Marc & Ian’s Blog Page

Apr 6

QIPP and Lean, Perfect Alignment ... But we see a gap

In the summer of 2009 David Nicholson (Chief Executive of the NHS) sent a letter to all Chief Executives of PCTs, NHS Trusts and NHS Foundation Trusts in England regarding the implementation of Lord Darzi's Next Stage Review (NSR): The Quality and Productivity Challenge.

At the Same time we published our findings, from five years research working in the NHS, in the form of the book Making Hospitals Work. Whilst the two came from completely different sources the messages contained within both are remarkably similar.

David Nicholson asked for contributions about improving Quality, Innovation, Productivity and Prevention (QIPP) stating that this is the most important challenge facing the NHS for the foreseeable future. “The real changes we seek will be designed and delivered locally with the centre playing an enabling role. Meeting the challenge is central to the role of every NHS leader and every NHS board. In short this is your day job”

Within the four principles that he had set out to guide the implementation of the NSR, he goes on to mention the importance of:

• Having the capacity and capability in terms of people with the right time, skills and support to properly support the scale and pace of change required.
• Great clinical leadership, supported by managers who back good ideas.
• Leadership behaviours, not necessarily the same as those during the period of growth.
• Organisations having a clear narrative about what this challenge means

Interestingly the House of Commons Health Committee: NHS Next Stage Review (First Report of Session 2008–09), a ‘review of the review’ if you like, echoes the need for the above points but voices concerns regarding the general lack of analytical and planning skills and that the quality of management is very variable, stating that “It is widely recognised that the quality of leadership in the NHS must improve”. It also expresses concerns about whether NHS institutions and staff were capable of delivering the proposals made in the NSR.

Anyone who has read Making Hospitals Work or follows the Lean Enterprise Academy’s healthcare articles and blogs will see a very clear alignment between these messages and ours. You will also be aware that we insist that all this should be the part of the day job, that clinical leadership is definitely the way forward and that leadership behaviours will need to change to face the challenges ahead.

However working daily, at many sites, gravitating (up and down) constantly between the frontline, middle management and executive level our concern about a clear narrative is that until healthcare organisations, at this local level, are capable of distilling and prioritising their objectives, to address the vital few problems facing them, then staff will neither be given or have the time (capacity) to develop their skills (capability) to enable them to deliver.

We share the House of Commons Health Committee’s concerns regarding implementation, but herein, we believe, lies the gap. The staff at the local level have not (yet) been shown how to do this, thereby enabling them to practice and become skilled at doing it, then they must be left alone, uninterrupted, to get on with doing it.

Apr 6

What problem are we really trying to solve here

As we work with more and more healthcare organisations in the UK it becomes more and more apparent that their biggest problems (the ones that keep their Chief Exec awake at night) are:

• Financial performance
• Hospital Acquired Infections
• The 18 week Access target
• The A&E/ED 4 hour and 8 hour targets
• Length of Stay (LoS)

It becomes even more evident that LoS (for medical patients in particular) is the deepest cause for concern.

Extended Medical Los is a massive drain on finances, necessitating the opening up unfunded beds which require un-budgeted bank and agency usage (it is unrealistic, however, to close beds without firstly reducing LoS). The longer a patient remains in hospital the greater their chances of acquiring an infection (which extends LoS even further). Extended medical LoS also results in the practice of out lying medical patients onto surgical wards (which prevents the admission of revenue generating elective patients), and leads to a lack of available beds for A&E patients requiring admission (resulting in excessive breaches).

We have yet to work with any organisation (to date) that do not insist that extended medical LoS is indeed their biggest problem. However they still typically have a portfolio of (on average) 500 ongoing projects (trust wide) attempting to address ALL of the Trust’s problems. This huge portfolio, perversely, prevents staff from working full time on reducing LoS, their biggest problem, and making it part of the day job.

