Bringing lean to life


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Bringing Lean to Life" provides a basic introduction and overview of Lean; the culture, principles and tools to understand, tackle and resolve issues within healthcare. It is not intended as a complete guide to implementing Lean as a management system. (May 2010).

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Bringing lean to life

  1. 1. NHSCANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement Bringing Lean to Life Making processes flow in healthcare
  2. 2. Bringing Lean to Life - Making processes flow in healthcare Contents Introduction - what is the problem in healthcare? 4 Identifying waste 18 What is Lean? 6 Making value flow 20 A3 thinking 7 Understanding pull 21 An example A3 report 8 Understanding Takt time 22 The importance of data and measures 10 Using 5S to improve safety 23 Example statistical process control (SPC) charts 11 Plan Do Check Adjust (PDCA) cycle 24 Current state value stream mapping 12 Continuous improvement 25 Designing the future state value stream map 14 Value stream mapping symbols 26 Standard work to produce high quality every time 15 Acknowledgements 27 Visual management 163
  3. 3. 4 Bringing Lean to Life - Making processes flow in healthcare Introduction - what is the problem in healthcare? We all come to work to do our very best - to The ‘processes’ are to blame not the people achieve what we are capable of and to add real value for our patients and ensure clinical Often, there is ambiguity in how certain tasks should be performed – so people work it out “…the best hope for expertise is supported by process excellence to enable healthcare processes to flow at the rate of patient demand - no one wants to get for themselves to secure the best outcome and get the job done. However, whilst saving lives lies in it wrong. Healthcare teams are dedicated and skilled professionals who are often under everyone develops their own bespoke solution, the variations introduced by different raising performance…” pressure to do their best and work terrifically people can be significant and harmful. Atul Gawande, Better, 2007 hard - but often with inadequate processes. Departments continue to work hard and in Each year, the National Patient Safety Agency isolation to ensure they improve their services handles over one million reported medical and practices. However, such silo’s often NHS Improvement has been using Lean with incidents in England alone. Figures illustrate mean that any good practice is lost which clinical teams and has proven that it can that approximately one in every ten patients increasingly impacts upon the patient flow improve quality, increase safety, reduce are unintentionally harmed by their healthcare between services. turnaround times, increase efficiency and providers. Most of these are not necessarily productivity, improve staff morale and reduce the result of medical errors or poor clinical This booklet provides a basic introduction and costs. The NHS Improvement website decisions, but are caused simply by the way overview of Lean; the culture, principles and has details of the system has been set up. tools to understand, tackle and resolve issues numerous case studies and recommended within healthcare. It is not intended as a reading. complete guide to implementing Lean as a management system. Together we can’t afford not to change!
  4. 4. “ Improvement usually means doing something that we have never done before. ” Shigeo Shingo5
  5. 5. 6 Bringing Lean to Life - Making processes flow in healthcare What is Lean? Lean was a term coined by researchers when In short, Lean is about building the problem studying the philosophy of the management solving capabilities of the team to produce Specify VALUE from system in place at Toyota and the culture they experts who can perform daily work to the the customer viewpoint had created amongst their workers to improve best standard – everyday. processes which led to the final product. Pursue PERFECTION Identify the These key steps and the necessary tools to in quality & quantity VALUE STREAM by continuous and remove The researchers noticed five key steps were in implement Lean are explained in this booklet. improvement waste Problem Solve problems by place to deliver what the customer wanted at root cause analysis solving the highest quality and safety level possible, Introduce Standard Working with the lowest associated costs from a workforce which also had high morale. Lean is the continuous and Remove Waste Set Up Visual Management Eliminate Batching People and Partners Respect, challenge and grow them systematic elimination of Eliminate waste. Identify Root Cause Right process will Process The five steps were: deliver right result Long-term thinking. Philosophy waste Continuous 1 Specify value improvement 2 Identify the value stream steps initiate PULL in line Make value Ref: Liker, 2004 with customer demand FLOW 3 Make value flow 4 Supply what is pulled by the customer 5 Continually improve and strive for perfection.
