bringing lean to life

Bringing Lean to Life

HEART LUNGCANCER DIAGNOSTICS

Making processes flow in healthcare

STROKE

NHSNHS Improvement

ContentsIntroduction - what is the problem in healthcare? 4

What is Lean? 6

A3 thinking 7

An example A3 report 8

The importance of data and measures 10

Example statistical process control (SPC) charts 11

Current state value stream mapping 12

Designing the future state value stream map 14

Standard work to produce high quality every time 15

Visual management 16

Identifying waste 18

Making value flow 20

Understanding pull 21

Understanding Takt time 22

Using 5S to improve safety 23

Plan Do Check Adjust (PDCA) cycle 24

Continuous improvement 25

Value stream mapping symbols 26

Acknowledgements 27

Bringing Lean to Life - Making processes flow in healthcare

3

Introduction - what is the problem in healthcare?We all come to work to do our very best - toachieve what we are capable of and to addreal value for our patients and ensure clinicalexpertise is supported by process excellence toenable healthcare processes to flow at therate of patient demand - no one wants to getit wrong. Healthcare teams are dedicated andskilled professionals who are often underpressure to do their best and work terrificallyhard - but often with inadequate processes.

Each year, the National Patient Safety Agencyhandles over one million reported medicalincidents in England alone. Figures illustratethat approximately one in every ten patientsare unintentionally harmed by their healthcareproviders. Most of these are not necessarilythe result of medical errors or poor clinicaldecisions, but are caused simply by the waythe system has been set up.

The ‘processes’ are to blame not the people

Often, there is ambiguity in how certain tasksshould be performed – so people work it outfor themselves to secure the best outcomeand get the job done. However, whilsteveryone develops their own bespokesolution, the variations introduced by differentpeople can be significant and harmful.

Departments continue to work hard and inisolation to ensure they improve their servicesand practices. However, such silo’s oftenmean that any good practice is lost whichincreasingly impacts upon the patient flowbetween services.

This booklet provides a basic introduction andoverview of Lean; the culture, principles andtools to understand, tackle and resolve issueswithin healthcare. It is not intended as acomplete guide to implementing Lean as amanagement system.

…the best hope forsaving lives lies inraising performance…”

“

NHS Improvement has been using Lean withclinical teams and has proven that it canimprove quality, increase safety, reduceturnaround times, increase efficiency andproductivity, improve staff morale and reducecosts. The NHS Improvement websitewww.improvement.nhs.uk has details ofnumerous case studies and recommendedreading.

Together we can’t afford not to change!


Atul Gawande, Better, 2007

4

“

5

Improvement usuallymeans doing something thatwe have never done before.”Shigeo Shingo

What is Lean?Lean was a term coined by researchers whenstudying the philosophy of the managementsystem in place at Toyota and the culture theyhad created amongst their workers to improveprocesses which led to the final product.

The researchers noticed five key steps were inplace to deliver what the customer wanted atthe highest quality and safety level possible,with the lowest associated costs from aworkforce which also had high morale.

The five steps were:

1 Specify value

2 Identify the value stream steps

3 Make value flow

4 Supply what is pulled by the customer

5 Continually improve and strivefor perfection.

In short, Lean is about building the problemsolving capabilities of the team to produceexperts who can perform daily work to thebest standard – everyday.

These key steps and the necessary tools toimplement Lean are explained in this booklet.


initiate PULL in linewith customer demand

Make valueFLOW

Problemsolving

People andPartners

Process

Philosophy

Solve problems byroot cause analysis

Respect, challengeand grow them

Ref: Liker, 2004

Introduce Standard WorkingRemove Waste

Set Up Visual ManagementEliminate BatchingIdentify Root Cause

Specify VALUE fromthe customer viewpoint

Pursue PERFECTIONin quality & quantityby continuousimprovement

Identify theVALUE STREAM

and removewaste

Eliminate waste.Right process willdeliver right result

Long-term thinking.Continuousimprovement

6

Lean is the continuous andsystematic elimination ofwaste

A3 thinkingAll Lean improvement work should begin withA3 thinking as it is a methodical approach toproblem solving.

Lean is primarily the description of amethodology to routinely solve problemseveryday so that the work is delivered tospecification. A3 thinking is the rigorousapplication of something known as the Plan,Do Check, Adjust (PDCA) approach.

