Can “Lean” Save Human And Animal Lives?

Author: Christian Bamber
Posted: Monday 10th October, 2011. 10:02:18

Can “Lean” Save Human and Animal Lives?

In previous articles in the Outside In series, we’ve talked about the application of Lean concepts to veterinary practice, but can Lean really save lives? Let’s begin to look at some of the evidence.

Healthcare, whether human or animal, is a fairly risky business. Healthcare professionals are often dealing with patients (and clients) who may be frail, vulnerable, aged and frightened. In larger veterinary practices and most hospitals, the degree of organisational complexity is high, and many procedures are performed which carry significant risk. It’s not surprising, therefore, that things can go wrong. A recent national audit report from the Department of Health showed that one in ten patients passing through NHS hospitals suffered an adverse event of some kind.

We don’t have the same information readily available for veterinary practices and it is likely that the more “one-to-one” nature of veterinary practice would result in more comforting figures. Nevertheless, mistakes and poor judgement do happen; drug errors, patient accidents, infections and misdiagnoses exist in both healthcare sectors.

In addition, we are constantly exposed to stories of poor staff morale in human healthcare and veterinary practice is not immune to this phenomenon either.

The Government’s response to this over the years has been a huge investment in public funds into healthcare. This has undoubtedly brought some short-term improvements to the service, particularly in access times and physical environment. However, improvements in the quality of care itself have been difficult to substantiate. Sadly, many problems still remain and as we are all too aware, funding is rapidly diminishing.

What is needed is something that can simultaneously improve quality, staff morale and productivity. Toyota managed to achieve this (and this is well documented) through their development and application of Lean. But the question is whether techniques developed in manufacturing can really work in hospitals.

Lean Myths Busted

This is a good point to dispel some of the more common myths regarding Lean. Sadly, it is widely misunderstood; “Lean and mean” is often what people think of the discipline, especially by frontline staff. There is fear and apprehension over paring things back to the bone and making staff work harder with less.

The reality is very different. It is by identifying the common frustrations and time-wasting activities and removing them that leads to a much more fulfilling working experience for staff.

Of course, there will always be the response, “we’re not Japanese and we don’t make cars” but the process of Lean implementation is also about understanding the principles of the Toyota approach and how any work regardless of industry or sector is an end-to-end process i.e. something enters a process and something comes out of the end of it.

The other important Toyota approach is to understand each step of the process and identify what adds value and what does not. Unlike the vast majority of other management approaches, Toyota suggested that the most effective way towards improvement is to focus on eliminating the non-value-adding steps as opposed to the more obvious improvements that could be made to the existing value-adding steps. In fact, in any given process, non-value-adding steps outnumber value-adding steps by 9:1! Going after waste is clearly a more effective way towards improvement.

Unfortunately, it is often difficult for staff to see the overall process as healthcare staff either work in siloed departments or are associated with specific wards or functions. Generally the only one who witnesses the whole patient journey is the patient themself. Throw in the administrative and information systems and the process becomes even more blurred.

It is therefore not surprising that a process can be so riddled with errors, delay and duplication, and that staff can be working as hard as possible and still fail to deliver a quality service. However, by learning to see processes in all their horror is the first step towards making improvements.

Lean in Action

Bolton Hospitals NHS Trust gives one of the first UK examples of applying Lean to bring about an entire organisation-wide improvement (Fillingham, 2007). Between 2005 and 2007, the Trust embarked on a systematic hospital-wide approach to improving quality. Until this point, Lean had only been applied piecemeal to particular areas or programmes within Trusts, diluting the full potential effect of Toyota’s practice.

From the outset, the Trust made a point of interpreting the Toyota way into its own language and adapted the practices to a healthcare context. One of the fundamental methods of embedding the Lean cultural change and achieving continuous transformation was the use of “Rapid Improvement Events” whereby five-day intensive improvement activities took place every seven weeks that gradually built better end-to-end processes for patient journeys. Such RIEs, or Kaizen blitzes as they are also known, have been proven over many decades to be the most effective way of bringing about rapid and sustainable change.

Trauma Case Study

Bolton is a busy emergency hospital with over 30,000 ambulance arrivals each year. More than 1,500 of these are complex fractures and many of the cases involve elderly patients and/or patients with other presenting problems such as respiratory or cardiac conditions, diabetes, or other chronic conditions. Historically, there have been serious concerns in Bolton regarding mortality levels, and productivity and morale within the service. Additionally, length of stay for fractured hips was higher than the national average. Although many attempts at improvement were made including the introduction of clinical audit procedures, the issues prevailed.

Consequently, urgent action was required and this was the first area chosen for a Lean review.

Understanding Value

The first step Bolton took was to understand what was valuable to the patient and then to eliminate those aspects of the service not adding value. Unfortunately, being in constant contact with patients is not the same as knowing what patients value and so the first step was to directly observe the clinical area and to put staff “in the shoes” of the patient. Taking a conscious step back and observing the flow will begin to reveal obstacles and barriers in a new light. Involving patients in this first step through interviews, focus groups and patient diaries also helps understand some of the non-value-adding steps (clearly, we can’t involve our veterinary patients in quite the same way but we can seek input from clients instead).

