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NHS
CANCER   DIAGNOSTICS   HEART   LUNG   STROKE                                         NHS Improvement




                                               Bringing Lean to Life
                                               Making processes flow in healthcare
Bringing lean to life
Bringing Lean to Life - Making processes flow in healthcare




    Contents
    Introduction - what is the problem in healthcare?   4    Identifying waste                   18
    What is Lean?                                       6    Making value flow                   20
    A3 thinking                                         7    Understanding pull                  21
    An example A3 report                                8    Understanding Takt time             22
    The importance of data and measures                 10   Using 5S to improve safety          23
    Example statistical process control (SPC) charts    11   Plan Do Check Adjust (PDCA) cycle   24
    Current state value stream mapping                  12   Continuous improvement              25
    Designing the future state value stream map         14   Value stream mapping symbols        26
    Standard work to produce high quality every time    15   Acknowledgements                    27
    Visual management                                   16


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4                                                                                                                                                        Bringing Lean to Life - Making processes flow in healthcare


    Introduction - what is the problem in healthcare?
    We all come to work to do our very best - to      The ‘processes’ are to blame not the people
    achieve what we are capable of and to add
    real value for our patients and ensure clinical   Often, there is ambiguity in how certain tasks
                                                      should be performed – so people work it out
                                                                                                         “…the best hope for
    expertise is supported by process excellence to
    enable healthcare processes to flow at the
    rate of patient demand - no one wants to get
                                                      for themselves to secure the best outcome
                                                      and get the job done. However, whilst
                                                                                                          saving lives lies in
    it wrong. Healthcare teams are dedicated and
    skilled professionals who are often under
                                                      everyone develops their own bespoke
                                                      solution, the variations introduced by different    raising performance…”
    pressure to do their best and work terrifically   people can be significant and harmful.
                                                                                                         Atul Gawande, Better, 2007
    hard - but often with inadequate processes.
                                                      Departments continue to work hard and in
    Each year, the National Patient Safety Agency     isolation to ensure they improve their services
    handles over one million reported medical         and practices. However, such silo’s often          NHS Improvement has been using Lean with
    incidents in England alone. Figures illustrate    mean that any good practice is lost which          clinical teams and has proven that it can
    that approximately one in every ten patients      increasingly impacts upon the patient flow         improve quality, increase safety, reduce
    are unintentionally harmed by their healthcare    between services.                                  turnaround times, increase efficiency and
    providers. Most of these are not necessarily                                                         productivity, improve staff morale and reduce
    the result of medical errors or poor clinical     This booklet provides a basic introduction and     costs. The NHS Improvement website
    decisions, but are caused simply by the way       overview of Lean; the culture, principles and      www.improvement.nhs.uk has details of
    the system has been set up.                       tools to understand, tackle and resolve issues     numerous case studies and recommended
                                                      within healthcare. It is not intended as a         reading.
                                                      complete guide to implementing Lean as a
                                                      management system.                                 Together we can’t afford not to change!
“
    Improvement usually
    means doing something that
    we have never done before.
                                  ”
                                 Shigeo Shingo




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6                                                                                                                                                                                                             Bringing Lean to Life - Making processes flow in healthcare


    What is Lean?
    Lean was a term coined by researchers when       In short, Lean is about building the problem
    studying the philosophy of the management        solving capabilities of the team to produce                     Specify VALUE from
    system in place at Toyota and the culture they   experts who can perform daily work to the                     the customer viewpoint
    had created amongst their workers to improve     best standard – everyday.
    processes which led to the final product.                                                        Pursue PERFECTION                     Identify the
                                                     These key steps and the necessary tools to      in quality & quantity              VALUE STREAM
                                                                                                     by continuous                         and remove
    The researchers noticed five key steps were in   implement Lean are explained in this booklet.   improvement                                 waste
                                                                                                                                                           Problem     Solve problems by
    place to deliver what the customer wanted at                                                                                                                        root cause analysis
                                                                                                                                                            solving
    the highest quality and safety level possible,                                                                Introduce Standard Working

    with the lowest associated costs from a
    workforce which also had high morale.
                                                     Lean is the continuous and                                           Remove Waste
                                                                                                                   Set Up Visual Management
                                                                                                                        Eliminate Batching
                                                                                                                                                          People and
                                                                                                                                                           Partners
                                                                                                                                                                             Respect, challenge
                                                                                                                                                                              and grow them



                                                     systematic elimination of
                                                                                                                                                                                  Eliminate waste.
                                                                                                                       Identify Root Cause                                          Right process will
                                                                                                                                                           Process
    The five steps were:                                                                                                                                                              deliver right result
                                                                                                                                                                                        Long-term thinking.
                                                                                                                                                          Philosophy

                                                     waste
                                                                                                                                                                                         Continuous
    1 Specify value                                                                                                                                                                        improvement

    2 Identify the value stream steps                                                                 initiate PULL in line          Make value
                                                                                                                                                                            Ref: Liker, 2004

                                                                                                     with customer demand              FLOW
    3 Make value flow
    4 Supply what is pulled by the customer
    5 Continually improve and strive
      for perfection.
A3 thinking
    All Lean improvement work should begin with       The A3 report is literally a one-page document    just on a single sheet of paper requires concise   The A3 represents the shared consensus
    A3 thinking as it is a methodical approach to     (11 x 17 inch [A3] sheet of paper) that records   information. This prevents excessive amounts       towards solving the problem. As a document,
    problem solving.                                  the agreed points of discussion in a systematic   of information being overwhelming,                 it encourages reflection on the learning that
                                                      way.                                              misinterpreted and incorrect conclusions being     has taken place and ensures that a consistent
    Lean is primarily the description of a                                                              reached.                                           message is discussed and scrutinized.
    methodology to routinely solve problems           The structure of the A3 (see pages 8 and 9)
    everyday so that the work is delivered to         takes individuals and teams through the           The best A3s:                                      For an A3 to work, the whole team needs to
    specification. A3 thinking is the rigorous        process of agreeing the problem statement or      • are handwritten in pencil with minimum text      contribute and agree.
    application of something known as the Plan,       issue, reviewing and analysing the current        • contain pictures/diagrams to convey the
    Do Check, Adjust (PDCA) approach.                 state and identification of a desired future        problem
                                                      state with a subsequent action plan for any       • are concise and hold all the relevant             Top tips
    The PDCA (PDSA) cycle provides a means of         agreed actions.                                     information
                                                                                                                                                            • Teach, coach and use A3 thinking as a standard tool for all new
    conducting safe experimentation or a number                                                         • represent the shared consensus
                                                                                                                                                              projects and problem solving
    of trials to see the effect of any changes made   Describing the entire process from current        • do not need verbal explanation
    in a bid to make improvement (see page 24).       state, through analysis and onto future state     • are agreed by the entire team.                    • Complete the A3 report with a pencil (corrections can be made following
                                                                                                                                                              further consensus with the team)
                                                                                                                                                            • This is a working document – each box should contain only the
                                                                                                                                                              information that has been agreed
                                                                                                                                                            • Resist the temptation to ‘type’ up the report. If an electronic version is
                                                                                                                                                              required, consider taking a digital photograph instead to share across
                                                                                                                                                              the wider organisation.



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8                                                                                                                                                                                         Bringing Lean to Life - Making processes flow in healthcare


    An example A3 report

                                                                                                                                                                                                                                   NHS
     A3 Lean Improvement                                                                                                                                                                                           NHS Improvement

                                                                                                                     Department Cervical Cytology Department Date: May 2010                        Author:
     Define the problem/opportunity: (Why are you talking about it? What are you trying to solve/improve?)
                                                                                                                     Team members:                              Agreed by:                         Version:
      Waiting times for turning around cervical screening samples are protracted. This could potentially delay any
      treatment required by the woman.
                                                                                                                      Future state: (What will it look like? Be visual - future state value stream map)




     Current state: (What happens now? Be visual - value stream map, graphs, facts and measurements etc.)
Action plan
                                                                                                                              Action - what, why and how?                                   Who?   When?      Progress status (ie completed, in progress)
    Goal: (State the specific target(s). State in measurable or identifiable terms)
                                                                                                                              Establish core transport group                                 RG    Jan 2010                  Completed
    100% in 14 days
    50% in 7 days                                                                                                             Implement zero tolerance policy of defects from 1˚ Care        AS    Jan 2010                  Completed
    Zero defects                                                                                                              Reduce backlog
                                                                                                                              Goal V actual measures                                         GF    Mar 2010                  Ongoing

    Waste identified: (Transport, Inventory, Motion, Automation, Waiting, Overproduction, Overprocessing, Defects, Skills.)   Capacity and demand                                            GF    Feb 2010                  In progress

     Transportation – up to 15 days ‘lost’                                                                                    Reduce batch sizes from 16 to 8                                AS    Mar 2010                  In progress
     Waiting – average TATs of 41 days from specimen taken to report issued                                                   Introduce water strider                                        AS    Apr 2010                  Ongoing
     Defects – 40% defects received from primary care
                                                                                                                              Results and measures:
                                                                                                                              (What was your PDSA cycle? How long did you run it for? What data did you collect before and
                                                                                                                              after the change? What did you find? Add charts, tables, and cost benefit analysis)
    Root Cause Analysis: (What is the root cause of the problem? Use fishbone/cause and effect diagram, five why analysis)
                                                                                                                              Transport group                                           Zero tolerance policy has
                                                                                                                              reduced delivery                                          reduced defects from 40%
                                                                                                                              times by an                                               to 20% within 6 weeks,
                                                                                                                              average of 12                                             with a further reduction in
                                                                                                                              days                                                      10% anticipated within
                                                                                                                                                                                        next 2 weeks



                                                                                                                              Next steps: (Are there any remaining issues/problems? Is there any further follow up required?)
                                                                                                                              Levelled workloads are required in laboratory.
                                                                                                                              This is being taken up by laboratory subgroup – April 2010.




