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Lean London Forum
19 September 2013Royal College of Surgeons
For more information, please email [email protected] or telephone 0207 824 8448
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Confidential not to be used without consent
We have some broad aims of the forum
• Create the environment where Lean Solutions in the NHS are shared, discussed and acted upon by practitioners in the health service
• Engage in a debate about strengths and weakness of lean/service improvement methods in the current NHS climate
– The QIPP agenda in reducing costs across the health system
– Clinical Commissioning Groups that will redefine ‘end to end’ health systems processes
• To network with colleagues and friends
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Confidential not to be used without consent
Agenda
• 1800 - 1810 Welcome and introductions
• 1810 - 1835 Taking a new look at your service; “LEAN” a process approach to change – Ms Pauline Connor (Bio Medical Scientist, North Middlesex University Hospital NHS Trust)
• 1835 - 1900 “Improvement; Infection; Impossible? – Dr Mathew Diggle (Consultant, Nottingham University Hospitals NHS Trust)
• 1900 - 1930 Hot seat session
• 1930 - 2000 Networking and drinks
4
Taking a new look at your
service
“LEAN” a Process Approach to
Change
Pauline Connor
Chief Biomedical Scientist
5
Context
• Histopathology department at NMUH serves a medium sized DGH, with approximately 10500 requests per annum
• Increase in complexity of cases (reflected as increased blocks and slides) by 49%
• Increased demands on Consultant reporting time, now support 43 MDT meetings per month
• Biomedical, Clerical and Medical staffing levels stable, but of 4.1 wte Consultants, only 1 is full time
• Opportunity to become one of nine pilot sites for NHS Service Improvement project “Learning how to achieve a
7 day turnaround time in histopathology”
6
Target• 95% of work reported in 7 days
• 50% of work reported in 3 days
• Baseline figures were 16% in 3 days; 50% in 7 days
• End of project figures 44% in 3 days; 92% in 7 daysTATs -Sep 2009 to june 2010
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
6887/09
6896/09
6905/09
6914/09
6923/09
6932/09
6942/09
6951/09
6960/09
6969/09
6978/09
6987/09
6996/09
7005/09
7014/09
7023/09
7032/09
7041/09
7051/09
HH004324B/10
HH004333M/10
HH004342C/10
HH004351W/10
HH004362W/10
HH004371Q/10
HH004385Y/10
HH004395E/10
HH004404C/10
HH004414A/10
HH004423C/10
HH004433A/10
HH004443W/10
HH004453H/10
HH004463Q/10
HH004475Q/10
HH004486N/10
HH004514E/10
lab no
days
days The Mean (Average) Upper Control Limit Lower Control Limit
What is lean?
• A whole Management Philosophy
• Perfected by Toyota in the 1970’s
• Toyota Production System (TPS) focuses on:
– Improving flow (pull)
– Increase value for user
– Get rid of waste
– Get it right first time
– Continually improve
• Puts the customer at heart of the process
8
A process approach to change: taking the
pathology service apart and reassembling
• Value stream maps - to look at every step in the specimen pathway
• Walk the walk, collect data, take photographs
• Assign timings to every part of the process
• Identified that our value added time = 1.5 days
• Non-value added time ranged from 0.5 to 17.5 days i.e. additional
activity that add cost and time but were of no value to the patient
No need for expensive software
10
Taking the process apart: where to
spend the time
• We identified waste such as movement;
waiting; duplication of effort; excessive
checking; poor utilisation of skills;
overproduction
• Looked for waste at all stages using tools
such as the “5 Whys?”; Plan,Do,Study,Act
cycles; A3 problem solving techniques
11
Case 1: Over processingThe value stream map identified over
processing at specimen reception
• Pre LEAN: all specimens were dealt with in one large
batch; large bags of specimens delivered in one or two
drops
Understanding the problem
• Multiple specimen
handling and checking
steps
• Sorting into separate
work streams
• Delayed the next
stage of the process
Measurable outcome
• Removed separate work streams
• Introduced one piece flow in specimen reception
Task Pre LEAN Post LEAN % Reduced by
Specimen
checks
7 3 43%
Specimen
handling
6 3 50%
14
Impact•Continuous flow
•Reduction in the error rate
•Less stressful, uncluttered
environment
•Visual management used
There is no point optimising a
process unless it is standardisedIf the process changes depending on who performs the work or other parameters, measurement is meaningless
Create standardised work procedures to produce process stability
Then Optimise
17
Case 2: Standardisation
The use of templates for cut up “LYSIS”
• Pre LEAN: tapes were used for dictation with a two part specimen request form
• Problem: the tapes and forms moved on average 82 m per cut up, this movement added no value to the process.
