NHS Scotland Wheelchair & Seating Service

1. NHS Scotland Wheelchair & Seating Service Outcomes from our Lean Rapid Improvement Event (RIE)

2. Purpose of Presentation • The rationale for completing a Lean (RIE) in the residential repairs area of our business. • The activities we completed across the 5 day RIE supported by the Atos Origin Alliance (AOA). • The early outputs and outcomes from our residential repairs focused RIE. • The results since completing the RIE using our performance data.

3. The Background to the RIE • Moving Forward identified that there were “significant opportunities to make improvements without committing major new resources”. Improving our Nov 2007 productivity levels and our patient experience levels was a key driver for running the RIE. • The speed of residential repairs as at Nov 2007 was a major challenge. Urgent (36% in 1 day); Priority (60% in 3 days); and Routine (78% in 5 days). • There was a recognised need to reduce the times patients have to wait between reporting an issue with their chair and the repair being completed. • We targeted setting stretching but realistic repair targets to support the development of a patient centric and continuous improvement culture.

4. The Background to the RIE • Improving the response rate to urgent and priority repairs, whilst recognising that the response triage must be appropriate. • Increasing the level of 1st time repairs – need to reduce the bottlenecks and ensure that the prioritisation is appropriate, the diagnosis is correct, the correct parts have been sourced and the technician has the correct skills. • Promoting an end to end view of repairs jobs across all teams: promote timely and effective hand shakes – “in it together for the benefits of patients”. The role of the Team Leader was recognised as vital to achieving this “one team” behavioural change. • Achieving and maintaining an appropriate economic balance between quality and cost in completing repairs and commissioning chair replacements.

5. The RIE Approach: Days 1 – 5 • TIMETABLE: • Start 10am Monday 19th November • Finish noon Friday 23rd November • 9am to 5pm in between • ATTENDEES: • Event team (from service) through-out • Service senior manager days 1 and 5 (open invitation to check in at end of each day to look at progress and assist) • ‘Customer’ involvement is recommended for some of days 2 and 3 • FACILITATION • The event will be managed by members of the AOA Lean Practice • OUTCOMES • Practical understanding of Lean • Thorough understanding of customers requirements and the current state • Detailed plan for Lean future state within next 6 months • Some immediate actions implemented • Implementation plan • Engagement and commitment of staff • Overview of the 5 Day RIE Approach EVENT KICK-OFF LEAN AWARENESS TRAINING Day 1 CURRENT STATE ANALYSIS Day 2 NEXT FUTURE STATE DESIGN Day 3 IMPLEMENTATION PLANNING Day 4 OUTBRIEF Day 5 IMPLEMENTATION 7

6. Day 1 – Lean Awareness Training • EVENT KICK-OFF: • Short presentation delivered by Service senior manager • Why are we here - what problems need to be addressed ? • Expectations of what will happen after this event • LEAN AWARENESS TRAINING: • Series of sessions run by AOA team • Principles of Lean • Experience of applying Lean in Healthcare • The process for this week (including tools and techniques) • Lean simulation game • PREPARATION: • Get ready for Day 2 EVENT KICK-OFF LEAN AWARENESS TRAINING Day 1 CURRENT STATE ANALYSIS Day 2 NEXT FUTURE STATE DESIGN Day 3 IMPLEMENTATION PLANNING Day 4 OUTBRIEF Day 5 IMPLEMENTATION 8

7. Day 2 – Current State Analysis • VOICE OF CUSTOMER: • Who are customers? (users of service; commissioners of service) • What is VALUE from the customers’ perspective? • How should this be measured? • VALUE STREAM MAP: • Construct the current state value stream map • Show how value is delivered to customers now • Gather data to measure performance (lead-time, flow efficiency) • Supporting analysis: • Swim-lane map • Spaghetti diagrams etc • WASTE IDENTIFICATION: • Highlight, categorise and quantify waste • OPPORTUNITY ASSESSMENT: • Highlight, quantify and prioritise opportunities • PREPARATION FOR DAY 3 EVENT KICK-OFF LEAN AWARENESS TRAINING Day 1 CURRENT STATE ANALYSIS Day 2 NEXT FUTURE STATE DESIGN Day 3 IMPLEMENTATION PLANNING Day 4 OUTBRIEF Day 5 IMPLEMENTATION 9