  6. 6. A3 thinking All Lean improvement work should begin with The A3 report is literally a one-page document just on a single sheet of paper requires concise The A3 represents the shared consensus A3 thinking as it is a methodical approach to (11 x 17 inch [A3] sheet of paper) that records information. This prevents excessive amounts towards solving the problem. As a document, problem solving. the agreed points of discussion in a systematic of information being overwhelming, it encourages reflection on the learning that way. misinterpreted and incorrect conclusions being has taken place and ensures that a consistent Lean is primarily the description of a reached. message is discussed and scrutinized. methodology to routinely solve problems The structure of the A3 (see pages 8 and 9) everyday so that the work is delivered to takes individuals and teams through the The best A3s: For an A3 to work, the whole team needs to specification. A3 thinking is the rigorous process of agreeing the problem statement or • are handwritten in pencil with minimum text contribute and agree. application of something known as the Plan, issue, reviewing and analysing the current • contain pictures/diagrams to convey the Do Check, Adjust (PDCA) approach. state and identification of a desired future problem state with a subsequent action plan for any • are concise and hold all the relevant Top tips The PDCA (PDSA) cycle provides a means of agreed actions. information • Teach, coach and use A3 thinking as a standard tool for all new conducting safe experimentation or a number • represent the shared consensus projects and problem solving of trials to see the effect of any changes made Describing the entire process from current • do not need verbal explanation in a bid to make improvement (see page 24). state, through analysis and onto future state • are agreed by the entire team. • Complete the A3 report with a pencil (corrections can be made following further consensus with the team) • This is a working document – each box should contain only the information that has been agreed • Resist the temptation to ‘type’ up the report. If an electronic version is required, consider taking a digital photograph instead to share across the wider organisation.7
  7. 7. 8 Bringing Lean to Life - Making processes flow in healthcare An example A3 report NHS A3 Lean Improvement NHS Improvement Department Cervical Cytology Department Date: May 2010 Author: Define the problem/opportunity: (Why are you talking about it? What are you trying to solve/improve?) Team members: Agreed by: Version: Waiting times for turning around cervical screening samples are protracted. This could potentially delay any treatment required by the woman. Future state: (What will it look like? Be visual - future state value stream map) Current state: (What happens now? Be visual - value stream map, graphs, facts and measurements etc.)
  8. 8. Action plan Action - what, why and how? Who? When? Progress status (ie completed, in progress) Goal: (State the specific target(s). State in measurable or identifiable terms) Establish core transport group RG Jan 2010 Completed 100% in 14 days 50% in 7 days Implement zero tolerance policy of defects from 1˚ Care AS Jan 2010 Completed Zero defects Reduce backlog Goal V actual measures GF Mar 2010 Ongoing Waste identified: (Transport, Inventory, Motion, Automation, Waiting, Overproduction, Overprocessing, Defects, Skills.) Capacity and demand GF Feb 2010 In progress Transportation – up to 15 days ‘lost’ Reduce batch sizes from 16 to 8 AS Mar 2010 In progress Waiting – average TATs of 41 days from specimen taken to report issued Introduce water strider AS Apr 2010 Ongoing Defects – 40% defects received from primary care Results and measures: (What was your PDSA cycle? How long did you run it for? What data did you collect before and after the change? What did you find? Add charts, tables, and cost benefit analysis) Root Cause Analysis: (What is the root cause of the problem? Use fishbone/cause and effect diagram, five why analysis) Transport group Zero tolerance policy has reduced delivery reduced defects from 40% times by an to 20% within 6 weeks, average of 12 with a further reduction in days 10% anticipated within next 2 weeks Next steps: (Are there any remaining issues/problems? Is there any further follow up required?) Levelled workloads are required in laboratory. This is being taken up by laboratory subgroup – April 2010.9
