December 10, 2016

Starting Blocks

Without a doubt, Lean is set to make a big impact on the Healthcare sector over the next few years and many Healthcare organisations in both the public and private sector are already exploring how they could apply it to their patient pathways and administrative processes.

Whilst many of the tools of Lean are familiar to the people in the Healthcare sector, particularly aspects of Process Analysis, the real difference that Lean will bring is a change in the way that improvements activities are implemented rather than the use of the tools themselves.

Many people in the Healthcare sector are looking to people with Lean skills gained in manufacturing to help guide them through the maze of implementing Lean, including helping the organisation to prepare for Lean as well as undertake the specific improvement activities, including Value Stream Events, Rapid Improvement Events etc. Running alongside this is the need to develop the internal capacity of organisations to lead improvements themselves, which is achieved by developing internal Lean facilitators (or Change Agents).

However, as we already know, not every problem in Healthcare can be related to a problem encountered in Manufacturing and there are some significant differences in approach required to make for a successful improvement programme for people more familiar with leading Lean improvements in Manufacturing.

In this article we review some of the key differences that we have found in pioneering Lean transformation in Healthcare and share the structure to Lean activities that we have been developing to ensure that the organisations make sustained improvements rather than isolated Lean ‘ram raids’.

Interestingly, our work to date is also providing some useful learning that can be applied in reverse – from Healthcare back into Manufacturing!

The Same, But Different

As we have already said, Lean will make a big difference to Healthcare and will help them achieve their operational and financial targets but it needs to be applied sensitively within organisations that have been ‘pummelled’ by initiatives and legislation and have a not unreasonable cynicism towards ‘this new initiative called Lean’.

Like in many manufacturing businesses first embarking on an improvement journey, Healthcare employees are concerned about Lean being a vehicle to cut jobs. This feeling has not been helped by the recent NHS guide issued about Lean Healthcare which has chosen to use a Chainsaw as their main logo and was referred to by a Service Improvement Lead within an SHA (Strategic Health Authority) as the ‘Slash & Burn’ guide to Healthcare.

Issues such as this, along with the use of manufacturing focused terminology, photos and case studies when working with employees in Healthcare, has the effect of building up internal resistance and leads to comments such as “My patients are not cars” made by a Renal Consultant we encountered recently.

Additional differences can be seen in the attitude towards risk in Healthcare. In Manufacturing, if you make a mistake with Lean you may increase the risk of accidents but it is more likely it will just reduce productivity or profits. In Healthcare, similar mistakes can impact on Patient Safety (including increasing Morbidity or even Mortality) and can attract significant media attention.

Making this scenario even more complex is the fact that the ‘care pathways’ that patients experience often interact and overlap in a way that Manufacturing value streams do not, with patients switching between pathways and specialities dependent on their specific needs and treatment plans.

Management of these processes and pathways is complicated by the need to balance clinical concerns (such as patient safety and medical best practice) with ‘business’ concerns (availability of resources and finance), and the often uneasy balance that has to be struck between senior clinicians and organisational managers on these issues.

Whilst this sort of complexity is not alien to manufacturing, where there is a constant need to balance cashflow against sales (for example), the fact that this balancing and the resulting management of risk in Healthcare is so prevalent leads to a very different style of management – being more consultative and inclusive than Manufacturing, which slows decision making and involves a lot more analysis than many Manufacturing decisions, and the need to prove things first to sceptical clinicians.

This constant need for balance between clinical and operational concerns leads to one of the biggest differences we encounter, namely the difficulty in engaging the right people for the right amount time to make the improvements sustainable. This is not a new problem in Healthcare with many improvement initiatives having fallen foul of changing priorities, the allocation of insufficient people to an improvement process or simply having failed to move from discussion into action quickly enough.

One final difference between Manufacturing and Healthcare that we thought useful to highlight is simply the differences between what ‘customers’ think of as Value Adding in the two sectors. Giving comfort and advice to a patient is highly valued (for example, a nurse accompanying a patient being taken to theatre) but does not translate easily into a manufacturing equivalent activity.

A Holistic Approach
To counter these issues, introducing Lean into Healthcare requires a holistic approach that takes into account the following points:

1. Understanding Customer Value

Whilst the patient is the obvious (and most important) customer in a process, they may not be the only customer in a Healthcare environment; with others including (say) a Primary Care Trust that has commissioned a Hospital to undertake some activity on a patient and which will be invoiced for the activity.

However, in exploring what customer think of as value adding we do find some customers (patients) in Healthcare have become conditioned by their experiences to date. In one example we were speaking to a patient who attended clinics weekly as part of their treatment plan and was required to wait at every appointment for up to two hours. When we discussed what they valued and whether a reduced waiting time would be beneficial, they said they had come to expect the wait and would place more value on access to free coffee and better magazines to read!

2. Scoping Effectively

Identifying a compelling need for the improvement process is absolutely essential. The need to improve productivity or finances are often driving improvement initiatives in Healthcare but a compelling need based on saving money will rarely engage people from across the pathway.

