lean healthcare - streamlining patient journeys

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Lean Thinking in Healthcare Doing the Right Thing for Every Patient Lean Enterprise Academy Copyright Lean Enterprise Academy 2010

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Page 1: Lean Healthcare - Streamlining Patient Journeys

Lean Thinking in Healthcare

Doing the Right Thing for Every Patient

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 2: Lean Healthcare - Streamlining Patient Journeys

Making Hospitals WorkHow to improve patient care while savingeveryone’s time and hospitals’

resources

by Marc Baker and Ian Taylor

Foreword by Daniel T. Jones

A Lean Action Workbook from the Lean Enterprise AcademyVersion 1.0 Goodrich UKMay 2009 www.leanuk.org

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 3: Lean Healthcare - Streamlining Patient Journeys

Exercise: Check Current Awareness

• Split in to Groups.• Objective: Each Group to give 5 mins

Presentation:• What is Lean?• Where does it come from?

• Use Flip charts. • Presentation must be on 1 Flip chart.

• Timescale: 20 mins

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 4: Lean Healthcare - Streamlining Patient Journeys

Lean Principles

Overview

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 5: Lean Healthcare - Streamlining Patient Journeys

Lean Thinking• Specify what creates value from the

customers perspective • Identify all steps across the whole value

stream• Make those actions that create value

flow• Only supply what is pulled by the

customer just-in-time• Strive for perfection by continually

removing successive layers of problems

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 6: Lean Healthcare - Streamlining Patient Journeys

Our Observations in Healthcare

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 7: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

Activity DailyBed Meetings (x3 daily) 2.25Morning Handover 0.508:15 - 08:30 (x2 weekly) 0.2ECIP 0.3Facilitators 1:1 (x1 fortnight) 0.35DHM 1:1 0.35Emergency Pathway 0.2Facilitators Meeting 0.3Corridor Meeting 0.25Hants Conf Call 0.5PAU 1:1 0.25MAU meet 0.2Op Commisioning Meeting 0.41:1 with Ed 0.05DGM DSN Meet (x1 fortnight) 0.15HMC 0.15COO Meet 0.15St Mary's transitional grop 0.075Nursing Workforce Committee 0.075Duty Managers Update 0.5DMOP Meeting 0.2Seeing Facilitators 1Duty Manager 1.6LEA 0.4Contract Review 0.05Bleep Holder 230 day review meetings 0.5Actions from Bed Meetings 1Ad Hoc Meetings 1Appraisals 1.11:1 with Mary 1Hospital Walkabout 1Discharge Lounge 0.25Update for DMTs 0.375E-Mails 100/Day 2Report Writing 0.6Budget Management 0.1Performance Managing 0.2DHM Induction 3

24.575

The Diary Exercise – Daily Personal Capacity V’s Daily Organisational Demand……. This is real data and absolutely typical. But What’s causing this?

Copyright Lean Enterprise Academy 2010

Page 8: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

The Five Point Checklist

•Simple? Can we explain it, so it is easily understood?

•Measurable? Can we measure it?

•Agreed? Who will be responsible and do they accept this responsibility?

•Relevant? What is its contribution?

•Trackable? Can we see the status at a glance whenever we want to?

Copyright Lean Enterprise Academy 2010

Page 9: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Target Focus No. ProjectsCost Improvement 300

4hr Performance Improvement 132Safety & Quality 4418 Week Access 39

TOTAL 515

Page 10: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

The Five Point Checklist

•Simple? Can we explain it, so it is easily understood?

•Measurable? Can we measure it?

•Agreed? Who will be responsible and do they accept this responsibility?

•Relevant? What is its contribution?

•Trackable? Can we see the status at a glance whenever we want to?

Copyright Lean Enterprise Academy 2010

Page 11: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

SCORECARD

StakeholdersResourceUtilisation

ManagementProcesses

Innovation& Learning

A B C A B A B A B C D

15 15 3 4 11 9 23 1 3 2 1

20 21 9 14 36 22 92 11 11 7 9

Scorecard – Descriptive Stats

Categories

Strategic Objectives

Specific Goals

Measures

Categories = 4

Strategic Objectives = 11

Specific Goals = 87

Measures = 252

Page 12: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

The Five Point Checklist

•Simple? Can we explain it, so it is easily understood?

•Measurable? Can we measure it?

•Agreed? Who will be responsible and do they accept this responsibility?

•Relevant? What is its contribution?

•Trackable? Can we see the status at a glance whenever we want to?

Copyright Lean Enterprise Academy 2010

Page 13: Lean Healthcare - Streamlining Patient Journeys

The BIG Problem

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 14: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

1. Compliance with 4 hour emergency access performance target.

2. Compliance with the 18 week scheduled service access targets

3. Cost reduction. Middleton was six months into the financial year and was already £6.5 million overspent year to date.

4. Medical length of stay (LoS). A previous benchmarking survey had revealed that Middleton’s medical patients were staying in the hospital longer than the national average.