Understandably finance in today’s environment seems to rule the roost resulting in many ‘turnaround’ initiatives. As a result, for example, Pathology or MAU are asked what can they contribute to financial savings but will their proposals also help reduce LoS? This applies to all the divisional and departmental silos.

Can you imagine if we all acknowledged that a reduction in LoS would be the greatest contributor to achieving all of our other targets and just worked on that. Then we would be asking all the divisions, departments and services “what can you contribute to a reduction in LoS”.

Every division, every department and every service would then be perfectly aligned to work on one goal, to reduced LoS. True North as we call it. Imagine how the project portfolio would look then.

Feb 25

Who’s Got Time for Lean in Healthcare?

If you have navigated to this article, then there is a fair chance that you are in a leadership position in healthcare and are interested in the application of lean thinking within your organisation. There is also a fair chance that you would agree that lean should be part of the day job, not an addition to it.

This is where the problem lies. We have worked with many health care organisations where the application of lean thinking is indeed an addition to the day job. Sure, these folks know it’s the right thing to do for both the organisation and the patient, but the truth is that they simply have not got the time, the capacity, to adopt lean.

Suspecting this, we have carried out what we call a ‘Diary Exercise’ with many Healthcare execs, senior managers and line managers. It is totally normal when conducting these exercises to find that the genuine demands placed on these individuals can be in excess of 24 hours a day. So, if you were to start in a new job on day one, you would come in to 24 hours worth of work to complete that day. If you were to work a 12 hour day on this first day, then you would come in to 36 hours of work on your second day (24 hours worth of work plus the 12 hours worth of work that was not completed yesterday) and so on. No wonder that inboxes and in trays are always full to overflowing.

This is not down to poor time management. It is the genuine current demand placed upon these people by their bosses right throughout the chain of command. Whilst conducting these diary exercises in one organisation, we were fortunate enough to be invited to assist them in their first steps towards formal strategy deployment.

During this exercise we discovered that this exec team believed that they had 252 targets imposed upon them and then when deployed to the next (General Manager) level, the number had mushroomed to 350. Why?

Upon close investigation, it transpired that the trust only had 36 external targets imposed upon them (6 of which were duplications anyway, so 30 really). It transpired that the trust themselves (or their Performance Dept more like) were generating this impossible amount of work. Hence the crippling 24 hours worth of demand placed upon individuals. So did this organisation have any time to invest in adopting lean?

More recently, whilst working with another health care organisation that are also keen to adopt lean thinking and more importantly the stability that basic lean Operational Management brings, we noticed that the key managers were unable to maintain the routine ‘check’ cadence that good Ops management requires. Again we performed the diary exercises with these folks and again found a very similar story. Digging deeper we helped them uncover the fact that in the medical division alone, these line management, operational folks were jointly working on over 140 improvement projects and initiatives yet no one person could see all 140 in one place or indeed even knew that there were so many. No wonder they didn’t have time to embrace lean thinking.

Whilst it is admirable that these organisations are striving to provide better and safer patient care at a reduced cost, expecting people to work on these vast volumes of work that has been self generated, is not only unrealistic and unsustainable but is unfair on the staff and provides no real benefit to the patient.

Just imagine that you are spinning plates. You have already got too many plates on the go, when somebody comes along and says “by the way, here are another couple of plates for you to spin”. It’s inevitable that they all come crashing down.

Understanding this situation has helped us work with these organisations to funnel down to their biggest problems, the vital few and to focus everybody’s attention on working on just these.

Medical Length of Stay (LoS) appears to be a good place to start, as a reduction in LoS combined with safe effective discharge, obviously, improves quality of care, reduces the risk of hospital acquired infections, assists in achieving emergency and elective targets whilst reducing costs.

It’s only when there is agreement from the top to unearth the ‘vital few’ and allow everybody else in the organisation to work just on these, will staff not only have time to learn and become skilled in lean, but will have the time and capacity for it to become part of their day job.

