David FillinghamChief Executive

Lean Healthcare – 16-17th March 2010

Experiences from a lean transformation – an English

hospital

Fostering Joy and Pride: the Stroke Team

Stroke - Results2006 2008

CT Scan within 24 hours 46% 100%

Patients on Acute Stroke Unit - 99%

Aspirin within 24 hours 63% 100%

Physio within 72 hours

Sentinel Audit Score

65%

60%

98%

92%

Mortality rate

Length of Stay

122

43

99

22

Stroke Mortality 2005-2009

Some encouraging early results

• Trauma – FNOF 31% mortality ; 33% Length of Stay ; 42% paperwork

• Stroke 92% Sentinel Audit Score, 23% mortality , 24% LOS • Ophthalmology – New One stop shop – patient visits 50% ; • High risk joint replacements – complications 85% ; Length of

Stay 43%• Pathology – Test turnarounds from x3 to x10 quicker; 40%

floor space saving• Laundry, Estates, Finance and others – six figure cost savings• 30% of staff engaged in week long improvement events and

1000 completed “Green” training

….. But still only scratched the surface

How can we engage the whole Hospital in a 20 (+) year journey of transformation that will reinvent lean for healthcare and change forever the way that hospitals are run?

• Background to Bolton• Our Lean journey: 2005-2009• : Building a system for

improvement• Redesigning every end to end

process• Creating a lean culture• The Future: better health and better

care at lower cost• Reflections: mistakes, dilemmas and

challenges

Bolton• Population 270,000• Northern industrial town• 12% ethnic minority population (>18% childhood

population)• Significant levels of deprivation and inequality• Reflected in health status

– SMR - Cancers – up to 123

- Circulatory disease – up to 136

• Part of Greater Manchester – 2.5m population

Royal Bolton Hospital

About the Hospital

• Approximately 700 beds• Busy emergency services – catchment about 310,000• 3,200 staff• £170m turnover• Most secondary elective and non-elective acute

specialties:»Medicine»Surgery/Urology»Orthopaedics»ENT, Ophthalmology, Oral»Children’s»Obstetrics»Diagnostics»A&E

Our Lean Journey 2005 - 2009

2004 – The case for change

• Substantial deficit

• Failing access targets

• Safety and quality problems

• Governance concerns

• Poor external relationships

P

P

P

P

V

eople erformance

ision & Strategy

atients &Partners

rocesses

Our Aims

No avoidable deaths or harm

No waste

No defects/best experience

Highest Morale

Improved Health

Best PossibleCare

Value forMoney

Joy andPride

Our Lean Journey: Important Milestones

• Late 2005

• 2006

• 2007

• 2008

• 2009

• 2010 onwards

• Early experiments - Trauma - Day Surgery

• Narrow & Deep vs Broad & ShallowEVSA

• Leadership for LeanDaily “BICS”

• BICS AcademyPolicy Deployment

• Urgent Care Transformation….with Bolton PCT

• Focus on productivity and on whole system redesign

: Building a system for Improvement

Characteristics

• Aim is to create a system for Improvement• Based on “lean” principles, creatively

adapted for the NHS• At heart of our Business Plan – drives

safety, quality and productivity• Comprises tools, methods, management

system and leadership• Seeks to engage all staff in a long term

cultural transformation

ImprovingHealth

Best PossibleCare

Value forMoney

Joy andPride in Work

UnderstandingValue

DeliveringBenefit

RedesigningCare

LearningTo See

The Bolton Improving Care System

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”

Linked series of “Cells” that embody Lean Tools/Principles

Redesigning every End to End Process

Why did we need to change stroke service?

2005/6

High mortality rate – SMR 122

• Long length of stay – 43 days

• Stroke patients all over the hospital only 22% getting specialist care

• 13 beds for stroke off the main site

• Few specialised staff

Value Stream Map

Value Stream Analysis:

• 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

Value Stream Analysis:

• Hand Off Chart• 197 handoffs to

discharge a patient!

