CASE STUDY
NHS Board NHS Lanarkshire Contact Colin Blair
Email [email protected]
Title Improving Efficiency in Monklands Medical Records Department Category Support Services
Background/
context
Under the terms of the Admin and Clerical review there was a
requirement to review the efficiency of medical records processes and the baseline staffing for medical records staff to identify areas for savings.
Problem The following factors were identified:
• significant number of staff breaching NHS Lanarkshire policy on return of medical records due to historic and cultural practices
• poor workforce design built around the need to cover for breaches of procedure by other staff
• inefficient layout design due to expansion of space required to store medical records without cognisance to efficient workflow
• flexible and rotational nature of staff made roles and responsibilities unclear and created difficulty in tracking and managing performance through the various sections
• data collecting for reporting but no history of predictive or real time data to understand demand and capacity and support performance management of staff
Aim To improve workflow, process and workforce efficiency through all sections, introduce data for performance management and ensure that medical records are available on day of outpatient appointment.
Action taken Changes made:
• policy for return of missing records enforced across the hospital
• WTE required by each section established to support predicted demand
• internal processes stabilised and redesigned to maximise efficiency through each section
CASE STUDY
• pulling and prepping section relocated and department layout redesigned to support efficient workflow and improve
supervision
• demand data via a whiteboard introduced to ensure that daily demand was understood and being met
• changes in some staff start/ finish times and days worked to level load the work and deal with peaks of activity
Strategy for change, methodology used Lean awareness
training/ DCAQ
Stakeholder interviews
Analysis of policies and procedures Individual
operator observations
Workflow analysis Data analysis
Tools and techniques used Time value
analysis
Circles of work Spaghetti diagrams Takt time
calculations
SIPOC diagrams Force-field analysis Waste spotting Voice of the
customer
Data analysis
Results A summary of results is as follows:
• clearer roles and responsibilities
• improved workforce and capacity planning
• better demand management
• improved productivity and efficiency through the sections – performance management introduced
• reduction in costs
A summary of the benefits:
• patient – medical records fully prepped and delivered on time
• staff - roles and responsibilities clear and tasks/ performance required understood
• • organisational benefits – improved efficiency and productivity
CASE STUDY
leading to cost reduction of circa £84,000 per annum Efficiency savings
and productive
gains Monklands pulling/
prepping section
Before redesign
After redesign
% Reduction
Mean pulling time/ case note (mins)
1.97 0.98 50%
Mean prepping time/ case note (mins)
3.38 3.38 N/a
Total time (mins)
5.35 4.36 18%
Mean number of case notes pulled and prepped per day = 440, therefore a time saving of 440 x 0.99 minutes = 7.26 hours per day Based on known demand for case notes staffing levels could be set on a daily basis to cover the demand if the pulling and prepping section delivered the required hours of pulling and prepping activity, however, an examination of productivity showed that there could be up to 12 individual operators pulling and prepping case notes on any one day, delivering less than the WTE hours required to meet the daily demand (see table 1 below)
CASE STUDY
6.5 WTE staff were supposed to be ring-fenced against pulling and prepping activity producing 42.25 hours of ‘useful work’ however interruptions to the workflow meant that staff were taken off this section to cover other work while multiple staff from other sections were brought in to cover the shortfall. As per the table above, the 12 people on pulling and prepping function on the day shown, between them only managed to produce 30.2 hours of useful work i.e. the work of 4.6 WTE staff whilst disrupting the workflow in the sections affected.
By genuinely ring-fencing the 6.5 WTE staff on this section, redesigning the workflow through other sections and introducing visual
performance management, staff capacity could be realistically set to meet daily demand and ensure maximum productivity (see table 2 below).
The staff time released helped to standardise workflow and improve quality through the other sections in medical records.
Improved productivity and efficiency within the department facilitated a reduction in 5 WTE permanent Band 2/ 3 staff with associated costs of circa £84,000 whilst maintaining and/ or improving service quality.
Sustainability Sustainability and continuous improvement ensured by means of:
• regular team meetings
• more proactive supervision with one-to-one discussions with staff
• extended use of the whiteboard to include:
• which staff are allocated to each duty
• staff on annual leave
• midday status update regarding case note
CASE STUDY
• pulling and prepping performance
• scheduling and staffing of trolley runs to
• departments
• continued use of performance data to analyse
• issues and identify areas for process improvement Lessons learned • Engaging with staff and ensuring buy-in and ownership of
changes during what is essentially a cost/ staff reduction programme is challenging. You need to be absolutely up front and transparent with both staff and trade unions about the expected outcome of the work and how you will go about it, and be available to talk to staff at all times
• Using data to understand and manage performance is daunting for both managers and staff. It is important that managers understand the few key metrics they need to monitor and control performance and have the confidence to use them and that staff understand the benefits of performance data in terms of improving the quality and reliability of the service they provide. It is therefore vital when setting up such a system that staff understand that performance relates to the processes within which they work, and not initially to the performance of individuals.
• Changing culture i.e. persuading staff who had previously decided to ‘opt out’ of agreed procedures for returning case notes prior to a clinic date, is very difficult to achieve. You need to plan for a prolonged period of resistance to a required change in culture and working practices and hold the line/
reinforce the message on a daily basis.