The PDCA (PDSA) cycle provides a means ofconducting safe experimentation or a numberof trials to see the effect of any changes madein a bid to make improvement (see page 24).

The A3 report is literally a one-page document(11 x 17 inch [A3] sheet of paper) that recordsthe agreed points of discussion in a systematicway.

The structure of the A3 (see pages 8 and 9)takes individuals and teams through theprocess of agreeing the problem statement orissue, reviewing and analysing the currentstate and identification of a desired futurestate with a subsequent action plan for anyagreed actions.

Describing the entire process from currentstate, through analysis and onto future state

just on a single sheet of paper requires conciseinformation. This prevents excessive amountsof information being overwhelming,misinterpreted and incorrect conclusions beingreached.

The best A3s:• are handwritten in pencil with minimum text• contain pictures/diagrams to convey theproblem

• are concise and hold all the relevantinformation

• represent the shared consensus• do not need verbal explanation• are agreed by the entire team.

Top tips

• Teach, coach and use A3 thinking as a standard tool for all newprojects and problem solving

• Complete the A3 report with a pencil (corrections can be made followingfurther consensus with the team)

• This is a working document – each box should contain only theinformation that has been agreed

• Resist the temptation to ‘type’ up the report. If an electronic version isrequired, consider taking a digital photograph instead to share acrossthe wider organisation.

The A3 represents the shared consensustowards solving the problem. As a document,it encourages reflection on the learning thathas taken place and ensures that a consistentmessage is discussed and scrutinized.

For an A3 to work, the whole team needs tocontribute and agree.

7

An example A3 report


NHSNHS ImprovementA3 Lean Improvement

Department Date: Author:

Team members: Agreed by: Version:Define the problem/opportunity: (Why are you talking about it? What are you trying to solve/improve?)

Current state: (What happens now? Be visual - value stream map, graphs, facts and measurements etc.)

Future state: (What will it look like? Be visual - future state value stream map)

8

Waiting times for turning around cervical screening samples are protracted. This could potentially delay anytreatment required by the woman.

Cervical Cytology Department May 2010

9

Action plan

Results and measures:(What was your PDSA cycle? How long did you run it for? What data did you collect before andafter the change? What did you find? Add charts, tables, and cost benefit analysis)

Action - what, why and how? Who? When? Progress status (ie completed, in progress)Goal: (State the specific target(s). State in measurable or identifiable terms)

Waste identified: (Transport, Inventory, Motion, Automation, Waiting, Overproduction, Overprocessing, Defects, Skills.)

Root Cause Analysis: (What is the root cause of the problem? Use fishbone/cause and effect diagram, five why analysis)

Next steps: (Are there any remaining issues/problems? Is there any further follow up required?)

100% in 14 days50% in 7 daysZero defects

Transportation – up to 15 days ‘lost’Waiting – average TATs of 41 days from specimen taken to report issuedDefects – 40% defects received from primary care

Levelled workloads are required in laboratory.This is being taken up by laboratory subgroup – April 2010.

Transport groupreduced deliverytimes by anaverage of 12days

Establish core transport group RG Jan 2010 Completed

Implement zero tolerance policy of defects from 1˚ Care AS Jan 2010 Completed

Reduce backlog

Goal V actual measures GF Mar 2010 Ongoing

Capacity and demand GF Feb 2010 In progress

Reduce batch sizes from 16 to 8 AS Mar 2010 In progress

Introduce water strider AS Apr 2010 Ongoing

Zero tolerance policy hasreduced defects from 40%to 20% within 6 weeks,with a further reduction in10% anticipated withinnext 2 weeks

The importance of data and measuresIn healthcare, we are used to taking clinicalmeasures such as temperature, pulse, bloodpressure, respiration rates, urine outputs etc.in order to understand if the condition isgetting better or worse. To understand if theprocess is improving, we can use statisticalmethods, programs and charts todemonstrate, for example, the number ofpatients on a waiting list or turnaround times.

Data and measures are important todemonstrate and factually prove that changehas occurred or needs to occur. Whether thechange was a success or a failure, you stillneed to demonstrate it!

Before starting your Lean journey, it isessential to understand what your aim is andwhat are your measures.