Often a successful compelling need will focus on improving patient outcomes and achieving the statutory targets within public Healthcare (such as achieving an 18 Week maximum lead-time from referral by a GP to the start of treatment) as well as the need to achieve best practice rates for activity. Because of the importance of this step in the process, we have shown what we believe are the key elements required to successfully scope an improvement project in the text box opposite. It is worth stating that to be truly successful, the scoping of Lean improvements relies on having representation from across the pathway – even if, as is so often the case, that means including people who have never considered themselves as co-workers before, such as the GP and the Hospital Porter we had sitting next to each other at a recent Scoping session.

3. Effective Sponsorship

Leading a Lean project that spans such broad patient pathways requires a high degree of influencing skills. Even seeking to improve a simple administrative process like a Patient Discharge for example, could require the Project Sponsor to liaise, cajole and drive change across several stakeholder groups including GPs, consultants (the real custodians of the NHS), ward staff, medical secretaries, pharmacy staff, IT, social services and porters!

The Sponsor’s belief in Lean will be tested daily by such a large group of interested parties and so their capacity to maintain enthusiasm and motivate the Change Agents is vital. The secret weapon at their disposal, once the Scoping session has been completed is that an agreed Compelling Need will create “clarity of purpose”. Ultimately, if they engage enough people with the same message enough times, the followers will start to assemble.

4. Building Awareness & Capacity

Given the concerns of many in Healthcare that Lean is going to be used to shed jobs, it is essential that there is thought given to the communication of the ‘Compelling Need’ – what Lean is, what it is not and what will happen. Running alongside the raising of awareness will be the need to focus on developing the capacity of individuals within the organisation to enable them to lead Lean improvements.

In addition to initial awareness activities, there is also a need to build on-going communication activities to report on progress, involve others in the design of new processes and ensure that the organisation embeds the improvements achieved before (or alongside) moving onto the next challenge.

Our experience of this shows that at the start of the process a lot of people think of Lean as being just about ‘Process Mapping’ and there is a certain cynicism about it in many areas. This is quickly overcome but can be quite demoralising when first encountered and this confusion about Lean underpins the need to develop broad awareness within the organisation of what Lean truly can deliver.

In terms of capacity, many Healthcare bodies are keen to build internal capability to develop themselves as Lean organisations. Performance Improvement Teams are popping up all over the place and we have found that a large part of our work has been focused on helping these teams of change agents develop the facilitation skills and leadership attributes that will enable them to not only deliver change but make it sustainable.

5. End 2 End Understanding

We mentioned earlier that one of the ways that Lean in Healthcare is different to Lean in Manufacturing is that the pathways (value streams) interact in a different way. Another problem is often encountered through isolated events in one area having an unexpected (and often negative) impact either upstream or downstream in the pathway. Given the risk associated with making changes in different parts of Healthcare, we believe it is essential to develop an understanding of how the pathway operates from End 2 End and to review its critical constraints, current operating performance and the impact that likely changes might have elsewhere before seeking to create a suitable ‘Future State’ and implementation plan.

6. Embedding the Change

Much like Manufacturing, a large percentage of Lean projects in Healthcare are going to fail to deliver the results that organisations hoped for and many of these problems are related to the challenge of embedding the changes. So, having gathered support for an improvement programme and achieved the changes (through Focused Improvement Teams, Rapid Improvement Events etc), it is critical to also conduct the activities that will assist the embedding of the changes including:

 Publicity and communication of how the new systems/processes work
 Celebration of the improvements achieved
 Reviews of achievements (Progress Gates) which look back at what has already been done
 Auditing to ensure the changes don’t slip back to ‘the old way’
 Further events and activities (as one success often breeds further successes)
 On-going Change Agent Development
 On-going, visible Sponsorship.

No Magic Bullet
When we opened this short article, we mentioned that Lean is set to have a big impact on Healthcare as it can address the needs for improved effectiveness as well as reduced lead-times and costs, but that its application is different to the way that improvement activities are led in Manufacturing and has different risks and threats to success than in other sectors.

We do not claim to have a monopoly on good ideas about how to address these points and have written this article from the basis of real experience of delivering improvements to a variety of Healthcare organisations. We would welcome feedback on your experiences.

As a closing thought to Lean practitioners everywhere who are looking to be (or are already) involved in Healthcare – whatever the operational benefits that are possible, no-one wants to achieve these at the expense of patient safety – as it is only by addressing both operational and clinical needs that Lean Healthcare will truly come to life.

Mark Eaton MSC MBA CEng MIET FIOM
Mark is a Fellow of the IOM and Chairs the Operations Development Panel. He is a frequent speaker on the topic of making improvement sustainable and has worked with the Armed Forces, NHS, Local Authorities and Manufacturers for over 10 years on improvement programmes.

Simon Phillips MA FRSA
Simon is a Fellow of the Royal Society of Arts and Manufacturing and has spent many years helping industry leaders and their organisations to embrace new ways of working. He was recently awarded a National Training Award and has worked across all sectors in the UK, Europe, South Africa and the US.

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