The basics of

Using lean for continuous improvement

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Why BICS in Bolton NHS Foundation Trust?Patients quite rightly have high expectations of their local health services. They want high quality care underpinned by respect and compassion. Equally, our staff want to provide healthcare that is seamless, high quality and patient and family focussed. However all too often we know our processes are not completely right. Equipment might not be in the right place, information not readily available, and the staff may not have time to stand back and review what they do each day. Our systems often get in the way of our ambition to provide the best possible care and service we can.

In 2005, we therefore looked to introduce a philosophy and framework of quality

improvement, where staff are at the heart of putting things right and consistently

aim for excellence. Based on a system pioneered in the Japanese car industry

using ‘lean methodology’, it was adapted for healthcare and became “The Bolton

Improving Care System” incorporating lean as our philosophy and evidence base

for quality improvement, and redesign of processes.

BICS is all about PEOPLE. At its heart is the belief that frontline staff understand

their own work best. We have a vision that we will be an organisation where the

whole workforce is involved, every day, in making services better. BICS aims to give

them some protected time and teach them some techniques that will help them

identify and solve problems in their day-to-day work. Every month, teams of front

line staff get together to problem solve, and make rapid and sustainable change to

improve the services which suit the needs of our patients.

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The BICS approach ensures that every single improvement made is directly related

to the Trust’s core goals, what we call our True Norths:

● Best care for better health – for patients and community

● Using our resources responsibly – for the tax payer

● Valued, respected and proud – for staff, patients and public

BICS has helped staff deliver some major changes to healthcare in Bolton, which

have ultimately saved lives. BICS is based on two key themes and five principles.

We have produced this booklet to provide you with a basic guide. We hope you

find it useful and informative as a starting point on your BICS journey.

For more detailed information you can visit our website at www.boltonft.nhs.uk or look at our staff intranet.

AT A GLANCE: SOME OF OUR IMPROVEMENTSThen Now

Mortality figures among the worst in the country

Named the ‘Most Improving Trust in England’ by Dr Foster health intelligence

Patients waiting longer than six months for surgery

Achieving national waiting time targets of 18 weeks (2012)

Only 61% of staff had an appraisal 90% of staff have an annual appraisal (staff survey 2011)

Average length of stay on respiratory wards of nine days

Average length of stay now seven days, saving an estimated £2 million worth of bed days per year

Short notice appointments were not offered to patients

Introduced in March 2011, with a 300% rise in patients offered unused appointment slots

At least 50 sets of patient notes lost per week

Now, only five each week due to improved methods, and we are still continuing to reduce this

Children’s Mental Health Services waiting times of 22 weeks

Now only eight weeks

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1. The continuous removal of wasteFor BICS, waste is any activity that takes up time or resource which does not

contribute to directly satisfying the needs of the customer. There are eight types of

waste:

Transportation Moving things unnecessarily such as

driving multiple journeys across Bolton as

basic supplies have not been collected.

Inventory ‘Stuff’ that is waiting to be worked. It

could be patients on a waiting list, or

excess stock being held.

Motion Unnecessary human movement because

things are not in the right place, for

example walking up and down a

department to obtain supplies.

Injuries Damage to people, such as a difficult

layout causing someone to hurt

themselves reaching, or through stress.

Waiting Waiting for something to happen, such as

waiting for information or patients waiting

for an appointment in a waiting room.

Overproduction Doing too much, such as reordering

items as it is not clear what is in stock, or

requesting too many tests.

Overprocessing Making things more complicated than

they need to be, such as duplicating

records on both paper and computer

based systems.

Defects ‘Stuff’ that is not right and needs fixing,

such as incorrectly completed paperwork

which needs re-doing.

The BICS themes

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All these things take time, energy and money. Many cause frustration for staff,

waste the skills that you have, and can impact on our patients’ experiences.

2. Respect for people and societyThis is about involving the people who do the work, or are affected by the work,

listening to their ideas, enabling and empowering them to make improvements .

It is about supporting an engaged workforce where staff are not working within

broken systems.

It is about offering the best services possible to our patients, carers, visitors and

other customers.

The BICS themes

Notes

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The five key principles of BICS:

1. Value Understanding what the ‘customer’ perceives as value

2. Value Stream How value is created and delivered to the customer

3. Flow Smoothing the journey, to deliver value, at the right pace,

one by one

4. Pull Triggering processes on demand from the customer

5. Perfection Developing a culture of continuous improvement

1. What is Value?We need our services to deliver value from our customer’s point of view.

Value is something the customer wants, would be prepared to pay for, has a clear

outcome, and is done correctly.

Understanding value is always the first step. If we don’t know what our customers

want, improvements could be in the wrong area and customers remain dissatisfied.

For any service, there may be more than one customer, such as patients, carers, or

other colleagues. Each customer may value different things.

2. What is a Value Stream?A value stream is how we deliver a service from start to finish. It is how we deliver

value to the customer. We need to understand the whole journey, not just part

of it, in order to truly improve things. The delivery of any service will involve many

departments that all impact on quality. This includes anything from car parking,

sending appointment letters, to seeing a clinician, getting treatment and follow-up

care at home.

The work we do comes under two categories:

Example: Air Travel

Example: Patient with a hernia

Value Added:

Any activity that directly contributes to

satisfying the needs of the customer

Arriving at your

destination

Having the

operation

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The five key principles of BICS:

Example: Air Travel

Example: Patient with a hernia

Non Value Added:

Any activity that uses time or resources but does not directly contribute to satisfying the needs of the customer

Waiting to

check in

Waiting for the

operation

Non Value added steps are examples of waste, and therefore, to make the biggest

impact we focus on removing or reducing these wasteful steps from the process.

