NHS

Improving Quality

BRINGING
LEAN TO LIFE
Making processes flow in healthcare
IMPROVEMENT. PEOPLE. QUALITY. STAFF. DATA.
Acknowledgements
STEPS. LEAN. PATIENTS. PRODUCTIVITY. IDEAS.
This document has been written in partnership by:

REDESIGN. MAPPING. SOLUTIONS. EXPERIENCE.

Zoë Lord
Email: [email protected]

SHARE. PROCESSES. TOOLS. MEASURES.

Lisa Smith
Email: [email protected]

INVOLVEMENT. STRENGTH. SUPPORT. LEARN.

CHANGE. TEST. IMPLEMENT. PREPARATION.
KNOW-HOW. SCOPE. INNOVATION. FOCUS.
ENGAGEMENT. DELIVERY. DIAGNOSIS. LAUNCH.
RESOURCES. EVALUATION. NHS. PLANNING.
TECHNIQUES. FRAMEWORK. AGREEMENT.
UNDERSTAND. IMPLEMENTATION. SUSTAIN.
 Bringing Lean to Life - Making processes flow in healthcare

Contents
Introduction - what is the problem in healthcare? 4 Identifying waste 18
What is Lean? 6 Making value flow 21
A3 thinking 7 Understanding pull 22
An example A3 report 8 Understanding Takt time 23
The importance of data and measures 10 Using 5S to improve safety 24
Example statistical process control (SPC) charts 11 Plan, Do, Check, Adjust (PDCA) cycle 25
Current state value stream mapping 12 Continuous improvement 26
Analysing your current state and designing your 14 Value stream mapping symbols 27
future state value stream map
Standard work to produce high quality every time 15
Visual management 16

3
4 Bringing Lean to Life - Making processes flow in healthcare

Introduction - what is the problem in healthcare?

We all come to work to do our very best - to The processes are to blame, not the people This booklet provides a basic introduction and
achieve what we are capable of and to add real overview of Lean; the culture, principles and
value for our patients and ensure clinical Often, there is ambiguity in how certain tasks tools to understand to enable you to tackle and
expertise is supported by process excellence to should be performed – so people work it out for resolve issues within healthcare. It is not
enable processes to flow at the rate themselves to secure the best outcome and get intended as a complete guide to implementing
of patient demand. Healthcare teams are the job done. However, whilst everyone Lean as a management system.
dedicated and skilled professionals who are develops their own bespoke solution, the
often under pressure to do their best and work variations introduced by different people can be NHS Improving Quality has been using Lean
terrifically hard - but often the processes are significant and harmful. with clinical teams and has proven that the
inadequate. methodology can improve quality, increase
Departments continue to work hard in safety, reduce turnaround times, increase
Each year, the National Patient Safety Agency isolation to ensure they improve their services efficiency and productivity, improve staff morale
handles over one million reported medical and practices. However, such silo’s often and reduce costs. The NHS Improving Quality
incidents in England alone. Figures illustrate that mean that any good practice is lost which website www.nhsiq.nhs.uk has details of
approximately one in every ten patients are increasingly impacts upon the patient flow numerous case studies and other titles in
unintentionally harmed by their healthcare between services. this series.
providers. Most of these are not necessarily the
result of medical errors or poor clinical decisions,
but are caused simply by the way the system has
been set up.

“…the best hope for

saving lives lies in
raising performance…”
Atul Gawande, Better, 2007
“Improvement usually means doing
something that we have never
done before.
Shigeo Shingo ”
5
6 Bringing Lean to Life - Making processes flow in healthcare

What is Lean?
Lean is the culture of relentless elimination
of ‘waste’ to ensure all the services Specify VALUE from
the customer viewpoint
provided are safe, high quality, available at
the time it is required and delivered at the
Pursue PERFECTION Identify the
appropriate cost. It is also about developing
in quality & quantity VALUE STREAM
people to problem solve everyday to pursue by continuous and remove
perfection. improvement waste
Problem Solve problems by
root cause analysis
solving
Introduce Standard Working
Lean was a term coined by researchers when Remove Waste
People and Respect, challenge
studying the philosophy of the management Set Up Visual Management
Partners
and grow them
system in place at Toyota and the culture they Eliminate Batching
Eliminate waste.
Identify Root Cause
had created amongst their workers to improve Process Right process will
deliver right result
processes which led to the final product. Long-term thinking.
Philosophy Continuous
improvement
The researchers noticed five key steps were in
place to deliver what the customer wanted at Ref: Liker, 2004
initiate PULL in line Make value
the highest quality and safety level possible, with with customer demand FLOW
the lowest associated costs from a workforce
which also had high morale.

