NH S Improving Quality

BRINGING LEAN TO LIFE Making processes flow in healthcare IMPROVEMENT. PEOPLE. QUALITY. STAFF. DATA. SATcEknPoSw.leLdgEeAmNen. tsPATIENTS. PRODUCTIVITY. IDEAS. This document has been written in partnership by: RZEoë LDord ESIGN. MAPPING. SOLUTIONS. EXPERIENCE. Email: [email protected]

Lisa Smith SEmHail:A [email protected] OCESSES. TOOLS. MEASURES. INVOLVEMENT. STRENGTH. SUPPORT. LEARN. CHANGE. TEST. IMPLEMENT. PREPARATION. KNOW-HOW. SCOPE. INNOVATION. FOCUS. ENGAGEMENT. DELIVERY. DIAGNOSIS. LAUNCH. RESOURCES. EVALUATION. NHS. PLANNING. TECHNIQUES. FRAMEWORK. AGREEMENT. UNDERSTAND. IMPLEMENTATION. SUSTAIN. Bringing Lean to Life - Making processes flow in healthcare

Contents

Introduction - what is the problem in healthcare? 4 Identifying waste 18 What is Lean? 6 Making value flow 21 A3 thinking 7 Understanding pull 22 An example A3 report 8 Understanding Takt time 23 The importance of data and measures 10 Using 5S to improve safety 24 Example statistical process control (SPC) charts 11 Plan, Do, Check, Adjust (PDCA) cycle 25 Current state value stream mapping 12 Continuous improvement 26 Analysing your current state and designing your 14 Value stream mapping symbols 27 future state value stream map Standard work to produce high quality every time 15 Visual management 16

3 4 Bringing Lean to Life - Making processes flow in healthcare Introduction - what is the problem in healthcare?

We all come to work to do our very best - to The processes are to blame, not the people This booklet provides a basic introduction and achieve what we are capable of and to add real overview of Lean; the culture, principles and value for our patients and ensure clinical Often, there is ambiguity in how certain tasks tools to understand to enable you to tackle and expertise is supported by process excellence to should be performed – so people work it out for resolve issues within healthcare. It is not enable processes to flow at the rate themselves to secure the best outcome and get intended as a complete guide to implementing of patient demand. Healthcare teams are the job done. However, whilst everyone Lean as a management system. dedicated and skilled professionals who are develops their own bespoke solution, the often under pressure to do their best and work variations introduced by different people can be NHS Improving Quality has been using Lean terrifically hard - but often the processes are significant and harmful. with clinical teams and has proven that the inadequate. methodology can improve quality, increase Departments continue to work hard in safety, reduce turnaround times, increase Each year, the National Patient Safety Agency isolation to ensure they improve their services efficiency and productivity, improve staff morale handles over one million reported medical and practices. However, such silo’s often and reduce costs. The NHS Improving Quality incidents in England alone. Figures illustrate that mean that any good practice is lost which website www.nhsiq.nhs.uk has details of approximately one in every ten patients are increasingly impacts upon the patient flow numerous case studies and other titles in unintentionally harmed by their healthcare between services. this series. providers. Most of these are not necessarily the result of medical errors or poor clinical decisions, but are caused simply by the way the system has been set up. “…the best hope for saving lives lies in raising performance…”

Atul Gawande, Better , 2007 “Improvement usually means doing something that we have never done before.

Shigeo Shingo ”

5 6 Bringing Lean to Life - Making processes flow in healthcare What is Lean?

Lean is the culture of relentless elimination of ‘waste’ to ensure all the services Specify VALUE from provided are safe, high quality, available at the customer viewpoint the time it is required and delivered at the appropriate cost . It is also about developing Pursue PERFECTION Identify the in quality & quantity VALUE STREAM people to problem solve everyday to pursue by continuous and remove improvement waste perfection. Problem Solve problems by solving root cause analysis Introduce Standard Working Lean was a term coined by researchers when Remove Waste People and Respect, challenge studying the philosophy of the management Set Up Visual Management Partners and grow them system in place at Toyota and the culture they Eliminate Batching Identify Root Cause Eliminate waste. had created amongst their workers to improve Process Right process will deliver right result processes which led to the final product. Long-term thinking. Philosophy Continuous The researchers noticed five key steps were in improvement place to deliver what the customer wanted at Ref: Liker, 2004 initiate PULL in line Make value the highest quality and safety level possible, with with customer demand FLOW the lowest associated costs from a workforce which also had high morale. The five steps were: Lean is the continuous and 1. Specify value ;

