3. Large healthcare provider
3 hospitals providing
acute services
3 hospitals providing
acute services
comprehensive
mental health
services
15 other hospitals
3 hospitals providing
acute services
comprehensive
mental health
services
3 hospitals providing
acute services
comprehensive
mental health
services
15 other hospitals
41 health centres and
clinics
3 hospitals providing
acute services
comprehensive
mental health
services
15 other hospitals
41 health centres and
clinics
serving 600,000 local
residents
4. Over 13,000 staff
6,000 nurses
1750 allied health workers
Over 1000 doctors
Including 260 Consultants
Major employer in Wales
5. Comprehensive services
Urology
ENT
Ophthalmology
Maxillo-Facial
Dermatology
GU Medicine
Renal Services
Mental Health
Obstetrics
Gynaecology
Pathology
Anaesthetics
Rheumatology
Palliative Medicine
Adult Medicine
Minor Casualty
Neurology
Accident &
Emergency
General Surgery
Dental
Haematology
Cardiology
Child Health
Trauma &
Orthopaedics
Psychology
Learning Disabilities
School Health
Community Nursing
Health Visiting
Family Planning
Vaccination &
Immunisation
Speech & Language
Therapy
Physiotherapy
Occupational Therapy
6. Emergency admissions
Non-emergency admissions
Day cases
New outpatients
Follow-up outpatients
Obstetric admissions
Accident & Emergency /Minor Cas.
68,300
15,017
49,350
115,000
277,113
9,200
158,670
692,650
187
41
134
316
759
25
434
1,896
Average
weekday
Last year we treated
9. 2002 - 2005 Context
No sustainable level of service provision
Acceptance that we could improve efficiency
Cannot carry on in the Current State
Massive investment and change programme
Capital etc
Infrastructure
Service redesign - Lean Thinking
10. Start of Lean Journey - June 2002
Gwent IT Services - “an image of the NHS”
Increasing demand outstripping resource
Rapid technology change
“Intelligent” & vociferous users
Bottlenecks / Delays / Waits
Unpredictable demand
Professional boundaries
Heavily process / transaction based
11. Pilot project IT installations - Analysis
It took 18 weeks from point of order to point
of installation (Average)
The whole process was ‘touched’ 154 times
in some way
4.5 miles were travelled excluding the
driving distance
93% time spent waiting somewhere or for
something
Large number of checks usually followed by
a wait
Less than 2% Value-add
12. Pilot project results
93% reduction in lead time for PC installation
80% reduction in PC stock held in Trust
80% reduction in PC stores
53% reduction in number of people in process
40% increase in productivity in first year
All achieved without extra resources
other than the time to make the change &
has been sustained for 4 years.
14. 2002 – 2005
Projects Commenced
0
5
10
15
20
25
30
35
40
45
2002 2003 2004 2005
86 5-day breakthrough events
30 Value Stream
56 5S Events
General Medicine
General Surgery
Community
Accident & Emergency
Radiology
Pathology
Pharmacy
Outpatients
Cardiology
HSDU
IT Services
Telephony
Recruitment
Financial services
Occupational Health
Ward 5S
District Nurse car boot 5S
Day Surgery
15. Some Achievements 2002 - 2005
Medical and Surgical Patient Journeys mapped
Waiting List reduction/elimination
Radiology National Award
Echos
Respiratory Medicine outpatients at Nevill Hall Hospital
Urology
A&E – Improved performance against 4 hour target
Reduction in rehab length of stay (Community)
Reduced Specimen turnaround time in Pathology
Etc.
