From Tools to Eternity

Gwent Healthcare NHS Trust Lean Journey June 2002 Present Day

Martin Turner, Chief Executive

600,000 resident population

Caerphilly 177,000 29.5%

Blaenau Gwent 76,400 12.7%

Torfaen 93,600 15.6%

Newport 140,400 23.4%

Monmouthshire 89,200 14.9%

Others 23,400 3.9%

Large healthcare provider

3 hospitals providing acute services3 hospitals providing acute services

comprehensive mental health services

15 other hospitals

3 hospitals providing acute services

comprehensive mental health services

3 hospitals providing acute services

comprehensive mental health services

15 other hospitals

41 health centres and clinics

3 hospitals providing acute services

comprehensive mental health services

15 other hospitals

41 health centres and clinics

serving 600,000 local residents

Over 13,000 staff6,000 nurses

1750 allied health workers

Over 1000 doctors

Including 260 Consultants

Major employer in Wales

Comprehensive services

UrologyENT

OphthalmologyMaxillo-FacialDermatologyGU Medicine

Renal ServicesMental Health

ObstetricsGynaecology

PathologyAnaesthetics

Rheumatology

Palliative MedicineAdult MedicineMinor Casualty

NeurologyAccident & Emergency

General SurgeryDental

HaematologyCardiology

Child HealthTrauma &

Orthopaedics

PsychologyLearning Disabilities

School HealthCommunity Nursing

Health VisitingFamily PlanningVaccination & Immunisation

Speech & Language Therapy

PhysiotherapyOccupational Therapy

Emergency admissionsNon-emergency admissionsDay casesNew outpatientsFollow-up outpatientsObstetric admissionsAccident & Emergency /Minor Cas.

68,30015,01749,350

115,000277,113

9,200158,670

692,650

18741

134316759

25 434

1,896

Average weekday

Last year we treated

2004/05 Income

(m)

38372232

101122

442

Gwent Local Health BoardsPowys Local Health BoardOther LHBsHealth Commission WalesVelindre NHS TrustOther NHS TrustsEducation & TrainingWelsh Assembly GovernmentOther income

Total

2004/05 Expenditure

(m)

199812185

345

8

442

EmergenciesNon EmergenciesObstetricsCommunity Services (including community hospitals)Out of Hours (part year)Mental HealthLearning Disabilities

Total expenditure by service

2002 - 2005 Context

No sustainable level of service provisionAcceptance that we could improve efficiencyCannot carry on in the Current StateMassive investment and change programme

Capital etcInfrastructureService redesign - Lean Thinking

Start of Lean Journey - June 2002

Gwent IT Services - an image of the NHSIncreasing demand outstripping resource Rapid technology changeIntelligent & vociferous usersBottlenecks / Delays / WaitsUnpredictable demandProfessional boundariesHeavily process / transaction based

Pilot project IT installations - Analysis

It took 18 weeks from point of order to point of installation (Average)The whole process was touched 154 times in some way4.5 miles were travelled excluding the driving distance93% time spent waiting somewhere or for somethingLarge number of checks usually followed by a waitLess than 2% Value-add

Pilot project results

93% reduction in lead time for PC installation80% reduction in PC stock held in Trust80% reduction in PC stores53% reduction in number of people in process40% increase in productivity in first year

All achieved without extra resources

other than the time to make the change & has been sustained for 4 years.

2002 - 2005

Lean Journey June 2002 Feb 2006

Ken Robertson

2002 2005

Projects Commenced

0

5

10

15

20

25

30

35

40

45

2002 2003 2004 2005

86 5-day breakthrough events

30 Value Stream

56 5S Events

General MedicineGeneral SurgeryCommunity Accident & EmergencyRadiologyPathologyPharmacyOutpatientsCardiology

HSDUIT ServicesTelephonyRecruitmentFinancial servicesOccupational HealthWard 5SDistrict Nurse car boot 5SDay Surgery

Some Achievements 2002 - 2005

Medical and Surgical Patient Journeys mappedWaiting List reduction/elimination

Radiology National AwardEchosRespiratory Medicine outpatients at Nevill Hall HospitalUrology

A&E Improved performance against 4 hour targetReduction in rehab length of stay (Community)Reduced Specimen turnaround time in PathologyEtc.