  9. 9. 10 Bringing Lean to Life - Making processes flow in healthcare The importance of data and measures In healthcare, we are used to taking clinical Measures might include: Manual data collection might feel like hard Data analysis doesn’t need to be complicated. measures such as temperature, pulse, blood • numbers of patients on waiting lists work at the time, but if you don’t collect this Line graphs, bar charts, scatter graphs and pressure, respiration rates, urine outputs etc. • staff numbers information before you start: statistical process control charts can all be in order to understand if the condition is • hours worked a) how will you know what your current used to visually show the before and after getting better or worse. To understand if the • patient experience state looks like? status (see examples on the following page). process is improving, we can use statistical • waiting days b) how do you know where to focus methods, programs and charts to • staff morale your efforts? demonstrate, for example, the number of • turnaround times c) how are you going to know if you patients on a waiting list or turnaround times. • number of incidents or defects have made an impact? • number of complaints Data and measures are important to • cost When you have made a small incremental demonstrate and factually prove that change • quality change using the PDCA (PDSA) approach, has occurred or needs to occur. Whether the review your original measures and collect the change was a success or a failure, you still Once you have agreed your aim and same data to see if your trial has made a need to demonstrate it! measures, you will need to collect current difference. state data. It isn’t always easy to collect data Before starting your Lean journey, it is essential to understand what your aim is and for this baseline. If you can’t get the information from the electronic systems, you It is not satisfactory to say “it feels better”, what are your measures. will need to collect the information manually. “I think it’s better”, “it seems better” - establish factual data and measures.
  10. 10. Example statistical process control (SPC) charts Once the raw data has been End to end turnaround times SPC showing root cause analysis converted into a graph, the outliers become visible and root cause analysis can be carried out to achieve your aim Waiting one extra day for Waiting two extra days for discharge medication physiotherapy assessment Waiting ten days for cancelled surgery Waited for lab results, interventional Waiting four extra diagnostics and delayed ward round days for CT scan January February March April May Each data point is a consecutively referred patient. This data demonstrates that the process changes implemented has had a positive effect. You can use data to identify the root cause of the problem in the process.11
  11. 11. 12 Bringing Lean to Life - Making processes flow in healthcare Current state value stream mapping A critical starting point in any problem solving How to make your value stream or improvement work is to map the situation map (VSM): (process) in its current state. This should be • Establish key start and stop points (agree done as a team and then added to the A3 the scope) document. • Document the key process steps • Add the data box below each process step One of the tools used to capture the current (cycle time, batch size at each step, number state or ‘as is’ performance is the value stream map (VSM). of defects/errors at each step and the trigger that starts the process step) “ If you don’t know where you are going, What is value? • Add a timeline at the bottom of your VSM and below each process step document the you will probably end up somewhere else.” Value can only be defined by the end cycle time (how long does it take to process Dr Laurence J Peter, customer. In healthcare the customer is accomplish the task?) Founder of The Peter Principle usually the patient. Value is any activity that • On the timeline between each process step, directly contributes to satisfying needs of the add the delay which occurs between each patient. Any activity that doesn’t add value is step! defined as waste. • Show all information flows • Work out the total time taken to get a Value stream map patient through the value stream by adding A current state value stream map is a visual all numbers in the timeline representation of all the actions currently required to deliver a product or a service.