2. Identify the value stream steps; systematic elimination of waste

3. Make value flow ; In short, Lean is about building the problem 4. Supply what is pulled by the solving capabilities of the team to produce customer; and experts who can perform daily work to the best standard – everyday. These key steps and the 5. Continually improve and strive necessary tools to implement Lean are explained for perfection . in this booklet. A3 thinking

All Lean improvement work should begin with Describing the entire process from current state, The A3 represents the shared consensus towards A3 thinking as it is a methodical approach to through analysis and onto future state just on a solving the problem. As a document, it problem solving. single sheet of paper requires concise encourages reflection on the learning that has information. This prevents excessive amounts of taken place and ensures that a consistent Lean is primarily the description of a information being overwhelming, misinterpreted message is discussed and scrutinised. methodology to routinely solve problems and incorrect conclusions being reached. everyday so that the work is delivered to specification. A3 thinking is the rigorous The best A3s: application of something known as the Plan, Do • are handwritten in pencil with minimum text; Check, Adjust (PDCA) approach. • contain pictures/diagrams to convey the problem or opportunity; The PDCA (sometimes known as PDSA - Plan, • are concise and hold all the relevant Do, Study, Act) cycle provides a means of information; conducting safe experimentation or a number of • represent the shared consensus; trials to see the effect of any changes made in a • do not need verbal explanation; and bid to make improvement (see page 25). • are agreed by the entire team.

The A3 report is literally a one-page document (42 x 29.7 cm [A3] sheet of paper) that records the agreed points of discussion in a systematic TOP TIPS way. • Teach, coach and use A3 thinking as a standard tool for all new projects and problem solving The structure of the A3 (see pages 8 and 9) • Complete the A3 report with a pencil (corrections can be made following further takes individuals and teams through the process of agreeing the problem statement or consensus with the team) opportunity, reviewing and analysing the current • This is a working document – each box should contain only the information that state and identification of a desired future state has been agreed with a subsequent action plan for any agreed • Resist the temptation to ‘type’ up the report. If an electronic version is required, actions. consider taking a digital photograph instead to share across the wider organisation.

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n N p p m m e g i g r r ( o p p o o o i l l g g n i e e n r r g t t g e e e e s s d d s s S H N 10 Bringing Lean to Life - Making processes flow in healthcare The importance of data and measures

In healthcare, we are used to taking clinical Once you have agreed your aim and measures, measures such as temperature, pulse, blood you will need to collect current state data for a pressure, respiration rates, urine outputs etc. in baseline. If you can’t get the information from order to understand if the condition is getting the electronic systems, you will need to collect the better or worse. To understand if the process is information manually. Manual data collection improving, we can collect and analyse data and might feel like hard work at the time, but if you use statistical methods, programs and charts to don’t collect this information before you start: demonstrate, for example, the number of patients on a waiting list, length of stay or admissions. a) how will you know what your current state looks like? Data and measures are important to b) how do you know where to focus demonstrate and factually prove that change has your efforts? occurred or needs to occur. Whether the c) how are you going to know if you change was a success or a failure, you still need have made a difference? It is not satisfactory to to demonstrate it! When you have made a small incremental Before starting your Lean journey, it is essential change using the PDCA (PDSA) approach (page say “it feels better”, to understand what your aim is and what are 24), review your original measures and collect your measures. the same data to see if your trial has made a difference. “I think it’s better”, Measures might include: • numbers of patients on waiting lists; Data analysis doesn’t need to be complicated. “it seems better” - • length of stay; Line graphs, bar charts, scatter graphs and • admissions and readmissions; statistical process control charts can all be used • patient experience; to visually show the before and after status (see establish factual data • waiting days; examples on the following page). • staff morale; • turnaround times; and measures. • number of incidents or defects; Don’t forget ‘better’ is not measurable, ‘soon’ is • number of complaints; not a timescale and ‘some’ is not a number! • cost; and ‘More’, ‘faster’, ‘safer’ or ‘cheaper’ can all be • quality. measured, but only if you know how many, how fast or how expensive things were to begin with. Example statistical process control (SPC) charts

