The Lean Midland Forum aims to: 1) Create an environment where Lean solutions in the NHS are shared and implemented. 2) Engage in a debate about the strengths and weaknesses of Lean methods in the current NHS climate. 3) Provide networking opportunities for colleagues. The agenda includes presentations on improving infection control through Lean and effective use of statistical process control in the NHS. A hot seat session is also scheduled for questions.

1. Lean Midland Forum
16 October 2013
Education Centre, Good Hope Hospital
For more information, please email help@leanlondon.org.uk or telephone 0207 824 8448

2. - 2 -
Confidential not to be used without consent
We have some broad aims of the forum
• Create the environment where Lean Solutions in the NHS
are shared, discussed and acted upon by practitioners in
the health service
• Engage in a debate about strengths and weakness of
lean/service improvement methods in the current NHS
climate
– The QIPP agenda in reducing costs across the health system
– Clinical Commissioning Groups that will redefine ‘end to end’ health systems
processes
• To network with colleagues and friends

3. - 3 -
Confidential not to be used without consent
Agenda
• 1800 - 1810 Welcome and introductions
• 1810 - 1835 “Improvement; Infection; Impossible? – Dr Mathew Diggle
(Consultant, Nottingham University Hospitals NHS Trust)
• 1835 - 1900 “How effective use of SPC in the NHS results in better
decision making” – Mike Davidge (Director, NHS Elect)
• 1900 - 1930 Hot seat session
• 1930 - 2000 Networking and drinks

5. Where?
Clinical
Microbiology
Department
No7ngham
University
Hospitals
NHS
Trust
Queens
Medical
Centre
Derby
Road
No7ngham
UK
NG7
2UH
hFp://www.nuh.nhs.uk/microbiology/

6. The
No7ngham
Experience
•
DiagnosOc
service:
24/7,
365
days
per
year
•
PopulaOon
served:
>2.5
million
(>
5
million)
•
Workload:
970,000
pa
(>
1.8
Million)
•
IsolaOon,
idenOficaOon
and
detecOon
of
•
medically
important
bacteria,
•
viruses
and
parasites.

7. And now for
something
completely
different...

8. NHS
Improvement
-­‐
EM
SHA
Microbiology
Sites

9. LEAN?

10. LEAN
Microbiology

11. What
the…………….

13. The
Path-­‐ology

14. The
Project

16. Challenges
• CollaboraOons
• ConsolidaOon
• CompeOOon
The
“C”s……….

17. The
No7ngham
Experience
Challenges
• Developing
a
lean
culture
• Find
a
champion
• Engagement
of
your
staff
• What
is
engagement?
• CommunicaOon
• While
under
a
seize
mentality

18. h:p://www.improvement.nhs.uk/documents/Microbiology_Guide.pdf

20. Thank
you!

21. How effective use of SPC in the NHS
results in better decision making
Mike Davidge

22. How
we
assess
performance:
RAG
raGngs
Sep 11 Oct11 Nov11 Dec 11 Jan12 Feb 12 Mar12 Apr12 May12 Jun12 Jul12 Aug 12
90 97 77 93 76 84 76 89 84 84 93 70
Why has performance deteriorated so badly in August 2012? What decision
are you going to make?

23. Indicator
YTD
Perf
Vs
Target
Perf
Trend
-­‐
Sustainability
(latest
3mths)
ExcepOon
Report
Produced
Perf View on
Quality
of Plan
Improve-­‐
Date
set
by
Owner/In-­‐Month
Performance
Target
Owner
Risks/Comments
and
likely
delivery
against
Improvement
date
PosiOon
vs.
last
month
&
PMO
Monitor
NoF
G G Not required Not required G CH
Patient Safety
Perf Notice Rec
Loss of Income in 2012
Improvement Date
slippage
A
&
E
-­‐
4
hours
R R G Not required G CH
Patient Safety
Perf Notice Rec
Loss of income in
2013/14
A
&
E
-­‐
CQIs
A A G A A CH
Patient Safety
Perf Notice Rec
Loss of Income in
2013/14
CQC visits
Regulatory issues
Stroke
Unit
-­‐
90%
G G Not required Not required R CH
Patient Safety
Increased risk of perf
measures. Feb has met
target – and sustained
HSMR
G G Not required Not required Not Req’d RC-H
CDiff
A A G Not required R CO
Patient Safety
CQC/Regulatory Issues
Performance Overview – April 2013

24. Follow
up
metric
Monito
r Q1
Return
Monito
r Q2
Return
Dec
Monito
r Q3
Return
Jan Feb RAG
YTD
Target
YTD
Actual
YTD
RAG &
12
month
Trend
l 95% 96.7% Ç96.7% 96.2% 97.4% 96.5% 96.9% 97.6%
Indicator
description
2012 /13
Annual/Year
end Target
Receiving follow up within
7 days of discharge (all
discharges)
95%
What you get presented with
What do you decide to do?

