Introduction into Leanand the Every Patient Matters Transformation ProgrammeSection A*

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Introductions/Objectives

Introduce yourself

Why have you come along today?

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Objectives

Explain what Lean is

Describe the aims of the Every Patient Matters Transformation Programme

Be able to apply at least one Lean technique in your workplace

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Introduction into..Section A*

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Why do we need Transformation?Fire-fighting has become the normPatients are pushed through the system no flowStressed out staffOutdated processes

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Previous Change InitiativesProductive Leader (on-going) RUH 2010Orthopaedic Lean ProjectProductive Operative Theatre (TPOT)Productive WardSection A*

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Improving QualityQuality, Innovation, Productivity and PreventionWhat are the programme objectives?

Perception is that its all about efficiency savings

Every Patient Matters falls under the QIPP umbrella and reports to PMO (programme management office)Section A*

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QIPP ProjectsAcute OncologyAmbulatory CareEmergency Surgery PathwayTheatre SchedulingOutpatientsAnd many more

Quality and the impact on patient experience is the most important factor to consider when scoping a project

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Vision for Transformation

To deliver the best possible care to every patient involving all staff indeveloping a culture ofcontinuous improvementSection A*

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What is Lean?What do you think the term Lean implies?

Lean is not an acronym, it is a collection of tools that assist in the identification and elimination of waste (e.g. queues, duplication, re-work, waits and delays) and focuses on the customer/patientSection A*

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History of LeanLean thinking, developed from the Toyota Production System, has been applied in many competitive sectors.

It is about changing a business from the roots up; working to a set of principles to produce a culture of continuous improvement that will drive sustainable results.Section A*

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Industry Examples of LeanSection A*

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Why use Lean?Such thinking is increasingly being applied to health services in the UK and overseas to:

improve the quality of patient careimprove safetyeliminate delaysreduce length of staywhile using no more resources

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5 Principles of Lean1. Value: Specify value, this must be defined by the customer/patient. Otherwise known as Voice of the Customer2. Value Stream: Identify the value stream/patient journey and the processes that define it.3. Flow: Align healthcare processes to facilitate the smooth flow of patients and information4. Pull: Deliver care on demand with the resources needed for it.5. Perfection: Develop and amend processes continuously.Section A*

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Value Stream MappingUsed to identify the processes involved in the value stream and which elements had value to the customer

Different from process mapping in that you identify value added and non value added steps for the customer and quantify time.

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Lean Principles ExerciseExercise 1:

In groups look at the value stream in front of you and complete the questions in the exercise sheet

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5s a simple tool to start with5s is a good first lean technique to use back in your work area;

SortStandardiseSet in OrderSweep and ShineSustainSection A*

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Before and After picturesSection A*

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5s Principles

Engage others in your workplace with the 5s

Start small with your own desk!

Take photos before and after

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WasteWaste is anything other than the minimum amount of equipment, space, staff time, which are essential to add value to the product or service.

In Lean 7 types of wastes have been identified, there may be more that you can think of

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7 Types of Lean WasteSection A*

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Waste ExerciseExercise 2:

In pairs, spend 15 minutes thinking of NHS examples for each of the 7 wastes

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Waste WalkWalking the process from beginning to end (or end to beginning);Walking each step, watching what actually happens (as opposed to what you are told that happens or what is contained in a process flow chart or procedure);Talking to the people who undertake each task to establish how it happens (and does it happen this way each and every time?);Observing for wasteful activities;Developing a shopping list of measures (data) required that will inform the investigation;Photographs anything and everything that appears relevant (do you require permission?);

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Best possible care through lean thinking is not a project, it is a fundamental change to the way in which the hospital delivers its services to patientsSection A*

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Lean Awareness200 RUH staffSection A*

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Lean LeadershipSection A*

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Culture and ClimateChange in an organisation calls for leaders to recognise and balance culture and climate dimensions.

Culture can be divides into five components: values, beliefs, myths, tradition and norms.

Climate is the label used to describe the dimensions of the work environment E.g. organisation structure, leadership style, communication, historical forces.

