Lean Thinking in Healthcare
Doing the Right Thing for Every
Patient
Lean Enterprise Academy
Copyright Lean Enterprise Acad...
Making Hospitals Work
How to improve patient care while saving
everyone’s time and hospitals’ resources
by Marc Baker and ...
Exercise: Check Current Awareness
• Split in to Groups.
• Objective: Each Group to give 5 mins
Presentation:
• What is Lea...
Lean Principles
Overview
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Lean Thinking
• Specify what creates value from the
customers perspective
• Identify all steps across the whole value
stre...
Our Observations in
Healthcare
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Lean Enterprise Academy
Activity Daily
Bed Meetings (x3 daily) 2.25
Morning Handover 0.5
08:15 - 08:30 (x2 weekly) 0.2
ECI...
Lean Enterprise Academy
The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can ...
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Target Focus No. Projects
Cost Improvement 300
4hr Performa...
Lean Enterprise Academy
The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can ...
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
SCORECARD
Stakeholders
Resource
Utilisation
Management
Proc...
Lean Enterprise Academy
The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can ...
The BIG Problem
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
1. Compliance with 4 hour emergency access performance target.
2. Compliance with t...
Copyright Lean Enterprise Academy 2009
The BIG Problem – Consructing the Matrix
A&E
Access
Cost
MedLoS
HAIs
A&E
Access
Cos...
Copyright Lean Enterprise Academy 2009
The BIG Problem – Looking for Leverage
A&E
Access
Cost
MedLoS
HAIs
A&E
Access
Cost
...
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
A&E
Access
Cost
MedLoS
HIAs
A&E
Access X
Cost X
Med LoS X
H...
Copyright Lean Enterprise Academy 2009
Medical LoS - The BIG Problem
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
Medical LoS - The BIG Problem
Lean Enterprise Academy
Seeing the
Process:
What is our
Current
Condition?
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
The Current State
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
From the total LoS of 7.6 days only 1.1 days receiving diagnostics or interventions...
Don’t worry if yours ends up looking like this !!!!
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Staff/Departmental Availability
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Nursing Availability to Discharge from Wards
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Thinking Differently
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
"Everything that can be invented has been invented.”
Charle...
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
"X-rays will prove to be a hoax.”
Lord Kelvin, British math...
Copyright Lean Enterprise Academy 2009
Waste
Lean Enterprise Academy
Typical Mgmt Approach – Squeeze the Boxes
Why - Because they can’t see the Triangles
Necessary but non value adding
35%
Va...
Process, obviously needs Re-designing but…….
Stability 1st
Then
Re-design
So what is stability & how do you get
it…….
Some...
Scientific Operational Management
Our Definition:
Scientific operational management is a closed loop
system that provides ...
P lan D o
A ct C heck
Now
Grasp the
Current State
The Abnormality
is Obvious
Gap
EffectCauses
The Possible Causes
EffectCa...
Plan for Every Patient Boards
By the Hour in ED
By the Day
on Wards
Back to the Frontline
Lean Enterprise Academy
Copyrigh...
Pilgrim Hospital (Boston) – Medical Visual Hospital - Day One
3 Empty Beds, 12 Medically Fit, 5 Potentially Fit, 30% shoul...
The Visual Hospital in action with the MPS
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Lean Enterprise Academy
Guess What
This ‘lean’ stuff really works in
healthcare
Copyright Lean Enterprise Academy 2010
Bottom Line Results:
Mean Medical LoS has reduced by 1.87 days (30%) from 6.23
days to 4.35 days within 32 days of change....
Huddersfield Royal Infirmary – Emergency Surgery LoS
Bottom Line:
Mean Emergency Surgery LoS has reduced by 4.4 days
(53%)...
Bottom Line Results:
Average LoS has reduced by 27.3% for
Medical patients
and by 28.3% for Surgical patients
LoS variatio...
And….. Aneurin Bevan Health Board
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
1215108094581067554040527...
Copyright Lean Enterprise Academy 2010
Lean Enterprise Academy
Hospital Level
Visual Hospital
Ward Level PfEP
Individual P...
