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Delivering Results in Healthcare by Marc Baker, Ian Taylor and Dr Paul Jarvis

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Shown at the Lean Summit 2013 - Lean Transformation: Frontiers and Fundamentals on 5th, 6th & 7th November

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Delivering Results in Healthcare by Marc Baker, Ian Taylor and Dr Paul Jarvis

  1. 1. Delivering Results in Healthcare Marc Baker & Paul Jarvis Doing the Right Thing for Every Patient
  2. 2. www.leanuk.org Our Core Tenet Our Core Tenet is a patient centred approach to re-design and has been the underlying principle of all our work in healthcare, we refuse to do local optimisation work. Over the years we have learned what works, and what does not, in healthcare (and why). This has been codified into our book ‘Making Hospitals work’.
  3. 3. www.leanuk.org 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
  4. 4. www.leanuk.org Exercise What is Takt Time? How is it Calculated? Why is it Important?
  5. 5. www.leanuk.org Pull and Flow We believe that our job in healthcare is to enable each individual patient to ‘pull’ themselves through the system and to ensure that our services ‘flow’ to provide exactly that which the patient needs exactly when they need it (pulled by the patient) during their journey through our system. There exists a natural pace or beat at which patients require our services and it is only when we can identify this pace or beat that can our services truly flow to meet the patient needs
  6. 6. www.leanuk.org Staff/Departmental Availability V’s Opportunities for Patient Flow (Door to Door) Example - Royal Gwent Staff Overflow Car Park
  7. 7. www.leanuk.org We Are Obsessed by Demand (and crave to see it)
  8. 8. HRI’s Medical Demand Map Where do they come from? What happens to them? Where do they go? Lean Enterprise Academy www.leanuk.org
  9. 9. www.leanuk.org Why is Demand so Important
  10. 10. www.leanuk.org Because we can translate Demand into Takt time
  11. 11. www.leanuk.org Takt Time comes from the German word for Pace or Beat & is used to describe the Rate at which Patients require a Service Takt Time
  12. 12. www.leanuk.org Takt Time is used to enable flow by matching the ‘Rate of Delivery’ with the ‘Rate of Demand’ Takt Time dictates how often one Request/Activity should be Completed – in line with Patient Demand Why is Takt Time so Important? Takt Time is used to scientifically calculate staffing levels Everything in the System Must be Synchronised to meet Takt otherwise queues WILL form
  13. 13. www.leanuk.org TAKT Time = 360 minutes 72 patients TAKT Time Calculation Example Cont’d One Patient Every 5 Minutes
  14. 14. www.leanuk.org Using Takt to calculate the Number of Staff Required Total Work Content Takt Time = = = 120 30 4 staff
  15. 15. www.leanuk.org ED Takt Example – Calderdale & Huddersfield
  16. 16. www.leanuk.org It is quite normal in Acute Hospitals that during the busiest time of day, patients are presenting on average at A&E Majors Departments every ten minutes or so. Service Level Agreements (SLAs) are now commonplace in healthcare. For example the path lab may have a SLA to turnaround blood results to A&E within 90 minutes but is this good enough? If at the busiest time of the day, patients are arriving on average, at A&E Majors every ten minutes - but cannot be admitted or discharged until the results are available - we have to ask “is a SLA of 90 minutes good enough?”
  17. 17. www.leanuk.org The diagram below illustrates that in this scenario with patients arriving every ten minutes and blood result ‘turn around time’ of ninety minutes Nine bays will be occupied by patients just requiring blood results alone. 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 Patient 1 X X X X X X X X X Patient 2 X X X X X X X X X Patient 3 X X X X X X X X X Patient 4 X X X X X X X X X Patient 5 X X X X X X X X X Patient 6 X X X X X X X X X Patient 7 X X X X X X X X X Patient 8 X X X X X X X X X Patient 9 X X X X X X X X X Minutes
  18. 18. www.leanuk.org Takt at the Back Door
  19. 19. www.leanuk.org JPUH Medical Takt Times 44 Mins 55 Mins 28 Mins Due to Opening Hours the Back Door Must work to a quicker Pace than the Front Door
  20. 20. www.leanuk.org Levelled Discharges being used in conjunction with the Visual Hospital Levelled Discharges – Small Numbers ‘Drip Fed’ Throughout the Day (As Legitimate as the A&E Target)
  21. 21. HSJ Best Acute Hospital 2010 Commissioners saved £1.1 m Trust saved £2.2 m from safely closing 100 medical beds 50% reduction in Locum/ Bank and Agency spend No compulsory redundancies Calderdale & Huddersfield NHS Foundation Trust Shortest Length of Stay Static readmission rate Continuing to improve www.leanuk.org© LEA
  22. 22. www.leanuk.org
  23. 23. What is Quality? You want to go out for dinner with some friends What constitutes a quality experience for you and your friends?
  24. 24. You run a restaurant What would constitute quality now? What is Quality?
  25. 25. Which is the more objective view of quality: Customer or Service Provider perspective?
