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A Programmatic Approach to Transformation. <PRESENTATION TITLE>. <Presenter’s name>. David J Dawson – Deputy Director of Service Transformation Karl Douglas – Senior Change Leader Lean Enterprise 2 nd October 2006. Contents.

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presentation title

A Programmatic Approach to Transformation

<PRESENTATION TITLE>

<Presenter’s name>

David J Dawson – Deputy Director of Service Transformation

Karl Douglas – Senior Change Leader

Lean Enterprise

2nd October 2006

contents
LOX-GNH053-20060905-PROBContents
  • What is First Choice Programme and why did we start this journey?
  • What is the philosophy of First Choice and what are some of the key enablers?
  • What does some of our work look like and is it producing results?
  • What have we learned and how are we reapplying the learning?
  • What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?
slide3
LOX-GNH053-20060905-PROB

King’s is a busy teaching hospital rooted in the local community

  • Major, complex university teaching hospital
  • Turnover of £385 million
  • 5,000 staff
  • Over 900 beds
  • Local emergency services
  • Local, regional and national elective work
  • Economically deprived & ethnically diverse local population
  • Strong links to local public, patients & primary care
king s must change if it is to cope with policy trends
LOX-GNH053-20060905-PROBKing’s must change if it is to cope with policy trends
  • Funding issues
  • Market Reform
  • Care delivery

1

  • Market reform
  • 3-fold increase in funding 98-08 – but leveling out from 2008 onwards

2

4

  • Creation of a contestable market / patient choice
  • Drive to increase productivity
  • Patient care

5

3

  • Increasing emphasis on demand management and integrated care
  • Increasingly open and transparent regulatory environment
  • Quality
  • Cost
  • Access
  • King’s Position
  • Foundation Trust application
  • Financial and performance targets
  • Rising local demand
in 2005 the trust invested in the first choice king s programme to deliver a set of objectives

1CK objectives

  • Improve on the already excellent quality of care
  • Make the patient experience for King’s patients more positive
  • Create a culture and capability of continuous operational and managerial improvement
  • Deliver a step change in financial efficiency by 2008
  • Service-based transformations
  • Cross-hospital enabling projects
  • GM
  • CCS
  • CH
  • Liver
  • TBC

Service based teams

  • Finance processes
  • Performance
  • Management

Change Leaders team

  • Improvement capability building
  • 1CK targets
  • Reduce ALOS
  • Comply with 18 weeks
  • Increase patient satisfaction
  • Build team of 80 Change Agents
  • Reduce cost per spell

McKinsey

  • Marketing & branding
  • Convenience and access
  • Environment
  • Communication and care

LOX-GNH053-20060905-PROB

In 2005 the Trust invested in the First Choice King’s Programme to deliver a set of objectives
contents6
LOX-GNH053-20060905-PROBContents
  • What is First Choice Programme and why did we start this journey?
  • What is the philosophy of First Choice and what are some of the key enablers?
  • What does some of our work look like and is it producing results?
  • What have we learned and how are we reapplying the learning?
  • What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?
we have come to see that a hospital is in some ways similar to industry and that we can learn
LOX-GNH053-20060905-PROBWe have come to see that a hospital is in some ways similar to industry and that we can learn
  • Manufacturing Industry
  • Hospital

Infrastructure

Processes

Materials and products

People

we use a suite of transformation tools to balance action in three organisational dimensions

Management Infrastructure

  • Operating System
  • Mindsets, Capabilities & Behaviours

LOX-GNH053-20060905-PROB

We use a suite of transformation tools to balance action in three organisational dimensions
slide10

What is process confirmation?

  • Process confirmation is the standardised way by which managers ‘go and see’ that the process is delivering its
  • target condition and where it isn’t, understand and act on the root causes

When, where and how to do PC is rigorously defined for all managers, from CEO to sisters

It is always done at the shop floor, where the care is given and value added to the patient

The exact standard of working, giving care, maintaining areas

“Shadow of the Leader” (Senn-Delaney)

  • Frequency
  • Shift
  • Daily
  • Weekly
  • Monthly
  • Quarterly
  • Trust Mgmt
  • Quarterly review
  • Monthly review
  • Ward Manager & Matrons
  • Level
  • Weekly meetings
  • G-grades
  • Daily work
  • Brief and debrief
  • Team leader
  • Wards
  • Process confirmation

LOX-GNH053-20060905-PROB

We underpin the programme with enabling projects – Performance Management (2) Process Confirmation and a “Go & See” approach
we underpin the programme with enabling projects improvement capability building

