The Relevance of Clinical Engagement

1. The Relevance of Clinical Engagement Involving pathologists in the Lean process

2. Do you need to bother?

3. What do pathologists do? Pathologists work hard

4. What do pathologists do? Pathologists work hard Am I doing value work or waste work?

5. What do pathologists do? Pathologists work hard Am I doing value work or waste work? Pathologists make work for other people

6. What do pathologists do? Pathologists work hard Am I doing value work or waste work? Pathologists make work for other people Themselves The lab staff The office staff Physicians & surgeons Patients

7. What do pathologists do? Pathologists work hard Am I doing value work or waste work? Pathologists make work for other people Themselves The lab staff The office staff Physicians & surgeons Patients Am I making value work or waste work?

8. Do you need to bother? Yes if You want to reduce medical reporting times You want deal with the reporting as part of an integrated process

9. Without the active engagement of pathologists changes are unlikely to be successful

10. Without the active engagement of pathologists changes are unlikely to be successful

11. Without the active engagement of pathologists changes are unlikely to be successful Lean an active process You don�t �get Leaned�

12. CHANGES

13. �There�s nothing wrong with the way we do it now. It works fine.�

14. �I�ve had a pile of unreported cases next to my microscope for the last 25 years�

15. �They just have to give us adequate registrar support again�

16. �It�s the lab and office. They need a real sorting out�

17. Facilitating change Awareness of the need Knowledge of the techniques Opportunity act

18. Leeds skin & lung pathologyAwareness of the need for change Increased work load transferred work and new work. Decreased consultant staffing two consultants resigned & the posts were lost. Service user dissatisfaction with long TATs PCTs Leeds dermatologists Yorkshire Cancer Network Lung Cancer Group

19. �The Board supported the following recommendations to be taken forward: 1) ............ 4) Implementation of the planned work to redesign the LTHT Pathology service should be given the highest priority as a matter of urgency.� From: YCN Management Board, Pr�cis of the meeting held on 01 July 2009

20. Leeds skin & lung pathologyKnowledge of the techniques to produce change We knew from our consultant colleagues there that histopathology department at Calderdale Royal Hospital had undergone a successful Lean based restructuring We had been involved in a Lean based restructuring of the Yorkshire Cancer Network lung cancer services earlier in 2009

21. Leeds skin & lung pathologyOpportunity to change Management enthusiasm for the Lean NHS Improvement project

22. Let your rapidity be that of the wind, your compactness that of the forest.

23. Understanding the problem 3 day Rapid Improvement Event Engagement of lab, medical & office staff in thinking through the problem, analysing it and developing an improvement experiment A3 process - define & quantify problems, develop solutions Value stream map - identify & quantify waste & waits in the system SPC charts to monitor work flow and effects of interventions on the system, not individuals

24. The present state - May 2010The problem - demand & capacity Considerable short term and long term cyclical and non-cyclical, predictable and unpredictable, variations in both demands on and capacity of the medical reporting system.

25. The present state - May 2010Work load management Cases were allocated to consultants on receipt in the department, lab TAT was unpredictable and slides were �pushed� out of the lab to consultants without regard to the current reporting capacity of that consultant

27. The general who wins a battle makes many calculations in his temple ere the battle is fought. The general who loses a battle makes but few.

28. The present state - May 2010Conclusion � work load management The present state of medical work load management fails to match demand with capacity The failure is due to the design of the system and not to the individuals working in the system

29. The future state design � May 2010 A system that as far as is possible allows capacity to be made available to meet demand allowing reports to be available when needed for decisions on patient care to be made. makes failure to match demand with capacity apparent before the service is affected and failure demand developed.

30. Moving towards the future stateThe key change - Pooled work Approach to single piece work reducing batching & queues Cases allocated to �XX pool� on receipt Cut up rota, pooled cut up to standard protocols Lab sign out into pool when slides available Reporting rota, designated pathologist �pulls� one case, reports it, then takes the next case Back up from other pathologists if demand exceeds capacity Typing rota, typing is done as soon as reports are dictated Pathologists edit & sign out reports as they are typed � no batching for sign out

31. The clever combatant looks to the effect of combined energy, and does not require too much from individuals.

32. So we moved �� 

33. and what happened?

34. SPC for lung resections

35. What�s working? Lean is working Common language for pathologists and managers A method of thinking about process management to identify problems flow, demand and capacity Using suitable �tools� to solve the problems SPC charts, value stream mapping, waste identification & waste removal Pooling cases for reporting Closer team working by consultants is working

36. What�s not working? Using unsuitable �tools� to guide improvement Takt time, due to degree and unpredictability of the variation between cases for medical reporting Pooling of cases for typing Failure to engage all of the secretarial staff (& all of the consultant staff) in the process

37. Engaging other pathologistsExpanding pool reporting Awareness of the need for the change and the benefits of change

38. Pathologistwatch High level of diagnostic skills Personally responsible for providing a professional diagnostic service to individual patients (so take care mentioning production lines or Toyota) Focused on the �quality� of the service rather than the costs Aware of the clinical targets & requirements of the diagnostic service Like certainty, averse to risk & failure Work hard, focus on tasks - compartmentalise Work independently

40. Selecting and training your pathologist 14-16 GCSE 10 grade A* 17-18 A-levels 4 grade A 18 Medical school admission 18 � 24 MB ChB, intercalated BSc 24 � 26 Foundation training programme 26 � 31 Specialist training programme 31+ FRCPath & Specialist Registration 31+ Consultant job interview

41. Selecting and training your pathologist 17+ years of success in examinations and selection procedures

42. Selecting and training your pathologist 17+ years regarding our peers as competitors

43. Selecting and training your pathologist 17+ years regarding our peers as competitors and beating them

45. Selecting and training your pathologist Some of us may not have highly developed team working skills

46. How to engage with pathologists

47. NotHow to engage with pathologists A large meeting held outside the department with a manager (or 2 or 3) no one has met before who tells the pathologists that the service they are providing isn�t adequate, costs too much and it has been decided to make the following changes in working practices: All pathologists will work in teams 2) All work will be pooled

48. NotHow to engage with pathologists or do the same thing by e-mail

50. To fight and conquer in all your battles is not supreme excellence; supreme excellence consists in overcoming resistance without fighting.

51. How we are raising awareness of the need for and benefits of change Softly-softly � with individuals or small groups Use the pathologists� knowledge & skills - they know the demands on their service and want to succeed in meeting them Initial focus � quality of the service and clinically agreed targets, bring up the cost saving later Customise implementation procedures � when a change is to be made groups should develop their own implementation procedures Incremental change � an entire department or group does not have to change together

52. How we will continue to engage with all consultants Central communication of the results, benefits and lessons from the skin / lung experiment in meetings and on notice boards Follow-up half-day sessions incorporating lean principles training and development of alternative reporting improvement experiments with interested groups of consultants Facilitated by NHS Improvement, supported by consultants and other staff already engaged

54. Thanks to Alan Lewitzky and NHS Improvement

55. If the campaign is protracted, the resources of the State will not be equal to the strain

56. Thanks also to Jane Ramsdale, Jas Kaur and all of the Leeds histopathology lab & office staff Will Merchant, Richard Bishop, Radhika Ramnath, Olurunda Rotimi, Pat Harnden and the all of Leeds histopathologists Uma Raja, Richard Knights and the Calderdale histopathologists for showing us how pooled reporting works

57. and to our guide and mentor Sun Tzu c544� c496 BC