Lean Healthcare

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Lean Healthcare

• Ann Esain
• esain_at_cardiff.ac.uk

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Ann Esain

• Head of the Health and Service Group at Lean
  Enterprise Research Centre, Cardiff Business
  School, Wales, UK
• Honorary Associate Professor Warwick Medical
  School
• Fellow of the The Improvement Faculty for Patient
  Safety and Quality Improvement (NHSi)
• Working in Healthcare since 2000
• UK Trusts/Local Authorities (whole systems and
  sub- processes)
• Thought Leadership for Modernisation Agency,
  NLIAH, NHSi, etc
• Flinders Medical Centre in depth visit 2005
• 2008/10 - EU project (Jens Dahlgaard)

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Outline

• Context Healthcare Trends
• Lean Healthcare
• Factors to consider
• Opportunities

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Current healthcare in the best the Western World
has seenLife Expectancy Increasing
1900 -1960 Public Health Initiatives (Safe
Water/Safe Food, etc) 1960 now Direct Disease
Treatment
Source https//www.cia.gov/library/publications/t
he-world-factbook/index.html.
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Hospital Stays Reducing, BUT
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The Motivation

• Rising Healthcare Costs
• While time in Hospital maybe reducing - the
  public dont want to have to wait
• Safety not aligned to other safety critical
  sectors
• Sweden Top Tier in the context of Healthcare
• UK and USA current focus
• Variation in Practice
• Often not doing what works - Reliably Pronvost,
  P (2009)
• Calls for Quality Improvement across the system
• UK health outcomes inequalities,
  inappropriate care, preventable injury/death

Source Brent C. James, Intermountain 2009
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What is Lean Healthcare?

• Applying lean principles to healthcare to improve
  patient care and safety
• Redesigning healthcare systems and processes to
  improve response, quality and safety.

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Improvement Stages
Three tasks Follow a standard (Maintenance) Cha
llenge a Standard (C.I) Catchball ideas for
future and respond (Policy)
Rich, at al (2006) Lean Evolution, Cambridge
University Press
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Top 10 Reasons for Failure

• Lack of a clear executive vision
• Lack of an effective communication strategy
• Failure to create and communicate a real sense of
  urgency
• Poor consultation with stakeholders
• Lack of structure methodology and project
  management
• Failure to monitor and evaluate the outcome
• Failure to mobilise change champions
• Failure to engage employees
• Absence of a dedicated and fully resourced
  implementation team
• Lack of sympathetic and supportive Human
  Resources policies
• (Lucey, Bateman and Hines, 2005)

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Survey on CSI with 19 Acute Trusts and 10 PCTs
in England

• Command and Control culture can obstruct
  engagement
• Methods for knowledge transfer are mainly
  traditional (staff involvement v top down
  communication)
• Most improvement is focused on targets
• Strong focus on cost rather than quality
• Improvement techniques applied are variable and
  mainly project based rather than system based
• Strategy and Improvement are poorly linked
• Walley, Rayment and Cooke, 2006

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Characteristics of Best Performers

• Strong leadership enabling difficult and
  sensitive change
• Senior Managers with a strong awareness of
  process and systems issues
• Receptive workforce to new ideas with no change
  fatigue
• Strategies deployed as a means of reconciling
  conflicting long and short term priorities
• A critical mass of capacity in improvement
• Management style which encourages staff driven
  improvement
• Walley, Rayment and Cooke, 2006

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Staying Lean
The Lean Iceberg Model (Hines et al, 2008)
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Five Principles of Lean Healthcare

1. Understand specify what our customer/patient
   want value.
2. Identify the value stream or patient journey
   eliminate waste
3. Make the process and value flow according to the
   needs (pull) of the customer/patient
4. Involve empower healthcare staff
5. Continuously improve in pursuit of perfection

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What the Patients wanted.Value

• No waits treatment results
• Appropriate information throughout the process
• Bed available when needed
• Private changing facilities
• Clean environment
• Know whats wrong
• Treated kindly by friendly staff
• Reduced duplication
• Not to be moved from one waiting area to another
• Relatives/carers kept informed appropriately

Same as other Lean projects
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The enemy of value comes in different forms
Hines et al 2008
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Waste Reduction Targets for National Priorities
Partnership

• A partnership between the National Quality Forum
  and 28 other organizations

Inappropriate medication use Targeting inappropriate antibiotic use and polypharmacy (for multiple chronic conditions of antipsychotics).
Unnecessary laboratory tests Targeting panels (e.g., thyroid, SMA 20), special testing (e.g., Lyme Disease with regional considerations).
Unwarranted maternity care interventions Targeting unwarranted cesarean section.
Unwarranted diagnostic procedures Targeting cardiac computed tomography (non-invasive coronary angiography and coronary calcium scoring), lumbar spine MRI prior to conservative therapy, without red flags, uncomplicated chest/thorax CT screening, bone or joint x-ray prior to conservative therapy, without red flags, chest x-ray, preoperative, on admission, or routine monitoring, endoscopy.
Unwarranted procedures Targeting spine surgery, percutaneous transluminal coronary angioplasty (PTCA)/Stent, knee/hip replacement, coronary artery bypass graft (CABG), hysterectomy, prostatectomy.
Unnecessary consultations
Preventable emergency department visits and hospitalizations Targeting potentially preventable emergency department visits, hospital admissions lasting less than 24 hours, and ambulatory care sensitive conditions.
Inappropriate non-palliative services at end of life Targeting chemotherapy in the last 14 days of life, inappropriate interventional procedures, and more than one ED visit in the last 30 days of life.
Potentially harmful preventive services with no benefit Targeting BRCA mutation testing for breast and ovarian cancer female, low risk, CHD Screening using ECG, ETT, EBCT adults, low risk, carotid artery stenosis screening general adult population, cervical cancer screening female over 65, average risk female, post-hysterectomy, prostate cancer screening male over 75 (from the U.S. Preventive Services Task Force D Recommendations List).
National Priorities Partnership.
http//www.nationalprioritiespartnership.org/about
npp.aspx
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• .we must never forget that safety is the
  foundation of all our activities
• Taiichi Ohno

