Experiences from a lean transformation – an English hospital

1. Experiences from a lean transformation – an English hospital David Fillingham Chief Executive Lean Healthcare – 16-17th March 2010

2. Fostering Joy and Pride: the Stroke Team

3. Stroke - Results

4. Stroke Mortality 2005-2009

5. Some encouraging early results • Trauma – FNOF 31% mortality ; 33% Length of Stay ; 42% paperwork • Stroke 92% Sentinel Audit Score, 23% mortality , 24% LOS • Ophthalmology – New One stop shop – patient visits 50% ; • High risk joint replacements – complications 85% ; Length of Stay 43% • Pathology – Test turnarounds from x3 to x10 quicker; 40% floor space saving • Laundry, Estates, Finance and others – six figure cost savings • 30% of staff engaged in week long improvement events and 1000 completed “Green” training ….. But still only scratched the surface

6. How can we engage the whole Hospital in a 20 (+) year journey of transformation that will reinvent lean for healthcare and change forever the way that hospitals are run?

7. Background to Bolton • Our Lean journey: 2005-2009 • : Building a system for improvement • Redesigning every end to end process • Creating a lean culture • The Future: better health and better care at lower cost • Reflections: mistakes, dilemmas and challenges

8. Bolton • Population 270,000 • Northern industrial town • 12% ethnic minority population (>18% childhood population) • Significant levels of deprivation and inequality • Reflected in health status • SMR - Cancers – up to 123 - Circulatory disease – up to 136 • Part of Greater Manchester – 2.5m population

10. Royal Bolton Hospital

11. About the Hospital • Approximately 700 beds • Busy emergency services – catchment about 310,000 • 3,200 staff • £170m turnover • Most secondary elective and non-elective acute specialties: • Medicine • Surgery/Urology • Orthopaedics • ENT, Ophthalmology, Oral • Children’s • Obstetrics • Diagnostics • A&E

12. Our Lean Journey 2005 - 2009

13. Substantial deficit Failing access targets Safety and quality problems Governance concerns Poor external relationships 2004 – The case for change

14. eople erformance P P V ision & Strategy P P atients & Partners rocesses

15. Our Aims No defects/best experience No avoidable deaths or harm Improved Health Best Possible Care Value for Money Joy and Pride Highest Morale No waste

16. Late 2005 2006 2007 2008 2009 2010 onwards Early experiments - Trauma - Day Surgery Narrow & Deep vs Broad & Shallow EVSA Leadership for Lean Daily “BICS” BICS Academy Policy Deployment Urgent Care Transformation….with Bolton PCT Focus on productivity and on whole system redesign Our Lean Journey: Important Milestones

17. : Building a system for Improvement

18. Characteristics • Aim is to create a system for Improvement • Based on “lean” principles, creatively adapted for the NHS • At heart of our Business Plan – drives safety, quality and productivity • Comprises tools, methods, management system and leadership • Seeks to engage all staff in a long term cultural transformation

19. The Bolton Improving Care System Understanding Value Learning To See Improving Health Best Possible Care Value for Money Joy and Pride in Work Delivering Benefit Redesigning Care

20. Move away from batching, Backlog and Queues. Reduce Variation & Complexity Clear to See: Straighten Sweep & Clean Safety Standardise Sustain Create signals To pull patients. Obvious when Something empty Linked series of “Cells” that embody Lean Tools/Principles 1 PIECE FLOW STANDARD WORK PULL SYSTEMS 6 S VISUAL MANAGEMENT: “ability to see the process”

21. Redesigning every End to End Process

22. Why did we need to change stroke service? 2005/6 High mortality rate – SMR 122 • Long length of stay – 43 days • Stroke patients all over the hospital only 22% getting specialist care • 13 beds for stroke off the main site • Few specialised staff

23. Value Stream Map

24. Value Stream Analysis: • 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

25. Value Stream Analysis: • Hand Off Chart • 197 handoffs to discharge a patient! • Duplication • Frustration • Huge source of potential error

26. Future State

27. Direct admission A&E care pathway CT in A&E Treatment rooms Dirty Utility High dependency on acute stroke unit Board rounds Planned discharges Early supported discharge BICS Redesign Aims to Achieve Improvement in … Bed management First 24 hours Roles and responsibilities 1 PIECE FLOW STANDARD WORK PULL SYSTEMS 6 S VISUAL MANAGEMENT: “ability to see the process”

28. De-cluttered and got rid of waste • 6s areas on both wards • Sluice • Treatment room • High dependency area on acute unit • Store Room

29. The waste !!

30. The store room – after

31. Standard Work • Operational policy ,bed management • Role of shift leader • Board rounds • First 24 hours • Role of MDT staff • Cleaning of commodes

32. Creating Flow • Direct admission from A&E • Hyper acute bay • On ward rehabilitation • Early Supported Discharge team

33. Visual Management

34. Fostering Joy and Pride • Staff sickness reduced to 3% in stroke from 15% • Awards and publicity • National Clinical Director visit • Very positive patient and carer feedback

35. “I can’t fault anything, it’s a very frightening time when you can’t walk ,or even stand or sit up , but I’m slowly getting mobile and looking forward to going home’ Stroke patient April 2009

36. Making Systematic Trust wide goals Improvement activities Daily work Policy Deployment Mission Control and Information Centres Team problem solving and action Logs; Exemplar Wards; “gateways”

37. Daily Problem Solving in Lean Blood Sciences Lab

38. Patient Gateways • A plan for every patient reviewed regularly • Gateways to check all steps completed • Reinforces evidence based practice • Strengthens multi-disciplinary team working • Bed-side handover involving the patient • Real time problem solving and process improved staff morale

39. This graph shows the increased throughput for respiratory and complex elderly showing significant performance change

40. Monthly Data

41. Creating a Lean Culture

42. Top down/externally imposed targets Problems worked around or passed upwards Few leaders…who are always in meetings Management based on anecdote and politics Self devised goals and measures for improvement Root causes addressed at source Many leaders who constantly “Go and See” Management based on data and scientific methods From To

43. Fillingham’s Motivational Matrix Positive Enthusiastic Pragmatist Naïve Idealist Outlook on Life Negative Disillusioned Sceptic Embittered Cynic High Low Grip on Reality

44. Converting the Sceptics • Rigorous use of lean methods • Convincing data • Hands on experience….RIE weeks • Reinforce through changed management system and leadership style • A coaching culture • The BICS Academy

45. BICS Academy

47. The Future: better health and better care at lower cost

48. Refocus our BICS effort – improve safety and quality and release “cashable benefit” • Extend beyond the hospital…health and social care system transformation

49. Urgent Care Redesign • End to End pathway redesign using lean • Demand management in primary care • Admissions avoidance: BCU and Rapid Response • Acute Physicians based in A&E; rapid access medical and surgical clinics • “Patient Gateways” and exemplar ward approach • A&E attendances – down 3% • Medical Non-Electives – down 3.5% • Surgical Non-Electives – down 2.2%

50. Productivity Realisation Medical Urgent Care -D3/D4/B3/B4/C3 April - October 2008 April – October 2009 Length of Stay (days) 14.13 10.85 Occupancy (%) 96% 95% Patient Throughput 2753 3337 Cost Avoidance / Potential Productivity Gain £1,403,936 Equivalent Beds Saved 9 Ward Closed for 3 months as part of cash releasing savings during same period