Measures might include:• numbers of patients on waiting lists• staff numbers• hours worked• patient experience• waiting days• staff morale• turnaround times• number of incidents or defects• number of complaints• cost• quality

Once you have agreed your aim andmeasures, you will need to collect currentstate data. It isn’t always easy to collect datafor this baseline. If you can’t get theinformation from the electronic systems, youwill need to collect the information manually.

Manual data collection might feel like hardwork at the time, but if you don’t collect thisinformation before you start:a) how will you know what your current

state looks like?b) how do you know where to focus

your efforts?c) how are you going to know if you

have made an impact?

When you have made a small incrementalchange using the PDCA (PDSA) approach,review your original measures and collect thesame data to see if your trial has made adifference.

Bringing Lean to Life - Making processes flow in healthcare10

It is not satisfactory to say “it feels better”,“I think it’s better”, “it seems better” -establish factual data and measures.

Data analysis doesn’t need to be complicated.Line graphs, bar charts, scatter graphs andstatistical process control charts can all beused to visually show the before and afterstatus (see examples on the following page).

Once the raw data has beenconverted into a graph, theoutliers become visible and rootcause analysis can be carried outto achieve your aim

End to end turnaround times

Waiting two extra days forphysiotherapy assessment

January February March April May

Example statistical process control (SPC) charts

Waiting one extra day fordischarge medication

Waiting four extradays for CT scan

Waiting ten days forcancelled surgery

Waited for lab results, interventionaldiagnostics and delayed ward round

11

SPC showing root cause analysis

Each data point is a consecutively referred patient. This data demonstrates that the process changes implemented has had a positive effect. You can use data to identify the root cause of the problem in the process.

Current state value stream mappingA critical starting point in any problem solvingor improvement work is to map the situation(process) in its current state. This should bedone as a team and then added to the A3document.

One of the tools used to capture the currentstate or ‘as is’ performance is the value streammap (VSM).

What is value?Value can only be defined by the endcustomer. In healthcare the customer isusually the patient. Value is any activity thatdirectly contributes to satisfying needs of thepatient. Any activity that doesn’t add value isdefined as waste.

Value stream mapA current state value stream map is a visualrepresentation of all the actions currentlyrequired to deliver a product or a service.

If you don’t know where you are going,you will probably end up somewhere else.”

“


How to make your value streammap (VSM):• Establish key start and stop points (agreethe scope)

• Document the key process steps• Add the data box below each process step(cycle time, batch size at each step, numberof defects/errors at each step and thetrigger that starts the process step)

• Add a timeline at the bottom of your VSMand below each process step document thecycle time (how long does it take to processaccomplish the task?)

• On the timeline between each process step,add the delay which occurs between eachstep!

• Show all information flows• Work out the total time taken to get apatient through the value stream by addingall numbers in the timeline

Dr Laurence J Peter,Founder of The Peter Principle

12

The map documents work activity and themovement of information across the entirepatient pathway from origin to final point ofdelivery.

• Calculate the ‘touch time’ - the timeactually required to get the patient throughthe value stream if seamless care were beingdelivered (i.e. all waste removed)

• Agree the value added (VA) activities andthe non VA activities, identifying those‘must do’s’ (i.e. business essential but notreally adding value directly to the patient)

• Determine the percentage of VA activities -don’t be surprised if this is very low!

Remember• Keep your value stream map high level,don’t focus on the detail

• Only focus on the main pathway – whathappens 80% of the time?

• Collect true and accurate information bywalking through the pathway yourself.

Why map the value stream?• The mapping process is a powerful tool tolook strategically at your process and quicklyidentify opportunities for improvement.

• Non value adding activities i.e. wastes canbe identified and documented.

• This provides a basis for a discussion around‘what should be the process?’

