Improving Services

1
Improving Services Releasing Capacity in
Primary CareApplying Lean Existing
Technologies
Iain Macfarlane (Atos Origin) John Crawford
(IBM)
SCIMP Conference_03 November 2009
2
The focus for todays discussion
By the end of our discussion we aim to have
demonstrated that

• Lean-led improvement can make an impact in the
  NHS, including in Primary and Community Care,
  across all areas of quality
• Safe
• Effective
• Timely
• Efficient
• Equitable
• Patient Centred
• Technology continues to evolve to support
  different models of care
• Patient Centred Medical Home
• Telemonitoring
• Participatory Medicine

3
Lean in the NHS and in Primary CareWhat is it,
has it worked, and if so where?
Iain Macfarlane (Atos Origin)
SCIMP Conference_03 November 2009
4
The service improvement context
There are multiple improvement outcomes to be
achieved Primary Care has a vital role to play.
5
The service improvement context
There must be a focus on delivering balanced,
affordable and sustainable quality improvements.
Safe Avoiding injuries to patients from the care
that is intended to help them
?
Safe
Effective Improving clinical decision making,
supporting multidisciplinary care and supporting
clinical audit
?
Patient Centred
Effective
Timely Reducing waits and sometimes harmful
delays for both those who receive and those who
provide care
?
Delivering balanced benefits for our patients
Efficient Avoiding waste, releasing time to
care, and reducing unnecessary expenditure
?
Equitable Providing care that does not vary in
quality because of personal characteristics or
circumstances
?
Timely
Equitable
Patient Centred Providing care that is
respectful of, and responsive to individual
patient preferences, needs, and values
?
Efficient
6
An appropriate blend of tools and methods is
required
gtgt Kaizen gtgt 8 Types of Waste
gtgt Quick Changeovers gtgt Spotlight
Continuous Improvement
Performance Measures
gtgt Maturity Matrix
gtgt Key Performance Indicators
Built In Quality
gtgt 7 Quality Tools
gtgt Poka Yoke
gtgt Demand Smoothing gtgt Pull Systems gtgt Cell Design
gtgt Takt Time gtgt Kanban gtgt Value Stream Mapping
Flow
gtgt 5 Whys gtgt Root Cause Analysis
gtgt Pareto Analysis
Problem Solving
Standardisation
gtgt Standard Work gtgt 6S gtgt Work Sequencing
gtgt Activity Sampling gtgt Visual Control
Management gtgt Total Productive Maintenance
Standardisation
7
The focus must be on continuous service
improvement
Continuous Improvement

• Reducing Waiting Times

• Enhancing Patient Safety

Performance Measures

• Releasing Time To Care

• Improving Patient Experience

Flow
Built In Quality

• Shifting the Balance of Care

• Achieving Financial Balance

Problem Solving

• Promoting a Performance Culture

Standardisation

• Accelerating and Sustaining Benefits

8
Some reflections on the impact of applying Lean
Cataract Pathway
Productive Ward
Health Board Whole System

• Significant results have been achieved. We are
  looking at productivity gains of up to 40, with
  waiting times slashed
• Operations Director

• For the first time, there is now a validated
  map of our entire health system. The where, how
  and why of major bottlenecks in the system is
  better understood, as are all the
  interdependencies
• - Director of Change Innovation

The impact on our people was the most positive
outcome. Improvement is now part of our everyday
language, not lean jargon its just the
method - General Manager
Knee Pain Pathway
Cardiology Pathway
GP Practice Improvement
I have found the Lean approach to be the fastest
way for an individual or team to move to a
position of positive engagement in a process of
change and get positive results -
General Manager
The whole experience has been invigorating,
resulting in an excellent solution to our access
issues. The best week Ive had in years of
being a GP - Senior GP Partner
I am so impressed this project has achieved such
potential improvement opportunities. The
techniques were incredibly powerful in persuading
those who needed to be brought on side that
things had to change - Service Manager
9
gtgt Increasing Productivity

• Business challenges
• The Trust was challenged to improve productivity
  by both saving cost and increasing throughput
• The Cataract pathway was chosen as a pilot due to
  its high volume
• The client particularly wanted to test lean
  thinking as to whether it was the solution to
  their business issues
• Solutions
• One day awareness training followed by a one week
  workshop with the client subject matter experts,
  full time
• The end to end process was analysed with the team
  and all waste was identified and actioned
• Benefits
• 40 increase in output/productivity
• 344k increase in contribution
• 15 week reduction in throughput time end to end

