30% Reduction in Average Length of Stay in just 38 days

Since the publication of Making Hospitals Work last summer we have become aware that several organisations are also convinced that improving door-to-door patient journeys and reducing length of stay (LoS) is the most promising route to improving overall performance in the current circumstances.

Earlier in the year, we sent an invitation to several acute organisations known to be working on the door-to-door patient journey, inviting them to join together to form a ‘door to door’ club where experiences both good and bad may be viewed and shared, an opportunity to work on one shared problem that if improved would elevate many problems. That of medical LoS

One of the first organisations to respond to this ‘call to action’ and start working with us seized the opportunity of employing the visual operational management processes described in ‘Making Hospitals Work’ and what a difference they’ve made!

At first they reported that it felt much better (in the morning they were coming in to large numbers of empty beds both in MAU and on the medical wards) and even their Trust data (in Excel with lots of pivot tables, graphs and colours) suggested an improvement

We always caution against declaring victory too early however and needed to confirm, statistically, that there had indeed been a significant change.

As a result we conducted a T-Test: looking for a p-value of less than 0.05 to confirm a statistical difference. The analysis showed that the p-value is 0.000 thereby confirming a statistically significant change.

Within just 38 days of implementation they had actually reduced their average medical LoS by 30% (along with a 25% reduction in the median) whilst significantly reducing the variation in LoS.

Below are their LoS results presented in some meaningful ways that way we like to view them:

LoS for patients admitted prior to the implementation V’s that of patients admitted on or post implementation.

Satisfied that there was a proven, significant, change the team were now in a position to reveal this news to their executive team.

You can imagine the interest generated, when they did so.
And they acknowledge that his is just the start of their journey in following the roadmap featured in ‘Making Hospitals Work’.

However, the scientific approaches already adopted by this organisation have been making real, and dramatic, improvements in their Length of Stay performance. We would welcome any comments or questions regarding your approach to tackling LoS and the impact that it is having.

May we also take this opportunity to thank Tania, Maureen, Eileen, Colin and the team for holding their nerve, believing in this approach and their considerable effort in achieving this remarkable result.

Lean Healthcare Executive Materclass

As we’ve mentioned in previous posts, one of the biggest wastes we see in the NHS is executive teams implementing countermeasures to problems before accurately defining what exactly the problem is.

This behaviour is both dangerous and fraught with risk. As opposed to improving services, this behaviour actually makes thing worse. For example, we have learnt that chasing financial targets will actually make financial performance worse.

A bi-product of this behaviour is the distraction it causes, consuming the organisation’s precious resources and preventing them from doing the right things.

Unless a problem (or set of problems) is accurately defined, the effectiveness of any solution is at the very least debatable.

It is easy to declare victory in this world of not really understanding problems, with an illusion of progress. However the problem will re-emerge having not really been solved.

Any premature leap to solutions (often mistaken for ‘increased pace’) is, in reality, nothing more than tampering.

The management mantra “don't bring me problems bring me solutions” is perilous. This approach directs organisations rapidly to the above issues. Additionally staff in the organisation will begin to act in the same way, further reducing the organisations' ability to solve its own problems.

Imagine that instead of pursuing several hundred projects your organisation was able to focus everyone’s’ efforts on the vital few objectives that would make the biggest difference to your performance. Imagine that the top team had identified the size of the performance gaps that need to be closed to meet these objectives.

As a result we have designed, tested and are now offering a Lean Healthcare Executive Materclass.

Problems always come in bundles, some big, some small but all impact upon each other. This masterclass is designed to show executive teams how to un-pick these problems and funnel down to their vital few, biggest problems. The vital few that if resolved will (more or less) resolve the many. The concept of ‘leverage’.

It is not hard to imagine the acceleration in performance that would result from this much more effective use of executive time. We call it ‘Results Driven Lean’, where action is only taken to resolve clearly defined problems with an evidence based plan to achieve measurable results in performance.

It is also significant that the top team sets the example for the rest of the organisation by doing it themselves on their own work, which gives enormous credibility when they ask everyone else to follow their example. It also means they are in a position to mentor the next level down in the disciplines of evidence based planning and problem solving by asking questions to teach them how to think rather than telling them exactly what to do.

Lean Thinking for the NHS – The Sequel. We’re about to light the blue touch paper……

LEA’s report ‘Lean Thinking for the NHS’ published in 2006 identified the then existing lean pioneers and exemplars in healthcare and how lean could improve quality of care whilst containing costs.

When this first report was published it was almost midway through a ten year period that had seen the annual budget for the NHS in England more than double to over £102 billion up to a point where £1 of every £13 (7.7% GDP) produced by the UK economy was spent on healthcare.

