outcomes from our lean rapid improvement event (rie) nhs scotland wheelchair & seating service
TRANSCRIPT
Outcomes from our Lean Rapid Improvement Event (RIE)
NHS Scotland Wheelchair & Seating Service
Purpose of Presentation
• The rationale for completing a Lean (RIE) in the residential repairs area of our business.
• The activities we completed across the 5 day RIE supported by the Atos Origin Alliance (AOA).
• The early outputs and outcomes from our residential repairs focused RIE.
• The results since completing the RIE using our performance data.
The Background to the RIE
• Moving Forward identified that there were “significant opportunities to make improvements without committing major new resources”. Improving our Nov 2007 productivity levels and our patient experience levels was a key driver for running the RIE.
• The speed of residential repairs as at Nov 2007 was a major challenge. Urgent (36% in 1 day); Priority (60% in 3 days); and Routine (78% in 5 days).
• There was a recognised need to reduce the times patients have to wait between reporting an issue with their chair and the repair being completed.
• We targeted setting stretching but realistic repair targets to support the development of a patient centric and continuous improvement culture.
The Background to the RIE
• Improving the response rate to urgent and priority repairs, whilst recognising that the response triage must be appropriate.
• Increasing the level of 1st time repairs – need to reduce the bottlenecks and ensure that the prioritisation is appropriate, the diagnosis is correct, the correct parts have been sourced and the technician has the correct skills.
• Promoting an end to end view of repairs jobs across all teams: promote timely and effective hand shakes – “in it together for the benefits of patients”. The role of the Team Leader was recognised as vital to achieving this “one team” behavioural change.
• Achieving and maintaining an appropriate economic balance between quality and cost in completing repairs and commissioning chair replacements.
The RIE Approach: Days 1 – 5
» Overview of the 5 Day RIE Approach
7
EVENT KICK-OFFLEAN AWARENESS TRAINING
IMPLEMENTATION
CURRENT STATE ANALYSIS
NEXT FUTURE STATE DESIGN
IMPLEMENTATION PLANNING
Day
1D
ay 2
Day
3D
ay 4
Day
5
OUTBRIEF
• TIMETABLE:– Start 10am Monday 19th November– Finish noon Friday 23rd November– 9am to 5pm in between
• ATTENDEES:– Event team (from service) through-out– Service senior manager days 1 and 5 (open invitation to check in at end of each day to look
at progress and assist)– ‘Customer’ involvement is recommended for some of days 2 and 3
• FACILITATION– The event will be managed by members of the AOA Lean Practice
• OUTCOMES– Practical understanding of Lean – Thorough understanding of customers requirements and the current state– Detailed plan for Lean future state within next 6 months– Some immediate actions implemented– Implementation plan– Engagement and commitment of staff
Day 1 – Lean Awareness Training
8
EVENT KICK-OFFLEAN AWARENESS TRAINING
IMPLEMENTATION
CURRENT STATE ANALYSIS
NEXT FUTURE STATE DESIGN
IMPLEMENTATION PLANNING
Day
1D
ay 2
Day
3D
ay 4
Day
5
OUTBRIEF
• EVENT KICK-OFF:
– Short presentation delivered by Service senior manager– Why are we here - what problems need to be addressed ?– Expectations of what will happen after this event
• LEAN AWARENESS TRAINING:
– Series of sessions run by AOA team– Principles of Lean– Experience of applying Lean in Healthcare– The process for this week (including tools and techniques)– Lean simulation game
• PREPARATION:– Get ready for Day 2
9
EVENT KICK-OFFLEAN AWARENESS TRAINING
IMPLEMENTATION
CURRENT STATE ANALYSIS
NEXT FUTURE STATE DESIGN
IMPLEMENTATION PLANNING
Day
1D
ay 2
Day
3D
ay 4
Day
5
OUTBRIEF
• VOICE OF CUSTOMER:– Who are customers? (users of service; commissioners of service)– What is VALUE from the customers’ perspective?– How should this be measured?
