LEARNING TO SEE

Once value is understood through the customers’ eyes we need to establish whether ornot what we are delivering is valuable. All too often we become so used to problems that we “work around them” and accept them as part of the necessities of day to day hospital life. 

Learning to see is about asking staff to put on their “waste goggles” and totry to see the waste inherent in all of our processes. We have adapted Toyota’s seven wastes to be relevant to healthcare (see Figure 2).

All too often hospitals are so cluttered and untidy it is hard to see where the wasteis, and almost impossible to create a smooth workflow. A lean consultant who worked with us remembered that he used to tell clients their factories should be well organizedand orderly as a hospital; after working in a hospital he no longer does so! A lean technique for creating order and cleanliness is “6S” (sometimes called 5S). This translates imperfectly from the Japanese but in Bolton it means:

1. Sort. Separate needed from not needed.
2. Straighten. A place for everything. . .
3. Shine. Clean and wash.
4. Standardise. Build into accepted routines.
5. Sustain. Discipline to ensure maintained.
6. Safety. Checking for hazards and defects.

Figure 2: Seven Wastes in Healthcare

• Transport - movement of patients and equipment
• Inventory - unneeded stocks and supplies
• Motion - movement of staff and information
• Waiting - delays in diagnosis and treatment
• Overproduction - unnecessary tests
• Over burden - stressed, overworked staff
• Defects - e.g. medication errors, infections

A 6S exercise is more than just a clean up of the workplace, it is a way of ensuring thatcalm and orderliness are built in to the day to day way of doing things. This has nowbeen carried out on a range of clinical areas. 

As a spin off of our trauma work a 6S exercise was undertaken in the A&E resuscitation room. One might imagine that this would have already have been in good order, however staff found that there were awide range of improvements that could be made. 

During a single week long 6S event 71separate improvements were made in the A&E resuscitation room. This has led tofewer clinical incidents, fewer medication errors and higher staff morale.

There is always a danger that a 6S exercise will be seen as a one-off clean up. In reality it should only prepare the ground for what needs to be a daily discipline. Withthe help of Michael Balle´ (2005), author of the lean novel The Goldmine, Bolton hasbeen working to instill this discipline at ward level. 

This has been termed the “Go andSee Approach”. Nurse Managers at ward level are encouraged to regularly look at their wards with fresh eyes to spot the waste and potential for harm to patients. 

Each week they are asked to identify at least three problems. They then work with their staff to identify and implement solutions before tackling a further three problems the following week. Over a period of weeks and months the cumulative effect can be dramatic. 

Most importantly it creates a culture where looking for and solving problems is the normrather than simply working around them as is all too often the case. Establishing sucha discipline is far from easy! 

Whilst this has begun to take hold in some areas in Bolton there remains a long way to go and other ways are needed of enabling staff to see the defects that exist within the hospitals processes.

The most developed form of “learning to see” is a valuestream analysis event. This sounds like a fairly dry bit of jargon but in reality it is an extremely powerful way of engaging frontline staff to identify problems and come up with solutions. 

The valuestream analysis event for the trauma service took place late in 2005. Amulti disciplinary team of doctors, nurses, therapists, managers and patients, spent aweek removed from their other duties focusing just on this task. 

They were taught the method and then put it into practice by mapping in detail the progress of the patient’sjourney from arrival at A&E through radiology, the wards, the atres, back to the wards and the discharge process. In doing this they identified enormous waste, error and duplication. In fact a number of staff were visibly moved by what they found. 

One doctor said he did not realize that the service we were delivering was so poor and reflected that he had never seen the whole journey end to end. On observing the complexity of our discharge processes one of the patients who had been invited to participate asked the question “how did I ever get out?” 

From a low point early in the week when they fully understood all of the problems the team moved to develop an exciting vision of how the service could be in the future. That future state was made challenging but achievable and pitched some 12-18 months into the future. 

Finally the team ended the week by developing an improvement plan to deliver their future state.This consisted of some major projects that would be needed; some “just do it’s” simple things which staff could do quickly to put things right; and other areas where further week long rapid improvement events would be beneficial in helping to transform the service.

REDESIGNING CARE

Throughout the early part of 2006 the trauma team worked to implement their future state vision for the service. 

