Transcript Improving Services & Releasing Capacity in Primary Care Applying Lean & Existing Technologies Iain Macfarlane (Atos Origin) & John Crawford (IBM) SCIMP Conference_03

Improving Services & Releasing Capacity in Primary Care
Applying Lean & Existing Technologies
Iain Macfarlane (Atos Origin) & John Crawford (IBM)
SCIMP Conference_03 November 2009
The focus for today’s discussion
By the end of our discussion we aim to have demonstrated that:
 Lean-led improvement can make an impact in the NHS, including in Primary and
Community Care, across all areas of quality:






Safe
Effective
Timely
Efficient
Equitable
Patient Centred
 Technology continues to evolve to support different models of care:
 Patient Centred Medical Home
 Telemonitoring
 Participatory Medicine
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Lean in the NHS and in Primary Care
What is it, has it worked, and if so where?
Iain Macfarlane (Atos Origin)
SCIMP Conference_03 November 2009
The service improvement context
There are multiple improvement outcomes to be achieved – Primary Care has a vital role to play.
Policy Objectives
(What needs to change?)
Delivery Commitments
(What will be delivered and by when?)
Delivery Programmes
(How will the changes be managed?)
Scottish Government Healthier Objective
Better Health Better Care Discussion Paper
Better Health Better Care Action Plan (117 Commitments)
Health Board HEAT Targets (30 Targets)
Patient Safety
Patient Experience
Long Term Conditions
18 Week Service Redesign
Mental Health
Efficiency & Productivity
eHealth
Innovation & Transformation
Remote & Rural
Shifting The Balance Of Care
Unscheduled Care
Health Improvement
Early Years
Neurosciences
Healthcare Acquired Infection
Mutuality & Equality
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The service improvement context
There must be a focus on delivering balanced, affordable and sustainable quality improvements.
 Safe: Avoiding injuries to patients from the care
that is intended to help them
Safe
Patient
Centred
Effective
 Timely: Reducing waits and sometimes harmful
delays for both those who receive and those who
provide care
Delivering
balanced
benefits
for our
patients
Equitable
 Efficient: Avoiding waste, releasing time to care,
and reducing unnecessary expenditure
Timely
Efficient
 Effective: Improving clinical decision making,
supporting multidisciplinary care and supporting
clinical audit
 Equitable: Providing care that does not vary in
quality because of personal characteristics or
circumstances
 Patient Centred: Providing care that is
respectful of, and responsive to individual patient
preferences, needs, and values
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An appropriate blend of tools and methods is required
>> Kaizen
>> Quick Changeovers
>> 8 Types of Waste
>> Spotlight
Performance Measures
>> Maturity Matrix
>> Key Performance Indicators
Built In Quality
>> 7 Quality Tools
>> Poka Yoke
>> Demand Smoothing
>> Takt Time
>> Pull Systems
>> Kanban
>> Cell Design
>> Value Stream Mapping
>> 5 Whys
>> Pareto Analysis
Continuous Improvement
Flow
Problem Solving
Standardisation
Standardisation
>> Root Cause Analysis
>> Standard Work
>> Activity Sampling
>> 6S
>> Visual Control Management
>> Work Sequencing
>> Total Productive Maintenance
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The focus must be on continuous service improvement
 Reducing Waiting Times
Continuous
Improvement
 Enhancing Patient Safety
Performance Measures
Flow
Built In Quality
 Releasing Time To Care
 Improving Patient Experience
 Shifting the Balance of Care
 Achieving Financial Balance
Problem Solving
 Promoting a Performance Culture
Standardisation
 Accelerating and Sustaining Benefits
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Some reflections on the impact of applying Lean
Cataract Pathway
Productive Ward
Significant results have been
achieved. We are looking at
productivity gains of up to 40%,
with waiting times slashed
The impact on our people was
the most positive outcome.
