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

1. Strand 3
Maximising efficiency and productivity
Transforming the service:
applying lessons from lean thinking
supported by

2. Lean Thinking for the NHS
Daniel T Jones
Chairman, Lean Enterprise Academy,
Lean Healthcare Network
www.leanuk.org

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Transforming the service:
applying lessons from lean thinking
David Fillingham
Chief Executive
Bolton Hospitals NHS Trust
Dan Jones
Chairman
Lean Enterprise Academy

20. The NHS is full of committed
staff who struggle to deliver
good care within a set of
broken processes

21. So…. what can we do that will
improve quality, morale
and productivity?
Can “Lean” do this?

22. Early lessons from Bolton…
• What can ‘Lean’ offer the NHS?
• Lean Improvement, Lean Operations, Lean Strategy
• Dilemmas and challenges

24. 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!

25. An organising framework
for quality improvement
– why use “Lean”?

26. 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

27. 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

28. Lean Strategy
Lean Operations
Lean Improvement

29. 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.

30. Lean Improvement at the Front Line
• Observations and Diaries (an NHS “Ohno” Circle!)
• “Go and See” rounds
• 6S and Visual Management
• Rapid Improvement Events

31. 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

32. BEFORE

33. MIDDLE

34. AFTER

35. Visual Management

37. Rapid improvement events
• Week long
• Teams of 8-12 staff
• Frontline involvement
• Make rapid change happen
• Learning by doing

38. 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

44. 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)

45. Lean Operations…
… managing cross cutting processes at a
Trust wide level using lean principles

46. 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

47. Lean Diagnostics
and Decision Making
GP requests
Inpatients
Outpatients

48. Developing a Lean Blood
Specimens Laboratory

49. 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

50. 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

51. Current Situation

52. Redesigned the Lean Laboratory

53. 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

54. Rethinking the overall configuration
of services using lean principles
and analysis
Lean Healthcare Strategy

55. 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

56. Lean Strategy – Work Programmes
• Redesign of outpatients/diagnostics with One Stop Shops
(ICATs)
• Community Based Urgent Care Centres
• Integrated Chronic Disease Management

57. 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”

58. 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

59. 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

60. Strand 3
Maximising efficiency and productivity
Transforming the service:
applying lessons from lean thinking
supported by