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10                                                                                                                                                                                                   Bringing Lean to Life - Making processes flow in healthcare


     The importance of data and measures
     In healthcare, we are used to taking clinical     Measures might include:                            Manual data collection might feel like hard       Data analysis doesn’t need to be complicated.
     measures such as temperature, pulse, blood        • numbers of patients on waiting lists             work at the time, but if you don’t collect this   Line graphs, bar charts, scatter graphs and
     pressure, respiration rates, urine outputs etc.   • staff numbers                                    information before you start:                     statistical process control charts can all be
     in order to understand if the condition is        • hours worked                                     a) how will you know what your current            used to visually show the before and after
     getting better or worse. To understand if the     • patient experience                                  state looks like?                              status (see examples on the following page).
     process is improving, we can use statistical      • waiting days                                     b) how do you know where to focus
     methods, programs and charts to                   • staff morale                                        your efforts?
     demonstrate, for example, the number of           • turnaround times                                 c) how are you going to know if you
     patients on a waiting list or turnaround times.   • number of incidents or defects                      have made an impact?
                                                       • number of complaints
     Data and measures are important to                • cost                                             When you have made a small incremental
     demonstrate and factually prove that change       • quality                                          change using the PDCA (PDSA) approach,
     has occurred or needs to occur. Whether the                                                          review your original measures and collect the
     change was a success or a failure, you still      Once you have agreed your aim and                  same data to see if your trial has made a
     need to demonstrate it!                           measures, you will need to collect current         difference.
                                                       state data. It isn’t always easy to collect data
     Before starting your Lean journey, it is
     essential to understand what your aim is and
                                                       for this baseline. If you can’t get the
                                                       information from the electronic systems, you       It is not satisfactory to say “it feels better”,
     what are your measures.                           will need to collect the information manually.
                                                                                                          “I think it’s better”, “it seems better” -
                                                                                                          establish factual data and measures.
Example statistical process control (SPC) charts
                                                                                                                                                                                                                                       Once the raw data has been
     End to end turnaround times                                                                                       SPC showing root cause analysis                                                                                 converted into a graph, the
                                                                                                                                                                                                                                       outliers become visible and root
                                                                                                                                                                                                                                       cause analysis can be carried out
                                                                                                                                                                                                                                       to achieve your aim
                                                                                                                                          Waiting one extra day for                Waiting two extra days for
                                                                                                                                          discharge medication                     physiotherapy assessment

                                                                                                                                 Waiting ten days for
                                                                                                                                 cancelled surgery
                                                                                                                                                                                              Waited for lab results, interventional
                                                                                                                                 Waiting four extra                                           diagnostics and delayed ward round
                                                                                                                                 days for CT scan




                January              February             March               April            May




      Each data point is a consecutively referred patient. This data demonstrates that the process changes implemented has had a positive effect. You can use data to identify the root cause of the problem in the process.




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12                                                                                                                                                     Bringing Lean to Life - Making processes flow in healthcare




     Current state value stream mapping
     A critical starting point in any problem solving   How to make your value stream
     or improvement work is to map the situation        map (VSM):
     (process) in its current state. This should be     • Establish key start and stop points (agree
     done as a team and then added to the A3              the scope)
     document.                                          • Document the key process steps
                                                        • Add the data box below each process step
     One of the tools used to capture the current         (cycle time, batch size at each step, number
     state or ‘as is’ performance is the value stream
     map (VSM).
                                                          of defects/errors at each step and the
                                                          trigger that starts the process step)
                                                                                                         “ If you don’t know where you are going,
     What is value?
                                                        • Add a timeline at the bottom of your VSM
                                                          and below each process step document the         you will probably end up somewhere else.”
     Value can only be defined by the end                 cycle time (how long does it take to process
                                                                                                          Dr Laurence J Peter,
     customer. In healthcare the customer is              accomplish the task?)                           Founder of The Peter Principle
     usually the patient. Value is any activity that    • On the timeline between each process step,
     directly contributes to satisfying needs of the      add the delay which occurs between each
     patient. Any activity that doesn’t add value is      step!
     defined as waste.                                  • Show all information flows
                                                        • Work out the total time taken to get a
     Value stream map                                     patient through the value stream by adding
     A current state value stream map is a visual         all numbers in the timeline
     representation of all the actions currently
     required to deliver a product or a service.
The map documents work activity and the         • Calculate the ‘touch time’ - the time
     movement of information across the entire         actually required to get the patient through     Current state value stream map
     patient pathway from origin to final point of     the value stream if seamless care were being
     delivery.                                         delivered (i.e. all waste removed)
                                                                                                                                                70 per day
                                                     • Agree the value added (VA) activities and                                              (352 per week)
                                                                                                                                                                                             Inpatients
                                                                                                                                                                                                                                                        1 x daily
                                                       the non VA activities, identifying those                                                                                              Outpatients
                                                       ‘must do’s’ (i.e. business essential but not
                                                       really adding value directly to the patient)
                                                     • Determine the percentage of VA activities -
                                                       don’t be surprised if this is very low!
                                                                                                                           36                     36                  409                  64                    61                  136                      13
                                                                                                           Vet referral           Data entry             Book scan               Scan           Dictate report             Type                Verify                Report issue
                                                     Remember
                                                     • Keep your value stream map high level,
                                                       don’t focus on the detail
                                                     • Only focus on the main pathway – what              CT = 120 sec          CT = 60 sec            CT = 60 sec          CT = 15 min         CT = 60 sec           CT = 60 sec          CT = 15 sec              CT = 60 sec
                                                       happens 80% of the time?                           C/O =                 C/O =                  C/O =                C/O =               C/O =                 C/O =                C/O =                    C/O =
                                                     • Collect true and accurate information by           defects = %           defects = %            defects = %          defects = %         defects = %           defects = %          defects = %              defects = %

                                                       walking through the pathway yourself.              Avail =               Avail =                Avail =              Avail =             Avail =               Avail =              Avail =                  Avail =
                                                                                                          Batch = 130           Batch = 100            Batch = 50           Batch = 32          Batch = 12            Batch = 12           Batch = 15-100           Batch = 100

                                                     Why map the value stream?                                            33325                 33325                37861                59245               56468                 12589                   21291
                                                                                                                                                                     7                                                              7
                                                     • The mapping process is a powerful tool to               120                      60                     60                900                    60                    60                   15                       60

                                                       look strategically at your process and quickly                                                                                                                                 Touch time = 1335s (22.2mins)
                                                       identify opportunities for improvement.                                                                                                                                        Flow time = 709703 secs
                                                     • Non value adding activities i.e. wastes can
                                                       be identified and documented.
                                                     • This provides a basis for a discussion around
                                                                                                                                                                                           See page 26 for the value stream mapping symbols
                                                       ‘what should be the process?’


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     Designing the future state value stream map
     Once you understand the current picture of      been have been eliminated, combined and
     what really happens throughout the value        simplified, review the sequence of events to    Future state value stream map
     stream, you can begin to agree what needs       promote efficiency.
     to happen and then analyse the gap between                                                                                   70 per day                   GPs
     the current and future states.                  When designing a future state, the takt time,                              (352 per week)                 Inpatients
                                                     the removal of waste and the introduction of                                                              Outpatients
     From your current state map you will be able    flow must be considered – all of which are                                                                                            1 x daily
     to identify where the significant problems      discussed in this booklet.
     occur. This might be the most prevalent waits
     and delays, the largest amount of work in       The aim is to produce a service where each
     progress between process steps or where         process step links seamlessly to the next, in
     there is considerable duplication.              the shortest amount of time at the highest                                            409                     136
                                                     quality and safety by a group of staff with a                  Booking                         Scanning                  Issue report

     There are four main techniques to design        high morale.                                                                         FIFO
     your future state. Just remember ECSS!
                                                     Once the future state Value Stream Map is
     • Eliminate                                     completed, it is then essential to review                   CT = 120 sec                    CT = 90 min                 CT = 60 sec
     • Combine                                       measures, analyse the gap between current                   C/O =                           C/O =                       C/O =
     • Simplify                                      and future state and then agree an action
                                                                                                                 Uptime =                        Uptime                      Uptime =
     • Sequence                                      plan of PDCA cycles to trial the changes.
                                                                                                                 Avail =                         Avail =                     Avail =

