Neil Westwood Associate Service Transformation and Hereford Hospitals NHS Trust Tel

Transcription

1 Lean Thinking

2 Neil Westwood Associate Service Transformation and Hereford Hospitals NHS Trust Tel NHS Institute for Innovation and Improvement

3 Plan for today What is Lean and what are benefits? 5s game How has it been applied to healthcare and mental health? 10 things leaders need to do

4 FREE short guide to Lean order hard copies from Over 300 NHS organisations have ordered 7000 copies

5 (Lean on a Ward)

6 Critical success factors Lean must be part of long term Trust strategy This is not a FAD!!! Dedicated service improvement resources accelerate change Staff must be empowered to make improvements Focus on the system, the flow that creates value, then apply the tools Board commitment and clinical leadership is essential Get results quickly deploy a series of rapid improvement events

7 What is Lean? Lean is the process of identifying the least wasteful way to provide value (better, safer care, with no unnecessary delays at lower cost) to our customers. Value must always be determined by the customer We spend 75-95% of our time doing things that increase our costs and create no value for the customer

8 Lean focuses on dramatically improving flow in the value stream and eliminating waste SPECIFY VALUE UNDERSTAND DEMAND FLOW PULL PERFECTION IMPROVED EFFICIENCY AND SPEED

9 Typical patient journey X X X X Non Value adding delays and waste NHS Institute for Innovation and Improvement

10 Implementation of Lean: benefits Hereford Hospitals NHS Trust Improved quality and safety Fewer mistakes, accidents and errors, resulting in better care Improved service experience Improved delivery/ timeliness Better work gets done sooner (meets targets) Improved throughput (more income) The same people, using the same equipment, find they are capable of achieving more Accelerated momentum Stable working environment with clear, standardised procedures creates foundations for constant improvement Value for money lower costs, less waste Improved staff morale

11 Lean Sigma complementary not competing Lean goals include Empowered staff Improve flow Doing work on time Identify problems (defects and backlog) before it s too late Learn by doing Eliminate waste Right first time, every time Match resources to meet demand NHS Institute for Innovation and Improvement

12 Lean Sigma complementary not competing LEAN TOOLS/PRINCIPLES Value Stream Mapping Pull signals Visual workplace/5s Match resources to demand Work standardisation Staff involvement Rapid Improvement Events Multi functional staff NHS Institute for Innovation and Improvement

13 AFTER LEAN NO WASTE, LITTLE VARIATION, NO DEFECTS and QUICK Push the Button for Lean Transformation in Healthcare NHS Institute for Innovation and Improvement

14 BEFORE LEAN LOTS OF WASTE, HIGH VARIATION, DEFECTS and SLOW (DELAYS and LONG WAITING TIMES) NHS Institute for Innovation and Improvement

15 Leaders need to shift the current thinking CURRENT Provider first Waiting is acceptable Errors are to be expected Add resources Reduce cost Problems not visible maximise use of capacity Functional management FUTURE Patient first Waiting is unacceptable Defect free processes No new resources Reduce waste Problems visible minimise cost of capacity End to end processes

16 Consistent processes = reliable, safe and fast NHS services DELAYS

17 Lean - improvement at all levels who leads on what Long term vision Chief Executive and Board 3-5 year strategy Yearly strategy and operational plan Senior leaders (clinical and managerial) Departmental leaders -Heads of Service - Matrons Departmental and ward plan Service managers and sisters Rapid improvement events Daily problem solving Service improvement team with above Everyone Adapted from Getting The Right Things Done Pascal Dennis

18 Convert non value adding time to value adding time to improve productivity Number of nurses per Trust = 800 Length of a shift = 480 minutes Typically, 50 % of time is value adding = 240 mins per shift 50 % of time is non value adding = 240 min per shift (searching for things, unnecessary movement, chasing results, redoing things) Now, if we can convert 10% of non value adding time to value adding time = 24mins extra value adding time This is the equivalent to 38 extra nurses (23 mins *800 nurses = extra value adding minutes)

19 Different value streams for mental health Emergency Assessment Home Treatment pathway Discharge A&E In patient Short LOS Long LOS Discharge Home Elective Outpatient Treatment pathway Discharge

20 5s 5 S standards Sort Straighten/Simplify (Set in order) Shine Standardise Sustain Not Used Sustain the gains

21 Pharmacy After a 5s

22 More appropriate stock levels based on clinical need BEFORE LEAN AFTER LEAN

23 There were some surprises! BEFORE LEAN AFTER LEAN

24 Visual management - helps you to see if equipment is out of place

25 Visual Standard start end = OK 13 = Reject Cross out numbers in sequence from 1 49 with a diagonal time as illustrated bottom left to top right Do not turn over the sheet until instructed Do not rotate sheet of paper

26 Score Sheet Each table shouts out average number crossed off Round 1 (60 seconds) Round 2 (50 seconds) Round 3 (40 seconds) Round 4 (20 seconds) Round 5 (20 seconds) Round 6 (20 seconds) Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person 8 Person 9 Person 10

