Implementing Lean The NHS Lothian Experience

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Implementing LeanThe NHS Lothian Experience
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Implementing Lean in Lothian

• Welcome and Introduction
• Professor James Barbour, Chief Executive
• Overview of programme to date
• Dr Brian Montgomery, Associate Medical Director
• CT and Breast Services experience
• Ms Lorraine Hudson, Associate Directorate
  Manager, Radiology
• Surgical Services experience
• Ms Tracey Gillies, Consultant GI Surgeon
• Questions and discussion

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Strategic Context

• Service Quality Outcomes
• Patient Safety
• Delivery of HEAT Targets
• Pay Modernisation and Productivity
• Single System Working and ensuring Public Value
• NHS Lothian Human Resources Strategy
• The Lothian Way
• Management Development

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Our Strategic Aims

• To create an environment that allows change to be
  embraced and empowers staff to challenge the way
  things are done
• To improve the capacity and capability of staff
  to revolutionise front line and support service
  processes
• To secure the best possible healthcare system for
  the people of Lothian.

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Why Lean?

• Job enrichment as staff are empowered to use Lean
  tools and methods to solve problems
• Reduced costs and increased capacity allows
  improved access to healthcare
• Enhances patient quality and safety through
  improved processes which promotes better
  outcomes, patient flow and reduced wait times
• Lean in healthcare provides an improvement in the
  patient experience by eliminating waste
  throughout the patient pathway.

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Lean in Lothian Programme Core Components
DELIVER PROJECTS
DEVELOP SKILLS

• Transfer knowledge and skills to local staff
• Classroom and on-the-job training
• Develop local lean leaders
• Develop in-house skills training capacity

• Deliver service improvements
• Focus on the patients
• Involve front line staff in delivering
  improvements
• Provide practical experience for lean leaders and
  change agents

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Lean Transformation
To improve
Lean attacks waste

• Cycles times
• Delivery Quality
• Capacity
• Productivity

Value is determined from the customers perspective

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Projects Delivered Phase 1

• CANCER
• CT scanning
• Colorectal referral to treatment
• Breast New Patient Clinic

• DELAYED DISCHARGES
• Post acute care
• Bed management
• Alternatives to Admission

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Projects Delivered Phase 2

• Colorectal diagnosis to treatment
• Outpatient Processes OPD4/1
• Cardiology
• Discharge Processes
• Pathology Processes
• Child Protection
• Substance Misuse (x2)

• HSDU
• Acute Mental Health Admissions
• Breast Unit Long Term follow up patients
• Prescribing
• Psychology
• RHSC admin processes
• 7 CMT/CHP/CHCP workouts
• to be completed

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Training

• 2 waves of training delivered in each year
• Over 230 staff have attended Awareness sessions
• 98 staff have completed one or more elements of
  Lean in Lothian training
• 7 are staff side partnership representatives
• 50 senior staff have completed sponsor/ process
  owner training

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• Outcomes Organisational Culture
• Clear link of QI to the delivery agenda
• Communication Plan
• Getting the right people in the room
• Staff Partnership involvement
• Board and Executive buy in and support
• Not just senior people can fix problems
• Improved quality of service to patients

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Lessons Learned

• Meticulous Preparation
• Engagement of process owners
• Early scoping of project areas with key
  stakeholders
• Metrics for success identified in advance
• Given authority to make changes
• Protected time (Kaizen, Work-out)
• Try storm
• Process owners own and deliver action plans and
  sustain improvements
• 30 60 day action plans and report outs
• Link to Delivery Agenda
• Appropriate projects not the answer to all
  problems

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Capability Capacity

• Full time Improvement Leads identified and
  trained
• Change agents trained
• releasing for projects an issue
• Link to quality improvement programmes
• Develop local training skills

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Next steps
Phase 3
Self Sufficiency
Phase 2
Further Deployment
Phase 1
Learning/ Experience/ Adaptation to Lothian
Initial Pilot
Time

• Becomes the way of working
• Lothian owned programme
• Cultural evolution empowered staff, strong
  sense of ownership

• Pilot methods
• Standard Training
• 1 main type of project
• Exec hands on
• Build early champions
• and promotors

• Build change leaders
• Adapt training where
• appropriate
• Multiple types of projects
• Exec ownership, devolved
• sponsorship

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NHS LEAN In Lothian Programme
The Kaizen Experience
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NHS LEAN In Lothian Programme
Lothians First Kaizen Our CT Service
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The CT Process
Up to 21 weeks
Protocolled by Radiologist




OP Request
Radiographer Vetting
Appointment made
Reception
2-4 days

1-3 days
Scan
Scan Archived


Scan Reported
Report typed

Report Verified


Report sent out
2-14 days
2-7 days
2-14 days
Same day usually
2-4 days
Report received
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,
Referral to Booking
Process took 0-31 days
Before
Referral
Post to radiology
Recd by Radiology
Vetting
Recd to radiologist
Post to radiologist
High variability
Lacking relevant info
Named Radiologists
After
New process max 2.5 days
Referral
Direct to modality
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Patient Information

• Next Steps

• Visual

• Impact

• Print distribute new patient leaflet
• CT Virtual Tour upload to website
• Appointment letters updated and matched to
  modality

• Patients arrive better prepared to reduce wasted
  time in prep
• Improved patient satisfaction
• Letter personalised and improved effectiveness
  (score from 8/10 to 10/10)