Report issueVerifyTypeDictate reportScanBook scanData entry

InpatientsOutpatients

Vet referral

36 36 409 64 61 136 13

CT = 120 sec

C/O =

defects = %

Avail =

Batch = 130

CT = 60 sec

C/O =

defects = %

Avail =

Batch = 100

CT = 60 sec

C/O =

defects = %

Avail =

Batch = 50

CT = 15 min

C/O =

defects = %

Avail =

Batch = 32

CT = 60 sec

C/O =

defects = %

Avail =

Batch = 12

CT = 60 sec

C/O =

defects = %

Avail =

Batch = 12

CT = 15 sec

C/O =

defects = %

Avail =

Batch = 15-100

CT = 60 sec

C/O =

defects = %

Avail =

Batch = 100

120 60 60 900 60 60 15 6033325 33325 37861 59245 56468 12589 21291

77

70 per day(352 per week) 1 x daily

Touch time = 1335s (22.2mins)

Flow time = 709703 secs

Current state value stream map

13

See page 26 for the value stream mapping symbols

Designing the future state value stream mapOnce you understand the current picture ofwhat really happens throughout the valuestream, you can begin to agree what needsto happen and then analyse the gap betweenthe current and future states.

From your current state map you will be ableto identify where the significant problemsoccur. This might be the most prevalent waitsand delays, the largest amount of work inprogress between process steps or wherethere is considerable duplication.

There are four main techniques to designyour future state. Just remember ECSS!

• Eliminate• Combine• Simplify• Sequence

Where possible, try to eliminate any processsteps. If it isn’t possible to eliminate anysteps, look to combine steps. Aftercombining, consider where the system can besimplified. Once steps in the system have

been have been eliminated, combined andsimplified, review the sequence of events topromote efficiency.

When designing a future state, the takt time,the removal of waste and the introduction offlow must be considered – all of which arediscussed in this booklet.

The aim is to produce a service where eachprocess step links seamlessly to the next, inthe shortest amount of time at the highestquality and safety by a group of staff with ahigh morale.

Once the future state Value Stream Map iscompleted, it is then essential to reviewmeasures, analyse the gap between currentand future state and then agree an actionplan of PDCA cycles to trial the changes.

Be clear about the purpose beforedesigning the process – then, organisethe people!

Issue reportScanningBooking

GPsInpatientsOutpatients

409 136

CT = 120 sec

C/O =

Uptime =

Avail =

Batch =

CT = 90 min

C/O =

Uptime

Avail =

Batch =

CT = 60 sec

C/O =

Uptime =

Avail =

Batch = 12

240 9017 60

3786 125897

70 per day(352 per week)

1 x daily

FIFO

Future state value stream map

14 Bringing Lean to Life - Making processes flow in healthcare

Standard work to produce high quality every timeThere are three key elements tostandardised work:

• Takt time – how fast we should beworking

• Work sequence – the order that workshould be done

• Work in progress – defining theworking inventory to makeabnormalities obvious.

It is important to understand that standardwork is not static. Standards are actually thebasis for subsequent improvements. Once abetter method is found, the team shouldagree on the new standard, update theprocesses, procedures and visual managementand then ensure that it is adopted by all.

Standardisation should exist for every processincluding meetings, health and safetyprocedures, budget reports, audits, allpaperwork etc.

15

One of the Lean tools which promotestandardisation is 5S, the foundation forsafety and quality.

Standardised work:• Ensures safety and maintains high qualityand efficiency

• Ensures process stability and thereforerepeatability

• Allows us to assess if we are in control,ahead or behind schedule

• Preserves the organisational expertise• Allows us to identify and rectify problems• Provides a gauge by which we can errorproof for the future

• Gives us a baseline from which tomeasure improvement and continuallystrive for a better way

• Provides a basis for employee training.

Lean is about the people who perform thework. It’s about developing people to be ‘thebest’ – utilising their ‘expert talent’ andestablishing excellent ways of working.

Standard work is about establishing outof all the possible ways, the best workmethod of conducting a task and thenensuring that everyone always works tothis gold standard.

The gold standard should have the leastamount of waste, with the highest qualityand safety. These standard procedures createstability and consistency in the system toproduce high performance results every time.


Visual managementVisual management is everywhere, from thegreen man at the cross the roads, to thenumbers on the front of busses, petrolindicator lights in cars, a water level on akettle, to a cricket scoreboard. These visualindicators allow us to easily understand thesituation and take action where necessary.

Visual management is a simple, yet highlyeffective way of indicating what shouldhappen (by setting a standard) and whatis actually happening in the workenvironment.

At a glance, colleagues, supervisors, managersand visitors to the area should be able tounderstand the process and see what is undercontrol and what isn’t without having to ask aquestion.

Visual management allows teams to:

• See the work in progress

• Recognise flow stoppers

• Assess inventory levels

• Identify defects

• See deviations from the standard

• Enable interventions

• Improve safety.