25. A&E
performance
Area
• Minor
aFendances
• Thursdays
• Q3
2004/05
Performance
• 96.9%
seen
and
discharged
within
4
hours
Verdict: Ok?

26. How long
does it take
you to get to
work? How many patients need a
home visit today?
How long does it take
to take a patients
BP?
In
the
real
world,
everything
varies....

27. What’s
a
person’s
normal
body
temperature?

28. “Data contains both signal and
noise. To be able to extract
information, one must separate
the signal from the noise within
the data.”
Walter Shewhart

29. There
are
two
types
of
variaGon
While
every
process
displays
variaOon:
• some
processes
display
controlled
variaOon
(common
cause)
– Stable
pa)ern
of
varia0on
=
noise
– constant
causes/
“chance”
• while
others
display
uncontrolled
variaOon
– pa)ern
changes
over
0me
=
signal
– special
cause
varia0on/“assignable”
cause
eg
infec0on
or
hypothermia
We should display data in a way that shows which is present

30. Control charts
• Plot data in time order
• Calculate and display mean as a line and
control limits as lines
• Analyse chart by studying how values fall
around mean and between control limits
Control
charts

31. SPC
chart
of
RAG
score
Sep 11 Oct11 Nov11 Dec 11 Jan12 Feb 12 Mar12 Apr12 May12 Jun12 Jul12 Aug 12
90 97 77 93 76 84 76 89 84 84 93 70

32. Indicator
YTD
Perf
Vs
Target
Perf
Trend
-­‐
Sustainability
(latest
3mths)
ExcepOon
Report
Produced
Perf View on
Quality
of Plan
Improve-­‐
Date
set
by
Owner/In-­‐Month
Performance
Target
Owner
Risks/Comments
and
likely
delivery
against
Improvement
date
PosiOon
vs.
last
month
&
PMO
Monitor
NoF
G G Not required Not required G CH
Patient Safety
Perf Notice Rec
Loss of Income in 2012
Improvement Date
slippage
A
&
E
-­‐
4
hours
R R G Not required G CH
Patient Safety
Perf Notice Rec
Loss of income in
2013/14
A
&
E
-­‐
CQIs
A A G A A CH
Patient Safety
Perf Notice Rec
Loss of Income in
2013/14
CQC visits
Regulatory issues
Stroke
Unit
-­‐
90%
G G Not required Not required R CH
Patient Safety
Increased risk of perf
measures. Feb has met
target – and sustained
HSMR
G G Not required Not required Not Req’d RC-H
CDiff
A A G Not required R CO
Patient Safety
CQC/Regulatory Issues
Performance Overview – April 2013

33. Not
so
peachy
Apr2012
May2012
Jun2012
Jul2012
Aug2012
Sep2012
Oct2012
Nov2012
Dec2012
Jan2013
Feb2013
Mar2013
Apr2013
Month
50
60
70
80
90
100
percentage % patients achieving 90% time in stroke unit
BaseLine
Verdict
Stable within
limits
(66 -100)
Not Capable of
achieving
target

34. Apr2012
May2012
Jun2012
Jul2012
Aug2012
Sep2012
Oct2012
Nov2012
Dec2012
Jan2013
Feb2013
Months
90
92
94
96
98
100
102
104
Percent Receiving follow up within 7 days of discharge
BaseLine
Verdict
Stable within
limits
(93 -100)
Not Capable of
achieving
target
Monito
r Q1
Return
Monito
r Q2
Return
Dec
Monito
r Q3
Return
Jan Feb RAG
YTD
Target
YTD
Actual
YTD
RAG &
12
month
Trend
l 95% 96.7% Ç96.7% 96.2% 97.4% 96.5% 96.9% 97.6%
Indicator
description
2012 /13
Annual/Year
end Target
Receiving follow up within
7 days of discharge (all
discharges)
95%