8. Day 3 – Next Future State Design • IDEAL STATE: • Define the ideal value stream map and performance targets • Stretch thinking about what is possible, using Lean principles • CONSTRAINTS ANALYSIS: • Understand real-world constraints (that prevent Ideal State) • Challenge constraints • NEXT FUTURE STATE: • Taking account of constraints, how much of the Ideal State can be implemented in 6 months? • Draw the NFS value stream map • Define KPIs • Agree baseline for KPIs • Agree targets phased over next 6 months • Validate with customers • PREPARATION FOR DAY 4 EVENT KICK-OFF LEAN AWARENESS TRAINING Day 1 CURRENT STATE ANALYSIS Day 2 NEXT FUTURE STATE DESIGN Day 3 IMPLEMENTATION PLANNING Day 4 OUTBRIEF Day 5 IMPLEMENTATION 10

9. Day 4 – Next Future State Implementation • BREAK DOWN THE NEXT FUTURE STATE: • What can we do today ? • What can we do next week ? • Which changes take longer ? • Which changes require permission ? • DO WHAT CAN BE DONE TODAY: • Implement immediate improvements • PLAN OTHER ACTIONS: • When / how / who • What investment is required ? • Layout changes • Facilities & tooling etc • What resources are required ? • Time • Support and training • Produce the schedule • PREPARATION FOR DAY 5 EVENT KICK-OFF LEAN AWARENESS TRAINING Day 1 CURRENT STATE ANALYSIS Day 2 NEXT FUTURE STATE DESIGN Day 3 IMPLEMENTATION PLANNING Day 4 OUTBRIEF Day 5 IMPLEMENTATION 11

10. Day 5 – Event Out-Brief • PREPARE PRESENTATION: • Summarise outcomes • Rehearse • DELIVER OUT-BRIEF: • Presented by the Event team • Audience should be Service managers and staff • Objectives: • Share learning with team • Permission to implement plan • Agreement to support / investment EVENT KICK-OFF LEAN AWARENESS TRAINING Day 1 CURRENT STATE ANALYSIS Day 2 NEXT FUTURE STATE DESIGN Day 3 IMPLEMENTATION PLANNING Day 4 OUTBRIEF Day 5 IMPLEMENTATION 12

11. The RIE Outcomes • November 2007 Value Stream. • November 2007 Repair Flow Efficiency. • November 2007 Repair Capacity Analysis. • Target Future State RIE + 6 Months. • Target Future State RIE + 48 Months.

12. November 2007 Value Stream 14

13. November 2007 Repair Flow Efficiency 1. Routine - all goes to plan : e.g. patient calls Monday morning – repair is completed (first time) on Thursday Clock stop Clock start 1 day Ø 1 day Ø Ø 1 day 3m Take patient calls 2m Schedule repair visit 1m Give promise 60m Detailed van schedule 60m Pick Parts 15m Collect Parts Variable (same day) travel to patient 20m repair Waiting time = 3.5 days = 5040mins Value Add time = 161 mins 161/5040 = 3.2% value adding time 2. Parts not available – repair delayed by two weeks (between pick parts and collect parts) Value adding time= 161 mins Waiting time = 17.5 days (25,200mins) 161/25,200 = 0.6% value adding time 3. Urgent – able to repair (first time) next day Day 2 8.30am 11.05 Day 1 9am 10.05 Ø Ø 9.05 Ø 2 hrs Ø 22 hrs 3m Take patient calls 2m Schedule repair visit 1m Give promise 60m Detailed van schedule 60m Pick Parts 15m Collect Parts 20m Repair 161/1440 = 11% value adding time 15

