Power of Process Skills Development Program ImprovesOperational Performance andEnhance Patient Care

Cambridge University HospitalsMiscellaneous Section Blood Sciences–BiochemistryBy Mobo Laniyan (Lab Manager, BloodSciences-Biochemistry | Addenbrooke’sHospital, Rosie Hospital)

23%TAT IMPROVEMENT OF

01 Introduction

02 INTRODUCTION | POWER OF PROCESS

Laboratory leaders are under constant pressure to do more with less and be more effective and efficient. Achieving and maintaining a high-quality, cost-effective service that delivers quality outputs supporting the best patient experience and care; requires decisive and confident management structures, supporting a sustainable, empowered workforce that delivers results in a fast-changing environment.

Power of Process delivered a lab-focussed skills development program at Cambridge University Hospitals that enhances patient care by empowering laboratory leaders to unlock operational excellence and accelerate process improvement with immediate value. The program develops a common process and problem-solving language from the bench to the management level. The program rewires employee thinking to enable a culture of collaboration, resilience, engagement, improvement, and change.

The program builds muscle memory by implementing a laboratory performance improvement project of choice at the end of the academic component, and dele-gates are required to document the steps and outcome.

03 THE PROJECT | POWER OF PROCESS

02 Miscellaneous Section BloodSciences –BiochemistryBackground: Cambridge University Hospitals NHS Foundation Trust and Pathology

“The NHS Foundation Trust provides accessible high-quality healthcare for the local people of Cambridge, together with specialist services, dealing with rare or complex conditions for a regional, national and international population. Pathology processes over 3.5 million samples every year including from patients within Addenbrooke’s Hospital and from GP surgeries and other hospitals across the East of England”

Vision and Area Focus:

With the onus on Pathology to provide an effective, efficient, safe and high quality,harm-free service, the team is always looking for innovative ways to improve service in order to meet patient safety and outcome. One such way is through the use of knowledge gained from courses such as ‘The Power Of Process’.

The Automated Biochemistry section of Blood Sciences forms part of the infrastructure within Pathology housed on Level 4 of the Pathology block in CUH. It has the appropriate equipment to cover the repertoire and workload required, including high tech Siemens analysers attached to an automated Aptio Track system interfaced to the LIMS system via a Centralink and IM middleware. About 9/10th of the daily workload goes through this section.

Other standalone equipment is not tracked and the remaining 1/10th of the workloadand processes are dealt with in the Miscellaneous section of Blood Sciences. The Osmolality service is provided from the Miscellaneous section.

AREA

Operational Goal Priority

Safety and Quality

Rational and Driver of Goal

Area of Focus

STRATEGIC OBJECTIVES

Compliance with ISO 15189 i.e. “The lab must develop quality indicators to monitor and evaluate performance through critical aspects to the pre-examination, examination and post -examination processes.”

Deliver high quality, patient-centered and clinically driven service

As a result of ensuring compliance with UKAS ISO standard, I was compelled to focus on one of our problem areas with a poor KPI, identify problems, pain point and opportunities to improve the performance of a service in this area.

The area I focused on was the Osmolality service which is provided from a separate bench in the Miscellaneous section of Automated Biochemistry of Blood Sciences.

04 THE CHALLENGE | POWER OF PROCESS

03 The Challenge | Which problem needed to be solved?“Serum and Urine samples for Osmolalities are received and processed in the Miscellaneous section of the lab. Other tasks (such as the aliquoting of random and 24-hour urine samples, the manual storage of samples and the centrifugation and distribution of samples) are also performed. Daily there is the potential for Osmolality samples not to be processed on a timely basis and as a result, would contribute towards the failure of meeting a 6 hour turn-around time.”

KPI’s:

There is a clinical requirement for Osmolality tests and to turn them around within 6 hours.

To meet and surpass a 95% compliance rate for turning around Osmolalities within 6 hours of receipt into the Laboratory Information System. (The lab has struggled to meet this target.)

To improve resilience around the way Osmolality testing is processed to ensure maximum and efficient staff utilization.

Endeavour to try and meet a timely Osmolality service at all times.

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05 IMPLEMENTATION | POWER OF PROCESS

04 Knowledge and Tools toexecute Project1. PDCA tool:The DO and CHECK phases allowed for the LIS Data analysis and calculation component learnt from the Masters course to construct, tabulate and evaluate data.

Average TAT before the start of the project = 67%

Results of Data evaluation:

PLAN

DO

CHECK

ACT

Identify problem, Prepare excel spreadsheets and error sheet for recording data. Communicate with staff

Execute ideas and scenarios, collect data weekly, tabulate and calculate TAT. Document issues.

Evaluate TAT data and use the results to check for clues. What worked well or did not work well? Did the change result in any Improvement?If it did, was it significant? Was the implemented change worth the time and effort and staff time realised?

Reflect on changes and outcomes. If improvement to TAT, maintain change.If improved resilience, sustain change. Implement, communicate and continue monitoring

06 IMPLEMENTATION | POWER OF PROCESS

04 Knowledge and Tools toexecute Project2. Process Map:The process mapping component learnt from both the Champion Blended course and Masters course was used to supplement ideas and understanding of visualizing, identify the problem area, and improve it.