5. Rates of Hospital Acquired Infections (HAI) such as MRSA and C. difficile were also higher than the national average.

Middleton’s Story

Middleton General has 5 big problems:

Lean Enterprise Academy

Page 15: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

The BIG Problem – Consructing the Matrix

A&E

Acc

ess

Cost

Med

LoS

HA

Is

A&E

Access

Cost

Med LoS

HAIs

Problems

Impa

ct (√

orX

)

Lean Enterprise Academy

Page 16: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

The BIG Problem – Looking for Leverage

A&E

Acc

ess

Cost

Med

LoS

HA

Is

A&E

Access

Cost

Med LoS

HAIs

Problems

Impa

ct (√

orX

)

Lean Enterprise Academy

EG if we fixed our A&E 4 Hour

Target problem

Would this also fix any of the

other problems for free

Page 17: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

A&E

Acc

ess

Cost

Med

LoS

HIA

s

A&E

Access X

Cost X

Med LoS X

HIAs X

Problems

Impa

ct (√

orX

)

EG if we fixed our A&E 4 Hour

Target problem

Would this also fix any of the

other problems for free

The BIG Problem – Looking for Leverage

Page 18: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

Medical LoS - The BIG ProblemLean Enterprise Academy

Page 19: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

Medical LoS - The BIG ProblemLean Enterprise Academy

Page 20: Lean Healthcare - Streamlining Patient Journeys

Seeing the Process:

What is our Current

Condition?Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 21: Lean Healthcare - Streamlining Patient Journeys

The Current State

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 22: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

From the total LoS of 7.6 days only 1.1 days receiving diagnostics or interventions (14.6%)

AND

Don’t get hung up on the cure time debate – it’s the triangles that we’re going for after all

Lean Enterprise Academy

Page 23: Lean Healthcare - Streamlining Patient Journeys

Don’t worry if yours ends up looking like this !!!!

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 24: Lean Healthcare - Streamlining Patient Journeys

Staff/Departmental Availability

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 25: Lean Healthcare - Streamlining Patient Journeys

Nursing Availability to Discharge from Wards

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 26: Lean Healthcare - Streamlining Patient Journeys

Thinking Differently

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 27: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy"Everything that can be invented has been invented.”

Charles H. Duell, Commissioner, U.S. Office of Patents, 1899.

"We don't like their sound, and guitar music is on the way out anyway.”President of Decca Records, rejecting The Beatles after an audition, 1962

"That is the biggest fool thing we have ever done [research on]... The bomb will never go off, and I speak as an expert in explosives.”

William D. Leahy, U.S. Admiral, advising President Truman on atomic weaponry, 1944

Man will not fly for 50 years.”Wilbur Wright, American aviation pioneer, to brother Orville, after a disappointing flying experiment, 1901 (their first successful flight was in 1903)

"... good enough for our transatlantic friends ... but unworthy of the attention of practical or scientific men.”

British Parliamentary Committee, on Edison's light bulb, 1878

"The Americans have need of the telephone, but we do not. We have plenty of messenger boys.”

Sir William Preece, Chief Engineer, British Post Office, 1878

"Space travel is bunk.”Sir Harold Spencer Jones, Astronomer Royal of the UK, 1957 (two weeks later Sputnik orbited the Earth)

" 640k ought to be enough for anybody.”Bill Gates, 1981

Page 28: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

"X-rays will prove to be a hoax.”Lord Kelvin, British mathematician and physicist, president of the British Royal Society, 1895(?)

"Louis Pasteur's theory of germs is ridiculous fiction.”Pierre Pachet, British surgeon, Professor of Physiology at Toulouse, 1872

"The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise and humane surgeon".

Sir John Eric Ericksen, British surgeon, appointed Surgeon Extraordinary to Queen Victoria, 1873

"The abolishment of pain in surgery is a chimera. It is absurd to go on seeking it...knife and pain are two words in surgery that must forever be associated in the consciousness of the patient.”

Dr. Alfred Velpeau, French surgeon, 1839

Page 29: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2009

Waste

Lean Enterprise Academy

Page 30: Lean Healthcare - Streamlining Patient Journeys

Typical Mgmt Approach – Squeeze the Boxes

Why - Because they can’t see the Triangles

Necessary but non value adding35%

Value adding5%

Non value adding60%

Why not start here instead

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

Page 31: Lean Healthcare - Streamlining Patient Journeys

Process, obviously needs Re-designing but…….

Stability 1st

Then

Re-design

So what is stability & how do you get it…….

Some form of standardisation

Flow, Pull, Perfection systems

Copyright Lean Enterprise Academy 2010

Lean Enterprise Academy

Page 32: Lean Healthcare - Streamlining Patient Journeys

Scientific Operational Management

Our Definition:

Scientific operational management is a closed loop system that provides the Measures & Stability required to enable Safe Experimentation (Re-design) : It is Lean within the Day job!!! Very important but omitted by many!

