In the first of a series of case studies from the healthcare sector, David Loughton CBE, Chief Executive at the Royal Wolverhampton NHS Trust in England, guides LMJ through three lean projects at the hospital, which collectively saved nearly £2.4 million.
Project number one
We didn’t have enough in-house capacity, and each week we outsourced six Orthopaedic elective theatre sessions. Not only were these sessions not as popular with patients as those carried out in-house, but they also represented a significant loss of income for us.
We asked consultancy firm Newton Europe to help us to repatriate all of the sessions. The project, like the following two, began with a detailed assessment. Historical data, live studies and discussions with staff were then used to identify losses.
Three key areas of opportunity were identified: unallocated sessions, inaccessible due to a multitude of complex and interdependent timetabling constraints; reduced day case theatre utilisation due to late starts and early finishes; and lost sessions due to cancellations.
We identified permutations of theatre timetables that would free up six sessions per week, working within constraints such as theatre clinical suitability and physical configuration, staff external commitments, surgeon and anaesthetist working partnerships and consultant job plans.
The problems solved included theatre preparation, communication, rota planning and synergy. Furthermore, a reduction in early finishes was achieved through decreasing inpatient cancellation rates and increasing theatre list booking efficiencies.
Working across a number of specialties, Newton quantified true capacity and demand in all types of theatres, understanding all constraints associated with possible moves and validating all opportunities to increase orthopaedic elective capacity.
Forty-six session moves were agreed and implemented, making use of sessions previously inaccessible and cascading case mix down from main theatre to day cases, and from day case to treatment rooms.
Within weeks of the project starting, we were so confident that the capacity was available in-house, that we terminated the contract for the outsourced theatres.
We also achieved increasing session uptake by simplifying the process of cancelling and reallocating theatre sessions. The new process, created with input from all levels of administration and management, improved the visibility of cancelled theatre sessions and simplified the process of cross-speciality list reallocation.
- All six outsourced sessions successfully repatriated and are now being carried out in-house – 14% increase. Annual savings: £744,000;
- Improvements made in day-case theatres led to a 15% increase in utilisation over all specialties. Annual savings: £303,000.
- Improvements to the visibility of cancelled sessions and the process by which they were booked, cancelled and re-used, has led to 2.4 additional sessions being available every week, which is worth an annualised £197,000.
In total, RWT have made £1.25m in recurrent annualised savings through optimising and improving Orthopaedic theatre sessions.
Project number 2
Another interesting project the Trust completed with Newton aimed to increase outpatient clinic productivity by 11% in six months across Rheumatology, Dermatology and Diabetes.
We realised there were three work streams where improvement was needed if we were to succeed: outpatient booking processes, medical and nursing staff utilisation, and outpatient treatment data capture.
A system to “hold” review patients was set up to minimise the number of times each appointment is rescheduled. The timeline for notifying and reminding patients of their appointment was revised to ensure convenience for patients whilst minimising the risk of non-attendees. We developed an information system to support this process, providing visibility of future booking levels and performance reporting. The tool provides a live forecast of the number of DNAs (Did Not Attends) and cancellations expected on each future clinic, allowing phone call reminders to be prioritised and for remaining DNAs and cancellations to be compensated for.
Staff timetables and clinic setups were benchmarked against their peers within the Trust and nationally. Those below the target levels were increased.
Simple and robust reporting and feedback loops were used to increase the accuracy of data capture of outpatient treatments.
By solving these top down problems, we allowed for a streamlined patient pathway, increased slot utilisation and enhanced staff optimisation.
- DNA rates were reduced by an average of 13% and all other clinic slot losses by 9%. Annual savings: £140,000.
- Staff utilisation work stream has resulted in an additional 3,400 additional slots being available to patients every year, improving patient choice and ensuring that waiting times can be controlled. Annual savings: £405,000.
- The final workstream has yielded a 19% increase in the number of outpatient treatments accurately captured, worth £140,000 a year.
- This initiative has allowed for the development of a standardised booking process that can be applied across outpatient clinics for all specialties. This is expected to greatly improve service delivery by virtually eliminating Trust-rescheduled outpatient appointments, which have typically been the only cause of patient complaints.
Project number 3
The Ophthalmology department at RWT struggled to meet demand. We had a backlog of 9,000 follow-up patients on waiting list, which was growing at a rate of 4,000 a year. We had to increase clinic capacity by 32.5%: 21% would come from efficiency improvements, with the remaining 13% to be delivered by the appointment of an additional consultant.
A new process for clinic appointments ensured that the most appropriate resource would see each patient at their next appointment. We then redistributed clinical staff timetables through the week to match availability to demand and smooth room requirements, hence freeing up nursing resource and physical space to enable additional clinics to be run (all patients could now be seen by the most appropriate resource and also the most cost-effective one).
We also developed a bespoke information system to support the booking process, improving visibility of unutilised slots and reporting historical performance to ensure that all future slots are filled and used.
- We recorded a 27% increase in capacity at RWT through the various efficiency improvements, exceeding our original target by 6%. With the appointment of one additional consultant we met the increase in demand as experienced nationally.
- We achieved a reduction in patient waiting times, patients being seen at their appropriate review frequency and a closer working relationship between management, medical, nursing and support staff.
- We saved £454,000 a year, because we avoided the cost of appointing several additional consultants to cope with the demand increase.