Statistical Process Control (SPC) is a simple and visual way of observing Inpatient stay showing root cause analysis variation in your systems and processes. Every process is subject to variation but generally speaking, the more variation there is in a system Waiting one extra day for discharge medication Waiting two extra days for or process, the less reliable it is, and the less certainty there will be that physiotherapy assessment Waiting ten days for the process or system will produce the outputs or results expected or cancelled surgery Waited for lab results, desired. SPC can help to identify variation as a first step in trying to Waiting four extra interventional diagnostics reduce and control it. days for CT scan and delayed ward round

An SPC chart is essentially a run chart with statistically calculated lines of variation with the main aim to understand what is ‘different’ and what is ‘norm’ within a process. By using these charts, you can then understand where the focus of the work needs to be concentrated in order to make a difference.

We can also use SPC charts to determine if an End to end turnaround times in a pathology department improvement intervention is directly improving a process (as opposed to occurring by chance) and to predict statistically whether a process is capable of meeting a set target.

When the raw data has been converted into a graph, the outliers become visible and root cause analysis can be January February March April carried out to achieve your aim

11 12 Bringing Lean to Life - Making processes flow in healthcare Current state value stream mapping

A critical starting point in any problem solving or improvement work is to map the situation “If you don’t know where you are going, (process) in its current state. This should be done as a team and then added to the A3 document. you will probably end up somewhere else.”

One of the tools used to capture the current Dr Laurence J Peter, Founder of The Peter Principle state or ‘as is’ performance is the value stream map (VSM).

What is value? How to make your value stream map (VSM): • Calculate the ‘touch time’ - the time Value can only be defined by the end customer. • Establish key start and stop points (agree actually required to get the patient through In healthcare the customer is usually the patient. the scope) the value stream if seamless care were being Value is any activity that directly contributes to • Document the key process steps delivered (i.e. all waste removed) satisfying needs of the patient. Any activity that • Add the data box below each process step • Agree the value added (VA) activities and the doesn’t add value is defined as waste. (cycle time, batch size at each step, number non VA activities, identifying those ‘must do’s’ of defects/errors at each step and the (i.e. business essential but not really adding Value stream map trigger that starts the process step) value directly to the patient) A current state value stream map is a visual • Add a timeline at the bottom of your VSM • Determine the percentage of VA activities - representation of all the actions currently and below each process step document the don’t be surprised if this is very low! required to deliver a product or a service. cycle time (how long does it take to process accomplish the task?) The map documents work activity and the • On the timeline between each process step, movement of information across the entire add the delay which occurs between each patient pathway from origin to final point of step delivery. • Show all information flows • Work out the total time taken to get a patient through the value stream by adding all numbers in the timeline Remember • Keep your value stream map high level, Current state value stream map don’t focus on the detail

• Only focus on the main pathway – what Home happens 80% of the time? 100 per day • Collect true and accurate information by GP System Xray Laboratory Physio Pharmacy walking through the pathway yourself. PAS

Why map the value stream? 4 50 20 51 5 125 55 30 50 25 GP MAU Diagnostic 1 Diagnostic 2 Cons review Admit - ward Theatre Rehab Ward round Discharge f/u =/- rehab • The mapping process is a powerful tool to look strategically at your process and quickly 1 3 2 2 1-5 2 6 2 1-2 2 3

identify opportunities for improvement CT = 4 mins CT = 2 days CT = 5 mins CT = 10 mins CT = 10 mins CT = 20 mins CT = 2 hours CT = 20 mins CT = 4 mins CT = 4 mins CT = 10 mins B = 1 B = 40 B = 10-100 B = 1 B = 1 B = 1 B = 1 B = 1 B = 1-40 B = 1-10 B = 1 • Non value adding activities i.e. wastes can Defects = 4% Defects = 10% Defects = 40% Defects = 30% Defects = 5% Defects = 15% Defects = 40% Defects = 20% Defects = 35% Defects = 40% Defects = 10% be identified and documented Trigger = Pt Trigger = Doc Trigger = Doc Trigger = Doc Trigger = Res Trigger = Doc Trigger = Doc Triger = Ref Triger = Doc Triger = WR Triger = DN • This provides a basis for a discussion around 0.5 days 0.5 days 0.5 days 1 day 1 day 5 days 1 day 1 day 1 day 2 weeks ‘what should be the process?’ 4 mins 3 mins 5 mins 10 mins 10 mins 20 mins 2 hours 20 mins 4 mins 4 mins 10 mins