27 The Current Workplace ROUND 1 Time to allowed : 60 seconds Goal: Cross out the numbers

28 ROUND 2 - sort Time to allowed : 50 seconds Goal: Cross out the numbers

29 ROUND 3 set in order Time to allowed : 40 seconds Goal: Cross out the numbers

30 ROUND 4 set in order Time to allowed : 20 seconds Goal: Cross out the numbers

31 ROUND 5 set in order/with standardisation Time to allowed : 20 seconds Goal: Cross out the numbers 1-49 Numbers from 1 to

32 ROUND 6 Time: 60 seconds Goal: Identify missing numbers

33 ROUND 7 sort and set in order Time: 5s Goal: Identify missing numbers Numbers from 1 to

34 Mental Health Examples - Analysis of Daily Admissions to Crisis Assessment Number of admissions Crisis assessment admissions - November 2005 to January UCL=4.430 _ X=1.011 Average number of admissions Average number of admissions by day of week 95% CI for the Mean 0 01/11/ /11/ /11/ /11/ /12/ /12/ /12/ /01/2006 date of admission 12/01/ /01/ /01/ Mon Tues Wed Thurs day number Fri Sat Sun On a daily basis on average there is 1 admission per day. This varies between no admissions and up to 4 per day More admissions on a Monday, Tuesday and Wednesday Few admissions on a Saturday

35 How many beds do we need? (based on current variation in demand (number of admissions) Recommended Beds required Recommended Beds required On Mondays you need about 3 beds On Tuesday you need about 2 beds Recommended Beds required Recommended Beds required On Wednesday you need about 4 beds On Thursday you need about 2 beds We advise that you set your capacity at 80% (not the average) of the variation in demand this is shown by the orange line. Note if you reduce the variation in number of admission you will require less beds.

36 Recommended Beds required On Friday you need about 2 beds Recommended Beds required Recommended Beds required On Saturday you need about 1 bed On Sunday you need about 2 beds

37 Understanding Demand - How many beds do we need available each day in Crisis Assessment Based on 3 months data (November 2005-January 2006) Day of week Number of beds required to meet daily demand Monday Tuesday Wednesday Thursday Friday Saturday Sunday

38 Admission by Hour of day Totals (November 2005 to January 3006 Midnight 2pm to 6pm

39 BREAK

40 Waste is Anything other than the minimum amount of equipment, materials, space, and worker s time which are essential to add value to the product or service. A symptom, not a cause, of a problem. We need to find and correct causes of waste.

41 What are these staff doing?

42 What are these staff doing?

43 CURRENT THINKING WASTE Making more than is necessary or making things faster than is necessary, working ahead Rework, work done because of errors in a previous process Redundant or unnecessary processing, work that is giving the customer more than he/she is willing to pay for Information or material waiting in queue Inventory Desired outcome (customer requirements) cannot be achieved within the existing process Waiting I W REQUIRED THINKING Processing P FORMS OF WASTE M Correction C O M Unreasonable -ness Over Production Motion People waiting for machines or information. Information waiting on people or machines Material Movement Unevenness Unnecessary people motions, travel, walking, searching Unnecessary handoffs, transfers, distances of material & information Fluctuation and variation in customer demand NHS Institute for Innovation and Improvement

44 Right first time every time? Request Received Examination Report Typed Sent 70% X 90% X 90% X 95% X 85% X 99% Complete and accurate = 45%

45 Three Keys to Leadership Go See. Senior managers must spend time in the workplace. Ask Why. Use the Why? technique daily. Show Respect. Respect your people. Learn the dirty details by getting involved and doing. Focus on the work and staff. Learn and revisit Standard Work. Use Value Stream Maps to expose the WASTE Think of yourself not as a firefighter, but as a teacher/coach and process owner/designer.

46 Lean - improvement at all levels who leads on what Long term vision Chief Executive and Board 3-5 year strategy Yearly strategy and operational plan Senior leaders (clinical and managerial) Departmental leaders -Heads of Service - Matrons Departmental and ward plan Service managers and sisters Rapid improvement events Daily problem solving Service improvement team with above Everyone Adapted from Getting The Right Things Done Pascal Dennis

47 Top Leadership s commitment to Lean journey START SHORT TERM TOOLS Are top leaders committed to a long term vision of adding value? Yes No Lean Tools Six Sigma Tools Theory of Constraints Cost Improvement Programmes Supply Chain Tools Are top leaders committed to developing and involving teams and partners from he whole system? Yes No No Leadership background Ownership structure Promote from within? Will there be continuity in the top leadership s philosophy? Yes BEGIN LEAN JOURNEY Environmental pressures Experience with Lean Adapted from The Toyota Way J Liker

48 Practical steps leaders must do 1. Embed problem solving approach in frontline staff. Learn by doing (PDSA) and empower staff to improve P-D-S-A Cycle

