creating a vision of lean healthcare at bolton
TRANSCRIPT
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Global Lean Healthcare Conference25-26th June 2007
Creating a Vision of Lean Healthcare at Bolton
David Fillingham, CBEChief Executive
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• The state our hospitals are in today
• What would lean healthcare be like?
• Making it happen– Building the vision– Redesigning patient journeys– Changing the physical layout– Creating new behaviours
• Reflections and lessons
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Today’s hospitals…….
• Wards and clinics are untidy and chaotic• Queues are everywhere• Processes are unplanned and of byzantine
complexity• Professional tribes and departmental silos
abound• Physical layouts and “monoliths” prevent a
smooth flow of work
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The Fantasy Patient Journey
Information
Clinical assessment
Investi-gations
Clinical decision
Admi-ssion
Treat-ment
Dis-charge
Patients
Information
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The Real Patient Journey
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WaitingTransportation/Motion
Waiting Waiting
Waiting
Waiting
Waiting
Waiting Waiting
Waiting
Waiting
Mistakes
Mistakes
Mistakes
UncoordinatedActivity
UncoordinatedActivity
UncoordinatedActivity
UncoordinatedActivity
UncoordinatedActivity
UncoordinatedActivity
UncoordinatedActivity
Stock
Stock
TransportationTransportation
Transportation
Transportation/Motion
Transportation/Motion
Transportation/Motion
InappropriateProcessing
InappropriateProcessing
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Patients suffer:- • Confusion and anxiety• Delays and cancellations• Harm• A sense of helplessness
Staff suffer:-
Taxpayers / Funders suffer:-
Today’s Healthcare
• Frustration and stress• Low morale• High sickness absence
• Waste and inefficiency• A “bottomless pit”
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What would Lean Healthcare be like?
• Processes purposely designed and managed• A smooth flow of patients, staff and information• A physical layout to support flow and make
problems visible• Evidence based practice for every single patient• Every staff member a problem solver every
single day
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Imagine a hospital with…….
• No needless deaths• No needless harm• No delays• No waste• No feelings of helplessness
(Don Berwick)
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Making it Happen in Bolton Hospital
• Building the vision of a lean hospital• Patient journey redesign• Changing the physical layout• Creating new behaviours• Making it a daily activity
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The beginnings of a lean journey……
• Began in August 2005• 856 (525 individuals) staff actively engaged in 85 Rapid Improvements Events • Early results promising
- Pathology: 40% floor space savingBlood Sciences processing time cut from hours to minutes
- Laundry: Capacity increase of 25%- Cataract Surgery: throughput increased by 30%- Trauma: 36% mortality reduction; 33% reduction in length of stay
• We now know just how much we don’t know!
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Bolton Hospital – Pen Picture
• Based in NW England close to Manchester• 3,200 staff• Busy emergency hospital:-
– 100,000 ER attendances– 59,524 IP/DC admissions p.a.
• 692 beds• General medicine, general surgery, paediatrics,
obstetrics, orthopaedics• £150million turnover
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A Vision of aLean Hospital
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Our “EVSA”(Enterprise Wide Valuestream Analysis Event)
• Full week event for 50 senior Directors and Clinical Leaders
• Carried out after one year of ‘trying stuff out’• Current state: strategic context and hands on
mapping• Future state• How to get there
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Hierarchy of Value Streams at Bolton Hospitals
Medical Conditions
Simple Complex
Condition Groups
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8 Step High Level Flow:-
ImplementCare Plan
Follow UpAnd Review
History &Examination
DifferentialDiagnosis
Investigations AnalyseResults
DefinitiveDiagnosis
DevelopCare Plan
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• Simple: one condition; likely to require only one medical discipline; little need for interagency working: likely to be day case or relatively short stay.