• VALUE STREAM MAP:– Construct the current state value stream map– Show how value is delivered to customers now– Gather data to measure performance (lead-time, flow efficiency)– Supporting analysis:
– Swim-lane map– Spaghetti diagrams etc
• WASTE IDENTIFICATION:– Highlight, categorise and quantify waste
• OPPORTUNITY ASSESSMENT:– Highlight, quantify and prioritise opportunities
• PREPARATION FOR DAY 3
Day 2 – Current State Analysis
10
EVENT KICK-OFFLEAN AWARENESS TRAINING
IMPLEMENTATION
CURRENT STATE ANALYSIS
NEXT FUTURE STATE DESIGN
IMPLEMENTATION PLANNING
Day
1D
ay 2
Day
3D
ay 4
Day
5
OUTBRIEF
• IDEAL STATE:– Define the ideal value stream map and performance targets– Stretch thinking about what is possible, using Lean
principles
• CONSTRAINTS ANALYSIS:– Understand real-world constraints (that prevent Ideal State)– Challenge constraints
• NEXT FUTURE STATE:– Taking account of constraints, how much of the Ideal State
can be implemented in 6 months?– Draw the NFS value stream map– Define KPIs– Agree baseline for KPIs– Agree targets phased over next 6 months– Validate with customers
•PREPARATION FOR DAY 4
Day 3 – Next Future State Design
11
EVENT KICK-OFFLEAN AWARENESS TRAINING
IMPLEMENTATION
CURRENT STATE ANALYSIS
NEXT FUTURE STATE DESIGN
IMPLEMENTATION PLANNING
Day
1D
ay 2
Day
3D
ay 4
Day
5
OUTBRIEF
• BREAK DOWN THE NEXT FUTURE STATE:– What can we do today ?– What can we do next week ?– Which changes take longer ?– Which changes require permission ?
• DO WHAT CAN BE DONE TODAY:– Implement immediate improvements
• PLAN OTHER ACTIONS:– When / how / who– What investment is required ?
– Layout changes– Facilities & tooling etc
– What resources are required ?– Time – Support and training
– Produce the schedule
• PREPARATION FOR DAY 5
Day 4 – Next Future State Implementation
12
EVENT KICK-OFFLEAN AWARENESS TRAINING
IMPLEMENTATION
CURRENT STATE ANALYSIS
NEXT FUTURE STATE DESIGN
IMPLEMENTATION PLANNING
Day
1D
ay 2
Day
3D
ay 4
Day
5
OUTBRIEF
• PREPARE PRESENTATION:– Summarise outcomes– Rehearse
• DELIVER OUT-BRIEF:– Presented by the Event team– Audience should be Service managers and staff– Objectives:
– Share learning with team– Permission to implement plan– Agreement to support / investment
Day 5 – Event Out-Brief
The RIE Outcomes
• November 2007 Value Stream.
• November 2007 Repair Flow Efficiency.
• November 2007 Repair Capacity Analysis.
• Target Future State RIE + 6 Months.
• Target Future State RIE + 48 Months.
Customers
Clinician job sheet/fax, letter
Patient (phone)
Health Boards Consortium
Steve Gray
ØRepair
ØOther
Schedule Job to Technician (Call centre)
Admin phone Pts. Added in by coordinator
Detailed Scheduling
1. Add more work 2.Chg schedule for geography or eng disability
- Print Job Sheet- ID Parts req’d- Pass for stores
-Work out Part numbers -RETIS-- Check stock available
Got Stock:-Pick-Update job sheet-Bag (copy Job sheet)-MARSMAC -trolley
Not Got Stock:
- Salvage- Source
Engineer-Collect trolley each morning-Some-check trolley -> tale problems to the stores-Plan route am/pm
Admin-Take AM/PM plan from engineer- Some patients call in
Collect deliveries Mobile
Target 9.30
Arrive Pt-Inspect chair-Check got right parts/what’s wrong-Do repair
Stores: remove part for salvage (ownership unclear): sometimes workshop- Check Part number (RETIS) ->manuals/CVS net-Rolling stock-Non standard stores
- Get quote from supplier (if non-standard)- Place Order (RETIS)
Central Purchasing Dept-> Move to another System -> PECOS? CEDAR -> fax to supplierSupplies dept GRI
6. Supplier Leadtime
Yoker expediteBook in stores -> flag up Patient Job sheet
Stores -> move job to scheduling-Van schedule(Coordinator)
Admin: Match delivery Note -> POSupplies: Authorise Payment
Customer
Complete Repair-Fill in job sheet-Pt signed
time
Patient
Return Job SheetReturn unused Parts-> Stores -> back into stock
AdminClose job on RETIS -> data entry
END
Can’t complete repair- Update reason on job sheet
Return job Sheet (Admin)-Update RETIS/special circumstances-Phone/letter to Patient-Job on hold-Back to scheduling RETIS
If eng finds reqt for further repair – NEW Job sheet!
