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