by Neil Westwood of Hereford Hospitals NHS Trust shown at the 3rd Lean Healthcare Forum 2006 ran by the Lean Enterprise Academy

1. Hereford Hospitals
NHS Trust
Rapid Improvements in Pathology – June
2006

2. Neil Westwood
Service Transformation and
Hereford Hospitals NHS Trust
neil.westwood@institute.nhs.uk
Jane Jones
Clinical Systems Engineer
Hereford Hospitals NHS Trust
Janelouise.jones@hhtr.nhs.uk

3. Expert Lean support and
facilitation provided by KM&T
www.kmandt.co.uk

4. AFTER LEAN
NO WASTE, LITTLE VARIATION, NO DEFECTS and QUICK
“Push the Button” for Lean Transformation in Healthcare
© NHS Institute for Innovation and Improvement

5. BEFORE LEAN
LOTS OF WASTE, HIGH VARIATION, DEFECTS and SLOW
© NHS Institute for Innovation and Improvement

6. Impact of Improvements
Biochemistry
Hereford Hospitals
NHS Trust
Metric Before
change
After
change
Ideal
state
Improvemen
t
Saving
£££ a
year
Turnaround time
(from receipt to
results available)
62
minutes
Up to 2 hours
38
minutes
30
minutes
40%
reduction
2 beds a
day
£365,000*
A&E
targets
met
Specimen pick
up time
Specimens
waiting to be
picked up
13 minutes
Up to 50
minutes
1 minutes
Up to 4
minutes
0
minutes
93%
reduction
£10,000
Double handling
(Labelling only)
40 minutes a
day
0 minutes a
day
0
minutes
Totally
eliminated
At least
£3000

7. Hereford Hospitals
NHS Trust
Staff identified waste and delays
X
X
X X X
X
X
X
X
Non value adding
steps
Delays and waste
Now all eliminated

8. Hereford Hospitals
NHS Trust
Demand data for Biochemistry and Haematology
4 GP vans all
arrive together,
causing chaos

9. Specimen Reception -
Before
Sorting area
ONLY
Hereford Hospitals
NHS Trust

10. Dispatch (couriers
pick up parcels
here)
Specimen
drop off
Sorting area
FIFO - Lane 1
FIFO - Lane 2
Large specimen
drop off
3 Centrifuges
Hereford Hospitals
NHS TrustSpecimen Reception –
After –
the specimens now flow

11. Hereford Hospitals
NHS Trust
Our Improvements
Improvement implemented Impact
Manned specimen
reception
Labelling, centrifuges and
booking relocated in
specimen reception and
synchronised
First in First Out (FIFO
system introduced)
PCT GP demand staggered
(batches reduced).
Improved flow,
waste eliminated
and variation
reduced.
Turnaround time
reduced by 40%
in 7 days

12. Photo on outside of cupboard
shows where to find spillage
kits – saves staff time
searching
Hereford Hospitals
NHS Trust

13. Hereford Hospitals
NHS TrustOur Improvements
Improvement implemented Impact
Phlebotomist sends work
via POD system
Specimen reception work
areas clearly labelled with
instructions
Photos added to PODS and
cupboards
Standard work introduced
for labelling, centrifuging
and booking in
Improved flow,
waste eliminated
and variation
reduced.
Turnaround time
reduced by 40%
in 7 days

14. Visual management on air tubes.
A&E PODS can be quickly identified
Hereford Hospitals
NHS Trust

15. Hereford Hospitals
NHS Trust
After
Hereford Hospitals
NHS Trust
Before
40 minutes a day saved
Specimens were put in rack
then taken to centrifuge,
unloaded and put in
centrifuge.
Specimens put directly into
centrifuge carriage - stops
double handling (in 20’s at
peak times). These are loaded
straight into centrifuge.

16. Hereford Hospitals
NHS Trust
After
Hereford Hospitals
NHS Trust
Before
Staff booking forms in - in specimen
reception.
Forms synchronised with specimens being
spun. This prevents rework at scanning and
specimens can be loaded quicker onto
analyser.
Staff booking in – in biochemistry.
Forms NOT synchronised with
specimens being spun. This causes
delays and rework at scanning, causing
delays at the analyser.

17. Hereford Hospitals
NHS Trust
After
Hereford Hospitals
NHS Trust
Before
Work waiting to go into
centrifuge. Various things left
waiting to be processed.
Centrifuges moved into specimen
reception freeing up a whole work
area. Work place tidied up.

