Transcript Slide 1

Lean in The NHS
Mark Rahman
IST
Changing face of NHS
• Better Health , Better Care
• Higher patient expectations and active
consumers
• 18 weeks referral to treatment target
• IHI patient safety initiative
• New HEAT targets
• SR07- challenging financial arena, need to
encourage innovation
Key Features of 18 weeks Programme
• Improving on the Delivery Strategy we know
works well
• But, not more of the same waiting list initiatives
• Continuing the momentum behind redesign
programmes
• Using existing capacity to best effect
• Stage-of-treatment milestones for OP, IP/DC,
diagnostics, moving to RTT measures
• Clear and open linkage between resources and
delivery
Performance
measures
With so many targets
and indicators it was
always easy to find a
red one…
Why is Lean Relevant?
“Lean thinking is not a manufacturing
tactic or a cost reduction programme, but
a management strategy that is applicable
to all organisations because it has to do
with improving processes. All
organisations – including health care
organisations – are composed of a series
of processes, or sets of actions, intended
to create value for those who use or
depend on them (customer/patients)”
(IHI: Going Lean in Health Care 2005)
Vision for 21st Century Health Care
Secrecy is necessary
Transparency is necessary
The system reacts to
needs
Cost reduction is
sought
Needs are anticipated
Preference is given to
professional roles over
the system
Co-operation among
clinicians is a priority
Waste is continually
decreased
Institute of Medicine 2001
“The NHS is full of
committed staff who
struggle to deliver good
care within a set of broken
processes”
D Fillingham, CEO Bolton NHS Trust
Where Lean Comes From
• Developed by Toyota as the Toyota Production
System over the last 50 years
• “Lean” title applied by Dan Jones and James
Womack
• Lean now spreading throughout the Public
Sector, Service Sector and the NHS (Warwick
University Report )
• The same principles apply
Lean Principles
Jones & Womack, Lean Thinking-Revised, 2000
Establish value in the
eyes of your customers
Map the total
Customer/Provider
value stream
Make value flow
with no
interruptions
Pull what you want
when you want it
Search for
perfection with
no waste
Change must be based on
knowledge of the work
Check
Implement
the changes
Do
Understand current
performance - “what and
why” – using staff who
do the work
Plan
Identify
levers for
change &
experiment to
get to perfect
11/11/2002
28/10/2002
14/10/2002
30/09/2002
16/09/2002
02/09/2002
19/08/2002
05/08/2002
22/07/2002
08/07/2002
24/06/2002
10/06/2002
27/05/2002
13/05/2002
29/04/2002
15/04/2002
01/04/2002
Number of Admissions
Data to provide understanding
Emergency & Elective Admissions
April-November 2002
60
50
40
30
Emergency
Admissions
20
Elective
Admissions
10
0
A&E admissions 24 hour Period 02/10/06
30
28
25
21
19
20
Number of
15
Patients
5
0 0
0
Escalation
1415
1212
12
10
22
9
9
9
6
5
4
5
60
Length of stay
120
180
0 1 0 1
240
300
Typical Performance Improvement Using
Lean in Laboratories
• Mater Misericordiae University Hospital,
Dublin reduced haematology turnaround
time by 57% through redesign of
reception layout and transport
• Leeds university Hospital 62% reduction
in turnaround time for specimens
• Calderdale NHS Trust 43% reduction in
turnaround time for histology
Improve Efficiency and Service Levels
• Eliminate wasted time
– Everywhere
• Improve Service Delivery
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Be responsive to demands
Lower costs
Increase productivity
Reduce stress
Improve morale
Items FLOW in One Direction
• Items move quickly from start to finish
– Once started keep going until finished
• The benefits:
– Minimum number of cases open at one time
– Exposes problems (rocks) for attention
– Brings elapsed time closer to “hands on” time
The ideal is “One piece flow”
Focus on Blockages to Flow & NVA
•Value-Add activity
Non-Value-Add activity
Eliminating Non Value Add has a major impact on
Quality, Cost and Service Delivery
Blockages to Flow & Waste
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Wrong, incomplete, unnecessary information
Incomplete understanding of the problem
Having too many things in process at one time
Correcting other people’s errors
Waiting for
• Approvals, people, supplies
• Customer acceptance
• Other departments
– Too many departments and handovers
– People walking too far
– Etc
Causes of Flow Blockages & Waste
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–
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–
–
–
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Management measures and controls
Functional organisations, silos
Job descriptions
Changing management priorities
Poor process design
Inadequate or inappropriate training
Information system gaps & problems
Authorisation sign off
Outdated / missing procedures
etc
Seeing Blockages and Waste
Waste is anything that does not
Add Value
for the customer
If you are not Adding Value
what are you adding?