18
Waste identified
• Movement - of forms and tapes
• Waiting – to be typed
• Re-duplication of effort – the same
description repeated again and again
• Errors: occasional tapes failed and some
were occasionally erased in error
19
Solution “LYSIS”
• Introduction of standardised templates for use in
specimen dissection
• No tapes – notes are typed into templates in real time
during cut-up on a two-screen computer
• Allows continuous flow of work and single unit flow
20
Measurable outcome
• Tapes had an efficiency of 9.5%
• LYSIS has an efficiency of 93.2%
• Less waiting, less movement
• Saved 20 days of secretarial time per annum
P ro c e s s S te p s A m o u n t
P ro c e ss in g -w h e n s o m e th in g h a p p e n s t o m o ve it o n 3 . 0 0 P ro c e ss
C he c k in g o f in f o rm a t io n /c o n tro ls /d e c is io n -m a kin g 2 . 0 0 C h e ck
W o rk m o ve s o n w it h o ut a n y th in g h ap p e n in g to it 3 . 0 0 M o ve
D ela y - w o rk flo w is p re v e nt e d f ro m m o vin g fo rw a rd 3 . 0 0 D e la y
1 1 . 0 0
D is ta n ce M e tr e s
P ro c e ss in g -w h e n s o m e th in g h a p p e n s t o m o ve it o n 1 0 . 2 0 P ro c e ss
C he c k in g o f in f o rm a t io n /c o n tro ls /d e c is io n -m a kin g 2 . 4 0 C h e ck
W o rk m o ve s o n w it h o ut a n y th in g h ap p e n in g to it 8 2 . 8 0 M o ve m e n t
D ela y - w o rk flo w is p re v e nt e d f ro m m o vin g fo rw a rd 1 5 . 6 0 D e la y
1 1 1 . 0 0
T im e m i n u te s
P ro c e ss in g -w h e n s o m e th in g h a p p e n s t o m o ve it o n 1 6 0 . 0 0 P ro c e ss
C he c k in g o f in f o rm a t io n /c o n tro ls /d e c is io n -m a kin g 3 . 0 0 C h e ck
W o rk m o ve s o n w it h o ut a n y th in g h ap p e n in g to it 7 . 0 0 M o ve m e n t
D ela y - w o rk flo w is p re v e nt e d f ro m m o vin g fo rw a rd 1 ,5 1 5 . 0 0 D e la y
1 ,6 8 5 . 0 0
S u m m a ry
T o ta l
T h e P r o c e s s C y c le E f fi c ie n c y is 9 . 5 % .
T h e re w e r e 3 d e la y s w h ic h p r e v e n t ed w o r k flo w fr o m m o v in g fo r w a rd , a n d t h e y la s te d
f o r 1 5 1 5 m in u t e s .
T h e w o rk f lo w m o v e d w i th o u t a n y t h in g h a p p e n in g to it 3 t im e s , a n d t ra v e l le d 8 2 . 8
m e tre s .
T o ta l
T o ta l
T h e w o rk f lo w w a s c h e c k e d , o r h a d a d e c is io n m a d e a b o u t it 2 t im e s , a n d t h is t o o k 3
m in u t e s .
