© Bolton Hospitals NHS Trust 2008. All rights reserved. Not to be reproduced in whole or in part without the permission of the copyright owner.

Undertaking the Journey of Lean in the NHS

HSJ Conference21st

May 2008David FillinghamChief Executive

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Recognise this…?

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……and this?

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How we usually “solve” problems in the NHS

• Retreat to a Boardroom or office

• Involve only managers and “higher ups”

• Speculate and tell anecdotes

• Go with the majority or loudest voice

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How we usually “solve” problems in the NHS

• Retreat to a Boardroom or office

• Involve only managers and “higher ups”

• Speculate and tell anecdotes

• Go with the majority or loudest voice

The Lean Way

• Go to the actual workplace

• Involve the whole team of front line staff

• Use data • Test solutions through

rapid experiments (PDCA)

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Developing Lean Healthcare is a never ending journey of transformation……

Technical Changes Cultural Changes

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• Bolton’s lean journey – the story so far

• Why healthcare is different and why it’s the same

• Tools vs People• Challenges and lessons

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Bolton’s Lean Journey

• Began in August 2005….part of a “turnaround” both in quality and financially

• Reinvented lean as • 21% of staff engaged in week long events• Many more involved in awareness raising

activities• Early results promising…but we’ve only

scratched the surface

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ImprovingHealth

Best PossibleCare

Value forMoney

Joy andPride in Work

No avoidableDeaths or Harm

No Waste Highest Morale

No Defects

True North Goals

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BICS…..some early results

• Trauma – FNOF 50% mortality ↓; 33% LOS ↓; 42% paperwork ↓

• Pathology – Test turnarounds from x3 to x10 quicker; 40% floor space saving

• Ophthalmology – New “CATS” service – patient visits 50% ↓; 18 weeks delivered early

• High risk joint replacements – complications ↓85%; LOS ↓43%

• Laundry, Estates, Finance and others – six figure cost savings

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Why the NHS is different

• Caring for patients not making motor parts

• Demand is totally unpredictable

• Medicine can’t be standardised

• Every patient is unique

• Doctors and nurses wont accept it

Why it’s not

• True…but all

processes can be improved

• Not true

• Not true…compliance with evidence improves outcomes

• True…but many are similar and pass through some processes

• Not true…engagement lifts morale

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Lean Healthcare can work at a range of levels

Complexity

AmbitionPointKaizen

FlowKaizen

InstitutionalChange

Whole SystemChange

DepartmentPatient Journey

Hospital/Provider

Whole Health Economy

Wider Society

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A lean transformation must keep an even balance…..

TECHNICAL CULTURAL

“Tools” “People”

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Too much emphasis on tools and methods….

TECHNICAL

CULTURAL

•Failure to embed or spread•Resistance to change•Results not sustained•No overall transformation

•Extensive use of “tools”•Use of Japanese terms and concepts•Some processes made more efficient•Lean belongs to a few enthusiasts

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Cultural concerns predominate….

TECHNICAL

CULTURAL

•Temporary feel good factor created•Better teamworking•Increased levels of involvement•But hard to sustain without results

•Failure to establish flow•Lack of rigour in use of tools•Lean “speak” without true understanding•Full potential not realised

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An even balance….TECHNICAL CULTURAL

•Concepts

•Tools

•Disciplines

•Board commitment

•Awareness raising to indepth training

•HR Frameworks

•Leadership for Lean

EventWeeks

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Technical

• Concepts

• Tools

• Disciplines

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Concepts –

Value and Waste

• Begin by UNDERSTANDING VALUE from the customer’s perspective

- technical efficiency- the aesthetics of the experience

• Continually eliminate waste and enhance value

• Redesign Horizontal Flows – ie Patient Journeys – end to end

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VISUAL MANAGEMENT:

1 PIECE FLOW

STANDARDWORK

6 SPULL

SYSTEMS

Move awayfrom batching,Backlog andQueues.

ReduceVariation & Complexity

Clear to See:StraightenSweep & CleanSafetyStandardiseSustain

Create signalsTo pull patients.Obvious whenSomething empty

“ability to see the process”

Concepts –

Summary of Lean Principles

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Lean Methods and Tools

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Lean Disciplines

• True north goals• Use of data• “A3” thinking• Mission Control and Executive Reviews• Standard Work of Leaders

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Cultural Transformation

“First we build people, then we build cars”

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Fillingham’s Motivational Matrix

NaiveIdealists

EnthusiasticPragmatists

EmbitteredCynics

DisillusionedSceptics

Atti

tude

To

Life

Posi

tive

Neg

ativ

e

Grasp on RealityLow High

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Cultural

• Board Commitment (or equivalent)