Processing waste – “stuff” we have
to do that doesn’t add value.
E.g continuing to care for patients
in hospital when they
could be discharged
Motion – unnecessary
movement e.g having
to walk up and down
the ward to obtain
appropriate supplies
Inventory
– “stuff” waiting to be
worked on
e.g patients
on a waiting list
What is Waste?
Defects – “stuff” that is not right and
needs fixing e.g a leaky tap
Injuries
– damage
to people
e.g stress
Waiting
– people
waiting for
“stuff” to arrive
e.g waiting
for a ward
round
Overproduction
– too much “stuff”
e.g. requesting unnecessary
tests and X-rays
Transportation
– moving “stuff” e.g
moving patients
from ward to ward
Lean and Value Add
• Lean is about identifying operations that
Add Value and causing them to FLOW
without interruption.
Lean Tools
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Glenday Sieve
Spaghetti Diagram
Standardisation
DCAQ
PDSA
• Links to IST Toolkit
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Demand Time (Takt)
Operator Cycle Time
Work Cell Features
Root cause & 5 Why’s
Changeover times
The Glenday Sieve
Cumulative %age of Cumulative %age of
procedures
procedure range
Green
50%
6%
• Only 6% of procedure range accounts for 50% of procedures
• Value Stream Map the “Greens and make them flow
• Create more time for the difficult cases
Glenday Sieve – Example
• Graeme Houston, Radiologist, Tayside
• 220 codes for appointments MRI RIE
– 63% of MRI throughput from 2.7% of
procedures codes (i.e. 6 codes)
• Group patients by the process they go
through (rather than clinical condition)
• Focus initially on smart process for the high
volume few [2.7%]
Spaghetti Diagram
Demand Time Calculation
Operating time per shift
Shift duration
= 480 minutes
Breaks (1x15 and 1x10 minutes) = 25 minutes
Clean up time
= 5 minutes
Net operating time per shift
= 450 minutes
Customer requirements
Monthly requirements
Daily (one shift) requirement
Customer requirement/shift
= 4,500 units
= 4,500/20 [20 days per month]
= 225 units
Demand Time
Net operating time per shift
Customer requirement/shift
= 450 = 2.0 minutes
= 225
Operator Cycle Time
• The manual work content time required for
an operator to complete one cycle of a
work process (exclusive of waiting time)
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•
•
•
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Manual operations
Walking
Loading/unloading
Measuring
Inspecting
• Shows distribution of work among operators
Demand Time / Cycle Time Balance
Demand Time = 450/225 = 2 minutes
Before RIE
After RIE
Over Demand Time
2 mins
Balanced operations
within Demand Time
Demand Time
Waiting
Op 1 Op 2 Op 3
Operator Cycle Times
Focus for RIE
effort
Op 1 Op 2 Op 3
Operator Cycle Times
Work Cell Features
• “U” shaped cell
• Output paced to Demand Time
• Small machines in the process
– Each cell self sufficient
• “One piece” flow in operation
• Operators capable of handling several
processes – go where the work is
• Standard operations on display
Right First Time Every Time
• Everything must be of acceptable quality
– Sub-standard items or information will cause
delays
Accept no defects
Make no defects
Pass no defects
• Find the root cause of defects fast
–Ask the “5 whys” and 1 “how”
Pull Process
• “Typical” Business: Push Process
WIP
Push
Bottlenecks
Space
Waiting
Imagine each Paperclip represents
an individual process within the Value Chain
Pull Process
Customer Pull
Reduced bottlenecks
Reduced work in progress
Reduced operating space
Improved quality
Reduce Changeover Times
Reduced changeover time gives increased capacity
Output
Extra
output
Lost time after
Lost time before RIE
Time
Standardisation
• Standardisation
• Current best way to do the task
– Least waste way
• Everyone must adhere to the procedure
– Until it is changed for all
• Procedures must be continuously upgraded
– Continuous search for improvement
Performance
Why Standardise?