720 Touch time = 210 mins (3.5 hours) Takt time = = 7.2 mins 100 Lead time = 639.5 hours (26.65 days)

See page 27 for the value stream mapping symbols

The current state map above indicates that it is taking almost 27 days for a patient to get through a system (Lead time) where there is only 3.5 hours of professionals ‘hands on’ time actually required (touch time). On this map, there is a legitimate 14 days of ‘waiting’ before the follow up appointment; however there is still a considerable difference between the lead time and touch time. This should promote some discussion amongst staff: Have we documented this ‘snapshot in time’ correctly? Is some of the waiting time between steps actually necessary? Is there an element of ‘recuperation’ or ‘watchful waiting’ before further intervention or follow up is required? Concentrate on getting a shared understanding of the true picture without justifying whether your current processes are the best for the service.

13 14 Bringing Lean to Life - Making processes flow in healthcare Analysing your current state & designing your future state value stream map

Once you understand the current picture of what really happens throughout the value Future state value stream map stream, you can begin to agree what needs to happen and then analyse the gap between the PAS Home current and future states. 100 per day From your current state map you will be able to GP System Xray Laboratory Pharmacy Physio identify where the significant problems occur. This might be the most prevalent waits and delays, the largest amount of work in progress 4 25 50 25 between process steps or where there is GP Test & consultant Surgery day case Discharge & TTOs F/U +/- rehab considerable duplication. FIFO FIFO There are four main techniques to design your future state: CT = 4 mins CT = 30 mins CT = 2 hours CT = 10 mins CT = 20 mins Batch = 1 Batch = 20 Batch = 1 Batch = 1 Batch = 1 • Eliminate Defects = 2% Defects = 5% Defects = 2% Defects = 5% Defects = 3% • Combine Trigger = Pt Trigger = Ref Trigger = Doc Trigger = Wr Trigger = Dn 0.5 day 5 days 3 hours 2 weeks • Simplify 4 mins 30 mins 2 hours 10 mins 20 mins • Sequence. 720 Touch time = 184 mins (3.06 hours) Where possible, try to eliminate any process Takt time = = 7.2 mins 100 Lead time = 474.06 hours (19 days) steps. If it isn’t possible to eliminate any steps, look to combine steps. After combining, consider where the system can be simplified. The aim is to produce a service where each Once the future state value stream map is Once steps in the system have been have been process step links seamlessly to the next, in the completed, it is then essential to review eliminated, combined and simplified, review the shortest amount of time at the highest quality measures, analyse the gap between current sequence of events to promote efficiency. and safety by a group of staff with a high and future state and then agree an action morale. plan of PDCA cycles to trial the changes. When designing a future state, the takt time, the removal of waste and the introduction of flow must be considered – all of which are Be clear about the purpose before designing the process – then, organise the people! discussed in this booklet. Standard work to produce high quality every time

Lean is about developing the people who It is important to understand that standard work Standardised work: perform the work to be ‘the best’ – utilising their is not static. Standards are actually the basis for • Ensures safety and maintains high quality ‘expert talent’ and establishing excellent ways of subsequent improvements. Once a better and efficiency working. method is found, the team should agree on the • Ensures process stability and therefore new standard, update the processes, procedures repeatability Standard work is about establishing out of and visual management and then ensure that it • Allows us to assess if we are in control, all the possible ways, the best work is adopted by all. ahead or behind schedule method of conducting a task and then • Preserves the organisational expertise ensuring that everyone always works to Standardisation should exist for every process, • Allows us to identify and rectify problems this gold standard. including ward rounds, meetings, health and • Provides a gauge by which we can error safety procedures, budget reports, cleaning proof for the future The gold standard should have the least amount equipment, consultations, all paperwork etc. • Gives us a baseline from which to of waste, with the highest quality measure improvement and continually and safety. These standard procedures create One of the Lean tools which promote strive for a better way stability and consistency in the system to standardisation is 5S, the foundation for safety • Provides a basis for employee produce high performance results every time. and quality. training.