Improvement is now part of our
everyday language, not lean
jargon – it’s just the method
For the first time, there is now a
validated ‘map’ of our entire
health system. The where, how
and why of major bottlenecks in
the system is better understood,
as are all the interdependencies
- Operations Director
- General Manager
- Director of Change & Innovation
Cardiology Pathway
GP Practice Improvement
I have found the Lean
approach to be the fastest way
for an individual or team to
move to a position of positive
engagement in a process of
change and get positive results
The whole experience has been
invigorating, resulting in an
excellent solution to our access
issues.
- General Manager
- Senior GP Partner
The best week I’ve had in years
of being a GP
Health Board Whole System
Knee Pain Pathway
I am so impressed this project has
achieved such potential
improvement opportunities. The
techniques were incredibly
powerful in persuading those who
needed to be brought ‘on side’ that
things had to change
- Service Manager
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>> Increasing Productivity
Business challenges
• The Trust was challenged to improve productivity by both
saving cost and increasing throughput
• The Cataract pathway was chosen as a pilot due to its high
volume
• The client particularly wanted to test lean thinking as to
whether it was the solution to their business issues
Solutions
• One day awareness training followed by a one week
workshop with the client subject matter experts, full time
• The end to end process was analysed with the team and all
waste was identified and actioned
Benefits
• 40% increase in output/productivity
• £344k increase in contribution
• 15 week reduction in throughput time end to end
The Mid Yorkshire Hospitals NHS Trust
Mid Yorkshire Health Trust controls 4 major hospitals in
the region. They have spent two years undergoing a
transformation programme and were looking for a process
to take them to the next level
50%
REDUCTION IN CATARACTS
TREATMENT TIME
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>> Reducing Waiting – Planned Care
Business challenges
• NHS South Central aimed to meet the national target that
no-one will wait longer than 18 weeks from GP referral to
hospital treatment
2009
14
WEEK RTT
REDUCTION
ACROSS ALL 27
PATHWAYS
NHS South Central
Strategic Health Authority
South Central SHA was
established in July 2006 and
comprises nine primary
Care Trusts and serves a
population of 4.5M
• The “Transforming Care” programme was set up to use
Lean Thinking to redesign patient pathways so that they
will deliver sustainable sub-18 weeks waiting time
Solutions
• We designed a tailored approach for South Central and
agreed this with the client. The programme deployed
Lean Thinking to minimise quality failures and increase
productivity
Benefits
• Redesigned Patient Pathways – 27 high priority patient
pathways redesigned to provide more efficient and
effective care
• Average 14 week reduction in RTT
• Between 30% and 70% increase in capacity
• 3000 additional outpatient appointments per annum
• Between 50% and 95% reduction in DNAs
• Cancellations on day reduced by up to 66%
• Significant patient experience and safety benefits
• Significant cost reduction, including CRES
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>> Reducing Waiting – Unscheduled Care
Business challenges
• The client was consistently failing to meet the DoH 4 hour turn around
time for 98% of patients presenting to ED. This is both a patient care
requirement and an enabler to achieve a foundation trust status
Solutions
• The first step was to gain consensus across the Trust of the reasons
for ‘breach’ and commitment Trust wide to work as a team to resolve
98%
• The ‘next future state’ for emergency care determined that:
- Blood tests would be processed within 56 minutes, mainly through
single piece flow of ED specimens, visual management and line
balancing in Pathology
- Time waiting for clinical assessment in ED could be reduced by rerolling of non-clinical ED staff, visual management, introduction of
patient ‘prep team’, and revising test guidelines
- Internal bed transfers would be streamlined by providing real time
status information, and by implementing a range of improvements
across planning, portering and cleaning
- Discharge processes would be streamlined and policies amended
Benefits
OF A&E PATIENTS
TREATED WITHIN
4 HOURS
Southampton University
Hospitals NHS trust
Southampton University Hospital
Trust (SUHT) is a non foundation
Trust reporting to the South Central
