The Content of Lean implementation

6.3.4.1 Description of Impact and outcomes

Many of the respondents remembered with clarity some of the changes made when GE were in the Trust two years ago as well as the outcomes and subsequent actions arising from the early stages of the IMPaCT programme. Regarding the IMPaCT programme the interviews taking place in March 2009 indicate clear evidence of a high level of engagement and empowerment among staff who have been involved in recent events, many of whom appear energised by the implementation of small changes to the process. These small changes are simple, easy to implement and effective in relation to the improvement of efficiency and flow, quality of patient care and as a means to ‘work smarter not harder.’

The impact of the Lean work is described under the following five sub-headings:

i. Simple changes

ii. Focus on Patient Value

iii. Team camaraderie and ‘Learning to See’

iv. Implementing New Standards

v. Challenging the steps

i. Simple changes

Some of the ‘simple’ changes that came out of the PAAC improvement event included changing the signage around the Trust and removing unnecessary patient data fields from multiple forms reducing the amount of time spent collecting unnecessary data from the patient. One department was found to have had several different names confusing both staff and patients leading to patients getting lost and staff sending patients in the wrong direction; this problem was collectively acknowledged during the PAAC RIE and steps towards remedial action were put in place immediately:

“They agreed with PFI people that they could put temporary signs up…just cut through before they had finished the weeks work” (General Manager)

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Other small changes discussed in interviews as part of the IMPaCT work included: implementing simple queuing systems, removing duplicate forms and adapting the terminology of a clinician’s letters to patients to avoid patient confusion. These changes were easy to implement yet very effective towards delivering a smoother service to patients resulting in a high level of enthusiasm and engagement amongst staff at the time of interview. When asked about longer term changes there were views that many small changes ‘add up.’ One senior respondent pressed about longer term actions in the Trust stated: ‘longer term

actions unfortunately are around the culture of the Trust’ (Associate Director of Finance and Operations). Referring to the small proportion of patients sent to PAAC (Pre-Anaesthetic Assessment Clinic) for a pre-op examination by clinicians this person highlighted the need for evidence of the benefits in order to bring about behavioural change in relation to their corresponding support services.

“a lot of consultants don’t use [PAAC] because they’ve got no faith in it…I think it’s about making changes and communicating them to get them to have faith in the system again and start using it. In terms of seeing the benefits of that (which is reduced cancellations) that’s going to be quite a long way off” (Project Manager)

ii. Focus on Patient Value

A key principle of Lean is to determine value from the perspective of the customer. In a hospital environment there are many stakeholders and thus the term customer can mean many things, some of which may present conflicting objectives as the following quote demonstrates:

“bringing back people 6 times before you operate on them is frustrating for the staff, it’s a waste of time for patients, we have to do 6 times the amount of preparation… the double edge sword to that is we get 6 lots of income, if you halve the number, you halve the income” (General Manager)

Evidence of a movement towards a patient focus was developing but the need to be reminded of the patient perspective was still apparent.

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“One of the outcomes of some of the events is that we’ve made a lot of presumptions as to what do the patients want, then when we’ve actually gone to do it it’s been completely different. Like for instance we’d been planning a one stop clinic but when we asked the patients they didn’t want a walk in clinic they wanted to come back at a particular slot” (Project Manager)

iii. Team camaraderie and ‘Learning to See’

There was strong evidence of team camaraderie relating to the recent work with IMPaCT and previous work with GE, suggesting there is long term value of getting people to come out of their functional silos and work collaboratively together.

“First of all the theatres staff were able to get together and have a good moan about all the problems and that was good” (Consultant)

“Everybody was there so we could flag up problems that are stopping the planning of operations” (Nurse)

“The event finished with us volunteering for tasks” (Sister)

The majority of participants, perhaps all of them, were learning about the process from one end to another and its wider context often for the first time. This ‘learning to see’ activity had a profound and lasting effect on many.

“You can see the people go, ‘oh yeah, that’s not good is it’, you sit back and take it all in” (Outpatients Administration & Performance Manager)

iv. Implementing New Standards

Some interesting projects were described relating to the implementation of Lean with GE that sought collective agreement upon the standardisation of certain processes. Some far reaching

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changes were recalled that had a sustained impact on patient flow, quality of service and quality of care. For example, in Trauma, the decision to protect a bed for neck-of-femur patients was made on the basis that this type of patient occurred around once a day and that patients were known to do badly if not operated on early. This was a major change to the scheduling of operations but the ‘list’ with the protected bed mitigated conflicting interests of specialist surgeons to ensure that when the neck of femur patient came in they would get a better and consistent quality of care that affords better long term prospects bringing the wait times down from 69 hours to 29, much closer to the national target of 24, thereby reducing mortality in this patient group.

Similarly in the PAAC event, one of the outcomes was to agree certain standards around the use of pre-operative assessment. Before the RIE it was established that just 1000 out of 4000 patients were sent to PAAC by clinicians for a pre-operative assessment leading to a number of cancelled operations on the day surgery unit because patients were found to be unfit for surgery on the day.

“What came out of Kaizen was that everybody should be told that anybody listed for a surgical procedure will have to go through PAAC, if they don’t then they are not classified as fit” (Support worker)

v. Challenging the steps

The radiology project was recollected by the Director of Finance as reducing waiting rooms from three down to one. Respondents who had participated in this project described it as ‘brilliant’ where the outcome was to change the way people wait giving rise to benefits for patient flow, patient service quality, and staff morale. Furthermore less waiting meant much needed space could be reallocated from Radiology to the Trauma clinic. These changes came about by staff challenging the necessity of the process steps to reduce batching, waiting and improve patient flow:

“When we looked at what the patients were doing (I remember the steps quite vividly really) we thought well ‘can they not walk round by themselves?’” (Lean Leader)

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The impact of successfully challenging this step and making a change led to improved service quality and greater staff morale:

“Less people in our waiting room so the receptionist is less grumpy, more welcoming” (Lean Leader)

“The change was not only in waiting time, they changed the way that they allocated the work because patients brought the form round, they could be greeted round there”

(Lean Leader)

The patient forms themselves presented an error prone scheduling arrangement:

“forms went into the box, they didn’t go in a particularly great order so a person waiting the longest in the waiting room might have ended up waiting the longest the other side” (Lean Leader)

Further evidence of challenging the process steps led to the unblocking of theatres where operations were unable to go ahead because patients were not being moved from recovery room onto the wards. Investigation into the root cause of this blockage revealed ‘all sorts of

silly little reasons why patients were not being collected from recovery’ (Lean Leader) leading to agreements as to what was a viable reason for not collecting patients and what was not.

6.3.4.2 Sustaining improvements

The sustainability of Lean was evident in the Trust where projects were known to be successful at time of implementation. For example, where waiting times were reduced by 70% two years ago the department was reportedly ‘still very invigorated’. When pressed as to the magnitude of the changes being made many were reported to be small but there were a few bigger changes as well. Ultimately though, the reduction in waiting time by 70% was the result of a ‘really really small change’ (Lean Leader).

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