making kings first choice for patients and staff a programmatic approach to transformation david j...
TRANSCRIPT
Making King’s 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 Enterprise2nd October 2006
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?
LOX-GNH053-20060905-PROB
King’s 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
LOX-GNH053-20060905-PROB
King’s 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
King’s Position
LOX-GNH053-20060905-PROB
In 2005 the Trust invested in the First Choice King’s Programme to deliver a set of objectives
1CK objectives1. Improve on the already
excellent quality of care2. Make the patient
experience for King’s 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 targets1. Reduce ALOS2. Comply with 18 weeks3. Increase patient
satisfaction4. Build team of 80
Change Agents5. 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
GM CCS LiverCH TBC
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?
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
HospitalManufacturing Industry
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
Lean Methods
Exhibit 10
We must still make value flow….
GP Referral
C/T: 10 minsNo. of GPs :
600No. 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-Assessm’t
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 Appt’s
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
PatientsPatients
PatientsPatients
EPRGalaxy
PIMS
Choose & Book
FIFO FIFO
10 min 15 min 5 min 10 min 20 min 1290 min 111 min 30 min 5760 min
3.6 days 50 days .1 days 01 days 132 days 15 days 2 days
Processing timeLead time
For longest stream = 7251 min = 7%202.8 days
121275 10 10 1500 90130
3150 F/U
Value Steam Map
Lean MethodsLean Methods
Exhibit 10
We must still make value flow….
GP Referral
C/T: 10 minsNo. of GPs :
600No. 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-Assessm’t
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 Appt’s
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
PatientsPatients
PatientsPatients
EPRGalaxy
PIMS
Choose & Book
FIFO FIFO
10 min 15 min 5 min 10 min 20 min 1290 min 111 min 30 min 5760 min
3.6 days 50 days .1 days 01 days 132 days 15 days 2 days
Processing timeLead time
For longest stream = 7251 min = 7%202.8 days
121275 10 10 1500 90130
3150 F/U
Value Steam MapExhibit 10
We must still make value flow….
GP Referral
C/T: 10 minsNo. of GPs :
600No. 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-Assessm’t
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 Appt’s
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
PatientsPatients
PatientsPatients
EPRGalaxy
PIMS
Choose & Book
FIFO FIFO
10 min 15 min 5 min 10 min 20 min 1290 min 111 min 30 min 5760 min
3.6 days 50 days .1 days 01 days 132 days 15 days 2 days
Processing timeLead time
For longest stream = 7251 min = 7%202.8 days
121275 10 10 1500 90130
3150 F/U
Value Steam Map
Exhibit 2
TODAY
POP Action PLan
FIRST CHOICE – OVERVIEW OF PROJECT PROGRESS – 05 Jun 2006 red yellow green
Status vs. plan
Status vs. outputs
Phase 3 – CC&s Women’s & Children
Sustained implementationEyes o’pts
Pain & Urol
Academy developmentChange Agents
Phase 2
ImplementationRevised solution
Initial solution
Analysis
Mar AprFeb
2006
May Jun Jul Aug Sept Oct
HPB & Vas
Implementation of Marketing Pan
Phase 2 – L&R Dental Spec Med
Ph 1
LOS & W/E discharges
Change Agents
Phase 1
General medicine
Critical care & surgery
Marketing & branding
Improvement capability building
Performance management
Children’s services
Project
Preparation & Strategy
Jan
Project Method
Exhibit 11
LOS % < 4 hours
80
82
84
86
88
90
92
94
96
98
100
01-
Apr
-04
14-
Apr
-04
27-
Apr
-04
10-
May
-04
23-
May
-04
05-
Jun
-04
18-
Jun
-04
01-
Jul-
04
14-
Jul-
04
27-
Jul-
04
09-
Aug
-04
22-
Aug
-04
04-
Sep
-04
17-
Sep
-04
30-
Sep
-04
13-
Oct-
04
26-
Oct-
04
08-
Nov
-04
21-
Nov
-04
04-
Dec
-04
17-
Dec
-04
30-
Dec
-04
date
=mea n
Nicola Le e te
97 9897 9797
