1. Making Kings First Choice for patients and staff A Programmatic Approach to Transformation David J Dawson – Deputy Director of Service Transformation Karl Douglas – Senior Change Leader Lean Enterprise 2 nd October 2006

2. LOX-GNH053-20060905-PROB Contents What is First Choice Programme and why did we start this journey? What is the philosophy of First Choice and what are some of the key enablers? What does some of our work look like and is it producing results? What have we learned and how are we reapplying the learning? What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?

3. LOX-GNH053-20060905-PROB Kings is a busy teaching hospital rooted in the local community Major, complex university teaching hospital Turnover of £385 million 5,000 staff Over 900 beds Local emergency services Local, regional and national elective work Economically deprived & ethnically diverse local population Strong links to local public, patients & primary care

4. LOX-GNH053-20060905-PROB Kings must change if it is to cope with policy trends Market reform Patient care Quality Cost Access Care delivery Increasing emphasis on demand management and integrated care 4 5 Drive to increase productivity 3-fold increase in funding 98- 08 – but leveling out from 2008 onwards 1 Funding issues 2 Creation of a contestable market / patient choice 3 Increasingly open and transparent regulatory environment Market Reform Foundation Trust application Financial and performance targets Rising local demand Kings Position

5. LOX-GNH053-20060905-PROB In 2005 the Trust invested in the First Choice Kings Programme to deliver a set of objectives 1CK objectives 1.Improve on the already excellent quality of care 2.Make the patient experience for Kings patients more positive 3.Create a culture and capability of continuous operational and managerial improvement 4.Deliver a step change in financial efficiency by 2008 1CK targets 1.Reduce ALOS 2.Comply with 18 weeks 3.Increase patient satisfaction 4.Build team of 80 Change Agents 5.Reduce cost per spell Change Leaders team McKinsey Service based teams Marketing & branding Convenience and access Environment Communication and care Improvement capability building Cross-hospital enabling projects Performance Management Finance processes Service-based transformations GMCCSLiverCHTBC

6. LOX-GNH053-20060905-PROB Contents What is First Choice Programme and why did we start this journey? What is the philosophy of First Choice and what are some of the key enablers? What does some of our work look like and is it producing results? What have we learned and how are we reapplying the learning? What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?

7. LOX-GNH053-20060905-PROB We have come to see that a hospital is in some ways similar to industry and that we can learn Infrastructure Processes People Materials and products Hospital Manufacturing Industry

8. LOX-GNH053-20060905-PROB We use a suite of transformation tools to balance action in three organisational dimensions Operating System Management Infrastructure Mindsets, Capabilities & Behaviours

9. LOX-GNH053-20060905-PROB We underpin the programme with enabling projects – Performance Management (1)

10. LOX-GNH053-20060905-PROB Shadow of the Leader (Senn-Delaney) We underpin the programme with enabling projects – Performance Management (2) Process Confirmation and a Go & See approach Process confirmation is the standardised way by which managers go and see that the process is delivering its target condition and where it isnt, understand and act on the root causes When, where and how to do PC is rigorously defined for all managers, from CEO to sisters It is always done at the shop floor, where the care is given and value added to the patient The exact standard of working, giving care, maintaining areas What is process confirmation? Process confirmation Trust Mgmt Ward Manager & Matrons G-grades Team leader Quarterly Level Wards ShiftDailyWeeklyMonthly Weekly meetings Monthly review Daily work Brief and debrief Quarterly review Frequency

11. LOX-GNH053-20060905-PROB We underpin the programme with enabling projects – Improvement Capability Building 1400+ hours of training delivered by Change Leader Team Change Agents (70–90) Change Leaders (8–10) Executive Institutional Capability Improvement Capability Improvement organisation design Improvement methodology Formal training infrastructure and materials Coaching and individual performance management Explicit capability-building and tracking processes Change agents Individual Capability Change leaders

12. LOX-GNH053-20060905-PROB Contents What is First Choice Programme and why did we start this journey? What is the philosophy of First Choice and what are some of the key enablers? What does some of our work look like and is it producing results? What have we learned and how are we reapplying the learning? What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?