• Duplication• Frustration• Huge source of

potential error

Future State

VISUAL MANAGEMENT:

1 PIECE FLOW

STANDARDWORK

6 S PULLSYSTEMS

Direct admissionA&E care pathway CT in A&E

Bed managementFirst 24 hoursRoles and responsibilities

Treatment rooms Dirty Utility High dependency on acute stroke unit

Board rounds Planned discharges Early supported discharge

“ability to see the process”

BICS Redesign Aims to Achieve Improvement in …

De-cluttered and got rid of waste

• 6s areas on both wards

• Sluice

• Treatment room

• High dependency area on acute unit

• Store Room

The waste !!

The store room – after

Standard Work

• Operational policy ,bed management

• Role of shift leader

• Board rounds

• First 24 hours

• Role of MDT staff

• Cleaning of commodes

Creating Flow

• Direct admission from A&E

• Hyper acute bay

• On ward rehabilitation

• Early Supported Discharge team

Visual Management

Fostering Joy and Pride

• Staff sickness reduced to 3% in stroke from 15%

• Awards and publicity

• National Clinical Director visit

• Very positive patient and carer feedback

““I can’t fault anything, it’s a I can’t fault anything, it’s a very frightening time when very frightening time when

you can’t walk ,or even stand you can’t walk ,or even stand or sit up , but I’m slowly or sit up , but I’m slowly

getting mobile and looking getting mobile and looking forward to going home’ forward to going home’

Stroke patient April 2009

Trust wide goals

Improvement activities

Daily work

Policy Deployment

Mission Control and Information

Centres

Team problem solving and action

Logs; Exemplar Wards;

“gateways”

Making Systematic

Daily Problem Solving in Lean Blood Sciences Lab

Patient Gateways

• A plan for every patient reviewed regularly

• Gateways to check all steps completed

• Reinforces evidence based practice

• Strengthens multi-disciplinary team working

• Bed-side handover involving the patient

• Real time problem solving and process improved staff morale

B3,B4,D3 & D4 Discharges

50

100

150

200

250

300

April 0

8

May

08

June

08

July

08

Augus

t 08

Septe

mbe

r 08

Octobe

r 08

Novem

ber 0

8

Decem

ber 0

8

Janu

ary 0

9

Febru

ary 0

9

Mar

ch 0

9

April 0

9

May

09

June

09

July

09

Augus

t 09

Septe

mbe

r 09

Octobe

r 09

Novem

ber 0

9

Decem

ber 0

9

Month

Nu

mb

er o

f D

isch

arg

es

Discharges Mean

7 Points above the mean.8 will demonstrate statistically

significant improvement

This graph shows the increased throughput for respiratory and complex elderly showing significant performance change

D3 Proportion of Deaths from all Discharges (Binomial Chart)

0%

5%

10%

15%

20%

25%

30%

Novem

ber 0

8

Decem

ber 0

8

Janu

ary 0

9

Febru

ary 0

9

Mar

ch 0

9

April 0

9

May

09

June

09

July

09

Augus

t 09

Septe

mbe

r 09

Octobe

r 09

Novem

ber 0

9

Decem

ber 0

9

Proportion of Deaths

UCL=3s

LCL=3s

Monthly Data

Creating a Lean Culture

From To

• Top down/externally imposed targets

• Problems worked around or passed upwards

• Few leaders…who are always in meetings

• Management based on anecdote and politics

• Self devised goals and measures for improvement

• Root causes addressed at source

• Many leaders who constantly “Go and See”

• Management based on data and scientific methods

Fillingham’s Motivational Matrix

Positive

Negative

Ou

tlo

ok

on

Lif

e

DisillusionedSceptic

EnthusiasticPragmatist

EmbitteredCynic

NaïveIdealist

Grip on Reality

High Low

Converting the Sceptics

• Rigorous use of lean methods

• Convincing data

• Hands on experience….RIE weeks

• Reinforce through changed management system and leadership style

• A coaching culture

• The BICS Academy

BICS Academy

Green Certification

Bronze Certification

Silver Certfication

Gold Certification

Advanced Reading

Advanced Reading

Advanced Reading

Business CaseEffective Team Management

VSA Methodology

Policy Deployment

Mentorships

History of Lean Bolton Mgt.

