Simon RattenburyHead of Laboratory Service

Microbiology

Seven Day Services supporting Improved Outcomes in Prevention

and Early Diagnosis 13th August

RFH Founded in 1828 Royal Charter 1837

Clinical Instruction for Women

• ~600 beds Reduced from 1200.• 700,000 patients a year from all over the

world.• Employ around 4,600 people and have a

turnover of about £450m.• Major A&E.• All branches of surgery and medicine

What am I Going to Cover

• Scientists / Pathology & its Role• What was the need & why consider 24/7?• What was the clinical need?• The outline planning of the 24/7 case?• What the key points/take home message?• What did it deliver / measure success today?

(time, Money, efficiency etc)

Why 24/7 Why Microbiology

– Patients aren't ill 9 to 5:• Better patient outcomes • Fit with patients care pathways• Antibiotic Stewardship• The new system of working was developed over several

years. It involved changes to staff roles, training and contractual arrangements and was a major restructuring exercise

The 63 heroes who saved our son: Revealed in the heart-tugging story of a critically ill baby and the astonishing army of NHS staff needed to save one life

To save one life: 7 doctors, 9 consultants, 18 nurses, 5 support staff, 22 scientists,1 professor and 1 receptionist

6

Pathology Challenge

• Organise services around the patient/users,– not disciplines, staff groups, hospital labs

• Transform structures and practicesReduce variabilityProvide evidence of progress

• No change is not an option• Take ownership and drive the agenda

Vision of 24/7

Providing an integrated service

end to end

Increasing productivity & delivering continuous

improvement

Providing quality services at

competitive prices

Pathology Services enabling better NHS care

Better patient outcomes & commitment to a

quality 24/7

A Department employees are proud

to be part of

Providing a Service for the Future

Delivering “end-to-end” Pathology

Service

Transforming the existing path

operating model

Developing scientific & clinical

knowledge

Target Markets:

Core pathology services in chosen geographies

Specialist reference services nationally & internationally

Innovation R&D

PATIENT

Improvement Cycle

User Satisfaction

Pathology Modernisation

Pathology Service Improvement

Current Service Provision Departments philosophy

Molecular Rapid Microbiology• Chlamydia/GC• TB• MRSA • Enteric Panel Real time• 16s RNA sequencing • Fungal 18ITs Sequencing• Typical & Atypical respiratory• C difficile toxin • MALDI ToF

Patient

The Past

• Staff turnover………..high• Staff cover at weekend and out of hours was

on a voluntary rather than a contractual basis. • Reliance on high cost locum staff and high

turnover meant the training and staff experience was variable and at times services had to be withdrawn due to lack of staff available to perform the work

The Past

• 2000 all new contracts were changed to 24/7 working including bank holidays

• Staff titles were changed to ‘Health Care Scientists’ in an attempt to remove glass ceilings and introduce equality and to gain greater job satisfaction

The Past• Two on call systems were in operation (routine and

High Secure Pathology Unit) plus additional staffing for – Blood cultures– MRSA– C difficile– Resistant Gram negative screening

• Shift Rota was complex and time consuming• Required at least 2 .5 days to prepare but was not

EWTD compliant

The Past

• 2004 Introduction of more support grades and Health Care Scientists

• Band re-profile 6 to 5• AP• MLA• No A&C grades

Staff grade 07/08 08/09 2011/13

8 6 5 57 BS 10 13 87 CS 6 4 46 BS 15 13 145 BS 0 0 34 AP 2 2 63 MLA 1 1 2

2 MLA 2 8 8

A&C 4 3 3 0

A&C 2 2 0 0

Totals 50 49 47

Year 06/07 07/08 08/09 11/12 12/13approxWorkload 250,000 300,000 350,000 500,000 600,000

Staffing 50 50 49 47 47

Workload & Staffing

• Major change • Negative and some positive impacts on staff • Time, effort and strong communication to

work through the issues with staff.• Major concern for staff was reduction in pay;

managed by providing pay protection for up to one year, variable lengths

Introduction of 24/7

• The benefits to staff – self roster – working hours 37.5hrs– Improved staff safety.

• New ways of working and career development – new roles to emerge e.g. the associate practitioner role.