49 2. Identify core value streams main patient journeys and eliminate waste Social services Pharmacy or elsewhere Discharges Deaths Long term care Home GP ER & EAU Quick Sick: specialist ward Radiology Pathology Tests Specialist clinic Specialist clinic Specialist clinic Specialist clinic theatre theatre Pre op assess ITU rehab > 3 / 52 1 to 10 days Day case unit (inc Endoscopy) Follow up Source Kate Silvester

50 Lambeth Mental Health Rehabilitation Bed System I

51 Lambeth Mental Health Rehabilitation Bed System II Rehab Supported Housing POOLED NELSON WARD MCKENZIE HOUSE SRT/PAMS Housing WAITING LIST HOPTON ROAD LIRU SNAP Housing Independent Living

52 Practical steps leaders must do 3. Participate in rapid improvement events Current State Future State Future State staff from Preoperative assessment, daycase and theatre work together to design the new improved system Chief Executive asks questions and challenges teams

53 Practical steps leaders must do 4. Make it part of your strategy Blue Sky Categories

54 4. Make it part of strategy (continued) A vision is translated from Blue Sky to Master Schedule into a detailed schedule. Organisation BLUE SKY Safety Quality Environment New Product/ System Blue Sky Master Schedule Policy Deployment Delivery People cat Item Cost Target Resp WK 14 WK 15 WK 16 WK 17 WK 18 Activity WK 19 WK 20 WK 21 WK 22 WK 23 Accident Reduction 40% Reduction AB Develop Safety Rules Agree Brief All Members Audit Aud SAFETY Accident Reporting Near Miss Culture 100% Accidents 100% Incidents Reported BS JB Write Procedure Brief All Members cat Item Start Develo Target Resp Detailed Schedule Activity WK WK WK WK WK WK WK WK WK WK QUALITY SAFETY Accident Reduction Accident Reporting 40% Reduction AB 100% Accidents BS Write Procedure AgreeBrief All Members Brief All Members Audit Start Aud A detailed schedule contains the activities and responsibilities to achieve the set vision targets. QUALITY Near Miss Culture 100% Incidents Reported JB Develo

55 Practical steps leaders must do 5. Leadership must commit to long term learning. Organise by value streams (patient journeys) not be departments - appoint value stream managers responsible for the whole value stream

56 6. Measure the change (before and after) Bradford Mental Health: bed occupancy Bed Occupancy % In-patient consultants in front line assessment Crisis team (trying to block admissions) Time: 3 day wait to same day assessment Savings: minimal: some agency Nurse costs, but Crisis team cost+ Quality: no increase in suicide rate.

57 Theatre TE Case Study Background BEFORE LEAN AFTER LEAN

58 More appropriate stock levels based on clinical need BEFORE LEAN AFTER LEAN

59 Practical steps leaders must do 7. Identifying opportunities for big financial impacts get results Metric Before change After change Ideal state Improvement Saving a year Turnaround time (from receipt to results available) 62 minutes Up to 2 hours 38 minutes 30 minutes 40% reduction 2 beds a day * A&E targets met 8. Grow and develop your own Lean culture. Adapt and make relevant for your environment. Adapted from The Toyota Way J Liker

60 Practical steps leaders must do 9. Develop leaders and coaches and to increase capability 10.Use experts for teaching and for getting quick results Neil Westwood coaching Endoscopy staff Adapted from The Toyota Way J Liker

61 Transforming healthcare using Lean Thinking Management owns the Vision Staff own the Vision Learning & Launch Value-stream mapping Implementation (Kaizen Plan) Lean Workshops Goals Commitment Planning Current state map Future state map Objectives Methods Responsibilities Timelines Reviews/checks Workplace organisation Flexible operation Standard/balanced work Built-in-quality Pull systems/load leveling Problem solving Value stream supports clinical care: Focus on patient journey as service model. Create the most value while consuming the fewest resources. Distinguish process steps that create value from those that do not. Improve and track performance to reduce lead time and build-in quality. NHS Institute for Innovation and Improvement

62 Planning your Lean journey Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Strategic (why) 1. Commit 8. Decision/c ommit 11. Next steps Operation (what) 2. Choose 4. Map current 5. Metrics 6. Map future 7. Plan 9. Implement 10. Report Capacity (how) 3. Learn NHS Institute for Innovation and Improvement

63 Learning Points Lean is a very big topic not fully covered today Key points See system from patient s view point Separate out the different value streams Optimise your activity to improve the flow through the whole system for the patients (mapping) Batching is usually bad for flow Reduce waste wherever you see it Create a culture of continuous improvement

64 Useful further information Womack and Jones several books and articles on lean thinking all accessed via for presentations on improving flow and other topics More reports and examples can be found at

65 Must read books for Lean thinkers create a whiteboard from a roll - anywhere, in seconds and NHS Institute for Innovation and Improvement