lean healthcare - streamlining patient journeys
TRANSCRIPT
Lean Thinking in Healthcare
Doing the Right Thing for Every Patient
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Making Hospitals WorkHow to improve patient care while savingeveryone’s time and hospitals’
resources
by Marc Baker and Ian Taylor
Foreword by Daniel T. Jones
A Lean Action Workbook from the Lean Enterprise AcademyVersion 1.0 Goodrich UKMay 2009 www.leanuk.org
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Exercise: Check Current Awareness
• Split in to Groups.• Objective: Each Group to give 5 mins
Presentation:• What is Lean?• Where does it come from?
• Use Flip charts. • Presentation must be on 1 Flip chart.
• Timescale: 20 mins
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Lean Principles
Overview
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Lean Thinking• Specify what creates value from the
customers perspective • Identify all steps across the whole value
stream• Make those actions that create value
flow• Only supply what is pulled by the
customer just-in-time• Strive for perfection by continually
removing successive layers of problems
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Lean Enterprise Academy
Our Observations in Healthcare
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Lean Enterprise Academy
Lean Enterprise Academy
Activity DailyBed Meetings (x3 daily) 2.25Morning Handover 0.508:15 - 08:30 (x2 weekly) 0.2ECIP 0.3Facilitators 1:1 (x1 fortnight) 0.35DHM 1:1 0.35Emergency Pathway 0.2Facilitators Meeting 0.3Corridor Meeting 0.25Hants Conf Call 0.5PAU 1:1 0.25MAU meet 0.2Op Commisioning Meeting 0.41:1 with Ed 0.05DGM DSN Meet (x1 fortnight) 0.15HMC 0.15COO Meet 0.15St Mary's transitional grop 0.075Nursing Workforce Committee 0.075Duty Managers Update 0.5DMOP Meeting 0.2Seeing Facilitators 1Duty Manager 1.6LEA 0.4Contract Review 0.05Bleep Holder 230 day review meetings 0.5Actions from Bed Meetings 1Ad Hoc Meetings 1Appraisals 1.11:1 with Mary 1Hospital Walkabout 1Discharge Lounge 0.25Update for DMTs 0.375E-Mails 100/Day 2Report Writing 0.6Budget Management 0.1Performance Managing 0.2DHM Induction 3
24.575
The Diary Exercise – Daily Personal Capacity V’s Daily Organisational Demand……. This is real data and absolutely typical. But What’s causing this?
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Lean Enterprise Academy
The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can we measure it?
•Agreed? Who will be responsible and do they accept this responsibility?
•Relevant? What is its contribution?
•Trackable? Can we see the status at a glance whenever we want to?
Copyright Lean Enterprise Academy 2010
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Target Focus No. ProjectsCost Improvement 300
4hr Performance Improvement 132Safety & Quality 4418 Week Access 39
TOTAL 515
Lean Enterprise Academy
The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can we measure it?
•Agreed? Who will be responsible and do they accept this responsibility?
•Relevant? What is its contribution?
•Trackable? Can we see the status at a glance whenever we want to?
Copyright Lean Enterprise Academy 2010
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
SCORECARD
StakeholdersResourceUtilisation
ManagementProcesses
Innovation& Learning
A B C A B A B A B C D
15 15 3 4 11 9 23 1 3 2 1
20 21 9 14 36 22 92 11 11 7 9
Scorecard – Descriptive Stats
Categories
Strategic Objectives
Specific Goals
Measures
Categories = 4
Strategic Objectives = 11
Specific Goals = 87
Measures = 252
Lean Enterprise Academy
The Five Point Checklist
•Simple? Can we explain it, so it is easily understood?
•Measurable? Can we measure it?
•Agreed? Who will be responsible and do they accept this responsibility?
•Relevant? What is its contribution?
•Trackable? Can we see the status at a glance whenever we want to?
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The BIG Problem
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Lean Enterprise Academy
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1. Compliance with 4 hour emergency access performance target.
2. Compliance with the 18 week scheduled service access targets
3. Cost reduction. Middleton was six months into the financial year and was already £6.5 million overspent year to date.
4. Medical length of stay (LoS). A previous benchmarking survey had revealed that Middleton’s medical patients were staying in the hospital longer than the national average.