16

There are two types of visualmanagement:

• Visual display, which is the provisionof information

• Visual control which is associatedwith action.

Both these types of visual management gainthe maximum amount of information, withouthaving to leave the work environment oraccess a computer system.

Visual management provides the knowledgeand certainty to make staff and patients livessafer.

Visual management can be used to answerthe following questions. Give some thoughtto how you could use visual management toanswer the following questions in your workarea:

1 Are we up to date with the work?2 What are our three biggest problems

in the area and what is being doneto resolve these problems?

3 How do you know that your ideashave been listened to?

4 How can you tell who is trained toperform each task?

5 Is there daily accountability? Who isit today?

6 How do you know where staff are –breaks, annual leave, study leave?

7 How do you know if the stock hasbeen ordered?

Cytology request form: Visual management has been sentto smear takers to ensure zero defects on the request form.

Communication boardThe board keeps all team members up to date withthe recent data, changes and improvements made,5S scores, team ideas which includes action takenagainst the ideas.

17


There are two other recognised wastes:the waste of unused staff creativity (skills utilisation)and automating an already inefficient process:

Elimination of wasteThese wastes can be remembered byremembering the name TIM A WOODS (thiscame from Lean office at Cooper Standard,Plymouth UK).

TRANSPORTTransport is the unnecessary movement of

items and materials. How often do we see peoplemoving items (notes, reports, slides, supplies etc.)from one locality to another - and back again?Stand for a short while in a hospital corridor andobserve these activities - you’ll be surprised.

For example:• Moving drugs, samples, equipment, suppliesexcessively around the hospital

• Moving paper notes excessively• Transporting samples from one location orsite to another.

Remove the waste of transport by:• The elimination of process steps and hand offs• Co-locating departments/processes/supplies• Introducing work cells.

INVENTORYInventory is work in progress and stock. A

common problem is lack of space. By reducinginventory and by combining process steps, staffhave more space to carry out duties in a saferworking environment.

How frequently do you run out of supplies only tofind another department has stock?

For example:• Over-ordering - consumables, paper• Different batch sizes at each step• Overstocked medication on wards• Overstocked items in the supplies departmentbecause it was cheaper to buy in bulk withoutthinking about the costs of storage, stock takingand distribution

• Staff hiding extra stock for ‘just in case’.

Remove the waste of inventory by:• Implementing the Lean tool of 5S• Establish visual systems (kanbans) - aids visibilityfor stock counting

• Understand what is needed to keep up• Establish first in first out principle with demand -implement ‘just In time’

• Keep stock audits correct and current.

MOTIONThe waste of motion is any unnecessary

movement by people. This is mainly related topoor ergonomics, bending, stretching, movingitems etc.

How many times during your shift do you have toget up and walk to use a certain piece ofequipment just because it is located in the wrongplace? How often do you find yourself searchingfor vital items because they were not put back inthe right place?

For example:• Poor layout of wards/surgeries/departments/laboratories

• Searching for equipment or stock• Location of printers, faxes, copiers andcomputers

• Looking for information and people.

Remove the waste of motion by:• Introducing standard layout• Introducing a standard way of working• Developing flow in work cells• Initiate and sustain 5S.

Eliminate Minimise

Maximise

Unnecessarywaste

Necessarywaste

Value

T

I M

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The elimination of waste is the maincharacteristic of Lean. Waste iseverything that doesn’t add valueto the patient or process.

There are three types of work:1) Value add – When you are adding valueto the patient/process (e.g. prescribingmedication, providing physiotherapy,reporting an image)

2) Necessary waste – This is when you arenot adding value but it is a necessary step.(e.g. incubation in a microbiology laboratory,vetting requests prior to radiologyexamination)

3) Unnecessary waste – This is where youare not adding value and these steps could beremoved (e.g. walking to get or find items,waiting for consultants/medication).

Researchers have found that there are sevenmain wastes and over the years other wasteshave been added.

Identifying waste

AUTOMATINGAutomation of poor processes just serves to

automate waste. The poor understanding of workcontent and takt time can result in purchase oflarge pieces of expensive equipment that actuallyhinders flow of the overall process. The result, is anexpensive poor process!

