LEAN IN HEALTHCARE
Service Operations lecturer Ann Esain introduces two articles by students who have recently completed the MSc in Lean Operations at Lean Enterprise Research Centre. All students on the executive programme are senior practitioners.
There is a global need to do more with the same resources in healthcare. Reported increases in demand for healthcare services and concerns about the rising costs have resulted in the adaption of lean thinking, initially in the Americas but more recently in UK, Australia, Scandinavia and Europe.
The following two articles are of particular importance to the debate on lean in healthcare and practitioners in particular.
The first article augments a special feature published in the LMJ a year ago. The author Nicola Burgess highlighted the increased popularity of using lean in English general acute hospital Trusts. Her work challenged practitioners to be wary about ‘fake lean’.
Thus this article is of particular relevance as it investigates an approach to improvement that is spreading globally as a means of ‘releasing time to care’ not only in hospitals but across healthcare provision in general. Drawing on research in the setting of mental health, it uses seven wards in a single organisation to compare the performance measurement. It evaluates the impact between wards which have introduced the ‘package’ and those which have not. The results support the need to test such interventions and reinforce the need for plan do check act in all that is done. This article highlights ‘acting’- driven by the need for solutions, before appropriate ‘checking’ perhaps?
The second article delves into the particular role of the professions in healthcare improvement, in particular the role of the doctor. There is a common view that the engagement of doctors is a critical success factor in the success or otherwise of lean transformations. However, many involved in lean healthcare report that such engagement is difficult to achieve, citing an array of reasons. Thus it is refreshing to gain some insights into this issue, which I am sure will be welcomed by managers and those who deal with professionals as part of the overall lean transformation process.
Both articles are excellent examples of the need to continually probe and think about what we are trying to achieve when implementing lean transformations.
Jackie Thomas works in service development for a Mental Health Trust in England. The organisation has been using the Productive programme as a way to introduce lean to staff. In this article she expresses some of her views following the research for her dissertation, “Does the productive ward make a difference to patient satisfaction, staff wellbeing and reflect a positive change in the productive ward measures?”
We are all aware of the need for healthcare to cut costs whilst ensuring increased quality of care. In order to support this, the NHS Institute of Innovation and Improvement developed the Productive programme based on lean principles. The Productive programme uses modules to develop an understanding of the lean tools and continuous improvement. The hypothesis is that it is to provide measures that matter and ensures frontline decisionmaking and empowerment to free up time to care. This ensures that patients and staff are satisfied and engaged in care and that leads to the productive measures being achieved. This, then, leads to improved patient care.
According to Jones and Mitchell, lean can improve safety, quality and staff morale whilst at the same time driving down costs. They go on to say the lean story in healthcare is 100% positive. However, does the Productive programme provide this and does it use the lean principles that matter? This question may need further research.
THE PRODUCTIVE PROGRAMME
The NHS Institute of Innovation and Improvement produced the productive programme, a house of lean for healthcare (figure 1). This is an approach that prescribes a lean implementation through the undertaking of modules that develop skills in the use of lean tools. The house of lean is built up using different modules, divided into foundation and process modules (figure 2). Interestingly, Jones and Mitchell state that lean could improve the quality of patient care, increase staff morale and add value for money; however, that one sure way to kill this would be to have a national or regional programme. The lead for the NHS Productive Ward states that the Productive Ward gives staff the tools to make what they do meaningful, builds leadership and provides a highly structured methodology to make improvements and this leads to increased motivation.
The Productive programme focuses on the use of tools and techniques (5S, spaghetti diagrams, activity follow, visual management, safety cross, process mapping, cost/benefit analysis, waste walks, 5 why analysis, audits, visit pyramids, dot voting and meetings) and the evidence around the programme seems to concentrate on them and not on system change. However, within manufacturing and lean literature, there is an overall understanding that lean is about system change and not simply about the use of tools. Lean in healthcare is frequently simply seen as a set of rules rather than a fundamental shift in culture.
