SHR Anatomic Pathology Life of PI - Communication - April 17-18, 2012
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SHR Anatomic Pathology Life of PI - Communication April 17-18, 2012
Anatomic Pathology • A group of services that provide diagnostic reports on tissue, fluids or smears – Surgical Pathology – Autopsy – Cytology
Support Patient Care • Cancer Clinic – to assist with cancer treatment plans • Surgeons/Clinicians – provide a report that will help define future treatment
Provide Services to
• Saskatoon
• Kelsey Trail
• Prairie North
• Prince Albert
• Heartland
• Regina
Qu’Appelle
Provide Services From • Saskatoon City Hospital • Royal University Hospital • St. Paul’s Hospital
Expertise • Dermatopathology • Renal Pathology • Breast Pathology • Hematopathology • Neuropathology • Cytopathology • Gynaecologic Pathology • Pediatrics
Surgical Initiative • Sooner Safer Smarter • Improve Experience • Reduce Wait Times
Goal • To come up with a two year work plan for process improvement to meet the most urgent needs
Communication is challenging • all sites receive information as close to the same time as possible. • Diversity - communicate what is important without wasting time
Where do we start?
The Team • Select a cross functional team technologists transcription pathologists lis support mentor - blackbelt
VOC • Interviewed all staff members to hear ideas and concerns • Add recommendations from accreditation • Add recommendations from external review • Add recommendations from college review
Effort Impact Grid
Low Effort High Impact High Effort High Impact
67 small projects 39 Large Projects
and just do its
Low Effort Low Impact High Effort Low Impact
33 just do it or 13 deferred to be
parking lot reviewed at a later
datePriority Selection Matrix
Criteria Rating of Importance 9 5 1
Project Duration (Measure
Time) 6 < 4 Months 4 to 8 Months > 8 Months
Resource Savings (Measure
in time saved -staff time (for < 1FTE but > 0.5 FTE freed up to < 0.5 FTE freed up to
reinvestment into PI work) 9 > 2FTE freed up to reinvest reinvest reinvest
Low (Questionable support
High (Support from Sponsor Medium (Support from Sponsor and of Sponsor and or
and Department(s), low effort Department(s), high effort for high Department(s), high effort
for high impact, low capital impact, low effort for low impact, for low impact, high capital
Probability of Success 8 requirement) capital required) requirement)
Resources (Measures Low (10 team members,
number of people and time) 8 2 hours/week) hours/week) >15 hours/week)
High (Aligned with SHR
Strategic Plan/Quality & Medium (Addresses Accreditation
Safety Objectives, probable ROP or Safer Healthcare Now, cross-
loss of life or harm to patient if functional implications, direct impact Low (Addresses an
not addressed). Accreditation, on patient experience, critical to other Accreditation flag,
Critical to Organization 10 patient first, safety. or overall project/program) Departmental need/want)9 High Very suitable Excellent
3 Medium Suitable Fair
Scoring Parameters 1 Low Not suitable Poor
Evaluation Criteria
Probability of
Organization
Resources
Critical to
Anatomic Pathology
Resource
Applicant
Required
Success
Savings
Duration
Criteria
Project
Score
Total
Project List
Category
14% 22% 20% 20% 24% 100%
Weighting
Floor Redesign at SCH - move special stains and IHC closer Raw Score 1 1 5 9 1
to histo, cyto move (redesign workstations) Weighted Score 0.14 0.22 1.00 1.80 0.24 3.40
EM process improvements - maybe purchasing new EM is Raw Score 1 1 5 9 1
PM project, but flow is lean Weighted Score 0.14 0.22 1.00 1.80 0.24 3.40
Raw Score 5 1 5 9 5
Purchase stainer and additional coverslipper
Weighted Score 0.70 0.22 1.00 1.80 1.20 4.92
Raw Score 9 5 9 9 5
Redesign histo workstations - PDCA cellular workflow
Weighted Score 1.26 1.10 1.80 1.80 1.20 7.16
