lean programme information session - nhs improvement · 6 lean programme: application to join...

Lean Programme Information Session

6 February 2018

Agenda

Welcome and Overview

Adam Sewell- Jones, Executive Director of

Improvement

14:00

The Application Process

Julie Fitzgerald, Head of Consultancy NHS

Improvement

14:30

Doing Lean: myths, realities

and practicalities

Bruce Gray, NHS Improvement Lean

Specialist 15:00

Our Lean Experience Louise Brennan, KPO specialist at SaTH 15:30

Questions, answers and

discussion All 16:00

Welcome and Overview

Adam Sewell-Jones

6 February 2018


Julie Fitzgerald

6 February 2018


5

Information for

trusts launched

17th January

Information

Sessions

6th & 7th

February

Closing

date

28th

February

Assessment

shortlisting

and Visits

March

Announcement

of six trusts

End of

March

6

Lean programme: application to join cohort 1

Please fill in your details below (expanding the space below the questions to add your

answers – please try to keep each answer to 500 words maximum). Send your completed

application to [email protected] by midnight on Wednesday 28 February

2018.

Trust name:

Contact name for the programme:

Contact role:

Contact email:

Contact telephone:

Q1: Please explain why a lean approach to quality improvement is right for your trust’s development at

this time. What specifically do you want to achieve by implementing a lean management system?

A:

Circumstance of the trust

Understanding of lean

What are the drivers for implementing a lean management system

What do you perceive to be the benefits, risks and challenges of a lean management system for

your trust

Q2: Please describe the Board’s understanding of what the programme will deliver and specifically how it

will support delivery of the organisation’s existing strategy?

A:

What is the organisations’ existing strategy i.e to what extent is it built around QI

What is the Board’s understanding of a lean approach to delivering strategy

Describe the Board’s understanding of what lean transformation can deliver

Q3: Please set out how the trust Board and senior executive team will engage with the programme and

how the work will be integrated into the way the trust works. What commitment will the CEO, Executive

team and Board members make to ensure that a lean approach to management becomes the way the

organisation is run day-to-day?

7

A:

Understanding of the different management approach

Commitment to learning and adopting a different approach individually

Commitment to learning and adopting a different approach collectively

Willingness to support frontline staff in their improvement work and reduce/eliminate the barriers

that they will face

Commitment to release staff for training and improvement work

Q4: Please confirm that Executive team and Board members are able and willing to undertake the

necessary training associated with the introduction of a lean management system. We expect all

executives and non-executives to commit to leading in a different way, using lean management

techniques.

A:

Commitment to undertake training

Willingness to sponsor and get involved with RPIWs and other lean activities

Commitment to engage with Executive coaching around lean and personal effectiveness, so that

they become capable of coaching others

Understanding of implications of visible management and going to the genba

Q5: Board stability and long term commitment to the approach is a necessary condition for success.

Please describe the Board membership, non-executives’ length of time in office and remaining terms, and

any known upcoming changes, such as retirement or restructuring.

A:

Description of current state

Know or anticipated changes over next three years

Plans for changes in exec and non exec teams

Possibilities – horizon scanning

Q6: How is succession planned for both non-executive and executive members? Please describe how

commitment to a lean management system will be maintained over time.

A:

Will new recruits be asked to commit to this approach before appointment

Will lean training and induction be put in place as part of induction for new recruits

Q7: Please describe how the Board will approach securing clinical engagement and leadership in this

work?

A:

How is clinical engagement, medical and nursing secured in current work

Do you foresee any resistance from clinical colleagues and how would you plan to address this

Do you see any significant differences between current clinical engagement and that required for

lean transformation

If yes, how would you address this

8

Q8: How has the trust approached quality improvement previously, and has it had any previous

exposure to lean? What has been learnt from this and how will those lessons apply to the outcomes your

trust wants to achieve from this programme?

A: short summary

Q9: How is quality improvement work currently delivered in the trust? For example do you have a quality

improvement team in place?

