Lean – where to start? - okyanusbilgiambari.com · Move away from batching, backlog and queues....

Lean – where to start?

Dr Jackie Bene, Medical DirectorJoy Furnival, Head of Lean Transformation

Royal Bolton Hospital NHS Foundation Trust

Copyright © Royal Bolton Hospital NHS Foundation Trust 2011. All Rights Reserved

Where we are now…

5 years of the Bolton Improving Care System;driving sustainable quality, safety and productivity across

the Trust


About Bolton

• Population 270,000• Northern industrial town• 12% ethnic minority population (>18%

childhood population)• Significant levels of deprivation and inequality• Reflected in health status

– SMR - Cancers – up to 123- Circulatory disease – up to 136

• Part of Greater Manchester – 2.5m population


About the Trust

• Approximately 700 beds• Busy emergency services – catchment about 310,000• 3,200 staff• £170m turnover• Integrating under TCS with Bolton Community Services• Most secondary elective and non-elective acute specialties:

» Medicine» Surgery/Urology» Orthopaedics» ENT, Ophthalmology, Oral» Children’s» Obstetrics» Diagnostics» A&E

» Community Provision from 1/7/11


In the beginning…

• No experience of Lean as an organisation

• Key strategic issues – HSMR- finance- failing to achieve key performance targets

- clinical engagement

• New CEO with big ideas!


Information

All work is a process….this is true of healthcare too!

Clinical assessment

Investigations Clinical decision

Patients

Information

Admission Treatment Discharge


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InappropriateProcessing

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The NHS is full of committed staff who struggle to deliver good care within a set of broken processes.Lean aims to tackle this by:“Respect for People & Society” “Continuous elimination of Waste”


What does “Lean” mean?

Current

Traditional

Lean

Time

Waste (NVA) Work (VA)

New Work?


The Eight WastesInjuries Damage to people, including anxiety, stress

and physical injury.Transportation Unnecessary movement of materials e.g.

recordsInventory Parts or product being stored e.g. ward stocks

Motion Unnecessary movement of workers e.g. nurses

Waiting Delays in the process e.g. 18 weeks!

Over-production Too much product or service being produced e.g. tests and x-rays

Over-processing Unnecessary steps or activities e.g. duplicate histories

Defects Errors or deficiencies that require re-work e.g. drug errors


Proven Sequence of Implementation: 5 Steps

1. VALUE ~ What is the customer really buying

2. VALUE STREAM ~ How value is created & delivered

3. FLOW ~ Improve the value stream

4. PULL ~ triggering every flow from actual demand

5. PERFECTION ~ Continuous improvement forever


VISUAL MANAGEMENT:

1 PIECE FLOW

STANDARDWORK

6 S PULLSYSTEMS

Move away from batching, backlog and queues.

Reducevariation & complexity.

SortStraightenScrubSafetyStandardiseSustain

Create signals to pull patients. Obvious when something empty.

“ability to see the process”

Basic Lean Principles


Getting started

• Organisational re-structure

• Links and networks – IHI- Thedacare- Toyota and other industries- Masterclasses

• External help - Consultancy

• Value stream analysis (VSA)


Key early questions

• The “Brand”

• Self sufficiency

• Which clinical pathways - linked to HSMR

• Waste or productivity opportunities


Key early decisions

• BICS and BICS Academy

• Clinical pathways – FNOF and Stroke

• Productivity opportunity » Cataracts» Day Surgery » Laboratory Medicine» Clinical Support Services


Some encouraging early results

• Trauma – FNOF 31% mortality ; 33% Length of Stay ; 42% paperwork

• Stroke 92% Sentinel Audit Score, 23% mortality , 24% LOS

• Ophthalmology – New One stop shop – patient visits 50% ;

• High risk joint replacements – complications 85%; Length of Stay 43%

• Pathology – Test turnarounds from x3 to x10 quicker; 40% floor space saving

• Laundry, Estates, Finance and others – six figure cost savings

• 30% of staff engaged in week long improvement events and 1000 completed “Green” training

….. But still only scratched the surfaceCopyright © Royal Bolton Hospital NHS Foundation Trust 2011. All Rights Reserved