Strategic Health Authority
• At least 98% of ED patients are seen and admitted or discharged
within the required 4 hour guideline. This is a 20% improvement on
previous performance
• Flowblockers are captured and new processes improve the
performance continually
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>> Releasing Time to Care
Business challenges
• NHS Lanarkshire required sustainable savings in all
resources especially clinical time, with an initial focus
on Orthopaedics Wards
• The SGHD wanted to demonstrate how Lean
Techniques could help drive productivity improvement
(Release Time To Care)
>400
• A repeatable approach that could be applied at a ward
or unit level was required
HOURS
Solutions
RELEASED TO
CARE BY
SINGLE WARD
NHS Scotland Lanarkshire
• A 3 week assessment and support model ensured
sustainable skills transfer
• A 1 day Lean awareness training programme
• Value stream mapping, waste identification
• Immediate implementation of quick wins
Benefits
• 400+ Hours released to care by single ward
• Significant savings in medical supplies identified
• Reduction in patient transfer and admin time
• Sustained benefits and continuous improvement
Map Current State
Processes, Identify
Waste and Agree
Prioritised Next States
Ensure Equipment Is
Best Positioned To
Support Efficient and
Safe Patient Care
Ensure Space is
Utilised as Effectively
as Possible and Stock
Management is
Optimised 12
>> Improving Theatre Utilisation
Business challenges
• Increase theatre utilisation for General Surgery from
69% to 85%
• Redesign the General Surgery pathway to achieve an
18 week referral to first treatment time (RTT); the
pathway was 27 weeks
• Improve the efficiency and effectiveness of the theatre
workspace
16%
• Move to a “can do” Lean culture
Solutions
• A redesigned patient pre-assessment process
• A new theatre planning and performance management
framework
• Reorganisation of theatre workspace to make it a safer
and more productive environment
INCREASE IN
THEATRE
UTILISATION
NHS Tayside
Benefits
• Pre-assessment process: resource used more
effectively to streamline patient journey, increased
patient safety
• Planning process: capable of increasing theatre
utilisation to 85%; this will reduce theatre wait times
from 16 weeks to 8 weeks
• Sustainability: the NHS team has an improved working
knowledge of Lean methods to take this work forward
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>> Improving Response Times (Blue Light)
Business challenges
• Ambulance service failing to achieve national targets for Category A
and B response times
• No agreement between PCT Commissioners of funding required to
achieve national targets due to an unclear view of operational and
financial performance, efficiency and value for money
Solutions
• Operational and financial analysis to determine a baseline
performance and opportunities for improved efficiency
• Agreement of minimum and stretch ROI to be achieved
Benefits
• Formulation and consensus agreement of a Trust owned 2 year
programme plan to achieve national targets by:
8minutes
TO REACH CRITICAL PATIENTS
•
Delivering the workforce / increasing front-line capacity
•
Minimising costs
•
Improving processes / reducing waste activities
•
Improving infrastructure
•
Focusing and enabling people to deliver
•
Future service delivery model
• Agreement amongst PCT commissioners and Ambulance Trust on
improvement priorities and how success will be measured
• £2.5M Ambulance Trust’s efficiency improvements agreed as target
based on the evidence base presented
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>> Improving Access – Primary Care
Business challenges
• Improving the patient experience, in particular making it easier to get the
appointment they want and providing better systems and processes to
enable faster access
• Ensure a better balance between patient demand for appointments and
clinical capacity to provide them
• Absorbing the workload from a retiring Senior Partner without replacing
with additional headcount (12,000 patient practice)
• Over 30% of patients visiting the practice, do so for non value adding
prescription related activities (dropping off/picking up etc.)
• Booking systems not being used as designed
• Low staff morale and significant pressure on all staff (clinical and nonclinical) as dealing with excess demand for services
100%
OF PATIENTS GET
GP CONSULTATION IN < 48 HRS
Milton Keynes GP Surgeries
All 5 Milton Keynes surgeries are funded
partnerships, reporting to the MK PCT, with 20
GPs and a combined patient base of
approximately 40,000.
