Lean Healthcare - Streamlining Patient Journeys

Lean Thinking in Healthcare
Doing the Right Thing for Every
Patient
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010

Making Hospitals Work
How to improve patient care while saving
everyone’s time and hospitals’ resources
by Marc Baker and Ian Taylor
Foreword by Daniel T. Jones
A Lean Action Workbook from the Lean Enterprise Academy
Version 1.0 Goodrich UK
May 2009 www.leanuk.org

Exercise: Check Current Awareness
• Split in to Groups.
• Objective: Each Group to give 5 mins
Presentation:
• What is Lean?
• Where does it come from?
• Use Flip charts.
• Presentation must be on 1 Flip chart.
• Timescale: 20 mins

Lean Principles
Overview

Lean Thinking
• Specify what creates value from the
customers perspective
• Identify all steps across the whole value
stream
• Make those actions that create value
flow
• Only supply what is pulled by the
customer just-in-time
• Strive for perfection by continually
removing successive layers of problems

Our Observations in
Healthcare

Activity Daily
Bed Meetings (x3 daily) 2.25
Morning Handover 0.5
08:15 - 08:30 (x2 weekly) 0.2
ECIP 0.3
Facilitators 1:1 (x1 fortnight) 0.35
DHM 1:1 0.35
Emergency Pathway 0.2
Facilitators Meeting 0.3
Corridor Meeting 0.25
Hants Conf Call 0.5
PAU 1:1 0.25
MAU meet 0.2
Op Commisioning Meeting 0.4
1:1 with Ed 0.05
DGM DSN Meet (x1 fortnight) 0.15
HMC 0.15
COO Meet 0.15
St Mary's transitional grop 0.075
Nursing Workforce Committee 0.075
Duty Managers Update 0.5
DMOP Meeting 0.2
Seeing Facilitators 1
Duty Manager 1.6
LEA 0.4
Contract Review 0.05
Bleep Holder 2
30 day review meetings 0.5
Actions from Bed Meetings 1
Ad Hoc Meetings 1
Appraisals 1.1
1:1 with Mary 1
Hospital Walkabout 1
Discharge Lounge 0.25
Update for DMTs 0.375
E-Mails 100/Day 2
Report Writing 0.6
Budget Management 0.1
Performance Managing 0.2
DHM Induction 3
24.575
The Diary Exercise – Daily Personal Capacity V’s
Daily Organisational Demand……. This is real
data and absolutely typical. But What’s causing
this?

The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can we measure it?
•Agreed? Who will be responsible and do they accept this responsibility?
•Relevant? What is its contribution?
•Trackable? Can we see the status at a glance whenever we want to?

Target Focus No. Projects
Cost Improvement 300
4hr Performance Improvement 132
Safety & Quality 44
18 Week Access 39
TOTAL 515

SCORECARD
Stakeholders
Resource
Utilisation
Management
Processes
Innovation
& Learning
A B C A B A B A B C D
15 15 3 4 11 9 23 1 3 2 1
20 21 9 14 36 22 92 11 11 7 9
Scorecard – Descriptive Stats
Categories
Strategic
Objectives
Specific
Goals
Measures
Categories = 4
Strategic Objectives = 11
Specific Goals = 87
Measures = 252

The BIG Problem

1. Compliance with 4 hour emergency access performance target.
2. Compliance with the 18 week scheduled service access targets
3. Cost reduction. Middleton was six months into the financial year and
was already £6.5 million overspent year to date.
4. Medical length of stay (LoS). A previous benchmarking survey had
revealed that Middleton’s medical patients were staying in the
hospital longer than the national average.
5. Rates of Hospital Acquired Infections (HAI) such as MRSA and C.
difficile were also higher than the national average.
Middleton’s Story
Middleton General has 5 big problems:

The BIG Problem – Consructing the Matrix
A&E
Access
Cost
MedLoS
HAIs
A&E
Access
Cost
Med LoS
HAIs
Problems
Impact(√orX)