Virginia Mason was one of the first American hospitals to undertake a lean transformation and focussed on leadership, process and culture. It was able to transform its service in the following ways:
- From functional silos to interdisciplinary teams;
- From managers directing staff to managers who taught and enabled staff;
- From a culture of blame to one that used root cause analysis to determine cause;
- From rewarding individuals to rewarding group sharing;
- From an internal focus to a patient focus;
- From being expert-driven to being process-driven.
Virginia Mason was able to take lean and implement it throughout the organisation. The Productive programme seems to miss the whole system approach and although it uses lean as a baseline it then develops it is a programme. This approach does not embrace the value to the patient and the value stream mapping across silos. The programme could, therefore, encourage silo thinking and stem creativity and innovation that could be achieved through teams coming together to achieve the organisation’s aims and objectives.
Like Toyota and other lean organisations, Virginia Mason had an overall vision and then developed this with the focus of all staff within the organisation on achieving the vision. This included staff being supported to understand their involvement and contribution to this achievement (in healthcare this would be towards the best possible patient care).
Although there is an initial meeting with executive teams to ensure buy-in, the focus is on the wards or individual teams. It seems that the Productive programme misses the respect for people aspect of lean and focuses more on the process and the tools that staff can use.
Initially the productive ward was, and in some cases still is, seen as freeing up nurses’ time to care. The name has changed to freeing up time to care but there still seems to be a focus, in the literature, on nursing time and on hospital wards that are predominantly staffed with nurses. Medical staff and clinical leaders need to be fully engaged in taking this work forward and there may not be enough focus within the programme on this aspect of care. This would also need to include changes in culture and ways that staff could feel empowered and able to take responsibility and feel respected for their contribution to patient care.
The productive literature concentrates on the first three modules of the Productive programme: knowing how you are doing, the well-organised ward (or workplace) and patient status at a glance. It concentrates on small single initiative process change rather than, as Virginia Mason did, full system change.
The literature is focussed on general acute nursing and does not reflect the needs and changes necessary in other areas such as mental healthcare. In my experience, as a mental healthcare worker, it is known that many initiatives are simply taken from general acute care and implemented in mental healthcare without much thought to the differences in the ways of working. In general healthcare there is a focus on tasks and processes whereas in mental healthcare this focus is less explicit and the predominant feature is on the nurse-patient relationship. It may, therefore, be necessary to acknowledge this and to work through how lean could be implemented in a way that is innovative and creative and takes this different way of working into account. The patient groups and structures within the healthcare environment are not all the same. Coming from a mental healthcare background I would like to further examine this aspect or would like to see further research around lean and mental healthcare.
MENTAL HEALTHCARE AND THE PRODUCTIVE PROGRAMME
Mental healthcare is provided through NHS organisations that offer community services, alternatives to admission services and inpatient care. Thus the patient journey may, and indeed is likely to, include all of these elements of care. The Mental Health Productive programme does have the productive Mental Health ward, but does not have a specific community or other programmes; the other general programmes are adapted for mental health and this does cause some issues as described above. It does, however, mean that the silos of healthcare are perpetuated through the Productive programme, which does not encourage the analysis of the handoff points between community staff and inpatient staff and therefore where there is likely to be some conflict and some possible delays in the care pathway.
I have undertaken research within one Mental Health Trust in England and the feedback from staff is that this programme:
- is a general nursing initiative which does not take into account relationship-building with patients and the need patients have for a safe space to recover. Therefore some of the time could be construed as waiting but really is time for the patient to reflect and recharge;
- is a top-down programme from a government organisation and then from the Trust board, with people coming into the teams from management or a team elsewhere to tell them what to do;
- features executive and management visits that are seen as checking up on them and not about encouragement and coaching;
- will end once they have completed all of the modules;
- has added to the paperwork already in place;
- has seen measures increase overall.
There are overall questions when looking at the productive ward principles that need to be asked; firstly, the customer in healthcare is not well-defined and within mental healthcare is even less well-defined. When asked, most front line staff believe the patient is their customer.
Secondly, the customer in other services pays at the point of service but of course in healthcare the primary care trusts pay for the service and lastly the general public are also customers of the healthcare system through tax payments and they can have very firm views about mental healthcare. The Productive programme measures customer satisfaction through patient and staff satisfaction surveys.