Production Control
Call Centre (Admin-Check user name/dob/contact details-What’s wrong with w/c-Determine Priority (U.P, R)-Raise Job Sheet-Identify chair ID number-Initial scheduling (next available slot) -Give date to user
-Pt records
-W/C records
-Scheduling post code
RETIS
Demand Analysis: 12 mth sample
No Urgent Jobs : 4% - 496
No Priority Jobs 12% - 1610
No Routine Jobs : 84% - 11282
Total no Jobs: 13388
An average Day
- 61 repair Jobs
- 3 urgent
- 7 priority
- 51 routine
- 4 jobs per day for 14 engineers
-Waiting
If capacity not clear on schedule cannot easily ‘shoehorn’ in
-Coordination 8 scheduling Waste
-Waiting – 2 days delay built into process
-Waiting
-If engineer is sick whole zone shut
-If job incomplete paperwork waits one day
-- Processing
-Confusion of roles
-Who owns checking of vans etc
-Time spent coordinating
-Always catch up
--Rework
-Coordinators 8 drivers checking over double work?
-Repeat jobs – why?
-Transportation
-Return to base to retock
-Hard to see if van in ‘resion??’ for filler
-Move work:
-2nd visits
-Non-scheduled work
-Deliveries
-Van routing 8 schedules. Cannot see all areas in one go. Schools a hassle
-Cannot do all areas every week -H2 ID
Parts? -> picking accuracy
Don’t schedule:
-outlying areas
-Holidays
VAN RUNS PLANS
Some salvage is inappropriate
-Not clean
-Not safe/Q
Stock Mgt
-Obsolescence
-Disposing of chairs
Stores
-Motion: Location of manuals, fax, m/c
Processing: over picking, multiple job sheets, patient parts ‘straight to store’
Inventory: runners out of stock
No info on stock outs
Stores: Waste
-Waiting: pick lists wait one day
-Waiting: part ID delays, no parts, try to salvage –delay, supplier response times
-Waiting: delay to quality check, delay driver returning parts, delays chair return
Order authorised… No order confirmation…
Don’t have times in system RETIS
Sometimes booked into stock without reference to patient order
Parts come in –JOB Done! Parts have been salvaged….
What time do you actually get mobile?
