Lean Thinking Healthcare Ann Esain Lean Enterprise Research Centre Ken Robertson Gwent Healthcare NHS Trust

1. Lean Thinking & Healthcare Ann Esain Lean Enterprise Research Centre Ken Robertson Gwent Healthcare NHS Trust

2. Lean Enterprise Research Centre Who�s Who Ann Esain Lean Enterprise Research Centre, Cardiff Business School Research in Lean for 9 years Research in Health 3 years Gwent Healthcare Trust Other Welsh Acute Trusts Welsh Assembly Government Modernisation Agency Trained Six Sigma Black Belt

3. Lean Enterprise Research Centre Who�s Who Ken Robertson Lifetime employment in NHS Professional Clinical Background in Pathology Labs across UK Senior Management Posts Interested in Performance Improvement for last 4 years

4. Lean Enterprise Research Centre Presentation What is Lean Thinking Whole Systems An example project

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7. Lean Enterprise Research Centre From Here to There Mass Production the prevalent operations paradigm Lean Thinking a more recent operations paradigm

9. Lean Enterprise Research Centre Problems with this approach include:- Slow and Protracted Decision making due to division of the organisation Strategies became functional and created conflict Structured Management Processes meant individuals in one department would need to involve senior functional managers to usefully have discussions with an individual in another department Improvement of processes was responsibility of the technical specialists rather than those involved daily

11. Lean Enterprise Research Centre Five Lean Principles for Healthcare Specify what creates value from the customer/patients perspective Identify all steps across the whole value stream Make those actions that create value flow Only to the pace of customer/patient demand Strive for perfection by continually removing successive layers of waste

12. Lean Enterprise Research Centre Lean Thinking is�. A way of thinking An approach to the way a product is made or service is delivered A �business system� Focus on value & waste Though not just a set of tools for waste elimination Many sources: Ford, Deming, Burbidge, TQM, Toyota Appropriate to all types of organisations, in all sectors

13. Lean Enterprise Research Centre Customers and Continual Improvement The Public Sector has undergone significant change over the last 30 years These changes are influenced by Private Sector reaction to customer service, and Focuses on becoming more accountable, efficient and responsive to customer and user requirements (Ferlie, 1994).

14. Lean Enterprise Research Centre Environmental Factors

15. Lean Enterprise Research Centre So what is the problem? Long waiting times Long total journey times Big queues Patients dissatisfied Mistakes because of number of hand offs

16. Lean Enterprise Research Centre Lean Healthcare Requires A systems view of the organisation & supply chain Key process streams identified Losses in the system (quality issues) eradicated Creativity - multi disciplinary groups - challenge the current organisational & supply chain models � to a PACE Change at all levels of the organisation & supply chain in the interests of the PATIENT

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18. Lean Enterprise Research Centre Hospital A

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20. Lean Enterprise Research Centre Can Flow & Patient Satisfaction be achieved? Doing the same thing = Getting the same results The Wanless report for Wales (2003) stressed that ��..the evidence we found was of people in health and social care working very hard. But they are working within systems which militate against good performance, and where there is excellence in our view it is despite rather than because of the system.

21. Lean Enterprise Research Centre Customer satisfaction is about expectations Defects and lateness are a good start  Objective is right first time on time Measure �moments of truth� or

22. Lean Enterprise Research Centre Lean Thinking PrinciplesFOR IMPLEMENTATION Starting point:

23. Lean Enterprise Research Centre Common Themes

24. Lean Enterprise Research Centre Clinical services

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26. Lean Enterprise Research Centre EVOLUTION OF LEAN

27. Lean Enterprise Research Centre What about other approaches? Six Sigma, Theory of Constraints, etc� All promise the resolution to operational difficulties But what problem does your organisation have?

28. Lean Enterprise Research Centre Process Thinking

29. Lean Enterprise Research Centre An Example Project Echocardiography

30. Lean Enterprise Research Centre Echocardiography Service The Problem: The perception is that patients are waiting too long for inpatient and outpatient echocardiography and subsequent results once it is decided by clinicians that an investigation is necessary. There is a perceived variation in the length of wait for an echocardiography and the results. It is believed that the demand on the service results in not enough specialist echo staff employed to provide a good service. There is a need to do more with the same.

