by Jane Bassham of Flinders Medical Centre shown at the 2nd Lean Healthcare Forum on 6th June 2006 ran by the Lean Enterprise Academy www.leanuk.org

1. The Flinders Journey
Jane Bassham
Clinical Facilitator Redesigning Care
Jane.Bassham@fmc.sa.gov.au

2. Healthcare in Australia
• Healthy private sector
– > substantial amount of all elective surgery is done privately for all
sectors> public hospitals are emergency driven
• Links between Primary Care & secondary/tertiary are problematic
– Primary Care fee based & Federally funded;
– secondary & tertiary care hospitals are output formula funded, by state
govt> messy & linking primary to hospitals is an issue.
– By international standards, people have good access to primary care.
• Hospitals are funded through a casemix approach> los in hospital
are short by international standards
• Hospitals like FMC are very well equipped with capital investments
eg CT, MRI, angiography capability, etc.

3. Flinders Medical Centre
• Adelaide, South Australia, population 1 million
• FMC catchment of 350,000
• Public tertiary teaching & research hospital
• 4,000 employees
• Trauma centre (incl. obstetric trauma), infant to old,
medical, surgical, gynaecological, obstetric,
paediatric, neonates, Mental Health (regional service)

4. Flinders Medical Centre
• 500 beds
• Of overnight stays: 15% elective; 85% emergency
work
• ED 54,000 presentations a year- highly predictable
arrival
– 55% discharged from ED, 45% admitted
• Admitted medical/surgical patients:
– 51% short < 60hours,
– 36% longer >60+ hours
– 4% > 14 days

5. So where did the FMC Lean Journey
start?
• With a crisis, of course!
• Winter (May-June 03) FMC struggling: we’re in the
paper regularly
• Overcrowding in ED, delays in timely treatment, elective
surgery cancelled, regular hospital executive crisis
meetings, ambulance diversion, clinical outcomes being
compromised, staff unhappy
• FMC exec were taking this seriously & wanted a serious
response
• Internal review of safety in the ED, external review of
safety in the ED

6. What had we tried in the past?
• Managing Emergency Demand day: made all aware
of problem, no real strategies came up
• Long stay outliers work
• ED things: fast track, MAAT, nurse initiated things
• Big Picture mapping-but what to do with it?
• Best efforts but nothing had helped
• Nationally other metro hospitals under same
pressures with little resolution

7. Why Lean?
• Looked internationally for ideas> went to UK, visited
Modernisation Agency, saw 5 ED’s
• UK MA came to FMC the next week & we ended up
doing a few things
– Read Lean Thinking book (or bits of it)
– Set up an improvement team/structure: each stream should
have a clinical leader & executive sponsor
– Hospital targets based on flow
– Redid ED flows & order patients were seen, the next week

8. Redesigning Care
• An improvement team set up 2 1/2 years ago in response to
hospital crisis
• Originally set up with Director, 4 Clinical Facilitators responsible
for a “Stream” each, with executive sponsor & clinical leader for
each Stream, for 1 year.
• RDC team came from a variety of sources & backgrounds:
medical & nursing clinical, epidemiology, management skills,
project, research
• We are passionate about patient care
• Managed our own, modest budget
• Decided to use Lean Thinking, with Quality Improvement Wheel
& PDSA’s
• So far RDC has survived a regional restructure & change of
hospital manager

9. Photo of the team with bandanas

10. Redesigning Care: Organisational Structure
Streams
• ED Works
• Surgical Stream
• Medical Stream
• Support services
Stream
• Combined work
FMC Management Executive
Redesigning Care Steering Group
StreamStream
Clinical FacilitatorClinical Facilitator
Redesigning Care Program Team
Director: David Ben-Tovim
Stream WorkStream Work
GroupsGroups
LeadershipLeadership
GroupGroup

11. Executive support critical
• GM & Director key
– For credibility- the hospital is taking this seriously
– Knew more data than others
– Able to address barriers
– Authorise access to some data, meet with key
stakeholders, attend key mappings etc.
– Attended the Lean Thinking studies, Lean service
summit etc
– Driving forces

12. Redesigning Care
• Include access to data rich/hospital info, clinical
epidemiology expertise, office manager support,
computer programming support
• Attends weekly hospital executive
• Reports regionally via Safety & Quality board

13. Education of the Team
• Peter Walsh from LEA met with us for 3/7 where he discussed how Lean
Thinking applied to the manufacturing industry. EDON & RDC members
attended
• 8 hospital members including GM, Clinical Governance Director, Senior
Epidemiologist, RDC members attended 1 subject for 10/52 of Lean
Manufacturing Systems
• Conferences: including Lean in manufacturing, Uni of Michigan
• Visited a local car factory
• See (or read about) one, do one, teach one> taught staff ourselves
• Read stuff: Lean Thinking, Lean articles, Toyota Way, Learning to See, Lean
Lexicon etc.
• Learning log
• PDSA’s learning by doing
• Visitors: Ben Gowland, Lynne Massey, Ian Glenday, Kaizen Institute, Graham
Eagles, John Long, Ann Esain, Dan Jones, John Shook & Kate Sylvester
• Organised 2 Australasian Redesigning Care Healthcare Summits