     Where possible, try to eliminate any process    Be clear about the purpose before
                                                                                                                 Batch =                         Batch =                     Batch = 12

     steps. If it isn’t possible to eliminate any    designing the process – then, organise                                               3786                   125897
     steps, look to combine steps. After             the people!
     combining, consider where the system can be                                                                      240                  17            90                          60

     simplified. Once steps in the system have
Standard work to produce high quality every time
     Lean is about the people who perform the        There are three key elements to                  One of the Lean tools which promote
     work. It’s about developing people to be ‘the   standardised work:                               standardisation is 5S, the foundation for
     best’ – utilising their ‘expert talent’ and                                                      safety and quality.
     establishing excellent ways of working.         • Takt time – how fast we should be
                                                       working                                        Standardised work:
     Standard work is about establishing out         • Work sequence – the order that work            • Ensures safety and maintains high quality
     of all the possible ways, the best work           should be done                                   and efficiency
     method of conducting a task and then            • Work in progress – defining the                • Ensures process stability and therefore
     ensuring that everyone always works to            working inventory to make                        repeatability
     this gold standard.                               abnormalities obvious.                         • Allows us to assess if we are in control,
                                                                                                        ahead or behind schedule
     The gold standard should have the least         It is important to understand that standard      • Preserves the organisational expertise
     amount of waste, with the highest quality       work is not static. Standards are actually the   • Allows us to identify and rectify problems
     and safety. These standard procedures create    basis for subsequent improvements. Once a        • Provides a gauge by which we can error
     stability and consistency in the system to      better method is found, the team should            proof for the future
     produce high performance results every time.    agree on the new standard, update the            • Gives us a baseline from which to
                                                     processes, procedures and visual management        measure improvement and continually
                                                     and then ensure that it is adopted by all.         strive for a better way
                                                                                                      • Provides a basis for employee training.
                                                     Standardisation should exist for every process
                                                     including meetings, health and safety
                                                     procedures, budget reports, audits, all
                                                     paperwork etc.


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16                                                                                         Bringing Lean to Life - Making processes flow in healthcare




     Visual management
     Visual management is everywhere, from the        Visual management allows teams to:
     green man at the cross the roads, to the
     numbers on the front of busses, petrol           • See the work in progress
     indicator lights in cars, a water level on a     • Recognise flow stoppers
     kettle, to a cricket scoreboard. These visual
     indicators allow us to easily understand the     • Assess inventory levels
     situation and take action where necessary.       • Identify defects

     Visual management is a simple, yet highly        • See deviations from the standard
     effective way of indicating what should          • Enable interventions
     happen (by setting a standard) and what
     is actually happening in the work                • Improve safety.
     environment.

     At a glance, colleagues, supervisors, managers
     and visitors to the area should be able to
     understand the process and see what is under
     control and what isn’t without having to ask a
     question.
There are two types of visual                    Visual management can be used to answer
     management:                                      the following questions. Give some thought    Cytology request form: Visual management has been sent
                                                      to how you could use visual management to     to smear takers to ensure zero defects on the request form.
     • Visual display, which is the provision         answer the following questions in your work
       of information                                 area:
     • Visual control which is associated
       with action.                                   1 Are we up to date with the work?
                                                      2 What are our three biggest problems
     Both these types of visual management gain         in the area and what is being done
     the maximum amount of information, without         to resolve these problems?
     having to leave the work environment or          3 How do you know that your ideas
     access a computer system.                          have been listened to?
                                                      4 How can you tell who is trained to
     Visual management provides the knowledge           perform each task?
     and certainty to make staff and patients lives   5 Is there daily accountability? Who is
     safer.                                             it today?
                                                      6 How do you know where staff are –
                                                                                                                                                                  Communication board
                                                        breaks, annual leave, study leave?
                                                                                                                                                                  The board keeps all team members up to date with
                                                      7 How do you know if the stock has
                                                                                                                                                                  the recent data, changes and improvements made,
                                                        been ordered?
                                                                                                                                                                  5S scores, team ideas which includes action taken
                                                                                                                                                                  against the ideas.




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18                                                                                                                                                                                                                          Bringing Lean to Life - Making processes flow in healthcare


     Identifying waste
     The elimination of waste is the main                                                                         These wastes can be remembered by                       I   INVENTORY
                                                                                                                                                                                                                                   M   MOTION
     characteristic of Lean. Waste is                   Elimination of waste                                      remembering the name TIM A WOODS (this                      Inventory is work in progress and stock. A               The waste of motion is any unnecessary
     everything that doesn’t add value                                                                            came from Lean office at Cooper Standard,              common problem is lack of space. By reducing             movement by people. This is mainly related to
     to the patient or process.                                                                                   Plymouth UK).                                          inventory and by combining process steps, staff          poor ergonomics, bending, stretching, moving
                                                        Eliminate                                  Minimise                                                              have more space to carry out duties in a safer           items etc.
                                                                                                                                                                         working environment.
     There are three types of work:                                                                                    TRANSPORT                                                                                                  How many times during your shift do you have to
     1) Value add – When you are adding value                                                                      T   Transport is the unnecessary movement of
                                                                    Unnecessary        Necessary                                                                         How frequently do you run out of supplies only to        get up and walk to use a certain piece of
     to the patient/process (e.g. prescribing                         waste             waste                     items and materials. How often do we see people        find another department has stock?                       equipment just because it is located in the wrong
     medication, providing physiotherapy,                                                                         moving items (notes, reports, slides, supplies etc.)                                                            place? How often do you find yourself searching
     reporting an image)                                                                                          from one locality to another - and back again?         For example:                                             for vital items because they were not put back in
                                                                                                                  Stand for a short while in a hospital corridor and     • Over-ordering - consumables, paper                     the right place?
                                                                               Value                              observe these activities - you’ll be surprised.        • Different batch sizes at each step
     2) Necessary waste – This is when you are
                                                                                                                                                                         • Overstocked medication on wards                        For example:
     not adding value but it is a necessary step.                                                                 For example:                                           • Overstocked items in the supplies department           • Poor layout of wards/surgeries/departments
     (e.g. incubation in a microbiology laboratory,                                                               • Moving drugs, samples, equipment, supplies             because it was cheaper to buy in bulk without            /laboratories
     vetting requests prior to radiology                                                                            excessively around the hospital                        thinking about the costs of storage, stock taking      • Searching for equipment or stock
     examination)                                                           Maximise                              • Moving paper notes excessively                         and distribution                                       • Location of printers, faxes, copiers and
                                                                                                                  • Transporting samples from one location or            • Staff hiding extra stock for ‘just in case’.             computers
     3) Unnecessary waste – This is where you                                                                       site to another.                                                                                              • Looking for information and people.
     are not adding value and these steps could be    There are two other recognised wastes:                                                                             Remove the waste of inventory by:
                                                                                                                  Remove the waste of transport by:                      • Implementing the Lean tool of 5S                       Remove the waste of motion by:
     removed (e.g. walking to get or find items,      the waste of unused staff creativity (skills utilisation)   • The elimination of process steps and hand offs       • Establish visual systems (kanbans) - aids visibility   • Introducing standard layout
     waiting for consultants/medication).             and automating an already inefficient process:              • Co-locating departments/processes/supplies             for stock counting                                     • Introducing a standard way of working
                                                                                                                  • Introducing work cells.                              • Understand what is needed to keep up                   • Developing flow in work cells
     Researchers have found that there are seven                                                                                                                         • Establish first in first out principle with demand -   • Initiate and sustain 5S.
     main wastes and over the years other wastes                                                                                                                           implement ‘just In time’
     have been added.                                                                                                                                                    • Keep stock audits correct and current.
AUTOMATING                                         For example:                                           For example:                                          Remove the waste of over production by:                      SKILLS UTILISATION
      A    Automation of poor processes just serves to        • Waiting for shared equipment (telephone/             • Duplicate testing/inappropriate testing             • Remove all unnecessary paperwork
                                                                                                                                                                                                                                   S    Every department has unused staff potential.
     automate waste. The poor understanding of work             computers)                                           • Duplicate data entry                                • Reduce batching - establish a visual system          There is someone in every department that knows
     content and takt time can result in purchase of          • Staff waiting for machines, deliveries, other        • Duplication of checking cards/slides                • When the process can’t flow, introduce               the issues and has the possible solutions. If only
     large pieces of expensive equipment that actually          members of staff                                     • Excessive bed moves                                   ‘pull’ systems with buffers and kanban’s.            they were asked, listened to and action was taken -
     hinders flow of the overall process. The result, is an   • Waiting for decisions                                • Excessive paperwork                                                                                        the people doing the job are the experts.
     expensive poor process!                                  • Waiting for others at meetings                       • Manual checking electronic data                            DEFECTS
                                                              • Patients waiting for appointments, in emergency
                                                                                                                                                                            D     Defects are all the errors that compromise      Unused skills and creativity also include highly
     For example:                                               departments/clinics, waiting for discharge           Remove the waste of over processing by:               quality, safety, cost and staff time. Make it right,   skilled staff undertaking duties that do not reflect
     • Did radiology reporting times reduce when              • Samples waiting in a batch to be analysed            • Eliminate non-value added steps                     first time, every time.                                there skills, e.g. band 8 staff routinely performing
       PACS was implemented?                                    in the laboratory                                    • Combine process steps and paperwork                                                                        band 3 duties.
     • Do samples get turned around any quicker with          • Requesters waiting for results or medication.        • Simplify tasks                                      Do you tolerate errors by reworking someone else’s
       track systems purchased and implemented in                                                                                                                          mistakes? How often do you accept incomplete or        How many times do we see supervisors/managers
                                                              Remove the waste of waiting by:
       biochemistry?
                                                              • Leveling the workload and balancing operations
                                                                                                                      O OVER PRODUCTION doing too much, too
                                                                                                                          Over production is about
                                                                                                                                                                           inaccurate requesting information?                     routinely booking appointments?