• Continuity of staffing – Provide better quality services and reduce the pressures that

had previously been experienced

Introduction of 24/7

• Addition of three bands 5 • Gradual introduction of band 4 to be trained as

Associate Practitioners.• Budget

– Funding for pay protection was required Overall the remaining staffing changes were managed within the existing budget by re-profiling the skill mix.

Introduction of 24/7

• Unions• Consultation• Committee• Staff questions• HR A4C pay rates• Reserve lists• Multidisciplinary HSPU training• Three monthly and weekly rota• Went live 1st Aug 2009

Challenges

Challenges• Terms and conditions• Working practices - consultants• - technical• Culture - professional• - Management

» - “siteism”• Corporate identity• Changing job roles• Ownership / territory• Takeover mentality• Disaffected staff

Staff View

STAFFFOCUS

HEALTH AND SAFETY

LOW SICKNESS RATES

CPD

A4C/KSF

TRAINING

INDUCTION

RECRUITMENT ANDRETENTION

WORKING CONDITIONS

What’s Needed• Management Support• Resources• Team Building• Organisational / Personal Development• Vision / Plan• Leadership• Resolve• Time• Stability• Communication

In Transition: Key Objectives

• Keep the system safe in transition• Drive sustainable innovation and service

excellence• Modernise planning to deliver a patient

centred approach that embraces patient pathways

• Enable service transformation– Move general services closer to patients’ homes– Centralise specialist services to leverage

expertise and drive economies of scale– Integrate across health and social care

• Have clear and measurable goals and realistic timeframes when planning the changes.

• Engage staff early in the change process and gain as much agreement with the project goals as possible.

• Ensure that all meetings have minutes taken and they are distributed to all staff

• Ensure negotiations with staff are reasonable and managed well

• Skill changes provide positive training and development opportunities for all staff and enable flexible rosters

Top Tips

• Develop key baseline measures and track the measures to demonstrate the improvements to all stakeholders…Win/Win

• Be prepared to modify original plans where possible so that staff are involved and are part of the decision making

• Allowing staff to design the shift and rosters system worked well

• Recognition of staff in their staff review

Top Tips

Types of Shift

Time Staff numbers

HCS MLAEarly 8.00 am to 4.30 pm 1 1

Core 9.00 am to 5.30 pm 15 7

Late 11.30 am to 8.00pm 2 2

Nights 8.00pm to 8.00am 7.30pm to 7.30am

11

00

Night Person Night Person 219:30 Hand over Hand over20:30 Blood Cultures Start final put up of all left 21:30 over samples22:30 Fluids Help with follow up23:30 "00:30 Follow up of both benches

Lunch01:30 Urines

Lunch "02:30 Any urgent samples PLUS "03:30 Help on urines "04:30 " "05:30 Make sure all samples "06:30 are booked in plus blood "07:30 cultures put on analyses "

MICROBIOLOGY WEEKEND ROTA (Prepared by ABhamra)

Sections Sat 21.04.12 Sun 22.04.12 SECTION LEADER

RECEPTION Sat only sorted

Taufiq am –please note reception / spa done

on night shift + tristel ® kumar (V) >2

Taufiq am –please note reception / spa done

on night shift + tristel

® kumar >1 SPA

Urines Put up Komal < 1 pm

Taufiq pm;♣Sarah>4 Taufiq pm

♣Sarah Waste collection / autoclave ® kumar (V) (minimal) priority<2 ® kumar ( minimal) <1

Stool Put up &CDT( 12.30)

Michelle + Stool Put up ( priority for CDT)

+ Sub SF/APW/Acetamide + OCP Prep / Crypto stain

+ Send TDM levels @ 10 am and 3 pm

♦Michelle + Stool Put up ( priority for CDT)

+ Sub SF/APW/Acetamide + OCP Prep / Crypto stain

+ Send TDM levels @ 10 am and 3 pm

BLOOD CULTURES + report TDM

+ GUM

Maria ( No Maldi) + IQC Oxidase / Nephelometer

+ GC Screen / Read & record AST +Sub ATCC Ctrls

+ Report TDM

Maria( No Maldi) + IQC Oxidase / Nephelometer

+ GC Screen / Read & record AST Sub ATCC Ctrls (if applicable)

+ Report TDM

FLUIDS NW+FU

RESPIRATORY NW+FU Includes reporting on Sunday

RESPIRATORY NW Putup

*Owen( No Maldi)