Optimize use of processors - stagger starts, stay the same, Raw Score 9 5 9 9 5
delivery times, shifts, shorten gut biopsy process,etc. Weighted Score 1.26 1.10 1.80 1.80 1.20 7.16
Raw Score 9 1 1 5 5
Create Regional Autopsy Service
Weighted Score 1.26 0.22 0.20 1.00 1.20 3.88
Raw Score 9 1 5 5 5
Pathologist Workload Balance - PDCA
Weighted Score 1.26 0.22 1.00 1.00 1.20 4.68
Raw Score 1 5 1 1 9
Uniting Pathologists on one site for service work - satellite
offices for frozens, etc. Weighted Score 0.14 1.10 0.20 0.20 2.16 3.80
Raw Score 5 5 9 9 5
Improve block filing process - in lab and in basement
Weighted Score 0.70 1.10 1.80 1.80 1.20 6.60
Raw Score
Improve data entry and capability of statistic collection
Weighted Score 0.00
Raw Score 9 1 9 9 5
Improve workflow through receiving and accessioning
Weighted Score 1.26 0.22 1.80 1.80 1.20 6.28
SOP Program - define AP way of doing business - updates, Raw Score 9 1 1 1 9
maintenance, process owners Weighted Score 1.26 0.22 0.20 0.20 2.16 4.04Root Cause • Fishbone diagrams to investigate causes of errors that create risk for our patients -Data Entry -Labelling -Lost blocks , slides, requisitions -Reporting -Variation in TAT
Gut Check • Did the prioritization matrix actually address our risks
Variable Turn Around Time
People Material Method
staffing shortages- Incorrect or incomplete
- lack of knowledge Boluses of work, batching specimens, slides,
- not all positions filled
- requisition not clear
- plans for coverage during vacation,
DE not well planned Tracking system not time wasted by transfer - no tracking, sharing across sites
- variation in incoming workload - variation in process
- non-compliance - not enough cardboard trays - access to equipment
- functionality
Competency workload single points of failure
numbering errors
- SOP not developed - numbers not checked - variable incoming work - not enough trained people
- SOP not followed printing of reports at - no clear expectations on required
- multiple variations of SOP Organization level or work to complete
- workload - LIS functionality
- prioritization - lack of a standard process
waiting on data entry weekly correction of
Staff shortages- Techs, reports
- vacation, sick time - competing priorities
- variable workload - batch process - competing priorities
Variable Turn Around Time
multitasking Double data entry
noise and interruptions - no interfaces
- competing priorities
- open concept lab - non patient related duties using mail for reporting
- competing priorities
- LIES or Fax not available for some physicians
backlog of specimens
Sharing across three EM photos slow
- lack of standard process consultation process
sites - outdated technology
- workload and staffing not level
- no standard approach to internal or
- not level workload division of external consultation
resources - no follow up on material being validating new
- couriers returned
no physician codes - no time to complete
travel time - competing priorities for staff and equipment
- distance between each - process to enter not followed
step of a process
- space issues
Measurement Machine/Equip
Environment
mentSurgical suite Med Cytology Surgical Suite
Diagnostoc Imaging
Physicians
Out Patient Clinics
Units CUSTOMER
SUPPLIER Physicians
Clinics
BackLog Units
Avg incoming/day
= 16
Min = 2
Max = 29 Average sign
out/day = 15
Min = 2
Max = 31
Cytology Primary Histology Pathologist Sign Out and
Accession Post Screen File
Processing Screen Processing Microscopic Report
Patient
Extract Transport Cycle Time Cycle Time Cycle Time Cycle Time Cycle Time Cycle Time Cycle Time Cycle Time (CT)
and Label (CT) = 28 min (CT) = (CT) = (CT) = (CT) = (CT) = (CT) = =
Number of Number of Number of Number of Number of Number of
Number of staff =
staff = staff = staff = staff = staff = staff =
CT = 3381 min
Min = 285 min
Max = 56 daysAction plan
12-Nov-10
19-Nov-10
26-Nov-10