                                                              • Eliminating or reducing batch sizes                  soon or ‘just in case’.                               For example:                                           The intellect and skill of staff should be used to
           WAITING
     W     The waste of waiting usually transpires when       • Eliminating hand-offs.                                                                                     • Wrong patient, wrong test, wrong procedure,          guide the continuous improvement of procedures
                                                                                                                     How many times do we complete the same                  wrong form                                           and processes. The inclusion and insistence of staff
     there is an in balance of process steps which all
                                                                   OVER PROCESSING                                   information and have to file it or store it in many   • Inappropriate/inadequate referrals                   in problem solving and decision making will also
     take different timings or the batch sizes are             O   The waste of over processing is all the things    different ways? How often do we see queues build      • Chasing inadequate patient information               support recruitment, retention and improve morale.
     different in each process step. The waste of
                                                              we do that don’t add any value to the process -        up in one part of the process because the previous    • Repeated checking
     waiting has a direct impact on flow as waiting
                                                              producing excess.                                      department kept producing more, regardless of         • Medication errors.
     creates a ‘stop-start’ process.
                                                                                                                     whether subsequent processes were ready or could
                                                              How many tasks are repeated simply because we          cope?                                                 Remove the waste of defects by:
     Do you ever find yourself becoming frustrated and                                                                                                                     • Making the system mistake proof
                                                              don’t have a system to ensure it serves the needs of
     your working day hindered because you are                                                                       For example:                                          • Introducing a zero tolerance to defects
                                                              the patient or process throughout the whole
     waiting for a colleague to do their role or for a                                                               • Making more than, faster than, earlier than is      • Introduce standard work to ensure the same
                                                              healthcare journey?
     machine to finish?                                                                                                required by the next process step                     process is completed every time ensuring high
                                                                                                                     • Duplicate entries in medical records                  quality process repeatability.
                                                                                                                     • Paper copies of results sent along with an
                                                                                                                       electronic copy
                                                                                                                     • Repeating tests before next test scheduled.

19
20                                                                                                    Bringing Lean to Life - Making processes flow in healthcare


     Making value flow
     Flow is the continual movement of value        To promote flow, batches should be reduced
     adding activities from the beginning to        and where possible removed to achieve the
     the end of the value stream.                   optimal flow - one piece flow. When flow is
                                                    achieved, it becomes easier to spot problems
     Processes which add value to the patient       and patients are no longer unnecessary held
     should not be held up by any non value         up in the health system.
     adding steps or waste in the system. Waste
     and non-value-adding steps create a ‘stop-     All Lean tools work towards promoting flow.
     start’ effect which prevents the flow of       Visual management can be used to highlight
     value adding steps the value stream.           flow stoppers. Standard work can be used to
                                                    ensure processes are repeatable and reliable,
     Systems which promote batching hinder flow,    with no variation. 5S can support workplace
     create waste and queues. Batching can be       organisation ensuring no time is lost trying to
     seen across healthcare. For example, ward      find the right tools to do the job.
     rounds completed at the same time of day
     causes a batch of work for the nursing staff
     and every support service that follows i.e.
     Pathology, Radiology and Pharmacy.
Understanding pull
     Flow and pull work to keep the entire value      stabilised. Over time, the buffer should be
     stream moving. Flow is the goal, but on          gradually reduced and ultimately removed.
     occasion, flow may not be achievable and in
     these situations the concept of pull can be      Kanban
     introduced to respond to demand.                 Kanban signs/signals are a form of pull. These
                                                      visual signs are mechanisms for the patient or
     Pull is a short term notion to gain control      internal customer (ie ward nurse, radiologist,
     and process stability.                           discharge staff) to say “I am ready for more.”

                                                                                                       “ Flow where you can, pull
                                                      There are many different forms of Kanban –
     Pull works with buffers and kanbans:             an empty container, a box, a marked area, an
                                                      empty shelf or a card.
     Buffer
     A buffer is a clearly defined holding area at
                                                                                                         where you must”
     the interface between two processes allowing                                                       Jeffery K. Liker, The Toyata Way, 2004
     patients, paperwork, information or items to
     wait for a defined amount of time between
     two process steps. A buffer could be a
     waiting room, empty beds, trolleys or chairs,
     or even a space for stock and inventory.
     Buffers are actually a ‘waste’ and should only
     be introduced when flow is not possible and
     the process needs to be controlled and



21
22                                                                                                                                                                                       Bringing Lean to Life - Making processes flow in healthcare


     Understanding takt time
     Takt time is simply the rate at which we          Every seven minutes a patient should move
     need to work to keep up with demand.              through the scanning process – this is the
                                                       takt time.
     The calculation for takt time is:                                                                              20
                                                       The cycle time is the time it takes to actually
        Available work time                            ‘do’ the task and the aim is to match (where
                                     = takt time                                                                    15
               Demand                                  possible) takt time.




                                                                                                          Minutes
     This sounds too simple, yet the ability to        If the cycle time is going to be identical to or             10
     achieve takt is the fundamental question to       less than takt, all the non value adding                                                                         Takt
     whether the system is set up to deliver what is   activities need to be removed from each
     required. If teams can not achieve takt, waste    step. Only when the non value adding                         5
     in the system needs to be removed and each        activities have been removed from each step
     process step needs to be levelled to ensure       should additional resources be considered.                   0
     takt is met.                                                                                                        Vet   Protocol   Book   Scan   Report   Type   Verify   Issue
                                                       As you can see from the graph on the right,
     Worked example:                                   the team would possibly need to either
     A scanning department is open and staffed         extend scanning hours or secure additional
     for seven hours per day has a daily demand of     scanning resource. The team would also
     60 referrals.                                     need more than one consultant reporting
                                                       in order to achieve takt.
                    7 hours     420 min
     Takt time =                          = 7 min
                       60          60
Using 5S to improve safety
     5S has traditionally been thought of as being   5S - What does it mean? How do I do it?
     just a ‘tidy up’, but when approached
     properly it is much more than that.               Sort                                                                                     Shine
                                                       ‘When in doubt, move it out!’                                                            ‘Lean means clean’
     5S is the basis for standardising work
                                                       1) Remove everything from the defined area.                                              1) Clean the area – it should be easier to clean now you have removed the clutter and
     and is used to improve efficiency by              2) Only return what is necessary for the daily duties.                                      every item has a location.
     eliminating waste, promoting flow,                3) Discard any broken, unnecessary items – e.g. clutter, old equipment, old              2) Develop a plan where cleaning is incorporated into the daily routine.
     improving staff morale and most                      unused paperwork.
     importantly improving safety.                     4) Move any items that you are unsure of into a holding bay for a team decision.         Standardise
                                                       5) If shelving or cupboards are not used or required, remove them too – this will        Create a consistent approach for carrying out tasks and procedures.
     Ultimately, it is about making the                   prevent unwanted items being stored there.
     processes and environment safe.                   6) Items necessary to complete the job need to be ‘set in order’ 2S                      Sustain
                                                                                                                                                ‘Sustain all gains through self discipline’
                                                       Set in order
                                                                                                                                                Make 5S become a way of life by:
                                                       ‘A place for everything and everything in its place.’
                                                                                                                                                1) Practicing and repeating the process.
                                                                                                                                                2) Educating all staff
                                                       1) Give every item a location - Items used on a regular /daily basis need to be placed
                                                                                                                                                3) Linking 5S directly to the day job
                                                          within arms length / accessible location
                                                                                                                                                4) Empowering staff to improve and maintain their workplace.
                                                          - Items used on a weekly basis should be stored on a shelf or in a cupboard in the
                                                            work environment.                                                                   When employees take pride in their work and workplace it can lead to greater job
                                                          - Items used on a monthly, quarterly or annual basis should be stored in an           satisfaction and higher productivity.
                                                            appropriate location – possibly outside the work area.
                                                       2) Mark off (with electrical tape or permanent marker) and label each location



23
24                                                                                                                                                                                                 Bringing Lean to Life - Making processes flow in healthcare


     Plan, Do, Check, Adjust (PDCA) Sometimes called a Plan, Do, Study, Act (PDSA)
     Change on a large scale can be daunting but        P - Plan
     you should not let that deter you.                 This is the most important part of the process.
     Before implementing a full proposal for            • What you are planning to trial?
     change a PDCA cycle (sometimes called              • What are your objectives?
                                                                                                                                                                                A P
     a Plan, Do, Study, Act (PDSA) cycle) can           • Who is needs to be involved/informed?                                                                                 C   D
     be used. A PDCA (PDSA) cycle will                  • How are you going to do it?




                                                                                                                                                                           D
     provide the opportunity to test out an             • How long will the trial run?                                 ADJUST        PLAN




                                                                                                                                                                       P
     idea on a small scale, without risking too         • How are you going to measure improvement?




