Strand 3Maximising efficiency and productivity

Transforming the service:applying lessons from lean thinking

supported by

Lean Thinking for the NHSDaniel T JonesChairman, Lean Enterprise Academy, Lean Healthcare Network

www.leanuk.org

The Challenge• The changing context is driving the search for new

business models for delivering healthcare• The existing model where doctors effectively manage their

own patients in someone else’s general hospital and the government picks up the bills is no longer sustainable

• We know the problem can’t be fixed by spending more, increasing capacity or changing structures

• So how can we deliver better quality outcomes and experiences for patients, as well as better working experiences for staff, with fewer resources?

• A truly sustainable win-win-win

The Lean ExampleThe most powerful example today is Toyota:• Their cars have the fewest defects - yet they take the least hours to

make • Their parts supply chain has the highest availability - with one tenth of

the inventories• They have the fastest time to market for new products - and lead in

hybrid engine cars• They are growing across the world - and will shortly overtake General

Motors to be No 1 Their lean business model is now being followed by others - Tesco,GE, Rolls Royce, Fujitsu, The Royal Air Force etc.And by the pharmaceutical giants - whose supply chains are at least as broken as healthcare!

Toyota’s Lean Strategy“Brilliant process management is our strategy.

We get brilliant results from average peoplemanaging brilliant processes.

We observe that our competitors often get average (or worse) results from brilliant people managing

broken processes.”

Underpinned with a management system that develops every employee into a problem solver

What did Toyota do?• And what can we learn from them in healthcare?• They basically transformed the way work is done and the

way people work together• There are three levels to this transformation:

– Improving the way each activity is performed and the work of departments like pathology, radiology etc. - Point Kaizen

– Redesigning complete patient journeys from beginning to end - Value Stream Kaizen

– Rethinking the way organisations manage these journeys and synchronise the necessary support activities - System Kaizen

Point Kaizen• Engage staff to:

– Redesign work to eliminate unnecessary steps– Create standard layouts with everything there– Make the work, progress and problems visible– Remove ambiguities and errors etc.

• Engage teams to redesign the flow of work through a department like pathology or pharmacy:– To simplify the steps, eliminate delays, level the workload,

reduce errors, save staff time etc.• Staff need support for this problem solving and these

islands of flow need to be linked

For the Patient - 6 Trips, 100 minutes of Value, 610 minutes Time, over 31 weeks

For Healthcare – 100 minutes of Value, 330 minutes Time, over 31 weeks

FollowUp Appt.

FollowUp

Test

Secre-tary

Pre OpAssess

Test

To ComeList

Ops.List

Admi-ssion

Proce-dure

Disc-harge

Test

5th Visit

Booking Outp.List

Refer Outpat.Appt.

Test

Wait

Hos

pita

l

Test

GPVisit

GPVisitGP

Is Healthcare so different?• “There are no standard patients” - yet they basically follow

a few routes through the hospital– Group the value streams not by department but by length of

stay and the facilities they need • “But demand is quite unpredictable” - actually it is quite

predictable in A&E– Batching, queuing and rescheduling causes the volatility in

elective work - try open access• “But every patient is different” - actually 6% of procedures

account for 50% of the work load– Start by creating a flow for these green patients and free up

more time for the red patients

Admission Diagnosis Treatment Discharge

Support processes:Pathology, Radiology, Pharmacy, CSSD, Laundry etc

Pull at work: every step pulls patients, materials and information towards it, one at a time, as and when needed

Pull at work: every step pulls patients, materials and information towards it, one at a time, as and when needed

System Kaizen• Lean thinkers see a hospital as a collection of value streams,

not of departments• Many support activities need to be synchronised to enable

these value streams to flow• And cooperation is vital because most value streams cross

several organisations• Moving activities into primary care may be right - but not if we

just replicate broken processes - and make existing hospitals unviable

• Redesigning diagnostic and treatment processes with their support processes opens up new models for service delivery -with right-sized tools

Lean and Process Thinking• Lean builds on the process work done in the NHS - and brings

together strands of process thinking:– Total Quality and Six Sigma is about measuring the root

causes of variance – Total Productive Maintenance is about improving

equipment availability– Theory of Constraints is about managing bottlenecks - until

we can get rid of them• Lean unites them in a set of principles for process redesign

and a management system for sustaining and improving them • With Toyota as the powerful reference model

Lean Principles• Specify value from the standpoint of the patient and the

organisation • Identify the value stream to diagnose and treat the patient

and remove wasted steps• Enable the patient to flow smoothly and quickly through

every step• Match capacity with demand so work is done in line with

the pull of the patient • While pursuing perfection through continuous

improvement of the value stream Purpose, then Processes and then People

The Results• The initial gains are a dramatic improvement in quality -

mortality, errors, patient satisfaction • Then better staff morale as things get done right first time

on time - and budgets are met!• Which leads to increased throughput with the same

resources - and better utilisation of theatres • Accelerating momentum as staff have time for problem

solving and continuous improvement• But because it depends on the willing cooperation of all

staff this can not be a quick fix• On the other hand it will undoubtedly separate the sheep

from the goats in this industry too

The Win-Win-Win• Is actually possible!• The theory and principles are tried and tested - with many

examples in many industries• The objectives of the Lean Healthcare Network are to

help to create examples in all aspects of healthcare - to translate lean into healthcare language - and to tell the stories to inspire others

• The job of the Lean Enterprise Academy is to write up the methods so others can follow them

• This all depends on people being willing to rise to this challenge - and convince their colleagues

• Will you be one of those pioneers?

Transforming the service: applying lessons from lean thinking

David FillinghamChief ExecutiveBolton Hospitals NHS Trust

Dan JonesChairmanLean Enterprise Academy

The NHS is full of committed staff who struggle to deliver

good care within a set of broken processes

So…. what can we do that will improve quality, morale

and productivity?