  12. 12. The map documents work activity and the • Calculate the ‘touch time’ - the time movement of information across the entire actually required to get the patient through Current state value stream map patient pathway from origin to final point of the value stream if seamless care were being delivery. delivered (i.e. all waste removed) 70 per day • Agree the value added (VA) activities and (352 per week) Inpatients 1 x daily the non VA activities, identifying those Outpatients ‘must do’s’ (i.e. business essential but not really adding value directly to the patient) • Determine the percentage of VA activities - don’t be surprised if this is very low! 36 36 409 64 61 136 13 Vet referral Data entry Book scan Scan Dictate report Type Verify Report issue Remember • Keep your value stream map high level, don’t focus on the detail • Only focus on the main pathway – what CT = 120 sec CT = 60 sec CT = 60 sec CT = 15 min CT = 60 sec CT = 60 sec CT = 15 sec CT = 60 sec happens 80% of the time? C/O = C/O = C/O = C/O = C/O = C/O = C/O = C/O = • Collect true and accurate information by defects = % defects = % defects = % defects = % defects = % defects = % defects = % defects = % walking through the pathway yourself. Avail = Avail = Avail = Avail = Avail = Avail = Avail = Avail = Batch = 130 Batch = 100 Batch = 50 Batch = 32 Batch = 12 Batch = 12 Batch = 15-100 Batch = 100 Why map the value stream? 33325 33325 37861 59245 56468 12589 21291 7 7 • The mapping process is a powerful tool to 120 60 60 900 60 60 15 60 look strategically at your process and quickly Touch time = 1335s (22.2mins) identify opportunities for improvement. Flow time = 709703 secs • Non value adding activities i.e. wastes can be identified and documented. • This provides a basis for a discussion around See page 26 for the value stream mapping symbols ‘what should be the process?’13
  13. 13. 14 Bringing Lean to Life - Making processes flow in healthcare Designing the future state value stream map Once you understand the current picture of been have been eliminated, combined and what really happens throughout the value simplified, review the sequence of events to Future state value stream map stream, you can begin to agree what needs promote efficiency. to happen and then analyse the gap between 70 per day GPs the current and future states. When designing a future state, the takt time, (352 per week) Inpatients the removal of waste and the introduction of Outpatients From your current state map you will be able flow must be considered – all of which are 1 x daily to identify where the significant problems discussed in this booklet. occur. This might be the most prevalent waits and delays, the largest amount of work in The aim is to produce a service where each progress between process steps or where process step links seamlessly to the next, in there is considerable duplication. the shortest amount of time at the highest 409 136 quality and safety by a group of staff with a Booking Scanning Issue report There are four main techniques to design high morale. FIFO your future state. Just remember ECSS! Once the future state Value Stream Map is • Eliminate completed, it is then essential to review CT = 120 sec CT = 90 min CT = 60 sec • Combine measures, analyse the gap between current C/O = C/O = C/O = • Simplify and future state and then agree an action Uptime = Uptime Uptime = • Sequence plan of PDCA cycles to trial the changes. Avail = Avail = Avail = Where possible, try to eliminate any process Be clear about the purpose before Batch = Batch = Batch = 12 steps. If it isn’t possible to eliminate any designing the process – then, organise 3786 125897 steps, look to combine steps. After the people! combining, consider where the system can be 240 17 90 60 simplified. Once steps in the system have
  14. 14. Standard work to produce high quality every time Lean is about the people who perform the There are three key elements to One of the Lean tools which promote work. It’s about developing people to be ‘the standardised work: standardisation is 5S, the foundation for best’ – utilising their ‘expert talent’ and safety and quality. establishing excellent ways of working. • Takt time – how fast we should be working Standardised work: Standard work is about establishing out • Work sequence – the order that work • Ensures safety and maintains high quality of all the possible ways, the best work should be done and efficiency method of conducting a task and then • Work in progress – defining the • Ensures process stability and therefore ensuring that everyone always works to working inventory to make repeatability this gold standard. abnormalities obvious. • Allows us to assess if we are in control, ahead or behind schedule The gold standard should have the least It is important to understand that standard • Preserves the organisational expertise amount of waste, with the highest quality work is not static. Standards are actually the • Allows us to identify and rectify problems and safety. These standard procedures create basis for subsequent improvements. Once a • Provides a gauge by which we can error stability and consistency in the system to better method is found, the team should proof for the future produce high performance results every time. agree on the new standard, update the • Gives us a baseline from which to processes, procedures and visual management measure improvement and continually and then ensure that it is adopted by all. strive for a better way • Provides a basis for employee training. Standardisation should exist for every process including meetings, health and safety procedures, budget reports, audits, all paperwork etc.15
  15. 15. 16 Bringing Lean to Life - Making processes flow in healthcare Visual management Visual management is everywhere, from the Visual management allows teams to: green man at the cross the roads, to the numbers on the front of busses, petrol • See the work in progress indicator lights in cars, a water level on a • Recognise flow stoppers kettle, to a cricket scoreboard. These visual indicators allow us to easily understand the • Assess inventory levels situation and take action where necessary. • Identify defects Visual management is a simple, yet highly • See deviations from the standard effective way of indicating what should • Enable interventions happen (by setting a standard) and what is actually happening in the work • Improve safety. environment. At a glance, colleagues, supervisors, managers and visitors to the area should be able to understand the process and see what is under control and what isn’t without having to ask a question.
