PowerPoint Presentation

The Application of Lean Management Practices to Improve Service Deliveryin the OPD Process at aSemi-rural District HospitalKgwadikgolo Mahosi FPDAnton Grtter - LIAQI Summit28 October 2013

Good day ladies and gentlemen, Im KG Mahosi

1What was Implemented at the Hospital?Focused on the four main sections in the OPD process:AdmissionsCasualtyOPDDispensaryMain objective was reduction of patient waiting timeTrained 3 cohorts of 16 participants over 1 year:5-day Rapid Process Improvement (RPI) workshop5 x 2-day Standard Work (SW) trainingProvided technical support to implement SW

Our focus was on the four main sections in the OPD process where the main objective was to reduce patient waiting time. We trained and coached 3 cohorts of participants over a period of 1 year. The training included a 5-day RPI workshop and 5 x 2 day SW training. The technical support was mostly focussed on implementing a WTS.2What was Implemented at the Hospital?The improvement projects were one element of a Lean Management (LM) system to institutionalize the SW practices that sustain performance improvementLean Management consistsof four layers:

Process mapping, A3 problem-solving, Etc.Standard Work PracticesVisible change in Leadership Behaviour (e.g. SW Go See)

The approach we took to implement LM at the hospital was a 4 layer approachThe outer layer of Lean Pr and Tech, such as process mapping and A3 problem-solving is the most visible part of the approachWhat is required to implement and sustain the use of the Lean Pr & Tch is the Lean Mngmnt system consisting of SW practicesThe next layer that is required to get the Lean Mngmnt system up and running is Lean Leadership And finally at the core of it all is the Lean Culture & values3Standard Work Practices required to Sustain Performance ImprovementsSW checklist used to monitor use of the following bundle of basic lean practices:For team:Visual performancemeasurementStandard operatingproceduresDaily teamworkProcess improvement5S housekeepingFor unit managersLean management

-To sustain performance improvements for the team and the manager, a SW checklist was implemented to monitor the actual use of the bundle of standard work practices. -5 sets of practices for the frontline teams and 1 for the unit managers-the table gives an eg of how the use of this practices were scored4Effective Lean Management requires Behaviour Change

Managers need to regularly Go See real-world operational performance & support staff to improve

Effective Lean Management can only be achieved if management also adopt appropriate behaviours. For example, they need to regularly visit the frontline teams to review performance graph trends and to support frontline staff to maintain and improve performance5Some Improvements Implemented

Basket far away from admin clerks caused delays with collecting patient cards to retrieve filesBefore

Here are some examples of the improvements that were implemented by the teams:Admissions dept had a basket to collect patient cards which was placed far away from the admin clerks desk, this used to cause delays in retrieving files.6

Basket eliminated and patient cards now handed in at counter where staff can collect them without leaving admin counter.Some Improvements ImplementedAfter

A new process was implemented where patients walk directly to the admin clerks to hand over their cards.

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BeforeAfterSome Improvements ImplementedQueue numberswere eliminated at a screening step to improve patient flow

All patients collecting files at the admissions section were also expected to collect a queue number for their respective clinics at a screening step outside the admissions section. This was eliminated and patients went straight to their clinics.8BeforeAfterSome Improvements Implemented

Files sorted & new shelving in file store

File retrieval time was a major problem because the filing room was very disorganised, mainly because the store ran out of shelving space. It took some months to procure new shelving and using 5S housekeeping files were sorted which made it easier and quicker to locate files. 9Institutionalization of SW Practices

Recording of performance measurements and other SW practices started

Here we see a team member updating their operational performance measures before their daily team meeting. It is critical for performance improvement that teams must monitor their own performance by reviewing graph trends and taking rapid corrective action where necessary.10Some Results

Script errors reduced after measurements fed back to doctors via clinical manager

Good day, I am Anton Grutter. This graph shows how patient and staff time wasted through having to correct script errors after patients arrived at dispensary started to reduce after doctors received feedback on the cause of those errors.11Some Results

File retrieval time started reducing over several months, but

After improving the situation in the file store file retrieval time also started to reduce after some months,12

Some Resultsrelapsed in the last two months

but started increasing again due to conflict over staff allocation between the managers of the file store and the admissions section. This highlights the need for rapid senior management intervention on issues outside the authority of the frontline teams.13Overall Result

Overall throughput time of patients in the OPD process did not decrease during the project

This graph shows the overall patient throughput time. It stacks up the waiting and service times of the primary services as patients move through the OPD process. As you can see total patient throughput time is about five hours on average and despite improvements in certain sections of the process overall throughput time did not improve over the duration of the project.14WHY?