35. A&E
–
the
real
situaGon
0
200
400
600
800
1000
1200
0
6
/0
1
0
0
:1
2
0
6
/0
1
1
2
:1
2
0
6
/0
1
1
8
:3
6
1
3
/0
1
1
0
:1
8
1
3
/0
1
1
5
:5
1
1
3
/0
1
2
3
:0
2
2
0
/0
1
1
1
:1
0
2
0
/0
1
1
6
:4
7
2
7
/0
1
0
0
:0
2
2
7
/0
1
1
2
:2
2
2
7
/0
1
1
8
:4
4
0
3
/0
2
0
9
:1
1
0
3
/0
2
1
5
:3
0
0
3
/0
2
2
2
:4
8
1
0
/0
2
1
1
:4
6
1
0
/0
2
1
7
:2
0
1
7
/0
2
0
3
:0
8
1
7
/0
2
1
3
:4
6
1
7
/0
2
1
8
:3
1
2
4
/0
2
0
4
:3
7
2
4
/0
2
1
4
:0
8
2
4
/0
2
2
1
:2
9
0
3
/0
3
1
2
:1
7
0
3
/0
3
1
9
:2
6
1
0
/0
3
0
9
:3
3
1
0
/0
3
1
6
:0
1
1
0
/0
3
2
2
:3
9
1
7
/0
3
1
1
:1
5
1
7
/0
3
1
6
:3
3
1
7
/0
3
2
1
:3
1
2
4
/0
3
1
2
:0
9
2
4
/0
3
1
8
:4
3
3
1
/0
3
0
7
:5
7
3
1
/0
3
1
5
:0
0
Time in A&E department Jan-Mar 2005
Infirmary : Minor attendance : Thursday
Time in
Dept
Average
(01:50)
LCL
(00:00)
UCL
(05:05)
4 hr target

36. The
two
types
of
mistake
Mistake
One
• InterpreOng
the
rouOne
variaOon
of
noise
as
if
it
amounted
to
a
signal
of
a
change
in
the
underlying
process,
thereby
sounding
a
false
alarm.
[false
posiOve]
Mistake
Two
• Thinking
that
a
signal
of
a
change
in
the
underlying
process
is
merely
the
noise
of
rouOne
variaOon,
thereby
missing
a
signal.
[false
negaOve]

37. SPC
–
do
it
right
• Use
the
correct
way
of
determining
the
measure
of
variaOon
• Use
the
correct
mulOple
of
variaOon
to
derive
the
control
limits
• Don’t
exclude
data
points
just
because
they’re
‘odd’

38. Using
the
wrong
calculaGon
0
100
200
300
400
500
600
700
800
0
2
A
p
r
1
2
3
0
A
p
r
1
2
2
8
M
a
y
1
2
2
5
Ju
n
1
2
2
3
Ju
l1
2
2
0
A
u
g
1
2
1
7
S
e
p
1
2
1
5
O
ct
1
2
1
2
N
o
v
1
2
1
0
D
e
c
1
2
0
7
Ja
n
1
3
0
4
F
e
b
1
3
0
4
M
a
r
1
3
N
u
m
b
e
r
A&E 4 hr breaches
52 weeks from 2 April 2012
St Elsewhere's Hospital
A&E 4 hr breaches Average (497.9) Lower limit (340.8) Upper limit (655.0)
Shaded area
using standard
deviation
statistic gives
lower limit if 272
and upper limit
of 723

39. Using
the
wrong
limits
01Apr2012
01May2012
01Jun2012
01Jul2012
01Aug2012
01Sep2012
01Oct2012
01Nov2012
01Dec2012
01Jan2013
01Feb2013
Months
0
10
20
30
40
50
60
70
80
Number Delayed transfers of care
BaseLine
2 sigma
limits

40. IniGal
chart
with
special
causes
flagged
01/10/2012
08/10/2012
15/10/2012
22/10/2012
29/10/2012
05/11/2012
12/11/2012
19/11/2012
26/11/2012
03/12/2012
10/12/2012
17/12/2012
24/12/2012
Week
0
50
100
150
200
250
300
350
400
Hours Weekly referral hours into MRI
BaseLine
Average and
limits driven by 2
final data points
that are very
low. Should we
exclude them?

41. Modified
chart
01/10/2012
08/10/2012
15/10/2012
22/10/2012
29/10/2012
05/11/2012
12/11/2012
19/11/2012
26/11/2012
03/12/2012
10/12/2012
17/12/2012
24/12/2012
Week
0
50
100
150
200
250
300
350
400
Hours Weekly referral hours into MRI
BaseLine

42. A
proper
RAG
status
• Green
=
stable
and
capable
i.e.
no
special
causes
and
process
limits
within
specificaOon
limits
– Ac0on:
masterly
inac0vity
and
catlike
observa0on
• Amber
=
unstable
i.e.
special
causes
– Ac0on:
inves0gate
special
causes,
diagnose
and
treat
with
a
countermeasure.
• Red
=
stable
but
incapable
i.e.
no
special
causes
and
process
limits
outside
specificaOon
limits
– Ac0on:
improve
or
redesign
depending
on
level
of
experience/
skill

43. My
final
slide:
Shipman
Source: Malcolm Gall in The Times, 1
February 2000
Taken from “Bristol, Shipman and clinical
governance: Shewhart’s forgotten lessons”
Mohammed et all, The Lancet, volume 357,
2001

44. • Focus on Value from a Customer (Patient) point of view on every step of
process
• Obsession on removing waste within the ‘whole system’
• Bottom up approach in identifying value and waste – assumption that
much of waste and value is hidden
• A true lean system would “flow” and need little command and control
Recap – What is Lean?