  16. 16. There are two types of visual Visual management can be used to answer management: the following questions. Give some thought Cytology request form: Visual management has been sent to how you could use visual management to to smear takers to ensure zero defects on the request form. • Visual display, which is the provision answer the following questions in your work of information area: • Visual control which is associated with action. 1 Are we up to date with the work? 2 What are our three biggest problems Both these types of visual management gain in the area and what is being done the maximum amount of information, without to resolve these problems? having to leave the work environment or 3 How do you know that your ideas access a computer system. have been listened to? 4 How can you tell who is trained to Visual management provides the knowledge perform each task? and certainty to make staff and patients lives 5 Is there daily accountability? Who is safer. it today? 6 How do you know where staff are – Communication board breaks, annual leave, study leave? The board keeps all team members up to date with 7 How do you know if the stock has the recent data, changes and improvements made, been ordered? 5S scores, team ideas which includes action taken against the ideas.17
  17. 17. 18 Bringing Lean to Life - Making processes flow in healthcare Identifying waste The elimination of waste is the main These wastes can be remembered by I INVENTORY M MOTION characteristic of Lean. Waste is Elimination of waste remembering the name TIM A WOODS (this Inventory is work in progress and stock. A The waste of motion is any unnecessary everything that doesn’t add value came from Lean office at Cooper Standard, common problem is lack of space. By reducing movement by people. This is mainly related to to the patient or process. Plymouth UK). inventory and by combining process steps, staff poor ergonomics, bending, stretching, moving Eliminate Minimise have more space to carry out duties in a safer items etc. working environment. There are three types of work: TRANSPORT How many times during your shift do you have to 1) Value add – When you are adding value T Transport is the unnecessary movement of Unnecessary Necessary How frequently do you run out of supplies only to get up and walk to use a certain piece of to the patient/process (e.g. prescribing waste waste items and materials. How often do we see people find another department has stock? equipment just because it is located in the wrong medication, providing physiotherapy, moving items (notes, reports, slides, supplies etc.) place? How often do you find yourself searching reporting an image) from one locality to another - and back again? For example: for vital items because they were not put back in Stand for a short while in a hospital corridor and • Over-ordering - consumables, paper the right place? Value observe these activities - you’ll be surprised. • Different batch sizes at each step 2) Necessary waste – This is when you are • Overstocked medication on wards For example: not adding value but it is a necessary step. For example: • Overstocked items in the supplies department • Poor layout of wards/surgeries/departments (e.g. incubation in a microbiology laboratory, • Moving drugs, samples, equipment, supplies because it was cheaper to buy in bulk without /laboratories vetting requests prior to radiology excessively around the hospital thinking about the costs of storage, stock taking • Searching for equipment or stock examination) Maximise • Moving paper notes excessively and distribution • Location of printers, faxes, copiers and • Transporting samples from one location or • Staff hiding extra stock for ‘just in case’. computers 3) Unnecessary waste – This is where you site to another. • Looking for information and people. are not adding value and these steps could be There are two other recognised wastes: Remove the waste of inventory by: Remove the waste of transport by: • Implementing the Lean tool of 5S Remove the waste of motion by: removed (e.g. walking to get or find items, the waste of unused staff creativity (skills utilisation) • The elimination of process steps and hand offs • Establish visual systems (kanbans) - aids visibility • Introducing standard layout waiting for consultants/medication). and automating an already inefficient process: • Co-locating departments/processes/supplies for stock counting • Introducing a standard way of working • Introducing work cells. • Understand what is needed to keep up • Developing flow in work cells Researchers have found that there are seven • Establish first in first out principle with demand - • Initiate and sustain 5S. main wastes and over the years other wastes implement ‘just In time’ have been added. • Keep stock audits correct and current.
