NHS should embrace lean times

A technique developed by the car industry could help staff, patients and reduce costs, says SA Mathieson

Since this event, the concept of lean healthcare does not appear to have spread widely across the NHS, unfortunately. In August 2012, the New Yorker reported on a few US hospital chains thinking of the same ideas.

Powered by Guardian.co.ukThis article titled “NHS should embrace lean times” was written by SA Mathieson, for theguardian.com on Wednesday 7th June 2006 23.11 UTC

When someone claims a technique can improve patient care and staff morale as well as reduce costs, health service staff may be forgiven for raising an eyebrow. When they hear that the technique was pioneered by Toyota, they may raise both.

But the application of a technique known as “lean”, first developed within the famously efficient Japanese vehicle-maker, has reduced one hospital’s mortality rate in one injury by more than a third, and its acolytes believe it can produce dramatic benefits across the NHS.

David Fillingham, chief executive of Bolton hospitals NHS trust, told a conference this week that his trust had greatly reduced its mortality rate for fractured neck of femur by re-designing the patient’s stay in hospital to reduce or remove the waits between “useful activity”. The mortality rate fell from 22.9% in 2004/5 to 14.6% for the first six months of 2005/6, which is the equivalent of 14 more patients surviving during those six months. Meanwhile, average length of stay has fallen by a third from 34.6 days to 23.5 days.

“We had far more people dying from fractured hips than should have been dying,” Mr Fillingham told the second Lean Healthcare Forum in Solihull.

The improvements came through examining the patient’s whole experience, and removing the sometimes-fatal delays in getting them into the operating theatre, such as creating a faster process for radiology and removing unnecessary paperwork.

These changes also lessen staff frustrations by allowing them to spend more time helping patients. Also, by cutting length of stay and complications, costs should also start to fall, although Mr Fillingham – former director of the NHS Modernisation Agency – said it will take several years for the savings to become substantial.

The trust’s redesign process relies on its staff. It has held five “rapid improvement events”, where groups of employees with varying responsibilities spend several days thinking through a process and planning how to improve it.

It also uses management consultants in such work, although in a subsidiary role, as well as third-party experts – including staff from the Royal Air Force, which has been applying the lean technique to running aircraft carriers – and patients.

“They ask all sorts of innocent, naïve questions,” said Mr Fillingham – to which, often, no member of staff has an answer.

Waiting for the results of tests is one source of delays for patients. Kate Hobson, who runs an ultrasound department at Salisbury district hospital, told a conference session how she cut her waiting list from 12 weeks to between a fortnight and zero, by sorting work into routine “green” streams and complex “red” ones.

She found 67% of demand coming from just 5% of the possible ultrasounds: abdominal, gynaecological and urological.

So Ms Hobson concentrated on doing this routine work more efficiently, such as timing each type of routine scan and scheduling appropriately. For example, an initial date scan used to check the age of a foetus took only two minutes, so Ms Hobson allocated a series of five-minute slots just for these, and simplified its paperwork so only a few numbers needed to be entered.

The streaming technique is comparable to differing lanes of traffic on a motorway: having easy and difficult work mixed together is equivalent to mixing fast cars and slow-moving lorries in every lane.

“The secret is to get the steady stream of high-volume, low-variety chugging down the ultrasound motorway,” said Ms Hobson.

The classification and quicker completion of routine work leaves more time to deal with complex jobs, but even so, staff are now more likely to leave work on time. This, along with a sense that the department is doing a better job, has improved morale: “I think people feel their day is more structured now,” said Ms Hobson. “It’s not that madness, opening the doors and people coming at you.”

Reducing her waiting list has other benefits. Ms Hobson added that she has stopped leaving slots open for emergencies or urgent cases, as the standard low waiting time is usually sufficient, and if not, the list can be rearranged. If someone cancels, she has instructed booking staff to call other patients to try to fill the gap.

Ms Hobson said the only problem is that her department’s efficiency means that the old ultrasound machine has not been scheduled for replacement. She joked that she will have to raise charitable funds instead: “I’ve got to immerse myself in a bath of baked beans.”

Daniel Jones, chairman of the Lean Enterprise Academy and co-author of books on the technique, said the next challenge for the NHS will be to examine processes that include several organisations, including primary care.

Mr Jones said a patient visiting a GP, then collecting a test result, then being referred to a consultant, then having an operation with visits before and after, would make six separate return journeys. In one measured example, a patient spent 510 minutes of non-productive travel and waiting for just 100 minutes of valuable activity, spread over 31 weeks.

“It’s not beyond the wit of man that this could be done in 18 weeks, not 31 weeks,” said Mr Jones, referring to the government’s English NHS target for patients to move from referral to hospital treatment in 18 weeks by December 2008.

“I think it could be done in 18 days, and that is the target we should be aiming for.”

· The next Lean Healthcare Forum will take place on October 2. More information here.

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