Sustainable Performance Improvement in the NHS

These case studies show how performance improvement can be successfully carried out at three levels:

the total organisation
a key function or process
a specific issue or area of activity.

1. TOTAL ORGANISATION

Imagine an Executive Team of a 'health economy' with multiple objectives as well as multiple internal and external stakeholders, wanting to implement Lean but in a structured and prioritised way.

The breadth and complexity of the issues provided major challenges, notably:

how to guide Executive and Stakeholders through a structured process that aligned the implementation of Lean with the priorities of the Executive
how to gain consensus across all parties on a Lean Implementation Programme.

The approach

The Executive and Stakeholders were guided through six stages:

the Executive reviewed its objectives across the economy and identified the Top 5 priorities that it had to achieve within the current year
the health economy was analysed in a series of interviews and workshops and the high level flows across the economy were identified and mapped
likely problem areas such as bottlenecks in patient flows were identified, then potential resolutions to the problems put forward and investigated
an away-day was held with the Executive and Senior Stakeholders where the Executive communicated its top priorities, the conclusions of the whole system analysis were presented, and the stakeholders split into natural areas of interest to decide on how best the issues to address the issues
the conclusions of the away-day were assessed and investigated in further detail and converted into a programme of Lean projects that would contribute to the Executive’s priorities
the projects were translated into a prioritised Lean Implementation Programme.

The outcomes

This encouraged the Executive to define its core priorities across the whole health economy. These were discussed with 40 senior stakeholders – the first time they had agreed such clarity around health economy-wide priorities.

The analysis and mapping of the whole system and the identification of the imbalances, and their potential resolutions, facilitated understanding and consensus as to the priority areas in which Lean projects should be undertaken.

The definition of the projects with specific targets, timescales and for which resources and costs were defined formed the basis of the Lean Implementation Programme.

A Lean Implementation Programme focused around the Executive’s key priorities was defined and followed.

The Executive and Senior stakeholders from across the health economy were able to gain consensus as to the priorities and the Lean Implementation Programme.

2. KEY FUNCTION OR PROCESS

A central support service for IT had multiple customer groups and needed to ensure that service levels were improved at a time when the service demands were increasing: the classic challenge of ‘improve service whilst reducing cost’.

The approach

Senior Managers were helped to define a Customer Service Improvement Programme using Lean tools and techniques at its core, by:

agreeing the 7 core service offering across the function
defining the key value streams for each service
establishing a review team and associated value streams for each service
training the review teams (approximately 30 staff) in Lean Tools and Techniques
understanding customers' requirements
critically reviewing existing value streams to identify waste and inefficiency
redesigning the value streams to be more efficient
consolidating the findings into a Programme of customer-focused improvements
training the trainers to facilitate Lean workshops for the roll-out of the project.

The project was undertaken over an intensive 10 week period.

The findings were documented and consolidated into a customer service programme that was presented by the Senior Management Team at the end of the project.

The project was extremely successful and proved the benefits of using Lean tools in a service function such as IT.

Of particular note were the benefits of formally liaising with customers to understand and debate their requirements (termed the Voice of the Customer) – this proved to be of value both to the customer and supplier.

Additionally, the participative and open door approach that involved approximately 40% of the staff in the workshops enabled them to own the redesigned processes and be positive towards the solutions.

3. A SPECIFIC ISSUE OR ACTIVITY

This is an example of how the Board of an Acute Hospital gained practical understanding of the benefits of Lean without committing to a big programme. Instead, it set up a pilot in its Acute Medical Assessment Unit (AMAU), with the dual aims of improving performance rapidly and understanding the real benefits of Lean.

The approach

It was agreed to run an extended Rapid Improvement Event (RIE). This involved forming and guiding a multi-disciplinary team of medical, nursing and administrative staff through a 3 week event. The key stages were

Training the team in Lean principles and showing how it was applicable in the NHS
Identifying and understanding the value streams that flowed through the ward
Critically reviewing these value streams and identifying associated wastes
Agreeing the ‘Future State’ value streams and likely ways of resolving existing issues
Prioritising their resolution and building them into an implementation plan
Trialling, redesigning and implementing the new value streams
Presenting the conclusions to the Board.

The Team was extremely positive towards the RIE and saw it as their 'opportunity to resolve problems they’d known about for years'. The training enabled the team to gain a consistent understanding of Lean, its five core principles and to overcome its healthy scepticism that 'Leans are not relevant to the NHS'.

Such was their enthusiasm that over 60 issues were identified across the value streams in the first 2 days of the event! Forthright views were expressed in the Future State design and consensus was gained across the Team as to how the issues should be resolved and who would take the lead on each one.

The Team then focused on implementing as many of the solutions prior to the presentation to the Board. The event culminated in each member of the Team taking a role in presenting the outcomes to the Board, which proved to be extremely rewarding.

The outcomes

The event was considered to be hugely successful and met the objectives of improving Patient care and proving the benefits of Lean to the Board. Almost 50% of the issues were resolved by the time the Team presented to the Board!

The Team was motivated as it had its opportunity to design the running of the ward and to resolve longstanding issues and irritations. The enthusiasm and achievements were recognised by the Board, who were taken on a tour of the ward to see the benefits that Lean 5S had provided. The benefits were such that the Board agreed to the roll-out of Lean in a further hospital within the Trust and also funded investment in marketing and training material.