16. Sept 2004
Core team confident that Lean approach worked
But:-
Projects taking too long
Waiting list developing for projects
Not getting the full benefits from the improvement
proposals
Not translated into Operational Management
Improvements were not ‘whole system’
Lacking powerful champions with staying power
Even successes were not repeated
17. Implementation
Many improvement projects fail at last hurdle
Lack of skills
Lack of time
Lack of commitment
Not everyone on board
People need to change to get the improvement
18. February – May 2005
Lean Masterclass
Chief Executive & Executive Directors, Senior
Managers and Chiefs of Staff
Voice of customer questionnaire from which 10
sessions were designed
Desired outcome was “How to deploy the Lean
Team in future”
1. Strengthen 5S program and deliver lots of small wins.
2. Combine VSM projects to date, to kick off a Scope debate with
Stakeholders to get buy-in and common way forward and next steps.
3. Investigate Implementation Performance using Six Sigma Blackbelt
project.
4. Deliver a big win by using a Value Stream transition approach in a high
impact area.
19. 6σ Implementation Investigation
20% of improvement proposals delivered on time and in
full (OTIF)
Discover reasons for this performance
By mapping our own process (involving original participants)
Undertaking FMEA
Developed 20 hypotheses for above level of performance
Tested hypotheses with original participants
Project Sponsors
Lean Facilitators
Improvement Implementers
Line Managers
20. Analysing the Hypotheses tests
Analysis undertaken on sample sets against
hypotheses from Potential Deep Causes to test
differences across groups
Question
WholePop
PopVSM
Pop5S
VSM
Complete
VSM
Late
VSM
Stopped
VSM
inProgress
5SComplete
5SLate
5SinProgress
VSM
Sponsor
VSM
Facilitator
VSM
Implementer
5sSponsor
5SFacilitator
5SImplementer
5SLineMgr
1 x x x x x x x x x x x x x o x x x
2 x x x x x x x x x x x x x o x x x
3 x x x x x x o x o o x x o o x o x
4 x x x x x x x x x x x x x o x x x
5 o x o o o O x O o o o o o o O o O
6 x x x x x o x o x x x x x o x o o
7 x o x o x o o o o o x o o o x o o
8 o o o o x o o o o o o o x o o o o
9 o o o o x o o o o o x o o o x o o
1 0 x x x x x o x x x x x x x o x o o
1 1 x x x x x x x o x x x x x x x x o
1 2 x x x x x o x x x x x x x o x x o
1 3 x x x x x o x x x x x x x O x x x
1 4 x x x x x o x x x x x x x o x x o
1 5 x x x x x o x x x x x x x x x x o
1 6 x x x x o o x o x x o x x o x o o
1 7 x x x x x o x o x x x x x o x x x
1 8 x x x x x o x x x x x x x x x x x
1 9 x x x x o x x o x x o x o o x o o
2 0 x x x x o o x o x o o x o o x o o
2 1 x x x x x x x o x o x x o o o o o
2 2 x x x o x x o x o o x o o x x o o
2 3 x x x x x o x x x x x x x x x x x
2 4 o x o o o o o o o o o o o o x o O
2 5 x x x x x x x x x x x x x o x x o
Theories Identified within Questions
No
Standard
Process
Change Of
Priority
Lack Of
Understanding
What "It" Is
Selection/
Deselection
No
Deployment
Strategy
Not enough
Time - P/T
resource
Lack Of
Operations
Management
Skills
Q1. Do you understand the purpose of the Lean Programme within the Trust? X X
Q2. Do you understand what it entails in terms of time and resource for the Programme to be fully effective? X X X
Q3. How involved have you been in planning VSM and CANDO projects? X X
Q4. How clear has communication been about the projects? X X X
Q5. Do you believe that the changes proposed by these projects are worthy of the effort required to implement improvements? X X X
Q6. Do you believe that adequate recognition/reward is being provided to accomplish effective implementation of these projects? X
Q7. How compatible do you believe the approach of these projects is with existing organizational values? X X X X
Q8. Do you believe that key individuals and professionals are genuinely supportive of the Lean Programme? X X X X
Q9. Do you believe that project participants are adequately briefed prior to the start of projects? X X