SPC FOR ATTENDANCES LENGTH OF STAY UNDER 4 HOURS IN A&E Process KPIs
Exhibit 2
TODAY
POP Action PLan
FIRST CHOICE – OVERVIEW OF PROJECT PROGRESS – 05 Jun 2006 red yellow green
Status vs. plan
Status vs. outputs
Phase 3 – CC&s Women’s & Children
Sustained implementationEyes o’pts
Pain & Urol
Academy developmentChange Agents
Phase 2
ImplementationRevised solution
Initial solution
Analysis
Mar AprFeb
2006
May Jun Jul Aug Sept Oct
HPB & Vas
Implementation of Marketing Pan
Phase 2 – L&R Dental Spec Med
Ph 1
LOS & W/E discharges
Change Agents
Phase 1
General medicine
Critical care & surgery
Marketing & branding
Improvement capability building
Performance management
Children’s services
Project
Preparation & Strategy
Jan
Project MethodExhibit 2
TODAY
POP Action PLan
FIRST CHOICE – OVERVIEW OF PROJECT PROGRESS – 05 Jun 2006 red yellow green
Status vs. plan
Status vs. outputs
Phase 3 – CC&s Women’s & Children
Sustained implementationEyes o’pts
Pain & Urol
Academy developmentChange Agents
Phase 2
ImplementationRevised solution
Initial solution
Analysis
Mar AprFeb
2006
May Jun Jul Aug Sept Oct
HPB & Vas
Implementation of Marketing Pan
Phase 2 – L&R Dental Spec Med
Ph 1
LOS & W/E discharges
Change Agents
Phase 1
General medicine
Critical care & surgery
Marketing & branding
Improvement capability building
Performance management
Children’s services
Project
Preparation & Strategy
Jan
Project Method
Exhibit 11
LOS % < 4 hours
80
82
84
86
88
90
92
94
96
98
100
01-
Apr
-04
14-
Apr
-04
27-
Apr
-04
10-
May
-04
23-
May
-04
05-
Jun
-04
18-
Jun
-04
01-
Jul-
04
14-
Jul-
04
27-
Jul-
04
09-
Aug
-04
22-
Aug
-04
04-
Sep
-04
17-
Sep
-04
30-
Sep
-04
13-
Oct-
04
26-
Oct-
04
08-
Nov
-04
21-
Nov
-04
04-
Dec
-04
17-
Dec
-04
30-
Dec
-04
date
=mea n
Nicola Le e te
97 9897 9797
SPC FOR ATTENDANCES LENGTH OF STAY UNDER 4 HOURS IN A&E Process KPIs
Exhibit 11
LOS % < 4 hours
80
82
84
86
88
90
92
94
96
98
100
01-
Apr
-04
14-
Apr
-04
27-
Apr
-04
10-
May
-04
23-
May
-04
05-
Jun
-04
18-
Jun
-04
01-
Jul-
04
14-
Jul-
04
27-
Jul-
04
09-
Aug
-04
22-
Aug
-04
04-
Sep
-04
17-
Sep
-04
30-
Sep
-04
13-
Oct-
04
26-
Oct-
04
08-
Nov
-04
21-
Nov
-04
04-
Dec
-04
17-
Dec
-04
30-
Dec
-04
date
=mea n
Nicola Le e te
97 9897 9797
SPC FOR ATTENDANCES LENGTH OF STAY UNDER 4 HOURS IN A&E Process KPIs
Working
Draft -
Last Mod
ified 7/28/2005 12:32:35 A
M
THE CONDITIONS FOR LASTING BEHAVIOURAL CHANGE
“ . . . I have the skills to behave in the new way”
Capability building
“. . . the systems reinforce the desired change “
Aligned systems and structure
“ . . . I see my leaders behaving differently”
Role-modeling and leadership
“. . . I know what I need to change andI want to do it “
Understanding
and commitment
“I will change my behaviour if . . . .” Influencing Clinicians + Mgt
Working
Draft -
Last Mod
ified 7/28/2005 12:32:35 A
M
THE CONDITIONS FOR LASTING BEHAVIOURAL CHANGE
“ . . . I have the skills to behave in the new way”
Capability building
“. . . the systems reinforce the desired change “
Aligned systems and structure
“ . . . I see my leaders behaving differently”
Role-modeling and leadership
“. . . I know what I need to change andI want to do it “
Understanding
and commitment
“I will change my behaviour if . . . .” Influencing
Working
Draft -
Last Mod
ified 7/28/2005 12:32:35 A
M
THE CONDITIONS FOR LASTING BEHAVIOURAL CHANGE
“ . . . I have the skills to behave in the new way”
Capability building
“. . . the systems reinforce the desired change “
Aligned systems and structure
“ . . . I see my leaders behaving differently”
Role-modeling and leadership
“. . . I know what I need to change andI want to do it “
Understanding
and commitment
“I will change my behaviour if . . . .” Influencing Clinicians + MgtClinicians + Mgt
LOX-GNH053-20060905-PROB
We underpin the programme with enabling projects – Performance Management (1)
LOX-GNH026-200500802-MVMF
Wo
rking
Dra
ft -La
st Mo
dified
08/0
9/20
05 1
4:0
4:25
Exhibit 15Exhibit 15
Developing Scorecards and KPIs . . .