10-Dec-10
17-Dec-10
24-Dec-10
31-Dec-10
11-Feb-11
18-Feb-11
25-Feb-11
11-Mar-11
18-Mar-11
Time
14-Jan-11
21-Jan-11
28-Jan-11
15-Oct-10
22-Oct-10
29-Oct-10
5-Nov-10
3-Dec-10
4-Feb-11
4-Mar-11
7-Jan-11
W ho % ne eded
(Accoun Complet For
No. Description table) Sharon
e Sharon
Rhonda
Diane 2 One hour
41 Complete Fire inspection recommendations Sharon days
1 f ront line monthly 5 h d
cyto tech,
Cross f unctional QC team - commitment, action, one f ront
17 communication Henny line
Rhonda 1 1hour 3
day Kim
Implement use of slide labeller - tw o identif iers 3days all
15 possibly Rhonda/Kimstaf f 2 hour 2 days
Shannon 2 d 2
days
New Fish Stain Protocol (stop sending to pathologist
39 Edmonton) Shannon X2 0.5 days
Shannon 3 4 hours 8 3
w eeks
Fish Slide Reader pathologists
100 Shannon 1w eek X 2 4 hours Dererred to Jan 2011 changing technology
Shannon 5
days IT
33 Interf ace w ith immuno machines Shannon Vendore 1 dat derferred to upgrad of SCC
Review and
Maintain consultant report on f ile indef initely - may report 1
48 just need communication Bonnie hour
each 1 hour 7
Eliminate/minimize interruptions such as phone transcriptio
calls, emails, etc - measure in, , clerical, Cytohisto n and
9 and pathologists (w ho's phoning and w hy?) Bonnie pathologist 3 days 7 3 5
Get "unknow n doc" page to stop printing (clerical -
59 IT) Vickie Vickie? e
Sharon 3
days
Fresh Specimen Project
Rhonda 1
day 3 days
Each
morgue
Task Analysis f or morgue attendants and attendant
35 pathologist assistants Alice 15
MLA minute
15 1 day b c d
minutes per
Task Analysis f or MLA's - prioritize w ork, day tw o
11 w orkload balance betw een sites Rhonda w eeks CM? 1day
Lab
6 d 5
process
Task Analysis f or Lab Process Worker - w orker 15
23 priorities, balance w orkload Rhonda mnutes per 1 day p d 5
Redesign histo w orkstations - PDCA cellular Histotechnol
w orkf low ogist X 3 2 3 hours a
78 Sharon w eeks
LIS Histo day 2 5
tech
Develop ability to track TAT at each station Cytotech
86 Sharon Transcriptio 2days 5 1 3 6 2
Shannon,
MOA 2
18 Review kidney transport process f rom Regina Shannon hours Tech 4 hours
Gross 8 5 q
Cytotech
Complete V oice Recognition project LIS Sharon
95 Sharon 2 w eeks4
Sharon 1 hour day 1 5 k 7
days, Rajni
Radiology 4
13 Improve kidney biopsy collection process Sharon hours
Rhonda 5 days 5 3
SOP Program - def ine A P w ay of doing business - Lori, Sharon
updates, maintenance, process ow ners pathologist
79 Rhonda cytology d h 5 3 7 8 9 1 k f
Sharon
Gross Tech
16 Implement use of macropath Sharon Pathologist
tw o hours 5 days 5
PLAN 5S EVERY WHERE - w hat should the f or each of
breakdow n be of manageable sizes - each one Rhonda
12 w ill be its ow n Alice
Erin/Alice/Rhonda and
LIS histotch
4 d
cytotech
Develop error reporting throughout the entire Transcriptio
24 process Lori n manager 2 days h 1 2 3
Develop a Preventative Maintenance program -
schedule, tracking, etc, Create a schedule w ith 3 days
19 Biomedical Technology, include clocks Kim histotech 9 5Pathologist
A standardized approach should be adopted and x2 and
review by QA f or correlation of FISH and HER2 docuement
results Shannon/Henny
w riter 1 day
Transcriptio 3 1
n MLA
Improve w orkf low through receiving and
Gross
accessioning
Sharon
Transcription YB 3 7 6
Optimize use of processors - stagger starts, stay
the same, delivery times, shif ts, shorten gut Histotech 2
biopsy process,etc. Optomize process f rom days per
beginning of processor to triage. w eek CM
Histotech YB 2 8 5 d 3
Cytology
tech 8
hours
Review current non gyne w orkf low include Pathologist
investigation of Cytotech at SPH 2 hours
Alice/HennyMLA 6 YB 1
days
Improve f iling process - in lab and in basement
Sharon 1
(may be able to incorporate into redesign)
MLA YB day
Shannon
2days 2
hours each
IHC Dako Upgrade Shannon staf f f or 8 2
Improve residency training program and