Before
After
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Managing Leave

• Next Steps

• Visual

• Impact

• Roll out model to other Lothian teams/sites
• Review workload/ skill requirement for vacant
  posts
• Standardise leave policy across all sites

• Commitment by Pan-Lothian Radiologists to ensure
  that lists are cross-covered
• Reduction in cancelled lists
• Better matching of capacity to demand
• Leave no longer impacts on waiting lists

Before
Lists Cancelled
Capacity lost due to leave
No Cross Cover
Unhappy Patients
After
Cross Cover in place
No Lists Cancelled
No Capacity lost due to leave
Happy Patients
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,
Pooling of Waiting Time Pan-Lothian
Max 21 weeks
Before
Max 6 weeks Across all Lothian
After
6.0
Pan-Lothian Max Waits
5.0
Jan
Feb
Mar
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Significantly Reduce CT Scan Reporting Cycle
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The CT Process
6 weeks
1 day
1 day
Up to 21 weeks
Protocolled by Radiologist




OP Request
Radiographer Vetting
Appointment made
Reception
2-4 days

1-3 days
Scan
Scan Archived


Scan Reported
Report typed

Report Verified


Report sent out
2-14 days
2-7 days
2-14 days
Same day usually
2-4 days
1 day
1 day
1 day
Report received
Before
After
Now takes up to 6 weeks
Took up to 27 weeks
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NHS LEAN In Lothian Programme
Breast Service New patient 1 stop Long Term
Follow-up Kaizens
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Breast Referral Current State
7 days
On the day
24-48hrs
Up to 7 weeks
GP
Referral
?Triage
Appt
Clinic
Dept
Admin Processes
Protocol
Waiting Time
Triage Processes
Admin Processes
7 weeks
7 days
7 days
7 days
Mammo Appt
Mammo
Clinic
Mammo
7 days
DNAs
Clinic
Clinic
Ultrasound
Waiting Time
Waiting Time -patients
Cancellations
FNA
Organisation
Waiting Time -staff
Core Biopsy
7-14 days
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Breast Referral Future State
GP
Referral
Triage
Appt
Clinic
Dept
2 weeks
History Physical Exam
Core Biopsy
Case Review
Clinic
Ultrasound
Mammo
Same day
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Lessons From One Stop Breast Clinic

• Hot Reporting Trial weeks
• Agreed cap of 30 new patients over 4 clinics
• Agreed protocols for referral to mammography and
  ultrasound
• Flow of patients through department
• Multiple appointments
• Agreed start and finish times
• Communication

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Breast LTFU Process

• Current Future
• Clinic Attendances 3200 1200
• Mammography Results Up to 69 days Up to 10
  days

2 4 days
1 29 days
Reporting
1 6 days
6 40 days
Letter Generation
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OPD4, Royal Infirmary of Edinburgh kaizen Oct 2007

• Mixed clinic area with GI, General Surgery and
  Vascular Surgery
• Some areas high volume, some highly specialised,
  some highly complex processes 600 patients per
  week.
• Issues with staff sickness and retention

Referrals waiting to be actioned
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OPD4/1 Registration, Triage Booking Process
4 58 days
Current State
0 11 days
1 36 days
0 5 days
1 14 days
1 - 9 days
2 8 days
Hosp
GP
Endoscopy
Sort
Registration
Triage
Sort/ Appoint
1 7 days
Endoscopy booked
Whole process could take up to a maximum of 90
days
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Referrals
RefHelp
SCI Gateway
Non SCI Gateway
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Kaizen in Action GPs, Consultants, Clinic
Nursing Staff, Administrative Staff
brainstorming solutions to delays in the process
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Triage
0 3 days
GI
1 - 7 days
Gen Surg
1 36 days
0 3 days
0 5 days
Vascular
1 21 days
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Outpatient Clinic Processes Appointment Process
1 14 days
Same day
Presenter Tracey Gillies
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dealing with todays work today

• Aim to receive, triage and action referral
  received on day of receipt
• Triage room with rota for GS and GI
• Interaction between AC and GI medical staff

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OPD4/1 Registration, Triage Booking Process
4 58 days
Current State
0 11 days
1 - 9 days
2 8 days
1 36 days
1 14 days
0 5 days
GP
Hosp
Registration
Sort
Triage
Sort/ Appoint
Endoscopy
1 7 days
Endoscopy booked
Future State
Same Day
0 3 days
0 3 days
0 11 days
0 5 days
GP
Hosp
Registration
Sort/Triage/Sort/Appoint
Endoscopy
1 4 days
Endoscopy Booked
Before Up to 90 days
After Up to 26 days
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Sustainability and Ownership
30 day action plan defined
Ongoing review
Monitoring mechanisms
Owned by
Tracey Gillies
Graeme Morrice
John Plevris
Lean In Lothian Programme
Planned Care Collaborative
Support
30 Day Report Out Friday 30th November
Support
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Work not yet evenly spread but making progress
Issues around timings and buy in
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Referrals/Triaged/Actioned
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Impact of process change in OPD4
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Benefits

• Better processes for patients and staff
• Increased focus and ownership- solving our own
  problems
• Development of skills and experience to be shared
  with other areas and used in other areas of work

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Beginning the redesign for 18RTT in Lothian in
Plastic Surgery
Future state 2011 18 week total journey
Present state 2008
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Summary of work begun in Plastic surgery

• Use of lean tools and techniques
• Beginning with high level process map
• Future projects identified- specialty specific
  and Lothian wide

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Questions?