The Key to Transitioning from Feef-for-Service to Value-Based Reimbursements
Leanlondon 19sep13
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Transcript of Leanlondon 19sep13
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Lean London Forum
19 September 2013Royal College of Surgeons
For more information, please email [email protected] or telephone 0207 824 8448
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Confidential not to be used without consent
We have some broad aims of the forum
• Create the environment where Lean Solutions in the NHS are shared, discussed and acted upon by practitioners in the health service
• Engage in a debate about strengths and weakness of lean/service improvement methods in the current NHS climate
– The QIPP agenda in reducing costs across the health system
– Clinical Commissioning Groups that will redefine ‘end to end’ health systems processes
• To network with colleagues and friends
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Confidential not to be used without consent
Agenda
• 1800 - 1810 Welcome and introductions
• 1810 - 1835 Taking a new look at your service; “LEAN” a process approach to change – Ms Pauline Connor (Bio Medical Scientist, North Middlesex University Hospital NHS Trust)
• 1835 - 1900 “Improvement; Infection; Impossible? – Dr Mathew Diggle (Consultant, Nottingham University Hospitals NHS Trust)
• 1900 - 1930 Hot seat session
• 1930 - 2000 Networking and drinks
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Taking a new look at your
service
“LEAN” a Process Approach to
Change
Pauline Connor
Chief Biomedical Scientist
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Context
• Histopathology department at NMUH serves a medium sized DGH, with approximately 10500 requests per annum
• Increase in complexity of cases (reflected as increased blocks and slides) by 49%
• Increased demands on Consultant reporting time, now support 43 MDT meetings per month
• Biomedical, Clerical and Medical staffing levels stable, but of 4.1 wte Consultants, only 1 is full time
• Opportunity to become one of nine pilot sites for NHS Service Improvement project “Learning how to achieve a
7 day turnaround time in histopathology”
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Target• 95% of work reported in 7 days
• 50% of work reported in 3 days
• Baseline figures were 16% in 3 days; 50% in 7 days
• End of project figures 44% in 3 days; 92% in 7 daysTATs -Sep 2009 to june 2010
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
6887/09
6896/09
6905/09
6914/09
6923/09
6932/09
6942/09
6951/09
6960/09
6969/09
6978/09
6987/09
6996/09
7005/09
7014/09
7023/09
7032/09
7041/09
7051/09
HH004324B/10
HH004333M/10
HH004342C/10
HH004351W/10
HH004362W/10
HH004371Q/10
HH004385Y/10
HH004395E/10
HH004404C/10
HH004414A/10
HH004423C/10
HH004433A/10
HH004443W/10
HH004453H/10
HH004463Q/10
HH004475Q/10
HH004486N/10
HH004514E/10
lab no
days
days The Mean (Average) Upper Control Limit Lower Control Limit
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What is lean?
• A whole Management Philosophy
• Perfected by Toyota in the 1970’s
• Toyota Production System (TPS) focuses on:
– Improving flow (pull)
– Increase value for user
– Get rid of waste
– Get it right first time
– Continually improve
• Puts the customer at heart of the process
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A process approach to change: taking the
pathology service apart and reassembling
• Value stream maps - to look at every step in the specimen pathway
• Walk the walk, collect data, take photographs
• Assign timings to every part of the process
• Identified that our value added time = 1.5 days
• Non-value added time ranged from 0.5 to 17.5 days i.e. additional
activity that add cost and time but were of no value to the patient
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No need for expensive software
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Taking the process apart: where to
spend the time
• We identified waste such as movement;
waiting; duplication of effort; excessive
checking; poor utilisation of skills;
overproduction
• Looked for waste at all stages using tools
such as the “5 Whys?”; Plan,Do,Study,Act
cycles; A3 problem solving techniques
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Case 1: Over processingThe value stream map identified over
processing at specimen reception
• Pre LEAN: all specimens were dealt with in one large
batch; large bags of specimens delivered in one or two
drops
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Understanding the problem
• Multiple specimen
handling and checking
steps
• Sorting into separate
work streams
• Delayed the next
stage of the process
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Measurable outcome
• Removed separate work streams
• Introduced one piece flow in specimen reception
Task Pre LEAN Post LEAN % Reduced by
Specimen
checks
7 3 43%
Specimen
handling
6 3 50%
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Impact•Continuous flow
•Reduction in the error rate
•Less stressful, uncluttered
environment
•Visual management used
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There is no point optimising a
process unless it is standardisedIf the process changes depending on who performs the work or other parameters, measurement is meaningless
Create standardised work procedures to produce process stability
Then Optimise
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Case 2: Standardisation
The use of templates for cut up “LYSIS”
• Pre LEAN: tapes were used for dictation with a two part specimen request form
• Problem: the tapes and forms moved on average 82 m per cut up, this movement added no value to the process.
