There were some useful insights about how hospitals work and what is required to improve them when Dan Jones and Marc Taylor from the Lean Enterprise Academy visited the Fund recently. Dan is the author of several best-selling books on Lean, a methodology developed by Toyota which aims to improve flow while minimising waste, and he has been working in health care for the past few years as a ‘Lean missionary’. He has been puzzling over why it is difficult to make Lean redesign stick in health care.
One reason is that operational managers in hospitals are often sucked in to hundreds of improvement projects, meetings and other activities – often the result of centrally set requirements. This means, as Henry Mintzberg observed some years ago, that clinical work is disconnected from management.
Meanwhile on the shop floor, care is often not planned, leading to blockages and problems with flow. These are caused by the design of the system rather than by unpredictable spikes in activity. For example, GP home visits – and subsequent transport to hospital for patients – take place at the end of the day, so patients arrive at the same time. Another example is arranging the bulk of elective admissions for the busiest emergency days.
Hospitals work on a heartbeat set by the pace at which work arrives, which may be 15 to 20 minutes in A&E or two to three hours on wards. This makes the system very sensitive to variations in flow. The lack of a plan for a patient’s journey through that system leads to a significant amount of variation, almost all of which causes delay. When things go wrong the patient requires a rapid intervention – but many of the people who could do this may not understand how the system works or may be busy on other activities – including working on improvement projects. This leads to work-arounds and fixes but does not deal with the fundamental issues.
Hospitals have to be protected from the need to carry out hundreds of projects. Staff, frontline supervisors and managers need to plan care and have mechanisms to escalate problems when they arise. Senior managers need to be available to assist in unblocking the problems and identifying where the process needs more significant redesign. All of this needs to happen at the heart of the hospital. The use of visual control systems, real-time information (white boards will do) and operational managers who are trained in solving problems in the system and who walk the floor are also important. Improvement then becomes something that happens as part of everyday work, rather than in separate projects, and this means that clinical and managerial work can be brought together.
What is striking is that the Lean approach challenges quite a lot of common assumptions about how improvement takes place and what makes a difference to complex systems. The final conclusion from Dan’s work is that, in many NHS organisations, there remains an important gap in skills and knowledge about effective Lean operations management. Chief Executives need to embrace Lean fully, rather than experiment with it around the edges, if they want to reap the rewards and commit to the training and support needed at all levels to deliver it well.
Find out more about the Lean methodology on the Lean Enterprise Academy website.
Comments
1 Staff engagement:in both the current future states
2 Leadership throughout the organisation (not just heroic leadership at the top)
3 Better 360 communications - 21st century comms are NOT just 2-way - they're factorial
If you want materials to stick, you need the right glue
We have a huge task to do in health, and rather than regret the failings of a method from the other world of manufacturing, we need to nurture and grow the best of what is already happening.
That's why, when I discovered an innovation by GPs which transforms their service, I picked it up with both hands. And we're running with the ball called Patient Access as fast as possible. The outcomes are staggering - for patients, doctors and the NHS.
patient-access.org.uk
From what I know there are NHS organisations that have done this and they can demonstrate the impact - why are others so slow to take it up.
The culture change that Lean demands is based on efficiencies in the the flow of production. It fails to include the human values that are essential in a high stress, high turnover environment of hospitals where the outcome has to be measured in clinical and personal as well as financial terms. Even the CEO of the Toyota company had to admit that, in the pursuit of efficiency, some quality issues were overlooked costing the company millions in vehicle recalls.
Kathy - take a look at the Vanguard in Health blog to see how lean principles can be applied in health and social care, based very much on human values. vanguardinhealth.blogspot.co.uk/2012/05/does-going-lean-going-wrong.html
To all NHS managers, if you don't know what 'failure demand' is, you need to know.
Take a look at the case studies
institute.nhs.uk/quality_and_value/productivity_series/the_productive_series.html
As for not sticking, The Productive Series was developed in 2005 following a call from nurses that what they required was time to be freed up - hence the Releasing Time to Care strapline.
7 years on the NHS is in a position where 70% of wards are implementing this programme (with high implementation in the subsequent Productive Mental Health and Theatre programmes... the implementation position in the rapidly transforming Community arena is slightly slower but good progress is being made). There is also massive international adoption of the programmes - i.e. were exporting to Oz, NZ, US etc.
In MSP terms we completed the tranches of 'programme development', 'stakeholder engagement' and 'building capacity and capability' and are just beginning to see the benefits.
I think some of the problem with public sector is that as leaders we don't normally wait for this to happen with large scale programmes, are too impatient, want quick results or there is a change of political focus to the next shiny new thing. This just leads to disengagement and confusion at the frontline.
With a constantly changing NHS structure maintining some of the stability within programmes (lean or otherwise) might not be a bad thing!
In 2 years we've come a long way in our attempt to introduce true operational management in our hospitals through Visual Hospital and Plan for Every Patient and have reduced medical length of stay by 28%. A by product of this has been a cost out saving in the region of £2million through ward closure.
We've still a long way to go but I believe we can demonstrate how Lean redesign can stick in healthcare - if you approach it in the right way.
If you've not read it "making hospitals work" by Marc Baker and Ian Taylor is an excellent introduction to a different way of thinking about Lean in healthcare.
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