Continuous
improvement
Business
as usual
Standard
Operating
Procedures
Time
Find Better Ways
• Capitalise on worker’s creativity
– Increase customer satisfaction
– Continuous improvement of all processes
– Identify/eliminate the “Seven Wastes”
• doing more with less
• More & better output with less resource
• Provide additional services
• Meet increased demand with same resources
NHS Tayside
Frank Haematuria
Area
Before
After
Date card received to verified report
96 days
max
14 days
Number of processes steps to book
a patient
15
3
Percentage vetted and booked in 2
days
variable
100%
Better quality of work life
Improvement
Huge
Gobsmacked
What is a 6S Programme?
A method of creating a self sustaining culture
that encourages a
£ Neat
£ Clean
£ Efficient workplace
6S Programme Reduces Wasted Time
• Finding
documents and procedures
• Training
new staff
• Tracking
keeping tabs on what is where
• Reworking
missing information, mistakes
• Waiting
for support services
• Waiting
for missing/requested documents
• Drifting
from the agreed best procedures
1) Sort
6S Programme
If in doubt throw it out, have only what is required in the area
2) Set in order
Place for everything (that is needed) & everything in its place
3) Shine and sweep
Daily clean and search for problems
4) Standardise
The State of maintaining the first three S’s and making them easier
to maintain
5) Sustain
The State of always following specified & standardised procedures
6) Safety
Begins with Top Management
Rapid Improvement Event
• Common “Kick-start” to Continuous
Improvement
• A key tool in the Lean toolkit
• Doing more with less
• Major, sustainable, business improvements - FAST
RIE Programme Timetable
RIE - 6wks
RIE - 4wks
RIE
Area
Identified
RIE – 2wks
RIE Week
Rapid
Improvement
Event
RIE + 4wks
RIE + 6wks
RIE + 12wks
or by
agreement
Review Progress
Final Presentation
(Project Closure)
Remove Blockages
Management
Commitment Meeting
• Critical success factors
• Set Scope & Goals
• Pick Team Leader
• Pick RIE Team
• Book Venue
• Advise Managers about
their attendance
• Gather data on
current performance
RIE + 2wks
Measure Improvements
Share Success
Support
• Run RIE PreMeeting
• Run RIE
Awareness visits
Team Leader to
Produce:
• Report
• Action Plan
Local Ownership
& Sustainability
Change Acceleration Message
*
QxA=E
Quality
Acceptance
* Stolen with pride from GE
Effectiveness
Scotland's Story So far…..
• NHS Tayside- 8 and counting!
• Imaging (CT, MRI)
• Endoscopy ( lower GI, upper GI, Cystoscopy)
• Plastics & dermatology
• Long term care
• 6s ward – orthopaedics & trauma
• NHS Forth Valley
• Ultrasound
• Laboratories
• Theatre ( this week!)
Scotland's Story So far…..
• NHS Lothian ( GE Healthcare)
• Endoscopy, CT , breast care plus many more
• NHS Grampian ( Ross International )
• Bank nursing
• NHS Greater Glasgow & Clyde
• CT
• NHS Ayrshire & Arran
• Laboratories ( February 2008)
Phases of Transformation
Changing Actions
1 – 2 years
(Tools)
Changing Habits
3 – 5 years
(Techniques)
Changing Values
5 – 10 years
(Developing new beliefs)
UNDERSTANDING AND EMBEDDING PRINCIPLES
CULTURE (for ever)
Further Reading
The Machine that Changed the World (1991), JP Womack, DT Jones + D
Roos
Lean Thinking: Banish Waste and Create Wealth in your Corporation
(1996), JP Womack + DT Jones
Lean Solutions (2005), JP Womack + DT Jones
Going Lean in Healthcare (2005), IHI White Paper
Breaking through to flow; banish fire fighting and increase customer
service (2006), Ian Glenday
IST – Power of Lean DVD