Trust/ Hospital
Care Groups/ speciality
Team
Ca
rdia
c
Ge
ne
ral M
ed
icin
e
Dia
gn
ost
icC
ath
. la
bS
urg
ery
Wa
rds
LOX-GNH026-200500802-MVMF
Wo
rking
Dra
ft -La
st Mo
dified
08/0
9/20
05 1
4:0
4:25
Exhibit 15Exhibit 15
Developing Scorecards and KPIs . . .
Trust/ Hospital
Care Groups/ speciality
Team
Ca
rdia
c
Ge
ne
ral M
ed
icin
e
Dia
gn
ost
icC
ath
. la
bS
urg
ery
Wa
rds
Visual QPFS ScorecardVisual QPFS Scorecard
LOX-GNH026-200500802-MVMF
Wo
rking
Dra
ft -L
ast M
od
ified
08
/09
/20
05 1
4:04
:25
Exhibit 0Exhibit 0
The cascade of meetings allows for problem solving and actions to be generated by the front line
Trust score-card & report
Performance Committee
Cardiac score-card & report
Performance Review meeting with Ops Director
Cardiac CG Management Team meeting
Scorecards & reports from each team
Surgery team meeting
Cath lab team meeting
Diagnostics team meeting
Wards team meeting
Feedback
Feedback
Feedback
LOX-GNH026-200500802-MVMF
Wo
rking
Dra
ft -L
ast M
od
ified
08
/09
/20
05 1
4:04
:25
Exhibit 0Exhibit 0
The cascade of meetings allows for problem solving and actions to be generated by the front line
Trust score-card & report
Performance Committee
Cardiac score-card & report
Performance Review meeting with Ops Director
Cardiac CG Management Team meeting
Scorecards & reports from each team
Surgery team meeting
Cath lab team meeting
Diagnostics team meeting
Wards team meeting
Feedback
Feedback
Feedback
LOX-GNH026-200500802-MVMF
Wo
rking
Dra
ft -La
st Mo
difie
d 0
8/0
9/2
00
5 1
4:0
4:2
5
Exhibit 21Exhibit 21
Performance Management Roll-out across all Care Groups
• CD/GM off-site
• Wave 1– Neuro (4 )– Gen Med (2)– CSDS (6)
Wave 2– Liver (5)– Renal (1)– Specialist
medicine (5)– Dental (3/4)
Wave 3– Critical care &
surgery– W omen’s– Children’s– Guthrie
• Care groups take the lead to drive implementation
• First Choice support is focused on
– Ensuring appropriate scorecards
– Establishing processes, meeting structures, etc
– Coaching team leads and CG leadership
Key assumptionsSep Oct Nov Dec Jan Feb Mar Apr May Jun
Wave 1
Sign-offWave 2
Sign-off
Jul Aug Sep Oct Nov
Sign-off
Wave 3
Project Trust Roll Out
LOX-GNH026-200500802-MVMF
Wo
rking
Dra
ft -La
st Mo
difie
d 0
8/0
9/2
00
5 1
4:0
4:2
5
Exhibit 21Exhibit 21
Performance Management Roll-out across all Care Groups
• CD/GM off-site
• Wave 1– Neuro (4 )– Gen Med (2)– CSDS (6)
Wave 2– Liver (5)– Renal (1)– Specialist
medicine (5)– Dental (3/4)
Wave 3– Critical care &
surgery– W omen’s– Children’s– Guthrie
• Care groups take the lead to drive implementation
• First Choice support is focused on
– Ensuring appropriate scorecards
– Establishing processes, meeting structures, etc
– Coaching team leads and CG leadership
Key assumptionsSep Oct Nov Dec Jan Feb Mar Apr May Jun
Wave 1
Sign-offWave 2
Sign-off
Jul Aug Sep Oct Nov
Sign-off
Wave 3
Project Trust Roll Out
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 itstarget condition and where it isn’t, 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
Le
ve
l
Wards
Shift Daily Weekly Monthly
Weekly meetings
Monthly review
Daily work
Brief and debrief
Quarterly review
Frequency
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
Exp
lici
t ca
pab
ilit
y-b
uil
din
g
and
tra
ckin
g p
roce
sses
Change agents
Individual Capability
Change leaders
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?