13. LOX-GNH053-20060905-PROB We started our transformation journey in General Medicine where there were acute problems Too big a problem Permanent bed crisis Budget – overspent Income – threatened in other specialties Capacity – constantly expanding Market reform Emergency demand – increasing Target – 4 hours maximum time in A&E to be maintained Control – silo mentality Site – split across 2-sites Trust View Outliers – 20 to 60 per day Cancellations - elective and tertiary work squeezed out

14. LOX-GNH053-20060905-PROB Spells Bed days 7,004 99,661 28+ 8-14 3-7 2 LOS (days) 100% = 15-27 *i.e., 5 day LOS reduction in 15-27 segment, 3 day LOS reduction in 8-14 segment, 1 day reduction in 3-7 segment Source:KCH PIMS database, team analysis ALOS was 14.2 days Outliers averaged 40 per day with min of 21 and max of 58 Spells with LOS > 28 days are only 13% of total but account for 62% of bed days. A 10 day (15%) reduction in LOS in this group would reduce ALOS by 9% to 12.9 days Spells with LOS between 3 and 27 days are also important but do not by themselves deliver the LOS reduction target ALOS by group 67.9 19.9 10.7 4.4 1.0 We analysed current state rigorously and learned surprising things Results

15. LOX-GNH053-20060905-PROB Management structure was diffuse and informal with few understood responsibilities * Not line accountable Senior management team Lead Consultant Lead Consultant (GI) Firm Chief (Firm C) Firm Chief (Firm B) Medical Therapies Nursing Ops/Admin Head of Nursing (A&E) Director of Therapies Firm Chief (Firm A) Matron Administrative Manager Outpatient Admin Mgr Lead Consultant Bowley Close Head of Physiotherapy Outpatient Serv Dev Mgr Bed Capacity Manager HR Manager* Finance Manager* Business Manager Recruitment Coordinator Junior Drs Hrs Coordinator Assistant Business Mgr Key features No overall objectives Operational accountability only with General Manager No formal operational accountability in Firm No formal operational accountability in wards No real responsibility for LOS at any level Firms & wards specialist silos Dislocation between Drs / Nurses / Admin / therapies - blame Some areas outside influence of senior management No meeting or information cascade Clear professional lines of accountability for nurses and physicians Chief Exec. Dir. Ops Head of Nursing (GM) General Manager Dir. Med.Dir. Nsg Clinical Director Operational line accountability Professional accountability

16. LOX-GNH053-20060905-PROB We found that we could categorise medical patients in two ways and provide tailored care regimes Accident & Emergency Patient Streamed at admission Category 1 Ward Category One Patients Single condition presentation Requires input from doctor, nurse and X1 therapist Standard discharge needs Category 2 Ward Category Two Patients Complex presentation with multiple pathology Requires input from clinical teams Complex discharge needs

17. LOX-GNH053-20060905-PROB Results from General Medicine are now clear and financially important to the Trust –Patients classified by expected LOS and streamed from A&E to designated wards –Bespoke MDMs for longer stay patients are in effect with improved meetings management –A&E maximum wait of 4h sustained through daily care group review of intake at lunchtimes in A&E –Redesigned consultant driven on-take arrangements improved continuity of care and aided earlier discharge of very short stay patients –Dulwich move executed successfully and on time –New multi-specialty two-firm structure with linked wards organisation structure replaced old speciality based divisions. Firm leaders – 1 consultant and 1 senior nurse –The cascade of performance meetings is in place with revised meeting calendar and terms of reference. Scorecards revised at CG and Firm level to drive the identified care group improvement needs Contributing SolutionsResults ALOS reduced by 20% Average daily outliers down by 59% 30 beds closed Normal winter allocation of 15 extra beds not used Savings £3.3 million and ward closed