: Building a system for Improvement


Characteristics

• Aim is to create a system for Improvement• Based on “lean” principles, creatively adapted for the

NHS• At heart of our FT Business Plan – drives safety, quality

and productivity• Comprises tools, methods, management system and

leadership• Seeks to engage all staff in a long term cultural

transformation linked to Trust values

• Creating 6000+ daily problem solvers – ‘the way we work round here’


1. Challenging the old mindsets

2. Redesigning every end to end process

3. Making it the way we manage every day

4. Embedding it in our culture

5. Creating a lean health and social care system

The Challenge


ClinicalEngagement

Patient Experience

Lean ProcessRedesign Safety

Care Bundles& Advancing

Quality

BICS asDaily Work

BICSAcademy

-Divisional Structure-Policy (Strategy) Deployment & Strategic Reviews-Leadership development

-Design Council & Diabetes-Virtual Care Cards-Experience Based Design-PROMS-Patients on Improvement Teams-100 Voices

-Orthopaedics-Stroke-Eye Services-Respiratory, -Gastroenterology andUrgent Care

-Outpatients-Theatres-- CAMHS

-Green-Bronze-Silver-Gold-Platinum

-Safer Clinical Systems-Patient Safety First-Safety Express Plus-NW Mortality Collaborative

-Advancing Quality-Sepsis-DVTs-Pneumonia

-Blood Sciences Lab-Exemplar Programme-Engaging Manager Programme

-Big Conversation


Programme 2005 - 2008• EVSA for Trust November 2006 - Mission Control & Policy Deployment

• Divisional Priorities - Individual Divisions burning bridges

• Engagement and involvement of staff

Programme 2009 - 2010 • Whole hospital focus on Urgent Care, Mortality & financial stability.• Burning bridges of HSMR and Urgent Care 98% 4hr maximum target.

Programme 2010 - 2011 • Burning bridges of HSMR and Urgent Care.• Response to financial pressures from economic downturn.• Increased focus on Productivity and Elective Pathway• Integration with Bolton Provider services under TCS


Trust Strategy

• Evolving into an Integrated Health Care Organisation during 2011 with acquisition of community services

• Centre of excellence for Women's and Children's Services -“Making It Better”

• Major Emergency Centre/redesign of urgent care

• Re-focused range of elective services

• (LEAN) driving sustainable quality, safety and productivity improvements -the way we do things around here!


Trust Wide Results (‘05 to ‘11)Releasing Benefits

*Data taken from Dr Foster December 2010

Staff Engagement•79% completed Green Training or Rapid Improvement Events

Theatre Performance•20% saving in time due to improved start times (Theatres)•Shortlisted for Patient Safety Awards 2010 & 2011•Stock savings through Kanban > £142,245 recurrent

However, despite all this fantastic work there is still a long way to go, only now are we beginning to see all the waste and problems intrinsic to the processes….“We just about know, what we didn’t know!”

We still have many challenges regarding our mortality rate, and sustaining the A&E Clinical Standards


Can it save money?2010/2011

• Directly Attributable Benefits = £1.5m

• Actual saving/cost avoidance due to reduced LoS £884k*

• Actual additional time, cost & productivity improvements : £0.6m*

2009/2010• Actual saving/ cost avoidance due to reduced LoS £2.3m*

*Source benefits tracker agreed February 2010. **A Sanderson & A Vincent 24/4/11


Productivity Realisation Medical Urgent Care

Wards A4, B3, B4, C3, D3, D4 & N3

Ward Closed for 3 months as part of cash releasing savings during summer period*Source: Finance October 2009A Sanderson & A Vincent 18/2/11

April - December 2008

April – December 2009

April – December 2010

Length of Stay (days)

11.5 10.6 8.8

Occupancy (%) 93.50% 96.70% 93.70%Patient

Throughput3953 4302 4616

Average income/med patient £2404*

Average income/med patient £2404*

Increased throughput 349 pts

Increased throughput 314pts

£838,996 £754,856Bed Days saved 733 Bed Days saved 597Time period 275 days Time period 275 days

3 beds 2.2 beds

Income Related Benefit*

Beds Saved


Reduction in HSMR Using 2009-2010 as Baseline Year

Despite these results overall Hospital HSMR remains significantly above ideal and much more work is required to reduce this. For this we continue our 5 point plan :