Six week long rapid improvement events were run looking at flow through A&E, the way the radiology service worked, the establishment of a trauma stabilization unit with significant input from the physicians, the processes within theatres, the discharge process, and multi disciplinary team working. 

It is at there designing care stage of the BICS cycle that we have really begun to creatively adapt lean methodology for a healthcare setting. Our consulting partners Simpler have shared with us a simple model which they use to help get lean principles embedded inany organization they work with.

Arranged in a deliberate order of implementation the logic (starting in the 12 o’clockposition in Figure 3) is as follows:

1. Get the process flowing one-by-one from one value adding step to the next without waste. For us this is the flow of patients and of information.
2. Underpin this new and counterintuitive working into staff habits through simple visual standard work that not only captures the current best way of performing the flow but also calculates correct staffing for given demand scenarios.
3. Make this flow and standard work easy to do through good 6S (correct arrangement, housekeeping and use of the workspace).
4. Next never try to force things through the process by pushing patients through in a false hope that things will speed up. Instead smooth out the irregularities in flow and ensure success by only having downstream steps; pull patients from upstream steps when they are ready.
5. Finally design visual management aids so that leaders can simply go-and-see what is happening and (because they have flow) exactly the next problem they should be solving without disturbing staff from their value added tasks.

FIGURE 3:

The trauma team worked creatively to apply this in a healthcare setting. They quicklycame to see that standard work should be what we have in the past termed effective clinical practice. 

The trick is not just to identify it but to embed it so it is carried out consistently on a daily basis. The team also concentrated on ensuring that patients flowed in a smooth manner through the unit. Previously very sick and more stable patients had been muddled together on the same ward. 

The team redesigned the area to create a trauma stabilization unit in which the sickest patients were received andstabilized medically prior to theatre.

A good flow was then established to allow quickeraccess to theatre, proper rehabilitation and effective multidisciplinary team workingafter patients had had their operation. 

A single set of much reduced paperwork wascreated for use by medical staff, nurses and therapists alike eliminating much of the form filling that had grown in an ad hoc way over the years. This greatly reduced the number of non-value adding steps and alleviated a large source of staff dissatisfactionand frustration.

6S was introduced into the area, particularly into the trauma stabilization unit, so that all of the equipment and information that would be needed forthe most poorly patients was always in the same place and always to hand. 

Finally visual management systems were set up so that staff could see on a continuing basis whether or not the process was operating as it should and what quality problems and defects were occurring.

DELIVERING BENEFIT

The final step in the BICS cycle is to close the loop and make sure that the changes thatare implemented really are delivering benefit. This phase also builds in reflection on what has worked and what has not as a precursor to starting the cycle again. 

One of the surprising things about a lean approach, as well as one of the most encouraging, in thateven though a single pass through produces a large percentage improvement repeated cycles can also produce a similar scale of gain. 

In a healthcare setting delivering benefitis one of the most difficult phases. We have found that the key is to be clear at the outset about aims whether these be for reductions in mortality, improvements inproductivity or increases in patient satisfaction. 

Unless line managers fully own the programme of work and are committed to implementing the changes and sustaining them on a continuing basis then gains made during the heady days of a rapid improvement event are likely to be quickly lost. 

In the case of trauma the strong commitment of the orthogeriatrician, the lead orthopaedic surgeon, the matron, the nurse ward manager and the senior therapist were absolutely critical in sustaining the improvements which the teams identified during rapid improvement weeks.

We have learned that it is vital for senior leadership to show a genuine interest in this work and pay attention to the results that are being delivered. 

In Bolton the Executive Board (made up of directors and senior clinical leaders which meets once amonth), now considers all of the previous months lean improvement activity, checking that the expected results have been delivered and asking questions as to why if they have not. 

It is necessary to program manage lean benefits realization in as disciplined and systematic a way as any other aspect of the hospital’s core business.

SO WHAT WAS ACHIEVED?

The outcomes delivered in the trauma pathway were surprising to us both in terms oftheir scale and their sustainability. Over a period of just nine months the team delivered:

• a 42 per cent reduction in paperwork;
• better multi disciplinary team working;
• a reduction in the time taken to get patients into theatre with a fractured hip from 2.3 days to 1.7 days (a 38 per cent decrease);
• faster recovery and lower demand on the rehabilitation ward;
• total length of stay reduced by 33 per cent; and
• mortality reduced by 36 per cent resulting in a relative risk adjusted mortality rate of 105.5.

