NHS Highland Board
3 April 2007
Item 3.2
LEAN MANAGEMENT AND ITS APPLICATION IN HIGHLAND
Report by the Director of Planning and Performance
The Board is asked to:
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Note the background to Lean thinking and it’s influence on the application of
redesign in NHS Highland.
BACKGROUND AND SUMMARY
A briefing was requested following national interest expressed in the potential
applications of Lean Management to the Scottish Health Service.
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LEAN THINKING
The concept of lean thinking was developed from the Toyota Production System.
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Toyota Production System – developed by Kiichiro Toyoda and Taiichi Ohno
from a study of mass production used by the Ford Motor Company.
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Lean Thinking – The Toyota Production System was “westernised” by Womack,
Roos and Jones in their book “The Machine that Changed the World”. They
named the concept Lean Thinking and summarised it as “using less to do more
through process improvement”.
Five Principles of Lean – Womack, Jones & Roos identified five principles of Lean
Thinking adopted towards health service application:
i.
Specify Value – need to identify and agree what we provide to patients and to
remember who the service provision is actually for.
ii. Identify the patient journey – identifying which steps add value and improve
quality for the patient.
iii. Make the process and value flow – align healthcare processes to facilitate the
smooth flow of patients and information.
iv. Let the customer pull – every step in the patient journey needs to “pull” people,
skills, materials and information towards it – one at a time, as needed.
v. Pursue perfection – continuous quality improvement of processes.
Types of Lean Waste
Defects
 readmission due to failed discharge
 repeating tests because correct info was not provided or communicated
Working with you to make Highland the healthy place to be
Overproduction
 requesting unnecessary tests from labs
 keeping investigation slots “just in case”
Transportation
 Patients finding their way around hospital or being moved around by porters
Waiting for
 patients
 results, prescriptions and medicines
 doctors to discharge patients
Inventory
 excess stock held in storeroom
 patients waiting to be discharged or for treatment
Motion
 staff looking for paperwork/notes
 equipment at other end of ward/clinic
Processing itself
 duplication of information and asking for patient details several times
 repeated clerking of patients
Some Benefits of Lean
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Improved patient flow
Inefficiency reduced
More patients treated
Faster treatment
Shorter waiting times
Safer, more reliable services
Best use of capacity
Reduced Length of stay
Standardised procedures and equipment
Cost savings
Increased productivity
Improved staff morale
LEAN EXAMPLES IN SCOTTISH PUBLIC SECTOR
Lean was nationally piloted with organisations from NHS, local government and the RAF.
This pilot was evaluated for the Office of Chief Researcher by Warwick Business School
in the autumn and winter of 2005.
The Lean tools used in these public sector pilots are different from those used in
manufacturing. In manufacturing, the emphasis is on a set of management tools that are
used to standardise processes. In the public sector, there is an engagement with the
principles and an embedding of those within the culture of the organisation, but less with
the “full range” of tools and techniques. The majority of tools and techniques are not
immediately applicable to the public sector organisations and need to be adapted to
cope with greater process flexibility.
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The Lean methodologies employed in this pilot are primarily those used in service
redesign projects; with the exception of the project format which used a Kaizen Blitz
format.
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A Kaizen Blitz is a rapid improvement event, which requires an intensive 3-5 day
workshop to identify problems, solutions and implementation plans.
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The focus of Kaizen Blitz workshops is primarily quick wins
There are some concerns about sustainability and long term benefits of this
workshop format.
SERVICE REDESIGN
The Service Redesign methodology used in NHS Highland is adapted from and built on
theories and tools used in Lean Thinking, Business Process Re-engineering and
Continuous Quality Improvement. This methodology was developed by Leicester Royal
Infirmary and King’s College Hospital for the NHS in England and Wales in the early
1990’s and adopted by the Designed Healthcare Initiative and subsequently the Centre
for Change and Innovation in Scotland. Service Redesign was designated as a National
Priority in Delivering for Health.
Redesign utilises most of the same processes and tools as Lean, namely;
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Engagement of all stakeholders in the process – staff and patients
Identifying patient journey via process mapping
Visioning the future state
Capacity and demand management
Continuous Quality Improvement
The national delivery vehicle for service redesign in Scotland is the Improvement &
Support Team, formerly the Centre for Change & Innovation. They are driving the
following national programmes using Lean/Redesign change methodology:
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Cancer Collaborative
Unscheduled Care Collaborative
Diagnostics Collaborative
Planned Care Programme
In addition to participating in the national collaborative programmes NHS Highland has a
small Redesign resource which has been involved with many Highland wide projects as
well as working with teams and departments to deliver small, localised change. Some of
these projects are outlined below:
Stroke, CHD, Diabetes Projects
 Formation of MCNs
 Whole system view of service provision
 Multi-disciplinary solutions
 Engagement of stakeholders in services
Cancer – Chemotherapy, ENT processes
 Identification of pathways
 Highlighting issues and streamlining processes
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Diagnostics - MRI, Endoscopy
 Identification of practice variation
 Identification of capacity and demand
Cardiac & Gynae ICPs
 Identification of pathway and variations in practice
 Redesigned pathway incorporating best practice
Rapid access chest pain clinic
 Identification of service inefficiencies
 Ongoing work to remodel pathway
 Target specialist resource to give best value
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LOCAL TRAINING AND DEVELOPMENT IN REDESIGN TOOLS AND TECHNIQUES
Over the last 5 or 6 years there have been a number of training initiatives to raise the
awareness of redesign and to apply the methodology:
Designed HealthCare Initiative
 2 day event in Nairn for approx 100 members of staff – Highland wide
 2 day event in Inverness for 60 Raigmore staff
 National coaching and training events
Internal Development
 6 staff have been either on secondment to, or established, in the NHS Highland
redesign team
 ½ day workshop delivered as part of the Essentials of Management course for junior
and middle managers – audience of approx 300 staff to date
 Exposure of staff to tools and techniques through their involvement in projects and
workshops
CCI Collaborative Programmes
Training events have been run to develop awareness of tools and techniques to be used in
the under noted programmes. Highland have taken teams of participants to these events
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Unscheduled care
Capacity and demand planning
Planned Care
Diagnostic
Cancer Collaborative
CONCLUSIONS
 Redesign methodology is the NHS in Scotland’s adaptation of the manufacturing
oriented Lean Management.
 The improvement skills exist in Highland – many staff have undergone training either
through the Designed Healthcare Initiative, CCI collaborative projects or by local
redesign practitioners.
 There is value in continuing to deliver training in redesign/lean tools and techniques
throughout the organisation.
 Tools and techniques need to become a natural and instinctive part of the mainstream
toolkit for managers and service planners.
 High level/executive commitment to the application and service improvement process is
key to its success.
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 The Board may consider it useful to avail itself to a potential opportunity for a leading
Lean Consultant and expert, to come to Highland to carry out a development session
involving Board Executives, Non-Executives, Senior Managers and clinicians. Such an
opportunity could be provided on the morning of 25 April 2007.
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CONTRIBUTION TO BOARD OBJECTIVES
Service redesign is a key methodology in delivering HEAT objectives and service
improvement and change.
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GOVERNANCE IMPLICATIONS
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Staff Governance - through Redesign staff are involved in the decisions that affect them.
Patient and Public Involvement – stakeholders are involved in the design of the services
they use.
Clinical Governance – redesign affords the opportunity to “design in” best practice
Financial Impact – efficiency through redesign
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IMPACT ASSESSMENT – EQUALITY & DIVERSITY
Not assessed.
Stuart Caldwell
Head of Service Redesign
Corporate Services
23 March 2006
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