A lean year for the NHS?

Applying lean thinking to healthcare in the UK could deliver long-term improvements and gold standards that decades of political initiatives have failed to provide, says Dr Paul Glossop

It will mean a radical rethinking of working procedures in hospitals and elsewhere and a long term commitment by management at the highest levels. But if we are to emulate the success of lean in the American healthcare sector it will be worth all the effort. In fact I firmly believe that we must instigate lean across the NHS now, for several urgent reasons.

There is the 18-week target, 31-day cancer pathway, four-hour A&E wait, foundation trust assessments - and no doubt much more to come. Many trusts will hit these through initiative lists while some have projects to design ways of working that should sustain 18 weeks. In other organizations, the driver for change may be pressure to resolve deficits. Whatever the challenge, the truly lean organisation can harness the ideas of its people to deliver even better care and world class performance. I am excited by the potential to help practitioners to spend more time with their patients, indeed to “end waiting, change lives”.

However, whilst a growing number of NHS managers and clinicians understand the basic concepts of lean, I would argue that the UK doesn’t yet have a hospital, PCT or SHA which has fully implemented the five lean principles described by Womack and Jones ten years ago (1):

1. Specify value in the eyes of the customer

Clearly, clinical care is value adding. Sitting in outpatients for up to eight hours to receive a total of 60 minutes of care is not. Booking and rebooking of appointments is not. These non-value adding activities occur because whilst the links in the chain do their best for the patients, they find it hard to make improvements that cross departmental boundaries.

2. Identify the value stream

Sounds like jargon, but it means mapping patient journeys right through primary and secondary care before launching into rapid improvement events. This is essential to co-ordinate improvements across outpatients, diagnostics, theatres, wards and social care. The focus is likely to be on support activities as much as the actual clinical pathway. Value stream mapping takes a very broad view and is conducted by people involved in every step of the way, including the patient!

3. Make value flow…

Essentially, do everything possible to dismantle barriers to flow. It means removing artificial variations in elective workloads caused by historical clinic templates. It means continuing to challenge length of stay so ward occupancy averages no more than 80 per cent and theatres run without cancellations or delays. It means eliminating opportunities for error in documents so lab tests don’t need to be repeated and medical records can be found.

4. …so the customer can pull.

Consignment stock of orthopaedic components is a great example of this. Other hospitals are experimenting with pulling patients through A&E into wards as beds become available. The trick here is to get flow in place first – otherwise it will all break down in three weeks and the doubters will say, “I told you we don’t make cars.”

5. Continuously improve in pursuit of perfection

Not a caption on an American motivational poster but having an awareness of what perfection is, a recognition that we are not there and a robust improvement system that lets healthcare professionals improve their processes every day.

Across the UK there are already good examples of lean taking place - the theatre manager setting up a day case ward with every patient having a planned discharge time (not date, time!); the clinician championing one-stop outpatients/pre-op/listing; the receptionist creating new ways of working to reduce patients’ wait.

At Wirral University Teaching Hospital Foundation Trust, lean techniques revealed that 4.2 per cent of elective surgery procedures – all of them routine – made up 52 per cent of the work. By prioritising this routine work and re-thinking the processes behind it (for example, combining in-patient ward with day case ward on quiet weekends), day patient throughput rose by 33 per cent and the number of in-patient urology beds fell by 28 per cent, which alone meant annual savings of £147,000.

In the UK, The Manufacturing Institute has been helping a number of NHS trusts to go lean and reap the benefits.

University Hospitals of Morecambe Bay NHS Trust embarked on its lean journey in 2007, targeting three interlinked areas at Lancaster Royal Infirmary - medical records, medical secretaries and outpatients – where they found duplication of effort, overstuffed filing systems, badly-designed working areas and wasted internal capacity which impacted on patients, consultants and staff. With full management support lean techniques were introduced, and initial results include easier and quicker retrieval of medical records, more patients seen, fewer missing clinic notes – and elimination of a backlog of unfiled reports that under the previous system would have taken 130 weeks to clear.

Meanwhile, Stockport NHS Foundation Trust - one of the first 10 foundation trusts in the NHS – launched is lean-based Stockport Improvement Programme at Stepping Hill Hospital, initially training 15 ‘SIP champions’ drawn from across the organisation before tackling problems in several departments. Radiology upped its throughput by 15 – 50 per cent.

At Royal Devon and Exeter NHS Foundation Trust, using ‘single piece flow’ in the dispensary for prescriptions reduced the average picking time from 1.5 hours to 20 minutes and showed how to reduce inventory by £150,000 without affecting supply.

NHS organisations that have started down the lean path are already achieving positive results, emulating their healthcare cousins across the Atlantic.

For several years, the US healthcare industry has been applying lean working practices to hospitals, clinics and related healthcare providers with very favourable results. One outstanding example is provided by the Virginia Mason Medical Center in Seattle, Washington. Using lean tools and techniques, the Virginia Mason production system improves healthcare delivery, promotes a culture of seeking zero defects and creates a more affordable product. The results of this lean programme include slashing infection rates to almost zero, freeing up over 13,000 sq ft of space, reducing staff walking by 50 miles a day and vastly improving patient satisfaction.

Christina Saint Martin, vice-president governance and administration, and Michael Rona, former president of Virginia Mason, will be joining The Manufacturing Institute’s team this year to help to spread best practice throughout the UK healthcare sector.

Mr Rona has said: “The potential gains of using lean in the NHS are huge, with the key benefit that improvements will be sustainable in the long term because lean embeds a new culture of continual checks and improvements. The NHS has a long history of trying to improve services against aggressive goals, but it lacks a sustainable methodology to achieve those goals and avoid the need to constantly set new ones. The Toyota Production System has been proven time and again to succeed across a wide range of industries. While people are not cars, everything we do in healthcare – procedures, appointments, bills – is a process. The trick is how to do it better.”

Reference (1) Lean Thinking: Banish Waste and Create Wealth in Your Corporation (paperback) by James P. Womack and Daniel T. Jones; ISBN 978-0743231640 Dr Paul Glossop is a lead practitioner for The Manufacturing Institute, which is spearheading the application of lean tools and techniques to the healthcare sector

www.manufacturinginstitute.co.uk