Closed Loop employs strict PDCA whereby the Check frequency is at the appropriate pitch to enable the required adjustment to minimise variation in the process

The scientific setting of warning and action limits and the standardisation of the actions required to return to the desired condition – “I will not fail”

Copyright Lean Enterprise Academy 2009

Lean Enterprise Academy

It IS a Science…… BUT it’s NOT Rocket Science

Page 33: Lean Healthcare - Streamlining Patient Journeys

P lan D o

A ct C heck

Now

Grasp the Current State

The Abnormalityis Obvious

Gap

EffectCauses

The Possible CausesEffectCauses

The Possible CausesEffectCauses

The Possible Causes for Gap

Pareto Graph

Highest Priority

Pareto Graph

Highest Priority

Pareto Graph

Highest PriorityAction Plan

No. WhoAction

Action PlanNo. WhoAction

Plan

Target

The Scientific ApproachWhat links these components? A standard method

Copyright Lean Enterprise Academy 2010

Lean Enterprise Academy

Page 34: Lean Healthcare - Streamlining Patient Journeys

Plan for Every Patient Boards

By the Hour in ED

By the Day on Wards

Back to the FrontlineLean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 35: Lean Healthcare - Streamlining Patient Journeys

Pilgrim Hospital (Boston) – Medical Visual Hospital - Day One

3 Empty Beds, 12 Medically Fit, 5 Potentially Fit, 30% should not be in acute beds whilst MAU is full and patients are breaching in A&E – Bed Man are declaring No

Beds!!!!What would you do?

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 36: Lean Healthcare - Streamlining Patient Journeys

The Visual Hospital in action with the MPSLean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 37: Lean Healthcare - Streamlining Patient Journeys

Lean Enterprise Academy

Guess What This ‘lean’ stuff really works in

healthcare

Copyright Lean Enterprise Academy 2010

Page 38: Lean Healthcare - Streamlining Patient Journeys

Bottom Line Results:

Mean Medical LoS has reduced by 1.87 days (30%) from 6.23 days to 4.35 days within 32 days of change.

The Median Medical LoS has reduced by 1 day (25%).

LoS variation has reduced significantly

Huddersfield Royal Infirmary – Medical LoS

Patients in time order

Day

s Lo

S

620558496434372310248186124621

40

30

20

10

0

_X=4.35

UCL=10.12

LCL=-1.41

581 894

111

1

1

1

11

1

111

1111

1

1111111

1

1

111

1

11

1

111

1

1

1

1

1

1

1

1

1

1

1111

Patient LoS Before & After changes

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 39: Lean Healthcare - Streamlining Patient Journeys

Huddersfield Royal Infirmary – Emergency Surgery LoS

Bottom Line:

Mean Emergency Surgery LoS has reduced by 4.4 days (53%) from 8.3 days to 3.9 days within 48 days of changes.

LoS variation has reduced significantly.

Patient LoS Before & After changes

Lean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Page 40: Lean Healthcare - Streamlining Patient Journeys

Bottom Line Results:

Average LoS has reduced by 27.3% for Medical patients

and by 28.3% for Surgical patients

LoS variation has reduced significantly for both

And…..more of the Same at United Lincoln Hospitals TrustLean Enterprise Academy

Copyright Lean Enterprise Academy 2010

Patients in Time Order

LoS

(day

s)

476042843808333228562380190414289524761

200

150

100

50

0

_X=7.2UCL=19.8

LB=0

2471 6197Med Patient LoS Before & After changes

Patients in Time Order

LoS

(day

s)

2880256022401920160012809606403201

200

150

100

50

0_X=3.8UCL=8.5

LCL=-1.0

3908 6442Surg Patient LoS Before & After changes

Clinical improvement facilitator Victoria Newlands- Bentley told the Target: "All staff involved in the project have worked hard to implement the changes and the results are proven."Our patients are receiving more streamlined, efficient care and are benefiting from earlier discharge from hospital."We will continue to look at ways in which the patient experience can be further improved in our hospital as we take this project forward."

Page 41: Lean Healthcare - Streamlining Patient Journeys

And….. Aneurin Bevan Health BoardLean Enterprise Academy

Copyright Lean Enterprise Academy 2010

121510809458106755404052701351

140

120

100

80

60

40

20

0

_X=7.6

UCL=24.9

LB=0

1 2 3Trauma LoS from 01/08/2010 up to 09/05/2011

Individual Patients in Time Series Order

LoS

(day

s)

The approach is now being adopted by the Toscana Health Authority (in Firenza, Pisa, Lucca and Prato) and Beth Israel (Harvard Medical School)

“We have completed week one of our Visual Hospital Pilot. The rounds are getting better and we gather more valuable information each day”. MJ Brogna - Associate 

Chief Nurse Beth Israel Deaconess Medical Centre

Page 42: Lean Healthcare - Streamlining Patient Journeys

Copyright Lean Enterprise Academy 2010

Lean Enterprise Academy

Hospital Level Visual Hospital

Ward Level PfEP

Individual Patient Level Nursing Handover Sheets

Closed Loop Check/Adjust

Closed Loop Check/Adjust

Visual Hospital Hierarchy