Lean Journey at Airedale Sue Speak Head of Lean Improvement

1. Lean Journey at Airedale Sue Speak Head of Lean Improvement

2. Airedale NHS Trust Looking over our shoulder • 200,000 people • vast geographical area covering 500 square miles • stretching as far as the Yorkshire Dales and the National Park in North Yorkshire, reaching areas of North Bradford in West Yorkshire and extending into Colne and Pendle in the East of Lancashire.

3. How far have we come since 2007? Looking over our shoulder Head of Lean came into post in February 2008 Over ~500 people attended training. Over 82 projects. 53 are now completed. 32 BIT NVQ level 2 champions 4 NVQ level 3 champions

4. Structure Chief executive Executive Lean Lead Head of Lean (FT) 10 L3 Champions (PT) 60 L2 Champions (PT) All staff working to improve

5. Momentum Critical point Progress

6. Momentum Only as you get near a critical point do you realise how much further you have to go! E.g. Dozens of people have been trained and Sops are now being used in IT Endoscopy, Wards and theatre yet there are hundreds more procedures and equipment need doing. Progress

7. Organisational Development Charge Nurse Personnel Education & Training Lean Healthcare Academy Theatre Manager Cancer Manager Medical Records Service Improvement Ward Clerk Laundry First Champions – BIT NVQ L2

8. Research Lead Secretary Hotel Services Consultant Head of Lean improvement FT Specialist Facilities Assistant Director of Nursing Second Champions – BIT NVQ L2 Found ~£40K of lost income from one clinic. Redesigned Endoscopy store room (6S and visually managed)

9. Business Manager Hotel Services Head of Lean improvement FT Co-ordinator First group of Champions – BIT NVQ L3 Undertook leading teams, problem solving SMED medicine round SPC data from A&E

10. Lean Tools currently in use 6S Visual management Process Flow SMED Capacity and Demand Problem Solving Rapid Improvement Events

11. 6s Workplace organisation What is 6S? Lost property cupboard A way of organising an area so all staff are involved in organising the workplace and everything has a place making it a safer, more controlled environment to work in. Empty cupboard Well organised cupboard

12. 6S A+E Resus Scope Project was to train a team to work on 6s in the resus department of A+E. The 6s training took place on a cold morning in December 2007. After the training the team set to work in the department. Rather than start removing things immediately the team set about a steady program of continuous improvement which is still in place today, Including work on all aspects of the layout and stock of the department. Gavin Anderson Matron for Emergency Medicine

13. A+E resus- Space to work Before After Space for anaesthetist to stand at head of patient Anaesthetic Machine Removed New monitors

14. Goods Inward Lean Project December 2008

15. Team 1 before

16. Team 1 after

17. Team 2 before

18. Team 2 after

19. Conclusion Reluctance- all team members have committed to this project and worked very hard to achieve a vast amount of work. Work in progress NOT chaos BUSY not messy Lack of available space. Limiting being able to achieve some of the perceived goals

20. Communication Room Short, sharp clear information on key trust objectives 1 hour once a week for key staff

21. Diabetic foot clinic Foot clinic Frequent flyer Take a group of NVQ 2 students An invitation to help with issues in the foot clinic you get a process map. Unfortunately that didn’t uncover any real issues so the team asked the staff to compile a frustrations board. The staff were unwilling to put their comments out in public so they were completed and sent to the team in brown paper envelopes. It was clear from the information in the letters that there was issues. The team then split up and went and observed in the clinic with different staff members They chatted to some of the patients, regular attendees The team made a second map and struck project gold, it was then clear where the issues lay Sometimes I can be sitting in the clinic for 20 minutes with my bandages off • What the team found: • Issues with roles in the clinics between Podiatrist, HCSW, Consultant and Diabetic Nurse • Four people could be looking at the same patient at the same time • There was no real flow of patients through the clinic • There was potential infection issues with dressings being removed up to 20 minutes before treatment • Different ways of working meant many new patients not put on PAS and no income generated • The Consultant only needed to see about half of the patients but was present for whole clinic • Diabetic reviews were being carried out in the clinic (no income, privacy and dignity issues) The team then met with the staff for a clinic redesign meeting! • Project outcomes: • Freed up 1 diabetic Nurse • Freed up some consultant time (now only sees patient they need to see) • Better process in clinic with bandages being removed for the minimum time. • Improved staff morale and teamwork • Fantastic learning for the NVQ students • No Privacy and dignity issues Project outcomes: £30,000pa lost income recovered-Patients put on the correct system. Foot ulceration, foot infection, foot and limb amputation and some forms of deformity are major forms of disability arising from types 1 and 2 diabetes. In the UK every year 5,000 people with diabetes have an amputation, meaning people with diabetes are 15% more likely to have an amputation than those without. Airedale runs a twice weekly foot clinic serving the local community

