by Ben Gowland of Mayday shown at the 3rd Lean Healthcare Forum 2006 ran by the Lean Enterprise Academy

1. Implementing Lean at
Mayday
Ben Gowland
Director of Service Improvement and Quality
Chris Bryant
Assistant Director of Service Improvement

2. Mayday
2900 employees
£160M turnover
700 beds
130,000 A&E attendances
Key organisational issue - financial deficit
05/06 - £5.8M end of year deficit
In ‘recovery’ for over 12 months
Turnaround Director in post

3. Lean in the context of financial
recovery
1. Gaining credibility
2. Lean techniques that work
3. Positioning Lean
4. Implementing Lean
5. Moving forward: value and income

4. 1. Gaining Credibility
Bold, relevant goals – 100 beds (not optional
extra)
Built links with work already undertaken
Board approved service improvement plan
Service improvement steering group

5. 100 beds/Length of Stay:
Key Elements
Day surgery
Elective surgery
Emergency surgery
Emergency short stay
Emergency Admission

6. Length of Stay
0
50
100
150
200
250
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57
Length of stay (days)
Numberofpatients

7. Short Stay
Medicine Length of Stay
MEDICINE
4
5
6
7
8
9
Jul-04
Aug-04
Sep-04
Oct-04
Nov-04
Dec-04
Jan-05
Feb-05
Mar-05
Apr-05
May-05
Jun-05
Jul-05
Aug-05
Sep-05
Oct-05
Nov-05
Dec-05
Jan-06
Feb-06
Mar-06
Apr-06
May-06
Jun-06
Jul-06
Introduction of new
assessment and
short stay model

8. 100 beds – Length of Stay
Length of stay reduced to 4.8 days (06/07 ytd)
Day case from 52% to 81%
Admission on day of surgery in every speciality
Elective LOS 5.1 to 4.2 Days
Theatre Utilisation from 75% - 90%
Non elective surgery (excluding T&O) 6.4. to 4.9 days
T&O 14.4 to 12.0 days
Medicine 7.8 to 5.3 Days
Closed 106 Beds

9. 18 weeks and process flows:
Outpatients – 0-4 follow ups
0
5000
10000
15000
20000
25000
30000
35000
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Number of Follow Ups
NumbersofPatients

10. Process based Pathways:
Diagnosis Treatment Post
Treatment
Know / Decision made Pre-Op Surgery No or limited Follow up
Don’t Know / Decision not
made
Medication, Chronic Management,
No Treatment
Ongoing Follow Up
High Volume
(60%): Feels
Difficult
Fairly High
Volume (40%):
Feels
Achievable
Multiple visits and
tests

11. 2. Lean Techniques that work
Identifying waste
First in First Out (FIFO) and small batches
5S
Case studies!

12. Sterile Services Cut Cancelled Operations
Findings
Sterile services struggled to meet demand on their services resulting in
disruption to theatres on most days
Instruments were unavailable, lost, in transit, or otherwise elsewhere
Theatre lists were run on Saturdays to make up for lost time.
Time taken to recycle and instrument was highly unpredictable due to the
behaviour of queues in the system.
This variation encouraged inappropriate prioritisation of sets as urgent.
Mismatch in the capacity and demand rates. Every morning Sterile
Services faced a backlog from the evening before.
Shift patterns at Sterile Services were not matched to demand from
Theatres, so people were overwhelmed at times.

13. Understand the process

14. Prioritise issues/actions

15. Data collection
0
25
50
75
100
125
150
175
200
225
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Out of Theatre Into SSD Wash

16. Action Plan

17. Sterile Services Cut Cancelled Operations
Outcomes
More consistent turnaround time for sets resulted in better availability of
sets and less time lost preparing Theatres lists, improving the performance
of the wider hospital in many ways.
Almost eliminated chasing, phone calls and the use of the prioritising
system as all sets are returned with 7 hours instead of any time up to 2.5
days
Clearer procedures for pickups from Theatre prevented overloading and
missing instruments were found faster
First In First Out of Queues not Piles made the time to recycle a set
predictable
Workplace organisation (5S) of the store room in Theatres and work area in
Sterile Services resulted in less time spent looking for sets.
Sterile Services and Theatres now understand each other’s needs.
No additional resource required

18. 0
25
50
75
100
125
150
175
200
225
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Out of Theatre Into SSD Wash
Demand Before
Demand After
0
25
50
75
100
125
150
175
200
225
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Out of Theatre Into SSD Wash

19. Sterile Services Before

20. Sterile Services After

21. Lean Material Management – ITU and Theatres
Findings
Clinicians had to spend time searching for items that should be spent
treating and caring for patients. Two senior nurses spent two to three hours
each ob average per week on materials management.
It was difficult to see what was in stock as cupboards were not labelled,
storage space was not identified, and there was no designated space for
items.
The system wasn’t designed around usage levels which resulted in too
much stock of low usage items and not enough stock of highly used items.
Managers spent time signing requisitions for the same materials repeatedly.

22. Lean Material Management – ITU and Theatres
Outcomes
Simplified the ordering process – 80% stock items (from 46%)
Reduced paperwork by 35% through increasing stock items which saved up
to 6 hours per week of clinician time.
Applied Workplace Organisation (5S) in ITU stores which was sorted and
reorganised during the Rapid Improvement Event.
The implementation of the first visual stock management and 2 Bin System
within hospitals in South West London.
Reduced stock levels of certain consumables by up to 70% therefore
improving cash flow.
No additional resource required.
Staff understand how to apply Lean.
Identified clinical and managerial champions of change

23. ITU Stores Before

24. ITU Stores After

25. Visual Stock
Management
2 Bin System

26. Catering for Patients Just in Time
Findings
Meals were not taking longer than the core standard of 20 minutes from
being served to being delivered to patients.
Trolleys, full of food, lose temperature waiting in the kitchen for a porter
At ward level it was difficult to identify patient names on menu cards on
meal trays.
Complaints from patients, relatives and carers concerning food temperature.
Wards unprepared for meal time, every meal, every day, came as a
surprise!

27. Catering for Patients Just in Time
Outcomes
From 16 audits over 2 weeks, wards with designated staff achieved 100%
meals served within 20 minutes. Wards without designated staff achieved
less than 60% served within 20 minutes.
All wards have a meal distribution schedule so they know when all meals
will arrive.
The kitchen is managing food distribution so that meals remain hot for as
long as possible.
Catering Services and Ward staff now understand each others’ needs and
how they can assist each other.
Staff understand how to apply Lean
Identified clinical and managerial champions of change.

28. 3. Positioning Lean
Lean? Service Improvement? Modernisation?
Different positioning for Board and front line
teams
Link to turnaround team
Unions
Constant battle not to be given ‘solution
implementations’

29. 4. Implementing Lean
Service improvement and operations
18 Weeks – service improvement or
operational target?
What is ‘Board level support’?
Middle management resistance (no funding
for project managers)

30. 5. Moving Forward: Value and Income
Changing landscape of NHS
PbR
Patient Choice
Practice Based Commissioning
Much clearer Trust focus on income
Leads to financial requirement to define value from
patient and GP perspective
Linking patient choice unit and service improvement
Clear route away from service improvement as cost
cutting tool