14. November 2007 Repair Capacity Analysis • Theoretical capacity [UOM = engineer days] • 16 engineers 16 x 5 x 52 = 4160 d/pa • 2 part time (2 x 5 x 52) x 50% = (260) 2 coordinators 16 x 35 = (448) 560 holidays 16 x 5 = (80) illness ----------- 3272 engineer days per annum Days Holidays/sickness 4160 Demand: 14000 calls pa c20 minutes per call 280,000 minutes pa 4667 hours pa Office/break time 25% 3272 21,576 hrs 2697 E/days Capacity 2697 x 8 hrs = 21576 hrs pa Other work? how quantify Build into demand RR = 56.5% of total jobs Other work = 3500 hours  assumes 20 mins per delivery/collection 3500 hrs D&C 4667 16

15. Identify part no Check stock not got got Allocate Confirm delivery date expedite (Production Control) Call Centre Manual Chairs/Uni • Check part details • Create job sheet • Check chair configuration • Fault diagnosis • ID parts required and part nos • Check and allocate stock • Confirm Engineer available • Agree appointment/ Urgent Routine Target Future State: RIE + 6 Mths Training Matrix F M J A • Accurate Data • Patient record • Chair details and configuration • Stock records RETIS Other Chairs - check part details - Create job sheet - Check chair config - Fault diagnosis • Opening hours – Patient Access • Demand for extended hours will be understood [ V.O.C. analysis] • Performance Targets • 1. Repair response time • URGENT = 1 DAY = 75% achieved • ROUTINE = 5 DAY = 90% achieved • 2. First time fix • TARGET = 90% • Ways of working • 1. Measure our business and share with staff • - daily team reviews (short/sharp) • - monthly team meetings • 2, Team Leader role • - Train staff • - coach people to continuously improve performance • 3. Personal accountability Order = w/c faulty Customers Better phone system -> patient can wait & queue Patient (phone) Clinician (advocate) Response Promise ROUTINE URGENT Job owned by coordinator Parts id; allocate; schedule UNI Call centre Manual Call centre trained on product range, repairs and part numbers GPS SYSTEM ON Update calls during the day Training Matrix Suppliers Engineers Supported by: • Product training • Better tooling • Better VAN STOCK • Parts for urgent repairs - castors - wheels - brakes - Better comms with Admin Manual URGENT – SAME DAY CUSTOMER • Allocate to driver via GPS txt • Fix via van stocks • Or ID parts reqd …OR Refurb engineer takes job from depot • Complete repair • Patient signs job sheet • Engineer texts admin Admin 1 day target applies regardless of zone • Can’t fix\ • Assist Pt as far as can • ID parts reqd • Text Admin  pick parts\\ URGENT – NEXT DAY CUSTOMER Van Schedule 8:30am Pick Parts 8:45am Collect Parts Mobile 9:30am • Complete Repair • Patient signs • Engineer texts admin Better capacity planning! CUSTOMER ROUTINE demand capacity Van Schedule Day 1 Pick Parts Day 2 Collect Parts Day 3 Do preventive maintenance [schedule to be agreed] • Complete Repair • Patient signs • Engineer texts admin Preventative maintenance formalised Maximum 5 days: better if capacity STORES PARTS PLANNING PROCESS  Confidence we have the parts… 20% 80% K K K K K Better stock system Training Matrix F J A Training for stores staff 100% stock accuracy Major suppliers on KANBAN FAST MOVERS 17