  18. 18. AUTOMATING For example: For example: Remove the waste of over production by: SKILLS UTILISATION A Automation of poor processes just serves to • Waiting for shared equipment (telephone/ • Duplicate testing/inappropriate testing • Remove all unnecessary paperwork S Every department has unused staff potential. automate waste. The poor understanding of work computers) • Duplicate data entry • Reduce batching - establish a visual system There is someone in every department that knows content and takt time can result in purchase of • Staff waiting for machines, deliveries, other • Duplication of checking cards/slides • When the process can’t flow, introduce the issues and has the possible solutions. If only large pieces of expensive equipment that actually members of staff • Excessive bed moves ‘pull’ systems with buffers and kanban’s. they were asked, listened to and action was taken - hinders flow of the overall process. The result, is an • Waiting for decisions • Excessive paperwork the people doing the job are the experts. expensive poor process! • Waiting for others at meetings • Manual checking electronic data DEFECTS • Patients waiting for appointments, in emergency D Defects are all the errors that compromise Unused skills and creativity also include highly For example: departments/clinics, waiting for discharge Remove the waste of over processing by: quality, safety, cost and staff time. Make it right, skilled staff undertaking duties that do not reflect • Did radiology reporting times reduce when • Samples waiting in a batch to be analysed • Eliminate non-value added steps first time, every time. there skills, e.g. band 8 staff routinely performing PACS was implemented? in the laboratory • Combine process steps and paperwork band 3 duties. • Do samples get turned around any quicker with • Requesters waiting for results or medication. • Simplify tasks Do you tolerate errors by reworking someone else’s track systems purchased and implemented in mistakes? How often do you accept incomplete or How many times do we see supervisors/managers Remove the waste of waiting by: biochemistry? • Leveling the workload and balancing operations O OVER PRODUCTION doing too much, too Over production is about inaccurate requesting information? routinely booking appointments? • Eliminating or reducing batch sizes soon or ‘just in case’. For example: The intellect and skill of staff should be used to WAITING W The waste of waiting usually transpires when • Eliminating hand-offs. • Wrong patient, wrong test, wrong procedure, guide the continuous improvement of procedures How many times do we complete the same wrong form and processes. The inclusion and insistence of staff there is an in balance of process steps which all OVER PROCESSING information and have to file it or store it in many • Inappropriate/inadequate referrals in problem solving and decision making will also take different timings or the batch sizes are O The waste of over processing is all the things different ways? How often do we see queues build • Chasing inadequate patient information support recruitment, retention and improve morale. different in each process step. The waste of we do that don’t add any value to the process - up in one part of the process because the previous • Repeated checking waiting has a direct impact on flow as waiting producing excess. department kept producing more, regardless of • Medication errors. creates a ‘stop-start’ process. whether subsequent processes were ready or could How many tasks are repeated simply because we cope? Remove the waste of defects by: Do you ever find yourself becoming frustrated and • Making the system mistake proof don’t have a system to ensure it serves the needs of your working day hindered because you are For example: • Introducing a zero tolerance to defects the patient or process throughout the whole waiting for a colleague to do their role or for a • Making more than, faster than, earlier than is • Introduce standard work to ensure the same healthcare journey? machine to finish? required by the next process step process is completed every time ensuring high • Duplicate entries in medical records quality process repeatability. • Paper copies of results sent along with an electronic copy • Repeating tests before next test scheduled.19
  19. 19. 20 Bringing Lean to Life - Making processes flow in healthcare Making value flow Flow is the continual movement of value To promote flow, batches should be reduced adding activities from the beginning to and where possible removed to achieve the the end of the value stream. optimal flow - one piece flow. When flow is achieved, it becomes easier to spot problems Processes which add value to the patient and patients are no longer unnecessary held should not be held up by any non value up in the health system. adding steps or waste in the system. Waste and non-value-adding steps create a ‘stop- All Lean tools work towards promoting flow. start’ effect which prevents the flow of Visual management can be used to highlight value adding steps the value stream. flow stoppers. Standard work can be used to ensure processes are repeatable and reliable, Systems which promote batching hinder flow, with no variation. 5S can support workplace create waste and queues. Batching can be organisation ensuring no time is lost trying to seen across healthcare. For example, ward find the right tools to do the job. rounds completed at the same time of day causes a batch of work for the nursing staff and every support service that follows i.e. Pathology, Radiology and Pharmacy.
