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1. 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

2. LOX-GNH053-20060905-PROB Contents • 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?

3. 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

4. LOX-GNH053-20060905-PROB King’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

5. 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

6. LOX-GNH053-20060905-PROB Contents • 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?

7. LOX-GNH053-20060905-PROB We 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

8. 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

9. LOX-GNH053-20060905-PROB We underpin the programme with enabling projects – Performance Management (1)

10. 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

11. 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

12. LOX-GNH053-20060905-PROB Contents • 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?

13. 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

14. LOX-GNH053-20060905-PROB We 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

15. 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

16. 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

17. 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

18. 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

19. LOX-GNH053-20060905-PROB We 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

20. 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

21. 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

22. LOX-GNH053-20060905-PROB Multi-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

23. 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

24. LOX-GNH053-20060905-PROB We are always asking – “Is there a clear standard for the process ?” OPERATION DISCHARGE

25. LOX-GNH053-20060905-PROB Contents • 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?

26. 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

27. LOX-GNH053-20060905-PROB Contents • 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?

28. 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