The obvious question is why?15Standard work necessary to sustain performance

Most lean initiatives focus on process improvement,but maintaining standard work in between isequally important

Requires disciplineduse of standardwork practices

This slide is used in training to highlight the importance of going beyond doing process improvement projects to putting in place the SW practices that sustain and further improve performance. We think that this could be part of the explanation why performance did not improve.16Institutionalization of SW Practices was not achieved

Capturing of files at cashier reducedbut measurements were not updated

In the admission section there was a delay at the cashier due to capturing of files on the system that should have been done by the admissions clerk before the patient went to pay. This graph shows how initially there was an improvement when the measurement made the problem visible to the people working in admissions. However the recording of the measurements stopped about two weeks before these photographs were taken when painters removed the graphs from the wall and no-one put it back up again. In other words the SW practice was not maintained.17Institutionalization of SW Practices was not achieved

OPD units did not keep SW score up to date & SW scores of OPD units by 3rd cohort of trainees show very low complianceTarget

This graphs shows the adoption of SW practices by one of the teams. The SW checklist scores for most of the teams show that despite significant efforts by the facilitators, the behaviours required to keep the basic SW practices going were not institutionalised.18Lean Service Implementation Assessment

Malmbrandt & Ahlstrom, An Instrument for Assessing Lean Service Adoption, IJOPM, V33 N9, 2013Very low scores on LSIA instrument

An assessment at the end of the intervention using the Malmbrandt & Ahlstrom Lean Service Implementation instrument also shows very low adoption of the practices required to sustain performance improvement.19WHY?

Once again the question is why?20Most Important Challenges ExperiencedStaff & management in chronic fire-fighting mindset & therefore revert back to traditional managementImplementation structures (eg lean committee & lean champion) did not function effectivelySystemic problems outside scope of LM project not addressed fast enough or decisivelySenior management distracted by other DoH projects and visits from provincial task teamsFacility embedded in an unsupportive organizational context

The challenges listed on the slide feature prominently in our interpretation of the causes of this disappointing outcome. In a nutshell the lesson is that the main challenge lies not so much with the frontline staff, but rather with the fact that successful institutionalization of lean management, or QI, require a systemic change in management behaviour and the organisational support systems. All is not lost in the sense that now that we can show management measurements that objectively demonstrate that performance has not improved , it has enabled a reflective dialogue with them in which the underlying causes of the unsuccessful transition are being opened up.21Normalization Process Theory Assessment

Finch et al, Improving the normalization of complex interventions: measure developmentbased on normalization process theory (NoMAD): study protocol, Implm Science, V8 N43, 2013

Another interesting perspective arises from the normalization process theory assessment. The average scores on the four NPT constructs show that the biggest problem is not staff identification with the purpose of the intervention at the outset, or their retrospective evaluation of the value of the intervention. The biggest challenge is their inadequate understanding of what they actually need to do to make it work and consequently their poor implementation of the required practices.22Revised Working HypothesesIn addition to the standard LM interventions such as:Securing buy-in from management & staffTraining & follow-up coaching to implement SW practicesTechnical support on performance measurement, etc.Monitoring & evaluationFuture LM interventions will include:Extended engagement with district & facility senior management prior to deployment at facility levelIntensive initial SW coaching to achieve minimum complianceRigorous monitoring of LM practice complianceRapid decisions with senior management to address major obstacles during implementation process

As a consequence our future interventions are shaped by more upfront facilitation work with senior management to try to support them to adopt the required lean leadership behaviours, more intensive coaching for frontline staff to help them acquire the work habits that maintain the SW practices, and putting in place the working relationships that enable rapid responses to systemic challenges that arise during the course of the intervention. Thank you and we hope you find this presentation helpful in your lean journey.23