Jan 29

OK, So You Know Your Demand To Get Into Your Hospital ... But Do You Know Your Demand To Get Out?

We now realise that it is difficult for a Medical patient to get out of hospital once they have been admitted. You are more likely to be moved to another ward when you are approaching a medically fit status (which we all know extends LoS) rather than remain on the same ward and be discharged when you are declared medically fit.

Talking recently to a senior nurse, who was unfortunate enough to have spent 3 spells in hospital over the last few years, she went on to explain that on each occasion this is exactly what had happened to her and that on each occasion her LoS was extended by an additional 3 days after she had become medically fit. It is hard to get out, she exclaimed, unless you discharge yourself. The main difference is that most patients (and their families) don’t actually know when they are medically fit. They have to wait for someone to tell them that it’s okay for them to go home. Some, obviously, whilst undergoing this protracted process contract hospital acquired infections which extends their LoS even further putting even more pressure on the entire system and the staff.

We have visited many hospitals where demand information is difficult to obtain. Some of the more enlightened hospitals, however, can now provide patient ‘demand to get in’ from their Emergency Department or via GP referral (some even by the hour and by the day of the week). We tend to have this annoying habit of saying “but I can’t see it” when factual, real time, data is not readily available and accessible. Our observation is that whilst organisations may know their demand to get in, they very rarely know their ‘demand to get out’, the demand for discharge. We just simply cannot “see it”.

In light of this, we have run several experiments in several hospitals where we employed a simple visual management technique to enable us see this demand to get out. To our astonishment (and to that of the organisations themselves) it turns out that it is absolutely normal to find that, at any given time (except over the Christmas period maybe) between 25% and 30% of beds on medical wards are occupied by patients who are medically fit for safe discharge, but they are still in the hospital. The demand to get out.

This 30% does not consist solely of DToC patients (bearing in mind that different organisations use different operational definitions to describe DToC patients), it also include many patients who are simply medically fit for a simple discharge but are still occupying a bed on the ward.

These same organisations freely admit that medical demand to get in is actually very predictable. Likewise, from our experiments we can confirm that demand to get out is equally predictable by the day and by specialty.

All this is good news because it means that due to this predictability, we can actually, for the first time, schedule discharges of unscheduled care patients.

For some time now many hospitals have attempted, without success to introduce discharges earlier in the day the ‘early bird’ or golden patient’ as some call it.

Seeing demand to get out, again for the first time, enables small numbers of discharges to be ‘drip fed’ throughout the day (which is all that is actually needed to cope with in-coming demand) as opposed to the usual large quantity, at the wrong time of the day (late afternoon and early evening) and the resultant chaos and stress that this causes.

To enable our experiments to unearth these medically fit patients we obviously rely heavily on the accuracy and honesty of the information provided by the ward staff. I’ve heard many nurses and managers declare that it’s far easier to retain a patient than to go through the process of discharging a patient and admitting the next one (unless the patient is an unpleasant individual – they like to hang on to nice, compliant, patients). It is human nature after all to avoid hard work if at all possible.

Some organisations have even gone so far as to announce to staff that it is a disciplinary offence not to declare medically fit patients. There is another side to this coin however. One senior nurse recently reported to us that her mother had been admitted into the hospital where she works. When this senior nurse went to the ward to find out her mothers medical status, she received one set of responses. However, upon explaining that the patient was actually her mother, she received a totally different set of responses. Reflecting on this, her hypothesis was that when she made the initial enquiry, the ward staff thought she was wearing her ‘management hat’ and was going to force them to do something with this patient that they did not believe would be in the best interest of the patient (maybe transfer her to another ward - off template as some organisations call it). It may be, she continued, that in an effort to create space for incoming demand, management were influencing, adversely, the behaviour of the ward staff.

We have witnessed this ‘cat and mouse’ game, with opposing agendas, all but disappear once this highly pressurised, highly charged and emotional environment is replaced with a transparent and stable process in which, through seeing and understanding this genuine demand to get out, discharges for un-scheduled care patients are being scheduled.