A: short summary

What links are there between QI work and trust priorities/strategies

Q10: To secure long term organizational change, the trust will need to dedicate resources to operate the

management approach. What resources does the trust currently dedicate to facilitating and effecting

change? How will the trust resource the necessary requirements of the improvement and development

process?

A: short summary

Q11: If relevant, please describe how you would plan to implement lean and deliver this programme

across multiple sites.

A:

Ideas on priorities

Outline of challenges identified

Q12: Please outline any discussions the trust has had with its local health and care partners.

A: short summary

Q13: Please outline any other NHS Improvement programmes of work the trust is currently involved with.

A: short summary

Q14: Please confirm that you have included a copy of your Board-approved quality improvement

strategy.

A: attached

Doing Lean: myths, realities and practicalities

Bruce Gray

6 February 2018

Health Care – what is possible?

10

Virginia Mason Production System Success Stories

• Patient Safety Alert system

• reports used to take 3-18 months to resolve – most now processed <24hrs, as well

as increased patient safety & reduced professional liability claims.

• Nurses spend 90% with Patients Vs 35%

• Through using RPIWs to evaluate their work and make improvements

• Primary Care Achieves Positive Net Margins

• Turnaround time for lab results from 25 days for normal results to <2 days.

• Faster Revenue Cycle

• Days Revenue Outstanding in the clinic from 52.3 in 2003 to 29.4 in 2009

• (a US example, but a process is a process is a process)

• Hyperbaric Centre Increases Patient Capacity

• Used VMPS tools to design and build a new hyperbaric centre in existing hospital

space, saving $2m in construction costs and increased capacity from two to three

patients at a time, to as many as 20.

Ref: https://www.virginiamason.org/vmps#Benefits

d. Designing & developing the

NHSI Lean Model

c. elements of a lean

transformation system

b. Working

definitions

Plan on a page – lean transformation

a. core

beliefs

Ref: RAE Engineering Better Care – systems design

3-6 months Engagement starts

What is the

problem?

How does the

system

perform?

a. Core beliefs

12

From Toyota Production System (TPS)

• Kaizen (practised daily) – change for the better.

• Respect for people (society & the environment).

From The Little Book of Lean – Chris Cooper

• Dissatisfaction with the status quo.

• Humility.

• A belief that Lean works wherever work is done.

• ‘Gemba’ wisdom that is valued over theoretical knowledge.

• Leadership that believes all of the above.


NHSI Lean Model



b. working

definitions


a. core

beliefs



What is the

problem?

How does the

system

perform?

14

• Doing Lean:

– is the continuous improvement of the flow

of value via the elimination of waste by

the people who do the work, in their

workplace, under the caring guidance of

a teacher.

• Lean Transformation:

• Lean Leadership:

b. Working definitions – reflect…

Improvement will be easier and more likely to succeed by focussing

on & removing the non-value added activities (waste) than trying to

improve the value adding element

The 1st Big Idea

Typically in a process there is usually a very high proportion of wasteful activity

We often focus on the Value Adding parts because that is what we can see and measure

95% WASTE 5%

Value

Adding

Start

Identify the NeedEnd

Outcome

Non Value Adding

8 Wastes

16

17

• Doing Lean:


– changing the way an enterprise

approaches improvement and views its

potential, such that collectively, people

create ever-improving results and a

culture in which Lean principles are

routinely practiced and supported forever.



2nd Big Idea – by the people who do the work

18

19

• Doing Lean:



– the creation of direction that results in an

environment in which every member of

the enterprise is nurtured and

encouraged to practise Lean principle-

based improvement in support of True

North goals (Human Development, Quality, Time &

Financial).


2. Environment – Culture – Basic Thinking

5. Process

Improvement

3. People

Capacity

Capability

Development

1. Purpose and Strategy

4. Role of leaders and Mgrs.

- Management system

- Leadership behaviors

“You Don’t Understand Our Culture Here!”