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Culture and Climate ExerciseDo we have a climate and culture that encourages change? Exercise 3:

Group 1 - Describe the current Culture and Climate of this organisationGroup 2 - Describe what the Culture and Climate of this organisation needs to be.

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What do our leaders think?Link to chief exec conference culture question

http://webserver.ruh-bath.swest.nhs.uk/everypatientmatters/Lean/leadership/index.asp?menu_id=5

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Factors to achieve desired culture and climate1. Clear Vision 2. Set of values in alignment with the vision3. Accountability for both performance and behaviours with consequences when standards arent met. 4. High performing teams that work independently and put the needs of the organisation before personal needs. 5. Value added communication6. Rewards/Recognition

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Next StepsGet your colleagues involved in a 5s activity

Think of a problem that you think you could apply some lean principles too

Book yourself onto the two day change agent training

Discuss location for waste walk

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Lean Change Agent TrainingTwo day change agent training follows this half day and includes; Exercises and group work to demonstrate lean principlesWaste Walk in your departmentProcess mapping value added, non value addedHuman dimensions of changeHandbook provided with Lean toolkit incl. Transformation ApproachPlease complete feedback sheets be honest as you like! Section A*

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Tricia welcome and then ice breaker*Section ASection ATricia 5 mins*Section ASection ATricia*Section ASection ATricia*Section ASection ATricia*Section ASection ATricia What things have they been involved in, what happened to it?

RUH 2010 3 yr programme (2007) how we wanted the RUH to look in 2010. lots of projects, lots of involvement with clinicians. Outside support by health foundation. Chief exec before James led it. Steve Boxhall heavily involved. Whole systems approach. Brigid Musslewhite the drive. Followed lean principles. Bed ManagementPatient SafetyPatient expereince

Orthopaedic project followed. Some changes implemented.

Productive Ward successful however, only did the foundations.

TPOT fizzled out, - good start

Issues with continuation; Engagement of all staff and release of time (particularly clinical folk), Dont finish what we started, constantly fire fighting our culture and climate. Sense that we have to busy cant dedicate time to project work. Political drivers force us to change constantly.

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Typical responses; doing more with less, cost cutting, trimming the fat, streamlining, What Lean is:Resources focused on understand the value stream removing waste

Aim for all team members to be leaders and followers

Intrinsically trust your people to deliver beyond expected results

Obsession with continuous improvement

What Lean is not:Resources focus on meeting Goal setting/meeting Targets & assurance

Educate people to work their specific job smarter

Have a leader that drives change hope others follow

Command and Control People to ensure delivery aim to hit target

Flavor of the year change initiative

*Section ASection ALisaRun through the pictures;From left to right; America invented the production line with ford motor carDuring WWII The Ford Production System was adopted to build bombers at Willow Run,Michigan, on anassembly line The target was to build a bomber an hour German engineers were sent to Japan toincrease their production of bombers:

So lean principles were developed by various people/industries over time , the success of toyota was pulling them altogether into a single system and TPS was born. toyata production system and implemented such terms as Kaizan (similar to our PDSA cycles) and Kanban which you learn about on day 1 of change agent training.

Jim Womak lean guru - famously wrote a book called the machine that changed the world that took the lean principles and said it can translate into any industry. He is a very successful author and speaker on lean techniques.

More industry examples*Section ASection ALisaAmazon , we look at the number of customer contacts per unit sold. Our customers dont contact us unless somethings wrong, so we want that number to move downand it has gone down every year for 12 years. Thats big-time process management. We try to implement those kinds of processes in various places. Theyre most naturally applied in our fulfillment centers and in customer service and so on, but weve actually found that they can be useful in a bunch of different things.When you are inexperienced with disciplined process management, you initially think that its equivalent to bureaucracy. But effective process is not bureaucracy. Bureaucracy is senseless processingand weve had some of that, too.