Lean is the continuous and

The five steps were:

1.Specify value;

2.Identify the value stream steps; systematic elimination of waste

3.Make value flow; In short, Lean is about building the problem
4.Supply what is pulled by the solving capabilities of the team to produce
customer; and experts who can perform daily work to the best
standard – everyday. These key steps and the
5.Continually improve and strive necessary tools to implement Lean are explained
for perfection. in this booklet.
A3 thinking
All Lean improvement work should begin with Describing the entire process from current state, The A3 represents the shared consensus towards
A3 thinking as it is a methodical approach to through analysis and onto future state just on a solving the problem. As a document, it
problem solving. single sheet of paper requires concise encourages reflection on the learning that has
information. This prevents excessive amounts of taken place and ensures that a consistent
Lean is primarily the description of a information being overwhelming, misinterpreted message is discussed and scrutinised.
methodology to routinely solve problems and incorrect conclusions being reached.
everyday so that the work is delivered to
specification. A3 thinking is the rigorous The best A3s:
application of something known as the Plan, Do • are handwritten in pencil with minimum text;
Check, Adjust (PDCA) approach. • contain pictures/diagrams to convey the
problem or opportunity;
The PDCA (sometimes known as PDSA - Plan, • are concise and hold all the relevant
Do, Study, Act) cycle provides a means of information;
conducting safe experimentation or a number of • represent the shared consensus;
trials to see the effect of any changes made in a • do not need verbal explanation; and
bid to make improvement (see page 25). • are agreed by the entire team.

The A3 report is literally a one-page document

(42 x 29.7 cm [A3] sheet of paper) that records
the agreed points of discussion in a systematic TOP TIPS
way.
• Teach, coach and use A3 thinking as a standard tool for all new projects and
problem solving
The structure of the A3 (see pages 8 and 9)
• Complete the A3 report with a pencil (corrections can be made following further
takes individuals and teams through the
process of agreeing the problem statement or consensus with the team)
opportunity, reviewing and analysing the current • This is a working document – each box should contain only the information that
state and identification of a desired future state has been agreed
with a subsequent action plan for any agreed • Resist the temptation to ‘type’ up the report. If an electronic version is required,
actions. consider taking a digital photograph instead to share across the wider
organisation.

7
An Lean
A3 example A3 report
Improvement
Define the problem/opportunity: (Why are you talking about it? What are you trying to solve/improve?)
Waiting times for turning around cervical screening samples are protracted.
This could potentially delay any treatment required by the woman.
Current state: (What happens now? Be visual - value stream map, graphs, facts and measurements etc.)
Goal: (State the specific target(s). State in measurable or identifiable terms)
100% in 14 days
50% in 7 days
Zero defects
Waste identified: (Transport, Inventory, Motion, Automation, Waiting, Overproduction, Overprocessing, Defects, Skills.)
Transportation – up to 15 days ‘lost’
Waiting – average TATs of 41 days from specimen taken to report issued
Defects – 40% defects received from primary care
Root Cause Analysis: (What is the root cause of the problem? Use fishbone/cause and effect diagram, five why analysis)
 NHS
NHS Improvement
Department Cervical Cytology Department Date: June 2012 Author:
Team members: Agreed by: Version:
Future state: (What will it look like? Be visual - future state value stream map)
Action plan
Action - what, why and how? Who? When? Progress status (ie completed, in progress)
Establish core transport group RS Jan 2012 Completed
Implement zero tolerance policy of defects from 1˚ Care ML Jan 2012 Completed
Reduce backlog
Goal V actual measures RS Mar 2012 Ongoing
Capacity and demand RS Feb 2012 In progress
Reduce batch sizes from 16 to 8 ML Mar 2012 In progress
Introduce water strider ML Apr 2012 Ongoing
Results and measures:
(What was your PDSA cycle? How long did you run it for? What data did you collect before and
after the change? What did you find? Add charts, tables, and cost benefit analysis)
Transport group Zero tolerance policy has
reduced delivery reduced defects from 40%
times by an to 20% within 6 weeks,
average of 12 with a further reduction in
days 10% anticipated within
next 2 weeks
Next steps: (Are there any remaining issues/problems? Is there any further follow up required?)
Levelled workloads are required in laboratory.
This is being taken up by laboratory subgroup – April 2012.
10 Bringing Lean to Life - Making processes flow in healthcare