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Lean Healthcare - Streamlining Patient Journeys

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By Marc Baker and Ian Taylor of Lean Enterprise Academy shown at the Lean Summit 2011 - Solving Business Problems on 10/11 November 2011

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Transcript of "Lean Healthcare - Streamlining Patient Journeys "

  1. 1. Lean Thinking in Healthcare Doing the Right Thing for Every Patient Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  2. 2. Making Hospitals Work How to improve patient care while saving everyone’s time and hospitals’ resources by Marc Baker and Ian Taylor Foreword by Daniel T. Jones A Lean Action Workbook from the Lean Enterprise Academy Version 1.0 Goodrich UK May 2009 www.leanuk.org Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  3. 3. Exercise: Check Current Awareness • Split in to Groups. • Objective: Each Group to give 5 mins Presentation: • What is Lean? • Where does it come from? • Use Flip charts. • Presentation must be on 1 Flip chart. • Timescale: 20 mins Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  4. 4. Lean Principles Overview Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  5. 5. Lean Thinking • Specify what creates value from the customers perspective • Identify all steps across the whole value stream • Make those actions that create value flow • Only supply what is pulled by the customer just-in-time • Strive for perfection by continually removing successive layers of problems Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  6. 6. Our Observations in Healthcare Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  7. 7. Lean Enterprise Academy Activity Daily Bed Meetings (x3 daily) 2.25 Morning Handover 0.5 08:15 - 08:30 (x2 weekly) 0.2 ECIP 0.3 Facilitators 1:1 (x1 fortnight) 0.35 DHM 1:1 0.35 Emergency Pathway 0.2 Facilitators Meeting 0.3 Corridor Meeting 0.25 Hants Conf Call 0.5 PAU 1:1 0.25 MAU meet 0.2 Op Commisioning Meeting 0.4 1:1 with Ed 0.05 DGM DSN Meet (x1 fortnight) 0.15 HMC 0.15 COO Meet 0.15 St Mary's transitional grop 0.075 Nursing Workforce Committee 0.075 Duty Managers Update 0.5 DMOP Meeting 0.2 Seeing Facilitators 1 Duty Manager 1.6 LEA 0.4 Contract Review 0.05 Bleep Holder 2 30 day review meetings 0.5 Actions from Bed Meetings 1 Ad Hoc Meetings 1 Appraisals 1.1 1:1 with Mary 1 Hospital Walkabout 1 Discharge Lounge 0.25 Update for DMTs 0.375 E-Mails 100/Day 2 Report Writing 0.6 Budget Management 0.1 Performance Managing 0.2 DHM Induction 3 24.575 The Diary Exercise – Daily Personal Capacity V’s Daily Organisational Demand……. This is real data and absolutely typical. But What’s causing this? Copyright Lean Enterprise Academy 2010
  8. 8. Lean Enterprise Academy The Five Point Checklist •Simple? Can we explain it, so it is easily understood? •Measurable? Can we measure it? •Agreed? Who will be responsible and do they accept this responsibility? •Relevant? What is its contribution? •Trackable? Can we see the status at a glance whenever we want to? Copyright Lean Enterprise Academy 2010
  9. 9. Lean Enterprise Academy Copyright Lean Enterprise Academy 2010 Target Focus No. Projects Cost Improvement 300 4hr Performance Improvement 132 Safety & Quality 44 18 Week Access 39 TOTAL 515
  10. 10. Lean Enterprise Academy The Five Point Checklist •Simple? Can we explain it, so it is easily understood? •Measurable? Can we measure it? •Agreed? Who will be responsible and do they accept this responsibility? •Relevant? What is its contribution? •Trackable? Can we see the status at a glance whenever we want to? Copyright Lean Enterprise Academy 2010
  11. 11. Lean Enterprise Academy Copyright Lean Enterprise Academy 2010 SCORECARD Stakeholders Resource Utilisation Management Processes Innovation & Learning A B C A B A B A B C D 15 15 3 4 11 9 23 1 3 2 1 20 21 9 14 36 22 92 11 11 7 9 Scorecard – Descriptive Stats Categories Strategic Objectives Specific Goals Measures Categories = 4 Strategic Objectives = 11 Specific Goals = 87 Measures = 252
  12. 12. Lean Enterprise Academy The Five Point Checklist •Simple? Can we explain it, so it is easily understood? •Measurable? Can we measure it? •Agreed? Who will be responsible and do they accept this responsibility? •Relevant? What is its contribution? •Trackable? Can we see the status at a glance whenever we want to? Copyright Lean Enterprise Academy 2010