Trend in HSMR

• Developing the response to deteriorating patient

• Focus on high-risk pathways

• Focus on end of life care

• Implementing Standard work & care bundles

• Coding and record keeping

Data from Dr Foster, Dec 10

Similar Charts are available to demonstrate reductions in the Stroke and Trauma pathways


Programme 2011 OnwardsEVSA

Enterprise Value Stream Analysis (EVSA) was used in November 2010 to identify the vision and strategic priorities of the organisation after the merger with the PCT provider arm in 2011.Board members, senior leaders, Governors, clinical leads, staff, patient, local government and ambulance representatives came together to describe how they felt the new organisation should be shaped.

Example of work completed during the 2 days

“We are all responsible for this new organisation, and become a leadership team that works together to common goals. Making real and deliverable changes will be a big, exciting achievable challenge”

Lesley Doherty Chief Executive


Policy (Strategy) Deployment

Second Level (L2)• Improvement owner develops second level.• Transfer strategies & breakthrough priorities.• The Divisional team develop detailed

strategies and measures as appropriate.

Top Level (L1)• 5 year breakthrough goals set.• Annual breakthrough priorities decided.• Strategic improvement priorities agreed.• Measures set. • Identify director ownership.

Further Deployment• Do not exceed three deployment levels. • Individual action plans created from level 3 matrix.


The Exemplar Programme uses the BICS principles of standard work, removing variation and waste, improving quality and reducing cost to deliver our commitment to provide a clean, safe and efficient environment of care, underpinned by Patient Safety.Achievement boards are used to demonstrate measures e.g. Infection control & mandatory training.

Designed by the Chief ExecutiveLead by the Director of Nursing

Exemplar ProgrammeUsing BICS in daily work

Work has commenced to develop a non-clinical model, due to staff demand.


Fractured Neck of Femur (#NOF)

2005 2010

Average Length of Stay 30 days 20 days

Average Time to Theatre 2.4 days 1.4 days

HSMR 173.9 84.6

The Trust focused attention on reducing mortality associated with hip fractures, developed a Trauma Stabilisation Unit and confirmed; much of which was initially presumed to be unavoidable, was found to be preventable.

201020092008200720062005

120

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HSMR

HSMR Fractured Neck of Femur 2005 - 2010: Baselined on Data Year


Productivity Rise (Relative to 1994/95)

0%

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250%

1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Productivity (%) Predicted Productivity

LEAN JOURNEY

Blood SciencesWhere have we been? Where are we now?

Sustainment and Growth

Visual Management

Pull 1 piece flow

6S Standard Work

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“I knew change was possible and we’d make some improvements, but I didn’t imagine we’d make as many as we have and it gives you the courage to go further and make even more changes” Dr Brian Bradley, Respiratory Consultant 2010

Respiratory Team

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Time Series Plot of D3 Length of Stay 1/4/08 to 31/12/10

BMJ2011

Dr Brian BradleyShortlisted

Clinical Lead of the Year

2011Process Excellence Awards

WinnersBest Process Improvement

Project in Service & Transaction


Emergency Department FlowBlood Diagnostics Patient Information

Patient records faced an administrative backlog sending GP letters and archiving A&E notes after patients were discharged from A&E

Improved the pathway and monitoring of blood samples and reduced ‘flow times’ from decision to take bloods to treatment, increasing compliance with max 4hr A&E target.

Patient Experience Based DesignDeveloped a structure and methodology for involving patients as co-designers in improving services.

Benefits:

Improvements in pain management.

Proactively involving patients in bedside handovers

Daily multi-disciplinary meetings ensure patients care is managed

‘Top tips’ leaflet, devised by patients.

Escorting patients to their cars and improved transfer awareness for patients and carers

Education for staff - Diabetic awareness.

Shortlisted

Originally designed in orthopaedics, now used in Respiratory Medicine and Stroke Services.

The Bolton News“Hospital in good health as patients have a say”20th January 2011“The NHS Confederation report says the Royal Bolton has made “significant progress in providing services that are truly patient-centred.” The NHS Confederation says there has been progress on patient experience, backed up by the examples, but there needs to be a consistent approach, across the NHS.”