The importance of data and measures

In healthcare, we are used to taking clinical Once you have agreed your aim and measures,
measures such as temperature, pulse, blood you will need to collect current state data for a
pressure, respiration rates, urine outputs etc. in baseline. If you can’t get the information from
order to understand if the condition is getting the electronic systems, you will need to collect the
better or worse. To understand if the process is information manually. Manual data collection
improving, we can collect and analyse data and might feel like hard work at the time, but if you
use statistical methods, programs and charts to don’t collect this information before you start:
demonstrate, for example, the number of patients
on a waiting list, length of stay or admissions. a) how will you know what your current
state looks like?
Data and measures are important to b) how do you know where to focus
demonstrate and factually prove that change has your efforts?
occurred or needs to occur. Whether the c) how are you going to know if you
change was a success or a failure, you still need
to demonstrate it!
have made a difference?
It is not satisfactory to
When you have made a small incremental
Before starting your Lean journey, it is essential
to understand what your aim is and what are
change using the PDCA (PDSA) approach (page
24), review your original measures and collect
say “it feels better”,
your measures.

Measures might include:

the same data to see if your trial has made a
difference. “I think it’s better”,
• numbers of patients on waiting lists;
• length of stay;
Data analysis doesn’t need to be complicated.
Line graphs, bar charts, scatter graphs and
“it seems better” -
establish factual data
• admissions and readmissions; statistical process control charts can all be used
• patient experience; to visually show the before and after status (see
• waiting days; examples on the following page).
• staff morale;
• turnaround times; and measures.
• number of incidents or defects; Don’t forget ‘better’ is not measurable, ‘soon’ is
• number of complaints; not a timescale and ‘some’ is not a number!
• cost; and ‘More’, ‘faster’, ‘safer’ or ‘cheaper’ can all be
• quality. measured, but only if you know how many, how
fast or how expensive things were to begin with.
Example statistical process control (SPC) charts
Statistical Process Control (SPC) is a simple and visual way of observing
Inpatient stay showing root cause analysis
variation in your systems and processes. Every process is subject to
variation but generally speaking, the more variation there is in a system
Waiting one extra day for
discharge medication Waiting two extra days for or process, the less reliable it is, and the less certainty there will be that
physiotherapy assessment
Waiting ten days for the process or system will produce the outputs or results expected or
cancelled surgery
Waited for lab results, desired. SPC can help to identify variation as a first step in trying to
Waiting four extra
days for CT scan
interventional diagnostics
and delayed ward round
reduce and control it.

An SPC chart is essentially a run chart with statistically calculated lines of

variation with the main aim to understand what is ‘different’ and what is
‘norm’ within a process. By using these charts, you can then understand
where the focus of the work needs to be concentrated in order to make
a difference.

We can also use SPC charts to determine if an

End to end turnaround times in a pathology department improvement intervention is directly improving a
process (as opposed to occurring by chance) and
to predict statistically whether a process is
capable of meeting a set target.

When the raw data has been

converted into a graph, the
outliers become visible and
root cause analysis can be
January February March April carried out to achieve your
aim

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12 Bringing Lean to Life - Making processes flow in healthcare

Current state value stream mapping

A critical starting point in any problem solving or
improvement work is to map the situation “ If you don’t know where you are going,
(process) in its current state. This should be done
as a team and then added to the A3 document. you will probably end up somewhere else.”
One of the tools used to capture the current Dr Laurence J Peter, Founder of The Peter Principle
state or ‘as is’ performance is the value stream
map (VSM).

What is value? How to make your value stream map (VSM): • Calculate the ‘touch time’ - the time
Value can only be defined by the end customer. • Establish key start and stop points (agree actually required to get the patient through
In healthcare the customer is usually the patient. the scope) the value stream if seamless care were being
Value is any activity that directly contributes to • Document the key process steps delivered (i.e. all waste removed)
satisfying needs of the patient. Any activity that • Add the data box below each process step • Agree the value added (VA) activities and the
doesn’t add value is defined as waste. (cycle time, batch size at each step, number non VA activities, identifying those ‘must do’s’
of defects/errors at each step and the (i.e. business essential but not really adding
Value stream map trigger that starts the process step) value directly to the patient)
A current state value stream map is a visual • Add a timeline at the bottom of your VSM • Determine the percentage of VA activities -
representation of all the actions currently and below each process step document the don’t be surprised if this is very low!
required to deliver a product or a service. cycle time (how long does it take to process
accomplish the task?)
The map documents work activity and the • On the timeline between each process step,
movement of information across the entire add the delay which occurs between each
patient pathway from origin to final point of step
delivery. • Show all information flows
• Work out the total time taken to get a
patient through the value stream by adding
all numbers in the timeline
Remember
• Keep your value stream map high level, Current state value stream map
don’t focus on the detail
• Only focus on the main pathway – what Home

happens 80% of the time? 100 per day

GP System Xray Laboratory Physio Pharmacy

• Collect true and accurate information by
walking through the pathway yourself. PAS