18. LOX-GNH053-20060905-PROB GP Referral C/T: 10 mins No. of GPs : 600 No. of Clinics: 4000/wk Time/clinic: 4 hrs Patient Sees Consultant C/T: 15 mins No. of Clincs :18/wk Time/Clinic: 3.5 hrs Pre- Assessmt C/T: 20 mins No. of Clinics : 8/wk Time/Clinic: 3.5 hrs Admission to Ward C/T: 21.5 hrs Capacity : 7 x 22 bed days X Ray C/T: 5 mins No. of Clincs :18/wk Time/Clinic: 3.5 hrs Util : 65% In-Patient Surgery C/T: 111 mins Time Available: 5 x 24 hrs C/O: 15 min Util : 75% Daily Referrals Daily Weekly Demand: 42 Weekly Demand: 1000 Customers Elective Care Population Suppliers Elective Care Population Orthopaedics - Elective Confirmed Appts Recovery C/T: 30 mins Time Available: 5 x 24 hrs No. of Beds : 8 Ward Care C/T: 4 days Capacity : 7x 22 bed days Util : 93% Patient Sees Consultant F/U C/T: 10 mins No. of Clinics :18/wk Time/Clinic: 3.5 hrs EPR Galaxy PIMS Choose & Book 10 min15 min5 min10 min 20 min1290 min111 min30 min 5760 min 3.6 days50 days.1 days01 days132 days15 days2 days Processing time Lead time For longest stream = 7251 min = 7% 202.8 days 12 1275 10 150090 130 3150 F/U Improvements to operational performance can… 23% in clinic throughput (orthopaedics) 17% in theatre throughput (orthopaedics) 5% ward LOS (~6 beds, at current activity, or stable bed-pool with activity to reach 18 weeks target) 8% ICU LOS (~80 bed-days) 6% HDU LOS (~100 bed-days) ~2,700 more DS conversions, incl. 1,800 CC&S (~15 ward bed reduction, of which 10 CC&S, at current activity) …deliver current activity with less resource …or deliver more activity with same resource* and reach the 18-weeks target Range of options in between Pre-requisites for performance improvements Participation and ownership of solution by surgeons and anaesthetists Strengthening theatre leadership by hiring a new theatre matron Appropriate resourcing of all workstreams with Change Agents (incl. theatre scheduling) Surgeon co-operation in scheduling additional patients in main theatres In Critical Care & Surgery extensive analysis of the current state identified improvement opportunities to reach the 18-weeks target

19. LOX-GNH053-20060905-PROB We designed a future state ….. Key elements of the future state 1.Establishing radically different scheduling in theatres and clinics: building lists that fully use available capacity, based on explicit, agreed-on standard times, and delivering against those lists 2.Helping staff work more effectively, with agreed-on, staff- developed protocols for key activities, clear roles and responsibilities, and better workplace and equipment layout 3.Improving performance management, with clear accountability for the end-to-end patient journey, better performance conversations and reviews, and appropriate individual and team incentives 4.Developing a different way of working together, based on shared valued, clear roles, a visual management system, and regular briefing and feedback 5.Becoming the leader in innovative outpatient care over time 6.Continuing day surgery conversion at an aggressive pace Outcome vision A dramatically better patient experience, delivered by motivated, capable, and well- trained staff working in high- performing teams, at levels of operational performance that allow Kings to be a national leader in innovative surgical care and high acuity elective care

20. LOX-GNH053-20060905-PROB Multi-Disciplinary focus on complex patient continuing care needs D-1 Focus on Discharge New processes work smarter rather than harder to ensure the patient journey is anticipated, planned for and supported by high quality care Morning brief Prepare for the days discharges Ward Team boards and issue sheets Scorecards Team problem solving Ward & Bed Boards Preparation for Theatre Ward Book Ward Boards Multi- Disciplinary Meetings TTAs, Pre-Packs & POD drugs control Prepare for next days Discharges Tracking of KPIs Process Confirmation Daily briefs Performance management 5S – Workplace Organisation Ward Rounds Surgery WARDS