*Owen

Komal >2pm

*Owen( No Maldi)

Rizalea ( V)

Rizalea( V)

MRSA CULTURE & PCR Mohammed + CDT PCR if required

Mohammed + CDT PCR if required

HVS

Kanti 9-1 Read the NW only and complete the FU

CLOSED

RNOH & MALDI ♣Sarah<4 ( RNOH Maldi only) ♣Sarah( RNOH Maldi only/ SPA

URINES NIGHT Jasim CLOSED

WOUNDS/ E.N.T/ACIN

NIGHT NIGHT

ENTERICS Komal only to Screen for Salm/ Shi < 11-45

Komal start to finish + reporting

SEROLOGY CLOSED CLOSED VIPER CLOSED CLOSED

Computing CLOSED Owen

Night staff Lucy • Wounds / ENT • Leave reporting for Sun night if

necessary Jasim: urine start to finish

Paul

• Night duties • Read TVs/BVs and Record + Sub LIMs • Help Lucy with + reporting

Lucy • Wounds / ENT • Leave FU on bench with instruction

Jasim • Night duties • Help Lucy with FU + reporting • Read TVs/BVs and Record + Sub LIMs

HSPU Day Night

Maria Jasim

Maria Lucy

Sickness Andrew Andrew

Early Late

No colour= Core Night

Over time / Xtra hours

Team leader:

Owen

Please ensure

relevant plates for closed

sections are placed in the

fridge

MICROBIOLOGY WEEKLY ROTA (Ed 23 March 2012) Rota Prepared by:A.Bhamra

on-leaders Monday 23/04/12 Tuesday24/04/12 Wednesday 25/04/12 Thursday26/04/12 Friday 27/04/12

Maker + weekly overdues Rajita Monica am Victoria Rajita Rajita Rajita Chris , Angela Judith Shaila Fitzroy 8-9

Chris Angela Judith Shaila Fitzroy 8-9

Chris AngelaJudith Shaila, θAudrey pm Fitzroy 8-9

Yonas Angela Judith Andrew Fitzroy 8-9;Rita

Chris Angela Judith Andrew Fitzroy 8-9 Rita

SL Rajita toria 0n tuesday

Ward Duties Jenny closed Yonas closed Yonas

URINE/ GU MED : Section leader Owen ine NW +AP

U +Microscopy

•Maferim<11.30 Temitayo Saroj ♥Komal>4.30

•Maferim<11.30 Temitayo Saroj γRizalea<4.30

•Maferim<11.30 Temitayo Dr Lakshi Saroj♥ Komal>4.30

Temitayo Dr Lakshi Saroj⊗Kanti >4.30

Temitayo Dr Lakshi Saroj ⊗Kanti >4.30

S+ GC+ settle plate < 4 LDI SPOTTING GC ONLY

Alan Vicky Alan Alan Alan

SWAB CULTURE: Section leader Kanti read / report Kanti, ♥Komal Kanti ♥Komal Kanti, ♥Komal ⊗Kanti,Komal ⊗Kanti,Komal follow-up < 3 Kanti, ♥Komal Kanti ♥Komal ♦Vicky >11 ♦Vicky >11 ♦Vicky >11

SPA)

↓Samer >10 Andrew •Maferim>11.30

Dr Anna pm

JennyChika>4.30 •Maferim>11.30 ↓Samer >10 Andrew

♦Vicky <11 Jenny •Maferim>11.30 Andrew↓Samer >10

♦Vicky <11 ↓Samer >10 Shaila°Mod >2

♦Vicky <11 ↓Samer >10 Shaila°Mod >2

HAI : Section leader Gemma m/pm)

+ MALDI SPOTTING ulture) +transferx2 runs

Kumar/ωMonica brief

ωMonica am

Kumar θAudrey am/2 pm

Kumar θAudrey am/2 pm

Kumar θAudrey am/2 pm

Kumar θAudrey am/2 pm

MYCOLOGY: Section leader Rebecca Shanti ♠Shanti koh Dr Daniel=dopsx2 * Rebecca/Shanti ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10

s & Fri) Thu) Rebecca/Shanti+koh Rebecca/Shanti+koh

BLOOD / FLUID: Section leader : Monica Victoria 0n Tuesday pm + MALDI SPOTTING Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi + MALDI SPOTTING Harry Emma Monica am /Dr Anna

am Victoria ♠Shanti +koh Emma

Anna Emma Anna Emma

<2 Sini /Mohammed Sini /Mohammed Sini/ Mohammed+caf °Mohammed °Mohammed

r 1-2 Kanti/Komal Purnima/Gemma Harry Sirilaksmi Anna Sirilaksmi Rajita Audrey RESPIRATORY / TB: Section leader Kanti