22. Paediatric Outpatient Appointments Scope Paediatric referrals into the paediatric outpatients department First job was to get the team together to map the process The team identified a good, well thought out pathway but even then it had 29 issues. The team then worked through the action list. The team identified 2 risks with the process which were dealt with; Printing urgent referrals before putting them on PAS- now stopped Ownership of venerable children between referral and conversion of C+B appointment- now clarified with national C+B Key Improvements • The matron was released from reviewing up to 50 paper referrals a week • All operational information OP1’s, ad hoc referrals and cancellations are now reported at the Paediatric Operational meeting (POP) allowing ongoing monitoring of activity. • Semi-formal Ad hoc referrals now all but eliminated and formalised by creating a Thursday afternoon Acute clinic for the POW (paediatrician of the week) £28,000 of lost income recovered • Less walking between clinic and Pharmacy for Patients and staff Improved communication between staff groups and patient satisfaction are the non tangible benefits- Dr Gary Savill Paediatric lead clinician

23. Capacity and Demand Teaching staff to use and understand Statistical Process Control to help manage activity.

24. Endoscopy Capacity and Demand Graphical illustration of lost sessions Scope Examine the Capacity and demand of Endoscopy. Find ways to help the department from getting behind in surveillance Endoscopies. A backlog of over 100 mostly surveillance Endoscopy patients had built up which equated to 5 weeks work. Step 1 Examine 17 weeks worth of data and report back to the team Step 2 Feedback to the Endoscopy management- • Sessions were being lost due to conflicting priorities- When and why • the lists were not always filled look at variation in lists. Step 3 Develop an endoscopy tracking tool to monitor demand an activity Key Outcomes • Examine the reasons for the shortfall look at true demand and activity of the department over a 17 week period and report • Develop an endoscopy tracking tool to match demand and activity Sally/Linda

25. Project process Healthy Ambitions key references to CDC Key outcomes Reference best practice Present plan- secure funding Write business plan Define Team Objective Set vision Local National Speciality Children's development centre (CDC) Scope To work with the CDC to create a 3 year strategy entitled “Compass, Commitment and Calendar” to enable them to build on what they have done to date and secure a future for the service. The service was under threat due to the way it was funded. Compass Commitment Calendar Other key documents referenced Key Improvements • Create a 3 year business plan to secure £500,000 of funding for the future of the service. • The team referenced Local, National, Quality and Professional best practice to create their business plan • Create a clear way forward for the team and a communication document “Compass, Calendar and Commitment” for internal and external use showing the 3 year plan. • Create 2 project teams focussing on Access/Efficiency and Quality/Children and family centred care “As a team we knew what we wanted to achieve, LEAN principles provided us with the tools to achieve it” Jean Racktoo CDC Lead

26. Example SOPs ANHST Changing gas cylinders ANHST Sluicemaster

27. Productive ward

28. Administration and clerical review

29. Admin Pathways *PAS- this refers to one group using PAS to achieve an objective such a booking an appointment. During that they many actually access the PAS system multiple times for one appointment This shows how the LEGO bricks- A+C activities look like for our one patient

30. Transportation of Notes Clinic room Clinic room Clinic Nurse Clinic Nurse Clinic Nurse Clinic Nurse HCSW Outpatients Clinic Appoint.. Clerk Outpatients Clinic Appoint.. Clerk Appoint.. Clerk Appoint.. Clerk/MS Appointments office Medical Secretary Medical records Appointments office Consultant Review Waiting list office Nurse Waiting list office Waiting list office/MS Theatre Waiting list office Waiting list office TCI ward Waiting list office Pre-op Waiting list office Medical Secretary Nurse PO Nurse PO Nurse OPA Ward Clerk Medical Secretary Post op ward Anaesthetic MR The minimum physical journey of the notes for one Elective Surgery Patient

31. Transportation of Notes The trust has an average of 2250 outpatient appointments per week. The journey of these patient’s notes is shorter but there are more of them That means ~117,000 OPA’s new and review pa. The notes are transported 58,500 miles and if they are grouped in 20’s for the clinic this is at least 1000 hours transportation ~58,500 Miles ~1000 hours The above figures take no account of the time spend looking for notes and is an absolute minimum time spent transporting

32. Medical Records Throughout the week, the locating and transfer of notes across the trust was flagged a major issue by every group • Currently : • every time a set of notes is removed from the library the tracer card is filed in it’s place. • every time a set of notes is sent to somewhere a tracer slip is completed and sent to medical records • When Medical records receive the tracer slip the tracer card is located, updated and re-filed. • Any time anyone is looking for a set of notes that go to medical records and consultthe tracer card Every year medical records receive and update 130,000 tracer slips • Currently : • every time a set of notes is removed from the library a set of demographic labels is printed. Every time they are returned the labels are removed and destroyed. It cost in excess of £25,000 per year to do this not counting time to do it.

33. Medical Secretaries The work of the medical secretaries is vital. Two of the main issues raised by the med secs in this and other pathway work; Clinic letters transcribed, printed and hand delivered by the Hospital Vans >117,000 clinic letters to GPs No cover for holidays- Patients stop in the pathway Medsecs return from Holiday to piles of work • Key changes proposed are: • Electronic discharge/ clinic reporting to GP’s (onto system 1/email?) • Medsecs work in teams cross cover (possible co-locate) with appropriately shared files and common working practices. • Expand the use of electronic dictation

34. Four new project teams to look at the issues raised in their area. Smaller actions taken up through existing groups (such as the PAS user group) or the departments themselves. All controlled by the steering group. The steering group also has responsibility for a trust wide approach to training. New Project team Project- existing resource

35. Thank You Any Questions