CONTINUOUSIMPROVEMENTIN CARE

LIVING OURVALUES

MAKING THE BEST USEOF OUR RESOURCES

TheImprovement Programme

saferbettersmarter

St George’s HealthcareNHS Trust

The Improvement HandbookA Users Guide

Introduction St George’s HealthcareNHS Trust

Improvement Programme Vision:

“Committed to continuous improvement in care through living our values and making the best use of our resources.”OverviewIn April 2012, the Trust was awarded exemplar service improvement status by NHS London and NHS Top Leaders. This means that the Trust will be setting service improvement standards and will be viewed both as a leader and a teacher. The Team will take an evidence-based approach, developing and publishing case studies on a regular basis to share what we have learned - what worked well and what didn’t.

The Improvement Programme is overseen by the Improvement Board and consists of clinicians, managers and five divisional improvement teams with experienced Programme and Project Managers.

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All members of staff are also welcomed to get in touch with the Team by sending their ideas and suggestions to a central email address ideas@stgeorges.nhs.uk.

This Improvement Handbook (the “Handbook”) provides a guide to how we run a project at St Georges. It takes you step by step through each part of the process, explaining what we do. Our methodology has been developed using GE Healthcare Performance Solutions which we have tailored to our local requirements. It will be revised and amended on an ongoing basis.

It also provides a glossary of terms and useful links to additional sources of information.

Our Approach St George’s HealthcareNHS Trust

The key objective of the Improvement Team is to improve patient care, typically by improving patient outcomes and/or by avoiding unnecessary costs. Improvement can be simply defined as doing things better”. In addition, the NHS has a £20 billion financial challenge to meet. This programme will support St Georges in meeting the challenge by ensuring that services are running as efficiently and productively as possible, whilst ensuring high quality, safe service delivery.

To achieve the objective, the team embraces an evidence-based approach, based on the principles of Lean (a methodology for identifying and removing waste) and Kaizen (which is the process used for a rapid change project) to identify opportunities to improve patient pathways.

Prince2 will be used as a project management methodology to ensure consistency.

Our approach can be broken down into five key stages – namelySTART, DIAGNOSE, IMPROVE, IMPLEMENT AND SUSTAIN:

In a typical project, Stage 1 (Start) will help to identify and narrow down a potential problem which will be further explored and measured in Stage 2 (Diagnose). In Stage 3 (Improve), the focus is on devising various feasible solutions to the areas where issues were identified as being either inefficient or unnecessary. The selected solution is then put in place in Stage 4 (Implement), first on a pilot basis to confirm that the change has the expected outcomes. Finally, Stage 5 (Sustain) helps to maintain momentum and provides a direct link to further improvement through regular evaluation.

The progress through stages does not have to be always forward – there will be situations where it is better to go back a step and then move forward again.

This approach provides a structured problem-solving platform, which will ensure that problems are identified and understood and that appropriate management decisions are taken and changes implemented in the shortest possible time.

Project Timeline (approx. 3 months)

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Overview of project process St George’s HealthcareNHS Trust

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Rapid change project

ProjectScoping &Planning

Ist TeamMeeting

TeamTraining

SettingGoals

Basic Training

60 dayAudit

90 dayAudit

ProcessObservation & Data Collection

Value Stream& ProcessMapping

Preparation forKaizen

(Rapid Change)

Kaizen Week(5 days)

30 Day Follow-upPeriod

CharterSign-Off

Kaizen PrepMeeting

Rapid Change(Kaizen) Launch

Exec-Report-Out30 Day Report Out

& Storyboard

Lessons Learnt

Audit Checks &Exec Report-Outs

Value Stream& Process

Mapping Sessions

Setting up for Success

Creating a Shared Need

Shaping a Vision

Mobilizing Commitment

Making Change Last

Monitoring Progress

Start Diagnose Improve Implement Sustain and Review

Stage 1: START St George’s HealthcareNHS Trust

Including project planning and Lean training

PurposeThe objective of Stage 1 is to begin defining the project. It is important to decide an approach, agree on the end result and determine how the project ties in with the Trust’s aims and values: Excellent, Kind, Respectful and Responsible - as well as its strategic objectives.