5. Rates of Hospital Acquired Infections (HAI) such as MRSA and C. difficile were also higher than the national average.
Middleton’s Story
Middleton General has 5 big problems:
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
The BIG Problem – Consructing the Matrix
A&E
Acc
ess
Cost
Med
LoS
HA
Is
A&E
Access
Cost
Med LoS
HAIs
Problems
Impa
ct (√
orX
)
Lean Enterprise Academy
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The BIG Problem – Looking for Leverage
A&E
Acc
ess
Cost
Med
LoS
HA
Is
A&E
Access
Cost
Med LoS
HAIs
Problems
Impa
ct (√
orX
)
Lean Enterprise Academy
EG if we fixed our A&E 4 Hour
Target problem
Would this also fix any of the
other problems for free
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Lean Enterprise Academy
A&E
Acc
ess
Cost
Med
LoS
HIA
s
A&E
Access X
Cost X
Med LoS X
HIAs X
Problems
Impa
ct (√
orX
)
EG if we fixed our A&E 4 Hour
Target problem
Would this also fix any of the
other problems for free
The BIG Problem – Looking for Leverage
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Medical LoS - The BIG ProblemLean Enterprise Academy
Copyright Lean Enterprise Academy 2009
Medical LoS - The BIG ProblemLean Enterprise Academy
Seeing the Process:
What is our Current
Condition?Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy
The Current State
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Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
From the total LoS of 7.6 days only 1.1 days receiving diagnostics or interventions (14.6%)
AND
Don’t get hung up on the cure time debate – it’s the triangles that we’re going for after all
Lean Enterprise Academy
Don’t worry if yours ends up looking like this !!!!
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Lean Enterprise Academy
Staff/Departmental Availability
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Lean Enterprise Academy
Nursing Availability to Discharge from Wards
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Lean Enterprise Academy
Thinking Differently
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Lean Enterprise Academy
Copyright Lean Enterprise Academy 2009
Lean Enterprise Academy"Everything that can be invented has been invented.”
Charles H. Duell, Commissioner, U.S. Office of Patents, 1899.
"We don't like their sound, and guitar music is on the way out anyway.”President of Decca Records, rejecting The Beatles after an audition, 1962
"That is the biggest fool thing we have ever done [research on]... The bomb will never go off, and I speak as an expert in explosives.”
William D. Leahy, U.S. Admiral, advising President Truman on atomic weaponry, 1944
Man will not fly for 50 years.”Wilbur Wright, American aviation pioneer, to brother Orville, after a disappointing flying experiment, 1901 (their first successful flight was in 1903)
"... good enough for our transatlantic friends ... but unworthy of the attention of practical or scientific men.”
British Parliamentary Committee, on Edison's light bulb, 1878
"The Americans have need of the telephone, but we do not. We have plenty of messenger boys.”
Sir William Preece, Chief Engineer, British Post Office, 1878
"Space travel is bunk.”Sir Harold Spencer Jones, Astronomer Royal of the UK, 1957 (two weeks later Sputnik orbited the Earth)
" 640k ought to be enough for anybody.”Bill Gates, 1981
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Lean Enterprise Academy
"X-rays will prove to be a hoax.”Lord Kelvin, British mathematician and physicist, president of the British Royal Society, 1895(?)
"Louis Pasteur's theory of germs is ridiculous fiction.”Pierre Pachet, British surgeon, Professor of Physiology at Toulouse, 1872
"The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise and humane surgeon".
Sir John Eric Ericksen, British surgeon, appointed Surgeon Extraordinary to Queen Victoria, 1873
"The abolishment of pain in surgery is a chimera. It is absurd to go on seeking it...knife and pain are two words in surgery that must forever be associated in the consciousness of the patient.”
Dr. Alfred Velpeau, French surgeon, 1839
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Waste
Lean Enterprise Academy
Typical Mgmt Approach – Squeeze the Boxes
Why - Because they can’t see the Triangles
Necessary but non value adding35%
Value adding5%
Non value adding60%
Why not start here instead
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Lean Enterprise Academy
Process, obviously needs Re-designing but…….
Stability 1st
Then
Re-design
So what is stability & how do you get it…….
Some form of standardisation
Flow, Pull, Perfection systems
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Lean Enterprise Academy
Scientific Operational Management
Our Definition:
Scientific operational management is a closed loop system that provides the Measures & Stability required to enable Safe Experimentation (Re-design) : It is Lean within the Day job!!! Very important but omitted by many!