  20. 20. Understanding pull Flow and pull work to keep the entire value stabilised. Over time, the buffer should be stream moving. Flow is the goal, but on gradually reduced and ultimately removed. occasion, flow may not be achievable and in these situations the concept of pull can be Kanban introduced to respond to demand. Kanban signs/signals are a form of pull. These visual signs are mechanisms for the patient or Pull is a short term notion to gain control internal customer (ie ward nurse, radiologist, and process stability. discharge staff) to say “I am ready for more.” “ Flow where you can, pull There are many different forms of Kanban – Pull works with buffers and kanbans: an empty container, a box, a marked area, an empty shelf or a card. Buffer A buffer is a clearly defined holding area at where you must” the interface between two processes allowing Jeffery K. Liker, The Toyata Way, 2004 patients, paperwork, information or items to wait for a defined amount of time between two process steps. A buffer could be a waiting room, empty beds, trolleys or chairs, or even a space for stock and inventory. Buffers are actually a ‘waste’ and should only be introduced when flow is not possible and the process needs to be controlled and21
  21. 21. 22 Bringing Lean to Life - Making processes flow in healthcare Understanding takt time Takt time is simply the rate at which we Every seven minutes a patient should move need to work to keep up with demand. through the scanning process – this is the takt time. The calculation for takt time is: 20 The cycle time is the time it takes to actually Available work time ‘do’ the task and the aim is to match (where = takt time 15 Demand possible) takt time. Minutes This sounds too simple, yet the ability to If the cycle time is going to be identical to or 10 achieve takt is the fundamental question to less than takt, all the non value adding Takt whether the system is set up to deliver what is activities need to be removed from each required. If teams can not achieve takt, waste step. Only when the non value adding 5 in the system needs to be removed and each activities have been removed from each step process step needs to be levelled to ensure should additional resources be considered. 0 takt is met. Vet Protocol Book Scan Report Type Verify Issue As you can see from the graph on the right, Worked example: the team would possibly need to either A scanning department is open and staffed extend scanning hours or secure additional for seven hours per day has a daily demand of scanning resource. The team would also 60 referrals. need more than one consultant reporting in order to achieve takt. 7 hours 420 min Takt time = = 7 min 60 60
  22. 22. Using 5S to improve safety 5S has traditionally been thought of as being 5S - What does it mean? How do I do it? just a ‘tidy up’, but when approached properly it is much more than that. Sort Shine ‘When in doubt, move it out!’ ‘Lean means clean’ 5S is the basis for standardising work 1) Remove everything from the defined area. 1) Clean the area – it should be easier to clean now you have removed the clutter and and is used to improve efficiency by 2) Only return what is necessary for the daily duties. every item has a location. eliminating waste, promoting flow, 3) Discard any broken, unnecessary items – e.g. clutter, old equipment, old 2) Develop a plan where cleaning is incorporated into the daily routine. improving staff morale and most unused paperwork. importantly improving safety. 4) Move any items that you are unsure of into a holding bay for a team decision. Standardise 5) If shelving or cupboards are not used or required, remove them too – this will Create a consistent approach for carrying out tasks and procedures. Ultimately, it is about making the prevent unwanted items being stored there. processes and environment safe. 6) Items necessary to complete the job need to be ‘set in order’ 2S Sustain ‘Sustain all gains through self discipline’ Set in order Make 5S become a way of life by: ‘A place for everything and everything in its place.’ 1) Practicing and repeating the process. 2) Educating all staff 1) Give every item a location - Items used on a regular /daily basis need to be placed 3) Linking 5S directly to the day job within arms length / accessible location 4) Empowering staff to improve and maintain their workplace. - Items used on a weekly basis should be stored on a shelf or in a cupboard in the work environment. When employees take pride in their work and workplace it can lead to greater job - Items used on a monthly, quarterly or annual basis should be stored in an satisfaction and higher productivity. appropriate location – possibly outside the work area. 2) Mark off (with electrical tape or permanent marker) and label each location23