Key stepsIt will be essential to identify the need for improvement and select a suitable team equipped with the necessary skills and experience. All staff that require it will be provided with basic Lean training at this point.

The team would typically explore the problem and its implications for patient care and define what is in the scope of the improvement project. The team will also set key project objectives (e.g. to improve patient experience by reducing avoidable waiting between diagnostic procedures), determine key benefits and complete a project plan.

Tools and techniques• Problem context diagram• Strategic alignment• Stakeholder management• Benefit realisation strategy and measures development• Vision workshops• Strength, weaknesses, opportunities and threats (SWOT) analysis • Risk log

Key documents• Project overview document (POD)• Project initiation document (PID)• Communications plan• Key performance indicator (KPI) alignment• Benefits realisation map• Project plan • Project charter• Lessons learned document

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Stage 1: START St George’s HealthcareNHS Trust

Including project planning and Lean training

• Assemble project team• Identify stakeholders and carry out interviews• Lock-in key milestone dates to project plan• Develop and sign-off project charter with team• Hold project kick-off meeting• Prepare for basic training

RCP2 Paediatrics/Elective Inpatient Surgical Admissions V4

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Stage 1: START St George’s HealthcareNHS Trust

Including project planning and Lean training

• Aimed at project team• Deeper introduction to Lean tools & techniques• Exploration of Rapid Change approach and the pre-work required

• Further development of Value Stream Mapping skills

• What to expect from the Kaizen (Rapid Change) Week !

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Stage 2: DIAGNOSE St George’s HealthcareNHS Trust

including process observation, data collection and process and value stream mapping.

Purpose• In Stage 2 we try to develop a comprehensive understanding of how the service, system or team works. It is important to undertake a full diagnostic in order to be able to identify potential improvement opportunities.

• Although this requires input from clinical teams; interviews with key stakeholders and data analysis, it will allow for a clearer understanding of the way forward. All support resources e.g. information team and finance team should be able to assist in the process.

Key steps• This normally starts with data and information analysis and mapping of current processes to identify bottlenecks and waste. From this we will identify the steps that add value from a patient’s perspective.

• Identification of improvement opportunities.

• Through the diagnostic and analysis phase you will identify opportunities to prioritise and take forward, to inform the Implement stage. Through a robust diagnostic process you will decide whether this project should progress.

Key steps, tools and techniques• Benchmarking • Current process map • Value stream mapping• Process observations• Staff & patient questionnaires, surveys and interviews • Data analysis • Focus groups

Key documents • Set of current process and value stream maps• A brief summary of the expected future state• Use the diagnostic stage to update project plans including roles & responsibilities and resources required• Revised project documentation

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Stage 2: DIAGNOSE St George’s HealthcareNHS Trust

including process observation, data collection and process and value stream mapping.

• Process observations• Waste Walks• Time Value Analysis• Circle of Work (see example opposite)• Subject matter expert interviews• Process data collection and measurement

Example: CoW graph on a receptionist in X-ray

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• More than 40% of receptionist work involves waiting

• More than 10% of activities are because of defects

• Less than 50% creates a value for the process

Defects and waiting here are not the fault of the receptionist but the fault of an un-Lean process!

Value Analysis Breakdown

11.2%3.3%

41.4%

43.1%

Wait

Defects

Value

Extra Processing

Motion

Stage 2: DIAGNOSE St George’s HealthcareNHS Trust

including process observation, data collection and process and value stream mapping.

• Build a Current State (the current process)• Identify improvement opportunities• Build Ideal State • Shape the vision for the project• Build the Future State• Prioritise improvement opportunities

High

Low

Low High

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Benefit(Increased Revenue,

Decreased Costs or Cycle Times)

Effort(Resources: Time, Money, People)

1

3

2

A B

C D

6

5

7

8

9

4

Value stream mapping: pink post-it notes represent waste in the process

Stage 3: IMPROVE St George’s HealthcareNHS Trust

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Prepare for Kaizen (the rapid change week)

Purpose• The improvement phase is where you take the findings of the diagnostic phase and work up the improvement opportunities into projects / initiatives, with the ultimate aim to improve patient experience and safety and to deliver excellent care. We also start to document the change activities and design the ‘future state’ or ideal model.