                                                                                                                                                                            C
                                                                                                                                                                        A
     much.                                              • What is your communication plan?




                                                                                                                                                               C
                                                        D - Do




                                                                                                                                                                   A
     New ideas should be introduced only after




                                                                                                                                                              D
                                                        • Test the change and collect the data                          CHECK         DO
     sufficient testing (or evidence) on a smaller




                                                                                                                                                                  P
     scale has proven to have a positive effect.
                                                        C - Check
     PDCA (PDSA) cycles allow us to introduce an
                                                        • Analyse the data you collected in the ‘plan’
                                                                                                                                                     A P
     idea in a safe, controlled way which will have
     less resistance, be less disruptive and use less
                                                          and ‘do’ phase                                                                             C    D
                                                        • Discuss outcomes with colleagues?
     resources. By building on the learning from
                                                        • What went well?
     each PDCA (PDSA) cycle, new processes can
                                                        • What went wrong?
     be introduced with a greater chance of
                                                        • Did anything unexpected happen?
     success.                                                                                             A - Adjust                                      • If the change was a measurable success,
                                                        • Could the process be improved?
                                                                                                          • If the trial did not improve the process,       adopt and spread the improvement in your
                                                        • If the trial didn’t go to plan, what was the
                                                                                                            could you treat the root cause in your next     PDCA (PDSA) cycle.
                                                          root cause?
                                                                                                            PDCA (PDSA) cycle?
Continuous improvement
     Continuous improvement is the final lean
     principle, which is to strive for perfection
     through continuous improvement. This is
     done by embracing the Lean philosophy
     and tools as described in this booklet.

     The staff are a fundamental part of Lean. It is
     important to develop staff and give them the
                                                       The key to success is                            During your Lean journey, don’t lose sight of
                                                                                                        perfection and what perfection means:
                                                                                                                                                        Act like a sponge - soak
     capability, autonomy and empowerment to
     solve the problems as they encounter them on
                                                       small, daily incremental                         • the right patient journey
                                                                                                                                                        it up and squeeze out
     a daily basis. Teaching and expecting rigorous
     problem solving by all staff is the only          improvements.                                    • the right support services when they
                                                                                                          are required by the patient                   improvements everyday
     sustainable way to strive for perfection.                                                          • the highest level of quality and safety
                                                                                                        • no defects or incidences
     Communication is imperative to develop staff      For Lean to be a success, the Lean culture       • delivered at the right price
     to continually improve the process.               needs to be accepted and embraced by all.        • delivered by a staff group with high
     A five minute daily meeting for all staff                                                            morale and pride in their work.
     around a central communication board to           When implemented, the tools and techniques
     discuss real time issues relating to waiting      can have an immense beneficial effect, but to
     times, quality, safety, morale and cost is        be sustainable, they need to be applied with a
     essential to ensure the work for that shift/day   Lean culture.
     proceeds as planned.


25
26                                                                                                                                  Bringing Lean to Life - Making processes flow in healthcare


     Value stream mapping symbols
       Data entry     Cycle time =                                                                                        FIFO
                                                                  W             i
                      Batch size =                                                                                   First-in First-out
                                     GP Surgery                                                                          Sequence
                      Defects   =                              Wait/delay   Inventory     Transport      Ambulance
                                                        Pull
                                                                                                                                             Information      Supermarket
       Process Step   Trigger   =                                                                                                               Bursts
                                                                                                                        Electronic
                                     Outside Agencies                                                                  Information                                           Buffer
                         Data Box                       Push    People      “Go See”    Load Levelling   Work Cell       Transfer             Paper Flow
Acknowledgements
     This document has been written in partnership by:

     Lisa Smith
     National Improvement Lead
     Email: lisa.smith@improvement.nhs.uk

     Zoe Smith
     National Improvement Lead
     Email: zoe.smith@improvement.nhs.uk




27
NHS
CANCER   DIAGNOSTICS   HEART   LUNG   STROKE                                                                                         NHS Improvement

                                               NHS Improvement

                                               With over ten years practical service improvement experience in cancer, diagnostics
                                               and heart, NHS Improvement aims to achieve sustainable effective pathways and
                                               systems, share improvement resources and learning, increase impact and ensure value
                                               for money to improve the efficiency and quality of NHS services.

                                               Working with clinical networks and NHS organisations across England, NHS
                                               Improvement helps to transform, deliver and build sustainable improvements across
                                               the entire pathway of care in cancer, diagnostics, heart’ lung and stroke services.




Delivering tomorrow’s                          NHS Improvement
                                               3rd Floor | St John’s House | East Street | Leicester | LE1 6NB
improvement agenda                             Telephone: 0116 222 5113 | Fax: 0116 222 5101

for the NHS                                    www.improvement.nhs.uk
                                               ©NHS Improvement 2010 | All Rights Reserved | May 2010

