David Fillingham Chief Executive Lean Healthcare – th March 2010 Experiences from a lean transformation – an English hospital

Fostering Joy and Pride: the Stroke Team

Stroke - Results CT Scan within 24 hours46%100% Patients on Acute Stroke Unit-99% Aspirin within 24 hours63%100% Physio within 72 hours Sentinel Audit Score 65% 60% 98% 92% Mortality rate Length of Stay

Stroke Mortality

Some encouraging early results Trauma – FNOF 31% mortality ; 33% Length of Stay ; 42% paperwork Stroke 92% Sentinel Audit Score, 23% mortality, 24% LOS Ophthalmology – New One stop shop – patient visits 50% ; High risk joint replacements – complications 85% ; Length of Stay 43% Pathology – Test turnarounds from x3 to x10 quicker; 40% floor space saving Laundry, Estates, Finance and others – six figure cost savings 30% of staff engaged in week long improvement events and 1000 completed “Green” training ….. But still only scratched the surface

How can we engage the whole Hospital in a 20 (+) year journey of transformation that will reinvent lean for healthcare and change forever the way that hospitals are run?

Background to Bolton Our Lean journey: : Building a system for improvement Redesigning every end to end process Creating a lean culture The Future: better health and better care at lower cost Reflections: mistakes, dilemmas and challenges

Bolton Population 270,000 Northern industrial town 12% ethnic minority population (>18% childhood population) Significant levels of deprivation and inequality Reflected in health status –SMR-Cancers – up to Circulatory disease – up to 136 Part of Greater Manchester – 2.5m population

Royal Bolton Hospital

About the Hospital Approximately 700 beds Busy emergency services – catchment about 310,000 3,200 staff £170m turnover Most secondary elective and non-elective acute specialties: »Medicine »Surgery/Urology »Orthopaedics »ENT, Ophthalmology, Oral »Children’s »Obstetrics »Diagnostics »A&E

Our Lean Journey

2004 – The case for change Substantial deficit Failing access targets Safety and quality problems Governance concerns Poor external relationships

P P P P V eople erformance ision & Strategy atients & Partners rocesses

Our Aims No avoidable deaths or harm No waste No defects/best experience Highest Morale Improved Health Best Possible Care Value for Money Joy and Pride

Our Lean Journey: Important Milestones Late onwards Early experiments - Trauma - Day Surgery Narrow & Deep vs Broad & Shallow EVSA Leadership for Lean Daily “BICS” BICS Academy Policy Deployment Urgent Care Transformation….with Bolton PCT Focus on productivity and on whole system redesign

: Building a system for Improvement

Characteristics Aim is to create a system for Improvement Based on “lean” principles, creatively adapted for the NHS At heart of our Business Plan – drives safety, quality and productivity Comprises tools, methods, management system and leadership Seeks to engage all staff in a long term cultural transformation

Improving Health Best Possible Care Value for Money Joy and Pride in Work Understanding Value Delivering Benefit Redesigning Care Learning To See The Bolton Improving Care System

VISUAL MANAGEMENT: 1 PIECE FLOW STANDARD WORK 6 S PULL SYSTEMS Move away from batching, Backlog and Queues. Reduce Variation & Complexity Clear to See: Straighten Sweep & Clean Safety Standardise Sustain Create signals To pull patients. Obvious when Something empty “ability to see the process” Linked series of “Cells” that embody Lean Tools/Principles

Redesigning every End to End Process

Why did we need to change stroke service? 2005/6 High mortality rate – SMR 122 Long length of stay – 43 days Stroke patients all over the hospital only 22% getting specialist care 13 beds for stroke off the main site Few specialised staff

Value Stream Map

Value Stream Analysis: Spaghetti Diagram We walk miles when we shouldn’t have to Things are not where they are needed (if they are even there at all) We have to look for the sick patients and they can be anywhere

Value Stream Analysis: Hand Off Chart 197 handoffs to discharge a patient! Duplication Frustration Huge source of potential error

Future State

VISUAL MANAGEMENT: 1 PIECE FLOW STANDARD WORK 6 S PULL SYSTEMS Direct admission A&E care pathway CT in A&E Bed management First 24 hours Roles and responsibilities Treatment rooms Dirty Utility High dependency on acute stroke unit Board rounds Planned discharges Early supported discharge “ability to see the process” BICS Redesign Aims to Achieve Improvement in …

De-cluttered and got rid of waste 6s areas on both wards Sluice Treatment room High dependency area on acute unit Store Room

The waste !!