Closed Loop employs strict PDCA whereby the Check frequency is at the appropriate pitch to enable the required adjustment to minimise variation in the process
The scientific setting of warning and action limits and the standardisation of the actions required to return to the desired condition – “I will not fail”
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Lean Enterprise Academy
It IS a Science…… BUT it’s NOT Rocket Science
P lan D o
A ct C heck
Now
Grasp the Current State
The Abnormalityis Obvious
Gap
EffectCauses
The Possible CausesEffectCauses
The Possible CausesEffectCauses
The Possible Causes for Gap
Pareto Graph
Highest Priority
Pareto Graph
Highest Priority
Pareto Graph
Highest PriorityAction Plan
No. WhoAction
Action PlanNo. WhoAction
Plan
Target
The Scientific ApproachWhat links these components? A standard method
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Lean Enterprise Academy
Plan for Every Patient Boards
By the Hour in ED
By the Day on Wards
Back to the FrontlineLean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Pilgrim Hospital (Boston) – Medical Visual Hospital - Day One
3 Empty Beds, 12 Medically Fit, 5 Potentially Fit, 30% should not be in acute beds whilst MAU is full and patients are breaching in A&E – Bed Man are declaring No
Beds!!!!What would you do?
Lean Enterprise Academy
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The Visual Hospital in action with the MPSLean Enterprise Academy
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Lean Enterprise Academy
Guess What This ‘lean’ stuff really works in
healthcare
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Bottom Line Results:
Mean Medical LoS has reduced by 1.87 days (30%) from 6.23 days to 4.35 days within 32 days of change.
The Median Medical LoS has reduced by 1 day (25%).
LoS variation has reduced significantly
Huddersfield Royal Infirmary – Medical LoS
Patients in time order
Day
s Lo
S
620558496434372310248186124621
40
30
20
10
0
_X=4.35
UCL=10.12
LCL=-1.41
581 894
111
1
1
1
11
1
111
1111
1
1111111
1
1
111
1
11
1
111
1
1
1
1
1
1
1
1
1
1
1111
Patient LoS Before & After changes
Lean Enterprise Academy
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Huddersfield Royal Infirmary – Emergency Surgery LoS
Bottom Line:
Mean Emergency Surgery LoS has reduced by 4.4 days (53%) from 8.3 days to 3.9 days within 48 days of changes.
LoS variation has reduced significantly.
Patient LoS Before & After changes
Lean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Bottom Line Results:
Average LoS has reduced by 27.3% for Medical patients
and by 28.3% for Surgical patients
LoS variation has reduced significantly for both
And…..more of the Same at United Lincoln Hospitals TrustLean Enterprise Academy
Copyright Lean Enterprise Academy 2010
Patients in Time Order
LoS
(day
s)
476042843808333228562380190414289524761
200
150
100
50
0
_X=7.2UCL=19.8
LB=0
2471 6197Med Patient LoS Before & After changes
Patients in Time Order
LoS
(day
s)
2880256022401920160012809606403201
200
150
100
50
0_X=3.8UCL=8.5
LCL=-1.0
3908 6442Surg Patient LoS Before & After changes
Clinical improvement facilitator Victoria Newlands- Bentley told the Target: "All staff involved in the project have worked hard to implement the changes and the results are proven."Our patients are receiving more streamlined, efficient care and are benefiting from earlier discharge from hospital."We will continue to look at ways in which the patient experience can be further improved in our hospital as we take this project forward."
And….. Aneurin Bevan Health BoardLean Enterprise Academy
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121510809458106755404052701351
140
120
100
80
60
40
20
0
_X=7.6
UCL=24.9
LB=0
1 2 3Trauma LoS from 01/08/2010 up to 09/05/2011
Individual Patients in Time Series Order
LoS
(day
s)
The approach is now being adopted by the Toscana Health Authority (in Firenza, Pisa, Lucca and Prato) and Beth Israel (Harvard Medical School)
“We have completed week one of our Visual Hospital Pilot. The rounds are getting better and we gather more valuable information each day”. MJ Brogna - Associate
Chief Nurse Beth Israel Deaconess Medical Centre
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Lean Enterprise Academy
Hospital Level Visual Hospital
Ward Level PfEP
Individual Patient Level Nursing Handover Sheets
Closed Loop Check/Adjust
Closed Loop Check/Adjust
Visual Hospital Hierarchy