04.01.11
Improving pathways
The big question facing healthcare leaders is how to deliver more effective services for less. Four years ago, NHS Lothian began a journey which would see them do just that, reports Richard Mackillican
It began when NHS Lothian brought in the services of an outside contractor who specialises in process and service improvement and who gave the board a set of skills which meant that they would then be able to train more staff in the ways of service improvement.
Libby Tait, associate director of modernisation at NHS Lothian, says between 700 and 800 staff have now been trained to understand Lean methodology and about the same number have been involved in projects.
“In terms of delivery, we carried out six projects in year one, fourteen projects in year two and a similar number in year three. These are our big impact projects, but we also have a lot of staff carrying out a variety of smaller Lean related projects.”
NHS Lothian’s first project was focused on CT scanning, as part of the cancer pathway, which at the time had a maximum wait of up to 21 weeks.
“Through a programme carried out with our Lean contractor, we were able to reduce that to a maximum of six weeks. After a number of months we were able to get this down to between four and five weeks through finding extra capacity in the system.”
By using Lean methodology in this improvement programme, NHS Lothian managed to save around £50,000 in extra staff wages and through pooling waiting lists they were able to generate an additional 500 scans using their existing equipment and staff.
“Our main emphasis was on reducing our cancer waits across the organisation and using Lean helped us to do this by reducing batching and waste. The process would involve firstly meeting and interviewing stakeholders then developing process maps, which outline which parts of the process add value to the patient. Wherever we found a process which didn’t add value, we could then analyse that with the staff to see if we could either make the process more efficient or get rid of it all together.”
Some of the improvements which the team recorded included clinicians being given dedicated time to report scans so that scans were not being taken and then waiting to be reported, as this only added waste to the process.
“This meant that staff had to be available to make the reports and that they would not be interrupted by disruptive things like phone calls. This also involved organising the medical secretaries so that they were ready to type up the report, once it had been dictated, as quickly as possible. This in turn meant that we reduced the turn around time from the original few days to only 24 hours.
“Reducing the turnaround time was crucial to adding value to the process, because it is only when the appropriate clinician has the report in their possession that the scan can truly add value for the patient.”
Another problem which NHS Lothian dealt with through their service improvement programme using Lean was delayed discharges and trying to get people out of hospital more quickly.
“This included analysing how we use day hospitals and then moving to use them more for urgent assessment, rather than planned assessments - adding extra capacity to the system.”
This enabled doctors to book in patients to be assessed at the day hospital, rather than them having to be admitted to hospital.
“Another project looked at how the integration with the downstream beds worked and was able to release expensive acute bed days by reducing the length of stay for some patients.”
NHS Lothian was also able to make improvements to its mental health service waiting time by changing administrative processes which resulted in them releasing 24,000 hours of psychologists’ time back into patient care.
“When this time saving is costed out, it is the equivalent of over £400,000 of psychologists’ time going back into the health service.”
Although these improvements and savings are extremely impressive, this doesn’t mean that the hard work has stopped at NHS Lothian.
“The staff are now capable of removing waste from the system,” says NHS Lothian medical director Dr Charles Swainson. “To put this into context, some of the most important steps which were taken to bring down radiology waiting times came from the secretarial staff.
“They told us that they were fed up with clinicians dumping lots of incomplete reports in their in trays because the system had not allowed for proper reports to be carried out. They were then involved in a project which, over a couple of days, streamlined the whole system to enable us to reduce the turn around time to a quarter of what it was.
“This whole process is about reducing waste and inefficiency and involving frontline staff in that process is essential.”
How did they deal with staff who can be rather suspicious when first approached with a new idea?
“We overcame this by thoroughly explaining why we were going through this process of service improvement, using solid data to back up our points. Then we found that as we went through the Lean process, for example a kaizen event, the staff really started to become engrossed in what is going on.”
Dr Swainson says staff soon realised that these kind of Lean events are a great way for them to get their ideas across to senior management, sometimes solving problems which had been causing trouble for years.
Success in service improvement is about listening to your frontline staff. They are the people who deal with the same problems every day and will have a fair understanding of the reasons why certain processes don’t work.
Managers need to ensure that they create effective channels of communication with their staff to ensure that inefficiencies within the system are identified and dealt with as a team and as quickly as possible.
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