There are three key elements to standardised work:

• Takt time – how fast we should be working (page 23) • Work sequence – the order that work should be done • Work in progress – defining the working inventory to make abnormalities obvious.

15 16 Bringing Lean to Life - Making processes flow in healthcare Visual management

Visual management is everywhere, from the Visual management is a simple, yet highly Visual management allows teams to: green man at the cross roads, to the numbers effective way of indicating what should on the front of busses, petrol indicator lights happen (by setting a standard) and what • See the work in progress in cars, a water level on a kettle, to a cricket is actually happening in the work • Recognise flow stoppers scoreboard. These visual indicators allow us environment. • Assess inventory levels to easily understand the situation and take • Identify defects action where necessary. At a glance, colleagues, supervisors, managers • See deviations from the standard and visitors to the area should be able to • Enable interventions understand the process and see what is under • Improve safety. control and what isn’t without having to ask a question. There are two types of visual management: Cytology request form: Visual management has been sent to smear takers to ensure zero defects on the request form. • Visual display; which is the provision of information Pathology Request Card • Visual control; which is associated with action.

Both types of visual management allow individuals to gain the maximum amount of information without having to leave the work environment or access a computer system.

Visual management provides the knowledge and certainty to make the lives of staff and patients safer.

Visual management can be used to answer the following questions. Give some thought to how you could use visual management to answer the following questions in your work area:

1. Are we up to date with the work? 2. What are our three biggest problems 7. How do you know if the stock has Communication board in the area and what is being done been ordered? The board keeps all team members up to date to resolve these problems? 8. Number of patients on the waiting list with the recent data, changes and improvements 3. How do you know that your ideas 9. Which patients should be discharged made, 5S scores, team ideas which includes have been listened to? 10. Number of patients on disease register action taken against the ideas. 4. How can you tell who is trained to who require an annual review. perform each task? 5. Is there daily accountability? Who is it today? 6. How do you know where staff are - breaks, annual leave, study leave?

17 18 Bringing Lean to Life - Making processes flow in healthcare Identifying waste

The elimination of waste is the main Remove the waste of transport by: characteristic of Lean. Waste is everything Elimination of waste • The elimination of process steps that doesn’t add value to the patient or • Co-locating departments/processes/supplies process. Eliminate Minimise • Introducing work cells • Redesigning the flow of work e.g. introducing There are three types of work: work cells. 1) Value add - When you are adding value to the patient/process (e.g. prescribing medication, Unnecessary Necessary I INVENTORY providing physiotherapy, reporting an image) waste waste Inventory is work in progress and stock. A common problem is lack of space. By reducing 2) Necessary waste - This is when you are not inventory and by combining process steps, staff adding value but it is a necessary step. (e.g. have more space to carry out duties in a safer incubation in a microbiology laboratory, vetting Value working environment. requests prior to radiology examination) How frequently do you run out of supplies only 3) Unnecessary waste - This is where you are not to find another department has stock? adding value and these steps could be removed Maximise (e.g.searching for items, waiting for consultants or For example: medication, not having the right equipment). • Over-ordering - consumables or drugs • Different batch sizes at each process step There are seven formally recognised wastes, T TRANSPORT • Overstocked medication however additional wastes identified: the waste of Transport is the unnecessary movement of • Overstocked items in the supplies department unused staff creativity (skills utilisation) and items and materials. How often do we see people because it was cheaper to buy in bulk without automating an already inefficient process. moving items (notes, reports, slides, supplies etc.) thinking about the costs of storage, stock from one locality to another - and back again? taking and distribution These wastes can be remembered by Stand for a short while in a hospital corridor or GP • Staff hiding extra stock for ‘just in case’. remembering the name TIM A WOODS (this practice and observe these activities - you’ll be Remove the waste of inventory by: acronym originated at Cooper Standard surprised. • Implementing the Lean tool of 5S (page 24) Automotive, Plymouth UK). For example: • Establishing visual systems (kanbans) - • Moving drugs, samples, equipment, supplies aid visibility for stock counting (page 22) excessively • Understanding what is needed to keep up • Moving paper notes excessively • Establishing first in first out principle with • Transporting equipment or consumables from demand - implement ‘just in time’ one location or site to another. • Keeping stock audits correct and current. M MOTION A AUTOMATING • Waiting for decisions The waste of motion is any unnecessary Automation of poor processes just serves to • Waiting for meetings to start movement by people. This is mainly related to automate waste. The poor understanding of work • Patients waiting for appointments, in emergency poor ergonomics, bending, stretching, moving content and takt time (page 23) can result in departments/clinics, waiting for discharge items etc. purchase of large pieces of expensive equipment • Samples waiting in a batch to be analysed that actually hinders flow of the overall process. in the laboratory How many times during your working day do you The result, is an expensive poor process! • Requesters waiting for results or medication. have to get up and walk to use a certain piece of equipment just because it is located in the wrong For example: Remove the waste of waiting by: place? How often do you find yourself searching • Did radiology reporting times reduce when • Evenly spread (levelling) the work and balance for vital items because they were not put back in PACS was implemented? tasks the right place? • Do samples get turned around any quicker with • Eliminating or reducing batch sizes track systems in biochemistry? • Smooth the flow and volume of work which For example: enters and exits your area. • Poor layout of wards/surgeries/departments WAITING /laboratories/offices W The waste of waiting usually transpires when OVER PROCESSING • Searching for equipment or stock O there is an in balance of process steps which all The waste of over processing is all the things • Location of printers, faxes, copiers and take different timings or the batch sizes are we do that don’t add any value to the process - computers different in each process step. The waste of producing excess. • Looking for information and people. waiting has a direct impact on flow as waiting How many tasks are repeated simply because we creates a ‘stop-start’ process. Remove the waste of motion by: don’t have a system to ensure it serves the needs of • Introducing standard layout the patient or process throughout the whole Do you ever find yourself becoming frustrated • Introducing a standard way of working healthcare journey? • Developing flow in work cells/areas and your working day hindered because you are • Initiate and sustain 5S. waiting for a colleague to do their role or for equipment to become available.

