| An Evolving Concept | | | | Although patients (and service users) are the |
| The application of Lean in manufacturing has | | | | primary 'customers' of healthcare organisations, |
| made a major impact to the performance within | | | | they may not be the only customer and |
| those organisations who have embraced it fully | | | | depending on your role you may not meet a real |
| and although it is a relatively new and evolving | | | | patient from one month to the next. However, in |
| concept within the healthcare sector it is already | | | | trying to explain Lean in healthcare it is worth not |
| offering opportunities to reduce the time taken | | | | complicating this issue by just assuming that it is |
| for patients to be seen by a specialist, the | | | | only patients who are the real customer of |
| effectiveness (and value for money) of the | | | | healthcare processes. |
| treatment they receive and even the length of | | | | A key concept of Lean is listening to the 'Voice of |
| time they spend in hospital. | | | | the Customer' (VotC) and using this to determine |
| Although the use of Lean in Healthcare has only | | | | what is value adding and what is not. Like many |
| taken off in the last four years, many of the | | | | service organisations, customers do not buy a |
| concepts that underpin Lean are familiar to | | | | 'product' but something else. It may be an |
| healthcare organisations through NHS organised | | | | experience (as in how they are treated by a |
| improvement initiatives (such as the previous | | | | health visitor) or an 'outcome' (such as an |
| 'Modernisation Agency' and the current NHS | | | | operation) and in trying to understand and define |
| Institute for Innovation & Improvement) and | | | | things that are value adding in healthcare I have |
| this means you are already working with some | | | | found it useful in identifying what is value adding |
| awareness of the tools even with the newest | | | | by using the following three tests:o Does the |
| 'Lean Team'. | | | | customer experience it?o Do they want it to |
| Where some previous initiatives have failed to | | | | happen?o Would they care if it was changed and |
| take hold at the organisation level in healthcare | | | | done effectively in a different way? |
| organisations, often because of it being applied in | | | | If the answer to any of these questions is 'No', |
| isolated areas, been treated as a 'quick fix' or | | | | then the action is unlikely to be value adding to |
| failed to get the engagement required to make it | | | | the patient. For example; |
| part of the 'way things are done', because of its | | | | 1. There is a discussion between the Nurses and |
| structure Lean offers a structure to enable | | | | Social Services about the needs of the patient |
| people to get from the problem to the solution | | | | before they can be discharged. The patient does |
| more easily. | | | | not 'experience' the discussion (although they may |
| A universal truth but not universal adoption | | | | benefit from the outcome) and therefore the |
| The evolution of Lean in Healthcare over the last | | | | discussion is not value adding to the customer. |
| five years has mirrored its adoption in | | | | 2. A patient experiences 'waiting' for an |
| manufacturing with a few organisations adopting it | | | | appointment, but they don't want it to happen - |
| as their long-term driver for Continuous | | | | therefore it is non-value adding to the customer. |
| Improvement and the majority using it to fix a | | | | 3. A patient experiences having their details taken |
| plethora of short term issues and this is where | | | | (maybe multiple times) and they may even value |
| the long-term danger exists for the wholesale | | | | it but if it were changed to something just as |
| uptake of Lean in Healthcare. | | | | effective (for example bar-coding or even using |
| However, unlike manufacturing where the success | | | | biometric data) they would not care and |
| (or failure) of Lean in one organisation does not | | | | therefore it is likely the activity is non value adding |
| normally get communicated to even their nearest | | | | to the customer. |
| neighbours, in healthcare news travels fast | | | | Some of the things that patients view as valuable |
| between organisations and luckily the organisations | | | | (and therefore value adding) include such things |
| that are doing Lean well are making a big noise | | | | as:o Timely and effective treatmento Simple and |
| about it and that is helping to shape thinking. | | | | quick access to a professional and accurate |
| Initially Lean was widely adopted in Hospitals, | | | | informationo Being treated with respect and |
| mostly because they consist of lots of people | | | | provided with comforto Having some privacy and |
| clustered together performing very similar | | | | the ability to maintain levels of dignity |
| activities. Latterly its use has expanded into other | | | | But like manufacturing and other sectors, whilst |
| parts of healthcare, including community based | | | | patients do experience significant 'value add' in |
| services, mental health and even into GP | | | | their healthcare journey there is also a large |