Obviously that’s all changed dramatically now so we thought it was time to write an up-date. This reflection has lead us to a massive discovery, albeit something that we had suspected all along.

Another realisation was that this paper’s target audience must be the mandarins, the people at the top, the only one’s that can really make a difference. Remaining true to the scientific approach this paper describes the problem, the deep rooted causes to the problem and proposes countermeasures (quite dramatic ones)

As soon as this paper is completed fully, copies will be sent directly to the mandarins whereby we will be asking them to take stock and hopefully agree with, and endorse what we are saying.

Watch this space

Lean Health: Our Approach - Unplugged

We are often asked “So what exactly is your phased approach?” so we thought that it was high time to spell it out. As a result we will do so in a series of posts. On this occasion we are the ‘pacemaker’ here (the pacemaker concept will be revealed in post number 5 or 6) so for now all that we can say is that we will release this information one piece at a time (as opposed to batching) outlining our phased approach.

We are all gainfully employed because there exists a customer problem that needs to be resolved – right?

In this post we’ll outline the importance of really understanding the customers’ problem before our phased approach actually commences.

I’m a solutions person – Really?

We shudder when we hear those words……

Based on experience and observation, implementing countermeasures to problems before accurately defining the problem is one of the biggest wastes we see in healthcare.

This behaviour is dangerous and fraught with risk. Instead of improving services this behaviour actually makes thing worse.

A bi-product of this behaviour is the distraction it causes, consuming precious resources and preventing them from doing the right things.

Unless a problem or set of problems are accurately defined, the effectiveness of any solution is at the very least debatable.

It is easy to declare victory in this world of ‘not really understanding problems’ with an illusion of progress. However the problem WILL re-emerge having not really been solved.

Any premature leap to solutions (often mistaken for ‘increased pace’) is, in reality, nothing more than tampering.

In all industries the management mantra 'don't bring me problems bring me solutions' is perilous. This approach directs organisations rapidly to the above issues. Additionally staff in the organisation will begin to act in the same way, further reducing the organisations' ability to solve its own problems.

Voice of the Customer (VoC)

Prior to commencing our phased approach we always obtain the Voice of the Customer (VoC):

This exercise is critical. If we don’t obtain the Voice of the Customer then we will never ‘hit the spot’

This VoC although hugely important tends to be, even if expressed in plain English, fairly vague in that it is not measurable. As a result we then employ a process to translate this VoC into CTQs (Critical to Quality).

CTQs are the key measurable characteristics of a process, the performance standards or specification limits that must be met in order to satisfy the customer. They align improvement or re-design efforts with customer requirements.

A CTQ must be interpreted from a qualitative customer statement to an actionable, quantitative business specification usually a set of numbers, KPIs or metrics by which we can all measure how successfully the improvements are being implemented through regular review.

Right now we already know that any folks reading this that are exponents of either six sigma or lean will be crying out “but so far, that’s not lean, that’s six sigma”. However the folks reading this that truly understand, the folks that really understand the scientific approach will be thinking “So, what’s wrong with that?”

This is just the start. Phase one coming soon.....

Lean in Sweden

Last week we had the privilege of entertaining a group of four guests from Sweden.

The team comprised of:

Catharina von Blixen Finecke (a senior politician) Vice chair of the regional federation of Skane and Chair of The Foundation for Employment Security Fund for Local and Regional Government in Sweden. Catharina arrived clutching a copy of 'Making Hospitals Work'

Bent Christensen (a senior clinician) Chief Executive of Skane University Hospital which is the amalgamation of two large university hospitals in Malmö and Lund that are well on their way down the path of their lean journey.

Isa Arbin and Birger Eriksson (senior lean coaches) from the Swedish government body that provide training to staff from these regional and local authorities. So they are, really, taking this lean stuff seriously.

We felt honoured that not only had these folks travelled from Sweden just to meet us, but that they had brought with them a very clear agenda, their focus on the continued implementation of lean in their regional authorities, (which includes hospitals in Sweden) as well as local authorities - and how could we possibly assist them on their mission. After many hours of friendly and humorous discussions we agreed that some form of a collaboration was the way forward.

Having, now, been approached by several regional authorities from mainland Europe, regarding one form of collaboration or another, this has left us wondering if lean is actually gaining more traction at a regional level in mainland Europe than in the UK?

May we take this opportunity to thank Catharina, Bent, Isa and Birger for their time invested in meeting with us and here’s to a long lasting and fruitful collaboration.

Hospital Acquired Infections

We often state that extended LoS in hospital increases a patient’s chances of acquiring an infection which will at best, extend their LoS even further - or in the worst case lead to a fatality.

Obviously, however, even in the rare cases where the patient’s LoS is appropriate and not extended the chance still exists.