Sept 2004

Core team confident that Lean approach workedBut:-

Projects taking too longWaiting list developing for projectsNot getting the full benefits from the improvement proposalsNot translated into Operational ManagementImprovements were not whole systemLacking powerful champions with staying powerEven successes were not repeated

Implementation

Many improvement projects fail at last hurdleLack of skillsLack of time Lack of commitmentNot everyone on boardPeople need to change to get the improvement

February May 2005

Lean Masterclass

Chief Executive & Executive Directors, Senior Managers and Chiefs of StaffVoice of customer questionnaire from which 10 sessions were designed Desired outcome was How to deploy the Lean Team in future

1. Strengthen 5S program and deliver lots of small wins.

2. Combine VSM projects to date, to kick off a Scope debate with Stakeholders to get buy-in and common way forward and next steps.

3. Investigate Implementation Performance using Six Sigma Blackbeltproject.

4. Deliver a big win by using a Value Stream transition approach in a high impact area.

6 Implementation Investigation

20% of improvement proposals delivered on time and in full (OTIF)Discover reasons for this performance

By mapping our own process (involving original participants)Undertaking FMEADeveloped 20 hypotheses for above level of performanceTested hypotheses with original participants

Project SponsorsLean FacilitatorsImprovement ImplementersLine Managers

Analysing the Hypotheses testsAnalysis undertaken on sample sets against hypotheses from Potential Deep Causes to test differences across groups

Ques

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5S L

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Pro

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Fac

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VSM

Impl

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5S F

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5S Im

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1 x x x x x x x x x x x x x o x x x2 x x x x x x x x x x x x x o x x x3 x x x x x x o x o o x x o o x o x4 x x x x x x x x x x x x x o x x x5 o x o o o O x O o o o o o o O o O6 x x x x x o x o x x x x x o x o o7 x o x o x o o o o o x o o o x o o8 o o o o x o o o o o o o x o o o o9 o o o o x o o o o o x o o o x o o

1 0 x x x x x o x x x x x x x o x o o1 1 x x x x x x x o x x x x x x x x o1 2 x x x x x o x x x x x x x o x x o1 3 x x x x x o x x x x x x x O x x x1 4 x x x x x o x x x x x x x o x x o1 5 x x x x x o x x x x x x x x x x o1 6 x x x x o o x o x x o x x o x o o1 7 x x x x x o x o x x x x x o x x x1 8 x x x x x o x x x x x x x x x x x1 9 x x x x o x x o x x o x o o x o o2 0 x x x x o o x o x o o x o o x o o2 1 x x x x x x x o x o x x o o o o o2 2 x x x o x x o x o o x o o x x o o2 3 x x x x x o x x x x x x x x x x x2 4 o x o o o o o o o o o o o o x o O2 5 x x x x x x x x x x x x x o x x o