Patient does not respond/ not there -> leave card…
Stock Data
No Salvage Jobs: avg 5-7 per day
No stock outs: avg 12-15 per day
Slow moving stock ---
Supplier/Parts
Order Data
4867 part nos on shelf
No Stocked parts 1962
No non-stocked parts ~5000
No supplier contracts ~29
2 parts nos in system 7106
Supplier lead time data –contract
0-2 days – 4
3-5 days – 6
6-10 days – 10
>10 days - 7
No contract time - 3
Repair Response time
Type Target %
Urgent - 1 day 33%
Priority 3 days 53%
Routine 5 days 69%
First time Fix Data
%jobs fixed first time = 74%
2nd Visit Reason Data:
-Pt not home 48%(pt cancels 7.5%
-Wrong parts/chair/spec –31%
-Follow on repair 2.5 %
-B.E.R 9%
-Engineer no time 2.5%
-No explan 3.5%
Call Centre Waste:
-Waiting: patients can’t get through; only office hours
-Rework: double handling; callbacks; no protocols or diagnostics
Stores Data
No Picklists per day: 16
No parts/per day: 50-75
Cycle time/picklist: ~20mins
No. staff (repair picking): 3
1 driver ~ 10 jobs per day
Noon, weds
8.30/9am Thu
+1 day, don’t know
November 2007 Value Stream
14
1. Routine - all goes to plan : e.g. patient calls Monday morning – repair is completed (first time) on Thursday
Clock start Clock stop
3m
Take patient calls
Ø
2m
Schedule repair visit
Ø
1m
Give promise
1 day
60m
Detailed van
schedule
1 day
60m
Pick Parts
1 day
15m
Collect Parts
Ø
Variable
(same day) travel to patient
20m
repair
Waiting time = 3.5 days = 5040mins
Value Add time = 161 mins
161/5040 = 3.2% value adding time
2. Parts not available – repair delayed by two weeks (between pick parts and collect parts) Value adding time= 161 mins
Waiting time = 17.5 days (25,200mins)
161/25,200 = 0.6% value adding time
3. Urgent – able to repair (first time) next day
3m
Take patient calls
Ø
2m
Schedule repair visit
Ø
1m
Give promise
60m
Detailed van
schedule
60m
Pick Parts
22 hrs
15m
Collect Parts
2 hrs
20m
Repair
Day 1
9am9.05 Ø Ø10.05 11.05
Day 2
8.30am
161/1440 = 11% value adding time
November 2007 Repair Flow Efficiency
15
• Theoretical capacity [UOM = engineer days]
• 16 engineers 16 x 5 x 52 = 4160 d/pa• 2 part time (2 x 5 x 52) x 50% = (260) 2 coordinators
16 x 35 = (448) 560 holidays
16 x 5 = (80) illness
-----------
3272engineer days per annum
Demand:
14000 calls pa
c20 minutes per call
280,000 minutes pa
4667 hours pa
Capacity
2697 x 8 hrs = 21576 hrs pa
4160 Holidays/sickness
25%3272
Office/break time
2697
E/days
21,576 hrs
4667
Other work?
how quantify
Build into demand
3500 hrs D&CRR = 56.5% of total jobs
Other work = 3500 hours
assumes 20 mins per delivery/collection
November 2007 Repair Capacity Analysis
Days
16
Customers
Clinician (advocate)
Patient (phone)
(Production Control)
Call Centre
Manual Chairs/Uni
-Check part details
-Create job sheet
-Check chair configuration
-Fault diagnosis
-ID parts required and part nos
-Check and allocate stock
-Confirm Engineer available
-Agree appointment/ Urgent Routine
-Accurate Data
-Patient record
-Chair details and configuration
-Stock records
Training Matrix
J F M A
Other Chairs
- check part details
- Create job sheet
- Check chair config
- Fault diagnosis
ROUTINE
Job owned by coordinator
Parts id; allocate; schedule
RETIS
UNI Call centre Manual
Call centre trained on product range, repairs and part numbers
Order = w/c faulty
Better phone system
-> patient can wait & queue
Response Promise
GPS SYSTEM ON
Update calls during the day
•Opening hours – Patient Access
Demand for extended hours will be understood [ V.O.C. analysis]
•Performance Targets
1. Repair response time
URGENT = 1 DAY = 75% achieved
ROUTINE = 5 DAY = 90% achieved
2. First time fix
TARGET = 90%
•Ways of working
1. Measure our business and share with staff
- daily team reviews (short/sharp)
- monthly team meetings
2, Team Leader role
- Train staff
- coach people to continuously improve performance
3. Personal accountability
Engineers Supported by:
-Product training
-Better tooling
-Better VAN STOCK
Parts for urgent repairs
- castors
- wheels
- brakes
- Better comms with Admin
Training Matrix
Manual
Suppliers
AdminAllocate to driver via GPS txtFix via van stocksOr ID parts reqd
…ORRefurb engineer takes job from depot
Complete repair-Patient signs job sheet-Engineer texts admin
Can’t fix\-Assist Pt as far as can-ID parts reqd-Text Admin pick parts\\
URGENT – SAME DAY
Van Schedule8:30am
URGENT – NEXT DAY
Pick Parts8:45am
Collect PartsMobile 9:30am
Complete Repair-Patient signs-Engineer texts admin
CUSTOMER
Van ScheduleDay 1
ROUTINE
Pick PartsDay 2
Collect PartsDay 3
Complete Repair-Patient signs-Engineer texts admin
CUSTOMER
Do preventive maintenance [schedule to be agreed]
Preventative maintenance formalisedMaximum 5 days: better if capacity
Bette
r cap
acity
plannin
g!