  13. 13. The BIG Problem Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  14. 14. Copyright Lean Enterprise Academy 2009 1. Compliance with 4 hour emergency access performance target. 2. Compliance with the 18 week scheduled service access targets 3. Cost reduction. Middleton was six months into the financial year and was already £6.5 million overspent year to date. 4. Medical length of stay (LoS). A previous benchmarking survey had revealed that Middleton’s medical patients were staying in the hospital longer than the national average. 5. Rates of Hospital Acquired Infections (HAI) such as MRSA and C. difficile were also higher than the national average. Middleton’s Story Middleton General has 5 big problems: Lean Enterprise Academy
  15. 15. Copyright Lean Enterprise Academy 2009 The BIG Problem – Consructing the Matrix A&E Access Cost MedLoS HAIs A&E Access Cost Med LoS HAIs Problems Impact(√orX) Lean Enterprise Academy
  16. 16. Copyright Lean Enterprise Academy 2009 The BIG Problem – Looking for Leverage A&E Access Cost MedLoS HAIs A&E Access Cost Med LoS HAIs Problems Impact(√orX) Lean Enterprise Academy EG if we fixed our A&E 4 Hour Target problem Would this also fix any of the other problems for free
  17. 17. Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy A&E Access Cost MedLoS HIAs A&E Access X Cost X Med LoS X HIAs X Problems Impact(√orX) EG if we fixed our A&E 4 Hour Target problem Would this also fix any of the other problems for free The BIG Problem – Looking for Leverage
  18. 18. Copyright Lean Enterprise Academy 2009 Medical LoS - The BIG Problem Lean Enterprise Academy
  19. 19. Copyright Lean Enterprise Academy 2009 Medical LoS - The BIG Problem Lean Enterprise Academy
  20. 20. Seeing the Process: What is our Current Condition? Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  21. 21. The Current State Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  22. 22. Copyright Lean Enterprise Academy 2009 From the total LoS of 7.6 days only 1.1 days receiving diagnostics or interventions (14.6%) AND Don’t get hung up on the cure time debate – it’s the triangles that we’re going for after all Lean Enterprise Academy
  23. 23. Don’t worry if yours ends up looking like this !!!! Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  24. 24. Staff/Departmental Availability Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  25. 25. Nursing Availability to Discharge from Wards Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  26. 26. Thinking Differently Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  27. 27. Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy "Everything that can be invented has been invented.” Charles H. Duell, Commissioner, U.S. Office of Patents, 1899. "We don't like their sound, and guitar music is on the way out anyway.” President of Decca Records, rejecting The Beatles after an audition, 1962 "That is the biggest fool thing we have ever done [research on]... The bomb will never go off, and I speak as an expert in explosives.” William D. Leahy, U.S. Admiral, advising President Truman on atomic weaponry, 1944 Man will not fly for 50 years.” Wilbur Wright, American aviation pioneer, to brother Orville, after a disappointing flying experiment, 1901 (their first successful flight was in 1903) "... good enough for our transatlantic friends ... but unworthy of the attention of practical or scientific men.” British Parliamentary Committee, on Edison's light bulb, 1878 "The Americans have need of the telephone, but we do not. We have plenty of messenger boys.” Sir William Preece, Chief Engineer, British Post Office, 1878 "Space travel is bunk.” Sir Harold Spencer Jones, Astronomer Royal of the UK, 1957 (two weeks later Sputnik orbited the Earth) " 640k ought to be enough for anybody.” Bill Gates, 1981
  28. 28. Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy "X-rays will prove to be a hoax.” Lord Kelvin, British mathematician and physicist, president of the British Royal Society, 1895(?) "Louis Pasteur's theory of germs is ridiculous fiction.” Pierre Pachet, British surgeon, Professor of Physiology at Toulouse, 1872 "The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise and humane surgeon". Sir John Eric Ericksen, British surgeon, appointed Surgeon Extraordinary to Queen Victoria, 1873 "The abolishment of pain in surgery is a chimera. It is absurd to go on seeking it...knife and pain are two words in surgery that must forever be associated in the consciousness of the patient.” Dr. Alfred Velpeau, French surgeon, 1839
  29. 29. Copyright Lean Enterprise Academy 2009 Waste Lean Enterprise Academy
  30. 30. Typical Mgmt Approach – Squeeze the Boxes Why - Because they can’t see the Triangles Necessary but non value adding 35% Value adding 5% Non value adding 60% Why not start here instead Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy
  31. 31. Process, obviously needs Re-designing but……. Stability 1st Then Re-design So what is stability & how do you get it……. Some form of standardisation Flow, Pull, Perfection systems Copyright Lean Enterprise Academy 2010 Lean Enterprise Academy