+ MALDI SPOTTING Manpreet Manpreet Manpreetam Victoria Manpreet ManpreetDr Anna am + MALDI SPOTTING Anna /Rachel Anna Rachel Rajita Rachel Rajita Rachel Rajita Rachel

pert-CepheidPCR) Rizalea/Chika+ind -AL γRizalea&Chika<4.3 Rizalea Chika Harry Chika Harry Chika ENTERICS / IQC: Section leader : Purnima Gemma ( Wed)

T/HP transfer 4-4.15 Purnima Gemma Purnima Gemma Gemma Purnima Gemma Purnima Gemma ori prep only( Mon & Thu) ◊ Michelle ◊ Michelle DT /OCP prep &CDT assay ◊ Michelle Yonas Michelle ◊ Michelle Michelle

ay Wednesday) Ω Rajita am till 7pm θAudrey pm Harry θAudrey pm θAudrey pm SEROLOGY: Section leader Rajita( Purnima on Tuesday)

M (if closed) Rita Rita Rita Night(Paul) Night(Sini) rology prep + send aways

on Mon/Thu only Fitzroy 9 -4.30Kristine +H.Pylori DS2

Fitzroy9 -4.30 Kristine

Fitzroy 9 -4.30 Kristine

Fitzroy9 -4.3Kristine +H.Pylori DS2

Fitzroy 9 -4.30 Kristine

MOLECULAR (VIPER): Section leader Victoria( Mon-Wed),Gemma( Thu-Fri) per / CDT & HPYL via DS2 Night( Sarah) Night( Sarah) Night( Sarah) Jenny Jenny

er results Night( Sarah) Night( Sarah) Night( Sarah) Night( Lucy) Night( Lucy) MOLECULAR (Other): Section leader Victoria( Mon-Wed),Gemma( Thu-Fri)

& others) / Atypical PCR ↑Damion Kevin ↑Damion Kevin Damion Kevin Damion Kevin Damion Kevin am ay 2 staff ) Anna Rob Rizalea Rob Rizalea Rob

s + R&D

Rebecca=maldi sort ΩRajita 7pm =Audit writMonica pm =caf sort Victoria =Eucast plan

Monica am =caf sort +dops for Dr Daniel- see Amrat

Monica =caf sort Maria pm= audit ‘f’ std Sini= audit –see mk Abh= Rota

Rebecca/♣Owen maldi sort ,Abh= Rota Monica =strep phx Maria till 7= audit

: ↑ Damion =CoSurv Owen↑Damion pm Owen ICE+CoSurv Owen/Maria am ♣Owen +CoSurv MEDIA / WASH-UP: Section leader Adrain

tock Tues / delivery Weds Taufiq Taufiq Taufiq Taufiq Taufiq ce /Enquiries Kelly, Valeria Kelly, Valeria Kelly, Valeria Kelly, Valeria Kelly, Valeria

SR,Abh,Mk am,AL Abh Mk AL Abh,Mk am AL SR,Mk AL Mk AL Lucy Sarah Paul Sarah Paul Sarah Paul Lucy Sini Lucy

= Medical (S) = Study y (O) = off duty due to 24/7

Time-In-Lieu Leave rnity (MT) = Meeting

eds,Fenella rfh –virology, @ rfh,Ingrid@Barts,Manar @

ver time Kristine Mon 9- u/Fri 9-11.30,Judith tue 9-

L:Yonas,Dallas,Audrey GinaPaulO:TomMaria, Owen,Jasim , Mk pm S:VickyRob MP AntheaMT:Michelle/Ab ccrp1-2,Sini & Abh 12.15-12.30, Sam/Abh 12-12.15

L:Dallas, Gina O:,Michelle, Tom,Lucy,Maria, Jasim Rajita MP: AntheaSHarry,ManarAlan,EmmaSamanthaRobMT:Yonas/Abh ccrp 12-1,Monica pm,SR,AL10.30-11