| surgeries, and although it is still early days the fact | | | | percentage of non-value adding activity. |
| that almost every week there is a briefing, | | | | Delivering 'waste free' services and care |
| conference or new paper on Lean in Healthcare | | | | Just like manufacturing, healthcare organisations |
| suggests it won't be long before everyone has | | | | suffer from a sizeable percentage of activities |
| heard of Lean and knows at least the basics, but | | | | and time being taken up undertaken non-value |
| I suspect that in the long term only around 20% | | | | adding (NVA) tasks. In exploring these I will use |
| of healthcare organisations will get the full benefit | | | | the acronym WORMPIT to explore some |
| of what it can deliver. | | | | common NVA activities in healthcare:o Waiting - |
| Variation in People - the difference that makes | | | | an endemic non-value adding activity in healthcare, |
| the difference | | | | from waiting for appointments to waiting for the |
| Of course, in much the same way that every | | | | results of tests and waiting even for someone to |
| manufacturing or service sector business is | | | | answer a phoneo Over-Processing (or Production) |
| different to one another in at least a few ways, | | | | - undertaking more work than is required, for |
| healthcare organisations also differ from one to | | | | example completing extra reports, taking details |
| another. | | | | from patients ten times or even repeating tests |
| Often these are issues related to geography (how | | | | (such as blood tests or X-Rays) because the |
| spread out the population they serve are), | | | | original results can't be foundo Rework (or |
| demographics (a young population will have | | | | Correction) - having to undertake work twice |
| differing health needs to that of an older | | | | because it was done incorrectly first time round, |
| population) and a whole range of other issues, | | | | for example having to chase missing information |
| such as whether they are a regional or national | | | | from referral letters, changing appointments |
| lead for a particular condition, the services they | | | | because patients were allocated to the wrong |
| offer and where they 'fit' in the overall structure | | | | 'slot' or even having to repeat an operation |
| of healthcare - for example whether they are | | | | because of an unexpected outcomeo Motion (and |
| involved in commissioning (buying) services or | | | | Transport) - the motion of human beings, such as |
| delivering them. | | | | patients being required to visit a clinic multiple |
| Whilst this complexity will be familiar to anyone | | | | times, and the transport of 'things' such as |
| who has delivered Lean in a variety of | | | | information being shunted around a hospital or |
| organisations and sectors, the difference that | | | | even an entire county!o Processing Waste - doing |
| makes the difference is the impact of human | | | | things that don't need to be done, for example |
| variation on the process and the potential risks to | | | | unnecessary diagnostics and tests, unwanted |
| both effectiveness and patients of this variability. | | | | reports or reports with too much information in |
| Variation in patient needs leads to the creation of | | | | themo Inventory - stacking patients and |
| flexible treatment pathways. For example, an 18 | | | | information, for example bringing a whole group of |
| year old with a broken leg with no other medical | | | | patients in for day surgery at 9am even though |
| condition will receive a care package very | | | | some may not be seen till 4pm that dayo Talent |
| different to an 80 year old with a heart condition | | | | - the misuse of skills, for example experienced |
| and dementia who has suffered the same form | | | | nursing sisters being used to chase up orders or |
| of trauma. | | | | diagnostic results |
| Variation in decision making can have a real impact | | | | The net effect of this in healthcare is the same |
| on the performance of a process and even the | | | | as in any other sector and everyone spends a |
| outcomes for the patients. For example, junior | | | | fair percentage of their day doing non-value |
| doctors are often prone to order more tests (or | | | | adding activity. |
| ask patients to come back more times) than are | | | | The keys to Lean success in healthcare |
| required because it is better to be safe than | | | | Lean has the power to do great things in |
| sorry, whereas a more experienced doctor will | | | | healthcare for those organisations who embrace it |
| often use their previous experience to manage | | | | correctly and those who are doing it well are |
| the process more effectively and with fewer | | | | generally doing most (if not all) of the following: |
| resources than the junior doctor. | | | | 1. Listening to the Voice of the Customer |
| Although human variation is a significant (and | | | | It is vital to actually listen to the voice of the |
| different issue) when compared to many sectors, | | | | customer and not try to 'second guess' them. For |
| there are some traits of human beings that | | | | example, the paediatric team who wanted to |