People with mental health needs can be very clear about their care and provide feedback and ways of moving forward; however, for some patients this would be much more difficult – for example, if a patient is detained under the mental health act.
One of the biggest issues for the Productive programme is that it is being implemented at a time when the government needs to make substantial cost savings in the NHS. The original aim of the productive ward is not about solving the Trusts’ financial problems or cutting nurses. However, paradoxically, the Productive programme is being used as a vehicle to make efficiency savings. As the NHS’s main asset is staff, it is easy to understand why there might be some fear around this aspect. Lean initiatives rarely succeed unless continuity of staff employment is guaranteed in advance; once jobs are not threatened and involvement at all levels and respect for people are in place, lean can unleash waves of enthusiasm.
SO, IS THE PRODUCTIVE PROGRAMME LEAN?
- It is using lean tools to develop single initiatives;
- It has made significant changes to single processes and has freed up time to care within some environments;
- It has a good focus on visual management and 5S;
- It is a starting point for people to learn tools and techniques and to develop some continuous improvement thinking;
- Does develop skills understanding what is happening on wards and how to collect data and evidence;
- It creates silo thinking – productive ward, productive community, productive operating theatre. It does not provide ways of creating flow through the patient pathway that includes the areas where there are hand-offs, for instance between community services and inpatient services;
- It does not inform staff of the cultural change and what a lean implementation means;
- It feels like a top-down approach which is driven by a predetermined box;
- It seems that when the modules are complete then you are lean;
- It does not reflect continuous improvement and sustainability.
BUT WHAT COULD BE DONE DIFFERENTLY?
The Productive programme could be developed further into a whole systems approach. This could be achieved through:
- Training that includes a background to lean and systems thinking;
- Regular workshops across systems that encourage learning, development and continuous improvement;
- A Mental Health approach that looks at relationships and not just tasks and focuses on the patient and therapeutic time spent with patient;
- An approach that looks at the crossovers and handoffs within healthcare systems and develops these to ensure flow for the patient. Within Mental Healthcare, this may be helped by the implementation of Care Clustering (which is a way of creating patient pathways and thus could be developed further through value stream mapping);
- The development of local rapid response teams, including the team and a member of management, to undertake Kaizen events with teams when struggling with a patient process, delay or rework;
- More focus on respect for people and building confidence and empowerment in frontline staff;
- Having six to eight measures that are the focus for the organisation (rather than hundreds). Within a lean context, it is well understood that a few right measures will ensure that all else the organisation wants to achieve will be achieved;
- A programme that should not be implemented when staff are feeling threatened by change and efficiency targets, but should be introduced after a period of helping staff to understand the reasoning and the benefits of lean or the Productive programme. In Mental Health this would include education and support to staff to understand processes and tasks and how they affect the time they have to spend with patients;
- Starting with a patient focus and the issues the patient has and then developing a strategy for undertaking the changes from this viewpoint, thus increasing patient satisfaction and wellness;
- The introduction of lean ways of working to all professionals within the healthcare system and ensure a clinical leadership focus alongside a real agenda to drive up quality of care.
More research is needed around the effectiveness of the Productive programme and whether there are further developments that can be made. The Institute has been iterative in its approach and has developed further programmes and is now asking for feedback regarding organisations that have used more than one of them. Therefore, it may well be working through how the programmes might work together. There is already enough evidence in the literature to say that lean as a concept works. Therefore, why would healthcare want to develop this in the way it has?
However, my last question would be, “How will this programme and way of working be sustained and ensure a better healthcare service for all if the Institute no longer existed, and if staff continued to believe it is a programme with a beginning and end that is driven from the top down?”
Sarah Powell, senior change manager at Guildford’s Royal Surrey County Hospital, explores the role of evidence in medical engagement with service improvements.
The change of government in 2010 saw the publishing of a White Paper, “Liberating the NHS”, which represents possibly the biggest shake up of the health system since the inception of the NHS. It aims to transform the system, reducing the tiers of management, removing some of the targets set by New Labour and further opening up the NHS to market forces and competition. It means acute Hospital Trusts must significantly change their approach to ‘doing business’ and requires them to redesign the service offered to ensure both quality and efficiency for patients.
