Lean in Healthcare

1. Lean in Healthcare Ben Gowland Director Service Improvement Mayday Healthcare NHS Trust

2. Healthcare Myths • Demand is unpredictable and uncontrollable • Each patient needs a uniquely designed pathway • We need more beds to reduce waiting times

3. 1. Demand is unpredictable and uncontrollable

4. 10 8 6 4 2 0 A&E Congestion Arrivals % of attendees Departures 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour

5. Elective and emergency inpatient admissions

6. Elective admissions and discharges

8. Healthcare Myth Demand is unpredictable and uncontrollable Lean mindset Demand is predictable and largely within our control New Lean mindset

9. Mayday Pathology: Demand Information – Feb 2006

10. Courier data

11. Pathology Reception • Improved number of samples per hour from 18 to 40 to match demand • Moved from 5 batched processes to all doing small baskets of 20 from start to finish, using FIFO • Changed layout & reduced number of steps to enable, including optimisation of rate limiting step (data entry) • Changed courier to hub and spoke model to reduce large 1-3 peak in demand

12. Sterile Services demand and supply

13. Sterile Services Department project • Smoothed demand by scheduling pickups from theatres hourly and applying First In First Out (FIFO) • Alignment of sterile services working hours to demand profile from theatres • Improved workplace organisation in both theatres and sterile services • Reduced interruptions to theatre lists - from every theatre every day to no theatres on any day • Average time kits returned to theatres - reduced from 11 hours 52 minutes to 6 hours 47 minutes

14. Outcomes – better match

15. Healthcare Myths • Demand is unpredictable and uncontrollable • Each patient needs a uniquely designed pathway • We need more beds to reduce waiting times

16. Abdomen pain Minors “Off legs” Elderly falls Chestpain Respiratory Improving emergency care – start with high volume low variety groups?

17. But for each high volume group: • High variety in journey time, treatment, and processes for individual patients • BUT Similarities in process across different clinical groups

18. Assessment MinorRx Disch Assessment Investigations Treatment Disch Admit ?theatre Assessment Investigations Treatment Disch Abdomen Pain

19. Emergency Services Collaborative Minor Injury / Illness Acute Assessment Medical Admission Surgical Admission

20. Healthcare Myth Each patient needs a uniquely designed pathway Lean mindset Systems can be designed around common process steps New Lean mindset

21. Patients with a minor injury • Often wait the longest due to triage • Range of different complaints • Require assessment and treatment • Short process time • See and Treat for minor injury patients • A competent clinician, seeing A&E patients as they arrive and then treating and discharging them • waiting times for minor injuries on one site down to 50 minutes from 3.5 hours

22. Monday, No See & TreatStatistical Process Control 7:12 6:40 6:00 5:49 5:28 4:48 3:50 Journey Time (hrs:mins) 3:36 3:32 2:24 1:27 1:12 0:00 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100 103 Patient No Journey Time Median Upper Process Limit Lower Process Limit

23. 7:12 6:00 4:48 3:36 3:05 2:24 2:18 2:02 1:12 1:03 0:03 0:00 1 3 5 7 9 11 13 15 17 19 21 23 25 27 Monday, See & Treat Journey Time (hrs:mins) 29 33 35 37 41 43 49 51 57 31 39 45 47 53 55 Patient No Journey Time Median Upper Process Limit Lower Process Limit

24. Healthcare Myths • Demand is unpredictable and uncontrollable • Each patient needs a uniquely designed pathway • We need more beds to reduce waiting times

25. Relationship between number of beds (per 000 pop) and lengths of stay

26. Relationship between number of beds (per 000 pop) and number of admissions (per 000 pop)

27. Healthcare Myth We need more beds to reduce waiting times Lean mindset Improvements that focus on the short high volume patient journeys have the biggest impact on waiting times New Lean mindset

28. Length of Stay

29. Acute Assessment • Patients with a short stay have common steps (assessment, diagnostics, treatment decision and discharge) • High volume, less complex • Generic unit for short stay patients with specialist input

30. Emergency Assessment Unit • Split Emergency Assessment Unit • 24 bedded rapid assessment area • 16 bedded short stay ward • Project to embed model • Train nurses in model • Increase discharge rate from short stay ward • Increase no. of short stay pts on short stay ward

31. Emergency Assessment Unit Introduction of new assessment and short stay model

32. Mayday • 2800 employees • £160M turnover • 700 beds • 130,000 A&E attendances • Key organisational issue - financial deficit

33. Improving Care, Changing Lives • Transformational Programme • Programme commenced in July 2005 • The aim of the Programme is to:- • Reduce overall length of stay for patients • Reduce current bed stock by 100 Beds • Build organisational capacity for continuous improvement

34. Key Elements • Day surgery rates • Admission on the day of surgery • Short stay medical ward • Redesign inpatient flows • Trauma & turnaround time in theatres

35. Results of Improving Care Changing Lives programme so far • Length of stay reduced from 8 days to 7 days • Day case from 52% - 66% ‘trolley’ • Admission of day of surgery in every speciality • Elective LOS 5.1 – 4.4 Days • Non elective surgery (excluding T&O) 6.4. – 4.9 days • T&O 14.4 – 12.0 days • Medicine 7.8 – 6.2 Days • Closed 86 Beds

36. Demand is unpredictable and uncontrollable Each patient needs a uniquely designed pathway We need more beds to reduce waiting times Demand is predictable and largely within our control Systems can be designed around common process steps Improvements that focus on the short high volume patient journeys have the biggest impact on waiting times Creating a Lean mindset for healthcare