For example:• Did radiology reporting times reduce whenPACS was implemented?

• Do samples get turned around any quicker withtrack systems purchased and implemented inbiochemistry?

WAITINGThe waste of waiting usually transpires when

there is an in balance of process steps which alltake different timings or the batch sizes aredifferent in each process step. The waste ofwaiting has a direct impact on flow as waitingcreates a ‘stop-start’ process.

Do you ever find yourself becoming frustrated andyour working day hindered because you arewaiting for a colleague to do their role or for amachine to finish?

For example:• Waiting for shared equipment (telephone/computers)

• Staff waiting for machines, deliveries, othermembers of staff

• Waiting for decisions• Waiting for others at meetings• Patients waiting for appointments, in emergencydepartments/clinics, waiting for discharge

• Samples waiting in a batch to be analysedin the laboratory

• Requesters waiting for results or medication.

Remove the waste of waiting by:• Leveling the workload and balancing operations• Eliminating or reducing batch sizes• Eliminating hand-offs.

OVER PROCESSINGThe waste of over processing is all the things

we do that don’t add any value to the process -producing excess.

How many tasks are repeated simply because wedon’t have a system to ensure it serves the needs ofthe patient or process throughout the wholehealthcare journey?

For example:• Duplicate testing/inappropriate testing• Duplicate data entry• Duplication of checking cards/slides• Excessive bed moves• Excessive paperwork• Manual checking electronic data

Remove the waste of over processing by:• Eliminate non-value added steps• Combine process steps and paperwork• Simplify tasks

OVER PRODUCTIONOver production is about doing too much, too

soon or ‘just in case’.

How many times do we complete the sameinformation and have to file it or store it in manydifferent ways? How often do we see queues buildup in one part of the process because the previousdepartment kept producing more, regardless ofwhether subsequent processes were ready or couldcope?

For example:• Making more than, faster than, earlier than isrequired by the next process step

• Duplicate entries in medical records• Paper copies of results sent along with anelectronic copy

• Repeating tests before next test scheduled.

Remove the waste of over production by:• Remove all unnecessary paperwork• Reduce batching - establish a visual system• When the process can’t flow, introduce‘pull’ systems with buffers and kanban’s.

DEFECTSDefects are all the errors that compromise

quality, safety, cost and staff time. Make it right,first time, every time.

Do you tolerate errors by reworking someone else’smistakes? How often do you accept incomplete orinaccurate requesting information?

For example:• Wrong patient, wrong test, wrong procedure,wrong form

• Inappropriate/inadequate referrals• Chasing inadequate patient information• Repeated checking• Medication errors.

Remove the waste of defects by:• Making the system mistake proof• Introducing a zero tolerance to defects• Introduce standard work to ensure the sameprocess is completed every time ensuring highquality process repeatability.

SKILLS UTILISATIONEvery department has unused staff potential.

There is someone in every department that knowsthe issues and has the possible solutions. If onlythey were asked, listened to and action was taken -the people doing the job are the experts.

Unused skills and creativity also include highlyskilled staff undertaking duties that do not reflectthere skills, e.g. band 8 staff routinely performingband 3 duties.

How many times do we see supervisors/managersroutinely booking appointments?

The intellect and skill of staff should be used toguide the continuous improvement of proceduresand processes. The inclusion and insistence of staffin problem solving and decision making will alsosupport recruitment, retention and improve morale.

A

W

O

O

D

S

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Making value flow

Flow is the continual movement of valueadding activities from the beginning tothe end of the value stream.

Processes which add value to the patientshould not be held up by any non valueadding steps or waste in the system. Wasteand non-value-adding steps create a ‘stop-start’ effect which prevents the flow ofvalue adding steps the value stream.

Systems which promote batching hinder flow,create waste and queues. Batching can beseen across healthcare. For example, wardrounds completed at the same time of daycauses a batch of work for the nursing staffand every support service that follows i.e.Pathology, Radiology and Pharmacy.

To promote flow, batches should be reducedand where possible removed to achieve theoptimal flow - one piece flow. When flow isachieved, it becomes easier to spot problemsand patients are no longer unnecessary heldup in the health system.

All Lean tools work towards promoting flow.Visual management can be used to highlightflow stoppers. Standard work can be used toensure processes are repeatable and reliable,with no variation. 5S can support workplaceorganisation ensuring no time is lost trying tofind the right tools to do the job.

