by David Fillingham of Bolton Hospitals NHS Trust shown at the 3rd Lean Healthcare Forum 2006 ran by the Lean Enterprise Academy

1. “What you measure is
what you get”
Evaluating the Impact of Lean
David Fillingham, Chief Executive
2nd October 2006

2. • The Bolton Lean Journey
• The importance of measurement
• Difficulties with measurement
• The Bolton “balanced scorecard”
• Some early results
• What we have learned

4. The Bolton Lean Journey
• Began on lean journey only in august 2005
• Since then 450 staff involved in Rapid
Improvement Events and double this in
awareness raising and other activities
• Significant early successes in trauma,
pathology, radiology, laundry, A&E
• Five year strategy for ‘lean’ agreed as vehicle
for organisational transformation
• Recent visit to Thedacare (USA) shows
distance yet to travel

5. The Importance of Measurement
• Understanding when a change is an
improvement
• Understanding what works and what doesn’t
• Building support and momentum for change
• Avoiding “happy dabbling by enthusiastic
amateurs”
• Focuses effort and resources

6. The Difficulties of Measurement
• Data and information illiteracy in the NHS
• Choosing the wrong measures and “gaming”
• Scientific method versus “pragmatic science”
• Translating “lean” data (e.g. steps, flow
versus touch time) and measures (Quantity,
Cost, Delivery, Morale) into an NHS ‘bottom
line’

7. Bolton’s Vision and Aims
Best Possible
Care
Joy & Pride
In work
Improved
Health

8. Best Possible
Care
Joy & Pride
In work
Improved
Health
Clinical &
Financial
Viability

9. The Bolton Balanced Scorecard
Improving
Health
Best Possible
Care
Value for
Money
Joy and
Pride in Work
Stakeholders:
Our Local Community
Stakeholders:
Patients Public
Taxpayers:
Our Local Community
Stakeholders:
Staff
Eg:
Death rates
Health promotion
Secondary prevention
Eg:
Efficiency
Productivity
Financial balance
Reduction of waste
Eg:
Staff morale
Workforce development
Eg:
Patient Safety Environment
Waiting times
Access
Patient satisfaction

10. Our Aim is to Evaluate
Improvement Efforts:-
• By project/Rapid Improvement Event
• By Value Stream (end to end)
• For Teams, Departments and
Divisions
• For the Trust as a whole

11. Lean Workstream: Orthopaedic Trauma Pathway
•Time to Theatre
reduced by 30%
•Reduced 30-day
mortality for # NoF
by 37%
•Reduced
documentation and
hand-offs from 144 to
83
•Reduced paperwork
by
42%
•Specialist care now
provided in high
dependency
environment
•Increased Ortho-
Geriatrician input
(125%)
Improved
Health
Best
Possible
Care
Value
for
Money
Joy and
Pride in
Work
•LoS reduced by 32%
•6S – value of drugs
returned £923.33,
plus 40 items of IV
fluids

12. Average Hospital LOS for Fractured Neck of Femur
April 2003 to March 2006
0.0
10.0
20.0
30.0
40.0
50.0
Apr-03
May-03
Jun-03
Jul-03
Aug-03
Sep-03
Oct-03
Nov-03
Dec-03
Jan-04
Feb-04
Mar-04
Apr-04
May-04
Jun-04
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
days
los mean UCL LCL

13. Deaths of patients with a presenting diagnosis of fractured neck of
femur 2004/5 v 2005/6
0
5
10
15
20
Apr-04M
ay-04Jun-04Jul-04Aug-04Sep-04O
ct-04Nov-04Dec-04Jan-05Feb-05M
ar-05Apr-05M
ay-05Jun-05Jul-05Aug-05Sep-05O
ct-05Nov-05Dec-05Jan-06Feb-06M
ar-06
Deaths
75 deathsin
04/05

14. Lean Workstream: 6S in A&E
•Faster response
times
•Fewer adverse
incidents
•Reduced staff
walking looking for
equipment/
documentation/
drugs etc
•Improved hand-over
for Ambulance staff
•Improved working
between A&E and
Anaesthetics staff
•Improved
confidentiality of
patient information
•Greater patient
confidence instilled
by
orderly environment
Improved
Health
Best
Possible
Care
Value
for
Money
Joy and
Pride in
Work
•Value of stock
returned £2,500