4 50 20 51 5 125 55 30 50 25
Why map the value stream? GP MAU Diagnostic 1 Diagnostic 2 Cons review Admit - ward Theatre Rehab Ward round Discharge f/u =/- rehab

• The mapping process is a powerful tool to

1 3 2 2 1-5 2 6 2 1-2 2 3
look strategically at your process and quickly
identify opportunities for improvement CT = 4 mins CT = 2 days CT = 5 mins CT = 10 mins CT = 10 mins CT = 20 mins CT = 2 hours CT = 20 mins CT = 4 mins CT = 4 mins CT = 10 mins
B=1 B = 40 B = 10-100 B=1 B=1 B=1 B=1 B=1 B = 1-40 B = 1-10 B=1
• Non value adding activities i.e. wastes can Defects = 4% Defects = 10% Defects = 40% Defects = 30% Defects = 5% Defects = 15% Defects = 40% Defects = 20% Defects = 35% Defects = 40% Defects = 10%

be identified and documented Trigger = Pt Trigger = Doc Trigger = Doc Trigger = Doc Trigger = Res Trigger = Doc Trigger = Doc Triger = Ref Triger = Doc Triger = WR Triger = DN

• This provides a basis for a discussion around

0.5 days 0.5 days 0.5 days 1 day 1 day 5 days 1 day 1 day 1 day 2 weeks
‘what should be the process?’ 4 mins 3 mins 5 mins 10 mins 10 mins 20 mins 2 hours 20 mins 4 mins 4 mins 10 mins

720 Touch time = 210 mins (3.5 hours)

Takt time = = 7.2 mins
100 Lead time = 639.5 hours (26.65 days)

See page 27 for the value stream mapping symbols

The current state map above indicates that it is taking almost 27 days for a patient to get through a system
(Lead time) where there is only 3.5 hours of professionals ‘hands on’ time actually required (touch time). On
this map, there is a legitimate 14 days of ‘waiting’ before the follow up appointment; however there is still
a considerable difference between the lead time and touch time. This should promote some discussion
amongst staff: Have we documented this ‘snapshot in time’ correctly? Is some of the waiting time
between steps actually necessary? Is there an element of ‘recuperation’ or ‘watchful waiting’ before further
intervention or follow up is required? Concentrate on getting a shared understanding of the true picture
without justifying whether your current processes are the best for the service.

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14 Bringing Lean to Life - Making processes flow in healthcare

Analysing your current state & designing your future state value stream map
Once you understand the current picture of
what really happens throughout the value Future state value stream map
stream, you can begin to agree what needs to
PAS Home
happen and then analyse the gap between the
current and future states.
100 per day
Physio
From your current state map you will be able to GP System Xray Laboratory Pharmacy

identify where the significant problems occur.

This might be the most prevalent waits and
4 25 50 25
delays, the largest amount of work in progress
between process steps or where there is GP Test & consultant Surgery day case Discharge & TTOs F/U +/- rehab
considerable duplication. FIFO FIFO

There are four main techniques to design

CT = 4 mins CT = 30 mins CT = 2 hours CT = 10 mins CT = 20 mins
your future state:
Batch = 1 Batch = 20 Batch = 1 Batch = 1 Batch = 1
Defects = 2% Defects = 5% Defects = 2% Defects = 5% Defects = 3%
• Eliminate
Trigger = Pt Trigger = Ref Trigger = Doc Trigger = Wr Trigger = Dn
• Combine
0.5 day 5 days 3 hours 2 weeks
• Simplify
4 mins 30 mins 2 hours 10 mins 20 mins
• Sequence.
720 Touch time = 184 mins (3.06 hours)
Where possible, try to eliminate any process Takt time = = 7.2 mins
100 Lead time = 474.06 hours (19 days)
steps. If it isn’t possible to eliminate any steps,
look to combine steps. After combining,
consider where the system can be simplified. The aim is to produce a service where each Once the future state value stream map is
Once steps in the system have been have been process step links seamlessly to the next, in the completed, it is then essential to review
eliminated, combined and simplified, review the shortest amount of time at the highest quality measures, analyse the gap between current
sequence of events to promote efficiency. and safety by a group of staff with a high and future state and then agree an action
morale. plan of PDCA cycles to trial the changes.
When designing a future state, the takt time,
the removal of waste and the introduction of
flow must be considered – all of which are Be clear about the purpose before designing the process – then, organise the people!
discussed in this booklet.
Standard work to produce high quality every time
Lean is about developing the people who It is important to understand that standard work Standardised work:
perform the work to be ‘the best’ – utilising their is not static. Standards are actually the basis for • Ensures safety and maintains high quality
‘expert talent’ and establishing excellent ways of subsequent improvements. Once a better and efficiency
working. method is found, the team should agree on the • Ensures process stability and therefore
new standard, update the processes, procedures repeatability
Standard work is about establishing out of and visual management and then ensure that it • Allows us to assess if we are in control,
all the possible ways, the best work is adopted by all. ahead or behind schedule
method of conducting a task and then • Preserves the organisational expertise
ensuring that everyone always works to Standardisation should exist for every process, • Allows us to identify and rectify problems
this gold standard. including ward rounds, meetings, health and • Provides a gauge by which we can error
safety procedures, budget reports, cleaning proof for the future
The gold standard should have the least amount equipment, consultations, all paperwork etc. • Gives us a baseline from which to
of waste, with the highest quality measure improvement and continually
and safety. These standard procedures create One of the Lean tools which promote strive for a better way
stability and consistency in the system to standardisation is 5S, the foundation for safety • Provides a basis for employee
produce high performance results every time. and quality. training.