capacity
de
ma
nd
Identify part noCheck stock
got not got
Allocate
Confirm
delivery date
expedite
PARTS PLANNING PROCESS Confidence we have the parts…
STORES
80% 20%
K K K K K Better stock system
Training for stores
staff
Training Matrix
J F A
100% stock
accuracyMajor suppliers
on KANBAN FAST MOVERS
CUSTOMER
1 day target applies regardless of zone
Target Future State: RIE + 6 Mths
URGENT
17
Training
1.Call Handlers:
- Know the product range
- Know how to diagnose faults
- Know configuration of patient’s chair
- Access to parts stock: a/allocate on time; b/give confirmed date to patient
- Knows what we don’t know -> warn engineer
2. Engineer/Coordinators
- Dedicated repair/not delivery
- Trained on full product range
- Hand-held kit
- Diagnosis tool
- Product info/web sites
- Parts availability
- Job sheets
- Tooling
- Patient “handling” – confidentiality
3. Stores
- Product range
- Stock management training
4. Clinicians
- Lots….
Basic diagnostic tool
Wheelchair manufacturer
Training Matrix
J F M A
ØIT
ØHow business Operates
Team Leader
User
® Urgent = 1 ~10/day
Not Urgent <= 5 ~50/day
Co-located
- Diagnosis
- Check parts-> allocate
- Real time driver
- Confirmed schedule
- Location and job status
-Diagnosis
-Product Info
-Allocate Stock
-Config of chairs
Call Centre
RETISeasy
Data Accuracy
How many calls get lost/don’t get answered?
Van ScheduleGive capacity
-Driver in-cab display
Same day/urgent work: go at even if no parts
Next Day “u”
Pick Collect
Change schedule – re-route
Parts
Wider van stock: wheels, castors, brakes
Or local stock points
- Satellite station (+4)
Or refurb engineers from depot
Means all zones
every day
KPIs
Response Time = U R
1 2-3
First Time Fix = 95-100%
Opening Hours: (check through V.O.C)
7 days, extended hours;
wknd, engineers on call??
Inventory Manager
Stock Management
Kanban?PickOr VMI
Vendor Managed Inventory
Fit for purpose system
Wheelchair suppliers
Top 80%
by parts value?
Staff and Culture
1. Visual Performance Measurement
2. Leadership stronger
3. Personal Accountability
4. No blame Culture
Van/Engineer:
-Van stock
-Time for training
-Used for delivery and collect
-3 untrained drivers
-Mobile coverage
Satellites:
-Space
-Stock Manager
-Where to locate
-Permission from health
board
-Funding
Refurb Eng Delivery Parts:
-Not all have licence (1/7)
-Job role
IT System:
-Data Accuracy
-Lack of info, chair config not being put on system
-No fault diagnosis
-Does not show driver position – there is a tracking system
-Cannot display picklist to stores
-No geographical locations display
-No job status update – real time
-No parts catalogue
-No driver display
Call Centre:
-Time for training
-Staff turnover: link to pay
-On call engineer for diagnosis
-Calibre of staff time to deal with each query
-Phone system – no hold
Stock Management
Time for training
Not a stock mgt system
Part identification ownership
Suppliers
Range of stock/LT/Stock levels
Patients out on the day
Constraints:R (Next available slot policy)
R
PM
1. Standardised
PM on repair visit
2. Targeted PM
L 3pm cut off- ish…
Target Future State: RIE + 48 Mths
18
The Change Constraints
• Understanding the skills of all staff, identifying training needs, and completing training.
• Current stock management processes, types/levels of stock held and its location.
• Access to real time management information on job status, driver location or parts status.
• Support for call centre staff – no knowledge management support, limitations of phone system.
• Time to plan and implement the changes!