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Waste identified
• Movement - of forms and tapes
• Waiting – to be typed
• Re-duplication of effort – the same
description repeated again and again
• Errors: occasional tapes failed and some
were occasionally erased in error
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Solution “LYSIS”
• Introduction of standardised templates for use in
specimen dissection
• No tapes – notes are typed into templates in real time
during cut-up on a two-screen computer
• Allows continuous flow of work and single unit flow
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Measurable outcome
• Tapes had an efficiency of 9.5%
• LYSIS has an efficiency of 93.2%
• Less waiting, less movement
• Saved 20 days of secretarial time per annum
P ro c e s s S te p s A m o u n t
P ro c e ss in g -w h e n s o m e th in g h a p p e n s t o m o ve it o n 3 . 0 0 P ro c e ss
C he c k in g o f in f o rm a t io n /c o n tro ls /d e c is io n -m a kin g 2 . 0 0 C h e ck
W o rk m o ve s o n w it h o ut a n y th in g h ap p e n in g to it 3 . 0 0 M o ve
D ela y - w o rk flo w is p re v e nt e d f ro m m o vin g fo rw a rd 3 . 0 0 D e la y
1 1 . 0 0
D is ta n ce M e tr e s
P ro c e ss in g -w h e n s o m e th in g h a p p e n s t o m o ve it o n 1 0 . 2 0 P ro c e ss
C he c k in g o f in f o rm a t io n /c o n tro ls /d e c is io n -m a kin g 2 . 4 0 C h e ck
W o rk m o ve s o n w it h o ut a n y th in g h ap p e n in g to it 8 2 . 8 0 M o ve m e n t
D ela y - w o rk flo w is p re v e nt e d f ro m m o vin g fo rw a rd 1 5 . 6 0 D e la y
1 1 1 . 0 0
T im e m i n u te s
P ro c e ss in g -w h e n s o m e th in g h a p p e n s t o m o ve it o n 1 6 0 . 0 0 P ro c e ss
C he c k in g o f in f o rm a t io n /c o n tro ls /d e c is io n -m a kin g 3 . 0 0 C h e ck
W o rk m o ve s o n w it h o ut a n y th in g h ap p e n in g to it 7 . 0 0 M o ve m e n t
D ela y - w o rk flo w is p re v e nt e d f ro m m o vin g fo rw a rd 1 ,5 1 5 . 0 0 D e la y
1 ,6 8 5 . 0 0
S u m m a ry
T o ta l
T h e P r o c e s s C y c le E f fi c ie n c y is 9 . 5 % .
T h e re w e r e 3 d e la y s w h ic h p r e v e n t ed w o r k flo w fr o m m o v in g fo r w a rd , a n d t h e y la s te d
f o r 1 5 1 5 m in u t e s .
T h e w o rk f lo w m o v e d w i th o u t a n y t h in g h a p p e n in g to it 3 t im e s , a n d t ra v e l le d 8 2 . 8
m e tre s .