This reminds me of a recent (& memorable) discussion with a good friend of ours, the Medical Director for Local Health in Florence, Fabrizio Gemmi.

Fabrizio’s current campaign involves the training staff in the importance of hand washing. During this training he states that the duration spent on this important hand washing activity should take a minimum of 20 seconds to be effective. To assist folk in ensuring that they spend at least 20 seconds washing their hands (without using a stopwatch) Fabrizio came up with a remarkably simple but effective solution. He suggests that whilst washing their hands staff should sing (in their heads - or out loud if they wish) Happy Birthday to You…… Twice.

I’ve since timed myself doing this (I chose the singing it in my head option – for obvious reasons) & it does actually take 20 seconds.

More recently I decided to do a little more research on the impact of HIAs on healthcare systems and came across one site in particular http://www.haiwatch.com/ that grabbed my attention. It is a commercial site belonging to Kimberly-Clark but features some frightening data that they have compiled.

In the US alone they state that:

The Centres for Disease Control (CDC) report published in March-April 2007 estimated the number of U.S. deaths from healthcare associated infections in 2002 was a staggering 98,987

HIAs represent an estimated annual financial impact of $6.7 billion to healthcare facilities.

World wide they state that:

According to the World Health Organization (WHO), at any point in time, 1.4 million people worldwide suffer from infections acquired in hospitals.

The risk of acquiring an infection whilst in a hospital in developing countries is 2-20 times higher than in developed countries.

Faced with these chilling and head spinning numbers and acknowledging that the basic precaution of hand washing is pivotal in preventing HAIs, Fabrizio’s business case for his Happy Birthday to You…… Twice campaign seems (without wishing to state the obvious) more than bullet proof. The investment required is minimal and the improvement opportunity is vast.

They Batch Whilst We Queue

I’ve just returned home from driving my youngest daughter and her friend to our nearest, local, cinema.

This cinema is located on the outskirts of town in a busy retail park, which seems to be the norm these days.

To service the retail park there is a very long three lane carriageway in both directions. There’s no alternative.

Unbeknown to me (and probably to all the other road users in both directions) the local authority had decided to conduct some important maintenance along this carriageway.

As a result both the inner and outside lanes, on both carriageways were completely closed for several miles, leaving just one lane open, the middle one.

I could only guess from the evidence (because nobody thought to tell me) that the outside lane was closed whilst folks from the local authority cut the grass on the central reservation whilst the inside lane was closed for them to sweep up leaves and clear the drains (I did actually witness this activity just starting to take place right at the beginning of the lane closure)

Not only had they closed a very long section of the inside lane whilst a very slow activity had just commenced (they could have closed just small sections at a time where the work was actually taking place) but the ‘grass cutting’ activity in the outside lane had obviously been completed some time ago yet the lane was still closed.

Assuming that both activities (being performed by the local authority) were planned to take place at the same time they obviously weren’t synchronised. Not even remotely.

So the outside lane was still closed even though the work had been completed and miles of the outside lane were closed even though the work hadn’t really started. And guess what - the paying customer, the road users had to do – queue (and for a very long time)

Fortunately my daughter and her friend had the foresight to figure out that they needed 3D glasses to watch the film so wanted to leave for the cinema early to buy some, so we made it just in time.

Sitting in the queue driving home (there is no alternative route from the retail park) gave me the opportunity to reflect on my frustration.

It reminded me of everyday practices in healthcare:

Processes are not synchronised to suit the customer, the patient, but to suit the care providers.

The care providers actually batch the customer, the patient, to suit their working patterns.

No one tells the customer, the patient, that any of this is going to happen.

The result being that the customer, the patient, ends up in a large queue just like me in suck in that middle lane, the difference being that whilst I was merely bored and frustrated the customer’s needs in healthcare are far, far, greater and yet share the same experience.

I hope the traffic has died down before I drive back to the cinema to pick my daughter up, because I’m sure those lanes will still be closed.

Yet Another Apprenticeship

We may know a little bit about lean and in particular the application of lean in healthcare but when it comes to posting videos onto our blog we're complete novices - yet another apprenticeship, again.

Our first attempt sees us presenting at the Lean Healthcare Transformation Summit held last July in London where our first book Making Hospitals Work was launched. Dan Jones provides the introductions and the segue.


Marc Baker on Lean Healthcare from Ian Taylor on Vimeo.


Ian Taylor on Lean in Healthcare from Ian Taylor on Vimeo.

Lean and Six Sigma in Healthcare?

I was asked the other day about the differences between lean and six sigma. Whilst attempting to explain, it dawned on me that we unconsciously morph the two. To us they are just both names, labels.

When for example we’re problem solving using the A3 approach we often, without thinking about it, employ so called six sigma approaches. DMAIC and A3 are one and the same to us really.