  32. 32. Scientific Operational Management Our Definition: Scientific operational management is a closed loop system that provides the Measures & Stability required to enable Safe Experimentation (Re-design) : It is Lean within the Day job!!! Very important but omitted by many! Closed Loop employs strict PDCA whereby the Check frequency is at the appropriate pitch to enable the required adjustment to minimise variation in the process The scientific setting of warning and action limits and the standardisation of the actions required to return to the desired condition – “I will not fail” Copyright Lean Enterprise Academy 2009 Lean Enterprise Academy It IS a Science…… BUT it’s NOT Rocket Science
  33. 33. P lan D o A ct C heck Now Grasp the Current State The Abnormality is Obvious Gap EffectCauses The Possible Causes EffectCauses The Possible Causes EffectCauses The Possible Causes for Gap Pareto Graph Highest Priority Pareto Graph Highest Priority Pareto Graph Highest Priority Action Plan No. WhoAction Action Plan No. WhoAction Plan Target The Scientific Approach What links these components? A standard method Copyright Lean Enterprise Academy 2010 Lean Enterprise Academy
  34. 34. Plan for Every Patient Boards By the Hour in ED By the Day on Wards Back to the Frontline Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  35. 35. Pilgrim Hospital (Boston) – Medical Visual Hospital - Day One 3 Empty Beds, 12 Medically Fit, 5 Potentially Fit, 30% should not be in acute beds whilst MAU is full and patients are breaching in A&E – Bed Man are declaring No Beds!!!! What would you do? Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  36. 36. The Visual Hospital in action with the MPS Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  37. 37. Lean Enterprise Academy Guess What This ‘lean’ stuff really works in healthcare Copyright Lean Enterprise Academy 2010
  38. 38. Bottom Line Results: Mean Medical LoS has reduced by 1.87 days (30%) from 6.23 days to 4.35 days within 32 days of change. The Median Medical LoS has reduced by 1 day (25%). LoS variation has reduced significantly Huddersfield Royal Infirmary – Medical LoS Patients in time order DaysLoS 620558496434372310248186124621 40 30 20 10 0 _ X=4.35 UCL=10.12 LCL=-1.41 581 894 11 1 1 1 1 1 1 1 1 11 1 1 1 1 1 1 1 11 1 11 1 1 1 11 1 11 1 1 11 1 1 1 1 1 1 1 1 1 1 1 11 1 Patient LoS Before & After changes Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  39. 39. Huddersfield Royal Infirmary – Emergency Surgery LoS Bottom Line: Mean Emergency Surgery LoS has reduced by 4.4 days (53%) from 8.3 days to 3.9 days within 48 days of changes. LoS variation has reduced significantly. Patient LoS Before & After changes Lean Enterprise Academy Copyright Lean Enterprise Academy 2010
  40. 40. Bottom Line Results: Average LoS has reduced by 27.3% for Medical patients and by 28.3% for Surgical patients LoS variation has reduced significantly for both And…..more of the Same at United Lincoln Hospitals Trust Lean Enterprise Academy Copyright Lean Enterprise Academy 2010 Patients in Time Order LoS(days) 476042843808333228562380190414289524761 200 150 100 50 0 _ X=7.2 UCL=19.8 LB=0 2471 6197 Med Patient LoS Before & After changes Patients in Time Order LoS(days) 2880256022401920160012809606403201 200 150 100 50 0 _ X=3.8 UCL=8.5 LCL=-1.0 3908 6442 Surg Patient LoS Before & After changes Clinical improvement facilitator Victoria Newlands- Bentley told the Target: "All staff involved in the project have worked hard to implement the changes and the results are proven. "Our patients are receiving more streamlined, efficient care and are benefiting from earlier discharge from hospital. "We will continue to look at ways in which the patient experience can be further improved in our hospital as we take this project forward."
  41. 41. And….. Aneurin Bevan Health Board Lean Enterprise Academy Copyright Lean Enterprise Academy 2010 121510809458106755404052701351 140 120 100 80 60 40 20 0 _ X=7.6 UCL=24.9 LB=0 1 2 3Trauma LoS from 01/08/2010 up to 09/05/2011 Individual Patients in Time Series Order LoS(days) The approach is now being adopted by the Toscana Health Authority (in Firenza, Pisa, Lucca and Prato) and Beth Israel (Harvard Medical School) “We have completed week one of our Visual Hospital Pilot. The rounds are getting better and we gather more valuable information each day”. MJ Brogna - Associate  Chief Nurse Beth Israel Deaconess Medical Centre
  42. 42. Copyright Lean Enterprise Academy 2010 Lean Enterprise Academy Hospital Level Visual Hospital Ward Level PfEP Individual Patient Level Nursing Handover Sheets Closed Loop Check/Adjust Closed Loop Check/Adjust Visual Hospital Hierarchy
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