T o ta l
T o ta l
T h e w o rk f lo w w a s c h e c k e d , o r h a d a d e c is io n m a d e a b o u t it 2 t im e s , a n d t h is t o o k 3
m in u t e s .
P ro ce s s
2 8 %
C h e c k
1 8 %M o v e
2 7 %
D e la y
2 7 %
P ro c e s s
9 %C h ec k
2 %
M o v e
7 5%
D e lay
14 %
P r o c e s s
9 %C he c k
0%
M o v e
0 %
D e la y
9 1 %
Process Steps Amount
Processing-when something happens to move it on 8.00 Process
Checking of information/controls/decision-making 1.00 Check
Work moves on without anything happening to it 2.00 Move
Delay - workflow is prevented from moving forward 1.00 Delay
12.00
Distance Metres
Processing-when something happens to move it on 7.20 Process
Checking of information/controls/decision-making - Check
Work moves on without anything happening to it 16.80 Movement
Delay - workflow is prevented from moving forward - Delay
24.00
Time minutes
Processing-when something happens to move it on 55.00 Process
Checking of information/controls/decision-making 1.00 Check
Work moves on without anything happening to it 3.00 Movement
Delay - workflow is prevented from moving forward - Delay
59.00
The Process Cycle Efficiency is 93.2%.
There was one delay which prevented workflow from moving forward, and it lasted
for 0 minutes.
The workflow moved without anything happening to it 2 times, and travelled 16.8
metres.
Total
Total
The workflow was checked, or had a decision made about it only once for a time of 1
minutes.
Summary
TotalProcess
67%
Check
8%
Move
17%
Delay
8%
Process
30%
Check
0%Move
70%
Delay
0%
Process
93%
Check
2%
Move
5% Delay
0%
Before
After
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Case 3: Introducing continuous flow:
optimising the Laboratory layout
Pre LEAN:
• poorly designed
• cramped and cluttered
Problem:
• the layout did not support
the flow of specimens.
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Analysis of the problem
• Used spaghetti diagrams to map the path of
a case through the Laboratory
• Used process sequence charts to look at
distance, timings and efficiency of the
processes
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Original layout of laboratory
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What did we do ?
• Used future state mapping to plan our ideal
journey for a case
• Data collection before and after changes
• Data gave us the confidence to redesign the
Laboratory
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Impact of optimising the layout
• Transposition of the two staining machines
has lead to a reduction in movement of
8463 m per annum
• Routine work cell has the added benefits of
reinforcing team work
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Laboratory layout today
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Case 4: Introduction of a “pull” system:
pooled Consultant reporting
• Pre LEAN: all slides processed from a day’s cut up were allocated to a single Pathologist
• Problem: this did not allow for capacity and demand issues
• Work was “pushed” into their rooms and often sat unreported due to other commitments
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Analysing the problem
• Waste: time spent in the Laboratory allocating
cases to individuals; time spent searching for
cases that were needed urgently
• Batch size: large - a whole day’s work to report
• No “first in, first out” – depended on Consultant
availability
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Implementing the solution
• Data collection showed
variation in turnaround times for
all Consultants, which was
related to their other
commitments
• Data was presented at
Consultant meetings and
agreed to try a pooled system
of reporting
• Emphasis placed on the
inefficiency of the process
rather than the individual
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The Process
• The majority of the cases are pooled into a common area in the laboratory
• Larger cancer cases to go directly to pathologist who cut up the specimen
• Consultants “pull” a reduced batch size tray of work only if they are ready to report it directly.
