Monday, 26 April 2010

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.

Sunday, 18 April 2010

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.

Thursday, 15 April 2010

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.

Sunday, 11 April 2010

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.

Tuesday, 6 April 2010

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.