Beliefs, behaviours & culture

c. Diagnostic & strategy deployment

Mission, values, guiding principles

Strategy

Diagnostic

Current State Ideal State (3-5 years)

Future State Plan for next 12-18 months

RIEs to get building

blocks of flow in place

Practising daily

improvement (PDI)

KPO

Level 3

Level 2

Level 1

Board

Staff


NHSI Lean Model



b. Working

definitions


a. core

beliefs



What is the

problem?

How does the

system

perform?

c. Elements of a lean transformation

system

23

• Kaizen Promotion Office

– Training/coaching/leading to develop capacity and capability.

– Establishes and runs schedule of daily, weekly, monthly, quarterly, and

annual activities, e.g. Rapid Improvement Events (RIEs), A3s,

reporting.

– Establishes and maintains benefits and impact tracking.

– Co-leads RIEs – preparation, event week, 30/60/90 day follow-up.

– Improvement and Coaching ‘routines’.

– Coaches ‘Practising Daily Improvement’.

• Value stream identification and analysis

• Flow cells (1 piece flow, standard work, pull systems, 6S).

• Visual management.

• Strategy alignment and organisation-scale PDSA (level 1)

Value Stream Analysis – Current State

24

Value Stream Analysis - Future State

25

• Day 2 & 3

• Define the process vision based on their experience and lean principles

• Define the “cell building blocks” for process control and continuous improvement

• Estimate the benefits

• Define an implementation plan

• Get senior leadership endorsement

26

Future State through RIEs and daily

improvement

7 Week RIE Cycle

27

RIE week

• 1 week facilitated workshops

• Assemble cross functional team

• Deliver that week at the workplace and learn by doing

• Deliver performance improvement using Lean tools to establish cells

• Train for daily improvement – PDCA cycle

– Scientific method (develop a thesis (idea for improvement), Conduct experiment, review results, implement of successful

• Define a plan to develop the team

• Define staff and leadership standard work to sustain

Results in the week!

Q: what runs through lean like letters

through a stick of rock?

A: problem-solving…

From the patient’s perspective, value comes

not from parts, but from the whole

30

Problem-solving is closing the gap between

A & B - clinicians are partway there

31

Clinical activity for a patient

• A: what we have

– illness, exacerbations, long-

term condition etc.

– stabilise, diagnostics, root

cause via differential diagnosis

– management plan

– diagnostics + revisions

• B: what we want

– gap closed, or at least reduced

– patient condition improved

32


• A: what we have

– illness, exacerbations, long-term condition etc.

– stabilise, diagnostics, root cause via differential diagnosis

– management plan


• B: what we want





33




• A: what we have



– management plan


• B: what we want



Operational activity for a process

• A: what we have

– 8 wastes (T.I.M.W.O.O.D + waste

of human creativity)

– Stabilise, diagnostics, root cause

via data analysis & small tests

– PDSA plan


• B: what we want


34




• A: what we have



– management plan


• B: what we want



Operational activity for a process

• A: what we have

– 8 wastes (T.I.M.W.O.O.D + waste

of human creativity)

– Stabilise, diagnostics, root cause

via data analysis & small tests

– PDSA plan


• B: what we want


A3 – problem-solving method 2 3 4 5 6 7 8 9 1

Start Date: Current Date:

End Date:

Title:

Process Owner:

Sensei:

4. Gap Analysis No GoGo

Problem Statement:

Reflections:Root Cause:

5. Solution Approach

Reflections:

No GoGo

Text

Cause/Priority Solution Affecting Current State FS E C

1 O ∆2

3

4

5

6

E (ease) and C (cost) scoring

O = Easy / Low Cost, ∆ =Medium / Medium Cost, X = Hard / High Cost

6. Rapid Experiments

Reflections:

No GoGo

Text

Experiment Anticipated Effect Actual Effect Follow up Action

7. Completion Plans

Reflections:

No GoGo

Text

Action TT Owner Due RAG

8. Confirmed State

Reflections:

No GoGo

Text

9. Insights

Reflections:

No GoGo

Text

What went well?

What helped? What hindered?

Even better if…Actions:

Team Photo

1. Reason for Action

Reflections:

No Go Go

What might it look like:

a.