For example: • Waiting for shared equipment (telephone/ computers) • Staff waiting for machines, deliveries, other members of staff

19 20 Bringing Lean to Life - Making processes flow in healthcare

For example: Remove the waste of over production by: S SKILLS UTILISATION • Duplicate testing/inappropriate testing • Removing all unnecessary paperwork Every department has unused staff potential. • Duplicate data entry • Reducing batch size - establish a visual system There is someone in every department that knows • Duplication of checking cards/slides • When the process can’t flow, introduce the issues and has the possible solutions. If only • Excessive bed moves ‘pull’ systems with buffers and kanban’s. they were asked, listened to and action was taken - • Excessive paperwork the people doing the job are the experts. • Manual checking electronic data. DEFECTS D Defects are all the errors that compromise Unused skills and creativity also include highly Remove the waste of over processing by: quality, safety, cost and staff time. Make it right, skilled staff undertaking duties that do not reflect • Eliminating non-value added steps first time, every time. there skills, e.g. band 8 staff routinely performing • Combining process steps and paperwork band 3 duties. • Simplifying tasks. Do you tolerate errors by reworking someone else’s mistakes? How often do you accept incomplete or How many times do we see supervisors/managers OVER PRODUCTION inaccurate information? routinely booking appointments? O Over production is about doing too much, too soon or ‘just in case’. For example: The intellect and skill of staff should be used to • Wrong patient, wrong test, wrong procedure, guide the continuous improvement of procedures How many times do we complete the same wrong form and processes. The inclusion and insistence of staff information and have to file it or store it in many • Inappropriate/inadequate referrals in problem solving and decision making will also different ways? How often do we see queues build • Chasing inadequate patient information support recruitment, retention and improve morale. up in one part of the process because the previous • Repeated checking department kept producing more, regardless of • Medication errors. whether subsequent processes were ready or could cope? Remove the waste of defects by: • Making the system mistake proof For example: • Introducing a zero tolerance to defects • Doing more, making more, faster than or earlier • Introducing standard work to ensure the same than is required by the next process step process is completed every time ensuring high • Duplicate entries in medical records quality process repeatability. • Results sent in both electronic and paper formats • Repeating tests before next test scheduled. Making value flow

Flow is the continual movement of value All Lean tools work towards promoting flow. adding activities from the beginning to the Visual management can be used to highlight end of the value stream. flow stoppers. Standard work can be used to ensure processes are repeatable and reliable, Processes which add value to the patient should with no variation. 5S can support workplace not be delayed by any non value adding steps organisation ensuring no time is lost trying to or waste in the system. Waste and non-value find the right tools to do the job. adding steps create a ‘stop-start’ effect which prevents the flow of value adding steps the value stream.