Can “Lean” do this?

Early lessons from Bolton…• What can ‘Lean’ offer the NHS?

• Lean Improvement, Lean Operations, Lean Strategy

• Dilemmas and challenges

The Beginnings of a Lean Journey…• 350 staff engaged (10%) over 9 months• Early results promising

– Trauma: 50% mortality reduction post #NOF– Pathology: Blood specimen processing

• 40% floor space saving• 20% productivity gain

• Antenatal; Radiology; Laundry; Musculo-skeletal• Focus is on quality and safety not cutting cost • We now know just how much we don’t know!

An organising framework for quality improvement

– why use “Lean”?

LEAN is well suited to help in:-• Reducing length of stay

• Increasing day case rates

• Improving diagnostic turnaround times

• Achieving the 18 week journey time

• Reducing errors and rework

• Improving mortality rates

• Reducing administrative burden

But…We need to “reinvent” lean for the NHS• Cultural acceptance and ownership

• Defining goals, understanding demand and flows

• Our ‘raw material’ is also the customer!

• Higher quality = lower overall cost requires a mindset shift

Lean Strategy

Lean Operations

Lean Improvement

Lean Improvement

Every Bolton hospital employee will solve problems in their work and bring about improvements every single day as the way they go about their job.

Lean Improvement at the Front Line• Observations and Diaries (an NHS “Ohno” Circle!)

• “Go and See” rounds

• 6S and Visual Management

• Rapid Improvement Events

6SSort - Separate needed from not needed

Straighten - A place for everything…

Shine - Clean and wash

Standardise - Build into accepted routines

Sustain - Discipline to ensure maintained

Safety - Checking for hazards and defects

BEFORE

MIDDLE

AFTER

Visual Management

Rapid improvement events• Week long

• Teams of 8-12 staff

• Frontline involvement

• Make rapid change happen

• Learning by doing

Trauma Pathway• Aim: reduced mortality

• Current state; ideal state; future state

• Flow through A&E and Radiology

• Trauma Stabilisation Unit

• Discharge and MDT Working

• Theatre Efficiency

Outcomes• 42% Reduction in paperwork

• Better MDT working

• Time to theatre for #NoF down from 2.3 days to 1.7(38% decrease)

• Faster recovery and lower demand on rehab ward

• Total length of stay reduced by 33%

• Expected lower mortality rates (early figures show 50% lower)

Lean Operations…… managing cross cutting processes at a

Trust wide level using lean principles

A Lean Approach to Bed Configuration and Theatre Scheduling• Seeking stability and repetition

• Abandoning traditional specialty constrained thinking

• Achieving a smooth flow of patients without complex planning and rework

• Aligning all support processes to minimise errors and waste

Lean Diagnosticsand Decision Making

GP requests

Inpatients

Outpatients

Developing a Lean Blood Specimens Laboratory

Patient ExampleA patient attends a GP practice and during theappointment the doctor requests blood tests for thefollowing:

• Tests A + B for Biochemistry• Test C for Haematology• Test D for Microbiology

• The GP will complete a hand written Pathology request form and takes blood from the patient into Brown tubes

Current laboratory working practiceUpon receipt in the laboratory the Pathology request formand blood samples will be:• Request form split for the 3 departments• Blood sample

– If 3 separate bottles are received, one bottle will be placed with each request form

– Or if 1 or 2 bottle are received, the sample will be split to provide a sample for each request form

• Processed by staff from the 3 departments– Biochemistry, Haematology and Microbiology– In 3 separate laboratory areas on 2 floors and 2 sides of th

hospital corridor

Current Situation

Redesigned the Lean Laboratory

Expected Outcomes• New laboratory design accepted by all staff

• Staff will have new roles

• Reduced number of staff required (20%)

• Reduction of floor space (40%)

• Reduction of travel distance (80%)

• Reduction of sample processing time from an average of 5 hours to approximately 35 minutes (Routine)

• Avoidance of major capital expenditure

Rethinking the overall configurationof services using lean principlesand analysis

Lean Healthcare Strategy

Lean Healthcare Strategy• As a whole Health Economy

• Understanding demand and high volume flows (which 5% is our 50%?)

• Fully understanding the current state(lean healthcare consumption maps)

• Visioning a future state (Radical redesign of patient pathways)

Use of lean analytical tools and designPrinciples to accelerate change

Lean Strategy – Work Programmes• Redesign of outpatients/diagnostics with One Stop Shops

(ICATs)

• Community Based Urgent Care Centres

• Integrated Chronic Disease Management

Some Dilemmas and Challenges• “We’re too busy to do this”

• “We’re not Japanese and we don’t make cars”

• “This touchy-feely stuff is ok, but we’ve got targets to hit”

• “We’ll leave it up to the Service Improvement team”

• “This will go away in a month or two when the Chief Exec reads another new book”

What we need to do“No Time” - Create dedicated time and resources for

frontline staff (this isn’t easy!)

“Not Japanese” - Reinvent lean” for the NHS context and culture

“Not relevant” - Link lean to our biggest priorities and problems especially safety and quality

“Not our job” - Make it a fundamental line management responsibility

“Flavour of the month”

- Be prepared for a long haul – stay focussed, resilient and optimistic

So, in conclusion,our early experience suggests:-• “Lean” can work in healthcare

• It can improve quality, productivity and morale

• It can operate at all levels – frontline improvement, operations and strategic

• It is a long term strategy – not a quick fix

• Lean can bring energy, enthusiasm and inspiration tohard pressed staff

Strand 3Maximising efficiency and productivity

Transforming the service:applying lessons from lean thinking

supported by