There are three key elements to

standardised work:

• Takt time – how fast we should be

working (page 23)
• Work sequence – the order that work
should be done
• Work in progress – defining the working
inventory to make abnormalities
obvious.

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16 Bringing Lean to Life - Making processes flow in healthcare

Visual management
Visual management is everywhere, from the Visual management is a simple, yet highly Visual management allows teams to:
green man at the cross roads, to the numbers effective way of indicating what should
on the front of busses, petrol indicator lights happen (by setting a standard) and what • See the work in progress
in cars, a water level on a kettle, to a cricket is actually happening in the work • Recognise flow stoppers
scoreboard. These visual indicators allow us environment. • Assess inventory levels
to easily understand the situation and take • Identify defects
action where necessary. At a glance, colleagues, supervisors, managers • See deviations from the standard
and visitors to the area should be able to • Enable interventions
understand the process and see what is under • Improve safety.
control and what isn’t without having to ask a
question.
There are two types of visual management:
Cytology request form: Visual management has been sent
to smear takers to ensure zero defects on the request form.
• Visual display; which is the provision
Pathology Request Card
of information
• Visual control; which is associated
with action.

Both types of visual management allow

individuals to gain the maximum amount of
information without having to leave the work
environment or access a computer system.

Visual management provides the knowledge and

certainty to make the lives of staff and patients
safer.

Visual management can be used to answer the

following questions. Give some thought to how
you could use visual management to answer the
following questions in your work area:

1. Are we up to date with the work?

2. What are our three biggest problems 7. How do you know if the stock has Communication board
in the area and what is being done been ordered? The board keeps all team members up to date
to resolve these problems? 8. Number of patients on the waiting list with the recent data, changes and improvements
3. How do you know that your ideas 9. Which patients should be discharged made, 5S scores, team ideas which includes
have been listened to? 10. Number of patients on disease register action taken against the ideas.
4. How can you tell who is trained to who require an annual review.
perform each task?
5. Is there daily accountability?
Who is it today?
6. How do you know where staff are -
breaks, annual leave, study leave?

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18 Bringing Lean to Life - Making processes flow in healthcare