P ro ce s s
2 8 %
C h e c k
1 8 %M o v e
2 7 %
D e la y
2 7 %
P ro c e s s
9 %C h ec k
2 %
M o v e
7 5%
D e lay
14 %
P r o c e s s
9 %C he c k
0%
M o v e
0 %
D e la y
9 1 %
Process Steps Amount
Processing-when something happens to move it on 8.00 Process
Checking of information/controls/decision-making 1.00 Check
Work moves on without anything happening to it 2.00 Move
Delay - workflow is prevented from moving forward 1.00 Delay
12.00
Distance Metres
Processing-when something happens to move it on 7.20 Process
Checking of information/controls/decision-making - Check
Work moves on without anything happening to it 16.80 Movement
Delay - workflow is prevented from moving forward - Delay
24.00
Time minutes
Processing-when something happens to move it on 55.00 Process
Checking of information/controls/decision-making 1.00 Check
Work moves on without anything happening to it 3.00 Movement
Delay - workflow is prevented from moving forward - Delay
59.00
The Process Cycle Efficiency is 93.2%.
There was one delay which prevented workflow from moving forward, and it lasted
for 0 minutes.
The workflow moved without anything happening to it 2 times, and travelled 16.8
metres.
Total
Total
The workflow was checked, or had a decision made about it only once for a time of 1
minutes.
Summary
TotalProcess
67%
Check
8%
Move
17%
Delay
8%
Process
30%
Check
0%Move
70%
Delay
0%
Process
93%
Check
2%
Move
5% Delay
0%
Before
After
21
Case 3: Introducing continuous flow:
optimising the Laboratory layout
Pre LEAN:
• poorly designed
• cramped and cluttered
Problem:
• the layout did not support
the flow of specimens.
22
Analysis of the problem
• Used spaghetti diagrams to map the path of
a case through the Laboratory
• Used process sequence charts to look at
distance, timings and efficiency of the
processes
23
Original layout of laboratory
24
What did we do ?
• Used future state mapping to plan our ideal
journey for a case
• Data collection before and after changes
• Data gave us the confidence to redesign the
Laboratory
25
Impact of optimising the layout
• Transposition of the two staining machines
has lead to a reduction in movement of
8463 m per annum
• Routine work cell has the added benefits of
reinforcing team work
26
Laboratory layout today
27
Case 4: Introduction of a “pull” system:
pooled Consultant reporting
• Pre LEAN: all slides processed from a day’s cut up were allocated to a single Pathologist
• Problem: this did not allow for capacity and demand issues
• Work was “pushed” into their rooms and often sat unreported due to other commitments
28
Analysing the problem
• Waste: time spent in the Laboratory allocating
cases to individuals; time spent searching for
cases that were needed urgently
• Batch size: large - a whole day’s work to report
• No “first in, first out” – depended on Consultant
availability
29
Implementing the solution
• Data collection showed
variation in turnaround times for
all Consultants, which was
related to their other
commitments
• Data was presented at
Consultant meetings and
agreed to try a pooled system
of reporting
• Emphasis placed on the
inefficiency of the process
rather than the individual
The Process
• The majority of the cases are pooled into a common area in the laboratory
• Larger cancer cases to go directly to pathologist who cut up the specimen
• Consultants “pull” a reduced batch size tray of work only if they are ready to report it directly.