In the trauma case, the outcome of this was a much clearer understanding of what patients valued. Pain relief came high up on the list closely followed by a desire for clearer and more coordinated information availability.

[This reminds me of a classic NHS joke: a lady phones the hospital asking if she could find out how a Mrs Ecclestone is progressing. After being put through to several different departments and wards, the lady finally convinces staff that they do have a Mrs Ecclestone staying with them. She eventually manages to speak to Sister.
“Hello. I was wondering if I could find out how Mrs Eccelstone is doing today.”
The Sister replies, “Yes, but who I am speaking to please?”
“It’s Mrs Ecclestone.”]

Even in smaller veterinary establishments, communication can often be improved; hand-overs between shifts, treatment plans, and progress reports to clients. As for pain relief, we are probably more aware of out patients’ needs given that we know they can’t tell us directly so we tend to “cover” them just in case, but there are surely times when we may not appreciate the degree of pain a particularly stoic animal may be in.

Waste Goggles

After understanding what was valuable to patients, Bolton then asked staff to put on their “waste goggles” and to look for waste inherent in their processes. In a previous article (“The Seven Deadly Wastes: Is Your Organisation Full of Muda?”) we looked at the Seven Wastes and this is precisely what staff undertook in their trauma process; waste associated with transport, waiting, overproduction, defects, inventory, motion and excess processing were eliminated.
In addition, they applied the principle of “5S”; sort, straighten, scrub, standardise and sustain (see the article “Go With the Flow: ‘5S’ Your practice”).

Finally, Bolton applied the Lean technique of Value Stream Analysis (VSA). This is an extremely powerful way of engaging frontline staff to identify problems and come up with solutions. Once the principles of VSA have been taught to staff, they become the experts in producing a detailed analysis of the processes they are involved in.

A group of doctors, nurses, managers, therapists and patients performed a VSA and mapped the detail of the progress of a patient’s journey from arrival at A & E through radiology, the wards, theatres, back to wards and the discharge process. They managed to identify huge areas of waste, error and duplication and following this particularly low point of realisation, created an exciting vision of how the future service could be. Although challenging, the future state was achievable and the team mapped out a strategy to eventually get there.

During 2006, Bolton worked on implementing the future state and embedding the improvements and Lean methodology in everyday practice.

The Outcome

The outcomes that were delivered in the trauma pathway were either quantifiably or qualitatively measured over a nine-month period and are summarised below:

• 38% reduction in time taken for fractured hip patients to get into theatre
• 33% reduction in length of stay time
• mortality reduced by 36%
• 42% reduction in paperwork
• better multidisciplinary team working
• faster recovery and lower demand on rehab ward
• increase in staff morale

These improvements were impressive but Lean is about continuous improvement and therefore the team continued to undertake further cycles of improvement to achieve still higher levels of importance. It is worth noting that similar successes were also seen in other areas of the Trust where Toyota’s methodology was implemented.

Final Thoughts

I am sure many of you are asking why, then, do we still have so many problems in our healthcare system? Well, much of the Lean philosophy is counter-cultural for the NHS (we’re not Japanese and we don’t make cars). However, staff need to understand that all work is a process and all processes can be improved. The great revelation is that good quality can genuinely cost less and this can be hard to accept at first.

It is easy to become cynical of the “latest new thing” which will no doubt go away again in a year or two when the CEO thinks of something new. But Lean has been around for a number of decades under different guises, more recently developed and formalised by Toyota. The Toyota Production System is an incredibly successful way of manufacturing cars. True, it cannot simply be translated without thought into the context of healthcare but we can learn important lessons from Toyota and adapt key principles to clinical practice.

And so, in Bolton’s case, Lean really can, and has, saved lives. With more examples of successful Lean adoption, more Trusts may begin to see the value in adopting Lean. In fact, the NHS Institute for Innovation and Improvement now has an array of Lean materials available for Trusts to use if they decide to embark on a Lean transformation and indeed more Trusts are doing so. However, the greatest efforts have been where a few individuals have recognised the power of Lean and have shown resilience, consistency and perseverance in championing its cause.

As for veterinary practice, why should it be any different?


References

FILLINGHAM, D., 2007. Can lean save lives? Leadership in Health Services, 20(4), 231-241.

Further Reading

WOMACK, J., and JONES, D., 2007. Lean Solutions. London: Simon and Schuster.

LIKER, J. K., 2004. The Toyota Way. New York: McGraw-Hill.

Christian Bamber is Principal Consultant and Director of Approach Strategy, a consulting firm specialising in strategy services to service industries and not-for-profit organisations. For more information, please contact Approach Strategy at christian@approachstrategy.co.uk. Tel: 01225 722 654 or visit their website www.approachstrategy.co.uk

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