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>> Improving Access – Primary Care
“When we were first approached to be involved
in the Lean Project, we signed up as we wanted
the opportunity to help improve our
appointments systems. We were optimistic
about the process but also had a degree of
scepticism as this is an area that we as a
business had tried to improve already.
Now at the end of the project we feel it has
been very successful in many areas. The main
is that it has involved all staff along the way and
this has helped increase team work and
ownership in the practice and team morale has
improved significantly”
Solutions
• Training in Lean skills across all staff to empower “ideas for
improvement” culture
•
•
Improvement focus on access and managing demand to
available capacity – improve throughput and experience
Appointment booking process redesign so that any patient
requiring an “On the Day” appointment with a GP is asked to
leave their details. The patient’s own GP will then deliver a 5
minute telephone consultation before deciding to:
•
•
- Dr. Moore (Lead GP)
•
•
•
•
take no further action (Telephone consultation was
sufficient)
book a 5 minute follow up face to face appointment with
patient
book a 10 minute face to face appointment with the Minor
Illness Nurse
An unmanned repeat prescription desk and drop off box was
established and patients are actively encouraged to pick up all
repeat prescriptions directly from local pharmacy
A standardised process for using Choose & Book was developed
and adopted by all GPs
34 Lean “Quick Wins” completed including optimised reception
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layout
>> Improving Access – Primary Care
Results
• Improved patient access to the most appropriate clinical
resource. Results include:
•
•
•
•
•
•
•
“Instead of our patients
having to ‘fight’ at reception
to get an appointment, we
put the expert – the doctors
themselves – at the front
line.
We knew we had to do
something fairly radical and
it has undoubtedly paid off”
Rod Marshall - Practice
Manager
•
•
•
•
96% of patients are now getting an appointment on the
day they request
100% of patients can expect to consult with their GP
the same or next day
Consultation capacity has increased by 32% or one
third without the addition of new GP resource
60% of patients requesting appointments no longer
need to be seen by a GP
50% of patients only require a 5 minute telephone
consultation (vs. 10 minute face to face appointment).
17% of patients can be handled by the Minor Illness
Nurse
84% of patients prefer the new appointment booking
process
At a cost of 8 hours additional minor illness nurse
capacity, the new appointment booking process has
created 27 hours of additional GP capacity
Improved patient access to surgery services such as
appointments, test results and prescriptions
Improved matching of demand to available capacity resulting
in increased throughput and experience (patient and staff)
Improved staff morale and empowerment to propose ideas for
improvement
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Innovative Use of IT in Primary Care
Forget the future, what’s out there now?
John Crawford (IBM)
SCIMP Conference_03 November 2009
How might universal access to broadband by 2012 (Digital
Britain) reduce the pressure on primary care services?
What can we learn from ‘connected health’ initiatives in
other countries?
 Technology-driven primary care practices
 Patient Centred Medical Home
 HelloHealth & Myca
 Telemonitoring as part of long-term condition management
 Participatory Medicine - a new movement in healthcare?