Executive

  • Change Agents(70–90)
  • Change Leaders(8–10)
  • Improvement Capability
  • Institutional Capability
  • Individual Capability
  • Improvement organisation design
  • Formal training infrastructure and materials
  • Change agents
  • Change leaders
  • Explicit capability-building and tracking processes
  • Improvement methodology
  • Coaching and individual performance management

LOX-GNH053-20060905-PROB

We underpin the programme with enabling projects – Improvement Capability Building

1400+ hours of training delivered by Change Leader Team

contents12
LOX-GNH053-20060905-PROBContents
  • What is First Choice Programme and why did we start this journey?
  • What is the philosophy of First Choice and what are some of the key enablers?
  • What does some of our work look like and is it producing results?
  • What have we learned and how are we reapplying the learning?
  • What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?
we started our transformation journey in general medicine where there were acute problems

Market reform

  • Emergency demand – increasing
  • Target – 4 hours maximum time in A&E to be maintained
  • Outliers – 20 to 60 per day
  • Cancellations - elective and tertiary work squeezed out

LOX-GNH053-20060905-PROB

We started our transformation journey in General Medicine where there were acute problems
  • Budget – overspent
  • Income – threatened in other specialties
  • Capacity – constantly expanding

Permanent bed crisis

Trust View

  • Too big a problem
  • Control – silo mentality
  • Site – split across 2-sites
we analysed current state rigorously and learned surprising things
LOX-GNH053-20060905-PROBWe analysed current state rigorously and learned surprising things

Results

  • ALOS by group
  • 99,661
  • 100% =
  • 7,004
  • ALOS was 14.2 days
  • Outliers averaged 40 per day with min of 21 and max of 58
  • Spells with LOS > 28 days are only 13% of total but account for 62% of bed days. A 10 day (15%) reduction in LOS in this group would reduce ALOS by 9% to 12.9 days
  • Spells with LOS between 3 and 27 days are also important but do not by themselves deliver the LOS reduction target
  • LOS (days)
  • 28+
  • 15-27
  • 8-14
  • 67.9
  • 3-7
  • 19.9
  • 10.7
  • ≤2
  • 4.4
  • 1.0
  • Bed days
  • Spells

* i.e., 5 day LOS reduction in 15-27 segment, 3 day LOS reduction in 8-14 segment, 1 day reduction in 3-7 segment

Source: KCH PIMS database, team analysis

management structure was diffuse and informal with few understood responsibilities

Outpatient Serv Dev Mgr

  • Bed Capacity Manager
  • Head of Nursing (A&E)
  • Firm Chief (Firm A)
  • Lead Consultant
  • Firm Chief (Firm B)
  • Firm Chief (Firm C)
  • Lead Consultant
  • Lead Consultant
  • Lead Consultant
  • Clinical Director
  • Bowley Close
  • Lead Consultant
  • AssistantBusiness Mgr
  • Outpatient Admin Mgr
  • Head of Nursing (GM)
  • Junior Drs Hrs Coordinator
  • Director of Therapies
  • Finance Manager*
  • Business Manager
  • HRManager*
  • Recruitment Coordinator
  • Administrative Manager
  • General Manager
  • Head of Physiotherapy

LOX-GNH053-20060905-PROB

Management structure was diffuse and informal with few understood responsibilities
  • Senior management team
  • Key features
    • No overall objectives
    • Operational accountability only with General Manager
    • No formal operational accountability in Firm
    • No formal operational accountability in wards
    • No real responsibility for LOS at any level
    • Firms & wards specialist silos
    • Dislocation between Dr’s / Nurses / Admin / therapies - blame
    • Some areas outside influence of senior management
    • No meeting or information cascade
    • Clear professional lines of accountability for nurses and physicians

Chief Exec.

  • Operational line accountability

Dir. Med.

Dir. Ops

Dir. Nsg

  • Professional accountability
  • Medical
  • Nursing
  • Lead Consultant (GI)
  • Matron
  • Matron
  • Matron
  • Ops/Admin
  • Therapies
  • * Not line accountable
we found that we could categorise medical patients in two ways and provide tailored care regimes

Accident & Emergency

Patient Streamed at admission

Category Two Patients

Category One Patients

  • Single condition presentation
  • Requires input from doctor, nurse and X1 therapist
  • Standard discharge needs
  • Complex presentation with multiple pathology
  • Requires input from clinical teams
  • Complex discharge needs

Category 1 Ward

Category 2 Ward

LOX-GNH053-20060905-PROB

We found that we could categorise medical patients in two ways and provide tailored care regimes
results from general medicine are now clear and financially important to the trust