The BIG Problem – Looking for Leverage
A&E
Access
Cost
MedLoS
HAIs
A&E
Access
Cost
Med LoS
HAIs
Problems
Impact(√orX)
EG if we fixed our
A&E 4 Hour
Target problem
Would this also
fix any of the
other problems
for free

A&E
Access
Cost
MedLoS
HIAs
A&E
Access X
Cost X
Med LoS X
HIAs X
Problems
Impact(√orX)
EG if we fixed our
A&E 4 Hour
Target problem
Would this also
fix any of the
other problems
for free
The BIG Problem – Looking for Leverage

Medical LoS - The BIG Problem

Seeing the
Process:
What is our
Current
Condition?

The Current State

From the total LoS of 7.6 days only 1.1 days receiving diagnostics or interventions
(14.6%)
AND
Don’t get hung up on the cure time debate – it’s the triangles that we’re going for
after all

Don’t worry if yours ends up looking like this !!!!

Staff/Departmental Availability

Nursing Availability to Discharge from Wards

Thinking Differently

"Everything that can be invented has been invented.”
Charles H. Duell, Commissioner, U.S. Office of Patents, 1899.
"We don't like their sound, and guitar music is on the way out anyway.”
President of Decca Records, rejecting The Beatles after an audition, 1962
"That is the biggest fool thing we have ever done [research on]... The bomb will never
go off, and I speak as an expert in explosives.”
William D. Leahy, U.S. Admiral, advising President Truman on atomic weaponry,
1944
Man will not fly for 50 years.”
Wilbur Wright, American aviation pioneer, to brother Orville, after a disappointing
flying experiment, 1901 (their first successful flight was in 1903)
"... good enough for our transatlantic friends ... but unworthy of the attention of
practical or scientific men.”
British Parliamentary Committee, on Edison's light bulb, 1878
"The Americans have need of the telephone, but we do not. We have plenty of
messenger boys.”
Sir William Preece, Chief Engineer, British Post Office, 1878
"Space travel is bunk.”
Sir Harold Spencer Jones, Astronomer Royal of the UK, 1957
(two weeks later Sputnik orbited the Earth)
" 640k ought to be enough for anybody.”
Bill Gates, 1981

"X-rays will prove to be a hoax.”
Lord Kelvin, British mathematician and physicist, president of the British Royal
Society, 1895(?)
"Louis Pasteur's theory of germs is ridiculous fiction.”
Pierre Pachet, British surgeon, Professor of Physiology at Toulouse, 1872
"The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise
and humane surgeon".
Sir John Eric Ericksen, British surgeon, appointed Surgeon Extraordinary to Queen
Victoria, 1873
"The abolishment of pain in surgery is a chimera. It is absurd to go on seeking it...knife
and pain are two words in surgery that must forever be associated in the consciousness
of the patient.”
Dr. Alfred Velpeau, French surgeon, 1839

Waste

Typical Mgmt Approach – Squeeze the Boxes
Why - Because they can’t see the Triangles
Necessary but non value adding
35%
Value adding
5%
Non value adding
60%
Why not start
here instead

Process, obviously needs Re-designing but…….
Stability 1st
Then
Re-design
So what is stability & how do you get
it…….
Some form of standardisation
Flow, Pull, Perfection systems

Scientific Operational Management
Our Definition:
Scientific operational management is a closed loop
system that provides the Measures & Stability required
to enable Safe Experimentation (Re-design) : It is Lean
within the Day job!!! Very important but omitted by many!
Closed Loop employs strict PDCA whereby the Check
frequency is at the appropriate pitch to enable the
required adjustment to minimise variation in the process
The scientific setting of warning and action limits and the
standardisation of the actions required to return to the
desired condition – “I will not fail”
It IS a Science…… BUT it’s NOT Rocket Science

