Transcript Slide 1

ACC Spring Conference 2008 at the
Merseyside Maritime Museum
Managing Lean Organisations
David Fillingham, CBE
Chief Executive
31st March 2008
• The state our hospitals are in today
• How can “lean” help?
• Making it happen in Bolton Hospital
– Redesigning patient journeys
– Changing physical layouts and workflows
– Making it a daily activity
• The Lean Blood Sciences Laboratory
• Reflections and lessons
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 “monuments” prevent a
smooth flow of work
The Fantasy Patient Journey
Information
Clinical
assessment
Investigations
Clinical
decision
Patients
Information
Admission
Treatment
Discharge
The Real Patient Journey
Uncoordinated
Transportation Activity Waiting
Waiting
Transportation
Transportation
Inappropriate
Processing
Uncoordinated
Activity
Stock
Transportation/
Motion
Uncoordinated
Activity
Mistakes
Transportation/
Motion
Uncoordinated
Activity
Inappropriate
Processing
Uncoordinated
Activity
Transportation/
Motion
Waiting
Uncoordinated
Activity
Waiting
Waiting
Waiting
Waiting
Waiting
Waiting
Waiting
Mistakes
Mistakes
Transportation/
Motion
Uncoordinated
Activity
Stock
Today’s Healthcare
Patients suffer:-
Staff suffer:-
Taxpayers /
Funders suffer:-
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Confusion and anxiety
Delays and cancellations
Harm
A sense of helplessness
• Frustration and stress
• Low morale
• High sickness absence
• Waste and inefficiency
• A “bottomless pit”
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
• A focus on eliminating waste and increasing
value
• Every staff member a problem solver every
single day
What is “Lean”?
What Lean is Not
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Just about manufacturing
The latest management fad
Simply a set of tools
“Lean and Mean”
What Lean is
• A way of thinking and organising
• Pioneered by Toyota and developed over
60 years
• The predominant method of quality and
productivity improvement in private sector
companies
• Spreading rapidly into services and the
public sector
• Focus on reducing waste and increasing
value
Problem solving in a lean
organisation
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Go to the actual workplace
Involve frontline staff
Use a scientific approach
Gather data
Plan, Do, Check, Adjust
Resolve the root causes
Making it Happen in
Bolton Hospital
• Redesigning Patient journeys
• Changing physical layouts and
workflows
• Making it a daily activity
The beginnings of a lean journey……
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Began in August 2005
1369 (762 individuals) staff actively engaged in 134 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: 50% mortality reduction; 33% reduction in length of stay
We now know just how much we don’t know!
It is easier to act
yourself in to a new
way of thinking, than it
is to think yourself into
a new way of acting
Redesigning Patient
Journey
Our aim is to redesign
all of the patient flows
through the Hospital.
This will take time!
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
– 50% mortality reduction
– 33% length of stay reduction
– 42% paperwork reduction
Value Stream Analysis:
Current State for Trauma
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
Value Stream Analysis:
Current State for Trauma
• Hand Off Chart
• 197 handoffs to
discharge a
patient!
• Duplication
• Frustration
• Huge source of
potential error
Rapid Improvement Events
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A&E and Radiology
Trauma Stabilisation Unit
Patient Flow
Emergency Theatre Operating
The Multi Disciplinary Team
Discharge Processes
Action! Creating the TSU
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
Changing the Physical
Layout and Workflows
Pathology
Before & During photos
Before
Redesign
• Each lab (discipline) wanted its own blood
sample and request form
• So a patient who required testing in
Haematology, Chemistry, Immunology &
Microbiology had to supply a blood sample and
a form for each different lab
• And although some disciplines used the same
machines to test the blood samples – they were
housed in different labs (in different buildings)
• Samples waited in large batches for processing
resulting in queues and delays
approach
• Using one piece flow, move the samples to
the appropriate test machine as soon as
possible after arrival
• Locate all the analyzers together and lay
them out to improve flow
• The samples are tested by competent
scientists (from any discipline)
• Work to reduce batch sizes and to improve
processes continually
Designed for Flow
Patient benefits
• Reduction in the number of sample bottles
required per patient (and therefore the
amount of blood taken)
– Hospital sample bottles reduced by 8.3%.