Theories Identified within Questions

No Standard Process

Change Of Priority

Lack Of Understanding

What "It" Is

Selection/ Deselection

No Deployment

Strategy

Not enough Time - P/T resource

Lack Of Operations

Management Skills

Q1. Do you understand the purpose of the Lean Programme within the Trust? X XQ2. Do you understand what it entails in terms of time and resource for the Programme to be fully effective? X X XQ3. How involved have you been in planning VSM and CANDO projects? X XQ4. How clear has communication been about the projects? X X XQ5. Do you believe that the changes proposed by these projects are worthy of the effort required to implement improvements? X X XQ6. Do you believe that adequate recognition/reward is being provided to accomplish effective implementation of these projects? XQ7. How compatible do you believe the approach of these projects is with existing organizational values? X X X XQ8. Do you believe that key individuals and professionals are genuinely supportive of the Lean Programme? X X X XQ9. Do you believe that project participants are adequately briefed prior to the start of projects? X XQ10. How confident are you that the organizational resources, required for the Lean Programme to be effective, will be made available? X X X XQ11. What level of improvement do you expect these projects to deliver? X X X XQ12. Do you believe that the amount of time to implement proposals is adequate? X X X X X XQ13. Do you believe that daily work patterns were adequately considered when planning these projects? X X X XQ14. Do you believe that the changes identified by these projects will have any negative impact on aspects of peoples jobs? X XQ15. How meaningful to you is the Lean Programme? X X X XQ16. How well do you think that mistakes made during implementation will be tolerated? X X X X X XQ17. Do you feel confident that the projects are planned and delivered in a standard way? X X XQ18. Do you believe that the skills and knowledge necessary to implement these projects are available? X X XQ19. What level of respect and trust do you have for the sponsor(s) of these projects? X XQ20. What level of respect and trust do you have for the facilitator(s) of these projects? X XQ21. What level of respect and trust do you have for the implementer(s) of these projects? X XQ22. How much stress are you currently facing in your job? X XQ23. Does the Lean Programme represent any threat to your personal interests? X XQ24. If improvements are abandoned or not fully implemented, how difficult do you feel it will be to reverse the effect? X XQ25. Do you believe that operational management deficiencies will be exposed by the Lean Programme? X XTotals 17 11 14 8 11 13

Totals 7 5 4 2 3 741% 45% 29% 25% 27% 54%

Hypothesis Accepted for 10 questions

Green Accept/Red Reject

Conclusion Reasons for Current State

Lack of Standard ProcessesLack of Measurement Systems for Control/ImprovementVariation in understanding what IT isResource shortages/distractionLack of understanding of capacityUsing existing day to day management systems to implement Changing Priorities

Future State (Our Current State)

30 day cycles for all projectsSufficient manpower to deliver 30 day targetOps Management for each project and the programme including targets and measures of progressFocussed on the Gemba, improvement is part of everyones day jobAuthority to make changes

Create an E2E Lean ExemplarWe want to align every bit of work that is done, up and down, through and across the organisation so that the patient flows through the process from end to end with minimal interruptions and with a supply of skill, expertise, materials and information that exactly meets demand.

Pathology DoctorsA&E

Start DischargePatient Journey

Place where people can see all processes aligned

Manageable size to experiment

Place where people can learn how to make it work

Patients receive safe treatment on time every timeMake this FlowRadiology Ward Pharmacy

ExemplarCaerphilly DMH Scope1. 4 Acute Wards. 2. Pharmacy3. Radiology4. Pathology5. Physiotherapy6. Speech & Language7. Occupational Health8. Occupational Therapy9. Theatre10. A&E11. Outpatients12. Administration13. Endoscopy14. Catering15. Works& Estates16. Cardiology17. Medical Records 18. Hotel Services. 19. Dietetics20. Birth Centre

All we need to do is to create smooth flowing Patient Journeys matching up

perfectly with smooth flowing provision processes.

Replenishment Process Improvement

It started with a glove

Dave Evans

Current State Summary

Distance Travelled = 314.55 km

Time Taken = 6 days 2hrs 40 min

Cycle Time = 323 mins

Value added Time = 7 mins

Number of people = 24 -26

Change in form = 5 types

Different Transport = 9 types

Ratio of Value added time to non-value added time:

= 7 mins= 2.2%

323 mins

Design the Future State & Transition Plan

Replenishment Transition

Transition plan made up of (in first phase). Establishing supermarkets for consumables at Ward level.

At the Exemplar site (CDMH) First ward 24/04/06 . Last ward started 12/7/06. Implemented 3S as foundation of this Last 2S is the Operations Management to keep it going.

Sort out the ordering process. Started pilot on Re Order Points 21/6 Roll out to all 4 wards 24/7 OTIF target for all orders

OTIF Measures

Replenishment - OTIF

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61

Order Number

R ep len ishm ent - IF

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61O rder N um ber

Delivery Target 95%

Actual 90%

OTIF Actual 64%

30 000 here from 3 General Medicine Wards:

We have more than 100 other wards to do

Has it made a Difference?