Identifying waste
The elimination of waste is the main Remove the waste of transport by:
characteristic of Lean. Waste is everything Elimination of waste • The elimination of process steps
that doesn’t add value to the patient or • Co-locating departments/processes/supplies
process. Eliminate Minimise • Introducing work cells
• Redesigning the flow of work e.g. introducing
There are three types of work: work cells.
1) Value add - When you are adding value
to the patient/process (e.g. prescribing medication, Unnecessary Necessary INVENTORY
providing physiotherapy, reporting an image) waste waste I Inventory is work in progress and stock.
A common problem is lack of space. By reducing
2) Necessary waste - This is when you are not inventory and by combining process steps, staff
adding value but it is a necessary step. (e.g. have more space to carry out duties in a safer
incubation in a microbiology laboratory, vetting Value working environment.
requests prior to radiology examination)
How frequently do you run out of supplies only
3) Unnecessary waste - This is where you are not to find another department has stock?
adding value and these steps could be removed Maximise
(e.g.searching for items, waiting for consultants or For example:
medication, not having the right equipment). • Over-ordering - consumables or drugs
• Different batch sizes at each process step
There are seven formally recognised wastes, TRANSPORT • Overstocked medication
T Transport is the unnecessary movement of • Overstocked items in the supplies department
however additional wastes identified: the waste of
unused staff creativity (skills utilisation) and items and materials. How often do we see people because it was cheaper to buy in bulk without
automating an already inefficient process. moving items (notes, reports, slides, supplies etc.) thinking about the costs of storage, stock
from one locality to another - and back again? taking and distribution
These wastes can be remembered by Stand for a short while in a hospital corridor or GP • Staff hiding extra stock for ‘just in case’.
remembering the name TIM A WOODS (this practice and observe these activities - you’ll be
surprised. Remove the waste of inventory by:
acronym originated at Cooper Standard
• Implementing the Lean tool of 5S (page 24)
Automotive, Plymouth UK).
For example: • Establishing visual systems (kanbans) -
• Moving drugs, samples, equipment, supplies aid visibility for stock counting (page 22)
excessively • Understanding what is needed to keep up
• Moving paper notes excessively • Establishing first in first out principle with
• Transporting equipment or consumables from demand - implement ‘just in time’
one location or site to another. • Keeping stock audits correct and current.
 MOTION AUTOMATING • Waiting for decisions
M The waste of motion is any unnecessary
A Automation of poor processes just serves to • Waiting for meetings to start
movement by people. This is mainly related to automate waste. The poor understanding of work • Patients waiting for appointments, in emergency
poor ergonomics, bending, stretching, moving content and takt time (page 23) can result in departments/clinics, waiting for discharge
items etc. purchase of large pieces of expensive equipment • Samples waiting in a batch to be analysed
that actually hinders flow of the overall process. in the laboratory
How many times during your working day do you The result, is an expensive poor process! • Requesters waiting for results or medication.
have to get up and walk to use a certain piece of
equipment just because it is located in the wrong For example: Remove the waste of waiting by:
place? How often do you find yourself searching • Did radiology reporting times reduce when • Evenly spread (levelling) the work and balance
for vital items because they were not put back in PACS was implemented? tasks
the right place? • Do samples get turned around any quicker with • Eliminating or reducing batch sizes
track systems in biochemistry? • Smooth the flow and volume of work which
For example: enters and exits your area.
• Poor layout of wards/surgeries/departments
WAITING
/laboratories/offices W The waste of waiting usually transpires when OVER PROCESSING
• Searching for equipment or stock O The waste of over processing is all the things
there is an in balance of process steps which all
• Location of printers, faxes, copiers and we do that don’t add any value to the process -
take different timings or the batch sizes are
computers producing excess.
different in each process step. The waste of
• Looking for information and people.
waiting has a direct impact on flow as waiting
How many tasks are repeated simply because we
Remove the waste of motion by: creates a ‘stop-start’ process.
don’t have a system to ensure it serves the needs of
• Introducing standard layout the patient or process throughout the whole
• Introducing a standard way of working Do you ever find yourself becoming frustrated
healthcare journey?
• Developing flow in work cells/areas and your working day hindered because you are
• Initiate and sustain 5S. waiting for a colleague to do their role or for
equipment to become available.

For example:
• Waiting for shared equipment (telephone/
computers)
• Staff waiting for machines, deliveries, other
members of staff

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20 Bringing Lean to Life - Making processes flow in healthcare

For example: Remove the waste of over production by: SKILLS UTILISATION
• Duplicate testing/inappropriate testing • Removing all unnecessary paperwork
S Every department has unused staff potential.
• Duplicate data entry • Reducing batch size - establish a visual system There is someone in every department that knows
• Duplication of checking cards/slides • When the process can’t flow, introduce the issues and has the possible solutions. If only
• Excessive bed moves ‘pull’ systems with buffers and kanban’s. they were asked, listened to and action was taken -
• Excessive paperwork the people doing the job are the experts.
• Manual checking electronic data. DEFECTS
D Defects are all the errors that compromise Unused skills and creativity also include highly
Remove the waste of over processing by: quality, safety, cost and staff time. Make it right, skilled staff undertaking duties that do not reflect
• Eliminating non-value added steps first time, every time. there skills, e.g. band 8 staff routinely performing
• Combining process steps and paperwork band 3 duties.
• Simplifying tasks. Do you tolerate errors by reworking someone else’s
mistakes? How often do you accept incomplete or How many times do we see supervisors/managers
O OVER PRODUCTION
Over production is about doing too much, too
inaccurate information? routinely booking appointments?

soon or ‘just in case’. For example: The intellect and skill of staff should be used to
• Wrong patient, wrong test, wrong procedure, guide the continuous improvement of procedures
How many times do we complete the same wrong form and processes. The inclusion and insistence of staff
information and have to file it or store it in many • Inappropriate/inadequate referrals in problem solving and decision making will also
different ways? How often do we see queues build • Chasing inadequate patient information support recruitment, retention and improve morale.
up in one part of the process because the previous • Repeated checking
department kept producing more, regardless of • Medication errors.
whether subsequent processes were ready or could
cope? Remove the waste of defects by:
• Making the system mistake proof
For example: • Introducing a zero tolerance to defects
• Doing more, making more, faster than or earlier • Introducing standard work to ensure the same
than is required by the next process step process is completed every time ensuring high
• Duplicate entries in medical records quality process repeatability.
• Results sent in both electronic and paper formats
• Repeating tests before next test scheduled.
Making value flow
Flow is the continual movement of value All Lean tools work towards promoting flow.
adding activities from the beginning to the Visual management can be used to highlight
end of the value stream. flow stoppers. Standard work can be used to
ensure processes are repeatable and reliable,
Processes which add value to the patient should with no variation. 5S can support workplace
not be delayed by any non value adding steps organisation ensuring no time is lost trying to
or waste in the system. Waste and non-value find the right tools to do the job.
adding steps create a ‘stop-start’ effect which
prevents the flow of value adding steps the
value stream.