• New work placed in the area so the flow is “first in, first out”
The Benefits
• Pooled work takes better account of consultants working part time
• Waste reduced within the laboratory
• Unforeseen urgent cases easily located and dealt with
• A common pool is a clear visual measure of demand (work awaiting reporting) with no hidden trays in rooms
The new system
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Impact
• Improved turnaround times allows prompt
discussion of patients at MDT meetings
• Predictable turnaround times allows earlier follow
up clinic appointments for patients
• Better use of Consultant availability to maximise
reporting time
• Morale has improved; a common challenge
• Has been easily adapted to allow for sub
specialist reporting
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:
Measurable outcomes
• Dramatic reduction in turnaround times
3 day turnaround improved from 19% to
40% (21% increase)
7 day turnaround improved from 56% to
95% (55% increase)
• Overall reduction in time taken to report by
Consultants has decreased from 4.5 days
to 1.8 days
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The Overall Results so far TATs More Consistent
TATs -Sep 2009 to june 2010
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
6887
/09
6896
/09
6905
/09
6914
/09
6923
/09
6932
/09
6942
/09
6951
/09
6960
/09
6969
/09
6978
/09
6987
/09
6996
/09
7005
/09
7014
/09
7023
/09
7032
/09
7041
/09
7051
/09
HH00
4324
B/10
HH00
4333
M/1
0
HH00
4342
C/1
0
HH00
4351
W/1
0
HH00
4362
W/1
0
HH00
4371
Q/1
0
HH00
4385
Y/10
HH00
4395
E/10
HH00
4404
C/1
0
HH00
4414
A/10
HH00
4423
C/1
0
HH00
4433
A/10
HH00
4443
W/1
0
HH00
4453
H/1
0
HH00
4463
Q/1
0
HH00
4475
Q/1
0
HH00
4486
N/1
0
HH00
4514
E/10
lab no
da
ys
days The Mean (Average) Upper Control Limit Lower Control Limit
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Where to spend the time:
Communication
• Laboratory huddles
• Time limited, no more than 10 minutes
• Review of that day’s workload and staffing
• Laboratory dashboard – daily targets, defects, interruptions
• LEAN project meetings –twice monthly.
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What do you need to do this?
• Equipment – NO – total cost of this project to date has been approx £2000 – a few trolleys; cabling
• Increased staffing levels – NO – this has been achieved with no increase in staff levels –consultant vacancy since March 2010, despite an increase of 20% in requests and 49% in work units
• Time – YES – data collection; team meetings
• Motivation and perseverance - YES
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Summary
• A department that has absorbed a 49% increase in work, with a 10% reduction in staff
• Motivated and engaged staff who know that they are fully included in service delivery and continuous improvement
• Emphasis on the end point of the process i.e. a patient requires a report, rather than the process itself
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Where?
Clinical Microbiology DepartmentNottingham University Hospitals NHS Trust
Queens Medical CentreDerby RoadNottinghamUKNG7 2UHhttp://www.nuh.nhs.uk/microbiology/
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The Nottingham Experience
• Diagnostic service: 24/7, 365 days per year
• Population served: >2.5 million (> 5 million)
• Workload: 970,000 pa (> 1.8 Million)
• Isolation, identification and detection of
• medically important bacteria,
• viruses and parasites.
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And now for
something
completely
different...
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NHS Improvement - EM SHA Microbiology Sites
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LEAN?
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LEAN
Microbiology
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What the…………….
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The Path-ology
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The Project
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Challenges
• Collaborations
• Consolidation
• Competition
The “C”s……….
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The Nottingham Experience
Challenges
• Developing a lean culture• Find a champion
• Engagement of your staff• What is engagement?
• Communication• While under a seize mentality
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http://www.improvement.nhs.uk/documents/Microbiology_Guide.pdf
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Thank you!
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Confidential not to be used without consent
• Focus on Value from a Customer (Patient) point of view on every
step of process
• Obsession on removing waste within the ‘whole system’
• Bottom up approach in identifying value and waste – assumption
that much of waste and value is hidden
• A true lean system would “flow” and need little command and
control
Recap – What is Lean?
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Confidential not to be used without consent
What’s Next?
• Today’s presentation and feedback survey sent out by email within 72 hours
• The Next Lean London Forum will be held on 5 March 2014.