• New work placed in the area so the flow is “first in, first out”
The Benefits
• Pooled work takes better account of consultants working part time
• Waste reduced within the laboratory
• Unforeseen urgent cases easily located and dealt with
• A common pool is a clear visual measure of demand (work awaiting reporting) with no hidden trays in rooms
The new system
31
Impact
• Improved turnaround times allows prompt
discussion of patients at MDT meetings
• Predictable turnaround times allows earlier follow
up clinic appointments for patients
• Better use of Consultant availability to maximise
reporting time
• Morale has improved; a common challenge
• Has been easily adapted to allow for sub
specialist reporting
32
:
Measurable outcomes
• Dramatic reduction in turnaround times
3 day turnaround improved from 19% to
40% (21% increase)
7 day turnaround improved from 56% to
95% (55% increase)
• Overall reduction in time taken to report by
Consultants has decreased from 4.5 days
to 1.8 days
The Overall Results so far TATs More Consistent
TATs -Sep 2009 to june 2010
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
16.00
18.00
20.00
6887
/09
6896
/09
6905
/09
6914
/09
6923
/09
6932
/09
6942
/09
6951
/09
6960
/09
6969
/09
6978
/09
6987
/09
6996
/09
7005
/09
7014
/09
7023
/09
7032
/09
7041
/09
7051
/09
HH00
4324
B/10
HH00
4333
M/1
0
HH00
4342
C/1
0
HH00
4351
W/1
0
HH00
4362
W/1
0
HH00
4371
Q/1
0
HH00
4385
Y/10
HH00
4395
E/10
HH00
4404
C/1
0
HH00
4414
A/10
HH00
4423
C/1
0
HH00
4433
A/10
HH00
4443
W/1
0
HH00
4453
H/1
0
HH00
4463
Q/1
0
HH00
4475
Q/1
0
HH00
4486
N/1
0
HH00
4514
E/10
lab no
da
ys
days The Mean (Average) Upper Control Limit Lower Control Limit
34
Where to spend the time:
Communication
• Laboratory huddles
• Time limited, no more than 10 minutes
• Review of that day’s workload and staffing
• Laboratory dashboard – daily targets, defects, interruptions
• LEAN project meetings –twice monthly.
35
What do you need to do this?
• Equipment – NO – total cost of this project to date has been approx £2000 – a few trolleys; cabling
• Increased staffing levels – NO – this has been achieved with no increase in staff levels –consultant vacancy since March 2010, despite an increase of 20% in requests and 49% in work units
• Time – YES – data collection; team meetings
• Motivation and perseverance - YES
36
Summary
• A department that has absorbed a 49% increase in work, with a 10% reduction in staff
• Motivated and engaged staff who know that they are fully included in service delivery and continuous improvement
• Emphasis on the end point of the process i.e. a patient requires a report, rather than the process itself
Where?
Clinical Microbiology DepartmentNottingham University Hospitals NHS Trust
Queens Medical CentreDerby RoadNottinghamUKNG7 2UHhttp://www.nuh.nhs.uk/microbiology/
The Nottingham Experience
• Diagnostic service: 24/7, 365 days per year
• Population served: >2.5 million (> 5 million)
• Workload: 970,000 pa (> 1.8 Million)
• Isolation, identification and detection of
• medically important bacteria,
• viruses and parasites.
And now for
something
completely
different...
NHS Improvement - EM SHA Microbiology Sites
LEAN?
LEAN
Microbiology
What the…………….
The Path-ology
The Project
Challenges
• Collaborations
• Consolidation
• Competition
The “C”s……….
The Nottingham Experience
Challenges
• Developing a lean culture• Find a champion
• Engagement of your staff• What is engagement?
• Communication• While under a seize mentality
http://www.improvement.nhs.uk/documents/Microbiology_Guide.pdf
Thank you!
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Confidential not to be used without consent
• Focus on Value from a Customer (Patient) point of view on every
step of process
• Obsession on removing waste within the ‘whole system’
• Bottom up approach in identifying value and waste – assumption
that much of waste and value is hidden
• A true lean system would “flow” and need little command and
control
Recap – What is Lean?
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Confidential not to be used without consent
What’s Next?
• Today’s presentation and feedback survey sent out by email within 72 hours
• The Next Lean London Forum will be held on 5 March 2014.