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Relation of Value, Cost/Waste
Cost-Value Equilibrium
x
Customer Perceived Value
x
Creating Lean Solutions 1. Reduce Internal
Waste 2. Develop Customer Value
Waste/Cost (of product/service)
Hines et al (2004) Learning to Evolve, IJOPM
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Hospital AValue Stream (End to End)
PACE every 12mins patient Discharged 24/7
General Medicine
These 2 patient Flows represent 63 of demand
Community - SW
PACE 1.5 patients a day
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PACE every 26mins patient Discharged 24/7
General Surgery
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20 patients of these types could be seen with
redesigned systems
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Good processes should be short and all in this
area
Store
Inspect
Transport
Operation
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DEMAND
Admissions
Main Patient Flows - Gen Surgery, Gen Medicine
PACE Pattern
Recruitment
Medical Records
Radiology
Linen
Pharmacy

Echo
I.T.
Telephony
Procurement
Initial Measurements e.g. 80 patients with
predicted LOS Discharge before 10
am Projected Daily Empty Beds
Aligned initiatives to critical path of the Main
Value Streams Remove Waste Activity to Expose
Capacity
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The Logic of Lean

• Quality Improvement will
• Reduce opportunity for error (safety)
• free up capacity
• High volume, short interval activity improvement
  of minutes equal hours of more capacity Use
  PDSA (discipline, measurement/evidence for
  feedback - learning)
• Free capacity redirected to more value activity
  and more complex
• Elimination of failure demand
• Poor information
• Return episodes

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Reduced Length of Stay as a proxy for Quality and
Safety
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Patient Flow Systems View
Home
Patient
GP
Acute Hospital
Community Hospital
Social Services Package
Feedback?
Demand
By Day
Demand predictable by day (pace). Demand impacts
on flow is constipated by strangers
No of Patient
No of Days (LOS)
Vast majority of patients could be short stay,
but constrained by strangers
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NHS Modernisation Agency (2004)

• Reduce the number of steps
• Understand patients needs
• Map the process
• Line up the process

Waste
Value
Value Stream
you could free up 12-20 of current capacity to
address waiting times
Flow
Capacity Demand
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Need to remember

• .the evidence found was of people in health
  and social care working very hard. But they are
  working within systems which militate against
  good performance, and where there is excellence
  in our view it is despite rather than because of
  the system.
• Wanless 2003

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www.leanenterprise.org.uk
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Preliminary Classification of Lean Healthcare
Point to Organisational End to End Organisational End to End to Systematic Across Org. Boundaries
Sweden Karolinska hospital, Stockholm Sahlgrenska hospital, Gothenburg St Göran Capio hospital, Stockholm Lund university hospital
UK Guys and St Thomas (Dr Fosters 2009 High Patient Safety) Good Hope Hospital (Graban, 2008) Luton and Dunstable (NAO, 2009), 53 English Hospitals claim some lean initiative (Burgess et al, 2009) Southport and Ormskirk Blackpool, Flyde and Wrye (Shingo). Brighton and Sussex (Dr Fosters, 2009, High Patient Safety) Shrewsbury and Telford Plymouth Blackpool Flyde and Wrye (Burgess et al, 2009). Bolton (Burgess et al, 2009), North East (Erskine, et al, 2009), Royal Devon and Exeter (Shingo), Gwent (Esain, et al. 2008 Dan Jones)
USA University of Pittstsburgh Medical Center (Spear, 2009), Massachusetts General Hospital (Spear, 2009), Allegheny General Hospital (Spear, 2009), West Penn Allegheny Hospital (Spear, 2009) The Mayo Clinic (Spear, 2009, Leapfrog, 2009),Virginia Mason Medical Centre (Leapfrog, 2009 Spear, 2005 2009, AQS), Seattle Children's (AQS), Park Nicolett (AQS), Avera McKennan (AQS), Deaconess Medical Centre (Leapfrog, 2009) Ascension Health (Spear, 2009), Intermountain, Kaiser Permanente (leapfrog, 2009), Thedacare (Shingo, AQS)
Spain Fundacion Hospital Calahorra Catalonia Healthcare network with acute, chronic and social care institutions
Spear 2005 'in healthcare, no organisation has
fully institutionalised to Toyota?s level the
ability to design work as experiments, improve
work through experiments, share the resulting
knowledge through collaborative experimentation
develop people as experimentalists. Used to
classify Hospitals -'systemic'
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Thank You

• Ann Esain
• esain_at_cardiff.ac.uk
• 44 2920 647028