– Register at www.leanlondon.org.uk
– We will send out reminders to all participants from today
– We have a Lean Midland Forum on 16 October 2013 taking place in Birmingham. Register at www.leanmidland.org.uk
– If you’d like to take up one our presentation slots, please do let us know. We are keen to hear from Community Trust and GP Groups
• Find us on and - LeanNHS
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Past Presentations at the Forum
http://kinetik.uk.com/pdf/Lean
London.pdf
1. The 'Leaning' of Bedford Hospital - the story so far, Susan
Whittaker, Bedford Hospital
2. Future Developments in Lean, Rob Worth, Kinetik Solutions
3. Transformation of Camberwell Sexual Health Centre, Rachel
Paxford-Jenkins, Camberwell Sexual Heath Centre
4. Building Lean Expertise, Daniel McDonald, Lean Executives
5. Use of Data in Lean Projects, Andrew Castle
http://kinetik.uk.com/pdf/Lean_
London_Sep_09_web.pdf
1. Radiology Lean Review - The Journey has begun, Carol Darnell,
Bedford Hospital Trust
2. Recruiting for the Lean & Service Transformation, Daniel
McDonald, Lean Executives
3. Lean and Systems Thinking, Rob Worth, Kinetik Solutions
4. Don't water your weeds - starting afresh with Lean, Ian Greddor,
Cyril Swett
http://kinetik.uk.com/pdf/Lean
London_Feb.pdf
1. Challenges in Implementing Lean - A Clinical Perspective, Dr
Ahmed Chekairi, Whittington Hospital
2. A Better Definition of 'Value' in Lean, Ketan Varia, Kinetik Solutions
3. Lean in the pharmaceutical drugs supply process, Niall Ferguson,
Milton Keynes Hospital
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Past Presentations at the Forum
http://kinetik.uk.com/pdf/leanlon
don_sep11.pdf
1. Transforming Surgical Productivity, Christopher Kennedy, Guy's
& St Thomas NHS Foundation Trust
2. Transforming Treatment Rooms, Dr Rebecca Hewitson, The
Whittington Hospital NHS Trust
http://kinetik.uk.com/pdf/leanlon
don_mar12_presentation.pdf
1. The Path-ology to Lean Thinking - Dr Mathew Diggle,
Nottingham Hospital Trust & Suzanne Horobin, NHS Improvement -
Diagnostics
2. Pre-Operative Health Evaluation - Engagement with Primary
Care, Dr Ahmed Chekairi, Whittington Hospital
http://kinetik.uk.com/pdf/leanmid
land0712.pdf
1. How many appointments do we need to make?, Kate Silvester,
South Warwickshire NHS Trust
2. The Path-ology to Lean Thinking - Dr Mathew Diggle,
Nottingham Hospital Trust
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Past Presentations at the Forum
http://kinetik.uk.com/pdf/leanlo
ndon_sep12.pdf
1. Sleek & Slim Hearing for Children - Dr Sebastian Hendrick, Barnet
& Chase Farm Hospital
2. Developing value through transformation of care - What does it
take?, Peter Lachman, Great Ormond Hospital
http://kinetik.uk.com/pdf/kineti
k_dec_12.pdf
1. Network Improvement Services in Tower Hamlets, Florence Cantle,
Tower Hamlets NHS Trust
2. Using improvement science in Ambulatory Care, Simon Dodds,
Heart of England Trust
http://kinetik.uk.com/pdf/Lean
Midland_June11.pdf
1. Lean Transformation at Bedford Hospital, Susan Whittaker, Bedford
Hospital
2. How do drive change by understanding patient value?, Ketan Varia,
Kinetik Solutions
3. Global Lean Knowledge: The Effects of Culture, Maria Gilgeous,
Kinetik Solutions
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Big Thanks To Our Presenters
Ms Pauline Connor
Dr Mathew Diggle
..and to you all for attending
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Confidential not to be used without consent
Thanks to Our Sponsors
Assisting with Lean Transformations
in the health sector and beyond
www.kinetik.uk.com