M o nt h

Po

unds

03 0701 0711 0609 0607 0605 0603 0601 06

5000

4000

3000

2000

1000

0

_X =899

UC L=1764

LC L=34

1 2

I C ha r t o f M A U D is pos a ble s S pe nd

UCL = 4438

X = 2193

BEFORE AFTER

58.4% Reduction in Mean monthly spend

Has it made a Difference?

Poun

ds

AfterBefore

4000

3500

3000

2500

2000

1500

1000

500

Boxplot of MAU Disposable Spend Before/After

Two-sample T test

C3 N Mean StDev SE Mean1 11 2193 936 2822 5 899 238 107

Difference = mu (1) - mu (2)Estimate for difference: 1293.8995% CI for difference: (636.67, 1951.11)T-Test of difference = 0 (vs not =): T-Value = 4.29 P-Value = 0.001 DF = 12

Has it made a Difference ?24th April - 54,000 items were counted on Bedwas Ward. Of which 11,734 items were out of date.The definition of error is that an item is out of date.Therefore chances of picking out of date product is approximately 1 in 5 Or in absolute terms 217,296 defects per million opportunities (2.22 Sigma process) But we check!!! (How good is check? Even if we can) Evidence is Human eye dependent has 85% effective (at best).Now all items in date. Pr = 0 beyond 6 sigma quality level

Store

Shower

Triage

SluiceTreatment

Store

Ward Initial 5S Targets

Ward CANDO: Bedwas Ward CMH (MAU)

30% Total Ward Area covered in this Phase

Trolley Storage

14 Beds

Further Opportunities for Improvement1. Problem Boards - expansion to all activities2. Signs and Walls (Sort & Set)3. Nurse Stations (Sort & Set)4. Kitchen Areas (Sort & Set)5. Arrest Trolleys (Sort & Set)6. Daily Clean2Check Roll out: 7. Set up kit required by ward to Sustain this: Tape, Laminator, etc8. Container types changes: Less opportunities for errors9. Expiry date checking into Clean/Check activities: 10. Set up Managers Clean2Check schedule:11. Pharmacy Stock areas & processes; Apply same rules to them12. Other Stock areas & processes: Apply same rules to them13. Infection Control issues: 14. Day by hour planning for ward staff: Everyone knows what is expected 15. Rostering process investigation: 16. Design a Put away processes:17. Stock transfer to Unit 13 process invention: To prevent throw away.18. Budget control simplification: Better control19. Train the Trainer program (roll out): So can speed up.20. Introduction of Kanban: Reduce all this ordering admin.21. Mixed load deliveries: reduce number of trucks.22. Quality, Delivery, Safety, Morale, Cost Visual management for ward/unit.

Can apply the same standard approach to these

Patient Journey: CDMH Sep 2006 Determine patient cohort to design experiments around

Stratify incoming demand Map all steps on Patient Journey Design E2E Future State Journey

Test ward data collection system Analysis of data and methods.

Set target discharges by ward for week by day improved rate (TAKT) Manage the performance v these targets. (Patient OTIF board).

Introduce Control charts (and visual measuring system for wards) using 5S.

Daily management meetings and problem solving on discharge performance.

Design & Implement Transition plan to Future State.

Safe Treatment, On time, Every time

What we have learnt

Lean methodology is compatible with Healthcare systemsIts not an easy quick fixIts not about projects its the about the day jobNeeds support and time from senior managers Need to be prepared for a long haulNeed to be self sufficient in staff who can do this

Gwent Lean Journey 2006 2007 2008 2009 2010

Create Exemplar

E2E Patient Journey Create Flow

Service Provision Process Create Flow

Replenishment/Support Process Create Flow

Staff Self Sufficient

Extend outside of Organisation Create Flow

Synchronize to the Rhythm