45. - 45 -
Confidential not to be used without consent
What’s Next?
• Today’s presentation and feedback survey sent out by email within
72 hours
• The Next Lean Midland Forum will be held on 26 February 2014.
– Register at www.leanmidland.org.uk
– We will send out reminders to all participants from today
– We have a Lean London Forum on 5 March 2014 taking place in London. Register at
www.leanlondon.org.uk
– If you’d like to take up one of our presentation slots, please do let us know. We are
keen to hear from Community Trust and GP Groups
• Find us on and - LeanNHS

46. - 46 -
Confidential not to be used without consent
Past Presentations at the Forum
http://kinetik.uk.com/pdf/Lean
London.pdf
1. The 'Leaning' of Bedford Hospital - the story so far, Susan
Whittaker, Bedford Hospital
2. Future Developments in Lean, Rob Worth, Kinetik Solutions
3. Transformation of Camberwell Sexual Health Centre, Rachel
Paxford-Jenkins, Camberwell Sexual Heath Centre
4. Building Lean Expertise, Daniel McDonald, Lean Executives
5. Use of Data in Lean Projects, Andrew Castle
http://kinetik.uk.com/pdf/
Lean_London_Sep_09_web.pdf
1. Radiology Lean Review - The Journey has begun, Carol Darnell,
Bedford Hospital Trust
2. Recruiting for the Lean & Service Transformation, Daniel
McDonald, Lean Executives
3. Lean and Systems Thinking, Rob Worth, Kinetik Solutions
4. Don't water your weeds - starting afresh with Lean, Ian Greddor,
Cyril Swett
http://kinetik.uk.com/pdf/Lean
London_Feb.pdf
1. Challenges in Implementing Lean - A Clinical Perspective, Dr
Ahmed Chekairi, Whittington Hospital
2. A Better Definition of 'Value' in Lean, Ketan Varia, Kinetik Solutions
3. Lean in the pharmaceutical drugs supply process, Niall Ferguson,
Milton Keynes Hospital

47. - 47 -
Confidential not to be used without consent
Past Presentations at the Forum
http://kinetik.uk.com/pdf/
leanlondon_sep11.pdf
1. Transforming Surgical Productivity, Christopher Kennedy, Guy's
& St Thomas NHS Foundation Trust
2. Transforming Treatment Rooms, Dr Rebecca Hewitson, The
Whittington Hospital NHS Trust
http://kinetik.uk.com/pdf/
leanlondon_mar12_presentation.
pdf
1. The Path-ology to Lean Thinking - Dr Mathew Diggle,
Nottingham Hospital Trust & Suzanne Horobin, NHS Improvement -
Diagnostics
2. Pre-Operative Health Evaluation - Engagement with Primary
Care, Dr Ahmed Chekairi, Whittington Hospital
http://kinetik.uk.com/pdf/
leanmidland0712.pdf
1. How many appointments do we need to make?, Kate Silvester,
South Warwickshire NHS Trust
2. The Path-ology to Lean Thinking - Dr Mathew Diggle,
Nottingham Hospital Trust

48. - 48 -
Confidential not to be used without consent
Past Presentations at the Forum
http://kinetik.uk.com/pdf/
leanlondon_sep12.pdf
1. Sleek & Slim Hearing for Children - Dr Sebastian Hendrick, Barnet
& Chase Farm Hospital
2. Developing value through transformation of care - What does it
take?, Peter Lachman, Great Ormond Hospital
http://kinetik.uk.com/pdf/
kinetik_dec_12.pdf
1. Network Improvement Services in Tower Hamlets, Florence Cantle,
Tower Hamlets NHS Trust
2. Using improvement science in Ambulatory Care, Simon Dodds,
Heart of England Trust
http://kinetik.uk.com/pdf/Lean
Midland_June11.pdf
1. Lean Transformation at Bedford Hospital, Susan Whittaker, Bedford
Hospital
2. How do drive change by understanding patient value?, Ketan Varia,
Kinetik Solutions
3. Global Lean Knowledge: The Effects of Culture, Maria Gilgeous,
Kinetik Solutions
http://kinetik.uk.com/pdf/
leanlondon_19sep13.pdf
1. Takeing a new look at your service - "Lean" a process approach to
change, Pauline Connor, North Middlesex University Hospital Trust
2. "Improvement; Infestion; Impossible?", Dr Mathew Diggle,
Nottingham University Hospital Trust

49. - 49 -
Confidential not to be used without consent
Big Thanks To Our Presenters
Dr Mathew Diggle
Mr Mike Davidge
..and to you all for attending

50. - 50 -
Confidential not to be used without consent
Thanks to Our Sponsors
Assisting with Lean Transformations
in the health sector and beyond
www.kinetik.uk.com