18. Steve Jones – Director of Pathology
Hereford Hospitals
Hereford Hospitals
NHS Trust

19. Some tips
Lean Sigma –
complementary not competing
• goals and strategy must drive our improvement
effort, not methods
• actively involve seniors leaders
• dedicated service improvement resources
accelerate change
• focus on the system, the flow that creates
value, then apply the tools
• get results quickly
• learn by doing – listen to staff
• tools are not prescriptive – use what works!!
© NHS Institute for Innovation and Improvement

20. Important Lessons Learned
cartoon copyright © U of M
• Focus on the system, the flow that
creates value, then apply the tools.
• A way of thinking underlies the
system and the tools.
• Cherry-picking the tools
is not enough
Learn the thinking by doing
Systems Thinking Techniques

21. Hereford Hospitals
NHS TrustHIGH LEVEL PATIENT JOURNEY
Mapping Phases
Preparation
Agreeing on what process to study, how
to map it and who will participate and
what resources are required.
Current State
Agreeing on a well understood map of
the current situation, with quantifiable
data
Future State
Agreeing on a shared vision improved
future state (without all the waste and
delays).
Agreeing on how to implement the
future state vision, with named staff
responsible for actions.
Planning

22. Team starts to map Pre-operative
Assessment, Daycase and
Theatres patient journey mapping –
Day 1
Hereford Hospitals
NHS Trust

23. Hereford Hospitals
NHS Trust
Data
collected on
causes of
cancelled
operations –
36% of the
cancelled
operations
were
because
patients were
not fit.

24. Current State – Preoperative
assessment, daycase and theatre
map
Hereford Hospitals
NHS Trust
Flow of patients

25. Spaghetti Diagram – show
movement and unnecessary
journeys
Hereford Hospitals
NHS Trust

26. Non Executive Director - Sebastian,
participates and discusses issues
with staff
Hereford Hospitals
NHS Trust

27. Hereford Hospitals
NHS Trust
Neil Westwood from Service Improvement Team
validates the map with endoscopy staff
Current state map

28. Future State – staff from
Preoperative assessment, daycase
and theatre work together to design
the new improved system
Hereford Hospitals
NHS Trust
Current State
Future State

29. Hereford Hospitals
NHS Trust
Future State – almost complete
(duplicate steps eliminated), delays
eliminated, less waste

30. Hereford Hospitals
NHS Trust
Improvements analysed in
terms of cost and benefit
High benefit and low cost
improvements (we will do these now)
High benefit and high cost
improvements (we will build
these into plan but won’t do at
the moment)

31. Hereford Hospitals
NHS Trust
Director of Finance -
Martin Woodford and
Peter Gorin – Clinical
Governance join the
activities

32. Hereford Hospitals
NHS TrustChief Executive asks questions and
challenges teams. Action plan
produced.

33. Improvements in Pharmacy
Reducing dispensary turnaround
times and errors

34. Improvements in Pharmacy
• Involving staff
• Understanding processes & demand
• Improving flow
• Eliminating waste
• Reducing dispensing times & errors

35. Medicines
collected
from stores
TTO arrives via
POD/ hatch/
porters
Clinical check by
pharmacist
Prioritise as fast
track or standard
track
Labels
printed
For collection by
porter/ ward
staff/POD
Accuracy check
assembly
TTO dispensary
process

36. Arrival Stamp in
Clinical
Check
Prioritisation
Labelling Assembly
Accuracy
check
Standard track TTO Dispensary Process
Collection by
porter
Av = 3.5 mins
(varies between
1 and 6 mins)
Av = 11.5 mins
(varies between
0 and 25 mins)
Av = 24.8 mins
(varies between
<1 and 380 mins)
Av = 5.7 mins
(varies between
0 and 30 mins)
Av = 28.1 mins
(varies between
2 and 92 mins)
Av = 3.67 mins
(varies between
1 and 24 mins)
Av = 3.75 mins
(varies between
0 and 18 mins)
Av = 101 mins
(varies between
9 and 185 mins)
Av = 3.64 mins
(varies between
<1 and 16 mins)
Av = 53 mins
(varies between
0 and 107 mins)
Average time = 220.8 minutes, varying from 120 to 250 mins (one exception)
Times in red font are waiting times = non value adding
Average time = 220.8 minutes, varying from 120 to 250 mins (one exception)
Times in red font are waiting times = non value adding