For the last few years, the Royal Surrey County Hospital (RSCH) in Guildford has drawn upon lean and six sigma to implement organisational change, looking to improve the efficiency and quality of its processes to ensure patients get the optimum service. Called ‘Patients First’, this programme has achieved many successes in improving the way the hospital works and is a fundamental part of the hospital’s plan to meet the challenges of the latest White Paper. However, an important component has not been totally accomplished: the full engagement of doctors in driving improvements and their involvement in making change stick. Those responsible for leading change programmes recognise the importance of securing this engagement;trying to make change happen without it often means such programmes are doomed to fail.
With the recognition that having doctors involved and engaged with improvement activities is important, it was thought necessary to understand these concepts further and highlight what might influence doctors’ attitudes and behaviours towards improvement activities. The spectrum in figure 1 describes the journey from active resistance to active involvement, which highlights the continuum of attitudes that can be displayed during an improvement activity and how moving one’s attitude from neutral to committed can result in ‘active involvement’ behaviour, and vice-versa.
Whilst there is limited research into the specific factors that influence doctors’ decisions to engage with change programmes, a research team has reviewed the success of an improvement programme called the ‘Safer Patients Initiative’ and from that identified multiple factors that influence medical engagement, the majority of which have not been researched in detail. They suggested that these factors should be investigated further, so that the influence each factor has on doctors’ decisions to get involved in change programmes could be fully understood. ‘Evidence of efficacy’ was one of those factors found, which, alongside conversations the researcher had previously had with doctors during her every-day role at the RSCH, prompted the researcher to want to understand this specific factor further.
The literature suggests that there is complexity surrounding the use of evidence in doctors’ decision-making, particularly with regard to clinical decisions. This is partly because evidence is rarely definitive and partly because of the role played by the individual in interpreting and reframing the ‘evidence’ presented to determine what is counted as ‘best evidence’. Doctors draw their own conclusions about the soundness of the evidence put in front of them and the science underpinning conclusions and recommendations.
The researcher used questionnaires and semi-structured interviews to gather information about the views of consultant surgeons and consultant anaesthetists at the Royal Surrey County Hospital. In the questionnaires, respondents were asked to express their views on the importance of a range of factors, including ‘evidence’. Evidence was found to be the second (out of seven) most important factor that influenced the doctors’ decision to get involved in change programmes. In the interviews, individuals’ views of evidence, and the role it plays in their deciding whether to get involved, were explored in detail.
The analysis of the primary research resulted in the creation of a model to help explain the views and opinions of those who took part. The model in figure 2 is a depiction of these synthesised findings, with each square representing an identified element, and numbered dots highlighting the amount of comments made in relation to each element.
The model describes how the research discovered four different levels:
- ‘Background’ elements, which appear to help shape the doctors’ attitudes and beliefs towards getting involved in improvement activities;
- ‘Underlying attitudes and beliefs’, which, whether they are visible to others or not, appear to help shape the interpretation of the factors;
- Influencing ‘factors’ upon which the doctors’ decisions to get involved in change programmes appear to be based;
- Barriers/enablers’ associated with each of these factors: a. Barriers (red), when present, seem to prevent doctors from engaging. b. Enablers (green), when present, seem to help persuade doctors to engage.
Most of the elements within each level are directly related to ‘evidence’, as would be expected given the research focus. An interesting discovery was the number of elements that came out of the research data, which were not directly about evidence, despite the focus in interview questions on the topic of evidence. The data suggest these elements are important in shaping the role of evidence in respondents’ decision-making as well as potentially in their own right, although this would need further investigation as was not the primary focus of this study.
The model shows how all of the elements described in each of the levels above appear to be ‘weighed up’ by the doctors to shape the way that they make the four decisions as identified on the right hand side:
- Is it worth my effort? (i.e. do I believe it will work?)
- Will it benefit patients?
- (related to no.2) Do I agree with the motive(s) behind the change?
- Am I involved early enough to influence the course of the change programme?