Results

  • Contributing Solutions
  • ALOS reduced by 20%
  • Average daily outliers down by 59%
  • 30 beds closed
  • Normal winter allocation of 15 extra beds not used
  • Savings £3.3 million and ward closed
  • Patients classified by expected LOS and streamed from A&E to designated wards
  • Bespoke MDMs for longer stay patients are in effect with improved meetings management
  • A&E maximum wait of 4h sustained through daily care group review of intake at lunchtimes in A&E
  • Redesigned consultant driven on-take arrangements improved continuity of care and aided earlier discharge of very short stay patients
  • Dulwich move executed successfully and on time
  • New multi-specialty two-firm structure with linked wards organisation structure replaced old speciality based divisions . Firm leaders – 1 consultant and 1 senior nurse
  • The cascade of performance meetings is in place with revised meeting calendar and terms of reference. Scorecards revised at CG and Firm level to drive the identified care group improvement needs

LOX-GNH053-20060905-PROB

Results from General Medicine are now clear and financially important to the Trust
slide18

Referrals

Customers

Elective Care Population

Confirmed Appt’s

Orthopaedics - Elective

Suppliers

Elective Care Population

  • Improvements to operational performance can…
    • ↑ 23% in clinic throughput (orthopaedics)
    • ↑ 17% in theatre throughput (orthopaedics)
    • ↓ 5% ward LOS (~6 beds, at current activity, or stable bed-pool with activity to reach 18 weeks target)
    • ↓ 8% ICU LOS (~80 bed-days)
    • ↓ 6% HDU LOS (~100 bed-days)
    • ~2,700 more DS conversions, incl. 1,800 CC&S(~15 ward bed reduction, of which 10 CC&S, at current activity)

Daily

Daily

  • …deliver current activity with less resource

Choose & Book

Weekly Demand:

1000

Weekly Demand:

42

PIMS

Galaxy

EPR

Range of options in between

3150 F/U

12

10

10

1500

90

130

1275

GP Referral

Patient Sees Consultant

X Ray

Patient Sees Consultant F/U

Pre-Assessm’t

Admission to Ward

In-Patient Surgery

Recovery

Ward Care

  • …or deliver more activity with same resource* and reach the 18-weeks target

C/T: 10 mins

No. of GPs : 600

No. of Clinics: 4000/wk

Time/clinic: 4 hrs

C/T: 15 mins

No. of Clincs :18/wk

Time/Clinic:3.5 hrs

C/T: 5 mins

No. of Clincs :18/wk

Time/Clinic:3.5 hrs

Util : 65%

C/T: 10 mins

No. of Clinics :18/wk

Time/Clinic: 3.5 hrs

C/T: 20 mins

No. of Clinics : 8/wk

Time/Clinic: 3.5 hrs

C/T: 21.5 hrs

Capacity : 7 x 22 bed days

C/T: 111 mins

Time Available: 5 x 24 hrs

C/O: 15 min

Util : 75%

C/T: 30 mins

Time Available: 5 x 24 hrs

No. of Beds : 8

C/T: 4 days

Capacity : 7x 22 bed days

Util : 93%

  • Pre-requisites for performance improvements
    • Participation and ownership of solution by surgeons and anaesthetists
    • Strengthening theatre leadership by hiring a new theatre matron
    • Appropriate resourcing of all workstreams with Change Agents (incl. theatre scheduling)
    • Surgeon co-operation in scheduling additional patients in main theatres

7251 min = 7%

202.8 days

Processing time

Lead time

For longest stream

=

20 min

1290 min

111 min

30 min

5760 min

10 min

15 min

5 min

10 min

3.6 days

50 days

.1 days

01 days

132 days

15 days

2 days

LOX-GNH053-20060905-PROB

In Critical Care & Surgery extensive analysis of the current state identified improvement opportunities to reach the 18-weeks target
we designed a future state
LOX-GNH053-20060905-PROBWe designed a future state …..
  • Key elements of the future state
  • Establishing radically different scheduling in theatres and clinics: building lists that fully use available capacity, based on explicit, agreed-on standard times, and delivering against those lists
  • Helping staff work more effectively, with agreed-on, staff-developed protocols for key activities, clear roles and responsibilities, and better workplace and equipment layout
  • Improving performance management, with clear accountability for the end-to-end patient journey, better performance conversations and reviews, and appropriate individual and team incentives
  • Developing a different way of working together, based on shared valued, clear roles, a visual management system, and regular briefing and feedback
  • Becoming the leader in innovative outpatient care over time
  • Continuing day surgery conversion at an aggressive pace
  • “Outcome” vision
  • A dramatically better patient experience, delivered by motivated, capable, and well-trained staff working in high-performing teams, at levels of operational performance that allow King’s to be a national leader in innovative surgical care and high acuity elective care
slide20

Prepare for the days discharges

LOX-GNH053-20060905-PROB

New processes work smarter rather than harder to ensure the patient journey is anticipated, planned for and supported by high quality care

