how we reduced turnaround times

Hereford HospitalsNHS Trust

Rapid Improvements in Pathology – June 2006

Neil WestwoodService Transformation and Hereford Hospitals NHS [email protected]

Jane JonesClinical Systems EngineerHereford Hospitals NHS [email protected]

Expert Lean support and facilitation provided by KM&T www.kmandt.co.uk

AFTER LEANNO WASTE, LITTLE VARIATION, NO DEFECTS and QUICK

“Push the Button” for Lean Transformation in Healthcare

© NHS Institute for Innovation and Improvement

BEFORE LEANLOTS OF WASTE, HIGH VARIATION, DEFECTS and SLOW


Impact of ImprovementsBiochemistry


Metric Before change

After change

Ideal state

Improvement

Saving£££ a year

Turnaround time(from receipt to results available)

62 minutesUp to 2 hours

38minutes

30 minutes

40% reduction

2 beds a day£365,000* A&E targets met

Specimen pick up timeSpecimens waiting to be picked up

13 minutesUp to 50minutes

1 minutesUp to 4 minutes

0minutes

93% reduction

£10,000

Double handling(Labelling only)

40 minutes a day

0 minutes a day

0minutes

Totally eliminated

At least£3000


Staff identified waste and delays

XX

X X XX

XX

X

Non value adding steps

Delays and waste

Now all eliminated


Demand data for Biochemistry and Haematology

4 GP vans all arrive together, causing chaos

Specimen Reception -Before

Sorting area

ONLY


Dispatch (couriers pick up parcels here)

Specimen drop off

Sorting area

FIFO - Lane 1

FIFO - Lane 2

Large specimen drop off

3 Centrifuges

Hereford HospitalsNHS TrustSpecimen Reception –

After –

the specimens now flow

Hereford HospitalsNHS TrustOur Improvements

Improvement implemented ImpactManned specimen reception

Labelling, centrifuges and booking relocated in specimen reception and synchronisedFirst in First Out (FIFO system introduced)PCT GP demand staggered (batches reduced).

Improved flow, waste eliminated

and variation reduced.

Turnaround time reduced by 40%

in 7 days

Photo on outside of cupboard shows where to find spillage kits – saves staff time searching


Hereford HospitalsNHS TrustOur Improvements

Improvement implemented ImpactPhlebotomist sends work via POD system

Specimen reception work areas clearly labelled with instructionsPhotos added to PODS and cupboardsStandard work introduced for labelling, centrifuging and booking in

Improved flow, waste eliminated

and variation reduced.

Turnaround time reduced by 40%

in 7 days

Visual management on air tubes. A&E PODS can be quickly identified



After


Before40 minutes a day saved

Specimens were put in rack then taken to centrifuge, unloaded and put in centrifuge.

Specimens put directly into centrifuge carriage - stops double handling (in 20’s at peak times). These are loaded straight into centrifuge.


After


Before

Staff booking forms in - in specimen reception.

Forms synchronised with specimens being spun. This prevents rework at scanning and specimens can be loaded quicker onto analyser.

Staff booking in – in biochemistry. Forms NOT synchronised with specimens being spun. This causes delays and rework at scanning, causing delays at the analyser.


After


Before

Work waiting to go into centrifuge. Various things left waiting to be processed.

Centrifuges moved into specimen reception freeing up a whole work area. Work place tidied up.

Steve Jones – Director of Pathology Hereford Hospitals


Some tipsLean Sigma –complementary not competing

• goals and strategy must drive our improvement effort, not methods

• actively involve seniors leaders • dedicated service improvement resources

accelerate change• focus on the system, the flow that creates

value, then apply the tools• get results quickly• learn by doing – listen to staff• tools are not prescriptive – use what works!!


Important Lessons Learned

cartoon copyright © U of M

• Focus on the system, the flow thatcreates value, then apply the tools.

• A way of thinking underlies the system and the tools.

• Cherry-picking the toolsis not enough

Learn the thinking by doing

Systems Thinking Techniques

Hereford HospitalsNHS TrustHIGH LEVEL PATIENT JOURNEY

Mapping Phases

Preparation Agreeing on what process to study, how to map it and who will participate and what resources are required.

Current StateAgreeing on a well understood map of the current situation, with quantifiable data

Future StateAgreeing on a shared vision improved future state (without all the waste and delays).

Agreeing on how to implement the future state vision, with named staff responsible for actions.

Planning

Team starts to map Pre-operative Assessment, Daycase and Theatres patient journey mapping –Day 1


Hereford HospitalsNHS TrustData

collected on causes of cancelled operations –36% of the cancelled operations were because patients were not fit.

Current State – Preoperative assessment, daycase and theatre map


Flow of patients

Spaghetti Diagram – show movement and unnecessary journeys


Non Executive Director - Sebastian, participates and discusses issues with staff



Neil Westwood from Service Improvement Team validates the map with endoscopy staff

Current state map

Future State – staff from Preoperative assessment, daycaseand theatre work together to design the new improved system


Current State

Future State


Future State – almost complete (duplicate steps eliminated), delays eliminated, less waste


Improvements analysed in terms of cost and benefit

High benefit and low cost improvements (we will do these now)

High benefit and high cost improvements (we will build these into plan but won’t do at the moment)


Director of Finance -Martin Woodford and Peter Gorin – Clinical Governance join the activities

Hereford HospitalsNHS TrustChief Executive asks questions and

challenges teams. Action plan produced.