3. Diary, errors and action plan:A Diary and check sheet of occurrences and further actions were used to record down events during the project.

A typical example of a process map depicting the lab process and to see what actions are performed and how it is performed.

WEEK

Week 1

Week 3

Week 4

Week 8

Week 11

Week 14

Week 16

SUMMARY, COMMENTS AND ERRORS

Communicate with staff about poor TAT and action plan. Encourage staff to find samples and to ensure that they check the outstanding list daily as part of their processing regime. A particular sample during this period had a TAT of over 1day as this sample had an add-on request, then got stored before its Osmo had been completed because the staff on the Misc bench did not check the outstanding list until the following day.

Staffing issues and staff deployment away from the Osmo bench

Introduce extra frequency of analysing, Communicate with staff

Introduce new analyser, Training of staff on new analyser, Communicate with staff and remind them of the increased frequency from 4 to 6 times a day. Visual display as another way to remind staff

Staffing issues, Track issues causing downtime which affected TAT

Track down for a whole week. Manual processing of work. Downtime.

Introduce new idea. Rearrange the Misc bench. Segregate Osmo samples from UPCR/ACR bench and move Osmo rack to Osmo bench so they are more visible.

Assessment of results pt 2

An additional change was introduced at week 16. The Miscellaneous bench was re-arranged. This involved the segregation of the Osmolality and Fluid samples from the ACR/PCR bench into a dedicated rack which was placed on the Osmolality bench. Samples would be visible and act as a prompt. This change was communicated with Biochemistry and specimen reception staff.

This meant that we eliminated the samples accidentally left with the other Urine ACR/PCR samples.

Weeks 16, 17, 18, and 19 saw a consistent improvement in TAT, rising to 92% in week 19.

07 PROJECT OUTCOME | POWER OF PROCESS

05 Assessment of ResultsAssessment of results pt 1

During the project, various conflicting factors led to downtime and a poor TAT. These factors were addressed in real-time, whilst others were beyond the scope and timeline of this project and handled as a 'passing concern' to ensure service continuity.

The project's timing fell into place at the same time as the Osmometer was replaced because it had reached its serviceable life. A separate business case and financial analysis outside of this project had been submitted for this replacement.

The introduction of the new Osmometer at week 8 saw an improvement in TAT.

There was also a remarkable resilience and improvement around the way Osmo lalities was performed. The replacement allowed staff to be more productive and resourceful by being deployed to help out in other areas of the lab instead of 'hanging around' compared to when using the old Osmometer.

Improvements in the TAT resulted in a rise of up to 80% of samples processed within 6hrs of receipt in Epic. (Apart from week 11, where staffing and Track issues, and week 14, when the Track was down for a whole week.)

The introduction in the frequency of testing also contributed to an improvement in the TAT. For example, staff were informed that Osmolality samples should be processed at least six times in every 24h hour cycle (i.e. every 4 hours instead of 6

08 PROJECT OUTCOME | POWER OF PROCESS

Issues that contributed to poor TAT

Challenges faced

Training – Training of staff and a new way of processing due to the introduction of a new analyser

Communication – Changes when communicated seemed to take longer to filter to some staff than others

Culture change – Compliance with frequency of sampling from 4 to 6 times a day

Systems – Took staff a while to get to grips with the reorganised ACR/PCR bench and the racking system on the Osmo bench

Inadequate staffing

Staff not rostered to the Misc bench

during ‘Core’ hrs

Introduction of newly trained staff on

bench

Samples not ‘Tracked’ on time

Track down leading to knock-on effect on

Osmo bench

Night time issues leading to staff

neglecting osmo bench

Samples lost amongst ACR/PCR

samples

Staff deployed away from Osmo bench

Outstanding list not check and therefore

sample missed

ROI"TAT improved remarkably from a low average of about 67% before the project to >90%. An improvement of 23%"

Staff time was utilized more adequately and efficiently and in a manner that allowed them to be more resourceful in the lab.

Provision of a more resilient and robust Osmolality service.

Overall positive impact and outcome on quality of Osmolality service were observed.

09 THE RETURN ON INVESTMENT | POWER OF PROCESS

Turnaround time Time Saving

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10 FUTURE PLANS | POWER OF PROCESS

07 The Bottom LineEven though KPI's were not met as contractually obligated by stakeholders during the project, the trajectory and expectations are that the target can be met provided issues identified can be eliminated, and we maintain the new, improved working practice.

Key possible areas for improvement:

Continuous communication with staff with TAT to allow them to understand the impact on our KPI and patients.

Staff to focus on ensuring that samples can be processed on time as per the 4hr frequency rate.

Staff to ensure that an outstanding list is checked before performing a run.

Networking the Osmometer to the LIS to remove the manual entry of results phase and prevent transcription errors, thus verifying results in real-time as soon as they are available.

TAT improved remarkably from a low average of about 67% before

the project to >90%. An improvement of 23%

Frequency of testing also contributed to an improvement in

the TAT