ‘rapid’ samples

Check database for previous

referral and print listings

Determine tests & tubes required. Complete sticker

Attach/complete appropriate

sticker, e.g. send out storage

AProblem case?

Y

N

Identify samples sent in in error, to be

forwardedB

Outcomes• No booking in incidents that lead to failure to test• Reduced number of corrections made at report authorisation• Less role confusion

• Solve problemso Request card handovers reduced from 3 to 1

o samples to be forwardedo Microarray samples

• Increased lab profile in hospital

Lessons learnt

• Need for constant communication

• Assistance of hospital facilitator

• Knock-on effects of changing one process

• Importance of a multidisciplinary team

• Huge time commitment

Further reading

• www.modern.nhs.uk/improvementguides

• www.institute.nhs.uk‘Going Lean in the NHS’

AcknowledgementsRoger Durack -improvement facilitator Gill HendryAnn Jackson Kamila JagielloRodger PalmerClaire PearceDenise RooneyBev Setterfield

Thanks to Denise Rooney and Mike Tinsley for help with the images