mapping the elective journey
DESCRIPTION
by David Fillingham and Mike Maguire of Bolton Hospitals NHS Trust shown at the 2nd Lean Healthcare Forum on 6th June 2006 ran by the Lean Enterprise Academy www.leanuk.orgTRANSCRIPT
Mapping the elective Journey: Mapping the elective Journey: using lean to avoid needless using lean to avoid needless
delaysdelays
Mike MaguireDirector of CommissioningBolton PCT
David FillinghamChief ExecutiveBolton Hospital
2am1
4
FRI
2 3
5
DAY 2
6
SUN
DAY 3
7
DAY4
DAY5
WEEK6
8
9WEEK11
10
2am1
4
FRI
2 3
5
DAY 2
6
SUN
DAY 3
7
DAY4
DAY5
WEEK6
8
9WEEK11
10
2am1
4
FRI
2 3
5
DAY 2
6
SUN
DAY 3
7
DAY4
DAY5
WEEK6
8
9WEEK11
10
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
The NHS is full of committed staff who
struggle to deliver good care within a set of broken
processes
Lean can help us to:-• See things through the patients eyes• See the hidden problems and waste• Create safe, clean, calm work
environments• Fix our broken processes• Turn every staff member into a problem
solver every single day
The Beginnings of a Lean Journey…….
• 350 staff engaged (10%) over 9 months• Early results promising
- Trauma: 50% mortality reduction post #NOF; 33% LOS reduction
- Pathology: Blood specimen processing- 40% floor space saving- 20% productivity gain
• Antenatal; Radiology; Laundry; Musculo-skeletal• Focus is on quality and safety not cutting cost • We now know just how much we don’t know!
We are using lean to:-
• Reduce mortality rates • Improve staff morale• Improve patients’ experience• Improve productivity• Achieve (then better) the 18 week wait
Achieving an 18 week maximum wait
• Wont be achieved just by working harder• Wont be achieved by a 6/6/6 mentality• Can only be delivered by working across
organisational boundaries• Requires deep understanding of end to end
processes• Demands removal of waste and non-value
adding steps and creation of flow
The Bolton Approach1. Understand the current state
- analyse, observe and map
2. Design the Future State- cells- linkages- flow
3. Deliver the Future State
4. Repeat the Cycle
Lean in practice – A recipe for success
The MSK experience
ELECTIVE PATIENT JOURNEY: GETTING THE LEAN DATA
OPDTier 2/ICATs
(currently Surgicalbut ?medical for future):
Pre-Assess
WLs/QueueMngt
Ward/DC IP Beds
Tx and/or;Theatre Discharge
Diagnostics:
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
•Demand•Activity/throughput•Capacity (planned v
supplied)•Queue/inventory•Blockage•Delay
Select High Volume Groups – Where are your flow problems?
The above data gives a current state of delivery and shows the mismatches (this gives you your baseline to measure improvements against. For the future state it is important to work out the essential value steps you are working towards. The pace will need to flex to meet demand (a no waste system), and your data should be focused on this journey. Old ways use data to calculate what we can and do deliver, rather than how we need to work differently to deliver a one piece flow system…. very different!
MSK - Current State: MSK - Future State:
MEASURE CURRENT STATE FUTURE STATE
Total Steps DC: 28IP: 40
DC: 5IP: 5
Value Added Steps DC: 7IP: 11
Key steps only + customer delighters
Flow Time Max:DC: 20 weeksIP: 40 weeks
Max:DC & IP: 18 weeks
Pure Value Added Time: DC: 71 minsIP: 106 mins
Lessons from the current state analysis
• Multiple OP visits• Diagnostics not fully aligned with OPD• OP wait – 40 to 60% of journey• Patients on waiting lists that need their health
optimising first• System not compatible with 18 weeks• Waste and inefficiencies exist within surgical
processes
Integrated Clinical Assessment Services in GMSHA
• Trauma and Orthopaedics (inc Rheumatology)• General Surgery• ENT• Gynaecology• Urology• Range of supporting diagnostics• 2/3 National IS procurement, 1/3 Local
procurement or NHS provision
SYSTEM TRANSFORMATION USING ICATS
Hospital 1
2nd LineDiag
1ryTreatTriage
1st lineDiag
Assess& Pre op
“Choice”C&BSelect
ICATS(RBMS)
Patient Referred by GP, Optometrist or Dentist
Community Services Hospital 2
ICATSHospital 3
Hospital 4
IS provider
Free choice 2008
Patient Flow
Benefits of ICATs• Patients arrive fully worked up to a
common standard in 1 stop shop• Only patients who need, want and are fit for
surgery arrive at hospital• Increased predictability and precision
through choose and book• Patients make choice with full treatment
plan• Removes unnecessary steps and waste
But this could still happen…..
SYSTEM TRANSFORMATION WITH ICATs
Referral Management
Patient Referred by GP, Optometrist or Dentist
Choose
And
Book
centre
IS
H 1
H 2
H 3
H 4
ICA
TS
Diagnostics/Initial pre op done here
OP TheatreAdditional diagnostics
Pre op
Timeline – 4 weeks Timeline – 6 weeks
Present Acute System will not hit 6 week time line
ICATS must have a 4 week timeline
Using “Lean” to redesign the Acute System
• Future state vision• Creation of efficient Preoperative and
Surgical Cells• “Lean” length of stay improvements• Implement through Rapid Improvement
Events, Projects and “Just Do its”
ORTHOPAEDICS – FOLLOWING ICATs and LEAN
Referral Management
Patient Referred by GP, Optometrist or Dentist
Choose
And
Book
centre
IS
H 1
H 2
H 3
H 4
ICA
TS
Diagnostics/Initial pre op done here
Theatre
Consenting Visit
Final preop
Timeline – 4 weeks Timeline – 6 weeks
Understanding Real Acute Capacity
Operating Capacity
GP admissions for surgery
% Removals other than Treatment
% Conversion from Outpatients
% Cancellations & DNAs
% Other Referrals
% GP referrals
Other OP Slots to service Theatres
NET RESULT – Know number of GP OP slots to service theatres
The Result
• An effective predictable system
• Transformational change
• Fit for purpose for 18 weeks
Lessons so far• Lean analysis gives a much better
understanding of the real processes and demands
• Some radical changes are needed (egICATs)
• Achieving flow reduces waste but also exposes the problems
• Active and enthusiastic involvement of frontline staff is the key to success