Locally the gap between taking a smear and getting the result
fluctuates between about 3 weeks and 12 weeks. The former seems
dilatory to the consultants who send smears taken in private practice
to a lab in London which returns a result in a couple of days, the
latter is far too long for patients and creates secondary work in
General Practice dealing with queries about the result.
I propose a scheme to reduce the variation and with it the secondary
work and anguish for patients to a minimum. It takes advantage of the
communication layer being established for Devon GPs by a collaborative
enterprise involving the LMCs, BMA Divsion, HAs and University of
Exeter, and will add a useful category of information to this
infrastructure which will encourage its use for other information
sharing.
I would welcome comments - particularly if somebody is already doing it.
Work Through the Lab
---------------------------
The determining factors on the rate at which the cytology lab processes
smear slides must be predominantly the number of people present to read
them, other factors are unlikely to be as significant by an order of
magnitude.
-staff holidays
-other staff absences
-unfilled posts
<needs confirmation by a cytologist/lab manager>
All of these are easy to know and measure, usually in advance.
Work In
---------
The determining factors on the rate at which smear slides arrive at the
lab include
- the rate at which invitations are sent
-by the PPSA to the Practices
-by the Practices to the patients
- quarter ends and searches causing Practices to make recalls
- general variations in the patient attendance such as summer holidays
<others?>
The Bottleneck identified, manage the process
--------------------------------------------------------
Leaving aside any perverse effects on the workflow and quality of
service caused by the quarterly target payments, which could be tackled
by a move to monthly target payments or an elimination of them
altogether,
the factors easiest to manage in this workflow are the rates at which
the invitations are distributed centrally and then from each practice.
Managing the rate at which smear appointments are booked into practices
is smore difficult to manage for physiological and financial reasons.
Inputs to the process control loop.
----------------------------------------
Essentially this is the annual leave calendar for the relevant
laboratory staff.
This is information which is undoubtedly held, it merely needs to be
viewed in terms of workflow and made available for weekly blocks a
suitable time in the future. I envisage that 6-8 weeks would be an
appropriate time, but with good organisation it may be possible to run
this down to 2 weeks, which represents a physiological limit.
Laboratory staff would be justly unhappy if required to give 8 weeks
notice of a long weekend, and clearly only significant absences would
need to be reflected in the forward planning. This probably means
anything over three working days in a month.
<magnitude of significant leave?>
If the process control is slightly imperfect there will be a trend to a
change in the size of the input stack of smear slides at the lab. A
factor to take account of this can be introduced, clearly if the size
approaches the upper control limit then the workload for the following
month should be suppressed to allow it to be cleared.
(the condition of a steady increase due to persistently insufficient
staff is a separate case, but it is my contention that it is more
sensible in all respects to leave the cells in the woman than on the
lab bench if the reading of the smear is to be delayed.)
Integrating the inputs
--------------------------
It is probable that the information required to do this is already held
in a single office.
It is likely that a simple spreadsheet would be helpful in modelling
and monitoring the process, and in reporting the effect and control
chart.
Distributing the control information
-----------------------------------------
Loop 1
--------
A negative feedback loop fron the laboratory input stack to the PPSA
cytology recall process should be trivially easy to contrive. Indeed
if it has not already been instituted this might be regarded as strange
or as reflecting the disintegrated way in which we have been working.
The information for this loop could be transmitted automatically or be
built into the Exeter system but the degree of effort involved seems
unlikely to be economic this century.
A member of the cytology staff told off to pass the number by
telephone, fax or memo on each Thursday to a named junior in the PPSA
seems adequate.
The nubers almost certainly are already collected and stored, this
information should be left where it is and access given as needed for
review, until it is convenient to automatically place it on a query
server accessed via the Web and automatically compiled into the
Authority Enterprise Information System (EIS) and as part of the public
reports.
Obviously this is a factor which will be considered, if it has not
already been, in the design of clinical systems handling NHS messaging
for Cytology call and results.
Loop 2
--------
The negative feedback loop to the Practices involves more organisations
and therefore is more likely to be worth making automatic and
asynchronous.
The obvious solution is to place a single message giving the percentage
of average or baseline cytology effort which should be made over a
particular period.
This message could be distributed by fax, expensively and
unsatisfactorily, or by an e-mail to a conference on the Devon Medical
Information Resource which is simultaneously exposed as a Web page or
an element of a framed web page.
Whatever system practices normally employ to access this information
will suffice, but using a proxy server programmed to update this URL
weekly on Monday would be a sensible approach. (NearSite is suitable
fo the purpose, and IE4 has some built-in features which coulf be used.)
Integration of the feedback into the process of call and recall in the
Practice should be left to the nurses and secretaries, and managed by
practice managers in the usual way.
It seems both unnecessary and, given the financial implications futile,
to attempt to manage the workflow generated by either patient requests
for a smear at the time their diary tells them it is due, or
opportunistic smears on poor attenders.
<what proportion of smears in practices are done as a result of the
recall
system and what is the variation>
Loop 3 - the overmanagement
------------------------------------
If the average effort practices are asked to put in declines below that
required to maintain smear targets there will be pressures from central
government and from practices to increase thoughput in the lab.
This is appropriate, and making defficiencies explicit should not be
seen to be adverse to anybody's interests.
This is the task of the upper layers of the professional (IE fulltime)
management personnel.
Disclosure
-------------
The process organisation and markers of its operation should be exposed
to the public by the usual methods of publication. Given the volatile
nature of th einformation and its integration into IT systems in
routine use, a Web page is the obvious method of publication and this
should be automatically updated on Thursdays.
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