The store room – after

Standard Work Operational policy,bed management Role of shift leader Board rounds First 24 hours Role of MDT staff Cleaning of commodes

Creating Flow Direct admission from A&E Hyper acute bay On ward rehabilitation Early Supported Discharge team

Visual Management

Fostering Joy and Pride Staff sickness reduced to 3% in stroke from 15% Awards and publicity National Clinical Director visit Very positive patient and carer feedback

“I can’t fault anything, it’s a very frightening time when you can’t walk,or even stand or sit up, but I’m slowly getting mobile and looking forward to going home’ “I can’t fault anything, it’s a very frightening time when you can’t walk,or even stand or sit up, but I’m slowly getting mobile and looking forward to going home’ Stroke patient April 2009

Trust wide goals Improvement activities Daily work Policy Deployment Mission Control and Information Centres Team problem solving and action Logs; Exemplar Wards; “gateways” Making Systematic

Daily Problem Solving in Lean Blood Sciences Lab

Patient Gateways A plan for every patient reviewed regularly Gateways to check all steps completed Reinforces evidence based practice Strengthens multi-disciplinary team working Bed-side handover involving the patient Real time problem solving and process improved staff morale

This graph shows the increased throughput for respiratory and complex elderly showing significant performance change

Monthly Data

Creating a Lean Culture

From To Top down/externally imposed targets Problems worked around or passed upwards Few leaders…who are always in meetings Management based on anecdote and politics Self devised goals and measures for improvement Root causes addressed at source Many leaders who constantly “Go and See” Management based on data and scientific methods

Fillingham’s Motivational Matrix Positive Negative Outlook on Life Disillusioned Sceptic Enthusiastic Pragmatist Embittered Cynic Naïve Idealist Grip on Reality HighLow

Converting the Sceptics Rigorous use of lean methods Convincing data Hands on experience….RIE weeks Reinforce through changed management system and leadership style A coaching culture The BICS Academy

BICS Academy

The Future: better health and better care at lower cost

Refocus our BICS effort – improve safety and quality and release “cashable benefit” Extend beyond the hospital…health and social care system transformation

Urgent Care Redesign End to End pathway redesign using lean Demand management in primary care Admissions avoidance: BCU and Rapid Response Acute Physicians based in A&E; rapid access medical and surgical clinics “Patient Gateways” and exemplar ward approach A&E attendances – down 3% Medical Non-Electives – down 3.5% Surgical Non-Electives – down 2.2%

Productivity Realisation Medical Urgent Care -D3/D4/B3/B4/C3 April - October 2008April – October 2009 Length of Stay (days) Occupancy (%) 96% 95% Patient Throughput Cost Avoidance / Potential Productivity Gain £1,403,936 Equivalent Beds Saved 9 Ward Closed for 3 months as part of cash releasing savings during same period

BICS enabled Savings 2009/10 Total Trust Savings£6.1M BICs Enabled£2.9M £K Including:- 3 month medical ward closure day ward into 5 day PIU108 Endoscopy208 Redesigned Outpatient processes227 Labs, Radiology and Therapies waste reduction 425 Estates services redesign256

Preventable ill health and avoidable hospitalisation are the biggest wastes in healthcare We aim to use Lean ( ) to redesign whole patient journeys Strengthen prevention and chronic disease management to reduce acute interventions “Lean” can build a shared culture and method for improvement across hospital, GPs, community services and social care Whole System Lean

Reflections: Mistakes, Dilemmas and Challenges

Mistakes: What we’d have done differently More emphasis on measurement and benefits realisation Better preparation before improvement events More rigorous design of improvement events and use of tools Earlier investment in “Academy” alongside improvement events Getting right balance between “events” and daily work Communicate, communicate, communicate

Dilemmas: Managing the Tensions “Staying on the pitch” vs delivering the transformation Celebrating success vs avoiding “over claiming” Directing from the top vs empowering frontline staff The “balance sheet” vs the “operating result” Systematic approach vs Making it Fun!

Challenges “We’re too busy to do this” “We’re not Japanese and we don’t make cars” “This improvement stuff is okay, but we’ve got targets to hit” “We’ll leave it up to the Service Improvement Team” “This will go away in a month or two when the Chief Exec reads another new book”

Countermeasures “No Time” “Not Japanese” “Not relevant” Not our job” “Flavour of the month” Create dedicated time and resources for frontline staff (this isn’t easy!) Reinvent “lean” for the healthcare context and culture Link lean to our biggest priorities and problems especially safety and quality Make it a fundamental line management responsibility Be prepared for a long haul – stay focussed, resilient and optimistic