  23. 23. 24 Bringing Lean to Life - Making processes flow in healthcare Plan, Do, Check, Adjust (PDCA) Sometimes called a Plan, Do, Study, Act (PDSA) Change on a large scale can be daunting but P - Plan you should not let that deter you. This is the most important part of the process. Before implementing a full proposal for • What you are planning to trial? change a PDCA cycle (sometimes called • What are your objectives? A P a Plan, Do, Study, Act (PDSA) cycle) can • Who is needs to be involved/informed? C D be used. A PDCA (PDSA) cycle will • How are you going to do it? D provide the opportunity to test out an • How long will the trial run? ADJUST PLAN P idea on a small scale, without risking too • How are you going to measure improvement? C A much. • What is your communication plan? C D - Do A New ideas should be introduced only after D • Test the change and collect the data CHECK DO sufficient testing (or evidence) on a smaller P scale has proven to have a positive effect. C - Check PDCA (PDSA) cycles allow us to introduce an • Analyse the data you collected in the ‘plan’ A P idea in a safe, controlled way which will have less resistance, be less disruptive and use less and ‘do’ phase C D • Discuss outcomes with colleagues? resources. By building on the learning from • What went well? each PDCA (PDSA) cycle, new processes can • What went wrong? be introduced with a greater chance of • Did anything unexpected happen? success. A - Adjust • If the change was a measurable success, • Could the process be improved? • If the trial did not improve the process, adopt and spread the improvement in your • If the trial didn’t go to plan, what was the could you treat the root cause in your next PDCA (PDSA) cycle. root cause? PDCA (PDSA) cycle?
  24. 24. Continuous improvement Continuous improvement is the final lean principle, which is to strive for perfection through continuous improvement. This is done by embracing the Lean philosophy and tools as described in this booklet. The staff are a fundamental part of Lean. It is important to develop staff and give them the The key to success is During your Lean journey, don’t lose sight of perfection and what perfection means: Act like a sponge - soak capability, autonomy and empowerment to solve the problems as they encounter them on small, daily incremental • the right patient journey it up and squeeze out a daily basis. Teaching and expecting rigorous problem solving by all staff is the only improvements. • the right support services when they are required by the patient improvements everyday sustainable way to strive for perfection. • the highest level of quality and safety • no defects or incidences Communication is imperative to develop staff For Lean to be a success, the Lean culture • delivered at the right price to continually improve the process. needs to be accepted and embraced by all. • delivered by a staff group with high A five minute daily meeting for all staff morale and pride in their work. around a central communication board to When implemented, the tools and techniques discuss real time issues relating to waiting can have an immense beneficial effect, but to times, quality, safety, morale and cost is be sustainable, they need to be applied with a essential to ensure the work for that shift/day Lean culture. proceeds as planned.25
  25. 25. 26 Bringing Lean to Life - Making processes flow in healthcare Value stream mapping symbols Data entry Cycle time = FIFO W i Batch size = First-in First-out GP Surgery Sequence Defects = Wait/delay Inventory Transport Ambulance Pull Information Supermarket Process Step Trigger = Bursts Electronic Outside Agencies Information Buffer Data Box Push People “Go See” Load Levelling Work Cell Transfer Paper Flow
  26. 26. Acknowledgements This document has been written in partnership by: Lisa Smith National Improvement Lead Email: Zoe Smith National Improvement Lead Email: zoe.smith@improvement.nhs.uk27
  27. 27. NHSCANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart’ lung and stroke services.Delivering tomorrow’s NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NBimprovement agenda Telephone: 0116 222 5113 | Fax: 0116 222 5101for the NHS ©NHS Improvement 2010 | All Rights Reserved | May 2010