Systems which promote batching can hinder

flow, create waste and queues. Batching can be
seen across healthcare. For example, ward
rounds completed at the same time of day
causes a batch of work for the nursing staff and
every support service that follows i.e. pathology,
radiology and pharmacy.

To promote flow, batches should be reduced and

where possible removed to achieve the optimal
flow - one piece flow. When flow is achieved, it
becomes easier to spot problems and patients
are no longer unnecessary held up in the health
system.

21
22 Bringing Lean to Life - Making processes flow in healthcare

Understanding pull
Flow and pull work to keep the entire value Kanban
stream moving. Flow is the goal, but on Kanban signs/signals are a form of pull. These
occasion, flow may not be achievable and in visual signs are mechanisms for the patient or
these situations the concept of pull can be internal customer (i.e. ward nurse, radiologist,
introduced to respond to demand. discharge staff) to say “I am ready for more.”
There are many different forms of Kanban -
Pull is a short term notion to gain control an empty container, a box, a marked area,
and process stability. an empty shelf or a card.

Pull works with buffers and kanbans:

Buffer “ Flow where you can, pull

A buffer is a clearly defined holding area at the
interface between two processes allowing
patients, paperwork, information or items to
where you must”
wait for a defined amount of time between two Jeffery K. Liker, The Toyata Way, 2004
process steps. A buffer could be a waiting
room, empty beds, trolleys or chairs, or even a
space for stock and inventory. Buffers are
actually a ‘waste’ and should only be introduced
when flow is not possible and the process needs
to be controlled and stabilised. Over time, the
buffer should be gradually reduced and
ultimately removed.
Understanding takt time
Takt time is simply the rate at which we needs, every 7.2 minutes a patient should be need to be removed from each step. Only
need to work to keep up with demand. able to move through the value stream i.e. the when the non value adding activities have
patient should be able to ‘pull’ the service they been removed from each step should
The calculation for takt time is: require at a rate of 7.2 minutes. additional resources be considered.

Available work time The cycle time is the time it takes to actually ‘do’ As you can see from the graph below, the
= takt time
Demand the task and the aim is to match (where team would possibly need to either: remove
possible) takt time. more waste from the individual processes;
This sounds too simple, yet the ability to achieve extend diagnostic hours, theatre time and
takt is the fundamental question to whether the If the cycle time is going to be the same as or follow up clinic; or secure additional resource
system is set up to deliver what is required. If less than takt, all the non value adding activities in order to achieve takt.
teams cannot achieve takt, waste in the system
needs to be removed and each process step
needs to be smoothed (levelled) to ensure takt Balance chart prior to achieving takt time
is met.
120
Worked example:
A general surgical pathway open and staffed for
12 hours per day has a daily demand of 100 90
referrals (see Value Stream Maps).
Minutes

12 hours 720 min 60

Takt time = = 7.2 mins
100 100
30
True to the first principle of ‘delivering customer
Takt
value,’ patients must be able to access each of
the services required along the whole clinical 0
pathway in referring, diagnosing, operating, Refer Diagnose Operate Discharge Follow up
caring, providing medication and rehabilitation
the moment they require it. In this case, for this
system to be capable of delivering patients

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24 Bringing Lean to Life - Making processes flow in healthcare