Capital Scheme SavingsBy using flow & Lean tools to design the layout of new builds and refurbishments, the Trust has made significant savings and avoided unnecessary costs.


Over the last year theatres have implemented and embedded the WHO checklist, trialled an Anaesthetic Referral Clinic, improved the theatre environment and increased session utilisation.

Operating Theatres A Team Approach to Safety in Theatre

2011Patient Safety AwardsWinnersSafe Surgery


Outpatient ServicesCentral Preparation of Casenotes Slot Utilisation

Most casenotes are stored centrally, however some were stored and prepared for clinics in devolved reception areas.

Centralisation of casenote preparation reduced waste and improves quality, safety and efficiency

Inconsistent booking protocols led to slots not being fully utilized or overbooked (equating in general surgery specialties to £46,436 lost income in 3 months).

Changes were made to standardise booking management and slot publication.Plans are now being made to roll out in this improvement across all specialties


Merger of Acute Trust and PCT

As both organisations use Lean based improvement methodologies and a well developed improvement culture. These too will merge under the BICS banner.

From 1st July 2011 Royal Bolton Hospital and NHS Bolton provider arm will merge to form Bolton NHS Foundation Trust.

Best

Possible

Care

Joy and Pride in Work

Improving Health

Value for Money

EQuIPEnabling Quality Improvement Programme


BICS AcademyA structured learning & development programme that forms a foundation for the Trust-wide service improvement transformation, to develop a culture of safety first and continuous improvement.

4 Key Aims:

Raising awareness and engagement.

Developing & supporting appropriate leadership skills.

Improving the quality & sustainment of improvement work.

Developing highly skilled improvement practitioners.

“The training promotes organisation wide understanding of this being an inclusive, not top down process.” Green Level Candidate


Creating Awareness of BICSAwards

2009 International Forum on Quality &

Safety Best Overall Poster - Winner

Trauma Unit Saves Lives

2010NHS Leadership Awards

WinnerDavid Fillingham

Chief Exec 2004-20102009HSJ Awards - ShortlistedPatient Experience Based Design


Sharing the Learning

Winn D (2009) Transformation in the NHS. Human Givens Journal, Volume 16, No2.“What is being undertaken at Bolton is utterly inspirational”

Academy of Medical Royal Colleges (2009) A Guide to Finance for Hospital Doctors.Audit Commission. “significant improvements have been made…. The capacity created has resulted in additional activity being undertaken within existing staff levels.”

NHS Confederation (2010) Feeling Better? Improving Patient Experience in Hospital. NHS Confederation.www.nhsconfed.org/publications

Patterson P & Leach J (2009) A Leaner Care System.Health Informatics Now, June 2009, pg 20-21.

Publications

Institute for Innovation and Improvement (2009) Lean Thinking. Cross Current, Winter 2009.

Lomas C (2007) Supplements People: Moving Policy from Board to Ward. Nursing Times, 12th November 2007

Lean Leaders II: Step by Step Application of Lean in the NHS Lesley Doherty Chief Executive Pod Cast. Accessed via http://www.leaders-in-lean.com/Event.aspx?id=407430

Brown M (2011) Lean Leadership. Health Manager, Journal of The Health Management Institute of Ireland. January 2011“….the Trust has demonstrated its application to transformational change and maintained and ensured respect for its staff and patients.”

Sharing the LearningSharing with external organisations

Visits to Other OrganisationsThank you to all those organisations who shared their learning with us including Thedacare USA, Toyota (GB) Plc, Unipart Group, Clydesdale Bank, Astra Zeneca and many others…….

Market Place & Strategic Reviews

Plans shared across health economy through market

place methodologyCopyright © Royal Bolton Hospital NHS Foundation Trust 2011. All Rights Reserved

Lessons LearnedLessons Learned

For the FutureAlthough we have taken great steps our journey has still

far to go

A&E Clinical Standards


Thank You

For further Information please contact

[email protected] 01204 390099

www.royalboltonhospital.nhs.uk/bics


mailto:[email protected]�

Lean – where to start? - okyanusbilgiambari.com · Move away from batching, backlog and queues....

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