P lan D o
A ct C heck
Now
Grasp the
Current State
The Abnormality
is Obvious
Gap
EffectCauses
The Possible Causes
EffectCauses
The Possible Causes
EffectCauses
The Possible Causes for Gap
Pareto Graph
Highest Priority
Pareto Graph
Highest Priority
Pareto Graph
Highest Priority
Action Plan
No. WhoAction
Action Plan
No. WhoAction
Plan
Target
The Scientific Approach
What links these components?
A standard method

Plan for Every Patient Boards
By the Hour in ED
By the Day
on Wards
Back to the Frontline

Pilgrim Hospital (Boston) – Medical Visual Hospital - Day One
3 Empty Beds, 12 Medically Fit, 5 Potentially Fit, 30% should not be in acute beds
whilst MAU is full and patients are breaching in A&E – Bed Man are declaring No
Beds!!!!
What would you do?

The Visual Hospital in action with the MPS

Guess What
This ‘lean’ stuff really works in
healthcare

Bottom Line Results:
Mean Medical LoS has reduced by 1.87 days (30%) from 6.23
days to 4.35 days within 32 days of change.
The Median Medical LoS has reduced by 1 day (25%).
LoS variation has reduced significantly
Huddersfield Royal Infirmary – Medical LoS
Patients in time order
DaysLoS
620558496434372310248186124621
40
30
20
10
0
_
X=4.35
UCL=10.12
LCL=-1.41
581 894
11
1
1
1
1
1
1
1
1
11
1
1
1
1
1
1
1
11
1
11
1
1
1
11
1
11
1
1
11
1
1
1
1
1
1
1
1
1
1
1
11
1
Patient LoS Before & After changes

Huddersfield Royal Infirmary – Emergency Surgery LoS
Bottom Line:
Mean Emergency Surgery LoS has reduced by 4.4 days
(53%) from 8.3 days to 3.9 days within 48 days of
changes.
LoS variation has reduced significantly.
Patient LoS Before & After changes

Bottom Line Results:
Average LoS has reduced by 27.3% for
Medical patients
and by 28.3% for Surgical patients
LoS variation has reduced significantly for both
And…..more of the Same at United Lincoln Hospitals Trust
Patients in Time Order
LoS(days)
476042843808333228562380190414289524761
200
150
100
50
0
_
X=7.2
UCL=19.8
LB=0
2471 6197
Med Patient LoS Before & After changes
Patients in Time Order
LoS(days)
2880256022401920160012809606403201
200
150
100
50
0
_
X=3.8
UCL=8.5
LCL=-1.0
3908 6442
Surg Patient LoS Before & After changes
Clinical improvement facilitator Victoria Newlands-
Bentley told the Target: "All staff involved in the project
have worked hard to implement the changes and the
results are proven.
"Our patients are receiving more streamlined, efficient
care and are benefiting from earlier discharge from
hospital.
"We will continue to look at ways in which the patient
experience can be further improved in our hospital as we
take this project forward."

And….. Aneurin Bevan Health Board
121510809458106755404052701351
140
120
100
80
60
40
20
0
_
X=7.6
UCL=24.9
LB=0
1 2 3Trauma LoS from 01/08/2010 up to 09/05/2011
Individual Patients in Time Series Order
LoS(days)
The approach is now being adopted by the Toscana
Health Authority (in Firenza, Pisa, Lucca and Prato)
and Beth Israel (Harvard Medical School)
“We have completed week one of our Visual Hospital
Pilot. The rounds are getting better and we gather more
valuable information each day”. MJ Brogna - Associate
Chief Nurse Beth Israel Deaconess Medical Centre

Hospital Level
Visual Hospital
Ward Level PfEP
Individual Patient Level Nursing Handover Sheets
Closed Loop Check/Adjust
Closed Loop Check/Adjust
Visual Hospital Hierarchy

Lean Healthcare - Streamlining Patient Journeys

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