KEY FEATURES OF A LEAN TRANSFORMATION
|Document Name |NHS Lean Implementation handbook draft |
|Version |2.0 |
|Status |DRAFT |
|Date of issue |15/01/06 |
|Owner |Ray Foley ray.foley@institute.nhs.uk |
| |Associate |
| |NHS Institute |
|Authority for Issue |Ray Foley |
|Revision Date |Na |
|Sensitivity |None |
|Configuration Librarian |Ray Foley |
|Whats changed & why |Boiled Liker’s 14 principles to 6. Is this too simplistic? |
| | |
|Whats to do |Move away from Toyota and Japanese words entirely by inventing a complete NHS approach starting with an|
| |NHS Purpose statement |
| | |
| |Xref with John Seddon’s public sector Lean approach? |
| | |
| |Put to bed (sorry) the patient as ‘customer’ and define ‘wants’ vs. ‘needs’ definition and language |
| |problem. |
| | |
| |Flesh out process tools in Principles 2,3,5 including SPC |
| | |
NHS LEAN TRANSFORMATION :
LEAN IS NOT A TOOLBOX. IT IS A WAY OF THINKING ABOUT WORK
A Lean transformation cuts across organisational boundaries of department and job description because:
The aim is to create smooth-flowing consumption streams (patients with needs) matched up with smooth-flowing provision streams (healthcare services)
So that patients get what they need, where they need it, when they need it, without waiting
Consumption and provision streams run across organisational departments
Most improvement efforts have been aimed at particularly deficient single points within discrete departments along the stream rather than viewing the whole stream.
No one tool will help, you may have to invent your own, just start doing something, get it wrong, learn and start again.
Because Lean naturally looks at the whole stream or process, it requires a Chief Process Officer (CPO). This person does not have to be managerially locked into the pathway.
This person has to report to the CEO because the CPO’s plans will require major organisational change.
Another way of viewing this is:
1. Strategy of a lean transformation is to create smooth-flowing consumption streams matched up with smooth-flowing provision stream
2. Processes must be re-organised to achieve this
3. Organisational structure must change to support the new processes supporting the new strategy.
Do not formulate strategy around the processes and structure you presently have
LEAN IS NOT A TOOLBOX. IT IS A WAY OF THINKING ABOUT WORK VIA 6 PRINCIPLES
1. Philosophy as the foundation
Base management decisions on the long-term goal of adding customer-value. Easier said than done when working in regulatory / target culture, but the Audit Commission has an interest in Lean and has accepted this principle in other sectors, such as Social Housing and allowed councils to ‘under-perform’ against target in the understanding they are embarking on Lean turn-arounds. (Steve Mason, Audit Commission, Cranfield Round Table). Maybe the DH will also change it’s view?
Practical things to do:
• Change focus of all board meetings to look at key Value Streams. All other considerations are secondary including national performance targets.
• Board Members must ask for new style Board Reports that inform them on the performance of the whole process from the customer’s perspective.
• Board Members must devise and promulgate a simple, clear message or mission statement that encapsulates the aims of the Lean Transformation that all staff locally understand.
• This is usually intrinsic ie not “we must meet national targets” but “patients will experience no unnecessary waits or errors while in our hospital”
2. Level out workloads
Have stability in all work processes so that problems are easily seen and so that continuous improvement is possible. Understand deeply the nature of the demand placed on the process and the capacity it has to meet that demand. Seek to match the two as a basis for all other improvement efforts.
Practical things to do:
• Capacity and demand analysis by day or hour or whatever is appropriate, using Runcharts. Feedback to all relevant managers, discuss reasons for variation
• Analysis of actual vs. planned capacity; root-cause reasons for any difference
• Analysis of demand: source, type, urgency, appropriateness
3. Work on flowing work faster and without batching or delays
Processes should work at the rate of demand placed on them. Queues or waiting lists are signals from a process that this is not happening. Process steps should quickly and automatically signal to each other along the Value Stream, they should act and think in a coordinated, customer-centric way.
Practical things to do:
• Map the process adding timings to each step and waiting list counts
• Involve everyone touching that process and ask why queues develop
• Look to where demand is coming from and seek to smooth that, eliminate inappropriate demand
• Foster ownership of a Value Stream, not just process steps, with a Value Stream Group, Patient Group, Chief Process Owner, Value-Stream oriented reports, not specialty or department oriented reports, ie total journey time measurement, demand vs. overall capacity reports.
• Start with anaesthetists: they want patients revived as soon as possible, so are likely to be motivated to help in flow projects involving theatre.