21. LOX-GNH053-20060905-PROB Patients to be discharged identified the day before discharge TTAs written by ward pharmacist and confirmed by doctors Setting a standard for 11:00 am discharges brings new focus & discipline to ward processes CURRENT - 63% of discharges before 11:00am (for those patients fit for discharge) 2005 - 94% of discharges after 11:00am

22. LOX-GNH053-20060905-PROB Multi-disciplinary working is structured, consistent, pre- emptive and action orientated Complex cases with special needs on discharge identified on admission and continuously assessed through structured MDM process Attendance by a named link Social Workers Effective Social Services relationships established with training from them re: referrals Early identification and preparation of patients to be discussed Clear ownership Short structured approach with effective issue capture and follow up Link to ward visual management systems, team board & briefings 3% Bed Usage due to Discharge Delays against previous 8% No. of Patients who are medically fit for Discharge or Transfer No. of bed Days Lost / Week / Ward

23. LOX-GNH053-20060905-PROB Regular review of visual process information by front-line managers and their teams places them at the heart of improvement 1 Ward Team Board clearly visualising performance v target 2 Daily Briefing linked to team KPIs and issues raised 3 Issues listed on specific sheet and responsibilities assigned Tasks emerging from issues carried out within deadline agreed 5 Improved KPIs thanks to structured issue logging, follow up and review 12 344 Linked to CC&S Nerve Centre for work stream and Care Group reviews 5 Improved Ward Team communication through daily briefing and Team Boards 6 Process confirmation to ensure engagement, coaching and direct feedback, on the wards Regular and structured review at ground level 6

24. LOX-GNH053-20060905-PROB OPERATION DISCHARGE We are always asking – Is there a clear standard for the process ?

25. LOX-GNH053-20060905-PROB Contents What is First Choice Programme and why did we start this journey? What is the philosophy of First Choice and what are some of the key enablers? What does some of our work look like and is it producing results? What have we learned and how are we reapplying the learning? What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?

26. LOX-GNH053-20060905-PROB Key Enablers Executive drive and support has to be consistent and focused on delivery Up front quantified strategic context is key to structuring and prioritising effective transformation Care group organisational structures clearly linked to objectives and performance management is a key enabler to allow managers to drive transformation and make it part of day-to-day life – people need to be in place before, not after 1CK The leadership and engagement of clinicians transforms impact – things happen The introduction of flexible working to cope with natural variation and maximise value added time is key to breaking through current disabling process rigidities Care Group teams must have capacity and capability made available in order for change to be self sustaining (e.g., analytical skills). The energy and drive of middle managers can take the programme so far, however, front line management is key to delivering day-to-day and require development The consequences of not achieving / non-compliance or recognition for achieving / exceeding agreed objectives should be more explicit and enacted Specific 1 st Choice communications at programme and team levels spreads knowledge, gets engagement and liberates ideas. 1CK is meeting KPIs and is delivering some results, particularly where supported by key enablers. The programme is learning and new themes are emerging that should shape our direction …

27. LOX-GNH053-20060905-PROB Contents What is First Choice Programme and why did we start this journey? What is the philosophy of First Choice and what are some of the key enablers? What does some of our work look like and is it producing results? What have we learned and how are we reapplying the learning? What are some of the key questions for us (and others?) to consider in order to become a truly Lean health organisation?

28. LOX-GNH053-20060905-PROB There are key questions to resolve as we continue forward: For discussion Does the transformation journey really have to be so long and arduous? How do medical staff really become excited and central to the change effort? Pioneers arent enough – can frontline managers sustain success? What else do we need to do to become a truly Lean hospital?