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.
Monday, 26 April 2010
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.
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.
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.
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:
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.
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.
Thursday, 11 March 2010
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:
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.
- Financial performance
- Hospital Acquired Infections
- The 18 week Access target
- The A&E/ED 4 hour and 8 hour targets
- Length of Stay (LoS)
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.
Wednesday, 10 March 2010
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.
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.
Sunday, 7 March 2010
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.
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.
Saturday, 27 February 2010
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:
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And checking out their excellent facilities and processes:
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Dan Jones tells the remarkable story [pdf].
Ian and Marc receiving a fantastic reception at Santa Maria Nuova:
.JPG)
And checking out their excellent facilities and processes:
.JPG)
.JPG)
Dan Jones tells the remarkable story [pdf].
Friday, 26 February 2010
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.
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.
Thursday, 25 February 2010
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.
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.
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.
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.
Saturday, 7 November 2009
Dan Jones speaks at Harvard Medical School
In the last week of October Dan Jones went to the USA to speak with some key healthcare leaders. Follow this link to read about his time at Harvard Medical School.
Saturday, 8 August 2009
Lean in Healthcare - Getting Started
The Lean Enterprise Academy (UK) are probably the world's greatest authority when it comes to Lean in Healthcare.
A good place to start is by navigating to their website and by purchasing their latest publication, the book Making Hospitals Work. Of particular note on this page is the 'what they say....' section.
You can also hear the the authors discussing their approach.
A good place to start is by navigating to their website and by purchasing their latest publication, the book Making Hospitals Work. Of particular note on this page is the 'what they say....' section.
You can also hear the the authors discussing their approach.
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