31. Lean Enterprise Research Centre Customers, Services & Stakeholders

32. Lean Enterprise Research Centre Customers Patients Referring Clinicians

33. Lean Enterprise Research Centre Customer wants��Echo� service Timeliness, flexibility Easily understood information, good communication High quality, accurate data, professional Friendliness Confidence in service Cleanliness Good facilities Car parking, appropriate transportation

34. Lean Enterprise Research Centre Mapping & Data Collection Value Stream Inpatient �Echo� Enema Service

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38. Lean Enterprise Research Centre Process Activity Map - Charts

39. Lean Enterprise Research Centre Detail from Process Activity Map Touches - 82 Stages - 52 Time � 7.2 days Distance � 1.2 km Operations - 5 Transports - 20 Inspections - 16 Delays - 11

40. Lean Enterprise Research Centre Big Delays Waiting for Echo Cumulative waits Batched requests on ward Requests wait in reception Wait in Department Wait for Report

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42. Lean Enterprise Research Centre What the Big Picture Maps show Lead time is more than 120 times the cycle time - most of the lead time is delay. The value added time is 30 minutes out of a cycle time of 85 mins. Scan Phase is 41 minutes

43. Lean Enterprise Research Centre Measurements Scheduled available time for echos per week = 3 x 5030 (wks 2,3,4) plus 4070 mins (wk 1) = 15090+4070/4 mins per week = average of 4790 mins per week. Scheduled available time for IPs = 4790/2 =2395 mins per week Reduce this to cover annual leave, sickness, study leave 2395 x 0.81 = 1940 minutes of available time for echos per week

44. Lean Enterprise Research Centre Takt time definition Takt is the German word for 'beat� or �rhythm� and represents the pace at which the patient requires the service. Takt time is the rate at which the service has to be supplied to match the patients requirements.

45. Lean Enterprise Research Centre Takt Time Takt time is the total net daily operating time divided by the total daily customer demand. Takt time is not how long it takes to perform a task. Takt time cannot be reduced or increased except by changes in production demand or available time to work.

46. Lean Enterprise Research Centre IP Echos RGH Takt Time = Scan time (both 41 min) This is too tight and does not allow for inevitable variations due to complexity & morbidity

47. Lean Enterprise Research Centre How can we improve to remove IP waits for scans Make more time available 23% of time is allocated to Admin and training (excl. trainee time & allowance for study leave) Is this amount of time appropriate ? Can admin be reduced or simplified ? Reduce the time spent in scanning room Reduce Demand Partial echos (Take care will only work if they release time) Audit re appropriateness (doesn�t necessarily reduce demand)

48. Lean Enterprise Research Centre How can we improve to remove IP waits for scans Reduce the time spent in scanning room �Identify an allotted time period for echos�s (20-30 mins) and encourage staff to complete them within this time scale whilst maintaining a professional relationship� One of the Top Tips for Redesigning Echo Services NHS Modernisation Agency Achieving a 30 minute throughput will remove your IP waiting list. � get rid of the phone

49. Lean Enterprise Research Centre Effect of 30 minute throughput Would allow demand to be met with 1410 minutes of time per week, potentially releasing 530 minutes of capacity per week. This could be utilised to reduce the OP waiting list 80% of 530 would allow 14 more scans per week

50. Lean Enterprise Research Centre Recommendations Remove interruptions in scanning room to increase throughput Implement all Top Tips for Redesigning Echo Services. Start with 30 minute target and measure achievement & effect Look at how training time is scheduled and what is appropriate. Smooth time out each week. The extra provision in week 1 can create a waiting list Revisit Process Activity Maps to see where admin time can be reduced or things done differently. Consider how Partial Echos will effect delivery Introduce robust data collection methods. Use tools to analyse OP service in same way Revisit Brown Paper Model to consider Quality Issues and to remove waste Devise measurements to see if things improve

51. Lean Enterprise Research Centre Current Position No Waiting for Inpatient Echocardiograph Measuring for sustainability

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53. Lean Enterprise Research Centre Other projects realising results through Lean �Hidden capacity� in day Surgery Improvement in 4 hr transit times Slashed max. wait for Prostate bx from 16 to 2 weeks Pathology sample turn round times improved Barium enema waiting list maintained at 2 weeks on all sites for 18 months Position before was 3 to 16 weeks Preadmission for General Surgery EDD Etc, etc.

54. Lean Enterprise Research Centre Thank You !!