Implementing Lean at Mayday Ben Gowland Director of Service Improvement and Quality Chris Bryant Assistant Director of Service Improvement
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Implementing Lean at Mayday
Ben GowlandDirector of Service Improvement and Quality
Chris BryantAssistant Director of Service Improvement
Mayday
2900 employees£160M turnover700 beds130,000 A&E attendancesKey organisational issue - financial deficit
05/06 - £5.8M end of year deficitIn ‘recovery’ for over 12 monthsTurnaround Director in post
Lean in the context of financial recovery1. Gaining credibility2. Lean techniques that work3. Positioning Lean4. Implementing Lean5. Moving forward: value and income
1. Gaining Credibility
Bold, relevant goals – 100 beds (not optional extra)Built links with work already undertakenBoard approved service improvement planService improvement steering group
100 beds/Length of Stay:Key Elements
Day surgery
Elective surgery
Emergency surgery
Emergency short stay
Emergency Admission
Length of Stay
0
50
100
150
200
250
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57Length of stay (days)
Num
ber o
f pat
ient
s
Short Stay Medicine Length of Stay
MEDICINE
4
5
6
7
8
9
Jul-0
4
Aug-
04
Sep-
04
Oct-0
4
Nov-0
4
Dec-0
4
Jan-
05
Feb-
05
Mar-0
5
Apr-0
5
May-0
5
Jun-
05
Jul-0
5
Aug-
05
Sep-
05
Oct-0
5
Nov-0
5
Dec-0
5
Jan-
06
Feb-
06
Mar-0
6
Apr-0
6
May-0
6
Jun-
06
Jul-0
6
Introduction of new assessment and short stay model
100 beds – Length of Stay
Length of stay reduced to 4.8 days (06/07 ytd)Day case from 52% to 81% Admission on day of surgery in every specialityElective LOS 5.1 to 4.2 DaysTheatre Utilisation from 75% - 90%Non elective surgery (excluding T&O) 6.4. to 4.9 daysT&O 14.4 to 12.0 daysMedicine 7.8 to 5.3 DaysClosed 106 Beds
18 weeks and process flows:Outpatients – 0-4 follow ups
0
5000
10000
15000
20000
25000
30000
35000
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
Number of Follow Ups
Num
bers
of P
atie
nts
Process based Pathways:
Diagnosis Treatment Post Treatment
Know / Decision made Pre-Op Surgery No or limited Follow up
Don’t Know / Decision not made
Medication, Chronic Management, No Treatment
Ongoing Follow UpHigh Volume (60%): Feels Difficult
Fairly High Volume (40%):
Feels Achievable
Multiple visits and tests
2. Lean Techniques that work
Identifying wasteFirst in First Out (FIFO) and small batches5S
Case studies!
Sterile Services Cut Cancelled OperationsFindings
Sterile services struggled to meet demand on their services resulting in disruption to theatres on most daysInstruments were unavailable, lost, in transit, or otherwise elsewhereTheatre lists were run on Saturdays to make up for lost time.Time taken to recycle and instrument was highly unpredictable due to the behaviour of queues in the system. This variation encouraged inappropriate prioritisation of sets as urgent. Mismatch in the capacity and demand rates. Every morning Sterile Services faced a backlog from the evening before.Shift patterns at Sterile Services were not matched to demand from Theatres, so people were overwhelmed at times.
Understand the process
Prioritise issues/actions
Data collection
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25
50
75
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250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Out of Theatre Into SSD Wash
Action Plan
Sterile Services Cut Cancelled OperationsOutcomes
More consistent turnaround time for sets resulted in better availability of sets and less time lost preparing Theatres lists, improving the performance of the wider hospital in many ways.Almost eliminated chasing, phone calls and the use of the prioritising system as all sets are returned with 7 hours instead of any time up to 2.5 daysClearer procedures for pickups from Theatre prevented overloading and missing instruments were found fasterFirst In First Out of Queues not Piles made the time to recycle a set predictableWorkplace organisation (5S) of the store room in Theatres and work area in Sterile Services resulted in less time spent looking for sets.Sterile Services and Theatres now understand each other’s needs.No additional resource required
0
25
50
75
100
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250
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Out of Theatre Into SSD Wash
Demand Before
Demand After
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Out of Theatre Into SSD Wash
Sterile Services Before
Sterile Services After
Lean Material Management – ITU and TheatresFindings
Clinicians had to spend time searching for items that should be spent treating and caring for patients. Two senior nurses spent two to three hours each ob average per week on materials management.It was difficult to see what was in stock as cupboards were not labelled, storage space was not identified, and there was no designated space for items.The system wasn’t designed around usage levels which resulted in too much stock of low usage items and not enough stock of highly used items.Managers spent time signing requisitions for the same materials repeatedly.
Lean Material Management – ITU and TheatresOutcomes
Simplified the ordering process – 80% stock items (from 46%)Reduced paperwork by 35% through increasing stock items which saved up to 6 hours per week of clinician time.Applied Workplace Organisation (5S) in ITU stores which was sorted and reorganised during the Rapid Improvement Event.The implementation of the first visual stock management and 2 Bin System within hospitals in South West London.Reduced stock levels of certain consumables by up to 70% therefore improving cash flow.No additional resource required.Staff understand how to apply Lean.Identified clinical and managerial champions of change
ITU Stores Before
ITU Stores After
Visual Stock Management2 Bin System
Catering for Patients Just in TimeFindings
Meals were not taking longer than the core standard of 20 minutes from being served to being delivered to patients.Trolleys, full of food, lose temperature waiting in the kitchen for a porterAt ward level it was difficult to identify patient names on menu cards on meal trays.Complaints from patients, relatives and carers concerning food temperature.Wards unprepared for meal time, every meal, every day, came as asurprise!
Catering for Patients Just in TimeOutcomes
From 16 audits over 2 weeks, wards with designated staff achieved 100% meals served within 20 minutes. Wards without designated staff achieved less than 60% served within 20 minutes.All wards have a meal distribution schedule so they know when all meals will arrive.The kitchen is managing food distribution so that meals remain hot for as long as possible.Catering Services and Ward staff now understand each others’ needs and how they can assist each other.Staff understand how to apply LeanIdentified clinical and managerial champions of change.
3. Positioning Lean
Lean? Service Improvement? Modernisation?Different positioning for Board and front line teamsLink to turnaround teamUnionsConstant battle not to be given ‘solution implementations’
4. Implementing Lean
Service improvement and operations18 Weeks – service improvement or operational target?What is ‘Board level support’?Middle management resistance (no funding for project managers)
5. Moving Forward: Value and Income
Changing landscape of NHSPbRPatient ChoicePractice Based Commissioning
Much clearer Trust focus on incomeLeads to financial requirement to define value from patient and GP perspectiveLinking patient choice unit and service improvementClear route away from service improvement as cost cutting tool
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