Mapping the elective Journey: Mapping the elective Journey: using lean to avoid needless using lean to avoid needless

delaysdelays

Mike MaguireDirector of CommissioningBolton PCT

David FillinghamChief ExecutiveBolton Hospital

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The NHS is full of committed staff who

struggle to deliver good care within a set of broken

processes

Lean can help us to:-• See things through the patients eyes• See the hidden problems and waste• Create safe, clean, calm work

environments• Fix our broken processes• Turn every staff member into a problem

solver every single day

The Beginnings of a Lean Journey…….

• 350 staff engaged (10%) over 9 months• Early results promising

- Trauma: 50% mortality reduction post #NOF; 33% LOS reduction

- Pathology: Blood specimen processing- 40% floor space saving- 20% productivity gain

• Antenatal; Radiology; Laundry; Musculo-skeletal• Focus is on quality and safety not cutting cost • We now know just how much we don’t know!

We are using lean to:-

• Reduce mortality rates • Improve staff morale• Improve patients’ experience• Improve productivity• Achieve (then better) the 18 week wait

Achieving an 18 week maximum wait

• Wont be achieved just by working harder• Wont be achieved by a 6/6/6 mentality• Can only be delivered by working across

organisational boundaries• Requires deep understanding of end to end

processes• Demands removal of waste and non-value

adding steps and creation of flow

The Bolton Approach1. Understand the current state

- analyse, observe and map

2. Design the Future State- cells- linkages- flow

3. Deliver the Future State

4. Repeat the Cycle

Lean in practice – A recipe for success

The MSK experience

ELECTIVE PATIENT JOURNEY: GETTING THE LEAN DATA

OPDTier 2/ICATs

(currently Surgicalbut ?medical for future):

Pre-Assess

WLs/QueueMngt

Ward/DC IP Beds

Tx and/or;Theatre Discharge

Diagnostics:

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

•Demand•Activity/throughput•Capacity (planned v

supplied)•Queue/inventory•Blockage•Delay

Select High Volume Groups – Where are your flow problems?

The above data gives a current state of delivery and shows the mismatches (this gives you your baseline to measure improvements against. For the future state it is important to work out the essential value steps you are working towards. The pace will need to flex to meet demand (a no waste system), and your data should be focused on this journey. Old ways use data to calculate what we can and do deliver, rather than how we need to work differently to deliver a one piece flow system…. very different!

MSK - Current State: MSK - Future State:

MEASURE CURRENT STATE FUTURE STATE

Total Steps DC: 28IP: 40

DC: 5IP: 5

Value Added Steps DC: 7IP: 11

Key steps only + customer delighters

Flow Time Max:DC: 20 weeksIP: 40 weeks

Max:DC & IP: 18 weeks

Pure Value Added Time: DC: 71 minsIP: 106 mins

Lessons from the current state analysis

• Multiple OP visits• Diagnostics not fully aligned with OPD• OP wait – 40 to 60% of journey• Patients on waiting lists that need their health

optimising first• System not compatible with 18 weeks• Waste and inefficiencies exist within surgical

processes

Integrated Clinical Assessment Services in GMSHA

• Trauma and Orthopaedics (inc Rheumatology)• General Surgery• ENT• Gynaecology• Urology• Range of supporting diagnostics• 2/3 National IS procurement, 1/3 Local

procurement or NHS provision

SYSTEM TRANSFORMATION USING ICATS

Hospital 1

2nd LineDiag

1ryTreatTriage

1st lineDiag

Assess& Pre op

“Choice”C&BSelect

ICATS(RBMS)

Patient Referred by GP, Optometrist or Dentist

Community Services Hospital 2

ICATSHospital 3

Hospital 4

IS provider

Free choice 2008

Patient Flow

Benefits of ICATs• Patients arrive fully worked up to a

common standard in 1 stop shop• Only patients who need, want and are fit for

surgery arrive at hospital• Increased predictability and precision

through choose and book• Patients make choice with full treatment

plan• Removes unnecessary steps and waste

But this could still happen…..

SYSTEM TRANSFORMATION WITH ICATs

Referral Management

Patient Referred by GP, Optometrist or Dentist

Choose

And

Book

centre

IS

H 1

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H 4

ICA

TS

Diagnostics/Initial pre op done here

OP TheatreAdditional diagnostics

Pre op

Timeline – 4 weeks Timeline – 6 weeks

Present Acute System will not hit 6 week time line

ICATS must have a 4 week timeline

Using “Lean” to redesign the Acute System

• Future state vision• Creation of efficient Preoperative and

Surgical Cells• “Lean” length of stay improvements• Implement through Rapid Improvement

Events, Projects and “Just Do its”

ORTHOPAEDICS – FOLLOWING ICATs and LEAN

Referral Management

Patient Referred by GP, Optometrist or Dentist

Choose

And

Book

centre

IS

H 1

H 2

H 3

H 4

ICA

TS

Diagnostics/Initial pre op done here

Theatre

Consenting Visit

Final preop

Timeline – 4 weeks Timeline – 6 weeks

Understanding Real Acute Capacity

Operating Capacity

GP admissions for surgery

% Removals other than Treatment

% Conversion from Outpatients

% Cancellations & DNAs

% Other Referrals

% GP referrals

Other OP Slots to service Theatres

NET RESULT – Know number of GP OP slots to service theatres

The Result

• An effective predictable system

• Transformational change

• Fit for purpose for 18 weeks

Lessons so far• Lean analysis gives a much better

understanding of the real processes and demands

• Some radical changes are needed (egICATs)

• Achieving flow reduces waste but also exposes the problems

• Active and enthusiastic involvement of frontline staff is the key to success