Business Case:

In scope:

Out of scope:

2. Initial State

Reflections:

No Go Go

Text

(a) Delivery / Timeliness

(c) Quality

(b) Cost

(d) Human

3. Target State

Reflections:

No Go Go

(a) Delivery / Timeliness (b) Cost

(c) Quality (d) Human

!Show!ME!Improvement!!

!showmeimprovement.com!

Business'improvement'you'will'see'

A3…practice, practice, practice

A system of systems, so act

on the system

36

• Do an RIE week in an Out Patient clinic

– Increases throughput by +10% (11 pts not 10)

– Over the year + 10% additions to theatre lists

– +10% to recovery, to wards, to AHPs, to discharge teams

– Understand and ‘see’ the end-to-end patient journey

– Have to work across the value stream in a coordinated way = why you need a KPO and constancy of purpose

Isolated islands of improvement, or…

Lean Leadership of org towards True North goals?


NHSI Lean Model



b. Working

definitions


a. core

beliefs



What is the

problem?

How does the

system

perform?

39


NHSI Lean Transformation model

• Inputs – Interviews with lean

transformation orgs

– Developing People,

Improving Care

– Benefits defined, valued,

measured and tracked

– Transformation FMEA

– How KPO is setup & run –

‘Big Room’ ideas?

– Baseline H, Q, C/P, T

– Transactional Analysis

training for Lean team

– Social movement

knowledge

– Other QI methods (IHI-QI,

Theory of Constraints, 6

Sigma, etc.)

• Process – A guiding coalition of:

– NHSE/I

– VMI trusts

– NHS trusts/orgs that are

working on Lean & QI

– Lean orgs/leaders outside

of NHS and healthcare

– Lean ‘gurus’

– Health Foundation etc

– Royal Colleges

– Use the ‘Engineering Better

Care’ system design model

(Royal Academy of Eng.)

– Cambridge University

Engineering Dept

– Large Scale Change &

NHS Change Model

• Outputs – Training material

– Standard work

– KPO

– Leaders/staff

– Events &

– Review schedule

– Diagnostic method

– Selection of work

– Lean strategy

– Improvement & coaching

routines

– Plan across 6 trusts

– Cross-client cover

– ‘Review and improve’

schedule

– JD & PS for KPO team

members

What precisely does 200k buy?

40

• Personal commitment and leadership of programme from Executive Director of Improvement = financial input.

• Full access to tools and training materials, no on-going cost.

• 0.5 FTE per trust with consultants working across 2 trusts, but with opportunities for training etc. maximised across the cohort.

• Input from Director of Lean and Lean Specialists to coach KPO leads, as well as targeted work with CEOs, leadership teams and boards.

• Bringing CEOs, Boards, leadership teams and KPOs together for events and learning – cohort.

• Connection into trusts working in partnership with VMI and other trusts working with lean in the NHS.

• Opportunity to co-design the NHS lean transformation method.

• Support with setting up and developing programme management, stakeholder management and reporting.

• Coordination of work problem solving.

• Point of contact at NHSI.

We need to talk about money!

• Hands up if you think lean works like this.

It’s not a tool for CIP

• Reducing/removing waste does not

automatically equate to cash out of the till…

You’re all good at CIP because you've been

doing it for years

43

• But its localised saving against a single budget and not joined-up.

• There will be unintended consequences.

• You won’t know what they are because you won’t be measuring them.

• Measures of Human Development, Quality, Financial, and Time across the value stream will be impacted.

So what does Lean improvement do?

44

“There are four purposes of improvement: easier, better, faster, and cheaper. These four goals appear in the order of priority.” Shigeo Shingo (Safety is fundamental via ‘respect for people’)

So what does Lean improvement do?

Lean: easier, better, faster, cheaper.

CIP: easier, better, faster, cheaper.

Individual &

team learning

Individual &

team learning

3rd Big Idea – Two Dimensions

– Numbers • Deliver improvement in

numbers – quality, delivery, cost and happiness!