communication throughout pathologist
Lin (s)
LIS 10
MLAdays o 3
Histotechnol
Improve process of ordering past slides - ogist
potential same as special stains Vickie Pathologist
2 days ? e 6 3 1
Develop a comprehensive and qualitative review Histotech
process of prof iciency testing including Cytotech
presentation to QA committee Kim IHC
Camera on the microscope in resident room Lin 4 hours
LIS , IT, 3
Clerical team assigned to w ork w ith LIS/IT to Transcriptio
address concerns - "slow time", "bridging", see n one hour
types of letter typed, Bonnie conf erence
Sharon 2 7 e
days
Implement barcoding system develope
Sharon business 5 m 1
Develop a Communication Strategy f or AP - roles
and responsibilities and reporting structure Erin/Sharon/Lori/
1 day each
V ickie if 4 5 h
Develop ability to scan into report sof t media - possblie
reqs and consults then
Vickie requires a e
Host pathologists training on software -
how to check if they've ordered stains,
etc. (part of interruptions point?) Vickie Sharon
Pathologist
Discontinue printing gross w orksheets - (need to Transcriptio
ensure easy access to past history in LIS) Vickie n, LIS 5 3 7 5 e
Develop a communication plan f or SHR - to
educate on our process and its importance,
recognition of Drs. Erin/Sharon/Lori
?
A ll A P Staf f 3 days 4 5 h
2 hours
Train all employees - SHR customer service supervisors
training, has to be complete by Mar 2011 Lori extra hou all
PM?
Supervisor
hot w ater at grossing stations Rhonda 1 hour
pathologist d
gross
Develop f eedback loop/communication to improve transcriptio
dictations - clarity, etc. Henny n 8 hours
Pathologist 3 k 7
X3,
Sharon1
IOC Correlation Pathologist day ? 3 5
Develop/communicate job descriptions Lab Supervisors
process w orker, MLA and morgue attendants , manager 2
(af ter task analysis) Lori days h
Histology
Tech
Cytology
Tech
Transcriptio
n
Focus group/Team to address teamw ork, happy Pathologist
w orkplace, motivation, complacency around manager
TAT,Begin a daily stretching/yoga program Sharon 4hours 1 3 7 2 5Help • Recognised the need for more staff with process improvement knowledge • Selected projects that could add to our depth of knowledge…
What is Histology?
Histology 1 2 3 4
Final product
WHY AREN’T WE GETTING
THE WORK OUT AT A
CONSISTENT RATE?
The development of dynamic
ReSOULutions!Support
Challenge
Huddles
Keep informed
Large visuals SIPOC diagram Fishbone diagram
Parking lot
Where to begin • .
“What’s New” What’s changing? Why are we changing? What does it mean to me? Permanent Temporary Evaluation required ( ) change ( ) change ( ) Start date End date * Who can answer my questions?
WHAT’S NEW:
Alternative
Responsibility
Issues/Solutions
Project Board
Helping hands
Cytology
Cytology is… • Preparation and staining of medical specimens • Screen for cancer cells: - Pap Tests - Fine Needle Aspirates - Body Fluids - Bronchoscopy Specimens
The Way We Were • Using manual staining methods from the 1940’s…Dr. Papanicolau would be proud • Requisitions from RUH circa 1977… • One person managing Non-gyne processing and Pap slides staining
Why go LEAN • 4185 Med Cyto cases in 2011; up 255 from 2010 • Experiencing variable TAT • Haven’t looked at updating our processes since…
Communication Challenge:
Finding a balance where people are
informed and stay engagedKeep it Simple Clear Direction Concise Consistent
Expand what you know Outlook: Email • Voting and receiving/read features • Need to know info… • Great feedback from staff
Engage • Your audience • Your team • Yourself
Rules of Engagement • Enthusiasm • Invite audience participation – let ideas flow • Enrich your presentations with humour: visuals; mnemonics; puns • Innovate • Organise – stick to your timeline; plan topics
E-I-E-I-O… Make it fun for yourself and fun for others
Communication Tools LEAN tools selected for each of the DMAIC phases.