15. Lean Workstream: Pathology – Blood Sciences
•Improved response
to clinicians in
primary and
secondary care
•Staff involved in
future state planning
•6S created a better
working environment
designed for flow
•Reduction in floor
space – 50%
•Reduced man-
hours – non-value
adding steps
•Optimise usage of
new equipment in
work flow
•Routine sample
processing time
reduced from
average of 5 hours
to less than
60 minutes
•GP sample
processing reduced
from 16 hours to less
than 60 minutes
Improved
Health
Best
Possible
Care
Value
for
Money
Joy and
Pride in
Work

16. Lean Workstream: Radiology (Plain Film)
•Clearance of film
backlog and
maintenance of
throughput - reduced
clinical risk
•Control Board in
place to indicate
when staffing
capacity is stretched
•Workplace organised
for flow
•Staff involved in
planning the redesign
•Improved teamwork
amongst staff
•On-the-day reporting
of “hot” and urgent
films
•GP film reporting
reduced from 5-7
weeks to average of
10 days
Improved
Health
Best
Possible
Care
Value
for
Money
Joy and
Pride in
Work
•Reduced the time
wasted searching for,
transporting and
matching films

17. Lean Workstream: Laundry
•Involvement of team
in
redesign and service
and work environment
•More variety in
routine
tasks – multi-tasking
•Improved health and
safety
•In-house service
successful tender –
jobs
secured and
potential
for growth in
commercial work
•Improved availability
of
products to
customers
(in-house and
external)Improved
Health
Best
Possible
Care
Value
for
Money
Joy and
Pride in
Work
•Floor space required
reduced by 35%
(commercial “sort”
cell)
•Overall capacity
increase (when
redesign complete)
25% (equivalent to
£300k income)

18. Programme Managing our Lean
Benefits Realisation
Key (Copy & Paste) On target Slight Delay Off track
Measurement Headings: Best Possible Care = BPC Improving Health = IH Joy & Pride = J&P Value for Money = VFM
Cost Measures
Date A3 Event Area DGM Owner
Measurement
Heading (BPC; IH; J&P; VFM) Measure Baseline Target Actual
Cost/
Quantity/B
Target/
Reduction Actual
Running
total ££ Action/Comment
Progress
Smiley
Diagnostics
VFM Reduced floor space Reduction by 50%
Reduction by
50%
No need for new build £500K+,
actual expenditure £40K
BPC
Decrease process time
for urgent samples <1 hr <1hr <1hr
Target 25%, actual 24% All data
in process of being re - collected
BPC
Decrease process time
for routine samples
Between <1 hr - 24
hr for GP samples
<1 hr all
samples Target 25%, actual 82%
VFM
Decrease steps for
van driver 2462 steps/run 57 steps/run Reduce by 97%
VFM
Reduce steps for analysis of
routine bloods 309 57 82% Reduce by 82%
VFM/IH
Reduce NVA steps for cross
match 323 69 Reduce by 79% Planning stage
VFM
Reduce NVA steps for group
& save 95 7 Reduce by 91%
VFM
Reduce NVA steps for
antibodies 111 30 Reduce by 73%
VFM
Reduce NVA steps for stock
blood fridge 160 50 Reduce by 70%
J&P
Decrease NVA steps formini
bags plus Reduce by 25%
Reduce NVA staff time
saved
per week
Time used up in additional QC
checks
Reduce NVA process steps 10 steps 6 steps
Reduce steps travelled by
staff 257 157 Reduced by 100 steps
Measures
Oct/Nov
05
Pathology Blood
Sciences
Andrew
Cogan
David Hamer/David
Slater/Peter Gray
Dec-05 Pathology
Andrew
Cogan
David Hamer/David
Slater/Peter Gray
Feb-06 Pharmacy
Andrew
Cogan
Christine Lowe
PROGRESS UPDATE PERIOD ENDING: 31st AUGUST 2006

19. Things I wish we’d done better
and/or sooner……
• Be clear about measurable goals at outset of any
‘lean’ initiative
• Link measurement of lean to line management goals
and targets
• Be tough on people about collecting and using
appropriate data
• Recognise that a failure to deliver the expected
improvement is an opportunity for invaluable learning
• Develop a tool for measuring impact of ‘lean’ on staff
attitudes and morale

20. “In God we Trust. For
everything else, show me
the numbers”.