20

Flow and pull work to keep the entire valuestream moving. Flow is the goal, but onoccasion, flow may not be achievable and inthese situations the concept of pull can beintroduced to respond to demand.

Pull is a short term notion to gain controland process stability.

Pull works with buffers and kanbans:

BufferA buffer is a clearly defined holding area atthe interface between two processes allowingpatients, paperwork, information or items towait for a defined amount of time betweentwo process steps. A buffer could be awaiting room, empty beds, trolleys or chairs,or even a space for stock and inventory.Buffers are actually a ‘waste’ and should onlybe introduced when flow is not possible andthe process needs to be controlled and

Understanding pull

Flow where you can, pullwhere you must”

“

Jeffery K. Liker, The Toyata Way, 2004

stabilised. Over time, the buffer should begradually reduced and ultimately removed.

KanbanKanban signs/signals are a form of pull. Thesevisual signs are mechanisms for the patient orinternal customer (ie ward nurse, radiologist,discharge staff) to say “I am ready for more.”There are many different forms of Kanban –an empty container, a box, a marked area, anempty shelf or a card.

21


Takt time is simply the rate at which weneed to work to keep up with demand.

The calculation for takt time is:

This sounds too simple, yet the ability toachieve takt is the fundamental question towhether the system is set up to deliver what isrequired. If teams can not achieve takt, wastein the system needs to be removed and eachprocess step needs to be levelled to ensuretakt is met.

Worked example:A scanning department is open and staffedfor seven hours per day has a daily demand of60 referrals.

Understanding takt timeEvery seven minutes a patient should movethrough the scanning process – this is thetakt time.

The cycle time is the time it takes to actually‘do’ the task and the aim is to match (wherepossible) takt time.

If the cycle time is going to be identical to orless than takt, all the non value addingactivities need to be removed from eachstep. Only when the non value addingactivities have been removed from each stepshould additional resources be considered.

As you can see from the graph on the right,the team would possibly need to eitherextend scanning hours or secure additionalscanning resource. The team would alsoneed more than one consultant reportingin order to achieve takt.

Available work time

Demand= takt time

7 hours

60Takt time =

420 min

60= 7 min

20

15

10

5

0Vet Protocol Book Scan Report Type Verify Issue

Takt

22

Minutes

5S has traditionally been thought of as beingjust a ‘tidy up’, but when approachedproperly it is much more than that.

5S is the basis for standardising workand is used to improve efficiency byeliminating waste, promoting flow,improving staff morale and mostimportantly improving safety.

Ultimately, it is about making theprocesses and environment safe.

Using 5S to improve safety

Sort‘When in doubt, move it out!’

1) Remove everything from the defined area.2) Only return what is necessary for the daily duties.3) Discard any broken, unnecessary items – e.g. clutter, old equipment, old

unused paperwork.4) Move any items that you are unsure of into a holding bay for a team decision.5) If shelving or cupboards are not used or required, remove them too – this will

prevent unwanted items being stored there.6) Items necessary to complete the job need to be ‘set in order’ 2S

Set in order‘A place for everything and everything in its place.’

1) Give every item a location - Items used on a regular /daily basis need to be placedwithin arms length / accessible location- Items used on a weekly basis should be stored on a shelf or in a cupboard in thework environment.

- Items used on a monthly, quarterly or annual basis should be stored in anappropriate location – possibly outside the work area.

2) Mark off (with electrical tape or permanent marker) and label each location

5S - What does it mean? How do I do it?

Shine‘Lean means clean’

1) Clean the area – it should be easier to clean now you have removed the clutter andevery item has a location.

2) Develop a plan where cleaning is incorporated into the daily routine.

StandardiseCreate a consistent approach for carrying out tasks and procedures.

Sustain‘Sustain all gains through self discipline’

Make 5S become a way of life by:1) Practicing and repeating the process.2) Educating all staff3) Linking 5S directly to the day job4) Empowering staff to improve and maintain their workplace.

When employees take pride in their work and workplace it can lead to greater jobsatisfaction and higher productivity.