We were once invited to conduct a review of a Trust’s lean implementation as they felt that they were not gaining enough traction across their organisation.

On this occasion, because it was appropriate, we actually employed the Six Sigma approach to conduct a review on lean implementation!!!!

Incidentally, the review revealed that this Trust were very early adopters of lean thinking in healthcare, and were employing the rapid improvement event (RIE) approach. In fact it transpired that over a period of three years they had conducted 86 RIEs although they didn’t actually know that they had done so many.

Upon further investigation it turned out that these 86 RIEs had consumed £1.9 million in people hours and yet had only achieved 10% of the planned deliverables.

A lesson learnt about the RIE approach there.

The interesting thing that has become apparent to us, is that whilst A3 thinking is currently very much in vogue, most of the ‘lean experts’ now adopting it have not been trained in the basic problem solving quality tools to really get to the deep causes of the problems that they are trying to solve.

So having stopped in my tracks whilst attempting to answer this question the other day, all I could really say is that lean and six sigma complement each other perfectly, and not to get hung up on the labels.

Unexpected Demand

LEA recently sent out an e-letter inviting acute hospitals to form a club called the Door to Door Club.

Whilst there was considerable interest from acute hospitals we also, interestingly, received an enquiry from a mental health organisation.

Our initial response was that we felt that the Door to Door Club would not be of particular relevance to this organisation as it would be focussing on medical patient length of stay

Within a day or two we had received enquiries from another two mental health organisations. This was an unexpected demand that could not be ignored. These organisations all have a QIPP that they have to deliver. As a result, yesterday, we held a very inspiring meeting with these three organisations to discuss the potential for creating another club focussing on mental healthcare.

They did ask if we knew of any other such organisations that might be interested in joining such a club. Several mental health organisations are subscribed to the LEA site and we will be contacting them but if you work for a mental health organisation and are not a subscriber to the LEA site, please to contact us.

Patient Flow, Pull and all that

Lean terminology is slowly entering the healthcare vocabulary in particular the terms Flow and Pull.

Our job in healthcare is to enable each individual patient to ‘pull’ themselves through the system and to ensure that our services ‘flow’ to provide exactly what the patient needs exactly when they need it (pulled by the patient) during their journey through our system.

What we actually witness however is reaction:

When pressure is on, to admit medical patients, at the front end of the hospital we see a reaction whereby there is suddenly a huge effort to discharge patients (sometimes unsafely) and if enough patients cannot be discharged, those approaching ‘medically fit status’ are moved to any empty available bed, usually in the wrong specialty ward or worse still into surgical beds. This practice, as we all know, extends LoS, it dismays Clinicians who then have to perform ‘safari ward rounds’ and causes cancellations of, revenue generating, elective procedures.

Even during these pressurised circumstances it sill takes an average of three hours from discharging a patient to the next patient occupying that bed. Which means the front end and the back end are not connected. We know it can be done in 20 minutes or so.

When however the pressure is off to admit medical patients at the front end of the hospital we see another reaction. People involved in the discharge process ’take their foot off the gas’ and breathe a ‘sigh of relief’. Unfortunately this situation is usually followed immediately by a sudden surge of patients turning up at the front end and so the exhausting cycle begins again.

We have learnt that the process must be reversed: Start at the back end

People involved in the discharge process must, all but, ignore what’s happening at the front end and instead constantly focus on their job: discharging small numbers of patients, drip fed throughout the day, which is all that is actually needed to accommodate demand for beds, (and we also know that there is, most definitely, a predictable demand for discharge)

As medical beds become available, priority number one is to repatriate patients who are in the wrong beds.

The wards, in turn, must be scheduling the discharges of their patients, based on the patient’s discharge complexity (planning to discharge a patient that needs special transport, take home drugs and oxygen first thing in the morning, for example, is probably fantasy planning)

This enables the people involved in the discharge process to know who to discharge and when.

In the mean time the front end MAU/Obs Wards must continually update the wards with their patient’s demand for beds by specialty and gender and admit new patients confident in the knowledge that the system can accommodate them.

Perfect Alignment ... But we see a gap

In the summer of 2009 David Nicholson (Chief Executive of the NHS) sent a letter to all Chief Executives of PCTs, NHS Trusts and NHS Foundation Trusts in England regarding the implementation of Lord Darzi's Next Stage Review (NSR): The Quality and Productivity Challenge.

At the Same time we published our findings, from five years research working in the NHS, in the form of the book Making Hospitals Work. Whilst the two came from completely different sources the messages contained within both are remarkably similar.