4. Get quality right first time
Stop and fix problems right now. Don’t ignore them or invent work-arounds. Management must invite alerts to problems and be prepared to solve them as quickly as possible. Foster culture of designing-out problems from occurring in the workplace with visual clues for example
Practical things to do:
• Never blame the person, blame the process
• Encourage staff to fix the problem and learn and disseminate
• Have a method agreed by all staff to report problems easily and quickly
• Have agreed escalation protocol so everyone knows who is responsible for diagnosing and fixing
• Enable quick ‘off line’ testing and remedying
• Keep local problems log, have regular reports on errors and fixes
• Advertise successes
5. Standardise tasks
Not to be confused with rigidity. Use standardised procedures simply as the commonly-understood base-point to improve the process from now on and to ensure sustainability as people move on.
Practical things to do:
• Standard work does not start with writing laminating and hanging-up standard work charts. That comes last.
• Start discussion on what are the repeatable, standard elements of work
• Establish a lead person in charge of identifying these, measuring the variation, investigating why. Do all this from standpoint of wishing to improve and help the staff have dependable processes.
• Investigate the relationship between the variation in demand coming in and work processes. Is variation due to the complexity of patients? Or poor processes? Ie missing materials, lack of space etc.
6. Grow Lean leaders and managers
Leaders instill the intrinsic motivation for this new way of thinking. Managers are doing it every day. Managers must be highly visible and near the value-adding work. Managers are there simply to improve the Value Stream. They should make improvement decisions through consensus and implement swiftly.
Practical things to do:
• Other site visits, short-term Lean Consultant support to management
• Encourage study, training and education in this area
• Succession plan, aim to keep promising leaders
• Improve management selection process, learn from others doing it well
• Encourage experimentation, allow mistakes, see who takes up that challenge
LEAN IMPLEMENTATION : WHERE TO START
(borrowed from Liker – Toyota Way Field Book)
You have at least 4 choices:
1. Philosophy: work with top team on how to think lean; how to ask the right questions, be welcoming of problems, be visible and near the work, instil intrinsic motivation to improve, not for sake of targets
2. Process: define your organisation as a set of value streams, start on optimising one
3. People: start to introduce this new way of working to all staff
4. Problem Solve: take lean’s relentless curiosity about errors and defects, combine with the toolset around root-causing and putting right and implement via small projects under banner of ‘right first time’ or ‘error free’
Which blend you choose you must decide locally by examining what levers / support / problems / culture / politics / timescale you have.
Just get started on something. Many organisations start with Value Stream Mapping.
Why? Because Lean is about starting with the customer, delivering what they need with no waste. This is the Value Stream or why your organisation exists, it does not exist to run an Outpatient Department or a Theatre. Looking across departments like this starts to generate new ways of doing things.
KEY FEATURES OF VALUE STREAM MAPPING
The CPO must be supported by a small full-time team.
They do 3 things:
IN PARTNERSHIP WITH ALL THE STAFF INVOLVED IN THE PROCESS:
1. Learn to see the process as it actually is:
Identify and understand purpose and customers
Use A3 to identify process purpose & customers
• Customers of the process: internal and external, do you know exactly what they want?
• Do you understand the types and nature of demand placed on the process over time?
Draw-up current State Map: Record every step in the process as it is like now
Define current state metrics like Yield, non-value adding steps, waiting times, batches, lead-time vs. target
Do you really understand present capacity: utilisation levels, why this varies and when
2. Engage in future state implementation activities with aim:
• All staff to understand whole process from the patient’s perspective
• All staff to understand why the process must change
• All staff to understand and help in how the process must change
• All staff to understand that their role may change but they will not be made redundant
Future State planning can be helped with a number of Lean ideas, this is where all the textbooks like Bicheno Lean Toolbox, Liker etc come in.
But key point is staff must choose the solution themselves.
3. Encourage Lean as a way of life
Managers and staff curious about all problems, root-causing them all, regular time-out for Kaizen events
Lean is about zero defects = reducing clinical errors by analysing the process and not blaming the person. Live this philosophy.
The process today is simply the best way to do the work today. Tomorrow there is a better way to be discovered.
GETTING INITIAL PROCESS STABILITY
DIFFERENCES BETWEEN TRADITIONAL AND LEAN THINKING
|‘Command & Control’ traditional management |Patient – centred, ‘lean’, process thinking |
|Top-down decision making concerning processes separated from |Those actually operating the processes heavily involved in |
|those actually operating the processes |decisions around them |
|Function specialisation; departments, budgets, roles, |Value-stream oriented processes and roles |
|splitting-up the value stream | |
|Leadership & management motivated by extrinsic factors |Leadership & management intrinsically motivated by continuous |
|(crises, targets, fads) |improvement and curiosity about their organisation |
|Manage budgets, departments |Manage the system |
|Guarded attitude to suppliers, partners (eg Social services, |Open partnership for one aim: better patient service |
|PCTs, GPs) | |
(Borrowed heavily from John Seddon)
From this table flows more detailed criteria against which to measure Trusts:
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