37. Arrival Stamp in
Clinical
Check
Prioritisation
Labelling Assembly
Accuracy
check
Fast track TTO Dispensary Process
Collection by
porter
Collection by
ward staff
Av =2.32 mins
(varies between
1 and 7 mins)
Av = 11.3
(varies between
0 and 41 mins)
Av = 3.25 mins
(varies between
<1 and 9 mins)
Av wait between end of clinical check and
labelling =20.76 mins (varies bet 2 and 85 mins)
Av =5.19 (varies
between 1 and 27
mins)
Av =3.26 (varies
between <1 and
16 mins)
Av = 63.7 mins
(varies between
0 and 148 mins)
Av = 3.47 mins
(varies between
1 and 15 mins )
Av = 41.1 mins
(varies between
0 and 96 mins)
Av = 9.88 mins
(varies between
0 and 43 mins)
Average time = 94.1 minutes, varying from 39 to
140 mins (& 2 special causes)
Times in red font are waiting times = non value adding
Average time = 94.1 minutes, varying from 39 to
140 mins (& 2 special causes)
Times in red font are waiting times = non value adding
Step bypassedStep bypassed

38. % Value adding time in Fast Track TTO dispensing process
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
09:09 09:27 10:28 10:44 10:52 10:52 11:10 11:36 12:25 11:44 12:52 12:55 12:59 13:00 13:31 13:45 13:56 14:40 14:44 14:54 16:10 16:47
TTO arrival time in pharmacy
%oftotaltime
% value –
adding
time in
each
process
% value –
adding
time in
each
process
% value adding time in Standard Track process
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
09:11 09:46 09:53 09:54 09:55 09:58 09:59 10:00 10:01 10:02 10:31 10:52 10:52 11:22 11:24 12:20 12:22 12:25
TTO arrival time

39. Measuring demand
Number of prescriptions received on busiest day
Hourly demand in dispensary on Thursday 29.06.06
0
10
20
30
40
50
day
before
checked
only
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
12:00-12:59
13:00-13:59
14:00-14:59
15:00-15:59
16:00-16:59
17:00-17:59
hour
numberofscripts
to follow
CD
A&E
pack down
clozaril
clin trial
Comm
psychi
MM profile
Non stock
IP
OP
310 scripts received (need to process 36.5 per hour x 8.5 hours)

40. Outpatients
TOTAL: 80
Hourly demand Outpatient TTOs
0
5
10
15
20
25
30
day
before
checked
only
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
12:00-12:59
13:00-13:59
14:00-14:59
15:00-15:59
16:00-16:59
17:00-17:59
time
numberofTTOs
Hourly demand inpatient TTOs
0
5
10
15
20
25
30
day
before
checked
only
08:00-08:59
09:00-09:59
10:00-10:59
11:00-11:59
12:00-12:59
13:00-13:59
14:00-14:59
15:00-15:59
16:00-16:59
17:00-17:59
time
numberTTOs
Inpatients
TOTAL: 68

41. Improving flow
• Reduced steps in process
• Layout of staff working stations and
resources
• Standard operating procedures
• Visual signals – trays and display boards
• Reducing variation in demand (batching)
• Streaming work – runners, repeaters &
strangers

42. FORMSFORMS
OFOF
WASTEWASTE
I
C
O
MW
P
M
Correction
Over
Production
Motion
Material
Movement
Waiting
Inventory
Processing
Unevenness
• Interruptions (= hours)
• Internal errors (rework = 10 scripts)
• Errors incoming scripts (10 – 20 %)
•
•Stock and materials
• TTOs
• Variation in demand
• Lack of notice
• Staff for machines
• Patients for TTOs
•TTOs for porters
• Spaghetti diagrams
for TTOS
• Resource location
• Stock in 2 locations
• Labelling porter bags, boxes
• Searching for TTOS
• Walking - stock, PCs,
phones, labels, printers,
bins (8000 steps for
pharmacist/ day)
Identifying waste

43. Reducing waste
• phone interruptions (tracking system) by ….
hours per day
• internal errors & rework
• Working with prescribing teams re incoming
errors
• porter collection & visual board
• use of air tubes
• staff movement – relocating resources, ie
PCs, equipment, top 20 drugs

44. Ongoing improvements
• Continual identification of improvements
• Staff involvement & time
• 5S planned day
• Action plan over coming months
• Involvement across Trust