Q10. How confident are you that the organizational resources, required for the Lean Programme to be effective, will be made available? X X X X
Q11. What level of improvement do you expect these projects to deliver? X X X X
Q12. Do you believe that the amount of time to implement proposals is adequate? X X X X X X
Q13. Do you believe that daily work patterns were adequately considered when planning these projects? X X X X
Q14. Do you believe that the changes identified by these projects will have any negative impact on aspects of peoples’ jobs? X X
Q15. How meaningful to you is the Lean Programme? X X X X
Q16. How well do you think that mistakes made during implementation will be tolerated? X X X X X X
Q17. Do you feel confident that the projects are planned and delivered in a standard way? X X X
Q18. Do you believe that the skills and knowledge necessary to implement these projects are available? X X X
Q19. What level of respect and trust do you have for the sponsor(s) of these projects? X X
Q20. What level of respect and trust do you have for the facilitator(s) of these projects? X X
Q21. What level of respect and trust do you have for the implementer(s) of these projects? X X
Q22. How much stress are you currently facing in your job? X X
Q23. Does the Lean Programme represent any threat to your personal interests? X X
Q24. If improvements are abandoned or not fully implemented, how difficult do you feel it will be to reverse the effect? X X
Q25. Do you believe that operational management deficiencies will be exposed by the Lean Programme? X X
Totals 17 11 14 8 11 13
Totals 7 5 4 2 3 7
41% 45% 29% 25% 27% 54%
•Hypothesis Accepted for 10
questions
Green Accept/Red Reject
21. Conclusion – Reasons for Current State
Lack of Standard Processes
Lack of Measurement Systems for
Control/Improvement
Variation in understanding what ‘IT’ is
Resource shortages/distraction
Lack of understanding of capacity
Using existing day to day management systems to
implement
Changing Priorities
22. Future State (Our Current State)
30 day cycles for all projects
Sufficient manpower to deliver 30 day target
Ops Management for each project and the
programme including targets and measures of
progress
Focussed on the Gemba, improvement is part of
everyone’s day job
Authority to make changes
23. Create an E2E Lean Exemplar
We want to align every bit of work that is done, up and down, through
and across the organisation so that the patient flows through the
process from end to end with minimal interruptions and with a supply of
skill, expertise, materials and information that exactly meets demand.
Pathology DoctorsA&E
Start Discharge
Patient Journey
•Place where people can see all processes aligned
•Manageable size to experiment
•Place where people can learn how to make it work
•Patients receive safe treatment on time every time
Make this FlowRadiology Ward Pharmacy
24. Exemplar…Caerphilly DMH… Scope
1. 4 Acute Wards.
2. Pharmacy
3. Radiology
4. Pathology
5. Physiotherapy
6. Speech & Language
7. Occupational Health
8. Occupational Therapy
9. Theatre
10. A&E
11. Outpatients
12. Administration
13. Endoscopy
14. Catering
15. Works& Estates
16. Cardiology
17. Medical Records
18. Hotel Services.
19. Dietetics
20. Birth Centre
All we need to do is to create
smooth flowing Patient
Journeys matching up
perfectly with smooth flowing
provision processes.
26. Current State Summary
Distance Travelled = 314.55 km
Time Taken = 6 days 2hrs 40 min
Cycle Time = 323 mins
Value added Time = 7 mins
Number of people = 24 -26
Change in form = 5 types
Different Transport = 9 types
Ratio of Value added time to
non-value added time:
= 7 mins
= 2.2%
323 mins
28. Replenishment Transition
Transition plan made up of (in first phase).
• Establishing “supermarkets” for consumables at Ward level.
• At the Exemplar site (CDMH)
• First ward 24/04/06 . Last ward started 12/7/06.
• Implemented 3S as foundation of this
• Last 2S is the Operations Management to keep it going.
• Sort out the ordering process.