System (BICS)VSA Scoping 2P / 3P Partnerships

Fundamentals of BICS

A3 Thinking6S & Visual

ManagementProduct/Service

DevelopmentTPOC/Mission Sponsorship

RIE PrepRIE Event

RIE Sustainment

Journey Update Thedacare Video

Problem Solving & CA Tools

Pull SystemsLeadership & Followership

Journey UpdatePathology Video

Team Leader Training

Standard WorkSteering

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 CertificateBronze Training

CertificateSilver Training

CertificateGold Training

CertificatePlatinum

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

Silver

3 Hours 3 Days 2 Weeks 2 Weeks

Bolton Hospital - Simpler Healthcare TM Certification

Green Bronze Gold Platinum

Kn

ow

led

ge

Pre

req

uis

ites

Req

uir

emen

ts

None

Ski

lls

Beh

avio

rs

Flow Game One Need FlowProject

ManagementFacilitation/Coaching

Cap

ability

Cu

lture

Pro

cessR

esults

The Future: better health and better care at lower cost

• Refocus our BICS effort – improve safety and quality and release “cashable benefit”

• Extend beyond the hospital…health and social care system transformation

Urgent Care Redesign

• End to End pathway redesign using lean• Demand management in primary care• Admissions avoidance: BCU and Rapid Response• Acute Physicians based in A&E; rapid access medical

and surgical clinics• “Patient Gateways” and exemplar ward approach

• A&E attendances – down 3%• Medical Non-Electives – down 3.5%• Surgical Non-Electives – down 2.2%

Productivity Realisation Medical Urgent Care

-D3/D4/B3/B4/C3

April - October 2008 April – October 2009

Length of Stay (days)

14.13 10.85

Occupancy (%) 96% 95%

Patient Throughput 2753 3337

Cost Avoidance / Potential

Productivity Gain

£1,403,936

Equivalent Beds Saved

9

Ward Closed for 3 months as part of cash releasing savings during same period

BICS enabled Savings 2009/10Total Trust Savings £6.1M

BICs Enabled £2.9M

£K

Including:-

3 month medical ward closure

150

7 day ward into 5 day PIU 108

Endoscopy 208

Redesigned Outpatient processes 227

Labs, Radiology and Therapies waste reduction

425

Estates services redesign 256

• Preventable ill health and avoidable hospitalisation are the biggest wastes in healthcare

• We aim to use Lean ( ) to redesign whole patient journeys

• Strengthen prevention and chronic disease management to reduce acute interventions

• “Lean” can build a shared culture and method for improvement across hospital, GPs, community services and social care

Whole System Lean

Reflections: Mistakes, Dilemmas

and Challenges

Mistakes: What we’d have done differently

• More emphasis on measurement and benefits realisation

• Better preparation before improvement events• More rigorous design of improvement events

and use of tools• Earlier investment in “Academy” alongside

improvement events• Getting right balance between “events” and daily

work• Communicate, communicate, communicate

Dilemmas: Managing the Tensions

• “Staying on the pitch” vs delivering the transformation

• Celebrating success vs avoiding “over claiming”

• Directing from the top vs empowering frontline staff

• The “balance sheet” vs the “operating result”• Systematic approach vs Making it Fun!

Challenges• “We’re too busy to do this”• “We’re not Japanese and we don’t make

cars”• “This improvement stuff is okay, but we’ve

got targets to hit”• “We’ll leave it up to the Service

Improvement Team”• “This will go away in a month or two when

the Chief Exec reads another new book”

Countermeasures

• “No Time”

• “Not Japanese”

• “Not relevant”

• Not our job”

• “Flavour of the month”

• Create dedicated time and resources for frontline staff (this isn’t easy!)

• Reinvent “lean” for the healthcare context and culture

• Link lean to our biggest priorities and problems especially safety and quality

• Make it a fundamental line management responsibility

• Be prepared for a long haul – stay focussed, resilient and optimistic