David Nicholson asked for contributions about improving Quality, Innovation, Productivity and Prevention (QIPP) stating that this is the most important challenge facing the NHS for the foreseeable future. “The real changes we seek will be designed and delivered locally with the centre playing an enabling role. Meeting the challenge is central to the role of every NHS leader and every NHS board. In short this is your day job”

Within the four principles that he had set out to guide the implementation of the NSR, he goes on to mention the importance of:

• Having the capacity and capability in terms of people with the right time, skills and support to properly support the scale and pace of change required.
• Great clinical leadership, supported by managers who back good ideas.
• Leadership behaviours, not necessarily the same as those during the period of growth.
• Organisations having a clear narrative about what this challenge means

Interestingly the House of Commons Health Committee: NHS Next Stage Review (First Report of Session 2008–09), a ‘review of the review’ if you like, echoes the need for the above points but voices concerns regarding the general lack of analytical and planning skills and that the quality of management is very variable, stating that “It is widely recognised that the quality of leadership in the NHS must improve”. It also expresses concerns about whether NHS institutions and staff were capable of delivering the proposals made in the NSR.
Anyone who has read Making Hospitals Work or follows the Lean Enterprise Academy’s healthcare articles and blogs will see a very clear alignment between these messages and ours. You will also be aware that we insist that all this should be the part of the day job, that clinical leadership is definitely the way forward and that leadership behaviours will need to change to face the challenges ahead.
However working daily, at many sites, gravitating (up and down) constantly between the frontline, middle management and executive level our concern about a clear narrative is that until healthcare organisations, at this local level, are capable of distilling and prioritising their objectives, to address the vital few problems facing them, then staff will neither be given or have the time (capacity) to develop their skills (capability) to enable them to deliver.
We share the House of Commons Health Committee’s concerns regarding implementation, but herein, we believe, lies the gap. The staff at the local level have not (yet) been shown how to do this, thereby enabling them to practice and become skilled at doing it, then they must be left alone, uninterrupted, to get on with doing it.

What problem are we really trying to solve here

As we work with more and more healthcare organisations in the UK it becomes more and more apparent that their biggest problems (the ones that keep their Chief Exec awake at night) are:

• Financial performance
• Hospital Acquired Infections
• The 18 week Access target
• The A&E/ED 4 hour and 8 hour targets
• Length of Stay (LoS)

It becomes even more evident that LoS (for medical patients in particular) is the deepest cause for concern.

Extended Medical Los is a massive drain on finances, necessitating the opening up unfunded beds which require un-budgeted bank and agency usage (it is unrealistic, however, to close beds without firstly reducing LoS). The longer a patient remains in hospital the greater their chances of acquiring an infection (which extends LoS even further). Extended medical LoS also results in the practice of out lying medical patients onto surgical wards (which prevents the admission of revenue generating elective patients), and leads to a lack of available beds for A&E patients requiring admission (resulting in excessive breaches).

We have yet to work with any organisation (to date) that do not insist that extended medical LoS is indeed their biggest problem. However they still typically have a portfolio of (on average) 500 ongoing projects (trust wide) attempting to address ALL of the Trust’s problems. This huge portfolio, perversely, prevents staff from working full time on reducing LoS, their biggest problem, and making it part of the day job.

Understandably finance in today’s environment seems to rule the roost resulting in many ‘turnaround’ initiatives. As a result, for example, Pathology or MAU are asked what can they contribute to financial savings but will their proposals also help reduce LoS? This applies to all the divisional and departmental silos.

Can you imagine if we all acknowledged that a reduction in LoS would be the greatest contributor to achieving all of our other targets and just worked on that. Then we would be asking all the divisions, departments and services “what can you contribute to a reduction in LoS”.

Every division, every department and every service would then be perfectly aligned to work on one goal, to reduced LoS. True North as we call it. Imagine how the project portfolio would look then.

The Visual Hospital Touchscreen Solution (e-VH)

Doing the right thing for every patient

We provide Lean Healthcare solutions to clinicians and managers that enable them to safely reduce the time patients stay in hospital.

After five years implementing Lean principles in various Healthcare establishments we wrote the book Making Hospitals Work and developed a bespoke ergonomic system, which accelerates Lean transformation, creates a common agenda for managers and clinicians, and enables hospitals to dramatically reduce patients’ length of stay.

Our patient-centric autonomated solution combines proven thinking with touchscreen technology supported by training and mentoring from recognised experts. It helps reduce the stress and administration overheads of clinicians and enables them to focus on individual patients. By using real-time patient information visible on the floor, clinicians can prioritise their daily workload and concentrate on their duties. It helps managers reduce costs by providing visual controls with action plans that enable them to make more informed decisions and schedule discharges to meet demand. The process increases throughput using the same resources * and provides managers with options to meet their targets.