The Mid Yorkshire Hospitals NHS Trust Mid
Yorkshire Health Trust controls 4 major
hospitals in the region. They have spent two
years undergoing a transformation programme and
were looking for a process to take them to the
next level
50 REDUCTION IN CATARACTSTREATMENT TIME
10
gtgt Reducing Waiting Planned Care

• Business challenges
• NHS South Central aimed to meet the national
  target that no-one will wait longer than 18 weeks
  from GP referral to hospital treatment
• The Transforming Care programme was set up to
  use Lean Thinking to redesign patient pathways so
  that they will deliver sustainable sub-18 weeks
  waiting time
• Solutions
• We designed a tailored approach for South Central
  and agreed this with the client. The programme
  deployed Lean Thinking to minimise quality
  failures and increase productivity
• Benefits
• Redesigned Patient Pathways 27 high priority
  patient pathways redesigned to provide more
  efficient and effective care
• Average 14 week reduction in RTT
• Between 30 and 70 increase in capacity
• 3000 additional outpatient appointments per annum
• Between 50 and 95 reduction in DNAs
• Cancellations on day reduced by up to 66 
• Significant patient experience and safety
  benefits
• Significant cost reduction, including CRES

2009
14
WEEK RTT REDUCTION ACROSS ALL 27 PATHWAYS NHS
South Central Strategic Health Authority South
Central SHA was established in July 2006 and
comprises nine primaryCare Trusts and serves a
population of 4.5M
11
gtgt Reducing Waiting Unscheduled Care

• Business challenges
• The client was consistently failing to meet the
  DoH 4 hour turn around time for 98 of patients
  presenting to ED. This is both a patient care
  requirement and an enabler to achieve a
  foundation trust status
• Solutions
• The first step was to gain consensus across the
  Trust of the reasons for breach and commitment
  Trust wide to work as a team to resolve
• The next future state for emergency care
  determined that
• - Blood tests would be processed within 56
  minutes, mainly through single piece flow of ED
  specimens, visual management and line balancing
  in Pathology
• - Time waiting for clinical assessment in ED
  could be reduced by re-rolling of non-clinical ED
  staff, visual management, introduction of patient
  prep team, and revising test guidelines
• - Internal bed transfers would be streamlined by
  providing real time status information, and by
  implementing a range of improvements across
  planning, portering and cleaning
• - Discharge processes would be streamlined and
  policies amended
• Benefits
• At least 98 of ED patients are seen and admitted
  or discharged within the required 4 hour
  guideline. This is a 20 improvement on previous
  performance
• Flowblockers are captured and new processes
  improve the performance continually

98
OF AE PATIENTS TREATED WITHIN4
HOURS Southampton University Hospitals NHS
trust Southampton University Hospital Trust
(SUHT) is a non foundation Trust reporting to the
South Central Strategic Health Authority
12
gtgt Releasing Time to Care

• Business challenges
• NHS Lanarkshire required sustainable savings in
  all resources especially clinical time, with an
  initial focus on Orthopaedics Wards
• The SGHD wanted to demonstrate how Lean
  Techniques could help drive productivity
  improvement (Release Time To Care)
• A repeatable approach that could be applied at a
  ward or unit level was required
• Solutions
• A 3 week assessment and support model ensured
  sustainable skills transfer
• A 1 day Lean awareness training programme
• Value stream mapping, waste identification
• Immediate implementation of quick wins
• Benefits
• 400 Hours released to care by single ward
• Significant savings in medical supplies
  identified
• Reduction in patient transfer and admin time
• Sustained benefits and continuous improvement

gt400HOURS
RELEASED TO CARE BY SINGLE WARD
NHS Scotland - Lanarkshire
Ensure Space isUtilised as Effectivelyas
Possible and Stock Management is Optimised
Map Current State Processes, Identify Waste and
Agree Prioritised Next States
Ensure Equipment Is Best Positioned To Support
Efficient and Safe Patient Care
13
gtgt Improving Theatre Utilisation

• Business challenges
• Increase theatre utilisation for General Surgery
  from 69 to 85
• Redesign the General Surgery pathway to achieve
  an 18 week referral to first treatment time
  (RTT) the pathway was 27 weeks
• Improve the efficiency and effectiveness of the
  theatre workspace
• Move to a can do Lean culture
• Solutions
• A redesigned patient pre-assessment process
• A new theatre planning and performance management
  framework
• Reorganisation of theatre workspace to make it a
  safer and more productive environment
• Benefits
• Pre-assessment process resource used more
  effectively to streamline patient journey,
  increased patient safety
• Planning process capable of increasing theatre
  utilisation to 85 this will reduce theatre wait
  times from 16 weeks to 8 weeks
• Sustainability the NHS team has an improved
  working knowledge of Lean methods to take this
  work forward