– Culture • Ensure each persons job is

aligned to provide value for the customer & a long-term future for the organisation

• Ensure staff “see abnormality & waste” and get each person to take initiative to solve problems & improve their work

Hard - Numbers

Soft - Culture

The Machine That Changed the World

Based upon MIT's five-million-dollar,

five-year study on the future of the

automobile, a ground breaking

analysis of the worldwide move from

mass production to lean production.

“The fundamentals of this system are

applicable to every industry across the

globe...[and] will have a profound

impact on human society--it will truly

change the world". --New York Times

Magazine

First published 1990

The Machine That Changed the World

Keep feeding it with: it will keep on producing:

A machine that could change our patients’, our

staff's and our organisations’ world.

• the creativity of staff

• nurturing &

encouragement

• lean leadership

• active involvement

• time

• small improvements

every day

• big improvements

regularly

• a self replicating culture

of improvement

• ever-improving value

for patients

Questions?

49

Louise Brennan – KPO Specialist

Kaizen Promotion Office

Transforming Care Institute, SaTH

February 2018

Virginia Mason Hospital 15 Year Journey

• Patients are at the heart of the improvements

• New ‘management method’ led clinically from top

• Consistent approach – in it for the long term, using

agreed ways of working

• Increased patient to clinician value-added contact time

• Patients benefit from greater safety, less delay in

seeing clinicians for care and more timely results and

treatments

• Virginia Mason saved $11 million in planned capital

investment by using space more efficiently and freed

an estimated 25,000 square feet of space using better

designs

• They reduced supply costs by $2 million through

inventory reduction and the 5S process.

Virginia Mason Hospital 15 Year Journey

• A not-for-profit medical group in Seattle, Washington providing primary and hospital care

• 336 bed hospital, 445 doctors, multiple primary and secondary care clinics

• A leader in setting patient care quality standards in the US

• From unsafe (Institute of Medicine, 2001) to very safe (the USA’s “Hospital of the Decade”)

• One of 5 Trusts in England to successfully apply to the TDA

for this partnership programme – previous successful individual NHS partnerships in North-East

England and Shropshire and Staffordshire Mental Health Trust

• 5 year partnership including: – training, mentorship and on-going support from a dedicated member

of the Virginia Mason Institute team

• Learn key principles and systems to help us to continue to

improve patient safety and experience in our Trust

The story so far: Cultural Transformation

The story so far: Cultural Transformation

54

• Successful Bid to NHSI/NHSE

• Formation of KPO team

• Launch of Organisational Strategy

• Underpinned by SaTH Values

• Launch of Transforming Care Institute

• Launch of Leadership Academy

• Values in Practice Agreements (Compact work) including Leaders/Medical/STP

TCI Self Sustaining

Guiding Team

56

Profile of Trust Guiding Team

Edwin Borman Medical Director/Executive Sponsor for Value Stream

#2 (Sepsis)

Julia Clarke Corporate Management Director

Deborah

Dollard

VMI Executive Sensei

Tony Fox Deputy Medical Director/Executive Sponsor for Value

Stream #4 (Outpatient Clinics)

Sara Biffen Interim Chief Operating Officer/Executive Sponsor for

Value Stream #1 (Respiratory Discharge)

Victoria Maher Workforce Director/Executive Sponsor for Value

Stream #3 (Recruitment)

Brian Newman Non-Executive Director

Neil Nisbet Finance Director

Deidre Fowler Director of Nursing & Quality/Executive Sponsor for

Value Stream #5 (Patient Safety)

Cathy Smith KPO Lead

Fran Steele NHSI Representative

Simon Wright Chief Executive

The story so far: embedding a Production System

57

• Leaders Standard Work • Huddles • Stand Ups • Genba Walks • Report Outs • 5 Whys