Jan 18

Who’s (or Where’s) the Boss ?

Back in the very early days of our time working in healthcare (our apprenticeship if you like) we asked to meet the Ward Manager of the first ward that we were working with. Asking her deputy if the ward manager was around she replied “I’ll have to check the Off Duty”.

We immediately though that this was strange, why ‘off duty’ what about who’s ‘on duty’ (the off duty - a whole other article in itself) and why doesn’t the deputy know where her manager is. That’s how naive we were in this industry.

It transpired that the Ward Manager was on a ‘Management Day’ but was contactable. So we met with her in the hospital library. This is where we learnt that although she was the Ward Manager, responsible for a 36 bed ward, around 50 staff and around 45 patients (per day due to admissions and discharges) she was actually ‘part of the numbers’ she was, when on duty, being a nurse looking after a bay of 9 patients.

This meant that she was working a shift pattern along with the rest of her staff and that when she was not working there was no manager available. Coming fresh from manufacturing and putting this into perspective, we were used to there being a Shift Manager or at the very least a Shift Team Leader so this came as a bit of a surprise.

We imagined the equivalent in manufacturing – a manager who with was responsible for 50 staff working a 27/7 shift system , manufacturing around 45 different batches per day but was actually working ‘full time’ on the line and on shifts.

So at this vital ‘unit level’ the Hospital Ward, if the Manager was working night shifts this week this meant that during the busiest period where everything happens, during the day, there was no one managing at all.

We could not imagine any other industry that would tolerate this. How can she possibly manage? So what was this management day all about? She explained that twice a month she was allowed to spend a shift working out the ‘off duty’, balancing budgets, staff issues and training, complaints and so on. In other words all the stuff that a manager, in other industries, normally does every day. It was admin work not management.

Being naive we had seen the old movies where ‘back in the day’ there was a Matron who was the boss but here it turns out there wasn’t one.

Over the ensuing moths we formed an excellent relationship with this ward manager, who freely admitted that due to her constraints had no chance to know her staff let alone all the patients on her ward. With her assistance we sat down with this ward manager and calculated that for no additional cost she could actually become as we tend to call it in the UK healthcare industry ‘supernumerary’. In other words, by applying a scientific approach to the ‘off duty’ we could free her up to Manage the Ward working normal office hours (when everything was happening) and no longer required to work in one single bay.

Like all experiments we needed to get a base line, a current state. It turned out that whilst on shift, and due to her position as the manager she was interrupted 194 times. As a result, through no fault of her own, if you happened to be a patient in the bay in which the ward manager was responsible for, you actually received less care than a patient occupying a bed in the other bays on the ward.

The ward manger’s boss, looking at both our calculations and base line data, agreed that she could and should, indeed, be supernumerary. Great for ward manager and us.

So we could now introduce simple, yet extremely effective visual operational management – a Plan for Every Patient (PFEP) whereby immediately upon a patient being admitted to the ward a complete plan was drawn up, visually, for the patient, from admission until they were medically fit for a safe discharge.

The process was drawn up and followed whereby the ward manager would at a given time of day invite the nurses responsible for each bay to attend and report whether the patient actually received what they were planned to receive yesterday and if not (variance to plan) how to catch back to achieve the plan, and to re-iterate today’s plan.

During this period planning accuracy, in other word the Patient receiving exactly what was planned for them (On Time and In Full) rose from 41% to 86%. It also provided an excellent means for the ward manager to ascertain which members of staff were ‘on the ball’ knew their patients status or did not.

Through Industrial Tourism this approach proved to be extremely popular with other hospitals within the organisation (and beyond) wishing to adopt it. Great, but a word of caution (from lessons learnt) – don’t tell the Finance Department. Once they know that you can actually install a supernumerary ward manager they may well cut the budget. On this occasion they actually attempted this, yet another battle and yet another article.