15. The Lean Team

16. What is our methodology?
• Improvement wheel:
– project phase- scope of work, stakeholders etc;
– diagnostic phase- big picture mapping, tracking, data analysis;
– intervention phase- PDSA’s;
– sharing learnings phase;
– embedding & sustaining phase
• Lean Thinking principles & tools:
– define your customer & what adds value from your agreed
customer’s perspective;
– identify value stream;
– look at flow & waste in the context of the value streams;
– where things don’t flow try pull;
– aim for perfection (continuous improvement)
• Analytical tools:
– Demand & capacity
– Glenday sieve

17. Redesigning Care
“The Flinders Way”
P D
A S
1
2
3
4
5
DiagnosticDiagnostic
PhasePhase
ProjectProject
PhasePhase
SustainSustain
new waysnew ways
of workingof working
Share keyShare key
learningslearnings
InterventionIntervention
PhasePhase
P D
A S
P D
A S
P D
A S
P D
A S
Lean Paradigm
•Learning to see
•Value stream approach
•Staff empowerment
•Leadership style
•Continuous improvement
•Constancy of purpose
Lean Tools
•VSM
•Visual management
•Standard Work
•Flow tools
•Built in Quality
•Load levelling

18. How do we decide what to tackle?
• ID the key value streams/core business- will
it have high impact for effort?
• Meet with GM & EDON to ensure we’re on the
same page
• For FMC surviving next winter is paramount

19. Flow improvements
Area / value stream Main strategies / focus
Emergency Department Streaming, Paeds, 5S, standardised practice, B side &
A side improvements, clerical processes
Medical & Surgical admissions Short stay ward, ward pull, visual management of
patient flows (traffic lights)
General Medicine Short stay & long stay value streams in General
Medicine, team based care, abolition of take system,
Acute Assessment Unit, Standardisation of Ward
round, Discharge communication
Pharmacy Improving discharge medication lead time
Central Sterilising Supply Unit Total process flow redesign
Cardiology Discharge ‘Flow’ Nurse, Introduction of Redesigning
care as QI system, Patient journey visual management,
Low risk chest pain
Mental health Redesign of flows, introduction of short stay value
stream
Endoscopy 5S, Demand & capacity, flow redesign
Whole of hospital 5S of medication rooms
Work in early stages ICCU, Admissions, Cancer, Older patient, Transition
Care

20. Education of Hospital Staff:
foundation for
Transforming the Organisation
• Key elements
– Communication: written, usual meetings, special meetings,
regular forums
– Education strategies:
• Lean Days
• Immersion program
• Summit
– Workgroups
– Consistent approach to problem solving, language,
structure/methodology (quality wheel, PDSA’s applied on a
background of Lean principles & thinking)
– Leaders: 1:1 focus by RDC members
• Impacted on 10% of employees to date

21. Struggles
• Change management
– Personally challenging
– communication
• What to work on & what/when to stop working on something
• Not all immersees are go-ers
• Some stakeholders not engaged
• Embedding & sustaining work
• Standardised work
• Engaging junior doctors
• Rotating medical staff
• Different system in hours, after hours, weekends
• Structures not aligned with value streams & flows
• What is a value stream manager, anyway????
• Regional engagement
• Business case
• When to transform the organisation

22. Learnings
• Leaders essential:
– Executive support/sanction essential
– Clinical leader for each stream
• Set up an improvement team structure if you’re serious: people time & tools to
impact
• You don’t have to have a consultant to do this
• Don’t start with a restructure or IT solutions
• Have one or two targets for whole of hospital that are linked with flow
• Start with a win, need to measure stuff (real time feedback for staff), even small
improvement of high volume stuff> biggest impact
• Start with biggest problem v’s high volume
• This is not a project & we don’t go away
• Consistent approach- for us, that’s Lean
• Deal with Value Streams & core business
• Sphere of influence/scoping
• Safety & Quality impact was surprising for us
• Just do it!

23. What we think we have done
• Survived
• Controlled the chaos
• Tackled high volume in the core business
• Found Value Streams
• Made the hospital safer
• Became Lean believers
• Getting “flow” language into common use