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Bringing lean to life

  • 1. NHS CANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement Bringing Lean to Life Making processes flow in healthcare
  • 3. Bringing Lean to Life - Making processes flow in healthcare Contents Introduction - what is the problem in healthcare? 4 Identifying waste 18 What is Lean? 6 Making value flow 20 A3 thinking 7 Understanding pull 21 An example A3 report 8 Understanding Takt time 22 The importance of data and measures 10 Using 5S to improve safety 23 Example statistical process control (SPC) charts 11 Plan Do Check Adjust (PDCA) cycle 24 Current state value stream mapping 12 Continuous improvement 25 Designing the future state value stream map 14 Value stream mapping symbols 26 Standard work to produce high quality every time 15 Acknowledgements 27 Visual management 16 3
  • 4. 4 Bringing Lean to Life - Making processes flow in healthcare Introduction - what is the problem in healthcare? We all come to work to do our very best - to The ‘processes’ are to blame not the people achieve what we are capable of and to add real value for our patients and ensure clinical Often, there is ambiguity in how certain tasks should be performed – so people work it out “…the best hope for expertise is supported by process excellence to enable healthcare processes to flow at the rate of patient demand - no one wants to get for themselves to secure the best outcome and get the job done. However, whilst saving lives lies in it wrong. Healthcare teams are dedicated and skilled professionals who are often under everyone develops their own bespoke solution, the variations introduced by different raising performance…” pressure to do their best and work terrifically people can be significant and harmful. Atul Gawande, Better, 2007 hard - but often with inadequate processes. Departments continue to work hard and in Each year, the National Patient Safety Agency isolation to ensure they improve their services handles over one million reported medical and practices. However, such silo’s often NHS Improvement has been using Lean with incidents in England alone. Figures illustrate mean that any good practice is lost which clinical teams and has proven that it can that approximately one in every ten patients increasingly impacts upon the patient flow improve quality, increase safety, reduce are unintentionally harmed by their healthcare between services. turnaround times, increase efficiency and providers. Most of these are not necessarily productivity, improve staff morale and reduce the result of medical errors or poor clinical This booklet provides a basic introduction and costs. The NHS Improvement website decisions, but are caused simply by the way overview of Lean; the culture, principles and www.improvement.nhs.uk has details of the system has been set up. tools to understand, tackle and resolve issues numerous case studies and recommended within healthcare. It is not intended as a reading. complete guide to implementing Lean as a management system. Together we can’t afford not to change!
  • 5. Improvement usually means doing something that we have never done before. ” Shigeo Shingo 5
  • 6. 6 Bringing Lean to Life - Making processes flow in healthcare What is Lean? Lean was a term coined by researchers when In short, Lean is about building the problem studying the philosophy of the management solving capabilities of the team to produce Specify VALUE from system in place at Toyota and the culture they experts who can perform daily work to the the customer viewpoint had created amongst their workers to improve best standard – everyday. processes which led to the final product. Pursue PERFECTION Identify the These key steps and the necessary tools to in quality & quantity VALUE STREAM by continuous and remove The researchers noticed five key steps were in implement Lean are explained in this booklet. improvement waste Problem Solve problems by place to deliver what the customer wanted at root cause analysis solving the highest quality and safety level possible, Introduce Standard Working with the lowest associated costs from a workforce which also had high morale. Lean is the continuous and Remove Waste Set Up Visual Management Eliminate Batching People and Partners Respect, challenge and grow them systematic elimination of Eliminate waste. Identify Root Cause Right process will Process The five steps were: deliver right result Long-term thinking. Philosophy waste Continuous 1 Specify value improvement 2 Identify the value stream steps initiate PULL in line Make value Ref: Liker, 2004 with customer demand FLOW 3 Make value flow 4 Supply what is pulled by the customer 5 Continually improve and strive for perfection.
  • 7. A3 thinking All Lean improvement work should begin with The A3 report is literally a one-page document just on a single sheet of paper requires concise The A3 represents the shared consensus A3 thinking as it is a methodical approach to (11 x 17 inch [A3] sheet of paper) that records information. This prevents excessive amounts towards solving the problem. As a document, problem solving. the agreed points of discussion in a systematic of information being overwhelming, it encourages reflection on the learning that way. misinterpreted and incorrect conclusions being has taken place and ensures that a consistent Lean is primarily the description of a reached. message is discussed and scrutinized. methodology to routinely solve problems The structure of the A3 (see pages 8 and 9) everyday so that the work is delivered to takes individuals and teams through the The best A3s: For an A3 to work, the whole team needs to specification. A3 thinking is the rigorous process of agreeing the problem statement or • are handwritten in pencil with minimum text contribute and agree. application of something known as the Plan, issue, reviewing and analysing the current • contain pictures/diagrams to convey the Do Check, Adjust (PDCA) approach. state and identification of a desired future problem state with a subsequent action plan for any • are concise and hold all the relevant Top tips The PDCA (PDSA) cycle provides a means of agreed actions. information • Teach, coach and use A3 thinking as a standard tool for all new conducting safe experimentation or a number • represent the shared consensus projects and problem solving of trials to see the effect of any changes made Describing the entire process from current • do not need verbal explanation in a bid to make improvement (see page 24). state, through analysis and onto future state • are agreed by the entire team. • Complete the A3 report with a pencil (corrections can be made following further consensus with the team) • This is a working document – each box should contain only the information that has been agreed • Resist the temptation to ‘type’ up the report. If an electronic version is required, consider taking a digital photograph instead to share across the wider organisation. 7
  • 8. 8 Bringing Lean to Life - Making processes flow in healthcare An example A3 report NHS A3 Lean Improvement NHS Improvement Department Cervical Cytology Department Date: May 2010 Author: Define the problem/opportunity: (Why are you talking about it? What are you trying to solve/improve?) Team members: Agreed by: Version: Waiting times for turning around cervical screening samples are protracted. This could potentially delay any treatment required by the woman. Future state: (What will it look like? Be visual - future state value stream map) Current state: (What happens now? Be visual - value stream map, graphs, facts and measurements etc.)
  • 9. Action plan Action - what, why and how? Who? When? Progress status (ie completed, in progress) Goal: (State the specific target(s). State in measurable or identifiable terms) Establish core transport group RG Jan 2010 Completed 100% in 14 days 50% in 7 days Implement zero tolerance policy of defects from 1˚ Care AS Jan 2010 Completed Zero defects Reduce backlog Goal V actual measures GF Mar 2010 Ongoing Waste identified: (Transport, Inventory, Motion, Automation, Waiting, Overproduction, Overprocessing, Defects, Skills.) Capacity and demand GF Feb 2010 In progress Transportation – up to 15 days ‘lost’ Reduce batch sizes from 16 to 8 AS Mar 2010 In progress Waiting – average TATs of 41 days from specimen taken to report issued Introduce water strider AS Apr 2010 Ongoing Defects – 40% defects received from primary care Results and measures: (What was your PDSA cycle? How long did you run it for? What data did you collect before and after the change? What did you find? Add charts, tables, and cost benefit analysis) Root Cause Analysis: (What is the root cause of the problem? Use fishbone/cause and effect diagram, five why analysis) Transport group Zero tolerance policy has reduced delivery reduced defects from 40% times by an to 20% within 6 weeks, average of 12 with a further reduction in days 10% anticipated within next 2 weeks Next steps: (Are there any remaining issues/problems? Is there any further follow up required?) Levelled workloads are required in laboratory. This is being taken up by laboratory subgroup – April 2010. 9
  • 10. 10 Bringing Lean to Life - Making processes flow in healthcare The importance of data and measures In healthcare, we are used to taking clinical Measures might include: Manual data collection might feel like hard Data analysis doesn’t need to be complicated. measures such as temperature, pulse, blood • numbers of patients on waiting lists work at the time, but if you don’t collect this Line graphs, bar charts, scatter graphs and pressure, respiration rates, urine outputs etc. • staff numbers information before you start: statistical process control charts can all be in order to understand if the condition is • hours worked a) how will you know what your current used to visually show the before and after getting better or worse. To understand if the • patient experience state looks like? status (see examples on the following page). process is improving, we can use statistical • waiting days b) how do you know where to focus methods, programs and charts to • staff morale your efforts? demonstrate, for example, the number of • turnaround times c) how are you going to know if you patients on a waiting list or turnaround times. • number of incidents or defects have made an impact? • number of complaints Data and measures are important to • cost When you have made a small incremental demonstrate and factually prove that change • quality change using the PDCA (PDSA) approach, has occurred or needs to occur. Whether the review your original measures and collect the change was a success or a failure, you still Once you have agreed your aim and same data to see if your trial has made a need to demonstrate it! measures, you will need to collect current difference. state data. It isn’t always easy to collect data Before starting your Lean journey, it is essential to understand what your aim is and for this baseline. If you can’t get the information from the electronic systems, you It is not satisfactory to say “it feels better”, what are your measures. will need to collect the information manually. “I think it’s better”, “it seems better” - establish factual data and measures.
  • 11. Example statistical process control (SPC) charts Once the raw data has been End to end turnaround times SPC showing root cause analysis converted into a graph, the outliers become visible and root cause analysis can be carried out to achieve your aim Waiting one extra day for Waiting two extra days for discharge medication physiotherapy assessment Waiting ten days for cancelled surgery Waited for lab results, interventional Waiting four extra diagnostics and delayed ward round days for CT scan January February March April May Each data point is a consecutively referred patient. This data demonstrates that the process changes implemented has had a positive effect. You can use data to identify the root cause of the problem in the process. 11
  • 12. 12 Bringing Lean to Life - Making processes flow in healthcare Current state value stream mapping A critical starting point in any problem solving How to make your value stream or improvement work is to map the situation map (VSM): (process) in its current state. This should be • Establish key start and stop points (agree done as a team and then added to the A3 the scope) document. • Document the key process steps • Add the data box below each process step One of the tools used to capture the current (cycle time, batch size at each step, number state or ‘as is’ performance is the value stream map (VSM). of defects/errors at each step and the trigger that starts the process step) “ If you don’t know where you are going, What is value? • Add a timeline at the bottom of your VSM and below each process step document the you will probably end up somewhere else.” Value can only be defined by the end cycle time (how long does it take to process Dr Laurence J Peter, customer. In healthcare the customer is accomplish the task?) Founder of The Peter Principle usually the patient. Value is any activity that • On the timeline between each process step, directly contributes to satisfying needs of the add the delay which occurs between each patient. Any activity that doesn’t add value is step! defined as waste. • Show all information flows • Work out the total time taken to get a Value stream map patient through the value stream by adding A current state value stream map is a visual all numbers in the timeline representation of all the actions currently required to deliver a product or a service.