L:Dallas,Gina, RebeccaO:TomLucy,Purnima,Jasim, MK pm,Monica pm S: Maria, Manpreet pm MP: Anthea MT:SR

L:Dallas,Gina, O: Maferima,Tom,Sarah Victoria,Jasim, MP: Anthea MT:Monica 10-11.30 & 1-2

L:Dallas,Gina,Jasim Kevin pm, SR,Chika O: Maferima,Tom, Sarah,Victoria,Paul, MP: Anthea S: Manpreet pm

Night Training Late shift Early HCS 1.5hrs Dr Rita Oladele: observer from ECCMID in dept for I month

Sections / Section-leaders Monday 23/04/12 Tuesday24/04/12 Wednesday 25/04/12

Thursday26/04/12 Friday 27/04/12

Deputy Rota Maker + weekly overdues Rajita Monica am Victoria Rajita Rajita Rajita

RECEPTION: SL RajitaMonica am Victoria 0n tuesday

Ward Duties

Chris , Angela Judith ShailaFitzroy 8-9

Chris AngelaJudith ShailaFitzroy 8-9

Chris AngelaJudith Shaila, θAudrey pm

Fitzroy 8-9

Yonas AngelaJudith AndrewFitzroy 8-9;Rita

Chris AngelaJudith AndrewFitzroy 8-9 Rita

Jenny closed Yonas closed Yonas

URINE/ GU MED : Section leader Owen

Urine Phx + Urine NW +APUrine NW & FU +Microscopy

•Maferim<11.30 TemitayoSaroj ♥Komal>4.30

•Maferim<11.30 Temitayo

Saroj γRizalea<4.30

•Maferim<11.30 Temitayo

Dr LakshiSaroj♥ Komal>4.30

TemitayoDr LakshiSaroj⊗Kanti >4.30

Temitayo Dr LakshiSaroj ⊗Kanti >4.30

GU MED HVS+ GC+ settle plate < 4 + MALDI SPOTTING GC ONLY

Alan Vicky Alan Alan Alan

SWAB CULTURE: Section leader Kanti

Wounds / Ent read / report Kanti, ♥Komal Kanti ♥Komal Kanti, ♥Komal ⊗Kanti,Komal ⊗Kanti,Komal

Wounds / Ent follow-up < 3 Kanti, ♥Komal Kanti ♥Komal ♦Vicky >11 ♦Vicky >11 ♦Vicky >11

Swab put-up (SPA) ↓Samer >10 Andrew•Maferim>11.30

Dr Anna pm

JennyChika>4.30•Maferim>11.30↓Samer >10 Andrew

♦Vicky <11 Jenny•Maferim>11.30Andrew↓Samer >10

♦Vicky <11↓Samer >10Shaila°Mod >2

♦Vicky <11↓Samer >10Shaila°Mod >2

HAI : Section leader Gemma

ACP MRSA (am/pm)+ MALDI SPOTTING

HAI (MRSA culture) +transferx2 runs

Kumar/ωMonica briefωMonica am

KumarθAudrey am/2 pm

KumarθAudrey am/2 pm

KumarθAudrey am/2 pm

KumarθAudrey am/2 pm

MYCOLOGY: Section leader Rebecca

Mycology (Tues & Fri)MLA 1 HPLC (Mon & Thu)

Shanti ♠Shanti koh Dr Daniel=dopsx2 * Rebecca/Shanti

↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10 ↓Samer 9-10

Rebecca/Shanti+koh Rebecca/Shanti+koh

BLOOD / FLUID: Section leader : Monica Victoria 0n Tuesday pm

Blood culture + MALDI SPOTTING Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi Sirilaksmi

Fluids + MALDI SPOTTING Harry Emma Monica am /Dr Anna am Victoria

♠Shanti +kohEmma

Anna Emma Anna Emma

MALDI LAB <2 Sini /Mohammed Sini /Mohammed Sini/ Mohammed+caf °Mohammed °Mohammed

Summary• To ensure that workforce planning, training, &

education drive sustainable innovations • To deliver a capable and flexible workforce

now and in the future. • An aim to improve the quality of care and the

experience of patients and staff at all levels and enable them to embrace change and improvement.”