Creating a vision of Lean Healthcare at Bolton
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The document discusses creating a vision for lean healthcare at Bolton Hospital in the UK. It describes the current state of hospitals as chaotic with queues and inefficient processes. The speaker outlines a vision for lean healthcare with smoothly designed processes, physical layouts to support flow, and evidence-based practices for patients. Bolton Hospital began its lean journey in 2005 with over 850 staff engaged in improvement events, resulting in initial successes like reduced pathology processing times. The hospital aims to redesign all patient flows using tools like standard work, visual controls, and daily management. This will help transform healthcare from a broken system to one with improved outcomes, experiences and efficiency.
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Creating a vision of Lean Healthcare at Bolton
- 1. Global Lean Healthcare Conference 25-26th June 2007 Creating a Vision of Lean Healthcare at Bolton David Fillingham, CBE Chief Executive
- 4. • The state our hospitals are in today • What would lean healthcare be like? • Making it happen – Building the vision – Redesigning patient journeys – Changing the physical layout – Creating new behaviours • Reflections and lessons
- 5. Today’s hospitals……. • Wards and clinics are untidy and chaotic • Queues are everywhere • Processes are unplanned and of byzantine complexity • Professional tribes and departmental silos abound • Physical layouts and “monoliths” prevent a smooth flow of work
- 6. The Fantasy Patient Journey Information Clinical assessment Investi- gations Clinical decision Admi -ssion Treat- ment Dis- charge Patients Information
- 7. The Real Patient Journey
- 11. Patients suffer:- • Confusion and anxiety • Delays and cancellations • Harm • A sense of helplessness Staff suffer:- Taxpayers / Funders suffer:- Today’s Healthcare • Frustration and stress • Low morale • High sickness absence • Waste and inefficiency • A “bottomless pit”
- 12. What would Lean Healthcare be like? • Processes purposely designed and managed • A smooth flow of patients, staff and information • A physical layout to support flow and make problems visible • Evidence based practice for every single patient • Every staff member a problem solver every single day
- 13. Imagine a hospital with……. • No needless deaths • No needless harm • No delays • No waste • No feelings of helplessness (Don Berwick)
- 14. Making it Happen in Bolton Hospital • Building the vision of a lean hospital • Patient journey redesign • Changing the physical layout • Creating new behaviours • Making it a daily activity
- 16. The beginnings of a lean journey…… • Began in August 2005 • 856 (525 individuals) staff actively engaged in 85 Rapid Improvements Events • Early results promising - Pathology: 40% floor space saving Blood Sciences processing time cut from hours to minutes - Laundry: Capacity increase of 25% - Cataract Surgery: throughput increased by 30% - Trauma: 36% mortality reduction; 33% reduction in length of stay • We now know just how much we don’t know!
- 17. Bolton Hospital – Pen Picture • Based in NW England close to Manchester • 3,200 staff • Busy emergency hospital:- – 100,000 ER attendances – 59,524 IP/DC admissions p.a. • 692 beds • General medicine, general surgery, paediatrics, obstetrics, orthopaedics • £150million turnover
- 18. A Vision of a Lean Hospital
- 19. Our “EVSA” (Enterprise Wide Valuestream Analysis Event) • Full week event for 50 senior Directors and Clinical Leaders • Carried out after one year of ‘trying stuff out’ • Current state: strategic context and hands on mapping • Future state • How to get there
- 22. Hierarchy of Value Streams at Bolton Hospitals Medical Conditions Simple Complex Condition Groups
- 23. 8 Step High Level Flow:- Implement Care Plan Follow Up And Review History & Examination Differential Diagnosis Investigations Analyse Results Definitive Diagnosis Develop Care Plan
- 24. • Simple: one condition; likely to require only one medical discipline; little need for interagency working: likely to be day case or relatively short stay. • Complex complicating co-morbidities; needs multidisciplinary team; demands close interagency co-operation; likely to require a longer hospital stay and after care
- 25. Condition Groups SIMPLE • Heart and Chest • First Contact • Musculoskeletal • Gastro • Eyes, Head & Neck • Simple Surgery • Women’s Care • Children • Skin COMPLEX • Adult • Women • Children