23

Change on a large scale can be daunting butyou should not let that deter you.Before implementing a full proposal forchange a PDCA cycle (sometimes calleda Plan, Do, Study, Act (PDSA) cycle) canbe used. A PDCA (PDSA) cycle willprovide the opportunity to test out anidea on a small scale, without risking toomuch.

New ideas should be introduced only aftersufficient testing (or evidence) on a smallerscale has proven to have a positive effect.PDCA (PDSA) cycles allow us to introduce anidea in a safe, controlled way which will haveless resistance, be less disruptive and use lessresources. By building on the learning fromeach PDCA (PDSA) cycle, new processes canbe introduced with a greater chance ofsuccess.

Plan, Do, Check, Adjust (PDCA) Sometimes called a Plan, Do, Study, Act (PDSA)


P - PlanThis is the most important part of the process.• What you are planning to trial?• What are your objectives?• Who is needs to be involved/informed?• How are you going to do it?• How long will the trial run?• How are you going to measure improvement?• What is your communication plan?

D - Do• Test the change and collect the data

C - Check• Analyse the data you collected in the ‘plan’and ‘do’ phase

• Discuss outcomes with colleagues?• What went well?• What went wrong?• Did anything unexpected happen?• Could the process be improved?• If the trial didn’t go to plan, what was theroot cause?

PLAN

DO

ADJUST

CHECK

P

DC

A

P

DC

A

PD

CA

PD

CA

24

A - Adjust• If the trial did not improve the process,could you treat the root cause in your nextPDCA (PDSA) cycle?

• If the change was a measurable success,adopt and spread the improvement in yourPDCA (PDSA) cycle.

Continuous improvement is the final leanprinciple, which is to strive for perfectionthrough continuous improvement. This isdone by embracing the Lean philosophyand tools as described in this booklet.

The staff are a fundamental part of Lean. It isimportant to develop staff and give them thecapability, autonomy and empowerment tosolve the problems as they encounter them ona daily basis. Teaching and expecting rigorousproblem solving by all staff is the onlysustainable way to strive for perfection.

Communication is imperative to develop staffto continually improve the process.A five minute daily meeting for all staffaround a central communication board todiscuss real time issues relating to waitingtimes, quality, safety, morale and cost isessential to ensure the work for that shift/dayproceeds as planned.

For Lean to be a success, the Lean cultureneeds to be accepted and embraced by all.

When implemented, the tools and techniquescan have an immense beneficial effect, but tobe sustainable, they need to be applied with aLean culture.

The key to success issmall, daily incrementalimprovements.

Act like a sponge - soakit up and squeeze outimprovements everyday

During your Lean journey, don’t lose sight ofperfection and what perfection means:

• the right patient journey• the right support services when theyare required by the patient

• the highest level of quality and safety• no defects or incidences• delivered at the right price• delivered by a staff group with highmorale and pride in their work.

25

Continuous improvement

26

Data entry

Process Step

Cycle time

Batch size

Defects

Trigger

=

=

=

=

Data Box

GP Surgery

Outside Agencies

Pull

Push

W

Wait/delay

i

Inventory

People “Go See”

Transport Ambulance

Load Levelling Paper Flow

FIFO

First-in First-outSequence

ElectronicInformationTransfer

InformationBursts

Supermarket

Buffer

Work Cell

Value stream mapping symbols


Acknowledgements

27

This document has been written in partnership by:

Lisa SmithNational Improvement LeadEmail: [email protected]

Zoe SmithNational Improvement LeadEmail: [email protected]

NHS Improvement3rd Floor | St John’s House | East Street | Leicester | LE1 6NB

Telephone: 0116 222 5113 | Fax: 0116 222 5101

www.improvement.nhs.uk

NHS Improvement

With over ten years practical service improvement experience in cancer, diagnosticsand heart, NHS Improvement aims to achieve sustainable effective pathways andsystems, share improvement resources and learning, increase impact and ensure valuefor money to improve the efficiency and quality of NHS services.

Working with clinical networks and NHS organisations across England, NHSImprovement helps to transform, deliver and build sustainable improvements acrossthe entire pathway of care in cancer, diagnostics, heart’ lung and stroke services.

Delivering tomorrow’simprovement agendafor the NHS

NHSNHS ImprovementHEART LUNGCANCER DIAGNOSTICS STROKE

©NHS Improvement 2010 | All Rights Reserved | May 2010

bringing lean to life

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