Whilst this research does not claim to have identified all of the key decisions, the role of evidence has been explored further than in previous work; the four decisions highlight how evidence is used to determine whether doctors will engage in change programmes.
In reviewing the research findings, there are four key topics for discussion that would be relevant to those trying to engage with doctors in change programmes. First of these is the element of ‘medical training and background’, which appears to lead to attitudes of scepticism and a desire for a scientific approach, both of which may drive the need to see evidence. The type and presentation of evidence as well as the method of data collection is also linked to their medical training and background, and is depicted above as either an enabler or a barrier to engagement. These can be differentiated due to descriptions the doctors made about what methods they would more readily accept in relation to evidence. There is a different tradition in management, which is less prescriptive about the method employed and begins to highlight a potential reason why there is a perceived gap between managers and doctors in change programmes.
Secondly is ‘measurements and data’, which was mentioned by all six interviewees and was the most frequently mentioned theme from the questionnaires. The doctors’ views of measurement and data were notably deductive, seeing ‘before’ and ‘after’ measures when constructing a concrete answer about a specific change. However, in lean thinking, the measurement of the whole system impact is more longer term, therefore the simplistic question of “has it worked?” when analysing the specific initiative before and after implementation may not be wholly suitable when assessing longerterm lean-style quality or efficiency improvements’ success. The doctors’ view may therefore not be naturally compatible with lean-style change programmes, which the Royal Surrey County Hospital is looking to implement – the changes here are system wide, with reviews of interactions between departments. It may not therefore be appropriate to measure these types of improvements in the same way as doctors might do in Randomised Controlled Trials.
During the process, there was a slight contradiction found with regards to measurement and data: whilst all expressed a desire for this type of evidence, another element that encouraged engagement is for the respondents to see the change for themselves through ‘best practice’ visits. A comment was that this could be ‘enlightenment’ for people who have been working in the same environment for many years. On the other hand, a clear barrier in terms of type of evidence is the use of solely anecdotal stories to try and influence doctors to get involved – this is likely to come up against resistance as it is unsubstantiated.
The third topic worthy of note is being able to show that the change is going to benefit the patients. The doctors interviewed and surveyed were consistently interested in making sure that any improvements actually benefited the patients and were often wary of the motives behind changes instigated in the hospital. With the current economic climate, many of the changes that take place appear to be motivated by cost-cutting. As such, it is perhaps no wonder that doctors are sceptical and wary about engaging with changes that they cannot directly see as benefiting the patients – even if these changes will enable the long-term sustainability of the services for patients.
The final interesting conclusion from this research is not directly related to evidence as such, but is an element that appears to be a mediator in the role evidence plays in engaging doctors in change programmes. It is that of early involvement of doctors and it appears to be important in shaping how the doctors respond to the evidence that is presented to them. For instance, even if strong evidence is presented after the decision has already been made to go ahead with a certain approach, it may be seen as being presented merely to persuade (or manipulate?) them, which appears to instantly lead to resistance.
The findings from this investigation have begun to explore how evidence can be used by doctors in their decision-making, not only for clinical decisions, but also when deciding whether to get involved and support a service improvement activity. This was a small study and further work needs to be done to expand on these findings and develop our understanding, to help ensure doctors are involved in all kinds of change programmes. An important point to end with is a message that came out clearly in the findings: all of the doctors were definite in their desire to make improvements that would benefit both patients and the hospital. All wanted to see their service improve and develop. It would appear managers need to harness this attitude earlier in the process of change to secure the involvement of doctors, equipping hospitals with the engagement they need to deal with the challenges the next few years will bring.
- Gollop, R. and Ketley, D. 2006. Shades of resistance: understanding and addressing scepticism. In: Buchanan, D. A, Fitzgerald. L. and Ketley, D. eds. The Sustainability and Spread of Organizational Change: Modernizing Healthcare. USA: Routledge
- Parand, A., Burnett, S., Benn, J., Iskander, S., Pinto, A. and Vincent, C. 2010. Medical engagement in organisationwide safety and qualityimprovement programmes: experience in the UK Safer Patients Initiative. Quality and Safety in Health Care 19, pp. 1-5.