Lean Thinking for the NHS


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by Daniel T Jones of the Lean Enterprise Academy shown at NHS Confed on 14th June 2006

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Lean Thinking for the NHS

  1. 1. Strand 3 Maximising efficiency and productivity Transforming the service: applying lessons from lean thinking supported by
  2. 2. Lean Thinking for the NHS Daniel T Jones Chairman, Lean Enterprise Academy, Lean Healthcare Network www.leanuk.org
  3. 3. 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
  4. 4. The Lean Example The 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!
  5. 5. Toyota’s Lean Strategy “Brilliant process management is our strategy. We get brilliant results from average people managing 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
  6. 6. 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
  7. 7. 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
  8. 8. 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 Follow Up Appt. Follow Up Test Secre- tary Pre Op Assess Test To Come List Ops. List Admi- ssion Proce- dure Disc- harge Test 5th Visit Booking Outp. List Refer Outpat. Appt. Test Wait Hospital Test GP Visit GP VisitGP
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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?
  16. 16. Transforming the service: applying lessons from lean thinking David Fillingham Chief Executive Bolton Hospitals NHS Trust Dan Jones Chairman Lean Enterprise Academy
  17. 17. The NHS is full of committed staff who struggle to deliver good care within a set of broken processes
  18. 18. So…. what can we do that will improve quality, morale and productivity? Can “Lean” do this?
  19. 19. Early lessons from Bolton… • What can ‘Lean’ offer the NHS? • Lean Improvement, Lean Operations, Lean Strategy • Dilemmas and challenges
  20. 20. 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!
  21. 21. An organising framework for quality improvement – why use “Lean”?
  22. 22. 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
  23. 23. 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
  24. 24. Lean Strategy Lean Operations Lean Improvement
  25. 25. 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.
  26. 26. Lean Improvement at the Front Line • Observations and Diaries (an NHS “Ohno” Circle!) • “Go and See” rounds • 6S and Visual Management • Rapid Improvement Events
  27. 27. 6S Sort - 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
  28. 28. BEFORE
  29. 29. MIDDLE
  30. 30. AFTER
  31. 31. Visual Management
  32. 32. Rapid improvement events • Week long • Teams of 8-12 staff • Frontline involvement • Make rapid change happen • Learning by doing
  33. 33. 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
  34. 34. 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)
  35. 35. Lean Operations… … managing cross cutting processes at a Trust wide level using lean principles
  36. 36. 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
  37. 37. Lean Diagnostics and Decision Making GP requests Inpatients Outpatients
  38. 38. Developing a Lean Blood Specimens Laboratory
  39. 39. Patient Example A patient attends a GP practice and during the appointment the doctor requests blood tests for the following: • 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
  40. 40. Current laboratory working practice Upon receipt in the laboratory the Pathology request form and 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
  41. 41. Current Situation
  42. 42. Redesigned the Lean Laboratory
  43. 43. 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
  44. 44. Rethinking the overall configuration of services using lean principles and analysis Lean Healthcare Strategy
  45. 45. 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 design Principles to accelerate change
  46. 46. Lean Strategy – Work Programmes • Redesign of outpatients/diagnostics with One Stop Shops (ICATs) • Community Based Urgent Care Centres • Integrated Chronic Disease Management
  47. 47. 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”
  48. 48. 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
  49. 49. 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 to hard pressed staff
  50. 50. Strand 3 Maximising efficiency and productivity Transforming the service: applying lessons from lean thinking supported by