Meetings: Less is Best
• 5 presentation meetings
• Weekly meetings - Project team (Define
phase mostly)
• Staff - updates via project board, email
and bimonthly staff meetings
- 10 minute Huddle for brainstormCommunication Tools:
Define Phase
• Lots of information to
share with team and
staff
• Idea from BC:
Communication
Board to outline
project stages
• Memo to explain
project details and
time lineDefine Phase: VOC
•Collected 36 ideas from Cytology staff
•Consolidate the ideas on master list
•Display VOC ideas on wall chart
•Sort ideas into related groups:
• Process Steps
• Business Case
• AP Committees
• Task Analysis
• AP Lab PoliciesDefine Phase: SIPOC
Process Map Expanded from SIPOC: Shows Process Steps from Receiving specimens to sending slides out in totes.
Communication Tools: Measure Phase
Data Collection Plan
Who Collects
Process Characteristic Measurement Method Target or Specification Date Data Collected
Data
measure process steps in
automated date/time stamp and NGYN MLA -
1. Variable TAT minutes and track specimen March 7 - 21, 2011
process step tracking form Jennifer Fehr
inventory
measure date and time of when
automated date/time stamp and Clerical/MLA - SCH;
2. Specimen Tracking a specimen comes into SCH or March 4 - 21, 2011
specimen tracking form MLA - SPH & RUH
off-site hospitals
delays caused by specimen;
automated date/time stamp and Clerical/MLA - SCH;
3. Disruptions/Delays requisition; phone calls; consult; March 4 - 21, 2011
delay tracking sheet MLA - SPH & RUH
inventory or machine
pedometer and spaghetti meaurement in steps/meters:
4. Distance specimen travelled Jilane/Ramona March 9 - 23, 2011
diagram distance travelled by specimen
5. Distance NGYN MLA pedometer and spaghetti measurement in steps/meters:
Jilane/Ramona March 9 - 23, 2011
travelled diagram distance covered by NGYN MLACommunication Tools: Analyze Phase
Stay the Charted Course VSM; Fish bone and Spaghetti . Missing Histograms and Trend Charts
Pareto Chart
Reason for Delay
14 120%
12 100%
10
Cumulative Percent
80%
8
Occurences
60%
6
40%
4
2 20%
- 0%
Specimen Inventory Machine Phone Consult Requisition All other
Quantity 12 10 7 3 3 - 0
Cum % 34% 63% 83% 91% 100% 100% 100%
% of Total 34% 29% 20% 9% 9% 0% 0%
Time Period: Mar 7-21FMEA
Process Name: NGYN Current Process
Process Number: N/A
Date: 29-03-2011 Revision Level: 1
RISK
A) SEVERITY B) OCCURRENCE C) DETECTION PRIORITY
Probability Probability NUMBER ACTION TO IMPROVE
FAILURE MODE
Rate 1-10 Rate 1-10 Rate 1-10 RPN REVISED VALUES
10=Most 10=Highest 10=Low est
Severe Probability Probability AxBxC A B C RPN
1) Equipment not functioning 7 3 1 21 Back-up Equipment 5 1 1 5
2) >1 operator 10 8 5 400 Require help: shift some 0
3) NGYN MLA not available 10 4 5 200 duties to non-techs;
4) TAT >36 H 10 4 5 200 hire/share MLA in system 0
5) Slide Quality 5 3 3 45 QC Checks 0
6) Errors: redo SCC entry 3 2 5 30 QC Checks 0
7) Errors: redo slides 5 1 5 25 QC Checks 0
8) Excessive travel 5 10 3 150 divide MLA tasks/1 NGPA rm 0
9) Specimen Waiting 7 5 5 175 divide MLA tasks 0
10) Carry-over: unprocessed 7 3 1 21 divide MLA tasks 0
11) Carry-over: unstained 7 3 1 21 divide MLA tasks 0
12) Carry-over: undelivered 7 3 1 21 divide MLA tasks 0
13) Carry-over: not entered SCC 7 3 1 21 divide MLA tasks 0Communication Tools: Improvement Phase
Improvements to NGYN Room: 5 S Fridge Before: Specimen After: Specimen Receiving Receiving
Error-proofing: Labels Unknown wrapped Wrapped specimen - specimen urine
SPH Pilot: Labels
Interdepartmental Communication
Strategy
• Coordination with LIS; Clerical and
Histology staff – 2 week trial period
• Trained SPH MLA with a demo
• Poster to help with training and
change managementNGYN Project: SPH Pilot Extra Labels
PILOT DATES: May 24-Jun10, 2011
OBJECTIVE: To help identify blue-pad wrapped specimens for
handling in the SCH NGYN Processing Room.