• The project team has to take ownership and sign up to the initiatives that are to be taken forward. It is key to review different options before making a final decision.

Key steps, tools & techniques• This is the redesign element of the project where the service is planned to achieve the future state. This includes improving both quality and efficiencies: removing waste and delays from the ‘system’ / pathway. Service redesign events as a series of sessions or as a rapid improvement event are key steps.

• Improved patient experience.

Key tools include:• Process mapping • Whole patient journey • Brain storming• Capacity and demand • Discharge planning • Plan-Do-Study-Act (PDSA)

Key documents• ‘Current vs. Future State’ document (more detailed work up of the future state) including evidence based care delivery • Implementation plans (revised project documentation)• Communications plan• Updated project initiation document with a Equality Impact Assessment (if required)• Risk log and Issue log • Future state process and value stream maps (project dependant)• Business case; if investment identified for future state; including options appraisals (project dependant)• Updated lessons learned document

Stage 3: IMPROVE St George’s HealthcareNHS Trust

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1. Ensure that Kaizen (Rapid Change) scope is clear & agreed upon by key Stakeholders… Scope creep must be dealt with fiercely for the Kaizen to be successful!

2. Determine specific Kaizen (Rapid Change) goals & deliverables… Understand your target metrics and how you want to achieve these targets by impacting change during the Kaizen

3. Ensure functional & leadership support… Visible support from senior service leaders is key to driving change via Kaizen

4. Invite participants… Ensure appropriate expertise/experience is involved, key stakeholders agree, and that these people are able to dedicate the time to the Kaizen

5. Hold preparation sessions with participants… Set expectations for what and how it will be done

Stage 4: IMPLEMENT St George’s HealthcareNHS Trust

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Kaizen (the rapid change week)

Purpose• The trial / improvement phases of the methodology is where the changes improvements identified earlier are delivered.

• The improvements identified for delivery should be fairly easy to implement, easily defined and can be implemented straight away. These are usually called ‘quick wins’.

• Other improvements may be harder to implement, require some ‘testing’ or take longer. These initiatives are the ones that may require to be trialled in a small area to ensure the model / solution is as good as possible before full roll out and implementation. This is usually done through the PDSA cycle. Testing the model can lead to easier and more beneficial implementation and therefore be worth pursuing. These changes can be implemented in the rapid change week.

Key steps, tools & techniques• Change management• Risk management• Issue management• Stakeholder management – stakeholder analysis• Stakeholder management – influencing stakeholders• Communication management• Project tracking & project reporting• Measurement for improvement• Standard operating procedures• PDSA• Benefits realisation (Financial)• Benefits realisation (Quality)

Key documents• Project / workstream progress updates• Tracked project plans (Excel / MS Project)• Risk log• Issue log• Financial tracker

Stage 4: IMPLEMENT St George’s HealthcareNHS Trust

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1. Kaizen starts with taking a look at the actual place of work - workstation, wards, theatre, office, cubicle…

2. Kaizen requires a bias for action Get your teams out of the conference room and onto the floor

3. Benefits must be apparent Show results not action items “to do”

“Quick and crude is better than slow and elegant”

“Take no action and nothing will happen!”

“Kaizen is not a spectator sport!”

Find the “low hanging” fruit !

Stage 4: IMPLEMENT St George’s HealthcareNHS Trust

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Example Kaizen (Rapid Change) timetable

Monday Tuesday Wednesday Thursday Friday

9am

10am

9am Ayr Hospital Lecture Theatre

Kick off &Introduction

Team work

Trystorming improvements

Implementing improvements

- Validating improvements

Team work

Trystorming improvements

Implementing improvements

- Validating improvements

Team work

Final Trystorming of improvements

Implementing Control mechanisms

Preparing 30-day Action plan

Prepare Kaizen report out & practice

presentation11am Team work

Validating pre-work

Finalising focus areas

Trystorming improvements

12 noon

1pm

2pm

2pm Ayr Hospital Lecture Theatre

Kaizen Week Report out

3pm

3.30pmWrap up & prep

next dayWrap up & prep

next day

4pm 4pm Ayr Hospital Lecture theatreDay 1 report out

4pm Ayr Skills LabDay 3

report out5pmWrap up & prep

next dayWrap up & prep

next day

Sponsors, other senior staff and stakeholders to attend

PROJECT MAP St George’s HealthcareNHS Trust

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MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER22