• Complex complicating co-morbidities; needs multidisciplinary team; demands close interagency co-operation; likely to require a longer hospital stay and after care
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Condition GroupsSIMPLE• Heart and Chest• First Contact• Musculoskeletal• Gastro• Eyes, Head & Neck• Simple Surgery• Women’s Care• Children• Skin
COMPLEX• Adult• Women• Children
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Conditions• We used Runners Repeaters and Strangers to
identify commonly occurring conditions and outcomes analysis to spot high risk groups
• Examples include: Cataracts, Joint Replacements, Stroke
• For each condition we are mapping the patient journey and developing a plan for improvement
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Emerging Thinking about the Hospital’s Future State
• Put senior decision makers and diagnostics at front end of process
• Stream quickly into simple and complex• Monitor closely and have ability to switch between streams• Create condition based work teams to put ‘simple’ patients
into flow:-– Reduce batch sizes; identify flow stoppers; relocate diagnostics into
the flow; create standard work and enforce it; establish pull systems; set up visual management
• For complex patients – create “one decision flow”; strengthen multidisciplinary team working; intensify support; co-locate where feasible
• Re-think “clinical effectiveness” to be the basis for standard work
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Lean Tools/PrinciplesMove awayfrom batching,Backlog andQueues.
ReduceVariation & Complexity
Clear to See:StraightenSweep & CleanSafetyStandardiseSustain
Create signalsTo pull patients.Obvious whenSomething empty
1 PIECE FLOW
STANDARDWORK
6 SPULL
SYSTEMS
“ability to see the process”
VISUAL MANAGEMENT:
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Patient Journey Redesign
Our aim is to redesign all of the patient flows through the Hospital.This will take time!
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We started with Trauma…• 9 month programme• 1 week Event (VSA) to create Vision and
Plan• 6 week long events (RIEs) and many
JDIs• Significant results
– 36% mortality reduction– 33% length of stay reduction– 42% paperwork reduction
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Value Stream Analysis: Current State for Trauma
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Value Stream Analysis: Current State for Trauma
• Spaghetti Diagram• We walk miles when we
shouldn’t have to• Things are not where they
are needed (if they are even there at all)
• We have to look for the sick patients and they can be anywhere
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Value Stream Analysis: Current State for Trauma
• Hand Off Chart• 197 handoffs to
discharge a patient!
• Duplication• Frustration• Huge source of
potential error
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Action! Creating the TSU
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Standard work layout for each bed space and the admin area Greatly reduced documentation in standard format and sequence
Floor markings for location of key equipment to aid flow
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Our next priorities are
• Cataracts• Joint Replacements
• Stroke • Acute abdomens
Mainly simple
Mainly complex
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Changing the Physical Layout
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PathologyBefore & During photos
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Designed for Flow
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Physical Layout
• Declutter and prepare for flow with 5S• Co-locate linked processes• Creation of “complex care” wards with
intensified multidisciplinary team support• Decentralisation and downsizing of
diagnostics• Development of Visual Management
approaches
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Creating New Behaviours
“It’s easier to act yourself in to a new way of thinking than it is to think
yourself in to a new way of acting”
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• Engaging clinical staff
• The power of the rapid improvement event
• Learning and development framework
• Making BICS a daily activity
• Developing a “brand”: the Bolton Improving Care system (BICS)
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Pathology Lean Management System
• Standard work– For workstations– For leaders
• Visual controls– Production control boards– Metrics– Workstations
• Daily accountability processes– Daily meetings of work groups– Daily meetings of supervisors
• Training– Awareness– Tools
• Discipline– Persistence & determination
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From this……
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…..To this
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Bolton PathologyBlood Sciences staff
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Pathology – Bottom Line• 40% Floor space saving• Turnaround times cut• £300K (10%) more income with
4.5 (2%) fewer staff
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Reflections and Lessons (1)
• Healthcare is an underperforming industry. We are failing our patients, staff and funders
• Our hospitals are full of committed and skilled staff who are struggling to deliver good care within a set of broken processes
• A lean mindset and methods offer the hope of transformational improvements
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Reflections and Lessons (2)• We need to:-
– Develop our vision for a lean healthcare system– Radically redesign the physical environment and the
flows of patients, staff and information … “big leaps”– Embed continuous improvement in the daily work of
healthcare staff … “thousands of small steps”– Have courage, persistence and determination …
… it will be a long journey