• Standard Work • 5S • Value Streams • Kaizen Events • Every Day Kaizen

• Alignment • One improvement method

Engagement and Pace

58

Target: Educate 3000 : Year 3 Target: Engage 750: Year 3

558 Engaged using VMI

Methodology

Guiding Team

Members

Value Stream Sponsor Teams

RPIW’s

5S

Roll out

Genba Rounding/

Walks

Lean for Leaders

Transforming Care

Methodology Report

Out

2327

Developing Lean Leaders

• Over 80 Lean for Leader set to

graduate from 2016/17 cohorts

• Over 45 Lean for Leaders set to

commence their L4L training in

2018

• Waiting list for 2019 L4L training

59

5S Kaizen Events

60

Value Streams

Value Stream #1: Respiratory Discharge

Value Stream #2: Sepsis Pathway

Value Stream #3: Recruitment

Value Stream #4: Outpatient Clinics (Ophthalmology)

Value Stream #5: Patient Safety

Value Stream #6: Emergency Department, PRH

(Launching March 2018)

Value Stream #6: Radiology (Launching April 2018)

61

Respiratory Value Stream

62

Improvements

• Lead time target has been met

with a reduction of over 40 hours

• Additional patient spells have

been accommodated

• Standard work has been

implemented including 4pm

huddles, board round and ward

round

• Visual controls to aid timely

provision of medication,

discharge summary and

handovers are supporting the

process

Sepsis Value Stream

63

Improvements

• 12 quality improvements made within the

sepsis pathway including use of screening tools,

Sepsis trolley, reduction in late observations and

blood culture processing

• 11 ½ hours of non value adding time

removed from screening for sepsis , diagnosis

of sepsis and delivery of sepsis bundle pathway

(single patient pathways)

• 968 steps no longer required to collect

equipment and collect/deliver blood culture

samples (single patient episodes)

• Sepsis Trolley rolling out to AMU,

Emergency Departments at RSH and PRH

• Sepsis Box rolling out to AMU at PRH

Recruitment Value Stream

64

Improvements • Lead time (from vacancy identified to staff

member’s first day) reduced by 10 weeks from 135 days to 63 days

• Delay in receiving candidate references reduced

from 21 days to 1 day • Reduction in length of time from approval to post

being advertised reduced to 1 day (in test

genba and having sustained at 90-days now

suitable for roll-out)

• Potential new staff aware of interview date at

advert stage – 19 day improvement

• Lead time from close of advert to interview

reduced by 15 days

Outpatient Clinic - Ophthalmology Value

Stream

65

Improvements

• 52 day reduction in the time from receipt of

referral until first contact is made with patient

• 47% reduction in the number of times letters are

delayed due to requesting a letter after the deadline for

electronic transfer to next process

• 100% reduction in the number of Booking staff

unaware of overall process for sending patient letters

(Process = from referral arriving at SATH, to patient

arriving in clinic)

• 5S applied to Ophthalmology clinic letters resulting in

reduction from 17 letters to 1 letter

• 32% reduction in lead time to prepare patient

notes for clinic

• 93% reduction in lead time with the introduction

of electronic grading

Patient Safety Value Stream

66

Improvements

• 80% reduction in time (229 mins to 90

mins) following an incident to reporting an

incident

• Safety huddle implemented with 100%

compliance to standard work at 30-day

remeasures

• Production board implemented to

support requirement for daily safety huddle

The Story so far….

• Over 57,000 patient journeys are safer and kinder

• Over 3,370 miles less walking for staff

• Over 9,500 patient experiences have been improved since the commencement of VS#4 (OPD – Ophthalmology)

• Over 2300 staff educated in Transforming Care Production System

• Over 550 staff using the Transforming Care Production System tools

• Over 80 Lean for Leaders deploying the Transforming Care Production System to improve patient safety and transform our organisational culture

• 6 staff successfully completed their ALT and progressing to TL role

Next Steps

• ALT certified staff undertaking improvement

workshops

• Share and Spread of the improvement work

• Expansion of the KPO Team

• 5S training for all staff

• All Leaders completing Lean for Leaders training

• Promoting Innovation Training

• Mistake Proofing Training

Any Questions ?

Thank You

[email protected]

www.improvement.nhs.uk/resources/

lean-programme

71

mailto:[email protected]

http://www.improvement.nhs.uk/resources/lean-programme/




lean programme information session - nhs improvement · 6 lean programme: application to join...

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