3. FlowFlow is about making decisions or carrying out activities in the right order, at the

right time, by people with the right skills, which helps each individual patient or

product to move smoothly through our systems.

This means putting the value-adding steps in the process as close together as

possible either in time, or physically, to reduce waste. It is not about grouping

things together into batches.

What it is What it is not

Subway Sandwiches – makes your sandwich fresh one at a time and fills it by ‘flowing’ your sandwich along the counter. Staff and products move very little.

McDonalds – most hamburgers are pre-made in batches and kept warm. Staff have to run around between the burgers, fries and drinks.

4. PullThis means you don’t start doing a task until you are triggered by demand from

the customer. Do not do it before you need to. It is also about pulling patients or

products through the whole system.

What it is What it is not

Making a cup of tea when you feel thirsty.

Making 20 cups of tea in the morning, just in case you feel thirsty throughout the day.

5. What is Perfection?Perfection is about creating a culture of continuous cycles of improvement. It is

not about one-off projects, but seeing and eliminating waste and problem solving

issues, every day as they arise.

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Remember the BICS Ground Rules● There are opportunities for working differently – we can use the people we

have much better – but there are no more people.

● We can use what we have in different ways – but there is no more resource.

● The space we have can be used much better but there is no more space.

● Improvement succeeds if it is designed and led by the people doing the job.

● Take part and get involved - ASK WHY!

Role of the BICS teamThere is a team of BICS facilitators and programme

managers, who are here to support you making

improvements in your area. We can offer advice,

coaching, support and facilitation.

The programme managers work in the Programme

Management Office (PMO) to support critical

corporate programmes of work such as e rostering.

Notes

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Other BICS terms you will come across A3 Thinking Is a structured and systematic team-based approach to making

improvements. It provides a step by step framework to identify:● where and why improvements need to be made● understand the service we currently provide● identify the root cause of problems● come up with potential solutions and test them● learn from the process and improve further and share

learning with others● identify benefits from the improvements.

Standard work Is about identifying the best known way of delivering a service that flows with minimal waste. It is clear who is responsible for carrying out activities, when and what skills are required. Standards are documented, and are easy to understand and adhere to.

Visual Management

This is a system that enables staff to quickly assess the current status of a given process at a glance. It makes the process easier to follow, reduces the risk of making mistakes, and it is clear what needs to be done, when and by whom. It is the basis of BICS as daily work.

6S A systematic way of creating a safe, clean and orderly workplace and keeping it that way. Better layout and organisation improves flow and reduces waste and creates a better working environment.

Rapid Improvement Event

Is one example of an improvement cycle including preparation, implementation and sustainment. A rapid improvement event involves a team of frontline staff exploring and implementing improvements within a focussed week. The whole cycle will be five months work around this week long period.

Strategy (policy) Deployment

Strategy Deployment is the framework to ensure that operational day to day actions relate directly to the achievement of the Trust’s strategic goals. It is a structured process aligning and deploying goals, measures and focus from the board of directors through to clinical divisions and other departments .

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Notes

Spreading the learning: BICS Learning & Development AcademyThe BICS Learning and Development Academy provides staff with differing levels

of awareness and skills to move towards all Trust staff adopting BICS methodology

as daily work. There are different levels of training available.

We also run a Shared Learning website where staff can share good ideas and

learning with other colleagues across the Trust.

If you have a problem or issue that you want to address you can look to see if

anyone else has done something similar or helpful. If you have a something that

has worked particularly well in your own department, you can also share it so

others can learn from your success.

For more information on the BICS Academy, contact the BICS team on 01204

390099 or email BICS@boltonft.nhs.uk, or look at the BICS Shared Learning

pages on the staff intranet.

Share your newsIf you have made improvements that you want to share with colleagues to gain

recognition and inspire more improvement, you can submit your learning to our

shared learning pages or the BICS newsletter and Outbrief for publication. Email

BICS@boltonft.nhs.uk

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BICS in practice – some of our success stories

BICS IN FOCUS: Laboratory medicineIn August 2011 Laboratory Medicine was challenged by the commissioner to

reduce costs to GPs by 20% and improve quality by 20%. Alongside this the

department was required by the Trust to deliver 5% recurrent savings whilst

improving quality and productivity. The team has since generated a £900,000

saving through efficiency savings, new ways of working, increased departmental

income by marketing services and the development of new services. The work

has improved quality and also protected jobs.

BICS IN FOCUS: Mortality ratesImprovement work is saving lives. In 2005, Bolton was among the worst

hospitals in the country for mortality rates. Thanks to focussed improvement

within respiratory illness, we have made key changes to the way clinical teams

work, ensuring patients receive the right care at the right time, every time.

In 2012, Bolton was named by Dr Foster as the fastest improving Trust in the

country.

BICS IN FOCUS: District nursingFollowing patient feedback, our district nursing team introduced a centralised

booking system to improve services. This has meant an 80% increase in patient

appointments per month and a 60% reduction in DNA rates, meaning patients

are getting better access to the services they need, at a time that suits them.

Find out moreTel: 01204 390099

Web: www.boltonft.nhs.uk/BICSEmail: bics@boltonft.nhs.uk

Follow us on Twitter @BICSnews