WARDS

  • Morning brief
  • 5S – Workplace Organisation
  • Ward Rounds

Ward & Bed Boards

Preparation for Theatre

  • TTAs, Pre-Packs & POD drugs control
  • Ward Boards
  • Multi-Disciplinary Meetings

Ward Book

  • Surgery
  • D-1 Focus on Discharge
  • Prepare for next days Discharges
  • Multi-Disciplinary focus on complex patient continuing care needs
  • Team problem solving
  • Performance management
  • Ward Team boards and issue sheets
  • Daily briefs
  • Process Confirmation
  • Scorecards
  • Tracking of KPIs
setting a standard for 11 00 am discharges brings new focus discipline to ward processes

Patients to be discharged identified the day before discharge

  • TTAs written by ward pharmacist and confirmed by doctors

2005 - 94% of discharges after 11:00am

CURRENT - 63% of discharges before 11:00am (for those patients “fit for discharge”)

LOX-GNH053-20060905-PROB

Setting a standard for 11:00 am discharges brings new focus & discipline to ward processes
multi disciplinary working is structured consistent pre emptive and action orientated
LOX-GNH053-20060905-PROBMulti-disciplinary working is structured, consistent, pre-emptive and action orientated
  • Complex cases with special needs on discharge identified on admission and continuously assessed through structured MDM process

No. of Patients who are medically fit for Discharge or Transfer

3% Bed Usage due to Discharge Delays against previous 8%

  • Attendance by a named link Social Workers
  • Effective Social Services relationships established with training from them re: referrals
  • Early identification and preparation of patients to be discussed
  • Clear ownership
  • Short structured approach with effective issue capture and follow up
  • Link to ward visual management systems, team board & briefings

No. of bed Days Lost / Week / Ward

slide23

6

  • 2
  • 3
  • 5
  • 4
  • 4
  • 1
  • 5
  • 2
  • 1
  • 6
  • 3
  • Improved Ward Team communication through daily briefing and Team Boards

LOX-GNH053-20060905-PROB

Regular review of visual process information by front-line managers and their teams places them at the heart of improvement
  • Ward Team Board clearly visualising performance v target
  • Daily Briefing linked to team KPIs and issues raised
  • Issues listed on specific sheet and responsibilities assigned
  • Tasks emerging from issues carried out within deadline agreed
  • Linked to CC&S Nerve Centre for work stream and Care Group reviews
  • Improved KPIs thanks to structured issue logging, follow up and review
  • Process confirmation to ensure engagement, coaching and direct feedback, on the wards
  • Regular and structured review at ground level
slide24
LOX-GNH053-20060905-PROB

We are always asking – “Is there a clear standard for the process ?”

OPERATION

DISCHARGE

contents25
LOX-GNH053-20060905-PROBContents
  • What is First Choice Programme and why did we start this journey?
  • What is the philosophy of First Choice and what are some of the key enablers?
  • What does some of our work look like and is it producing results?
  • What have we learned and how are we reapplying the learning?
  • What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?
slide26
LOX-GNH053-20060905-PROB

1CK is meeting KPIs and is delivering some results, particularly where supported by key enablers. The programme is learning and new themes are emerging that should shape our direction …

  • Executive drive and support has to be consistent and focused on delivery
  • Up front quantified strategic context is key to structuring and prioritising effective transformation
  • Care group organisational structures clearly linked to objectives and performance management is a key enabler to allow managers to drive transformation and make it part of day-to-day life – people need to be in place before, not after 1CK
  • The leadership and engagement of clinicians transforms impact – things happen
  • The introduction of flexible working to cope with natural variation and maximise value added time is key to breaking through current disabling process rigidities
  • Care Group teams must have capacity and capability made available in order for change to be self sustaining (e.g., analytical skills). The energy and drive of middle managers can take the programme so far, however, front line management is key to delivering day-to-day and require development
  • The consequences of not achieving / non-compliance or recognition for achieving / exceeding agreed objectives should be more explicit and enacted
  • Specific 1st Choice communications at programme and team levels spreads knowledge, gets engagement and liberates ideas.

Key Enablers

contents27
LOX-GNH053-20060905-PROBContents
  • What is First Choice Programme and why did we start this journey?
  • What is the philosophy of First Choice and what are some of the key enablers?
  • What does some of our work look like and is it producing results?
  • What have we learned and how are we reapplying the learning?
  • What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?
there are key questions to resolve as we continue forward for discussion

Does the transformation journey really have to be so long and arduous?

How do medical staff really become excited and central to the change effort?

Pioneers aren’t enough –can frontline managers sustain success?

What else do we need to do to become a truly Lean hospital?

LOX-GNH053-20060905-PROB

There are key questions to resolve as we continue forward: For discussion