Lean transformation; finding the balance between tools and people

1. 27th May 2011 Lean transformation; finding the balance between tools and people Cellular Pathology, Royal Victoria Infirmary Terry Coaker, Histopathology Operations Manager

2. 27th May 2011 Cellular Pathology, RVI, Newcastle • 1981: RVI 9,700 requests per annum • 1995: NGH acute services • 1996: NGH histology • 1997: Dental Hospital – oral pathology • 2002: Freeman histology; muscle & nerve; cytology decant • 2005: Histopathology decant – 42,000 pa • 2007: Lean tools – examination phase • 2008: Neuropathology decant • 2009: New building (planned 2004) – 47,000 pa • 2009: Pre-examination phase • 2010: People

3. 27th May 2011 Drivers for change • Lord Carter 20% reduction • Modernising Scientific Careers • Private sector • NHS Modernisation • Improve the service

4. Cytology Improvement Guidehttp://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Cardiac%2FNational%2FWebsite%2FDiagnostics%2FCytology_14day_TAT.pdf Cytology 14 day TAThttp://clinicalcytology.co.uk/resources/pdf/14dayturnaround.pdf 27th May 2011

5. HistopathologyImprovement Guidehttp://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Diagnostics%2fNational%2fWebsite%2fHistology%20Guide%202.pdf 27th May 2011

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7. 27th May 2011 Unconscious incompetence Conscious incompetence Conscious competence Unconscious competence

8. 27th May 2011 Lean Methods Continuous Improvement Toolbox Pull Systems Work Cells TPM Performance Measurement Setup Reduction Quality at the Source Continuous Flow Batch Size Reduction Lean Tools Standardized Work Teams POUS Visual Controls Value Stream Mapping 5S System Layout

9. 27th May 2011 A lean transformation must keep an even balance….. ‘People’ ‘Tools’ CULTURAL TECHNICAL

10. 27th May 2011 Too much emphasis on tools and methods…. CULTURAL Extensive use of “tools” Use of Japanese terms and concepts Some processes made more efficient Lean belongs to a few enthusiasts Failure to embed or spread Resistance to change Results not sustained No overall transformation TECHNICAL

11. 27th May 2011 If Cultural concerns predominate…. Temporary feel good factor created Better teamwork Increased levels of involvement But hard to sustain without results TECHNICAL Failure to establish flow Lack of rigour in use of tools Lean “speak” without true understanding Full potential not realised CULTURAL

12. 27th May 2011 Peters and Waterman 1982 “Managers themselves are the major barriers to high levels of commitment on the part of staff. People come to work motivated and interested but they are soon alienated by the web of rules and constraints which govern their lives. If only management could find ways to release and tap employees creativity for example visa employee involvement, then their commitment to organisational goals would follow”

13. 27th May 2011 NHS Improvement “We’re looking for exemplar sites Er, no, not you ! Q. What would make us an exemplar ? A. Staff engagement” so… • Visual Display • Daily meetings

14. 27th May 2011 People Pitfalls • Managing from the office • Use all the brains in the Department • “We are different” • Not invented here e.g. COSHH, Quality and Lean

15. 27th May 2011 The Lean Leader • Go and See • Ask Why • Respect People • Force Reflection

16. Spec Rec Slide Production ICC General Office Cytology 27th May 2011 Re-organisation of meetings Weekly Huddle Review Histology Performance ? Medical specialty team meetings

17. 27th May 2011 Benefits • Daily ! Addresses issues immediately • Clarifies duties • Encourages feedback • Staff know more about their role • Ownership • Motivating and enjoyable!

18. 27th May 2011 Visual Display

19. 27th May 2011 Slide Delivery

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21. 27th May 2011 A3 • One side of A3 • Pencil and eraser • Root cause analysis • 5 Whys? • Plan, Do, Check, Act • 6σ (Sigma) 3.4 defects per million opportunities

22. 27th May 2011 Six sigma • 3.4 defects per million opportunities • One SUI in 47 000 • One in 470 000 (10 years) • One in 940 000 (20 years)

