Lean Healthcare

1. Lean Healthcare Ann Esain esain@cardiff.ac.uk

2. Ann Esain • Head of the Health and Service Group at Lean Enterprise Research Centre, Cardiff Business School, Wales, UK • Honorary Associate Professor – Warwick Medical School • Fellow of the The Improvement Faculty for Patient Safety and Quality Improvement (NHSi) • Working in Healthcare since 2000 • UK Trusts/Local Authorities (whole systems and sub- processes) • Thought Leadership for Modernisation Agency, NLIAH, NHSi, etc • Flinders Medical Centre in depth visit 2005 • 2008/10 - EU project (Jens Dahlgaard)

3. Outline • Context – Healthcare Trends • Lean Healthcare • Factors to consider • Opportunities

4. Current healthcare in the best the Western World has seenLifeExpectancy Increasing 1900 -1960 Public Health Initiatives (Safe Water/Safe Food, etc) 1960 – now Direct Disease Treatment Source: https://www.cia.gov/library/publications/the-world-factbook/index.html.

5. Hospital Stays Reducing, BUT

6. The Motivation • Rising Healthcare Costs • While time in Hospital maybe reducing - the public don’t want to have to wait • Safety not aligned to other safety critical sectors • Sweden – Top Tier in the context of Healthcare • UK and USA – current focus • Variation in Practice • Often not ‘doing what works’ - Reliably Pronvost, P (2009) • Calls for Quality Improvement across the system • UK – health outcomes – inequalities, inappropriate care, preventable injury/death Source: Brent C. James, Intermountain 2009

7. What is Lean Healthcare? • Applying lean principles to healthcare to improve patient care and safety • Redesigning healthcare systems and processes to improve response, quality and safety.

8. Improvement Stages Three tasks: Follow a standard (Maintenance) Challenge a Standard (C.I) Catchball ideas for future and respond (Policy) Rich, at al (2006) Lean Evolution, Cambridge University Press

9. Top 10 Reasons for Failure • Lack of a clear executive vision • Lack of an effective communication strategy • Failure to create and communicate a real sense of urgency • Poor consultation with stakeholders • Lack of structure methodology and project management • Failure to monitor and evaluate the outcome • Failure to mobilise change champions • Failure to engage employees • Absence of a dedicated and fully resourced implementation team • Lack of sympathetic and supportive Human Resources policies (Lucey, Bateman and Hines, 2005)

10. Survey on CSI with 19 Acute Trusts and 10 PCT’s in England • ‘Command and Control’ culture can obstruct engagement • Methods for knowledge transfer are mainly traditional (staff involvement v top down communication) • Most improvement is focused on ‘targets’ • Strong focus on cost rather than quality • Improvement techniques applied are variable and mainly project based rather than system based • Strategy and Improvement are poorly linked Walley, Rayment and Cooke, 2006

11. Characteristics of Best Performers • Strong leadership enabling difficult and sensitive change • Senior Managers with a strong awareness of process and systems issues • Receptive workforce to new ideas with no change fatigue • Strategies deployed as a means of reconciling conflicting long and short term priorities • A critical mass of capacity in improvement • Management style which encourages staff driven improvement Walley, Rayment and Cooke, 2006

12. Staying Lean The Lean Iceberg Model (Hines et al, 2008)

13. Five Principles of Lean Healthcare • Understand & specify what our customer/patient want & value. • Identify the value stream or patient journey & eliminate waste • Make the process and value flow according to the needs (pull) of the customer/patient • Involve & empower healthcare staff • Continuously improve in pursuit of perfection

14. What the Patients wanted….Value • No waits treatment & results • Appropriate information throughout the process • Bed available when needed • Private changing facilities • Clean environment • Know what’s wrong • Treated kindly by friendly staff • Reduced duplication • Not to be moved from one waiting area to another • Relatives/carers kept informed appropriately Same as other Lean projects

15. Muda (Waste) Muri (Burden) Mura (Unevenness) The enemy of value comes in different forms Hines et al 2008

16. Waste Reduction Targets for National Priorities Partnership* *A partnership between the National Quality Forum and 28 other organizations National Priorities Partnership. http://www.nationalprioritiespartnership.org/aboutnpp.aspx

17. ‘….we must never forget that safety is the foundation of all our activities…’ Taiichi Ohno

18. 2 1 Relation of Value, Cost/Waste Cost-Value Equilibrium x Customer Perceived Value x Creating Lean Solutions: 1. Reduce Internal Waste 2. Develop Customer Value Waste/Cost (of product/service) Hines et al (2004) Learning to Evolve, IJOPM

19. Hospital AValue Stream (End to End) PACE every 12mins patient Discharged 24/7 General Medicine These 2 patient Flows represent 63% of demand Community - SW PACE 1.5 patients a day 40 PACE every 26mins patient Discharged 24/7 General Surgery 18 ~ 20% patients of these types could be seen with redesigned systems

20. Good processes should be short and all in this area Store Inspect Transport Operation

21. DEMAND Admissions Main Patient Flows :- Gen Surgery, Gen Medicine PACE & Pattern Recruitment Medical Records Radiology Linen Pharmacy Echo I.T. Telephony Procurement Initial Measurements e.g. 80% patients with predicted LOS Discharge before 10 am Projected Daily Empty Beds Aligned initiatives to critical path of the Main Value Streams Remove Waste Activity to Expose Capacity

22. The Logic of Lean • Quality Improvement will • Reduce opportunity for error (safety) • ‘free up’ capacity • High volume, short interval activity improvement of minutes equal hours of more capacity – Use PDSA (discipline, measurement/evidence for feedback - learning) • Free capacity redirected to more value activity and more complex • Elimination of failure demand • Poor information • Return episodes

23. Reduced Length of Stay as a proxy for Quality and Safety

24. Patient Flow – Systems View Home Patient GP Acute Hospital Community Hospital Social Services Package Feedback? Demand By Day Demand predictable by day (pace). Demand impacts on flow & is constipated by ‘strangers’ No of Patient No of Days (LOS) Vast majority of patients could be short stay, but constrained by ‘strangers’

25. NHS Modernisation Agency (2004) Reduce the number of steps Understand patients needs Map the process “Line up the process” Waste Value Value Stream “you could free up 12-20% of current capacity to address waiting times” Flow Capacity & Demand

26. Need to remember “….the evidence… found was of people in health and social care working very hard. But they are working within systems which militate against good performance, and where there is excellence in our view it is despite rather than because of the system.” Wanless 2003

27. www.leanenterprise.org.uk

28. Preliminary Classification of Lean Healthcare * Spear 2005 'in healthcare, no organisation has fully institutionalised to Toyota‟s level the ability to design work as experiments, improve work through experiments, share the resulting knowledge through collaborative experimentation & develop people as experimentalists”. Used to classify Hospitals -'systemic'

29. Thank You Ann Esain esain@cardiff.ac.uk +44 2920 647028