| remain the same irrespective of the sector. For | | | | have a 'one stop shop' for their patients (to avoid |
| example, the impact of Lean on staff in | | | | multiple attendances at hospital for the same |
| healthcare has much the same impact as in | | | | condition). On first view this is a great idea, unless |
| manufacturing businesses where employees are | | | | you speak to the customer (the parents of the |
| concerned about Lean being used as a vehicle to | | | | children mostly) who generally cannot afford to |
| cut jobs or 'de skill' jobs, but whereas in | | | | wait for the five hours required by this service |
| manufacturing this will generally be contained | | | | because of childcare and other personal issues. |
| within the four walls of the business, a badly | | | | 2. Scoping effectively |
| handled transformation programme in healthcare | | | | The need to improve productivity or finances are |
| can lead to front page news and candlelit vigils. | | | | often driving the need for improvement in |
| This makes the importance of communication of | | | | Healthcare but a compelling need based on the |
| Lean in healthcare even more important than in | | | | need to save money will rarely engage front line |
| other sectors, and also introduces the concept of | | | | staff in healthcare. Often the compelling need will |
| risk to Lean. | | | | focus on improving the patient experience, safety |
| Risk - real or perceived | | | | and 'outcomes', but you also have to bear in mind |
| In Manufacturing, if you make a mistake with the | | | | that different people involved in the patient |
| way you introduce Lean you may increase the | | | | journey will have a different view of what this |
| risk of accidents but it is more likely it will just | | | | means so being clear on the 'Measures of |
| reduce productivity or profits. In Healthcare, similar | | | | Success' will be vital. |
| mistakes can impact on patient safety and the | | | | 3. Building awareness & capacity |
| whole patient experience and in the process can | | | | The real art to Lean is when it becomes part of |
| attract significant media attention. | | | | the way 'things are done' and this requires the |
| Making this scenario even more complex is the | | | | organisation to think about tackling the 'WIIFM' |
| fact that the 'care pathways' that patients | | | | issues of staff (What's In It For Me?) through |
| experience often interact and overlap in a way | | | | awareness sessions and also training to build skills |
| that manufacturing value streams do not, with | | | | and capability. There is a bigger issue in healthcare, |
| patients switching between pathways and | | | | as in any other sector, of feeling they can use |
| specialities dependent on their specific needs and | | | | these skills without the fear of being vilified if they |
| treatment plans. This can have the impact that a | | | | get them wrong or make the occasional minor |
| change in one area can simply transfer the risk | | | | mistake. |
| upstream or downstream or to a new process | | | | 4. End to end understanding |
| completely. | | | | Very few processes in healthcare exist in isolation |
| Management of healthcare processes is | | | | and it is important to think about a process from |
| complicated by the need to balance clinical | | | | 'end to end' so that the teams avoid just |
| concerns (such as patient safety and medical best | | | | transferring risks and this is best achieved by |
| practice) with 'business' concerns (availability of | | | | helping them to become aware of how the |
| resources and finance), and there are often | | | | upstream and downstream processes work. |
| uneasy balances that have to be struck between | | | | 5. Changing behaviours not just processes |
| senior clinicians and organisational managers on | | | | Perhaps the biggest change being undertaken by |
| these issues. | | | | successful healthcare organisations using Lean is |
| Whilst this is not necessarily different to | | | | that they are focusing on changing behaviours not |
| manufacturing where there is a constant need to | | | | just processes. Whilst you can issue a new |
| balance cash-flow against sales (for example), the | | | | process every hour you cannot change |
| fact that the complexity and risk in Healthcare is | | | | behaviours so quickly and thought needs to go |
| so different leads to a very different style of | | | | into changing the way that people work, not just |
| management - being more consultative than in | | | | the processes they are using. |
| manufacturing, which can slow down decision | | | | No Magic Bullet |
| making and make the need to set up a good | | | | Like many things tried by healthcare organisations, |
| structure for your Lean programme (such as | | | | there is no magic bullet to getting the best from |
| identifying champions, having an improvement | | | | Lean but those who are living Lean and tackling |
| board and communicating the process) prior to | | | | the problems as they arise are going to be the |
| the start of implementation even more important. | | | | ones providing the best care for their patients and |
| Understanding the Voice of the Customer | | | | the best working environment for their staff. |