Mar29

Mar05

Apr12

Apr19

Apr26

Apr03

May10

May17

May24

May31

May07Jun

14Jun

21Jun

28Jun

05Jul

12Jul

19Jul

26Jul

02Aug

09Aug

16Aug

23Aug

30Aug

06Sep

13Sep

20Sep

27Sep

MIL

EST

ON

ES

Use this as your project map. To create your map display, print this page and enlarge it on a photocopier to A3 size, then cut out the symbols from the next page and adhere them to your map to fit your agreed timescales.

Week ending:

PROJECT MAP St George’s HealthcareNHS Trust

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OCTOBER NOVEMBER DECEMBER JANUARY FEBRUARY MARCH04

Oct11

Oct18

Apr25

Apr08

Nov15

Nov22

Nov29

Nov06

Dec13

Dec20

Dec27

Dec03Jan

10Jan

17Jan

31Jan

7Feb

14Feb

21Feb

28Feb

07Mar

14Mar

21Mar

28Mar

MIL

EST

ON

ES

Use this as your project map. To create your map display, print this page and enlarge it on a photocopier to A3 size, then cut out the symbols from the next page and adhere them to your map to fit your agreed timescales.

Week ending:

St George’s HealthcareNHS Trust

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PROJECT SCOPING & PLANNING

PROJECT SCOPING & PLANNING

VSM

VSM

KAIZEN PREP

KAIZEN PREP

KAIZEN

KAIZEN

OBSERVATIONS AND DATA GATHERING

OBSERVATIONS AND DATA GATHERING

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

30 DAY SUSTAIN PERIOD 60 DAY SUSTAIN PERIOD 90 DAY SUSTAIN PERIOD

Stage 5: SUSTAIN AND REVIEW St George’s HealthcareNHS Trust

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Purpose• Once the improvement ideas have been trialled, tested and implemented, they require standardisation, with the aim of sustaining the positive outcomes of the project.

• In this stage, it is essential to validate that the project has delivered what it set out to deliver and has realised all associated benefits. This can be done through ongoing monitoring of the relevant processes.

• In addition, the entire project should be reviewed to identify key learning points in order to help shape future projects.

Key steps, tools & techniques• Project tracking • Project reporting• Financial management• Post project evaluation / post implementation review• Measurement for improvement• Benefits realisation (Financial)• Benefits realisation (Quality)

Key documents• Project / workstream progress updates• Tracked project plans • Risk log• Issue log• Financial tracker • Project closure report• Updated lessons learned document• Kaizen (rapid change) action plan• Case study development• Post project review report

Stage 5: SUSTAIN St George’s HealthcareNHS Trust

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Post Kaizen (Rapid Change) Sustain

30 Day Action Plan• Who will be doing what to make the Kaizen week improvements “stick”?• Who and how will we collect data to evidence the benefits?• Weekly progress reviews to help support service staff in sustaining

Action OwnerTarget

Completion% Complete

Comments25 50 75 100

Observe the process A N Other 03-Sep

Collect Data B C Smith 25 Sep

LESSONS LEARNED St George’s HealthcareNHS Trust

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Within each programme lessons learned should inform the development and culture of the organisation. Within a project setting the lessons learned should be captured and shared across the programme to other projects to improve the methodology and approach. This following section outlines the process for both of these areas. The lessons learnt process will be continuous as the improvement culture develops within the organisation.

Strategic• After each report out, Steering group and Programme Board, there will be a 10 minute run of the cycle to capture strategic actions that will develop the organisation both culturally and operationally. Project• Throughout the project lifecycle lessons learned will be captured, documented and shared broadly within the organisation.

STRATEGIC LESSONS LEARNED St George’s HealthcareNHS Trust

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Programme Organisational cycle of learning

What was the impact?

How does that fit with

the organisation Strategically?What did we

do (high level)?