The Key Focus Areas
20
The following areas were identified as priorities for improvement:
Focus Area Focus Area
>> Training >> Repair Categorisation
>> Stock Management >> Driver Communications
>> Data Accuracy >> Delivery/Collection Policy
>> Van Stock Review >> Individual and Team Behaviours
>> Capacity Training >> Extended Hours Analysis
>> Parts Planning >> Workspace Layout and 6S
>> Preventative Maintenance >> Quality Control
>> Telephony Configuration >> HR/Staff Implications
The Improvement Actions
21
The following actions were identified, prioritised and agreed:
What? By When? 6 Month Status?
Comment?
Implement new repair categorisation
End November 2007 Now in place
Develop staff training matrices
End November 2007 Now in place
Develop a staff training plan
End December 2007 Now in place
Review purchasing arrangements with suppliers
End December 2007 Procurement processes redesigned
Review the salvage policy
End January 2008 Completed
Review the obsolesce policy
End February 2008 On-going
Review the RCR chair policy
End February 2008 On-going
Define a new parts planning role
End December 2007 Now in place
Define interface to prescribing clinicians
End December 2007 On-going
100%
100%
70%
100%
70%
70%
100%
70%
100%
The Improvement Actions
22
The following actions were identified, prioritised and agreed:
What? By When? 6 Month Status?
Comment?
Review chair list arrangements
End November 2007 Completed
Review van parts arrangements
End November 2007 Completed
Identify optimal parts and stock arrangements
End February 2008 On-going
Agree stock process for van replenishment
End January 2008 Completed
Start weekly team meetings
End November 2007 Now in place
Develop call scripts End December 2007 Now in place
Implement role shadowing
End January 2008 On-going
Implement performance boards
End December 2007 Now in place
Review van communications options
End November 2007 On-going
100%
100%
70%
100%
100%
70%
100%
70%
100%
The 6 Month KPI Results
23
The following KPIs highlight our performance at RIE + 6 months:
KPI Target RIE + 6 Months
Comment
Urgent Repairs In 1 Day 75%
Routine Repairs In 5 Days 90%
Call Waiting Times -
Patient Experience -
Staff Satisfaction -
Waste Levels -
TBD%
TBD%
Routine Repairs Performance
0102030405060708090
100
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Calander Weeks 2008
Per
cent
age
0
50
100
150
200
250
300
Qua
ntity
% routine within 5 daysTarget within 5 daysNo of routine repairs
Urgent Repair Performance
0102030405060708090
100
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Calander Weeks 2008
Per
cent
age
No of urgent repairs% urgent within contractTarget within 1 day
The 6 Month Learning Points• The scope of the RIE was “about right”. Priority
improvements were identified and actioned. However, maintaining the improvement momentum on the back of a single 5 day event is not easy and agreeing completion dates is easier than achieving them.
• Agreeing stretch improvement targets helps to drive a sense of purpose and urgency. However, motivation must be maintained even if/when target dates slip. The day to day role of supervisors is vital in sustaining positive progress.
• Embedding the use of lean tools and techniques is vital if improvements are to be sustainable. However, this requires culture and behavioural change which takes time.
• The 5 day RIE identified improvements that have benefited the repairs activities at the Yoker depot. However, there was insufficient time to consider the wider upstream and downstream value stream impacts and opportunities in other areas of the business.
The 6 Month Learning Points
• The maturity of the IT and telephony is a significant constraint in implementing desired improvements e.g. Kanban arrangements with suppliers have been difficult to implement due to limitations of IT and access to real time data.
• Identifying the single KPI that MUST be achieved is key. This should be the focus of the RIE analysis. However, people will tend to focus on identifying changes that are in their organisational area and sphere of influence. Must think big if real change is to result.
• The Rapid Improvement Event (RIE) allowed us to focus on point improvements which are making a real positive impact. However, there was insufficient time to focus on key themes such as Demand & Capacity Planning which underpin our performance.
Contact Points
27
For additional information on our RIE experience and learning points contact:
John Colvin
Head of Service
WESTMARC
0141 201 2641
Andrew Love
Technical Services Manager
WESTMARC
0141 951 5312