[ PATENT PENDING: 0903144.4 ]





Visual Healthcare Solutions has brought together the Healthcare expertise of Senior Faculty Members from the Lean Enterprise Academy and Energized Work's innovative product development. We work closely with our clients to understand their needs and, being (and wishing to remain) a small company, we are able to respond quickly and deliver solutions that work.

Click here to learn more about the e-VH

* At one District General Hospital a 1.5 day reduction in the average length of stay (for acute medical patients) was realised within just thirty days. At another, a 47% increase in the throughput of acute medical patients was realised.

Free Webinar discussing the application of Lean in Healthcare

More than ever, in today's demanding economic climate, nothing is more important than Healthcare. All of us will need a good hospital some day and countries can easily go broke supporting traditional hospital management practices as the baby boomers begin to check in. Healthcare contains the most important value streams in society - those that touch our lives directly.

Clinicians use the scientific method to diagnose and treat patients - which is the foundation of evidence based medicine. In this webinar Marc and Ian discuss how we can use the same scientific method to diagnose the root causes of broken healthcare systems and, using evidence based management, come up with the appropriate countermeasures to improve the patient experience, relieve the overburden on hospital staff and treat more patients while saving hospitals’ resources.

A Remarkable Story

How Lean is transforming the patient journeys through what is thought to be the oldest hospital in Europe, founded on the 23rd of June 1288!

Ian and Marc receiving a fantastic reception at Santa Maria Nuova:



And checking out their excellent facilities and processes:






Dan Jones tells the remarkable story [pdf].

The Use (Or Misuse) of Lean Terminology in Healthcare

Flow
There are countless Flow Co-ordinaters and Flow Managers in Healthcare, but all we actually witness, really, is movement not flow. Sure we may out lie patients, for example, to accommodate incoming patients. At face value this may look like flow at the front end of the hospital but from the patient who has just been outlied’s perspective it certainly isn’t Flow.

True Flow is still the holy grail for even the most advanced lean organisations in any industry and even then it usually only occurs very briefly. Which is why we need Pull.

Pull
How often do you hear “we’re going to pull a patient from MAU to a ward” when a bed becomes available. That’s really saying we’ll accept you onto our ward now that we’re good and ready for you – that’s actually push as far as the patient is concerned.

You cannot pull the customer. The customer pulls our services. It’s our job to help the patient (the customer) to pull themselves through the system providing whatever they need, safely, in the right quantity, whenever they need it.

Lean
Even the word lean itself is grossly misused. “We’re going to lean out the number of staff in ED” for example. Not a good way to win over converts to lean.

Reduce your average Medical Length of Stay by more than half

Typically over 85% of Medical Patient’s LoS consists of Waiting Time. Time spent waiting for diagnostics, treatment and therapies etc. It is during these waiting times where it both becomes un-safe for the patient and the money is pouring out of the system. Mapping the Patient’s Journey in your hospital (door to door from the patients perspective) will enable you, for the first time, to see where these waits reside, enabling you to get to the root causes of these waits thereby enabling their systematic elimination.

OK, So You Know Your Demand To Get Into Your Hospital ... But Do You Know Your Demand To Get Out?

We now realise that it is difficult for a Medical patient to get out of hospital once they have been admitted. You are more likely to be moved to another ward when you are approaching a medically fit status (which we all know extends LoS) rather than remain on the same ward and be discharged when you are declared medically fit.

Talking recently to a senior nurse, who was unfortunate enough to have spent 3 spells in hospital over the last few years, she went on to explain that on each occasion this is exactly what had happened to her and that on each occasion her LoS was extended by an additional 3 days after she had become medically fit. It is hard to get out, she exclaimed, unless you discharge yourself. The main difference is that most patients (and their families) don’t actually know when they are medically fit. They have to wait for someone to tell them that it’s okay for them to go home. Some, obviously, whilst undergoing this protracted process contract hospital acquired infections which extends their LoS even further putting even more pressure on the entire system and the staff.

We have visited many hospitals where demand information is difficult to obtain. Some of the more enlightened hospitals, however, can now provide patient ‘demand to get in’ from their Emergency Department or via GP referral (some even by the hour and by the day of the week). We tend to have this annoying habit of saying “but I can’t see it” when factual, real time, data is not readily available and accessible. Our observation is that whilst organisations may know their demand to get in, they very rarely know their ‘demand to get out’, the demand for discharge. We just simply cannot “see it”.

In light of this, we have run several experiments in several hospitals where we employed a simple visual management technique to enable us see this demand to get out. To our astonishment (and to that of the organisations themselves) it turns out that it is absolutely normal to find that, at any given time (except over the Christmas period maybe) between 25% and 30% of beds on medical wards are occupied by patients who are medically fit for safe discharge, but they are still in the hospital. The demand to get out.