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
LOX-GNH053-20060905-PROB
29%
2%
32%
10%
16%
12%
10%
14%
13%
62%
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
LOX-GNH053-20060905-PROB
Management structure was diffuse and informal with few understood responsibilities
* Not line accountable
Senior management team
Lead ConsultantLead
ConsultantLead ConsultantLead
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)
MatronMatron
Matron
Administrative Manager
Outpatient Admin MgrLead
Consultant
Lead Consultant
Bowley Close
Head of Physiotherapy
Outpatient Serv Dev Mgr
Bed Capacity Manager
HRManager*
Finance Manager*
Business Manager
Recruitment Coordinator
Junior Drs Hrs Coordinator
AssistantBusiness 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 Dr’s / 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
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
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
LOX-GNH053-20060905-PROB
GP Referral
C/T: 10 minsNo. of GPs :
600No. 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-Assessm’t
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 Appt’s
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
PatientsPatients
PatientsPatients
EPRGalaxy
PIMS
Choose & Book
FIFO FIFO
10 min 15 min 5 min 10 min 20 min 1290 min 111 min 30 min 5760 min
3.6 days 50 days .1 days 01 days 132 days 15 days 2 days
Processing timeLead time
For longest stream
= 7251 min = 7%202.8 days
121275 10 10 1500 90130
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
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 King’s to be a national leader in innovative surgical care and high acuity elective care
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 BoardsMulti-
Disciplinary Meetings
TTAs, Pre-Packs & POD drugs control
Prepare for next days Discharges
Tracking of KPIsProcess Confirmation
Daily briefs
Performance management
5S – Workplace Organisation
Ward Rounds
Surgery
9
42
51
79
Target = 80%
9
42
51
79
Target = 80%
P Patient Experience
F Financial &
Operational Efficiency
S Staff Development
A4
QQuality of Care
…………. WARD OWNER :
A4
How Are We Doing ?
Work Stream KPI
A4
Work Stream KPI
Work Stream KPI
A4
Work Stream KPI
Work Stream KPI
45
6
7
8
9
10
1112
131415161718
1920
21
22
23
24
25
2627
31 1 23
2829 30
Q U A L IT Y O F C A R E
W a r d : ___________
M o n th : ________
21 2223
24
25
26
27
2829
3031
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
P A T IE N T E X P E R IE N C E
W a r d : ___________
M o n th : ________
WARDS
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
CC&S: Ward Discharge Times (includes patients unfit for discharge before 11:00am)
0
50
100
150
200
250
300
350
400
450
6-7 7-8 8-9 9-10 10-11 11-12 12-13 13-14 14-15 15-16 16-17 17-18 18-19 19-20 20-21 21-22 22-23
Discharge Time
No
. of P
atie
nts
Q1 05 Q2 05 Q4 05 Q1 06 Q2 06
CURRENT - 63% of discharges
before 11:00am (for those patients “fit
for discharge”)
2005 - 94% of discharges after
11:00am
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
No. of Patients On Ward Who Are Medically
Fit for Discharge or Transfer
0
10
20
30
40
50
60
70
80
90
100
3% Bed Usage due to Discharge Delays against previous 8%
No. of Patients who are medically fit for Discharge or Transfer
No
. of
bed
Day
s L
ost
/ W
eek
/ War
d
CC&S - Bed Days Saved due to 1st Choice Activity (assuming previous 2 day inpatient stays)
0
500
1000
1500
2000
2500
3000
Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 Sep-06 Oct-06
Bed
Day
s
Bed Days Saved due to Discharge of "Fit for Discharge" Patients CC&S Bed Days Saved due to DSU Conversions
TOTAL CC&S Bed Days saved due to 1st Choice Activity Linear (TOTAL CC&S Bed Days saved due to 1st Choice Activity)
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
1
2
34
4 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
LOX-GNH053-20060905-PROB
OPERATION
DISCHARGE
We are always asking – “Is there a clear standard for the process ?”
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?
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 1st 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 …
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?
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 aren’t enough –can frontline managers
sustain success?Toyota Production System
Highest Quality
Respect for
People
Flexible ProductionResponse
basedon market
Elimination of
Waste
For customer
•Quality•Highest Value•Shortest lead-time
For the Member
•Work Satisfaction•Job Security•Fair Treatment
For the Company
•Market Flexibility•Profit (cost reduction)•Long Term Prosperity
FlexibleMotivatedMembers
Standardisation
Maintenance of Standards
Continuous Improvement
Ju
st In
Tim
e
Goals
Outcomes
Au
ton
om
atio
n
Toyota Production System
Highest Quality
Respect for
People
Flexible ProductionResponse
basedon market
Elimination of
Waste
For customer
•Quality•Highest Value•Shortest lead-time
For the Member
•Work Satisfaction•Job Security•Fair Treatment
For the Company
•Market Flexibility•Profit (cost reduction)•Long Term Prosperity
FlexibleMotivatedMembers
Standardisation
Maintenance of Standards
Continuous Improvement
Ju
st In
Tim
e
Goals
Outcomes
Au
ton
om
atio
nWhat else do we need to do to become a truly
Lean hospital?