- 26. Conditions • We used Runners Repeaters and Strangers to identify commonly occurring conditions and outcomes analysis to spot high risk groups • Examples include: Cataracts, Joint Replacements, Stroke • For each condition we are mapping the patient journey and developing a plan for improvement
- 27. Emerging Thinking about the Hospital’s Future State • Put senior decision makers and diagnostics at front end of process • Stream quickly into simple and complex • Monitor closely and have ability to switch between streams • Create condition based work teams to put ‘simple’ patients into flow:- – Reduce batch sizes; identify flow stoppers; relocate diagnostics into the flow; create standard work and enforce it; establish pull systems; set up visual management • For complex patients – create “one decision flow”; strengthen multidisciplinary team working; intensify support; co-locate where feasible • Re-think “clinical effectiveness” to be the basis for standard work
- 28. Lean Tools/Principles Move away from batching, Backlog and Queues. Reduce Variation & Complexity Clear to See: Straighten Sweep & Clean Safety Standardise Sustain Create signals To pull patients. Obvious when Something empty 1 PIECE FLOW STANDARD WORK 6 S PULL SYSTEMS “ability to see the process” VISUAL MANAGEMENT:
- 29. Patient Journey Redesign Our aim is to redesign all of the patient flows through the Hospital. This will take time!
- 30. We started with Trauma… • 9 month programme • 1 week Event (VSA) to create Vision and Plan • 6 week long events (RIEs) and many JDIs • Significant results – 36% mortality reduction – 33% length of stay reduction – 42% paperwork reduction
- 31. Value Stream Analysis: Current State for Trauma
- 32. Value Stream Analysis: Current State for Trauma • Spaghetti Diagram • We walk miles when we shouldn’t have to • Things are not where they are needed (if they are even there at all) • We have to look for the sick patients and they can be anywhere
- 33. Value Stream Analysis: Current State for Trauma • Hand Off Chart • 197 handoffs to discharge a patient! • Duplication • Frustration • Huge source of potential error
- 34. Action! Creating the TSU
- 35. Standard work layout for each bed space and the admin area Greatly reduced documentation in standard format and sequence Floor markings for location of key equipment to aid flow
- 36. Our next priorities are • Cataracts • Joint Replacements • Stroke • Acute abdomens Mainly simple Mainly complex
- 38. Pathology Before & During photos
- 41. Physical Layout • Declutter and prepare for flow with 5S • Co-locate linked processes • Creation of “complex care” wards with intensified multidisciplinary team support • Decentralisation and downsizing of diagnostics • Development of Visual Management approaches
- 42. Creating New Behaviours “It’s easier to act yourself in to a new way of thinking than it is to think yourself in to a new way of acting”
- 43. • Engaging clinical staff • The power of the rapid improvement event • Learning and development framework • Making BICS a daily activity • Developing a “brand”: the Bolton Improving Care system (BICS)
- 45. Pathology Lean Management System • Standard work – For workstations – For leaders • Visual controls – Production control boards – Metrics – Workstations • Daily accountability processes – Daily meetings of work groups – Daily meetings of supervisors • Training – Awareness – Tools • Discipline – Persistence & determination
- 46. From this……
- 47. …..To this
- 48. Bolton Pathology Blood Sciences staff
- 49. Pathology – Bottom Line • 40% Floor space saving • Turnaround times cut • £300K (10%) more income with 4.5 (2%) fewer staff
- 50. Reflections and Lessons (1) • Healthcare is an underperforming industry. We are failing our patients, staff and funders • Our hospitals are full of committed and skilled staff who are struggling to deliver good care within a set of broken processes • A lean mindset and methods offer the hope of transformational improvements
- 51. Reflections and Lessons (2) • We need to:- – Develop our vision for a lean healthcare system – Radically redesign the physical environment and the flows of patients, staff and information … “big leaps” – Embed continuous improvement in the daily work of healthcare staff … “thousands of small steps” – Have courage, persistence and determination … … it will be a long journey