Using 5S to improve safety

5S is occasionally misinterpreted as being a
‘tidy up’, but when approached properly Set in order - ‘A place for everything and Standardise
it is much more than that. everything in its place.’ Create a consistent approach for carrying out
tasks and procedures.
1) Give every item a location - Items used on
5S is the basis for standardising work and
a regular/daily basis need to be placed
is used to improve efficiency by
within arms length/accessible location:
eliminating waste, promoting flow, Sustain - ‘Sustain all gains through self
• Items used on a weekly basis should be
improving staff morale and most discipline’
stored on a shelf or in a cupboard in the
importantly improving safety. work environment. Make 5S become a way of life by:
• Items used on a monthly, quarterly or 1) Practicing and repeating the process.
Ultimately, it is about making the annual basis should be stored in an 2) Educating all staff.
processes and environment safe. appropriate location – possibly outside 3) Linking 5S directly to the day job.
the work area. 4) Empowering staff to improve and maintain
5S - What does it mean? How do I do it? 2) Mark off (with electrical tape or permanent their workplace.
marker) and label each location.
When staff take pride in their work and
Sort - ‘When in doubt, move it out!’ workplace it can lead to greater job
satisfaction and higher productivity.
1) Remove everything from the defined area. Shine - ‘Lean means clean’
2) Only return what is necessary for the daily
duties. 1) Clean the area – it should be easier to
3) Discard any broken, unnecessary items – clean now you have removed the clutter
e.g. clutter, old equipment, old unused and every item has a location.
paperwork. 2) Develop a plan where cleaning is
4) Move any items that you are unsure of into incorporated into the daily routine.
a holding bay for a team decision.
5) If shelving or cupboards are not used or
required, remove them too – this will
prevent unwanted items being stored
there.
6) Items necessary to complete the job need
to be ‘set in order’ 2S.
Plan, Do, Check, Adjust (PDCA) Sometimes called a Plan, Do, Study, Act (PDSA)
Change on a large scale can be daunting but
you should not let that deter you.
Before implementing a full proposal for A P
change a PDCA cycle (sometimes called
a Plan, Do, Study, Act (PDSA) cycle) can C D
be used. A PDCA cycle will provide the

D
opportunity to test out an idea on a small ADJUST PLAN

C
scale, without risking too much.

A
C
New ideas should be introduced only after

A
sufficient testing (or evidence) on a smaller scale

D
CHECK DO
has proven to have a positive effect. PDCA

P
cycles allow us to introduce an idea in a safe,
controlled way which will have less resistance, A P
be less disruptive and use less resources.
By building on the learning from each PDCA C D
cycle, new processes can be introduced with a
greater chance of success.

P - Plan: The trial

This is the most important part of the process. C - Check: Study the results A - Adjust: Act on the results
• What you are planning to trial? • Analyse the data you collected in the ‘plan’ • If the trial did not improve the process,
• What are your objectives? and ‘do’ phase could you treat the root cause in your next
• Who is needs to be involved/informed? • Discuss outcomes with colleagues? PDCA cycle?
• How are you going to do it? • What went well? • If the change was a measurable success,
• How long will the trial run? • What went wrong? adopt and spread the improvement in your
• How are you going to measure improvement? • Did anything unexpected happen? PDCA cycle.
• What is your communication plan? • Could the process be improved?
• If the trial didn’t go to plan, what was the
D - Do: Carry out the trial root cause?
• Test the change and collect the data.

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26 Bringing Lean to Life - Making processes flow in healthcare

Continuous improvement
Continuous improvement is the final Lean
principle, which is to strive for perfection
through continuous improvement. This is
done by embracing the Lean philosophy
and tools as described in this booklet.

The staff are a fundamental part of Lean. It is

important to develop staff and give them the
The key to success is Act like a sponge - soak
capability, autonomy and empowerment to solve
the problems as they encounter them on a daily
small, daily incremental it up and squeeze out
improvements. improvements
basis. Teaching and expecting rigorous problem
solving by all staff is the only sustainable way to
strive for perfection.

Communication is imperative to develop staff to During your Lean journey, don’t lose sight of everyday
continually improve the process. A five minute perfection and what perfection means:
daily meeting for all staff around a central
communication board to discuss real time issues • the right patient journey;
relating to waiting times, quality, safety, morale • the right support services when they
and cost is essential to ensure the work for that are required by the patient;
shift/day proceeds as planned. • the highest level of quality and safety
• no defects or incidences;
For Lean to be a success, the Lean culture needs • delivered at the right price; and
to be accepted and embraced by all. • delivered by a staff group with high
morale and pride in their work.
When implemented, the tools and techniques
can have an immense beneficial effect, but to be
sustainable, they need to be applied with a Lean
culture.
Value stream mapping symbols

Surgery
Data entry Cycle time =
W i
Batch size =
GP Surgery Wait/delay Inventory
Defects = Pull
Process Step Trigger =
Outside Agencies
Data Box Push People “Go See”

FIFO
First-in First-out
Sequence
Transport Ambulance
Information Supermarket
Bursts
Buffer

Electronic
Information
Load Levelling Work Cell Transfer Paper Flow

27
 NHS
Improving Quality

To find out more about NHS Improving Quality:

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Published by: NHS Improving Quality - Publication date: May 2014 - Review date: May 2015
© NHS Improving Quality (2014). All rights reserved. Please note that this product or material must not be used for the
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