16. Target Future State: RIE + 48 Mths Call Centre KPIs • Diagnosis • Product Info • Allocate Stock • Config of chairs Co-located - Diagnosis - Check parts-> allocate - Real time driver - Confirmed schedule - Location and job status User RETIS easy How many calls get lost/don’t get answered? Response Time = U R 1 2-3 First Time Fix = 95-100% Training 1.Call Handlers: • Know the product range • Know how to diagnose faults • Know configuration of patient’s chair • Access to parts stock: a/allocate on time; b/give confirmed date to patient • Knows what we don’t know -> warn engineer • 2. Engineer/Coordinators • Dedicated repair/not delivery • Trained on full product range • Hand-held kit • Diagnosis tool • Product info/web sites • Parts availability • Job sheets • Tooling • Patient “handling” – confidentiality • 3. Stores • Product range • Stock management training • 4. Clinicians • - Lots…. Basic diagnostic tool Opening Hours: (check through V.O.C) 7 days, extended hours; wknd, engineers on call?? Team Leader ® Urgent = 1 ~10/day Not Urgent <= 5 ~50/day Training Matrix Data Accuracy F M J A Inventory Manager L 3pm cut off- ish… Same day/urgent work: go at even if no parts Wheelchair suppliers Stock Management Kanban? Pick -Driver in-cab display Or VMI Top 80% by parts value? Vendor Managed Inventory Or refurb engineers from depot R Change schedule – re-route Fit for purpose system Next Day “u” Staff and Culture Visual Performance Measurement Leadership stronger Personal Accountability No blame Culture Pick Collect Van Schedule Give capacity Means all zones every day • IT • How business Operates Wheelchair manufacturer Parts Wider van stock: wheels, castors, brakes Or local stock points - Satellite station (+4) Call Centre: • Time for training • Staff turnover: link to pay • On call engineer for diagnosis • Calibre of staff time to deal with each query • Phone system – no hold IT System: • Data Accuracy • Lack of info, chair config not being put on system • No fault diagnosis • Does not show driver position – there is a tracking system • Cannot display picklist to stores • No geographical locations display • No job status update – real time • No parts catalogue • No driver display Refurb Eng Delivery Parts: • Not all have licence (1/7) • Job role Constraints: R (Next available slot policy) Stock Management Time for training Not a stock mgt system Part identification ownership Suppliers Range of stock/LT/Stock levels PM Standardised PM on repair visit 2. Targeted PM Satellites: • Space • Stock Manager • Where to locate • Permission from health • board • Funding Van/Engineer: • Van stock • Time for training • Used for delivery and collect • 3 untrained drivers • Mobile coverage Patients out on the day 18

17. The Change Constraints • Understanding the skills of all staff, identifying training needs, and completing training. • Current stock management processes, types/levels of stock held and its location. • Access to real time management information on job status, driver location or parts status. • Support for call centre staff – no knowledge management support, limitations of phone system. • Time to plan and implement the changes!

18. The Key Focus Areas The following areas were identified as priorities for improvement: 20

19. The Improvement Actions The following actions were identified, prioritised and agreed: 100% 100% 100% 70% 100% 70% 70% 100% 70% 21

20. The Improvement Actions The following actions were identified, prioritised and agreed: 100% 100% 70% 100% 100% 100% 70% 100% 70% 22

21. The 6 Month KPI Results The following KPIs highlight our performance at RIE + 6 months: TBD% TBD% 23

24. The 6 Month Learning Points • The scope of the RIE was “about right”. Priority improvements were identified and actioned. However, maintaining the improvement momentum on the back of a single 5 day event is not easy and agreeing completion dates is easier than achieving them. • Agreeing stretch improvement targets helps to drive a sense of purpose and urgency. However, motivation must be maintained even if/when target dates slip. The day to day role of supervisors is vital in sustaining positive progress. • Embedding the use of lean tools and techniques is vital if improvements are to be sustainable. However, this requires culture and behavioural change which takes time. • The 5 day RIE identified improvements that have benefited the repairs activities at the Yoker depot. However, there was insufficient time to consider the wider upstream and downstream value stream impacts and opportunities in other areas of the business.

25. The 6 Month Learning Points • The maturity of the IT and telephony is a significant constraint in implementing desired improvements e.g. Kanban arrangements with suppliers have been difficult to implement due to limitations of IT and access to real time data. • Identifying the single KPI that MUST be achieved is key. This should be the focus of the RIE analysis. However, people will tend to focus on identifying changes that are in their organisational area and sphere of influence. Must think big if real change is to result. • The Rapid Improvement Event (RIE) allowed us to focus on point improvements which are making a real positive impact. However, there was insufficient time to focus on key themes such as Demand & Capacity Planning which underpin our performance.

26. Contact Points For additional information on our RIE experience and learning points contact: Andrew Love Technical Services Manager WESTMARC 0141 951 5312  Andrew.Love@ggc.scot.nhs.uk John Colvin Head of Service WESTMARC 0141 201 2641  John.Colvin@ggc.scot.nhs.uk 27