  26. 26. Healthcare is a unique industry because a patient is both the customer and the product Quality should always be viewed from the patient’s perspective
  27. 27. 3 characteristics of quality: • Service • Product • Environment For a quality patient experience all of these need to be right Understanding Quality
  28. 28. • Would you go back to a hotel that wakes you up at 3am so they can move you to a different room? • Would you return to a shop that makes you wait several hours before they serve you? • How would you feel if the person serving you talked to you like you were an idiot? • Would you carry on using the same garage if your car had to go back in because the work done was inadequate 10% of the time? These are everyday examples – Why are they tolerated in healthcare? Why do we need Quality Improvement in Healthcare?
  29. 29. We’re not a hotel, a shop or a garage, but we do provide a service. Patients tolerate poor care because there is very little alternative (and it’s free) Huge initiative throughout health service on improving the patient experience Need for Change
  30. 30. X Y Patient encounter Healthy & satisfied with Dr patient Sadly, life isn’t this simple? How Complex is one patient’s Journey
  31. 31. Reality is more like this… This is one patient’s real hospital journey!
  32. 32. Old System Traditional ED System Treatment CT = 20 min Disposal CT = 3min Triage CT=6 min Dr Review CT = 37 min Investigations CT = 63 min Nurse Assessment CT= 27min Dr Review CT = 15 min Walking Ambulance Consultant
  33. 33. Old System Traditional ED System Treatment CT = 20 min Disposal CT = 3min Triage CT=6 min Dr Review CT = 37 min Investigations CT = 63 min Nurse Assessment CT= 27min Dr Review CT = 15 min Walking Ambulance Consultant 32 41 9 32 7 201 28 15
  34. 34. What is the problem? • System designed to make patients wait (Triage is a step to decide how long you should wait) • Two access points to the service • Investigations requested late • Potential for inexperienced staff to order unnecessary investigations 34
  35. 35. www.leanuk.org ED Takt Example – Calderdale & Huddersfield 9am – 9pm Takt is 12 mins
  36. 36. Old System Traditional ED System Treatment CT = 20 min Disposal CT = 3min Triage CT=6 min Dr Review CT = 37 min Investigations CT = 63 min Nurse Assessment CT= 27min Dr Review CT = 15 min Walking Ambulance Consultant 32 41 9 32 7 201 28 15 9am – 9pm Takt is 12 mins Exercise: Draw Bar Chart of Delay/ CycleTimes v Takt for walking patients
  37. 37. Takt Time 201
  38. 38. EDIT CT= 16 min ED Dr CT = 37min Treatment CT = 20min Disposal CT = 3min Ambulance Walking Consultant 1 Consultant 2 Emergency Dept Intervention Team System Redesign ED Process 201 9am – 9pm Takt is 12 mins 784 Exercise: Draw Bar Chart of Delay/ CycleTimes v Takt
  39. 39. Takt Time 201 2 x Resource 3 x Resource
  40. 40. Phase 1 – Evaluate the performance of the traditional ED model - 1st April to 24th May 2013 (3835 patients) Phase 2 – Evaluate introducing POCT into traditional ED model - 28th May to 29th September 2013 (7033 patients) Phase 3 – Evaluate POCT and EDIT model together – 30th September to 18th October 2013 (1200 patients) 3 Phase Trial
  41. 41. Before Trial Median Blood Results being available: 63 minutes Trial Results Median: 3 minutes Able to do 60% of ED bloods using iStat Point of Care Testing
  42. 42. Effect of the 3 Different Working Models on the Median ED Times 68% Overall Reduction 40% Overall Reduction 60% Overall Reduction Time hh:mm Results
  43. 43. • Introduction of Point of Care Testing (POCT) • • i-Stat® System Introduced Point of Care Testing
  44. 44. With traditional model 9 patients are undergoing ED Care in the ED central area at any one time (Monday to Friday 9- 5) EDIT & iStat reduces this to 5 due to quicker processing of patients 45 Results Reduces Overcrowding Frees up time to Care
  45. 45. With Traditional Model 3% of patients seen in ED Central Area Monday to Friday 9-5 are discharged with 30 minutes of arriving. With EDIT & iStat this is increased to 10% with the additional benefit of being seen by a consultant. Results Reduces Overcrowding Frees up time to Care
  46. 46. With Traditional Model 11.4% of patients seen in ED Central Area Monday to Friday 9-5 return within 7 days of their initial presentation With EDIT & iStat this is 9.1% Shorter patient journey times do not equate to more patients having to return to the ED within 7 days Results
  47. 47. 48 Results * - only 1 consultant When only 1 consultant causes special cause variation in performance r = -0.8 UCL * *
  48. 48. Before Trial Median Blood Results being available: 63 minutes Trial Results Median: 3 minutes Able to do 60% of ED bloods using iStat Point of Care Testing
  49. 49. 360 ED attendances per day cross site 2.5% reduction = 9 few admissions per day Rates of Admission
  50. 50. Introduction of a consultant-led assessment process (EDIT) and POCT provides a 40% reduction in the time from patient arrival to being declared ‘ED Ready’ and 2.5% reduction in the number of patients admitted Conclusion

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