  • 13. The map documents work activity and the • Calculate the ‘touch time’ - the time movement of information across the entire actually required to get the patient through Current state value stream map patient pathway from origin to final point of the value stream if seamless care were being delivery. delivered (i.e. all waste removed) 70 per day • Agree the value added (VA) activities and (352 per week) Inpatients 1 x daily the non VA activities, identifying those Outpatients ‘must do’s’ (i.e. business essential but not really adding value directly to the patient) • Determine the percentage of VA activities - don’t be surprised if this is very low! 36 36 409 64 61 136 13 Vet referral Data entry Book scan Scan Dictate report Type Verify Report issue Remember • Keep your value stream map high level, don’t focus on the detail • Only focus on the main pathway – what CT = 120 sec CT = 60 sec CT = 60 sec CT = 15 min CT = 60 sec CT = 60 sec CT = 15 sec CT = 60 sec happens 80% of the time? C/O = C/O = C/O = C/O = C/O = C/O = C/O = C/O = • Collect true and accurate information by defects = % defects = % defects = % defects = % defects = % defects = % defects = % defects = % walking through the pathway yourself. Avail = Avail = Avail = Avail = Avail = Avail = Avail = Avail = Batch = 130 Batch = 100 Batch = 50 Batch = 32 Batch = 12 Batch = 12 Batch = 15-100 Batch = 100 Why map the value stream? 33325 33325 37861 59245 56468 12589 21291 7 7 • The mapping process is a powerful tool to 120 60 60 900 60 60 15 60 look strategically at your process and quickly Touch time = 1335s (22.2mins) identify opportunities for improvement. Flow time = 709703 secs • Non value adding activities i.e. wastes can be identified and documented. • This provides a basis for a discussion around See page 26 for the value stream mapping symbols ‘what should be the process?’ 13
  • 14. 14 Bringing Lean to Life - Making processes flow in healthcare Designing the future state value stream map Once you understand the current picture of been have been eliminated, combined and what really happens throughout the value simplified, review the sequence of events to Future state value stream map stream, you can begin to agree what needs promote efficiency. to happen and then analyse the gap between 70 per day GPs the current and future states. When designing a future state, the takt time, (352 per week) Inpatients the removal of waste and the introduction of Outpatients From your current state map you will be able flow must be considered – all of which are 1 x daily to identify where the significant problems discussed in this booklet. occur. This might be the most prevalent waits and delays, the largest amount of work in The aim is to produce a service where each progress between process steps or where process step links seamlessly to the next, in there is considerable duplication. the shortest amount of time at the highest 409 136 quality and safety by a group of staff with a Booking Scanning Issue report There are four main techniques to design high morale. FIFO your future state. Just remember ECSS! Once the future state Value Stream Map is • Eliminate completed, it is then essential to review CT = 120 sec CT = 90 min CT = 60 sec • Combine measures, analyse the gap between current C/O = C/O = C/O = • Simplify and future state and then agree an action Uptime = Uptime Uptime = • Sequence plan of PDCA cycles to trial the changes. Avail = Avail = Avail = Where possible, try to eliminate any process Be clear about the purpose before Batch = Batch = Batch = 12 steps. If it isn’t possible to eliminate any designing the process – then, organise 3786 125897 steps, look to combine steps. After the people! combining, consider where the system can be 240 17 90 60 simplified. Once steps in the system have
  • 15. Standard work to produce high quality every time Lean is about the people who perform the There are three key elements to One of the Lean tools which promote work. It’s about developing people to be ‘the standardised work: standardisation is 5S, the foundation for best’ – utilising their ‘expert talent’ and safety and quality. establishing excellent ways of working. • Takt time – how fast we should be working Standardised work: Standard work is about establishing out • Work sequence – the order that work • Ensures safety and maintains high quality of all the possible ways, the best work should be done and efficiency method of conducting a task and then • Work in progress – defining the • Ensures process stability and therefore ensuring that everyone always works to working inventory to make repeatability this gold standard. abnormalities obvious. • Allows us to assess if we are in control, ahead or behind schedule The gold standard should have the least It is important to understand that standard • Preserves the organisational expertise amount of waste, with the highest quality work is not static. Standards are actually the • Allows us to identify and rectify problems and safety. These standard procedures create basis for subsequent improvements. Once a • Provides a gauge by which we can error stability and consistency in the system to better method is found, the team should proof for the future produce high performance results every time. agree on the new standard, update the • Gives us a baseline from which to processes, procedures and visual management measure improvement and continually and then ensure that it is adopted by all. strive for a better way • Provides a basis for employee training. Standardisation should exist for every process including meetings, health and safety procedures, budget reports, audits, all paperwork etc. 15
  • 16. 16 Bringing Lean to Life - Making processes flow in healthcare Visual management Visual management is everywhere, from the Visual management allows teams to: green man at the cross the roads, to the numbers on the front of busses, petrol • See the work in progress indicator lights in cars, a water level on a • Recognise flow stoppers kettle, to a cricket scoreboard. These visual indicators allow us to easily understand the • Assess inventory levels situation and take action where necessary. • Identify defects Visual management is a simple, yet highly • See deviations from the standard effective way of indicating what should • Enable interventions happen (by setting a standard) and what is actually happening in the work • Improve safety. environment. At a glance, colleagues, supervisors, managers and visitors to the area should be able to understand the process and see what is under control and what isn’t without having to ask a question.
  • 17. There are two types of visual Visual management can be used to answer management: the following questions. Give some thought Cytology request form: Visual management has been sent to how you could use visual management to to smear takers to ensure zero defects on the request form. • Visual display, which is the provision answer the following questions in your work of information area: • Visual control which is associated with action. 1 Are we up to date with the work? 2 What are our three biggest problems Both these types of visual management gain in the area and what is being done the maximum amount of information, without to resolve these problems? having to leave the work environment or 3 How do you know that your ideas access a computer system. have been listened to? 4 How can you tell who is trained to Visual management provides the knowledge perform each task? and certainty to make staff and patients lives 5 Is there daily accountability? Who is safer. it today? 6 How do you know where staff are – Communication board breaks, annual leave, study leave? The board keeps all team members up to date with 7 How do you know if the stock has the recent data, changes and improvements made, been ordered? 5S scores, team ideas which includes action taken against the ideas. 17
  • 18. 18 Bringing Lean to Life - Making processes flow in healthcare Identifying waste The elimination of waste is the main These wastes can be remembered by I INVENTORY M MOTION characteristic of Lean. Waste is Elimination of waste remembering the name TIM A WOODS (this Inventory is work in progress and stock. A The waste of motion is any unnecessary everything that doesn’t add value came from Lean office at Cooper Standard, common problem is lack of space. By reducing movement by people. This is mainly related to to the patient or process. Plymouth UK). inventory and by combining process steps, staff poor ergonomics, bending, stretching, moving Eliminate Minimise have more space to carry out duties in a safer items etc. working environment. There are three types of work: TRANSPORT How many times during your shift do you have to 1) Value add – When you are adding value T Transport is the unnecessary movement of Unnecessary Necessary How frequently do you run out of supplies only to get up and walk to use a certain piece of to the patient/process (e.g. prescribing waste waste items and materials. How often do we see people find another department has stock? equipment just because it is located in the wrong medication, providing physiotherapy, moving items (notes, reports, slides, supplies etc.) place? How often do you find yourself searching reporting an image) from one locality to another - and back again? For example: for vital items because they were not put back in Stand for a short while in a hospital corridor and • Over-ordering - consumables, paper the right place? Value observe these activities - you’ll be surprised. • Different batch sizes at each step 2) Necessary waste – This is when you are • Overstocked medication on wards For example: not adding value but it is a necessary step. For example: • Overstocked items in the supplies department • Poor layout of wards/surgeries/departments (e.g. incubation in a microbiology laboratory, • Moving drugs, samples, equipment, supplies because it was cheaper to buy in bulk without /laboratories vetting requests prior to radiology excessively around the hospital thinking about the costs of storage, stock taking • Searching for equipment or stock examination) Maximise • Moving paper notes excessively and distribution • Location of printers, faxes, copiers and • Transporting samples from one location or • Staff hiding extra stock for ‘just in case’. computers 3) Unnecessary waste – This is where you site to another. • Looking for information and people. are not adding value and these steps could be There are two other recognised wastes: Remove the waste of inventory by: Remove the waste of transport by: • Implementing the Lean tool of 5S Remove the waste of motion by: removed (e.g. walking to get or find items, the waste of unused staff creativity (skills utilisation) • The elimination of process steps and hand offs • Establish visual systems (kanbans) - aids visibility • Introducing standard layout waiting for consultants/medication). and automating an already inefficient process: • Co-locating departments/processes/supplies for stock counting • Introducing a standard way of working • Introducing work cells. • Understand what is needed to keep up • Developing flow in work cells Researchers have found that there are seven • Establish first in first out principle with demand - • Initiate and sustain 5S. main wastes and over the years other wastes implement ‘just In time’ have been added. • Keep stock audits correct and current.