Systems which promote batching can hinder flow, create waste and queues. Batching can be seen across healthcare. For example, ward rounds completed at the same time of day causes a batch of work for the nursing staff and every support service that follows i.e. pathology, radiology and pharmacy.

To promote flow, batches should be reduced and where possible removed to achieve the optimal flow - one piece flow. When flow is achieved, it becomes easier to spot problems and patients are no longer unnecessary held up in the health system.

21 22 Bringing Lean to Life - Making processes flow in healthcare Understanding pull

Flow and pull work to keep the entire value Kanban stream moving. Flow is the goal, but on Kanban signs/signals are a form of pull. These occasion, flow may not be achievable and in visual signs are mechanisms for the patient or these situations the concept of pull can be internal customer (i.e. ward nurse, radiologist, introduced to respond to demand. discharge staff) to say “I am ready for more.” There are many different forms of Kanban - Pull is a short term notion to gain control an empty container, a box, a marked area, and process stability. an empty shelf or a card.

Pull works with buffers and kanbans:

Buffer “Flow where you can, pull A buffer is a clearly defined holding area at the interface between two processes allowing where you must” patients, paperwork, information or items to wait for a defined amount of time between two Jeffery K. Liker, The Toyata Way, 2004 process steps. A buffer could be a waiting room, empty beds, trolleys or chairs, or even a space for stock and inventory. Buffers are actually a ‘waste’ and should only be introduced when flow is not possible and the process needs to be controlled and stabilised. Over time, the buffer should be gradually reduced and ultimately removed. Understanding takt time

Takt time is simply the rate at which we needs, every 7.2 minutes a patient should be need to be removed from each step. Only need to work to keep up with demand. able to move through the value stream i.e. the when the non value adding activities have patient should be able to ‘pull’ the service they been removed from each step should The calculation for takt time is: require at a rate of 7.2 minutes. additional resources be considered.

Available work time The cycle time is the time it takes to actually ‘do’ As you can see from the graph below, the = takt time Demand the task and the aim is to match (where team would possibly need to either: remove possible) takt time. more waste from the individual processes; This sounds too simple, yet the ability to achieve extend diagnostic hours, theatre time and takt is the fundamental question to whether the If the cycle time is going to be the same as or follow up clinic; or secure additional resource system is set up to deliver what is required. If less than takt, all the non value adding activities in order to achieve takt. teams cannot achieve takt, waste in the system needs to be removed and each process step needs to be smoothed (levelled) to ensure takt Balance chart prior to achieving takt time is met. 120 Worked example: A general surgical pathway open and staffed for 12 hours per day has a daily demand of 100 90 referrals (see Value Stream Maps). s e t

12 hours 720 min u 60 n Takt time = = 7.2 mins i 100 100 M 30 True to the first principle of ‘delivering customer Takt value,’ patients must be able to access each of the services required along the whole clinical 0 pathway in referring, diagnosing, operating, Refer Diagnose Operate Discharge Follow up caring, providing medication and rehabilitation the moment they require it. In this case, for this system to be capable of delivering patients

23 24 Bringing Lean to Life - Making processes flow in healthcare Using 5S to improve safety