This 30% does not consist solely of DToC patients (bearing in mind that different organisations use different operational definitions to describe DToC patients), it also include many patients who are simply medically fit for a simple discharge but are still occupying a bed on the ward.

These same organisations freely admit that medical demand to get in is actually very predictable. Likewise, from our experiments we can confirm that demand to get out is equally predictable by the day and by specialty.

All this is good news because it means that due to this predictability, we can actually, for the first time, schedule discharges of unscheduled care patients.

For some time now many hospitals have attempted, without success to introduce discharges earlier in the day the ‘early bird’ or golden patient’ as some call it.

Seeing demand to get out, again for the first time, enables small numbers of discharges to be ‘drip fed’ throughout the day (which is all that is actually needed to cope with in-coming demand) as opposed to the usual large quantity, at the wrong time of the day (late afternoon and early evening) and the resultant chaos and stress that this causes.

To enable our experiments to unearth these medically fit patients we obviously rely heavily on the accuracy and honesty of the information provided by the ward staff. I’ve heard many nurses and managers declare that it’s far easier to retain a patient than to go through the process of discharging a patient and admitting the next one (unless the patient is an unpleasant individual – they like to hang on to nice, compliant, patients). It is human nature after all to avoid hard work if at all possible.

Some organisations have even gone so far as to announce to staff that it is a disciplinary offence not to declare medically fit patients. There is another side to this coin however. One senior nurse recently reported to us that her mother had been admitted into the hospital where she works. When this senior nurse went to the ward to find out her mothers medical status, she received one set of responses. However, upon explaining that the patient was actually her mother, she received a totally different set of responses. Reflecting on this, her hypothesis was that when she made the initial enquiry, the ward staff thought she was wearing her ‘management hat’ and was going to force them to do something with this patient that they did not believe would be in the best interest of the patient (maybe transfer her to another ward - off template as some organisations call it). It may be, she continued, that in an effort to create space for incoming demand, management were influencing, adversely, the behaviour of the ward staff.

We have witnessed this ‘cat and mouse’ game, with opposing agendas, all but disappear once this highly pressurised, highly charged and emotional environment is replaced with a transparent and stable process in which, through seeing and understanding this genuine demand to get out, discharges for un-scheduled care patients are being scheduled.

Who’s (or Where’s) the Boss

Back in the very early days of our time working in healthcare (our apprenticeship if you like) we asked to meet the Ward Manager of the first ward that we were working with. Asking her deputy if the ward manager was around she replied “I’ll have to check the Off Duty”.

We immediately though that this was strange, why ‘off duty’ what about who’s ‘on duty’ (the off duty - a whole other article in itself) and why doesn’t the deputy know where her manager is. That’s how naive we were in this industry.

It transpired that the Ward Manager was on a ‘Management Day’ but was contactable. So we met with her in the hospital library. This is where we learnt that although she was the Ward Manager, responsible for a 36 bed ward, around 50 staff and around 45 patients (per day due to admissions and discharges) she was actually ‘part of the numbers’ she was, when on duty, being a nurse looking after a bay of 9 patients.

This meant that she was working a shift pattern along with the rest of her staff and that when she was not working there was no manager available. Coming fresh from manufacturing and putting this into perspective, we were used to there being a Shift Manager or at the very least a Shift Team Leader so this came as a bit of a surprise.

We imagined the equivalent in manufacturing – a manager who with was responsible for 50 staff working a 27/7 shift system , manufacturing around 45 different batches per day but was actually working ‘full time’ on the line and on shifts.

So at this vital ‘unit level’ the Hospital Ward, if the Manager was working night shifts this week this meant that during the busiest period where everything happens, during the day, there was no one managing at all.

We could not imagine any other industry that would tolerate this. How can she possibly manage? So what was this management day all about? She explained that twice a month she was allowed to spend a shift working out the ‘off duty’, balancing budgets, staff issues and training, complaints and so on. In other words all the stuff that a manager, in other industries, normally does every day. It was admin work not management.

Being naive we had seen the old movies where ‘back in the day’ there was a Matron who was the boss but here it turns out there wasn’t one.

Over the ensuing moths we formed an excellent relationship with this ward manager, who freely admitted that due to her constraints had no chance to know her staff let alone all the patients on her ward. With her assistance we sat down with this ward manager and calculated that for no additional cost she could actually become as we tend to call it in the UK healthcare industry ‘supernumerary’. In other words, by applying a scientific approach to the ‘off duty’ we could free her up to Manage the Ward working normal office hours (when everything was happening) and no longer required to work in one single bay.