• Awareness Raising Indepth Training

• HR Framework

• Leadership for Lean

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Green Certification

Bronze Certification

Silver Certfication Gold Certification

Advanced Reading

Advanced Reading

Advanced Reading

Business Case Effective Team Management

VSA Methodology

Policy Deployment Mentorships

History of Lean Bolton Mgt. System (BICS) VSA Scoping 2P / 3P Partnerships

Fundamentals of BICS A3 Thinking 6S & Visual

ManagementProduct/Service

DevelopmentTPOC/Mission Sponsorship

RIE PrepRIE Event

RIE SustainmentJourney Update

Thedacare VideoProblem Solving

& CA Tools Pull Systems Leadership & Followership

Journey UpdatePathology Video

Team Leader Training Standard Work Steering

Committee

Certification Assessment

Flow CellBasic Tools

Understand Bolton's

Commitment to Patient Care

Understand each role as it relates

to BICS

How to select key areas for

targeted improvement

How to link improvement to

strategy

How to apply transformational

thinking

Understand the History of

Continuous Improvement

How to use A3 Thinking to Solve

Problems

How to use basic tools to see and eliminate waste

How to use advanced tools when and where

appropriate

How to apply the technique for

each respective tool

Understand How I can Learn &

Contribute

Understand your role in team

participation & event mgmt

How to lead others in the

application of the methods

Understand how to develop the

BICS infrastructure

The ability to mentor the

application of BICS at all levels

Can describe the high level BICS

approach

Using A3 thinking to solve

problems

Working effectively in a

team

Leading improvement in

a systematic way

Unquestionable belief that the

tools apply everywhere

Can describe why BICS is

important

Seeing elements of waste

Identifying process

problems before people problems

Working with complexity

(people, process & tools)

Confidence to teach others at

any level

Green Certificate Bronze Training Certificate

Silver Training Certificate

Gold Training Certificate

Platinum Certificate

Participate in one PS/CA Activity**

Participate in one VSA Activity

Lead one VSA Activity

Participated/Lead 20+ RIEs

Participate in two RIEs** Lead 2 RIEs** Developed 3

Mission A3s

** Must demonstrate proper preparation, execution and sustainment using A3 methodology

3 Days

Silver3 Hours 3 Days 2 Weeks 2 Weeks

Bolton Hospital - Simpler Healthcare TM CertificationGreen Bronze Gold Platinum

Kno

wle

dge

Prer

equi

site

sR

equi

rem

ents

None

Skill

sB

ehav

iors

Flow Game One Need Flow Project Management

Facilitation/Coaching

Capability

Culture

ProcessR

esults

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The Lean Leader

• Go and See• Ask Why• Respect People• Force Reflection

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Event Weeks

• Integrate the technical and cultural aspects of lean transformation

• At best they can:-– Deliver improvements– Train concepts and tools– Change attitudes and habits

• But…..difficult to do well consistently…..not sufficient on their own

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Role of Events• VSAs

(Value Stream Analysis)

3 days - Understand current state- Agree Future State Vision- Develop Improvement Plan

• RIEs(Rapid Improvement

Events)

5 days - Implement Rapid Changes

Knowledge, skills, attitudes

Learning by doing

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Value Stream Analysis: Current State for Trauma

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Value Stream Analysis: Current State for Trauma

• Spaghetti Diagram• We walk miles when we

shouldn’t have to• Things are not where they

are needed (if they are even there at all)

• We have to look for the sick patients and they can be anywhere

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Value Stream Analysis: Current State for Trauma

• Hand Off Chart• 197 handoffs to

discharge a patient!

• Duplication• Frustration• Huge source of

potential error

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Redesigning Care

VISUAL MANAGEMENT:

1 PIECE FLOW

STANDARDWORK

6 SPULL

SYSTEMS

“ability to see the process”

CURRENT STATE IDEAL STATE FUTURE STATE

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Improvement Plans

• Just Do Its• Rapid Improvement Events

(RIEs)• Projects• Daily Habits

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Trauma RIEs• Flow through A&E• Radiology• Trauma Stabilisation Unit• Theatres• Discharge and Multi Disciplinary

Team Working• Patient Flow

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It is easier to act yourself in to a new

way of thinking, than it is to think yourself into

a new way of acting

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Events

• A highly valuable intervention• Generate excitement and

commitment• Need to avoid event-itis• Build a bridge into lean as a daily

activity

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Challenges and Lessons

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Challenge

• Engaging clinical staff

• Lean jargon can alienate

• Fear of job losses

Lesson

• Patient focus, results, time

• Invent your own system and language

• Fully engage staff side; no layoffs promise

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Challenge

• Lean activities become talking shops

• Results aren’t delivered or sustained

• Enthusiasts vs Sceptics

Lesson

• Rigorous use of tools and disciplines

• Hold line managers accountable

• Roll out to everyone; ‘change the people’

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In conclusion……..

– Reinvent lean for your part of the NHS

– Balance technical and cultural change

– Be patient and resilient

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In conclusion……..

• From….. LEAN“Less Employees Are Needed”

• To..…… BICS“Best Ideas are Common Sense”