PRINCIPLES OF LEAN

1. PRINCIPLES OF LEAN

2. Lean Awareness Workshop Outline • Introduction and Welcome • Background to Lean • Lean Principles • Flow Exercise • Value-stream Mapping • Waste Spotters Exercise • Lean Toolbox • Rapid Improvement Events (RIEs)

3. The Six Challenges • Re-engineered care processes • Effective use of information technology • Knowledge and skills management • Development of effective teams • Co-ordination of care across pathways • Making change possible Institute of Medicine Crossing the Quality Chasm: A new Health System for the 21st Century Corrigan JM 2001

4. Timeliness Safety Dimensions of Quality Efficiency Effectiveness Equity Patient -centeredness

5. Where Does Lean Originate? • Developed by Toyota as the Toyota Production System (TPS) over the last 50 years • Study of TPS led to academics defining the approach as “Lean” • The application of Lean is not new – principles have been used in many industries. • In the last ten years, increasing application of the Lean approach in healthcare

6. Lean Strategy for TPS... • Requires a focus on whole systems and processes • Relentless focus on delivering services/products • which meet the needs of the customer, or in healthcare, • the patient • The application of the PDSA (Plan, Do, Study, Act) • rapid change cycle

7. Lean PrinciplesJones & Womack, Lean Thinking-Revised, 2000

8. Why is Lean Relevant? • “Lean thinking is not a manufacturing tactic or a cost reduction programme, but a management strategy that is applicable to all organisations because it has to do with improving processes. All organisations – including healthcare organisations – are composed of a series of processes, or sets of actions, intended to create value for those who use or depend on them (customer/patients)” • IHI: Going Lean in Health Care, 2005

9. Lean in Healthcare • Virginia Mason – USA • Theadacare - USA • Bolton NHS - England • Gwent NHS – Wales • NHS Tayside, NHS Lothian - Scotland

10. The Nun and the BureaucratA book and DVD outlining how 2 hospitals used Lean principles to transform their systems • “The fact is that a patient is not a car, and never will be. So. If that were the problem we were trying to solve, we’d be stopped. • However, the Toyota system is set up to identify customer needs in very clear ways and to meet those needs in explicit, efficient, rapid supplier-building methods. • They’re quite superior in the world of work, so if you said there was no work in healthcare then we’ve got a gap. But as long as you confess that work’s there, then I’ve got a solution.” • G. Kenneth Turnbull, Ph.D., • Executive Vice President of Alcoa Business Systems

11. Economies of Flow

12. Staff Process Patients motivation age unclear motivation skills disease guidelines differ holiday illness education race training shifts sex complications anaesthetics Machines/rooms not the same suppliers transcription transport applications Information Resource Sources of variation in a clinical system GP 80% is under our control

13. Resulting in.. Systemic issues Poor Scheduling of appointments and resources Absence of process ownership and control Unquantified capacity and demand Overly complex pathways built in waits and delays Few defined processes and no standard working

14. Healthcare processes are all about flow. “Toyota revolutionised our expectations of production; Federal Express revolutionised our expectations of service. Processes that once took days or hours to complete are now measured in minutes or seconds. The challenge is to revolutionise our expectations of healthcare: to design a continuous flow of work for clinicians and seamless experience of care for patients” Don Berwick, “Reducing Delays and Waiting Times Throughout the Healthcare System” IHI 1996

15. Value-Stream Thinking • “Stop looking at aggregated activities and isolated machines…Start looking at all the specific activities and see how they interact with each other.” Womack and Jones

16. What does it do to our patients? • When a patient experiences a service it is either good - and therefore what they expect - or it is bad. Patients do not experience “averages” • As consumers in the outside world we have expectations of good quality and service, if these expectations are not met then we take our business elsewhere… • In health our patients do not readily have that choice.

17. Process Map A process map answers questions, such as… • What is the waste in the process? • Where are any blockages to flow? • How long does each process step take? • How many handovers are there?

18. Mapping and analysis of the Process Increasing level of detail

19. Two Elements to Every Job Value Adding Valuable Effort Costs Time Costs Money Adds Value VALUABLE Non-Value Adding Valueless Effort Obvious Waste Costs Time Cost Money Adds No Value WASTE

20. Types of Waste • Toyota’s Seven Wastes • * Transport • * Inventory (work in progress) • * Motion • * Waiting Time • * Over-processing • * Over-production • * Defects • TIMWOOD

21. Wastes in a Healthcare Process Lean Thinking – Improving flow and eliminating waste - Neil Westwood, NHS Institute for Innovation and Improvement

22. Standardisation • This is an important challenge in healthcare • delivery • It requires agreement from all groups in the • pathway of the best way to do the job • Requires a clear way in which this is shared • Needs a clear procedure for agreeing any • process changes • Performance management to track adherence

23. Lean Tools • Value-stream mapping • PDSA cycles • Understanding Demand, Capacity and Variation • Root Cause Analysis – often called 5 Whys and How (5W + H) • 6S/Visual management • Glenday Sieve • Rapid Improvement Events (RIEs)

24. Lean PrinciplesJones & Womack, Lean Thinking-Revised, 2000

25. ‘Flow’ in health care Progressive uninterrupted movement of patients, information and equipment between departments, staff groups or organisations as part of their care pathway. - NHS Modernisation Agency, 2005

26. Effective flow is a property of the entire system Patient Pathway Micro-system Micro-system Micro-system Micro-system Teams make day to day, minute by minute decisions in their own micro-systems without a view of the whole system. Even if they have optimised their own system it may do nothing for the whole patient pathway. Patients need to flow through the healthcare system, however if underlying processes are inefficient we will not manage patients effectively.

27. Effective flow in action – Unscheduled Care Collaborative 5 Patient Flows Group 1 - Minor Injury & Illness Group 2 – Acute Assessment Group 5 - Out of Hospital Care Group 3 – Medical Admissions Group 4 – Surgical Admissions

28. Advantages of Improving Patient Flow • Improved patient outcomes and improved service quality • Reduced time that patients stay in hospital, improving patient experience and freeing up inpatient capacity • Reduced DNAs, improved resource utilisation and improved overall value for money • Improved discharge pathways and reduced variation in length of stay • Improved appropriateness of care – to make sure that patients get the right treatment, from the right professional, in the right place, at the right time - Planned Care Improvement Programme, Patient Flow in Planned Care, IST, 2007