Like all experiments we needed to get a base line, a current state. It turned out that whilst on shift, and due to her position as the manager she was interrupted 194 times. As a result, through no fault of her own, if you happened to be a patient in the bay in which the ward manager was responsible for, you actually received less care than a patient occupying a bed in the other bays on the ward.

The ward manger’s boss, looking at both our calculations and base line data, agreed that she could and should, indeed, be supernumerary. Great for ward manager and us.

So we could now introduce simple, yet extremely effective visual operational management – a Plan for Every Patient (PFEP) whereby immediately upon a patient being admitted to the ward a complete plan was drawn up, visually, for the patient, from admission until they were medically fit for a safe discharge.

The process was drawn up and followed whereby the ward manager would at a given time of day invite the nurses responsible for each bay to attend and report whether the patient actually received what they were planned to receive yesterday and if not (variance to plan) how to catch back to achieve the plan, and to re-iterate today’s plan.

During this period planning accuracy, in other word the Patient receiving exactly what was planned for them (On Time and In Full) rose from 41% to 86%. It also provided an excellent means for the ward manager to ascertain which members of staff were ‘on the ball’ knew their patients status or did not.

Through Industrial Tourism this approach proved to be extremely popular with other hospitals within the organisation (and beyond) wishing to adopt it. Great, but a word of caution (from lessons learnt) – don’t tell the Finance Department. Once they know that you can actually install a supernumerary ward manager they may well cut the budget. On this occasion they actually attempted this, yet another battle and yet another blog.

Who’s Got Time for Lean in Healthcare?

If you have navigated to this then there is a fair chance that you are in a leadership position in healthcare and are interested in the application of lean thinking within your organisation. There is also a fair chance that you would agree that lean should be part of the day job, not an addition to it.

This is where the problem lies. We have worked with many health care organisations where the application of lean thinking is indeed an addition to the day job. Sure, these folks know it’s the right thing to do for both the organisation and the patient, but the truth is that they simply have not got the time, the capacity, to adopt lean.

Suspecting this, we have carried out what we call a ‘Diary Exercise’ with many Healthcare execs, senior managers and line managers. It is totally normal when conducting these exercises to find that the genuine demands placed on these individuals can be in excess of 24 hours a day. So, if you were to start in a new job on day one, you would come in to 24 hours worth of work to complete that day. If you were to work a 12 hour day on this first day, then you would come in to 36 hours of work on your second day (24 hours worth of work plus the 12 hours worth of work that was not completed yesterday) and so on. No wonder that inboxes and in trays are always full to overflowing.

This is not down to poor time management. It is the genuine current demand placed upon these people by their bosses right throughout the chain of command. Whilst conducting these diary exercises in one organisation, we were fortunate enough to be invited to assist them in their first steps towards formal strategy deployment.

During this exercise we discovered that this exec team believed that they had 252 targets imposed upon them and then when deployed to the next (General Manager) level, the number had mushroomed to 350. Why?

Upon close investigation, it transpired that the trust only had 36 external targets imposed upon them (6 of which were duplications anyway, so 30 really). It transpired that the trust themselves (or their Performance Dept more like) were generating this impossible amount of work. Hence the crippling 24 hours worth of demand placed upon individuals. So did this organisation have any time to invest in adopting lean?

More recently, whilst working with another health care organisation that are also keen to adopt lean thinking and more importantly the stability that basic lean Operational Management brings, we noticed that the key managers were unable to maintain the routine ‘check’ cadence that good Ops management requires. Again we performed the diary exercises with these folks and again found a very similar story. Digging deeper we helped them uncover the fact that in the medical division alone, these line management, operational folks were jointly working on over 140 improvement projects and initiatives yet no one person could see all 140 in one place or indeed even knew that there were so many. No wonder they didn’t have time to embrace lean thinking.

Whilst it is admirable that these organisations are striving to provide better and safer patient care at a reduced cost, expecting people to work on these vast volumes of work that has been self generated, is not only unrealistic and unsustainable but is unfair on the staff and provides no real benefit to the patient.

Just imagine that you are spinning plates. You have already got too many plates on the go, when somebody comes along and says “by the way, here are another couple of plates for you to spin”. It’s inevitable that they all come crashing down.

Understanding this situation has helped us work with these organisations to funnel down to their biggest problems, the vital few and to focus everybody’s attention on working on just these.

Medical Length of Stay (LoS) appears to be a good place to start, as a reduction in LoS combined with safe effective discharge, obviously, improves quality of care, reduces the risk of hospital acquired infections, assists in achieving emergency and elective targets whilst reducing costs.

It’s only when there is agreement from the top to unearth the ‘vital few’ and allow everybody else in the organisation to work just on these, will staff not only have time to learn and become skilled in lean, but will have the time and capacity for it to become part of their day job.