Clean In, Clean Through, Clean Out - A Methodology for Delivering Purposeful Pathology

This post summarises the work that has been happening in North Devon over the last few years to deliver more effective pathology. We will show that a focus on purpose, and attention to key points of leverage, has led to substantial improvements in the quality of care whilst making make cost savings. Our methodology has achieved this at pace and scale, and in a manner that is sustainable. We suggest that the problems facing pathology are not ones of efficiency, but rather of effectiveness.

What is the purpose of pathology? 

Our work started by talking to patients about what matters to them about their diagnostic tests. We heard

• that they want to trust those that are providing their care 
• they want to feel cared for 
• they want to know if they are normal 
• they generally want to be involved in their care. 

In essence, what this means for pathology is that our purpose is :

 "To enable citizens, and their carers, to make informed decisions about their care" 

What is the cost of sub-optimal pathology?

Diagnostic testing has been growing at about 5% per annum. There is a frequent assumption that this is linked to value, but this is not proved. As we will discuss in subsequent posts, there is considerable evidence that over-testing is now endemic in modern healthcare. There is an obvious link here to increased testing costs, which are not insubstantial. However, the greatest costs lie outside pathology. We will discuss how overtesting adds to an already stretched workload, and adds further costs from follow-on investigation. Most insidiously though, sub-optimal testing leads to considerable patient anxiety. Fran's story tells what it is like to be told as a patient you have an incidental finding of an abnormal result.

Deriving points of leverage from what matters - Clean In, Clean Through, Clean Out

Our work led us to the hypothesis that we will be delivering purpose if the following conditions of "Clean In, Clean Through, Clean Out" are met. In subsequent posts we will describe case examples (urinary tract infection, leg ulcer management, chronic disease monitoring) that provide illustration of these points of leverage. We will also consider the difference between 'inside out thinking' (in our case seeing the world from the perspective of the pathology service and the problems we have) and ’outside in’ thinking (seeing the world from the perspective of the citizen and the problems they have).

Clean In. 

Our standard definition requires tests to be 

1. Necessary

Our work showed numerous examples of tests that were not necessary to answer the clinical question being asked. As we will show this is expensive in and of itself, but that the true cost of inappropriate testing is under-recognised and lies outside the laboratory.

2. Maximally appropriate 

We also saw examples of where tests were not being done at a time when they would have most effectively answered the clinical question, leading to delayed and sub optimal decision making 

3. Informed 

Citizens often have little idea why things are being done to them in healthcare. Our work forced us to confront the implications of this, and it goes both ways. People are often surprised by the result of a test they were not expecting, and were not psychologically prepared for the implications. This goes someway to explaining why results are then not acted upon in the most rational manner. We also saw citizens who thought tests were doing something that they weren't, gaining false reassurance about their health.

4. Sufficient. 

When the above conditions are met, specimens should arrive at the point of analysis in a state and with sufficient information to allow the clinical question to be answered.

Clean through. 

Our standard definition requires specimens to be analysed :

1. Without error. 

In this context, we define error as variation that the system is attempting to avoid - or special cause variation. This should be viewed through the prism of citizen understanding, and this really means error that has a material effect on care.

2. With known variation 

This is similar in scope to “without error”, but looking at predictable variation which the system may accept (but needs to describe) - or common cause variation.

3. On time 

The results should be available within the clinically appropriate timeframe, ready to help informed decision making when it needs to happen.

Clean out. 

Our standard definition requires test results to be reported in a way that is:

1. Understood

Patients and their carers should know what the result means

2. Helpful 

The result should facilitate good decision making

3. Reflective of what is “normal for me “ 

For example, using reference ranges that reflect populations of people like me, and distinguish pathological values from outlying values.

Applying Clean In, Clean Through, Clean Out in Clinical Practice

In subsequent posts, we show that by applying these definitions to typical and predictable scenarios by looking at what happens to real citizens and why, then we are able to take simple, focussed and practical action based on what we learn. The results of doing this are predictably:

• more purpose
• more capacity
• less cost
• less harm