Maria Teresa Mechi, a Senior Executive in the healthcare department of Tuscany’s regional government, shares with LMJ the interesting initiative the region is conducting to encourage Tuscan hospitals to become leaner.

Florence’s Ospedale Santa Maria Annunziata was the first hospital to successfully implement lean in Italy. Our journey began in 2007, and by 2011 we were ready to involve other ASLs (Azienda Sanitaria Locale – the equivalent of a Trust in the UK) in the ambitious Net-VisualDEA project. Trusts in Prato, Lucca and Pisa began their own lean journeys.

With the aim to improve patient flow in each Trust in Tuscany, the regional government launched a regionwide programme to promote the adoption of lean principles in hospitals.

Today, nine Trusts have launched a lean programme, with three more that are about to start a training cycle. Out of 16 aziende sanitarie operating in Tuscany, 12 have already started. It’s a common programme, with shared objectives. We are monitoring the situation based on the KPIs we have established, and I have to say the results are very positive: waiting time and convalescence are both decreasing considerably.

In each of the ASL that have started a lean journey, staff are feeling increasingly engaged – we see it, for example, in the enthusiastic contribution of nurses to the cause as they redesign their stations. There is more sense of identity than there was before, and it is clear that people have started to feel like they are part of something, even if they are not directly involved in rethinking the processes.

We held kick-off meetings, during which the management of each organisation committed to supporting the implementation of lean. Considering the lack of financial resources and the dire state of the Italian economy, this is seen as a useful exercise to find efficiencies and remove waste.

The programme is made possible by the investment the region granted: it is a sort of risk-free gamble, which aims to support the creation of processbased operations management capabilities. We are providing for the development of a new professional figure: individuals with a background in engineering or economics, to whom we give managerial skills. We didn’t want to limit it to, say, the engineers because we believe that the contribution of different professionals will lead to wider margins of growth.

We have developed a bespoke training course for these people, in partnership with academic institutions. We are now halfway through this sixmonth journey to perfect management skills, which sees the trainees bring their first-hand experience, problems and case studies to the universities that can in turn develop a better educational offering, which will serve them well in the future. It is tit-for-tat.

The funds the region invests (€2.5 million in 2012, of which €2,380,000 went to the Trusts and €120,000 to Careggi Hospital’s FORMAS – an acronym for Formazione Sanitaria, a healthcare training institution in Florence) are used used to develop and then hire these professionals and we are confident that, if their knowledge is used properly, the rewards will be far greater than the costs.

Tuscany is forced to cut costs just like other regions in Italy, but we are also aware of the fact that cuts alone will not be enough. Refreshingly, we have reacted to the crisis and challenges it brought with an ambitious programme, whose benefits we are already starting to see.

This initiative is now wider than Net-VisualDEA used to be. It’s called Ottimizzazione del Flusso del Paziente (Patient Flow Optimisation), and represents a new strategy for healthcare in the region: from Arezzo to Siena, Pisa and Pistoia, our hospitals are focusing their attention on improving patient flow.

Unsurprisingly, some of the hospitals are doing very well and others are struggling a bit more. The Ospedale Santa Maria alle Scotte, a university hospital in Siena, for example, is progressing very quickly. A young and highly motivated workforce and a strong commitment from leadership is ensuring that the Azienda Ospedaliera Universitaria Senese gets lot of work done very quickly, despite belonging to the second wave of Tuscan Trusts that have joined the programme and launched a lean implementation.

The same thing is happening in nearby Arezzo, where we have seen an incredible commitment from doctors since the very first meetings. In ASL number 10, Florence’s, what we have done since 2007 is now spreading to another hospital with great results.

In Pisa, they have perfected a number of tools to reduce the delay in freeing up beds in the Emergency Room: like on a lean production line, real-time monitoring of the situation makes it easier to identify and remove waste. They have codified a number of solutions that are standardised and that the worker can deploy under certain conditions. Some of these solutions are quite crafty, like the provision of a tesoretto, a small fund (perhaps coming from the money saved thanks to lean) that can be used for, say, hire an extra ambulance just to free up a bed. It’s all about the analysis of costs and benefits (what’s the cost of keeping a patient who can be discharged against the cost of hiring an extra ambulance?) and we will get better at it with time. The sensation is that we have opened Pandora’s box, and that all the problems inside are in fact opportunities.

The most negative experiences occur when, as often happens in Italy, a new, less enthusiastic leadership replaces the old one. Regional councillors can decide to change or move an ASL’s direttore generale (general director) even before their mandate is over – not always the successor follows in the predecessor’s footsteps.