– Register at www.leanlondon.org.uk
– We will send out reminders to all participants from today
– We have a Lean Midland Forum on 16 October 2013 taking place in Birmingham. Register at www.leanmidland.org.uk
– If you’d like to take up one our presentation slots, please do let us know. We are keen to hear from Community Trust and GP Groups
• Find us on and - LeanNHS
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Confidential not to be used without consent
Past Presentations at the Forum
http://kinetik.uk.com/pdf/Lean
London.pdf
1. The 'Leaning' of Bedford Hospital - the story so far, Susan
Whittaker, Bedford Hospital
2. Future Developments in Lean, Rob Worth, Kinetik Solutions
3. Transformation of Camberwell Sexual Health Centre, Rachel
Paxford-Jenkins, Camberwell Sexual Heath Centre
4. Building Lean Expertise, Daniel McDonald, Lean Executives
5. Use of Data in Lean Projects, Andrew Castle
http://kinetik.uk.com/pdf/Lean_
London_Sep_09_web.pdf
1. Radiology Lean Review - The Journey has begun, Carol Darnell,
Bedford Hospital Trust
2. Recruiting for the Lean & Service Transformation, Daniel
McDonald, Lean Executives
3. Lean and Systems Thinking, Rob Worth, Kinetik Solutions
4. Don't water your weeds - starting afresh with Lean, Ian Greddor,
Cyril Swett
http://kinetik.uk.com/pdf/Lean
London_Feb.pdf
1. Challenges in Implementing Lean - A Clinical Perspective, Dr
Ahmed Chekairi, Whittington Hospital
2. A Better Definition of 'Value' in Lean, Ketan Varia, Kinetik Solutions
3. Lean in the pharmaceutical drugs supply process, Niall Ferguson,
Milton Keynes Hospital
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Confidential not to be used without consent
Past Presentations at the Forum
http://kinetik.uk.com/pdf/leanlon
don_sep11.pdf
1. Transforming Surgical Productivity, Christopher Kennedy, Guy's
& St Thomas NHS Foundation Trust
2. Transforming Treatment Rooms, Dr Rebecca Hewitson, The
Whittington Hospital NHS Trust
http://kinetik.uk.com/pdf/leanlon
don_mar12_presentation.pdf
1. The Path-ology to Lean Thinking - Dr Mathew Diggle,
Nottingham Hospital Trust & Suzanne Horobin, NHS Improvement -
Diagnostics
2. Pre-Operative Health Evaluation - Engagement with Primary
Care, Dr Ahmed Chekairi, Whittington Hospital
http://kinetik.uk.com/pdf/leanmid
land0712.pdf
1. How many appointments do we need to make?, Kate Silvester,
South Warwickshire NHS Trust
2. The Path-ology to Lean Thinking - Dr Mathew Diggle,
Nottingham Hospital Trust
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Confidential not to be used without consent
Past Presentations at the Forum
http://kinetik.uk.com/pdf/leanlo
ndon_sep12.pdf
1. Sleek & Slim Hearing for Children - Dr Sebastian Hendrick, Barnet
& Chase Farm Hospital
2. Developing value through transformation of care - What does it
take?, Peter Lachman, Great Ormond Hospital
http://kinetik.uk.com/pdf/kineti
k_dec_12.pdf
1. Network Improvement Services in Tower Hamlets, Florence Cantle,
Tower Hamlets NHS Trust
2. Using improvement science in Ambulatory Care, Simon Dodds,
Heart of England Trust
http://kinetik.uk.com/pdf/Lean
Midland_June11.pdf
1. Lean Transformation at Bedford Hospital, Susan Whittaker, Bedford
Hospital
2. How do drive change by understanding patient value?, Ketan Varia,
Kinetik Solutions
3. Global Lean Knowledge: The Effects of Culture, Maria Gilgeous,
Kinetik Solutions
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Confidential not to be used without consent
Big Thanks To Our Presenters
Ms Pauline Connor
Dr Mathew Diggle
..and to you all for attending
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Confidential not to be used without consent
Thanks to Our Sponsors
Assisting with Lean Transformations
in the health sector and beyond
www.kinetik.uk.com