NHSBolton NHS Foundation Trust is a leader in the application of lean principles in health care, through the development of our own Bolton Improving Care System (BICS). This is a way of reducing wasteful processes in the system (e.g. duplication, errors and work-round solution) to ensure we provide safe and high quality services that our patients' value, whilst reducing frustrations and enhancing job satisfaction for our staff. o problem solve, and make rapid and sustainable change to improve the services which suit the needs of our patients.Key to BICS is getting rid of waste - the kind of thing that we all see too often in our everyday work - wasted journeys because things are in the wrong place; wasted supplies; wasted time doing things twice, or doing unnecessary things or just hanging around waiting; wasted effort, sometimes having to put right things that weren't right the first time; wasted talent of people who are distracted from what they really come to work to do - delivering a good service for our patients and customers.

FujitsuService/s deliveredThe application of Lean, Kaizen and Six Sigma principles, tools and techniques in order to create a culture of continuous improvementBenefits Enhanced customer service standardisation of processesreduces errors and improves service quality Increased staff satisfaction active involvement of staff in thechange process has improved staff motivation Improved resource usage has increased productivity by 30%,enabling new customers to be taken on with no additional resources Reduced costs removes duplicate effort, waste andunnecessary processes Enabled continuous improvement empowers people to makechanges and continually look for ways to improve service delivery

Ministry of Defence Supply chain managementThe team focused on introducing new strategies, tools and techniques, based on commercial practice and tailored for the support chain in a defence environment. They used at the retail sector and applied the principles of stock control to defence. So a lot of the tools and techniques are interchangable.

Tesco

Real example of diversification and focusing on the customer; tesco metro, tesco online. Also they have one touch replenishment. There most frequently used products e.g. Bread and moved in and out of the store aware on crates, so taken off on a fork lift truck and delivered straight to the shop floor with minimal handling and intervention. They would have done this by looking at the value stream for the supply of bread to the customer and anything that didnt add value to the customer they removed. So for example the customer doesnt need the bread to be stored on shelves they removed that step. *Section ASection ALIsaPath Lab Example

Cellular Pathology used lean improvement science techniques such as walking the process and go see, detailed data collection and root cause analysis to look at our processes. Staff from all the different groups in the laboratory have been involved including secretarial staff, biomedical scientists, medical laboratory assistants, associate practioners, consultant pathologists and a user clinician. This allowed us to draw on the knowledge, skills and experience of the wide range on staff involved in the specimen journey to and through the laboratory to identify less efficient parts of the process, the underlying causes and the ways to start addressing these issues.

In 2010 prior to the changes the overall, all specimen turnaround times were 86% specimens reported in 10 days and 65% in 7 days. Between February and end of April this year we equalled or exceeded 98% all specimens reported in 10 days and 95% in 7 days from the day of collection each week apart from the week of the long Easter weekend when we still had better turnaround times than in 2010. No additional staff have been recruited.

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*Section ASection ALIsa*Section ASection ALisaOne value stream here with one flow that looks at ordering a take away by phone. If you had a flow that incorporated ordering on line that would be another flow.

Can you identify the value added steps for the customer? And the non value added steps?

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Value Stream:Passenger arriving at airport to boarding the plane

Value:Boarding the planeSecurity check

Flows:Upper and standard class

Pull:Call passenger to gateCall passenger to planeCheck in desk

PerfectionImprovements: consolidate check in, security and passport check into one step thus reducing handoffs and duplication.

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Triangle one traditional approach to leadership driven from the top, often at the RUH we have a command and control approach to leadership target and financial driven.

Second triangle is where we want it to be, leaders are supportive of staff who have ideas and empower them to make changes in the best interest of patients. *Section ASection ALisa

People talk about changing the culture and the only way to implement successful change projects is to change the culture of the staff that work here. That is incorrect, you cant change peoples values and beliefs but you can influence this by changing the climate of an organisation. *Section ASection ATriciaPerhaps discuss the different cultural groups within the organisation e.g. doctors, nursing, managerial, departmental*Section ASection ATricia*Section ASection ATriciaFactors to achieve desired culture and climatePoint 2 do you know the RUH 10 values and behaviours? Do you think they instil behaviour in staff

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