Improvements in Pharmacy

Reducing dispensary turnaround times and errors

Improvements in Pharmacy

• Involving staff• Understanding processes & demand• Improving flow • Eliminating waste• Reducing dispensing times & errors

Medicines collected from stores

TTO arrives via POD/ hatch/ porters

Clinical check by pharmacist

Prioritise as fast track or standard track

Labels printed

For collection by porter/ ward staff/POD

Accuracy checkassembly

TTO dispensary process

Arrival Stamp in Clinical Check Prioritisation

Labelling Assembly Accuracy check

Standard track TTO Dispensary Process

Collection by porter

Av = 3.5 mins(varies between 1 and 6 mins)


Av = 24.8 mins(varies between <1 and 380 mins) Av = 5.7 mins

(varies between 0 and 30 mins)



Av = 3.75 mins(varies between 0 and 18 mins) Av = 101 mins


Av = 3.64 mins(varies between <1 and 16 mins) Av = 53 mins


Average time = 220.8 minutes, varying from 120 to 250 mins (one exception)Times in red font are waiting times = non value adding

Average time = 220.8 minutes, varying from 120 to 250 mins (one exception)Times in red font are waiting times = non value adding

Arrival Stamp in Clinical Check Prioritisation

Labelling Assembly Accuracy check

Fast track TTO Dispensary Process

Collection by porter

Collection by ward staff

Av =2.32 mins(varies between 1 and 7 mins)

Av = 11.3 (varies between 0 and 41 mins)

Av = 3.25 mins(varies between <1 and 9 mins) Av wait between end of clinical check and

labelling =20.76 mins (varies bet 2 and 85 mins)

Av =5.19 (varies between 1 and 27 mins)

Av =3.26 (varies between <1 and 16 mins) Av = 63.7 mins


Av = 3.47 mins(varies between 1 and 15 mins )



Average time = 94.1 minutes, varying from 39 to 140 mins (& 2 special causes)Times in red font are waiting times = non value adding

Average time = 94.1 minutes, varying from 39 to 140 mins (& 2 special causes)Times in red font are waiting times = non value adding

Step bypassedStep bypassed

% Value adding time in Fast Track TTO dispensing process

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

09:09 09:27 10:28 10:44 10:52 10:52 11:10 11:36 12:25 11:44 12:52 12:55 12:59 13:00 13:31 13:45 13:56 14:40 14:44 14:54 16:10 16:47

TTO arrival time in pharmacy

% o

f tot

al ti

me

% value –adding time in each process

% value –adding time in each process

% value adding time in Standard Track process

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

09:11 09:46 09:53 09:54 09:55 09:58 09:59 10:00 10:01 10:02 10:31 10:52 10:52 11:22 11:24 12:20 12:22 12:25

TTO arrival time

Measuring demandNumber of prescriptions received on busiest day

Hourly demand in dispensary on Thursday 29.06.06

0

10

2030

40

50

day b

efore

chec

ked on

ly

08:00

-08:59

09:00

-09:59

10:00

-10:59

11:00

-11:59

12:00

-12:59

13:00

-13:59

14:00

-14:59

15:00

-15:59

16:00

-16:59

17:00

-17:59

hour

num

ber o

f scr

ipts

to followCDA&Epack downclozarilclin trial CommpsychiMM profileNon stockIPOP

310 scripts received (need to process 36.5 per hour x 8.5 hours)

Outpatients

TOTAL: 80

Hourly demand Outpatient TTOs

05

1015202530

day b

efore

chec

ked on

ly 08

:00-08

:5909

:00-09

:5910

:00-10

:5911

:00-11

:5912

:00-12

:5913

:00-13

:5914

:00-14

:5915

:00-15

:5916

:00-16

:5917

:00-17

:59

time

num

ber

of T

TOs

Hourly demand inpatient TTOs

05

1015202530

day b

efore

chec

ked on

ly 08

:00-08

:5909

:00-09

:5910

:00-10

:5911

:00-11

:5912

:00-12

:5913

:00-13

:5914

:00-14

:5915

:00-15

:5916

:00-16

:5917

:00-17

:59

time

num

ber

TTO

s

Inpatients

TOTAL: 68

Improving flow

• Reduced steps in process• Layout of staff working stations and

resources• Standard operating procedures• Visual signals – trays and display boards• Reducing variation in demand (batching) • Streaming work – runners, repeaters &

strangers

FORMS FORMS OFOF

WASTEWASTE

I

C

O

MW

P

M

Correction

OverProduction

Motion

MaterialMovement

Waiting

Inventory

Processing

Unevenness

• Interruptions (= hours)• Internal errors (rework = 10 scripts)• Errors incoming scripts (10 – 20 %)

•

•Stock and materials• TTOs

• Variation in demand • Lack of notice

• Staff for machines • Patients for TTOs•TTOs for porters

• Spaghetti diagrams for TTOS• Resource location

• Stock in 2 locations • Labelling porter bags, boxes

• Searching for TTOS• Walking - stock, PCs, phones, labels, printers, bins (8000 steps for pharmacist/ day)

Identifying waste

Reducing waste

• phone interruptions (tracking system) by …. hours per day

• internal errors & rework• Working with prescribing teams re incoming

errors• porter collection & visual board• use of air tubes• staff movement – relocating resources, ie

PCs, equipment, top 20 drugs

Ongoing improvements

• Continual identification of improvements• Staff involvement & time• 5S planned day• Action plan over coming months• Involvement across Trust

how we reduced turnaround times

Education