16
INCREASE IN THEATRE UTILISATION NHS Tayside
14
gtgt Improving Response Times (Blue Light)

• Business challenges
• Ambulance service failing to achieve national
  targets for Category A and B response times
• No agreement between PCT Commissioners of funding
  required to achieve national targets due to an
  unclear view of operational and financial
  performance, efficiency and value for money
• Solutions
• Operational and financial analysis to determine a
  baseline performance and opportunities for
  improved efficiency
• Agreement of minimum and stretch ROI to be
  achieved
• Benefits
• Formulation and consensus agreement of a Trust
  owned 2 year programme plan to achieve national
  targets by
• Delivering the workforce / increasing front-line
  capacity
• Minimising costs
• Improving processes / reducing waste activities
• Improving infrastructure
• Focusing and enabling people to deliver
• Future service delivery model
• Agreement amongst PCT commissioners and Ambulance
  Trust on improvement priorities and how success
  will be measured
• 2.5M Ambulance Trusts efficiency improvements
  agreed as target based on the evidence base
  presented

8minutes TO REACH CRITICAL PATIENTS
15
gtgt Improving Access Primary Care

• Business challenges
• Improving the patient experience, in particular
  making it easier to get the appointment they want
  and providing better systems and processes to
  enable faster access
• Ensure a better balance between patient demand
  for appointments and clinical capacity to provide
  them
• Absorbing the workload from a retiring Senior
  Partner without replacing with additional
  headcount (12,000 patient practice)
• Over 30 of patients visiting the practice, do so
  for non value adding prescription related
  activities (dropping off/picking up etc.)
• Booking systems not being used as designed
• Low staff morale and significant pressure on all
  staff (clinical and non-clinical) as dealing with
  excess demand for services

100 OF PATIENTS GET GP CONSULTATION IN lt 48 HRS
Milton Keynes GP Surgeries All 5 Milton Keynes
surgeries are funded partnerships, reporting to
the MK PCT, with 20 GPs and a combined patient
base of approximately 40,000.
16
gtgt Improving Access Primary Care
When we were first approached to be involved in
the Lean Project, we signed up as we wanted the
opportunity to help improve our appointments
systems. We were optimistic about the process
but also had a degree of scepticism as this is an
area that we as a business had tried to improve
already. Now at the end of the project we feel it
has been very successful in many areas. The main
is that it has involved all staff along the way
and this has helped increase team work and
ownership in the practice and team morale has
improved significantly - Dr. Moore (Lead GP)

• Solutions
• Training in Lean skills across all staff to
  empower ideas for improvement culture
• Improvement focus on access and managing demand
  to available capacity improve throughput and
  experience
• Appointment booking process redesign so that any
  patient requiring an On the Day appointment
  with a GP is asked to leave their details. The
  patients own GP will then deliver a 5 minute
  telephone consultation before deciding to
• take no further action (Telephone consultation
  was sufficient)
• book a 5 minute follow up face to face
  appointment with patient
• book a 10 minute face to face appointment with
  the Minor Illness Nurse
• An unmanned repeat prescription desk and drop off
  box was established and patients are actively
  encouraged to pick up all repeat prescriptions
  directly from local pharmacy
• A standardised process for using Choose Book
  was developed and adopted by all GPs
• 34 Lean Quick Wins completed including
  optimised reception layout

17
gtgt Improving Access Primary Care

• Results
• Improved patient access to the most appropriate
  clinical resource. Results include
• 96 of patients are now getting an appointment on
  the day they request
• 100 of patients can expect to consult with their
  GP the same or next day
• Consultation capacity has increased by 32 or one
  third without the addition of new GP resource
• 60 of patients requesting appointments no longer
  need to be seen by a GP
• 50 of patients only require a 5 minute telephone
  consultation (vs. 10 minute face to face
  appointment).
• 17 of patients can be handled by the Minor
  Illness Nurse
• 84 of patients prefer the new appointment
  booking process
• At a cost of 8 hours additional minor illness
  nurse capacity, the new appointment booking
  process has created 27 hours of additional GP
  capacity
• Improved patient access to surgery services such
  as appointments, test results and prescriptions
• Improved matching of demand to available capacity
  resulting in increased throughput and experience
  (patient and staff)
• Improved staff morale and empowerment to propose
  ideas for improvement

Instead of our patients having to fight at
reception to get an appointment, we put the
expert the doctors themselves at the front
line. We knew we had to do something fairly
radical and it has undoubtedly paid off Rod
Marshall - Practice Manager
18
Innovative Use of IT in Primary CareForget the
future, whats out there now?
John Crawford (IBM)
SCIMP Conference_03 November 2009
19
How might universal access to broadband by 2012
(Digital Britain) reduce the pressure on primary
care services? What can we learn from
connected health initiatives in other
countries?