These improvements were spectacular. 

Clearly however they do not go far enough as mortality has only been reduced to the expected national average level. The team are therefore about to embark on a further cycle of improvement to find ways of taking the service forward and achieving still higher levels of performance.

In other parts of the hospital where BICS has been applied, similar successes havebeen achieved. In pathology there has been a reduction in floor space of almost 50 percent which has allowed the Trust to bring in new work at a fraction of the expected cost. 

The routine sample processing time in the blood sciences area has reduced from an average of five hours to less than 60 minutes. 6S has created a much better working environment in the laboratory which is now designed for flow whilst visual management means that staff know on a daily basis how well they are doing and are actively engaged in solving problems as they arise. 

The pathology department has increased its income by 10 per cent in the last year with 2 per cent fewer staff and the management team believe that BICs has been a highly important contributor to this.Similarly in the laundry the productivity improvements have been impressive. 

This was an area which the Trust was previously considering moving out to an external contractor. Pressure from laundry management and staff side representatives led to ususing lean techniques to see whether or not the in-house service could be improved. Itcertainly could! 

To date the laundry has generated almost £300,000 worth of savings and additional commercial income using its lean approach. This in itself has more than funded the total cash outlay on the first two years of our lean initiative.

The approach taken in trauma is now being replicated in other areas. Four end-to-end patient journeys are being tackled - cataract surgery, joint replacements,stroke care and patients with acute abdominal pain. 

All of this is intended to move us towards a desired future state for the hospital as a whole, our vision of what a truly “lean” hospital should be. Our vision is that we should move rapidly to assess patients upon admission and stream them as simple or complex whether or not they are elective or emergency patients. 

For simple patients we are concentrating on reducing batchsizes, putting patients in to flow, taking out unnecessary steps and non-value adding work and making sure that we give the right kind of customer care at key points in the process to achieve a good patient experience. Our aim for this group of simple patients is to improve throughput and improve patient and staff satisfaction. 

For complex patients we have quickly learned that the challenge is somewhat different and unlike any car factory! It is often in these areas that we have higher mortality rates and unsatisfactory outcomes. 

Our work here is not so much about putting the patients themselves into flow as achieving “one decision flow” i.e. getting the right information and clinical decision makers together in a timely manner to get a speedy diagnosis and the right treatment plan. 

This will lead to improved outcomes and also improve productivity through lower infection rates, quicker recovery and shorter lengths of stay.

REFLECTIONS AND LESSONS

Secondly, much of this is counter-cultural for the NHS. It is certainly true that we arenot Japanese and we do not make cars! However staff can quickly come to understand that all work is a process and all processes can be improved. 

The result is the revelation that good quality can cost less not more. This is something that staff will rarely accept when told it in theory but are beginning to see for themselves throughtheir hands on involvement with the BICS work. 

General managers at times haveperhaps felt that the effort going in to BICS is a distraction from the importance business of hitting targets and delivering financial balance. It is true that this has beena challenge as to some extent we are trying to build the aeroplane whilst flying it! 

In the long term however it is clear that the BICS approach is a sustainable way of achieving targets and financial balance whilst at the same time improving staff morale andpatient satisfaction. This is a prize worth fighting for.

Finally we are all too well aware that the NHS suffers from “initiativitis”. It feels as if every possible improvement methodology, programme or fad has been tried out inthe NHS in recent years. As a result staff can become battle weary and cynical. 

There isthe temptation for some to see lean as the latest new idea that will go away again in ayear or two when the Chief Executive thinks of something new. The only way of risingto this particular challenge is to show resilience, consistency and perseverance.Implementing lean in a healthcare setting is far from easy but the potential gains are enormous. Our early experience is that lean really can save lives. 

The Toyota production system is an amazingly successful way of manufacturing cars. It cannot besimply translated unthinkingly into a hospital but lessons can be learned from it andthe method can be adapted and developed so that it becomes owned by healthcare staff and focused towards the goal of improved patient care. Perhaps most heart-warming ofall has been the response of frontline staff themselves. 

Working in healthcare is astressful and difficult thing to do. Everyone needs a touch of inspiration and encouragement. Applying lean to healthcare in Bolton seems to be achieving just that for those who work there.