Current Method Changed Method
CHANGED METHOD: 2 Extra specimen labels will be printed by
SPH clerical and affixed to the requisition.
SPH MLA or designate will attach 1 specimen label on the outside
of the blue-pad and package the requisition and specimen in the
biohazard bag as per usual.
Please leave the other specimen label attached to the requisition;
it is for the NGYN MLA or Tech use to label centrifuge tubes.
Thanks for your co-operation – please address any comments or
concerns to the NGYN Project team at SCH 655-8476. If all goes
well at SPH, this new method will be starting at RUH effective
June 13.Improvement Phase: Error
ProofingCell Block Report
• Takes less time
to generate list
then hand-
written string
sheetControl Plan No more outdated requisitions, basically.
Control Plan
Organization SHR - Cytology Department
Location NGPA 5526 SCH
Revision Level 1.1 Date 02-Jun-11
Key Process Measurement Target Or Who Collects When Is Where Is The Reaction Plan
Characteristic Method Specification And Charts Data Data Collected Chart Located
Which vital signs of the How are the key How do w e know if Who is responsible to What is the schedule Data should be Corrective Actions - What
process w ill be monitored. characteristics the process is collect the data - and sampling plan for accessible to those should be done w ith
measured? performing as including backups to data collection? running the process to mistakes or system
intended? cover absences? allow quick feedback. failure?
supervisor or
NGPA room 5526; inform supervisor/mgr;
manager to review
replace with NGYN MLA supervisor office phone call to remind
wrong requistions tracking form form monthly until
correct requisitions Cytotech room 5530; manager wards/clinics to use
requisitions are
office room 5704 proper requisition
changed over
pilot at SPH May
phone site to ask
24 - Jun 10; RUH
extra label is on about issue; if SCC is
extra specimen lables begins Jun 13;
outside of blue-pad NGYN MLA down - hand label
for blue-pad and test visual check Project team to NGPA room 5526
and one attached Cytotech blue-pad with black
tube consult with sites
to requisition marker; label tubes
weekly in June
with black marker
2011
Ask LIS (Vickie) to
notify supervisor of
generate
occurenece;
accessioning TAT
investigate why TAT
Sask Surgical Initiative report for required
NGYN Project Lead; for specimen was
- opens up EDO for date(s); time/date September - date Cytology Screening
TAT 36 H and determine
RUH and SCH to send difference TBD room 5527
designate if causitive action(s)
slides specimen received
are incidental or
and time/date sent
systematic; modify
in NGYN log book
action(s) accordingly
is TATGetting Automated Current LBS Project
MedCyto Specimens and Slides
Series1 Series2
549
174 180
146
104 75
73
36 26 22 17 44
Total # Urines FNA Fluids Bronch Other
Specimens
Current: number of slides generated per
specimen
Future Improvement: Liquid-based system would see number
of Med Cyto Cases equal number of slides generated.Liquid Base System Validation Project started November 2011 and is ongoing
Today • We have completed 55 projects and just do its • We have 28 open projects – 6 are in the control phase • We have one project with a failed trial deferred • We have 36 projects not started • Some items were removed as out of scope and some were combined to reach current numbers
What’s next • Regional Case distribution
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