5S is occasionally misinterpreted as being a ‘tidy up’, but when approached properly Set in order - ‘A place for everything and Standardise it is much more than that. everything in its place.’ Create a consistent approach for carrying out tasks and procedures. 1) Give every item a location - Items used on 5S is the basis for standardising work and a regular/daily basis need to be placed is used to improve efficiency by within arms length/accessible location: Sustain - ‘Sustain all gains through self eliminating waste, promoting flow, • Items used on a weekly basis should be discipline’ improving staff morale and most stored on a shelf or in a cupboard in the importantly improving safety. work environment. Make 5S become a way of life by: • Items used on a monthly, quarterly or 1) Practicing and repeating the process. Ultimately, it is about making the annual basis should be stored in an 2) Educating all staff. processes and environment safe. appropriate location – possibly outside 3) Linking 5S directly to the day job. the work area. 4) Empowering staff to improve and maintain 5S - What does it mean? How do I do it? 2) Mark off (with electrical tape or permanent their workplace. marker) and label each location. When staff take pride in their work and Sort - ‘When in doubt, move it out!’ workplace it can lead to greater job satisfaction and higher productivity. 1) Remove everything from the defined area. Shine - ‘Lean means clean’ 2) Only return what is necessary for the daily duties. 1) Clean the area – it should be easier to 3) Discard any broken, unnecessary items – clean now you have removed the clutter e.g. clutter, old equipment, old unused and every item has a location. paperwork. 2) Develop a plan where cleaning is 4) Move any items that you are unsure of into incorporated into the daily routine. a holding bay for a team decision. 5) If shelving or cupboards are not used or required, remove them too – this will prevent unwanted items being stored there. 6) Items necessary to complete the job need to be ‘set in order’ 2S. Plan, Do, Check, Adjust (PDCA) Sometimes called a Plan, Do, Study, Act (PDSA)

Change on a large scale can be daunting but you should not let that deter you. Before implementing a full proposal for A P change a PDCA cycle (sometimes called

a Plan, Do, Study, Act (PDSA) cycle) can C D

be used. A PDCA cycle will provide the D opportunity to test out an idea on a small ADJUST PLAN P

scale, without risking too much. C A

C New ideas should be introduced only after A

sufficient testing (or evidence) on a smaller scale D CHECK DO P has proven to have a positive effect. PDCA cycles allow us to introduce an idea in a safe, controlled way which will have less resistance, A P be less disruptive and use less resources. By building on the learning from each PDCA C D cycle, new processes can be introduced with a greater chance of success.

P - Plan: The trial This is the most important part of the process. C - Check: Study the results A - Adjust: Act on the results • What you are planning to trial? • Analyse the data you collected in the ‘plan’ • If the trial did not improve the process, • What are your objectives? and ‘do’ phase could you treat the root cause in your next • Who is needs to be involved/informed? • Discuss outcomes with colleagues? PDCA cycle? • How are you going to do it? • What went well? • If the change was a measurable success, • How long will the trial run? • What went wrong? adopt and spread the improvement in your • How are you going to measure improvement? • Did anything unexpected happen? PDCA cycle. • What is your communication plan? • Could the process be improved? • If the trial didn’t go to plan, what was the D - Do: Carry out the trial root cause? • Test the change and collect the data.

25 26 Bringing Lean to Life - Making processes flow in healthcare Continuous improvement

Continuous improvement is the final Lean principle, which is to strive for perfection through continuous improvement. This is done by embracing the Lean philosophy and tools as described in this booklet.

The staff are a fundamental part of Lean. It is The key to success is Act like a sponge - soak important to develop staff and give them the capability, autonomy and empowerment to solve the problems as they encounter them on a daily small, daily incremental it up and squeeze out basis. Teaching and expecting rigorous problem solving by all staff is the only sustainable way to improvements. improvements strive for perfection.

Communication is imperative to develop staff to During your Lean journey, don’t lose sight of everyday continually improve the process. A five minute perfection and what perfection means: daily meeting for all staff around a central communication board to discuss real time issues • the right patient journey; relating to waiting times, quality, safety, morale • the right support services when they and cost is essential to ensure the work for that are required by the patient; shift/day proceeds as planned. • the highest level of quality and safety • no defects or incidences; For Lean to be a success, the Lean culture needs • delivered at the right price; and to be accepted and embraced by all. • delivered by a staff group with high morale and pride in their work. When implemented, the tools and techniques can have an immense beneficial effect, but to be sustainable, they need to be applied with a Lean culture. Value stream mapping symbols

D aSutarg eenry try Cycle time =

W i Ba tch s ize =

GP Surgery Wait/delay Inventory Defects = Pull

Process Step = Trig g e r Outside Agencies

Data Box Push People “Go See”

FIFO

First-in First-out

Sequence Transport Ambulance

Information Supermarket Bursts Buffer

Electronic Information Load Levelling Work Cell Transfer Paper Flow

27 NHS Improving Quality

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Published by: NHS Improving Quality - Publication date: May 2014 - Review date: May 2015 © NHS Improving Quality (2014). All rights reserved. Please note that this product or material must not be used for the purposes of financial or commercial gain, including, without limitation, sale of the products or materials to any person.