• Technology-driven primary care practices
• Patient Centred Medical Home
• HelloHealth Myca
• Telemonitoring as part of long-term condition
  management
• Participatory Medicine - a new movement in
  healthcare?

20
The Patient - Centered Medical Home (PCMH)
provides care that is accessible, continuous,
comprehensive and coordinated and delivered in
the context of family and community. 1
Principles of PCMH

• Patient-centric
• Medical team approach
• Whole person orientation
• Coordinated and integrated care
• Emphasis on quality and safety
• Enhanced access
• Appropriate reimbursement

Personal Relationship with Care Team

Proactive Focus

Holistic Systems Clinical Integration
Source (1) www.medicalhomeinfo.org/join20stateme
ntpdf
21
High - level Technology Components of a Patient -
Centred Medical Home Solution (A platform to
deliver connected health)
Collaborative Care User Interaction
Patient Portal
Care Team Portal
Wellness Disease Management Dashboards
Business Technology Services
Process Management
Strategy Change, Implementation, Hosting,
Application Management,Help Desk
Work Flow Engine
Business Rules Manager
Information Management
Analysis Discovery
Information Integration
Data Model Design Deployment
22
Patient - Centered Medical Home
Download study atwww.ibm.com/healthcare/medicalho
me
23
HelloHealth and Myca

• HelloHealth (http//hellohealth.com/)
• A more convenient way to access and pay for
  primary care services
• Online self-registration
• 35 a month membership fee
• 100 - 200 per hour for online or in-person
  consultations
• Myca (http//www.myca.com/)
• A web-based platform to enable new forms of
  patient interaction
• Electronic health record
• Practice management
• Social networking collaboration (appointment
  booking, feedback etc)

24
Communication from the European Commission on
Telemedicine for the benefit of Patients,
Healthcare Systems and Society - COM(2008)689

• A challenge from the European Union to member
  states response due March 2010
• Section 2.1. Telemonitoring a major opportunity
  for chronic disease management
• Telemonitoring is a telemedicine service aimed at
  monitoring the health status of patients at a
  distance.
• Data can be collected either automatically
  through personal health monitoring devices or
  through active
• patient collaboration (e.g. by entering weight or
  daily blood sugar level measurements into a
  web-based
• tool). Data, once processed and shared with
  relevant health professionals, may be used to
  optimise the
• patient's monitoring and treatment protocols.
  Telemonitoring is particularly useful in the case
  of
• individuals with chronic illnesses (such as
  diabetes or chronic heart failure). Many of these
• patients - who are often elderly people - need
  regular monitoring because of the prolonged
  duration of
• their disease, the nature of their health
  condition and the drugs that they are using.
• Focus areas
• Building confidence in and acceptance of
  telemedicine services
• Bringing legal clarity
• Solving technical issues and facilitating market
  development

25
Telemonitoring - Continua Health Alliance and
IBMs role

• Continua Health Alliance is a non-profit, open
  industry coalition of healthcare and technology
  companies collaborating to improve the quality
  of personal healthcare.
• IBM joined when Continua first launched in June
  2006 (20 founding members).
• Now gt 175 members covering spectrum of healthcare
  solutions.
• Members cover entire spectrum of everything to do
  with personal healthcare.

26
Chronic Disease Management with
Telemonitoring(Diabetes demo, Boston, October
2009 - using Continua Health Alliance standards)
PAN
WAN
xHR
27
Participatory Medicine a new movement in
healthcare?

• Society for Participatory Medicine
  (http//participatorymedicine.org/)
• Bringing together e-patients healthcare
  professionals
• A cooperative model of health care that
  encourages and expects active involvement by all
  connected parties (patients, caregivers,
  healthcare professionals, etc.) as integral to
  the full continuum of care.
• E-Patients (http//e-patients.net/)
• Because health professionals cant do it alone
• A blog and a patient pressure group for change
• Journal of Participatory Medicine
  (http//jopm.org/index.php/jpm)
• A new peer reviewed, open-access journal launched
  22 October 2009

28
Evolution of Technology Enabled Participatory
Medicine
The imagined future (1924)
The real future? (2009)
Electronic Health Coach On-line Personal Health
Portal with health information,
personalised care plans, PHR with medical device
input, social networking, collaboration tools
Remote Consultations
29
The Limits of Participatory Medicine?
30
Iain MacfarlaneAtos Originm 44 (0) 7733
312779iain.macfarlane_at_atosorigin.com
Question Answer Session
John CrawfordIBMm 44 (0) 7802 916370
john_crawford_at_uk.ibm.com