1

2

3

45Where is there an

opportunity to improve

What do we need to do differently to

improve? (Actions assigned)

Impact on: OrganisationCulture/engagement Improvement Leadership Governance Exemplar Status

Strategy: DirectionImperatives Growth Goals Exemplar Status

Programme Activity:Improvement ProjectsTrainingLearning and sharing Innovation OD Leadership

Developments:AspirationGoalsExpectation Strategy Exemplar Status

LESSONS LEARNED St George’s HealthcareNHS Trust

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Feedback Themes

The improvements identified as part of the Strategic Lessons Learnt Cycle are grouped into activities so that improvements can be targeted according to the programme of organisational development and projects for methodology improvements.

Programme Activity Lessons learned feedback themesImprovement Projects Early Successes

ExcitementCommitment

Resources Integration

Learning from experienceTraining Content

Application to work areasRequests for support

Learning and sharing AudienceMedium of sharing

Innovation Boundaries extendedRisk levels

Early SuccessesCommitment

OD ResourcesExcitementIntegration

Commitment

Leadership OwnershipCommunication

Unblocking Issues

Glossary St George’s HealthcareNHS Trust

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• Evidence-based approach: An approach that is informed by robust evidence and where results/impact can be validated using equally robust evidence.

• Patient outcomes: Any clinical, quality or other outcomes relevant from the patient perspective, typically related to the health status achieved following a health problem, the process of recovery and sustainability of health.

• Lean: In the healthcare context, Lean is a methodology that can be used to address patient demand and its benefits include very high quality, rapid response and low costs of space, time and materials.

• Six Sigma: A methodology focusing on quality and customer satisfaction as a starting point, with transformational implications for the entire organisation.

• Kaizen: Rapid change

• Patient pathways: A patient journey through the cycle of care, typically starting with a GP appointment followed by a hospital outpatient attendance, admission to hospital often followed by surgery, recovery and discharge back to the care of community teams and a GP. There are two key types of pathways – emergency pathways for all acutely ill patients and elective pathways for other patients.

• Prince2: A standard project management methodology based on clearly defined project stages and using uniform project management techniques.

• Problem Context Diagram: A diagram highlighting potential causal processes of a problem within a system – it focuses on a problem as not being a single event, but in the context of process variation.

• SWOT Analysis: An analysis aiming to pin down key internal strengths and weaknesses as well as external opportunities and threats. It is typically used to compare various different options

• Project Overview Document: An internal project management document capturing, at a high level, key aspects of a proposed project, including its description, key benefits, stakeholders, timelines and financial implications.

• Project Initiation Document: A more detailed project management document capturing a detailed financial profile of a project, key milestones and project actions, including owners and communication plans

Glossary St George’s HealthcareNHS Trust

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• Bottleneck: A resource in the process which cannot keep up with the demand and causes disruptions and queuing. Typically, removing one bottleneck will reveal a different bottleneck elsewhere in the system, until resources perfectly match the demand.

• Waste: Any activity which can be avoided and does not add value from the patient perspective. DOWNTIME refers to various types of waste, namely defects (errors), overproduction, waiting, non-utilised talent, transportation, inventory, motion and excessive processing.

• Benchmarking: A comparative methodology based on comparing one’s performance with the performance of others, ideally on a like-for-like basis. It has known limitations, but can reveal useful insights into performance of any system for which comparative data is available.

• Current process map: A map depicting the entire process from start to end, very useful when considering potential problems and in identifying suitable solutions.

• Value stream map: A more detailed map which highlights (1) value adding activities as steps, (2) gaps between these activities and (3) resources required for each step. The objective is to reduce and/or remove the gaps as much as possible in order to speed up the process and reduce the amount of resources required.

• Plan-Do-Study-Act: PDSA is an improvement cycle which allows one to identify real effects of any changes and adjust based on these actual effects. It is a key element of the 3-Question Approach which is based on the assumption that only and exclusively those changes that brought about improvement should be implemented and sustained. The three questions are: (1) What are we trying to accomplish? (2) How will we know that a change is an improvement? (3) What changes can we make that will result in improvement?

• Quick win: An improvement which can be identified and implemented fairly quickly, typically within a couple of weeks/months.