  • 19. AUTOMATING For example: For example: Remove the waste of over production by: SKILLS UTILISATION A Automation of poor processes just serves to • Waiting for shared equipment (telephone/ • Duplicate testing/inappropriate testing • Remove all unnecessary paperwork S Every department has unused staff potential. automate waste. The poor understanding of work computers) • Duplicate data entry • Reduce batching - establish a visual system There is someone in every department that knows content and takt time can result in purchase of • Staff waiting for machines, deliveries, other • Duplication of checking cards/slides • When the process can’t flow, introduce the issues and has the possible solutions. If only large pieces of expensive equipment that actually members of staff • Excessive bed moves ‘pull’ systems with buffers and kanban’s. they were asked, listened to and action was taken - hinders flow of the overall process. The result, is an • Waiting for decisions • Excessive paperwork the people doing the job are the experts. expensive poor process! • Waiting for others at meetings • Manual checking electronic data DEFECTS • Patients waiting for appointments, in emergency D Defects are all the errors that compromise Unused skills and creativity also include highly For example: departments/clinics, waiting for discharge Remove the waste of over processing by: quality, safety, cost and staff time. Make it right, skilled staff undertaking duties that do not reflect • Did radiology reporting times reduce when • Samples waiting in a batch to be analysed • Eliminate non-value added steps first time, every time. there skills, e.g. band 8 staff routinely performing PACS was implemented? in the laboratory • Combine process steps and paperwork band 3 duties. • Do samples get turned around any quicker with • Requesters waiting for results or medication. • Simplify tasks Do you tolerate errors by reworking someone else’s track systems purchased and implemented in mistakes? How often do you accept incomplete or How many times do we see supervisors/managers Remove the waste of waiting by: biochemistry? • Leveling the workload and balancing operations O OVER PRODUCTION doing too much, too Over production is about inaccurate requesting information? routinely booking appointments? • Eliminating or reducing batch sizes soon or ‘just in case’. For example: The intellect and skill of staff should be used to WAITING W The waste of waiting usually transpires when • Eliminating hand-offs. • Wrong patient, wrong test, wrong procedure, guide the continuous improvement of procedures How many times do we complete the same wrong form and processes. The inclusion and insistence of staff there is an in balance of process steps which all OVER PROCESSING information and have to file it or store it in many • Inappropriate/inadequate referrals in problem solving and decision making will also take different timings or the batch sizes are O The waste of over processing is all the things different ways? How often do we see queues build • Chasing inadequate patient information support recruitment, retention and improve morale. different in each process step. The waste of we do that don’t add any value to the process - up in one part of the process because the previous • Repeated checking waiting has a direct impact on flow as waiting producing excess. department kept producing more, regardless of • Medication errors. creates a ‘stop-start’ process. whether subsequent processes were ready or could How many tasks are repeated simply because we cope? Remove the waste of defects by: Do you ever find yourself becoming frustrated and • Making the system mistake proof don’t have a system to ensure it serves the needs of your working day hindered because you are For example: • Introducing a zero tolerance to defects the patient or process throughout the whole waiting for a colleague to do their role or for a • Making more than, faster than, earlier than is • Introduce standard work to ensure the same healthcare journey? machine to finish? required by the next process step process is completed every time ensuring high • Duplicate entries in medical records quality process repeatability. • Paper copies of results sent along with an electronic copy • Repeating tests before next test scheduled. 19
  • 20. 20 Bringing Lean to Life - Making processes flow in healthcare Making value flow Flow is the continual movement of value To promote flow, batches should be reduced adding activities from the beginning to and where possible removed to achieve the the end of the value stream. optimal flow - one piece flow. When flow is achieved, it becomes easier to spot problems Processes which add value to the patient and patients are no longer unnecessary held should not be held up by any non value up in the health system. adding steps or waste in the system. Waste and non-value-adding steps create a ‘stop- All Lean tools work towards promoting flow. start’ effect which prevents the flow of Visual management can be used to highlight value adding steps the value stream. flow stoppers. Standard work can be used to ensure processes are repeatable and reliable, Systems which promote batching hinder flow, with no variation. 5S can support workplace create waste and queues. Batching can be organisation ensuring no time is lost trying to seen across healthcare. For example, ward find the right tools to do the job. rounds completed at the same time of day causes a batch of work for the nursing staff and every support service that follows i.e. Pathology, Radiology and Pharmacy.
  • 21. Understanding pull Flow and pull work to keep the entire value stabilised. Over time, the buffer should be stream moving. Flow is the goal, but on gradually reduced and ultimately removed. occasion, flow may not be achievable and in these situations the concept of pull can be Kanban introduced to respond to demand. Kanban signs/signals are a form of pull. These visual signs are mechanisms for the patient or Pull is a short term notion to gain control internal customer (ie ward nurse, radiologist, and process stability. discharge staff) to say “I am ready for more.” “ Flow where you can, pull There are many different forms of Kanban – Pull works with buffers and kanbans: an empty container, a box, a marked area, an empty shelf or a card. Buffer A buffer is a clearly defined holding area at where you must” the interface between two processes allowing Jeffery K. Liker, The Toyata Way, 2004 patients, paperwork, information or items to wait for a defined amount of time between two process steps. A buffer could be a waiting room, empty beds, trolleys or chairs, or even a space for stock and inventory. Buffers are actually a ‘waste’ and should only be introduced when flow is not possible and the process needs to be controlled and 21
  • 22. 22 Bringing Lean to Life - Making processes flow in healthcare Understanding takt time Takt time is simply the rate at which we Every seven minutes a patient should move need to work to keep up with demand. through the scanning process – this is the takt time. The calculation for takt time is: 20 The cycle time is the time it takes to actually Available work time ‘do’ the task and the aim is to match (where = takt time 15 Demand possible) takt time. Minutes This sounds too simple, yet the ability to If the cycle time is going to be identical to or 10 achieve takt is the fundamental question to less than takt, all the non value adding Takt whether the system is set up to deliver what is activities need to be removed from each required. If teams can not achieve takt, waste step. Only when the non value adding 5 in the system needs to be removed and each activities have been removed from each step process step needs to be levelled to ensure should additional resources be considered. 0 takt is met. Vet Protocol Book Scan Report Type Verify Issue As you can see from the graph on the right, Worked example: the team would possibly need to either A scanning department is open and staffed extend scanning hours or secure additional for seven hours per day has a daily demand of scanning resource. The team would also 60 referrals. need more than one consultant reporting in order to achieve takt. 7 hours 420 min Takt time = = 7 min 60 60
  • 23. Using 5S to improve safety 5S has traditionally been thought of as being 5S - What does it mean? How do I do it? just a ‘tidy up’, but when approached properly it is much more than that. Sort Shine ‘When in doubt, move it out!’ ‘Lean means clean’ 5S is the basis for standardising work 1) Remove everything from the defined area. 1) Clean the area – it should be easier to clean now you have removed the clutter and and is used to improve efficiency by 2) Only return what is necessary for the daily duties. every item has a location. eliminating waste, promoting flow, 3) Discard any broken, unnecessary items – e.g. clutter, old equipment, old 2) Develop a plan where cleaning is incorporated into the daily routine. improving staff morale and most unused paperwork. importantly improving safety. 4) Move any items that you are unsure of into a holding bay for a team decision. Standardise 5) If shelving or cupboards are not used or required, remove them too – this will Create a consistent approach for carrying out tasks and procedures. Ultimately, it is about making the prevent unwanted items being stored there. processes and environment safe. 6) Items necessary to complete the job need to be ‘set in order’ 2S Sustain ‘Sustain all gains through self discipline’ Set in order Make 5S become a way of life by: ‘A place for everything and everything in its place.’ 1) Practicing and repeating the process. 2) Educating all staff 1) Give every item a location - Items used on a regular /daily basis need to be placed 3) Linking 5S directly to the day job within arms length / accessible location 4) Empowering staff to improve and maintain their workplace. - Items used on a weekly basis should be stored on a shelf or in a cupboard in the work environment. When employees take pride in their work and workplace it can lead to greater job - Items used on a monthly, quarterly or annual basis should be stored in an satisfaction and higher productivity. appropriate location – possibly outside the work area. 2) Mark off (with electrical tape or permanent marker) and label each location 23
  • 24. 24 Bringing Lean to Life - Making processes flow in healthcare Plan, Do, Check, Adjust (PDCA) Sometimes called a Plan, Do, Study, Act (PDSA) Change on a large scale can be daunting but P - Plan you should not let that deter you. This is the most important part of the process. Before implementing a full proposal for • What you are planning to trial? change a PDCA cycle (sometimes called • What are your objectives? A P a Plan, Do, Study, Act (PDSA) cycle) can • Who is needs to be involved/informed? C D be used. A PDCA (PDSA) cycle will • How are you going to do it? D provide the opportunity to test out an • How long will the trial run? ADJUST PLAN P idea on a small scale, without risking too • How are you going to measure improvement? C A much. • What is your communication plan? C D - Do A New ideas should be introduced only after D • Test the change and collect the data CHECK DO sufficient testing (or evidence) on a smaller P scale has proven to have a positive effect. C - Check PDCA (PDSA) cycles allow us to introduce an • Analyse the data you collected in the ‘plan’ A P idea in a safe, controlled way which will have less resistance, be less disruptive and use less and ‘do’ phase C D • Discuss outcomes with colleagues? resources. By building on the learning from • What went well? each PDCA (PDSA) cycle, new processes can • What went wrong? be introduced with a greater chance of • Did anything unexpected happen? success. A - Adjust • If the change was a measurable success, • Could the process be improved? • If the trial did not improve the process, adopt and spread the improvement in your • If the trial didn’t go to plan, what was the could you treat the root cause in your next PDCA (PDSA) cycle. root cause? PDCA (PDSA) cycle?
  • 25. Continuous improvement Continuous improvement is the final lean principle, which is to strive for perfection through continuous improvement. This is done by embracing the Lean philosophy and tools as described in this booklet. The staff are a fundamental part of Lean. It is important to develop staff and give them the The key to success is During your Lean journey, don’t lose sight of perfection and what perfection means: Act like a sponge - soak capability, autonomy and empowerment to solve the problems as they encounter them on small, daily incremental • the right patient journey it up and squeeze out a daily basis. Teaching and expecting rigorous problem solving by all staff is the only improvements. • the right support services when they are required by the patient improvements everyday sustainable way to strive for perfection. • the highest level of quality and safety • no defects or incidences Communication is imperative to develop staff For Lean to be a success, the Lean culture • delivered at the right price to continually improve the process. needs to be accepted and embraced by all. • delivered by a staff group with high A five minute daily meeting for all staff morale and pride in their work. around a central communication board to When implemented, the tools and techniques discuss real time issues relating to waiting can have an immense beneficial effect, but to times, quality, safety, morale and cost is be sustainable, they need to be applied with a essential to ensure the work for that shift/day Lean culture. proceeds as planned. 25
  • 26. 26 Bringing Lean to Life - Making processes flow in healthcare Value stream mapping symbols Data entry Cycle time = FIFO W i Batch size = First-in First-out GP Surgery Sequence Defects = Wait/delay Inventory Transport Ambulance Pull Information Supermarket Process Step Trigger = Bursts Electronic Outside Agencies Information Buffer Data Box Push People “Go See” Load Levelling Work Cell Transfer Paper Flow
  • 27. Acknowledgements This document has been written in partnership by: Lisa Smith National Improvement Lead Email: lisa.smith@improvement.nhs.uk Zoe Smith National Improvement Lead Email: zoe.smith@improvement.nhs.uk 27
  • 28. NHS CANCER DIAGNOSTICS HEART LUNG STROKE NHS Improvement NHS Improvement With over ten years practical service improvement experience in cancer, diagnostics and heart, NHS Improvement aims to achieve sustainable effective pathways and systems, share improvement resources and learning, increase impact and ensure value for money to improve the efficiency and quality of NHS services. Working with clinical networks and NHS organisations across England, NHS Improvement helps to transform, deliver and build sustainable improvements across the entire pathway of care in cancer, diagnostics, heart’ lung and stroke services. Delivering tomorrow’s NHS Improvement 3rd Floor | St John’s House | East Street | Leicester | LE1 6NB improvement agenda Telephone: 0116 222 5113 | Fax: 0116 222 5101 for the NHS www.improvement.nhs.uk ©NHS Improvement 2010 | All Rights Reserved | May 2010