– GP sample bottles reduced by 25.2%.
• Reduction in time taken for test results to
be available to patients’ care team.
Clinician benefits
• Reduction in the time taken filling in request
forms – because only one form is now required
– Wards - reduced by 53.5%.
• Improvement in turnaround times for a whole
range of lab tests, e.g.
– Thyroid test
- 3x faster.
– Haematinics
- 4x faster.
– C-reactive Protein - 10x faster.
• These figures will improve as the staffing
structure and working systems evolve.
Staff benefits
• Reduction in number of request cards to
be input into the Pathology computer.
• Reduction in travel distance by 80%.
• Reduced bottle necks – less stress.
• More time for value adding work due to
reduction in inefficient processes.
• Change in job roles will give staff
opportunities to develop new services.
Laboratory/Trust benefits
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Strategic positioning of analysers and removal of ‘wasteful’ practices
has enabled us to
– Reduce distances travelled by staff & samples by 80%.
– Reduce lab space required by 50%.
Cost savings
– Reduction in number of analysers due to strategic positioning and
transferring tests
• £24,000 recurrent saving per annum.
– Reduction in cost of request forms (fewer used / new design)
• GP request form costs down by 30%.
• Ward request form costs down by 50%.
– Reduction in cost of sample bottles (fewer used)
• GP sample bottle costs down by 25%.
• Ward sample bottle costs down by 10%
Staff are more engaged and motivated and new leaders have emerged
Making
A Daily Activity
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
Standard Work
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Standard work is the current best
practice, and, as such, forms the
baseline for continuous improvement
Same job, same way, every time taking
into account
– Takt time
– Standard in-process inventory
– Standard work sequence
STANDARD WORK SHEET
Performed by:
Stage:
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Work Steps – Photographs, Key Points, any other relevant info
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Q = Quality Check S = Standard WIP
C = Caution (Safety/Risk)
H
Time
Visual Controls
• Workstations
• Production control boards
– Simple graphical representations of targets &
progress
– Process Continuous Improvement sheets
– Audit results
Visual Management
Visual Management
Daily Accountability
Processes
• Daily morning meetings
– Staff teams
– Supervisor teams
• Build the foundation skills necessary for
sustainability and success
• Set goals and monitor performance
Simpler
®
Bolton Hospitals
Process Continuous Improvement
Department
Team
Process Step
Date Started
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Issue
Root Cause
Tools
1 Piece Flow
Standard Work
Visual Management - Process Instructions
6S
Pull System
Takt Time Studies
Performance Measurement - Data collection
Created by RBH CI Team. Aug 2006
NHS Trust
NHS
Review day / time
What
How
Who
When
Status
What
How
Who
When
Status
Training
• Awareness sessions
– Delivering the vision (chief exec)
– Basic introduction delivered by staff involved
– Visits to other Lean organisations
• Training
– Involvement in Lean events within Pathology & the
hospital generally
– Daily application of tools (e.g. root cause analysis)
– Joint ventures with other Lean companies
Discipline
• Persistence & determination
• Embedding in the culture
• Whole organisation approach (enterprise
VSA)
From this……
…..To this
Bolton Pathology
Blood Sciences staff
Some Dilemmas and
Challenges
• “We’re too busy to do this”
• “We’re not Japanese and we don’t make cars”
• “This touchy-feely stuff is ok, but we’ve got
targets to hit”
• “We’ll leave it up to the Service Improvement
team”
• “This will go away in a month or two when the
Chief Exec reads another new book”
What we need to do
“No Time”
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“Not Japanese” -
Create dedicated time and resources
for frontline staff (this isn’t easy!)
Reinvent lean” for the NHS context
and culture
“Not relevant”
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Link lean to our biggest priorities and
problems especially safety and
quality
“Not our job”
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“Flavour of the
month”
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Make it a fundamental line
management responsibility
Be prepared for a long haul – stay
focussed, resilient and optimistic