PRINCIPLES OF LEAN

Introduction and Welcome Background to Lean Lean Principles Flow Exercise Value-stream Mapping Waste Spotters Exercise Lean Toolbox Rapid Improvement Events (RIEs) Lean Awareness Workshop Outline

The Six Challenges Re-engineered care processes Effective use of information technology Knowledge and skills management Development of effective teams Co-ordination of care across pathways Making change possible Institute of Medicine Crossing the Quality Chasm: A new Health System for the 21 st Century Corrigan JM 2001

Dimensions of Quality Safety Effectiveness Patient -centeredness Equity Timeliness Efficiency

Where Does Lean Originate? Developed by Toyota as the Toyota Production System (TPS) over the last 50 years Study of TPS led to academics defining the approach as “Lean” The application of Lean is not new – principles have been used in many industries. In the last ten years, increasing application of the Lean approach in healthcare

Lean Strategy for TPS... Requires a focus on whole systems and processes Relentless focus on delivering services/products which meet the needs of the customer, or in healthcare, the patient The application of the PDSA (Plan, Do, Study, Act) rapid change cycle

Lean Principles Jones & Womack, Lean Thinking-Revised, 2000 Map the total customer/ provider value stream Make value flow with no interrup-tions Pull what you want when you want it Search for perfection with no waste Establish value in the eyes of your customer

Why is Lean Relevant? “Lean thinking is not a manufacturing tactic or a cost reduction programme, but a management strategy that is applicable to all organisations because it has to do with improving processes. All organisations – including healthcare organisations – are composed of a series of processes, or sets of actions, intended to create value for those who use or depend on them (customer/patients)” IHI: Going Lean in Health Care, 2005

Lean in Healthcare Virginia Mason – USA Theadacare - USA Bolton NHS - England Gwent NHS – Wales NHS Tayside, NHS Lothian - Scotland

The Nun and the Bureaucrat A book and DVD outlining how 2 hospitals used Lean principles to transform their systems “The fact is that a patient is not a car, and never will be. So. If that were the problem we were trying to solve, we’d be stopped. However, the Toyota system is set up to identify customer needs in very clear ways and to meet those needs in explicit, efficient, rapid supplier-building methods. They’re quite superior in the world of work, so if you said there was no work in healthcare then we’ve got a gap. But as long as you confess that work’s there, then I’ve got a solution.” G. Kenneth Turnbull, Ph.D., Executive Vice President of Alcoa Business Systems

Mass/Volume Thinking Economies to Scale Lean thinking Economies of Flow Big is good/cheap – fast production rates Right size is good – rate-based production Focus on operation – doing the job (s)Focus on process – gluing jobs together Specialists have skills – centralised in few people Everyone has skills – and expected to use them Information – need to know?Information – visual Performance is about tradeoffs – example: better quality costs money Performance is about root cause – example: better quality is cheaper Manage by variety – by batching together similar items Manage variety – by skills to rapidly change from item to item Economies of Flow

Staff skills illness holiday motivation training shifts Patients Resource Process Machines/rooms not the same suppliers age sex race education motivation disease unclear guidelines differ complications anaesthetics 80% is under our control GP Information transcription transport applications Sources of variation in a clinical system

Resulting in.. Systemic issues Poor Scheduling of appointment s and resources Overly complex pathways built in waits and delays Absence of process ownership and control Few defined processes and no standard working Unquantified capacity and demand

Healthcare processes are all about flow. “Toyota revolutionised our expectations of production; Federal Express revolutionised our expectations of service. Processes that once took days or hours to complete are now measured in minutes or seconds. The challenge is to revolutionise our expectations of healthcare: to design a continuous flow of work for clinicians and seamless experience of care for patients” Don Berwick, “Reducing Delays and Waiting Times Throughout the Healthcare System” IHI 1996

Value-Stream Thinking “Stop looking at aggregated activities and isolated machines…Start looking at all the specific activities and see how they interact with each other.” Womack and Jones

What does it do to our patients? When a patient experiences a service it is either good - and therefore what they expect - or it is bad. Patients do not experience “averages” As consumers in the outside world we have expectations of good quality and service, if these expectations are not met then we take our business elsewhere… In health our patients do not readily have that choice.

Process Map A process map answers questions, such as… What is the waste in the process? Where are any blockages to flow? How long does each process step take? How many handovers are there?

Mapping and analysis of the Process Increasing level of detail

Two Elements to Every Job Value Adding Valuable Effort Costs Time Costs Money Adds Value VALUABLE Non-Value Adding Valueless Effort Obvious Waste Costs Time Cost Money Adds No Value WASTE

Types of Waste Toyota’s Seven Wastes * Transport * Inventory (work in progress) * Motion * Waiting Time * Over-processing * Over-production * Defects TIMWOOD

Wastes in a Healthcare Process Lean wasteExamples in radiology DefectsRunning unnecessary scans; forms not being signed, faxes sent that are illegible OverproductionUndertaking multiple scans Excess inventoryExtra supplies Excess processingThe process for ringing porters in the evening is to ring the Help Desk and then to be routed to the porters; entering duplicate information; printing paper reports to send in post Unnecessary motionTime spent looking for staff; entering duplicate information; looking for parts and forms; interruptions from other staff Unnecessary transportation Transportation of scan results in post WaitingWaiting for referrals/scans; waiting for reports/signatures; waiting for patients, doctors, porters Underutilised staffHelpers in waiting rooms; secretaries waiting for reports to be signed Lean Thinking – Improving flow and eliminating waste - Neil Westwood, NHS Institute for Innovation and Improvement

Standardisation This is an important challenge in healthcare delivery It requires agreement from all groups in the pathway of the best way to do the job Requires a clear way in which this is shared Needs a clear procedure for agreeing any process changes Performance management to track adherence

Lean Tools Value-stream mapping PDSA cycles Understanding Demand, Capacity and Variation Root Cause Analysis – often called 5 Whys and How (5W + H) 6S/Visual management Glenday Sieve Rapid Improvement Events (RIEs)

Lean Principles Jones & Womack, Lean Thinking-Revised, 2000 Map the total customer/ provider value stream Make value flow with no interrup-tions Pull what you want when you want it Search for perfection with no waste Establish value in the eyes of your customer

‘Flow’ in health care Progressive uninterrupted movement of patients, information and equipment between departments, staff groups or organisations as part of their care pathway. - NHS Modernisation Agency, 2005

Effective flow is a property of the entire system Patient Pathway Micro-system Teams make day to day, minute by minute decisions in their own micro-systems without a view of the whole system. Even if they have optimised their own system it may do nothing for the whole patient pathway. Patients need to flow through the healthcare system, however if underlying processes are inefficient we will not manage patients effectively.

Effective flow in action – Unscheduled Care Collaborative 5 Patient Flows Group 1 - Minor Injury & Illness Group 2 – Acute Assessment Group 3 – Medical Admissions Group 5 - Out of Hospital Care Group 4 – Surgical Admissions

Advantages of Improving Patient Flow Improved patient outcomes and improved service quality Reduced time that patients stay in hospital, improving patient experience and freeing up inpatient capacity Reduced DNAs, improved resource utilisation and improved overall value for money Improved discharge pathways and reduced variation in length of stay Improved appropriateness of care – to make sure that patients get the right treatment, from the right professional, in the right place, at the right time - Planned Care Improvement Programme, Patient Flow in Planned Care, IST, 2007