24. Initial care
M
Disch direct from ED type
55-60%
Short
Short stay Med/
Card/Surg types
Op th
13%
Long
AAU
process
CCU
Process
10%
Gen Med ward
types
Spec Med Ward
types
Surg spec ward
types
Paeds short/long
types
Mental H
Short/long types
ED
Lab/Deliv
Gynae
types
In-pt rehab
Adm care
M
Med/card/surg
UNPLANNED
PLANNED
Paeds
EECU
Clinics
Op th
76%
HDU
28%
Surg + Gynae ward
types
Ante/Post NICU/
Nurs.Op th
Endos HODU
types
Dial
ICU
3.5% all acute
adms
Complex
Discharge to
usual residence
Complex
discharge- change
place residence
When complex
discharge
processes
required: staff
move to pt.
No
bb
mmm
No stay: 0-12 hours Short stay: 12-60 hours
Long stay: 60+ hours
Op th
HDU
Process
23%
Cath lab
Short med
Types
Op th Surg short +gynae st
types
9% acute adms; 85%
short,,75% emergency
1.3% acute adm, 91%
long, 72% emergency
23% all acute adms, 48%
all med/surg emerg adms.
(4% ICU)
19% all acute adms. 40% all
med/surg emerge adms,
10% ICU
5% all acute adms, 11% all
med/surg emerge adm
5%ICU
Long-4% acute adm, 76%
med/surg elect used Op th
Short,
28% acute
adms
Short-11% acute adms,
40% short med/surg
elects
Short-16% acute
adms, 60% short
med/surg elects
9% acute
adms

25. ContinuousContinuous
ImprovementImprovement
Environment of
continuous learning
Culture that embraces
change
Respect forRespect for
PeoplePeople
Actively involve staff
in improving their job
Develop mutual trust
Work toward common
goal
Best QualityBest Quality -- Lowest CostLowest Cost -- Shortest Lead TimeShortest Lead Time--
Best SafetyBest Safety-- Highest MoraleHighest Morale
Plan Do Study Act (PDSA) Learning CyclesPlan Do Study Act (PDSA) Learning Cycles
The Toyota WayThe Toyota Way

26. Toyota house

27. So what does FMC’s
house look like after 2 ½ years of
work?

29. FMC’s
Future State
House

30. Flow: we are coping with more activity
RC began Last year

31. Flow: we are coping with more activity
RC began This time last
year

32. Flow: reduced long waits in ED
Rate for 12+ and 8+ Hours wait for Bed (triage to ward) Adult (>=17) Admissions to FMC from
ED [Nov 2002 to March 2006]
0%
10%
20%
30%
40%
50%
60%
2002/01
2002/02
2002/03
2002/04
2002/05
2002/06
2002/07
2002/08
2002/09
2002/10
2002/11
2002/12
2003/01
2003/02
2003/03
2003/04
2003/05
2003/06
2003/07
2003/08
2003/09
2003/10
2003/11
2003/12
2004/01
2004/02
2004/03
2004/04
2004/05
2004/06
2004/07
2004/08
2004/09
2004/10
2004/11
2004/12
2005/01
2005/02
2005/03
2005/04
2005/05
2005/06
2005/07
2005/08
2005/09
2005/10
2005/11
2005/12
2006/01
2006/02
2006/03
600
800
1,000
1,200
1,400
1,600
1,800
12+ Rate 8+ Rate Number
Presentations

33. Flow has improved with a decreased
ALOS of 1 day for General Medicine
Unit: GENERAL MEDICINE - average length of stay
0
1
2
3
4
5
6
7
8
9
Jan-03
Mar-03
May-03
Jul-03
Sep-03
Nov-03
Jan-04
Mar-04
May-04
Jul-04
Sep-04
Nov-04
Jan-05
Mar-05
May-05
Jul-05
Sep-05
Nov-05
Jan-06
LOS(days)
ALOS Linear (ALOS)
Redesign Work
Commenced

34. Elective surgery cancellations due
to lack of beds

35. Safety & Quality: Patients in the right place
is safer & better for patients & staff
Medicine Outliers
0%
5%
10%
15%
20%
25%
29-Sep-03
27-Oct-03
24-Nov-03
22-Dec-03
19-Jan-04
16-Feb-04
15-Mar-04
12-Apr-04
10-May-04
7-Jun-04
5-Jul-04
2-Aug-04
30-Aug-04
27-Sep-04
25-Oct-04
22-Nov-04
20-Dec-04
17-Jan-05
14-Feb-05
14-Mar-05
11-Apr-05
9-May-05
6-Jun-05
4-Jul-05
1-Aug-05
29-Aug-05
26-Sep-05
24-Oct-05
21-Nov-05
19-Dec-05
16-Jan-06
Week Starts (Monday)
OutlierHours(%oftotalhours)
Percent of Outlier Hours Linear (Percent of Outlier Hours)

36. Safety & Quality: Patients who come to ED &
don’t wait for treatment

37. Safety & Quality
Serious adverse events (as reported to our
insurers).
Dec 02-Nov 03
81 serious adverse events-
15 events in the Emergency Departments, including 7 patient
deaths.
Dec 03- Nov 04
27 serious adverse events
4 events in the Emergency Department, including 1 patient
death.
Dec 04-Nov 05
31 serious adverse events
5 events in the Emergency Department- no deaths.

38. Guru Quote:
Continuous Improvement:
Think of the way you do your
work today as the worse
possible way

39. Guru Quotes:
No Problem is PROBLEM
Kaizen (continuous improvement) doesn’t need
much money
• If no money, use your brain
• If no brains, sweat it out!
Don’t start with the solution
No blame, no excuses

40. Quote:
Go to the Gemba!

41. Jane.Bassham@fmc.sa.gov.au