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“The Patient - Centered Medical Home (PCMH)
provides care that is “accessible, continuous,
comprehensive and coordinated and delivered in the
context of family and community.” 1
Principles of PCMH
Personal Relationship
with Care Team
+
Proactive Focus
• Patient-centric
• Medical team approach
• Whole person orientation
• Coordinated and integrated care
• Emphasis on quality and safety
• Enhanced access
• Appropriate reimbursement
+
Holistic Systems
Clinical Integration
Source: (1) www.medicalhomeinfo.org/join%20statementpdf
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High - level Technology Components of a Patient - Centred
Medical Home Solution (A platform to deliver ‘connected
health’)
Collaborative Care User Interaction
Business &
Technology Services
Strategy & Change, Implementation,
Hosting, Application Management,
Help Desk
Patient Portal
Care Team Portal
Wellness & Disease Management Dashboards
Process Management
Work Flow Engine
Business Rules Manager
Information Management
Information Integration
Analysis & Discovery
Data Model Design & Deployment
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Patient - Centered Medical Home
Information
Technology
EMR/PHR/E
HR
Portals
Credentialing
Registration
Social
Networks
Basic IT
support
Scheduling
Content
Management
Incentive
Management
ePrescribing
Remote
Monitoring
Accounting
Record
Retention
Accounting
B&C
Doctors
Help Desk IT
B&C
Lockbox
Purchasing
Medical
Analytics
Training
Claims
TPA
Contacts
HR
Resourci
ng
Compliance
Download study at
www.ibm.com/healthcare/medicalhome
ACH Transfer
Wellness
Programs
CRO Clinical
Trials
Peer Reviews
Liability
Insurance
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HelloHealth and Myca
HelloHealth (http://hellohealth.com/)
A more convenient way to access and pay for primary
care services
 Online self-registration
 $35 a month membership fee
 $100 - $200 per hour for online or in-person
consultations
Myca (http://www.myca.com/)
A web-based platform to enable new forms of patient
interaction
 Electronic health record
 Practice management
 Social networking & collaboration (appointment
booking, feedback etc)
Communication from the European Commission on
Telemedicine for the benefit of Patients, Healthcare
Systems and Society - COM(2008)689
A challenge from the European Union to member states – response due March 2010
Section 2.1. Telemonitoring: a major opportunity for chronic disease management
Telemonitoring is a telemedicine service aimed at monitoring the health status of patients at a distance.
Data can be collected either automatically through personal health monitoring devices or through active
patient collaboration (e.g. by entering weight or daily blood sugar level measurements into a web-based
tool). Data, once processed and shared with relevant health professionals, may be used to optimise the
patient's monitoring and treatment protocols. Telemonitoring is particularly useful in the case of
individuals with chronic illnesses (such as diabetes or chronic heart failure). Many of these
patients - who are often elderly people - need regular monitoring because of the prolonged duration of
their disease, the nature of their health condition and the drugs that they are using.
Focus areas:
 Building confidence in and acceptance of telemedicine services
 Bringing legal clarity
 Solving technical issues and facilitating market development
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Telemonitoring - Continua Health Alliance and IBM’s role
Continua Health Alliance is a non-profit, open
industry coalition of healthcare and technology
companies collaborating to improve the quality
of personal healthcare.
IBM joined when Continua first launched in June
2006 (20 founding members).
Now > 175 members covering spectrum of
healthcare solutions.
Members cover entire spectrum of everything to
do with personal healthcare.
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Chronic Disease Management with Telemonitoring
(Diabetes demo, Boston, October 2009 - using Continua Health Alliance
standards)
Remote
Monitoring
Server
Device
Manager
Devices
PAN
Provider
Applications
PHR
WAN
Wired Glucose Meter
EMR
Medication Pack
xHR
Disease
Management
Wired Weighing
Scale
Devices to collect
personal health data
regarding diabetes
·
·
·
Collect device data
Reliable Messaging
Identification
IBM Websphere Sensor
Events
·
·
·
Aggregate data from large
number of devices
Perform event processing
Map into Provider
application
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Participatory Medicine – a new movement in healthcare?
Society for Participatory Medicine – (http://participatorymedicine.org/)
 ‘Bringing together e-patients & healthcare professionals’
 ‘A cooperative model of health care that encourages and expects active involvement by
all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to
the full continuum of care’.
E-Patients – (http://e-patients.net/)
 ‘Because health professionals can’t do it alone’
 A blog and a patient pressure group for change
Journal of Participatory Medicine – (http://jopm.org/index.php/jpm)
 A new peer reviewed, open-access journal launched 22 October 2009
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Evolution of Technology – Enabled Participatory
Medicine
The imagined future (1924)
The real future? (2009)
Electronic Health Coach
On-line Personal Health Portal
with health information, personalised
care plans, PHR with medical device input,
social networking, collaboration tools
Remote Consultations
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The Limits of Participatory Medicine?
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Question & Answer Session
Iain Macfarlane
John Crawford
Atos Origin
IBM
m +44 (0) 7733 312779
[email protected]
m +44 (0) 7802 916370
[email protected]