23. COMMUNICATE COLLABORATE MENTOR & RESPECT PRESENTING PROBLEM CLARIFY PROBLEM WHY? CAUSE WHY? CAUSE WHY? CAUSE WHY? CAUSE WHY? ROOT CAUSE Grasp the situation • Actual vs standard • Actual vs ideal Understand how the work is done ‘GO SEE’ Establish ‘Point of Cause’ Time and place where events cause abnormality 27th May 2011 AUTHOR: NAME:DATE: SPONSOR / MANAGER: NAME:DATE FINAL A3 APPROVED: TITLE: WHAT IS THE PERCEIVED PROBLEM? IDEALLY FROM A CUSTOMER VIEWPOINT • BACKGROUND • WHY ARE WE TALKING ABOUT THIS PROBLEM? • FOCUS ON THE CUSTOMER (Internal or External) • BRIEFLY STATE HOW THIS PROBLEM IMPACTS ON THE PURPOSE OF THE ORGANISATION & THE PROCESS • GIVE RELEVANT BACKGROUND INFORMATION • WHO ARE THE STAKEHOLDERS? • CURRENT CONDITION • WHERE DO THINGS STAND TODAY? • USE DIRECT OBSERVATIONS & MEASUREMENTS • GO SEE (where activity actually occurs e.g. laboratory, office etc.) • REPRESENT VISUALLY – USE CHARTS, GRAPHS, DRAWINGS, VALUE STREAM MAPS etc. • BE OBJECTIVE,THOROUGH & SUMMARISE CONCISELY • GOALS & TARGETS • WHAT SPECIFIC OUTCOMES ARE REQUIRED? • ANALYSIS – WHAT IS THE ROOT CAUSE OF THE PROBLEM? • ASK 5 WHYS ? • PROPOSED COUNTERMEASURES • WHAT ARE THE POSSIBLE MEASURES THAT WILL ACHIEVE THE TARGET CONDITION? • ALWAYS CONSIDER A RANGE (OR SET) OF COUNTERMEASURES • HOW WILL EACH COUNTERMEASURE AFFECT THE ROOT CAUSE? • SELECT A COUNTERMEASURE (S) THAT BEST ADDRESSES THE ROOT CAUSE • 6. PLAN • IMPLEMENTATION OF CHOSEN COUNTERMEASURE(S) • WHAT ACTIVITIES ARE REQUIRED FOR IMPLEMENTATION? • WHO IS RESPONSIBLE & WHEN WILL THEY HAPPEN? • DEFINE SPECIFIC PERFORMANCE INDICATORS & MILESTONES • BE VISUAL – USE TABLES OR GANTT CHARTS • WHAT?WHO?WHEN?OUTCOME • FOLLOW UP • WHAT ISSUES CAN BE ANTICIPATED? • CHECK OUTCOMES ARE BEING ACHIEVED. IF NOT, THEN CHECK TO SEE IF CURRENT CONDITION [2] & ROOT CAUSE ANALYSIS [4] WERE CORRECT • CAPTURE & SHARE LEARNING – COMMUNICATE • STANDARDISE TO MAKE CHANGE TO CURRENT CONDITION • – AMEND POLICY, PROCEDURES, SIGNAGE, TRAINING etc • REPEAT THE CYCLE - PLAN DO • CHECK ACT A3 PROBLEM SOLVING PROCESS – GO SEE, ASK WHY ?, RESPECT PEOPLE

24. Rogers diffusion curve Early adopters Early Majority Late Majority Innovators Laggards 20 30 30 20 18th June 2007 People - Attitude curve Ready for change “Lets get started!” Range of attitudes “Wait and see” “Show me” Resistant to change

25. 18th June 2007 The Lean Champion is a Farmer Kegan and Lahey Horses Sheep Dogs Goats Jackals Lemmings 20 30 30 20 Ready for change “Lets get started!” Range of attitudes “Wait and see” “Show me” Resistant to change

26. 27th May 2011 Issues • ‘No problems’ – is a problem! • Discipline • Poor performance – must be addressed – outside the huddle.

27. 27th May 2011 Gemba audits – What is the problem? • Issues remain unresolved • Not seen as the number one priority • Lack of time to investigate and fix • Superficial solutions – ‘sticking plasters are not ‘root cause’ • No clear ownership • Med / tech barrier blocks communication • Performance not reviewed (no huddle) • What defines a good days work?

28. 27th May 2011 Gemba audits - Actions • Open issues and outstanding CAPA’s discuss at histo performance meeting • Add “waste walks” to PI’s • Define checklist of Gemba audits • Define dashboard for audit • Audit visual display boards

29. 27th May 2011 Gemba audits – The Future • Robust gathering of problems • Speedy and binding resolution of issues

30. 27th May 2011 TAT February 30 25 20 Days 15 10 7 5 5 3 0 Neuro Histo BR CT GI GYN HPB Lymph OA OR Paed RE SK UR Histo Total MN referral 7.00 18.15 12.95 13.00 22.60 20.10 13.00 21.10 11.00 6.95 24.00 8.00 17.95 13.00 21.25 95% 3.00 3.00 4.00 5.00 7.25 7.00 5.00 9.00 5.00 3.00 7.00 3.00 5.00 4.00 7.00 50% Team

31. 27th May 2011 ‘Not everything that counts can be counted, and not everything that can be counted counts.’ Einstein

32. 27th May 2011 Thankyou Cellular Pathology, Royal Victoria Infirmary Terry Coaker …any questions ?

33. 27th May 2011 • Also known as… • Process improvement • Re-engineering • Continuous improvement • Total Quality Management • Six Sigma 3.4 DPMO– Motorola - DMAIC • Lean – Toyota • Common sense?!