Earlier Diagnosis of Cancer

Dean Harmse

Carole Stoddard

Madeleine Stephens

The Innovation

Based on Lean Principles Green Stream, Yellow Stream, Red Stream Established flow, reduced carve out and

moved towards FIFO Scheduling of tasks throughout the process Collection of meaningful data and

presentation of data in a useful format.

The Context of the Challenge

Backlog of > 500 unreported cases in the laboratory

Turnaround Times of more than 10 weeks

Delays in diagnosis of Cancer Critical Incidents due to delayed cancer

diagnosis

Patient M.E. -Male 64 yrs

Lesion on finger removed 12 Jan. 06

Reported 14 Mar. 06

Dx: MALIGNANT MELANOMA with infiltration of bone

9 WEEK DELAY IN DIAGNOSIS OF POTENTIALLY FATAL NEOPLASIA

Previous Strategies

Internal Reviews (including my own) External Reviews Focused on demand & capacity Need for more staff Never explored change in working

practice. Need to do More with Less

National Base Lines

RCPath. Key Performance Indicators% of cases reported within 7 days and 10 days

NHS Improvement% of cases reported in 3 days, 7 days and 10 days

Comparison to Standards

TAT National Standard

Local Baseline

3 Day 50% 15%

7 Day 80% (biopsies)

38%

10 Day 80% (all cases)

48%

The Change

‘The Hard Side’ - What we did - Maddie

‘The Soft Side’ – Team Engagement - Carole

The Hard Side The way things were……..

Historic prioritisation of consultant cut up in the laboratory (carve out)

Inefficient work output ↑ Laboratory staff time spent on ↓ numbers of

cases Delay of many diagnostic biopsies

.........and the aim of the Innovation

The Hard Side What we did……….

Red Stream Very complex biopsies and

large resections requiring a vast amount of technical work

Large numbers of blocks Range of complex staining

techniques

The Hard Side What we did……….

Yellow Stream Small biopsies and

excision specimens requiring a moderate amount of technical

work More than one block

and/or levels

The Hard Side What we did……….

Green Stream Small biopsies and excision

specimens requiring little technical work

One block One H&E slide

This includes Basal Cell Carcinomas

& Squamous Cell Carcinomas

The Hard Side What we did……

Cut up Green Streams

highlighted and segregated

Design of in-house digital template

system to facilitate voice

recognition reporting

The Hard Side What we did………..

Main Laboratory Green stream cases scheduled

with designated members of laboratory and consultant staff nominated to deal with them

Technical target 9.15 Consultant target 12.00

The Hard Side Control Systems……

Visual

control system for target

day of reporting

to achieve

7 day turnaround time

First In First Out

New Quality Control Procedure

Change Leaderstaking the ‘soft’ side

Working together to overcome the

perception that it was counterintuitive

to change what we had done for the last

10-15 years

Change Leaderstaking the ‘soft’ side

Out performed

to show that the

target was

achievable

Whole Departmental Team participation in the change was instrumental in making the

difference

Maintained Open communication

for feedback and fine tuning

Encouraged Ownership

rather than just Buy In

Communicating the Change

Communicating the Innovation

Change Leaders monitoring the change

Technical Dashboards

Set time targets

Traffic light colour scheme

Good for positive sense of achievement and increased work satisfaction

Change Leadersmonitoring the change

Weekly publishing of TATs

Email to all staff

& posted on Departmental Notice

Board

Good for morale and ownership

of the effort

6 months on...........

The Results

Histo Turnaround Times 2011

0

10

20

30

40

50

60

70

80

90

100

07Mar

14Mar

28Mar

04Apr

11Apr

18Apr

25Apr

02May

07May

16May

23May

30May

06Jun

13Jun

20Jun

27Jun

04Jul

11Jul

18Jul

25Jul

01Aug

08Aug

15Aug

22Aug

29Aug

Week Ending

%

3 days

7 days

10 days

Histology Weekly Backlog 2011

0

100

200

300

400

500

600

700

Week

Nu

mb

er

of

cases

Typing

Consultant

Technical

Influence on 18 Week Wait Suspected Cancer Diagnosis

18 Week Cancer Breaches

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2009 2010 2011

18 Week Cancer Breaches

Basal Cell Carcinoma

Delayed Diagnosis and Treatment

Basal Cell Carcinoma (Annually for August)

0

2

4

6

8

10

12

14

16

2007 2008 2009 2010 2011

Improved BCC Reporting

Impact on Cost Changes were cost neutral

Human Resource : No additional staff employed Consumables : No additional use of consumables

The change was achieved despite: Cost saving measures in Trust (£1.54 M saving target for directorate) Loss of Staff: 1 x WTE Consultant Pathologist

2 x Biomedical Scientists2 x Assistant Technical Officers23% overall reduction in staffing level in terms of posts filled

We are doing More with Less

Potential for Spread

Moderately easy Identification of work streams Scheduling of work Collection of meaningful data Convincing people that the ‘traditional

way’ of working is not always the best

Summary

Established flow through the laboratory by using Lean principles

Resulted in overall improvement of TAT Dramatic improvement of TAT for

patients on the 18WW Cancer pathway The key to success was involvement of

the whole departmental team at every level

The Team That Made It Happen!