• Started pilot on Re Order Points 21/6
• Roll out to all 4 wards 24/7
• OTIF target for all orders
31. £ 30 000 here from 3 General
Medicine Wards:
We have more than 100
other wards to do
32. Has it made a Difference?
M o nt h
£Pounds
03 0701 0711 0609 0607 0605 0603 0601 06
5000
4000
3000
2000
1000
0
_
X =899
UC L=1764
LC L=34
1 2
I C ha rt of M AU D is pos a ble s S pe nd
UCL = 4438
X = 2193
BEFORE AFTER
58.4% Reduction in Mean monthly spend
33. Has it made a Difference?
£Pounds
AfterBefore
4000
3500
3000
2500
2000
1500
1000
500
Boxplot of MAU Disposable Spend Before/After
Two-sample T test
C3 N Mean StDev SE Mean
1 11 2193 936 282
2 5 899 238 107
Difference = mu (1) - mu (2)
Estimate for difference: 1293.89
95% CI for difference: (636.67, 1951.11)
T-Test of difference = 0 (vs not =): T-Value = 4.29
P-Value = 0.001 DF = 12
34. Has it made a Difference ?
24th April - 54,000 items were counted on Bedwas Ward.
Of which 11,734 items were out of date.
The definition of error is that an item is out of date.
Therefore chances of picking out of date product is
approximately 1 in 5
Or in absolute terms 217,296 defects per million
opportunities (2.22 Sigma process)
But we check!!! (How good is check? Even if we can)
Evidence is Human eye dependent has 85% effective (at
best).
Now all items in date. Pr = 0 beyond 6 sigma quality level
36. Further Opportunities for Improvement
1. Problem Boards - expansion to all activities
2. Signs and Walls (Sort & Set)
3. Nurse Stations (Sort & Set)
4. Kitchen Areas (Sort & Set)
5. Arrest Trolleys (Sort & Set)
6. Daily Clean2Check Roll out:
7. Set up kit required by ward to Sustain this: Tape, Laminator, etc…
8. Container types changes: Less opportunities for errors
9. Expiry date checking into Clean/Check activities:
10. Set up Managers Clean2Check schedule:
11. Pharmacy Stock areas & processes; Apply same rules to them
12. Other Stock areas & processes: Apply same rules to them
13. Infection Control issues:
14. Day by hour planning for ward staff: Everyone knows what is expected
15. Rostering process investigation:
16. Design a Put away processes:
17. Stock transfer to Unit 13 process invention: To prevent throw away.
18. Budget control simplification: Better control
19. Train the Trainer program (roll out): So can speed up.
20. Introduction of Kanban: Reduce all this ordering admin.
21. Mixed load deliveries: reduce number of trucks.
22. Quality, Delivery, Safety, Morale, Cost Visual management for ward/unit.
Can apply the same
standard approach to
these
37. Patient Journey: CDMH Sep 2006
• Determine patient cohort to design experiments around
– Stratify incoming demand Map all steps on Patient Journey
– Design E2E Future State Journey
• Test ward data collection system
• Analysis of data and methods.
• Set target discharges by ward for week by day
• improved rate (TAKT)
– Manage the performance v these targets. (Patient OTIF board).
• Introduce Control charts (and visual measuring system for
wards) using 5S.
• Daily management meetings and problem solving on
discharge performance.
• Design & Implement Transition plan to Future State.
Safe Treatment, On time, Every time
38. What we have learnt…
Lean methodology is compatible with Healthcare
systems
It’s not an easy quick fix
It’s not about projects – it’s the about the “day job”
Needs support and time from senior managers
Need to be prepared for a long haul
Need to be self sufficient in staff who can do this
39. Gwent Lean Journey
2006 2007 2008 2009 2010
Create Exemplar
E2E Patient Journey Create Flow
Service Provision Process Create Flow
Replenishment/Support Process Create Flow
Staff Self Sufficient
Extend outside of Organisation Create Flow
Synchronize to the Rhythm