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Applied Systems Improvement Programme Management Training Scheme

Clinical Systems Improvement www.warwick.ac.uk/go/csi

• Sharon Williams

Matthew Cooke Clinical Systems Improvement www.warwick.ac.uk/go/csi

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

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www.warwick.ac.uk/go/csi

Today’s Programme

10.00am Welcome & introductions 10.15am Introduction to the origins of systems improvement 10.45am CSI principles & defining value 11.15am Coffee 11.30am Identifying waste 12.15pm Introduction to value stream mapping 1.00pm Lunch 1.45pm Mapping & improving the patient journey 2.30pm See & Treat case study 3.15pm Tea 3.30pm Leadership & Teams 4.30pm Break 5.15pm Lean simulation activity 7.15pm Summary, feedback & questions 7.30pm Close

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Tommorrow’s programme

9.00am Review of Day 1 and simulation activity 9.15am Introduction to problem solving tools & visual management 10.15am Project management & action plans 11.00am Coffee 11.15am Managing change and sustainability 12.00md Systems Improvement & Safety 1.00pm Lunch 1.45pm Systems Improvement & Safety 2.15pm Lean meetings 2.30pm Strategy & policy deployment 3.00pm Tea 3.15pm Facilitated discussion - future application of learning 3.45pm Summary, feedback & questions 4.00pm Close

Clinical Systems Improvement www.warwick.ac.uk/go/csi

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Learning and reflection

Please complete the handout at the appropriate points

Handout - CSI – its personal impact

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Evidence based medicine

• vs. improvement impact
• Clot busters

Which drug? When? Getting it to everyone who needs it Consistently Reliably

Clinical Systems Improvement www.warwick.ac.uk/go/csi

History of CSI

Techniques from Manufacturing Modernisation Agency Collaboratives Improvement Programmes Process vs Clinical Pathway Systems and Safety

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Survey on CSI with 19 Acute Trusts and 10 PCT’s in England

Command and Control culture can obstruct engagement Methods for knowledge transfer are mainly traditional (staff involvement v top down communication) Most improvement is focused on ‘targets’ Strong focus on cost rather than quality Improvement techniques applied are variable and mainly project based rather than system based Strategy and Improvement are poorly linked

Walley, Rayment and Cooke, 2006

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Characteristics of Best Performers

Strong leadership enabling difficult and sensitive change Senior Managers with a strong awareness of process and systems issues Receptive workforce to new ideas with no change fatigue Strategies deployed as a means of reconciling conflicting long and short term priorities A critical mass of capacity in improvement Management style which encourages staff driven improvement

Walley, Rayment and Cooke, 2006 Clinical Systems Improvement www.warwick.ac.uk/go/csi

Handout- suggestions

Clinical Systems Improvement www.warwick.ac.uk/go/csi

COST TIME QUALITY S A T I S F A C T I O N SAFETY OUTCOME

TEAMWORK USER INVOLVEMENT CULTURE

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

The NHS is different…….

More variation Unpredictable No measurable output Not profit making No staff reward scheme Inverted skills pyramid

Clinical Systems Improvement www.warwick.ac.uk/go/csi

What is lean healthcare?

Applying lean principles to healthcare to improve patient care and safety Redesigning healthcare systems and processes to improve response, quality and safety.

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Lean in health care

Specify value 1

Identify the Value stream Make the Process & Value flow Let the Customer pull Pursue Perfection

2 3 4 5

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Five principles of lean healthcare

1. Understand & specify what our customer/patient want & value value. 2. Identify the value stream value stream or patient journey & eliminate waste 3. Make the process and value flow flow according to according to the needs ( the needs (pull pull) of the customer/patient ) of the customer/patient 4. Involve & empower healthcare staff 5. Continuously improve in pursuit of perfection perfection

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Lean Thinking

Systems approach – rather than functional Based on eliminating unnecessary actions Linking value activity in a continuous sequence Move away from ‘batch & queue’ to continuous flow It has a very long history (around since 1950s) and is a continuous cycle

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Lean Thinking

Systems approach – rather than functional Based on eliminating unnecessary actions Linking value activity in a continuous sequence Move away from ‘batch & queue’ to continuous flow It has a very long history (around since 1950s) and is a continuous cycle

Learning by doing

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

What can we expect to get from CSI?

• Improved patient care
• Improved quality & levels of efficiency
• Improved information flows
• Improved patient safety
• Reduced mortality
• Reduced length of stay
• Reduced/ remove waste
• Eliminate delays
• Improved staff morale
• Lowered costs

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Need to remember

‘…..the evidence… found was of people in health and social care working very hard. But they are working within systems which militate against good performance, and where there is excellence in our view it is despite rather than because of the system.’

Wanless 2003

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Symptoms of a sick system

System Rework Delays Variation Frustration/ Demoralised

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Customer value

Clinical Systems Improvement www.warwick.ac.uk/go/csi Clinical Systems Improvement www.warwick.ac.uk/go/csi

Specify value in the eyes of the customer Who is the customer? Which steps actually add value for the patient? What does patient want?

Specify value

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Defining value

Value Adding

– Activities within a organisation or value stream that the customer would be happy to pay for – or improves the patient’s health, well-being or experience.

Necessary non value adding

– Non value adding activities which are necessary under the present operating system. Usually difficult to remove in the short term (I.e. quality inspection due to an unreliable machine but cannot be replaced in the short term).

Non value adding

– Activities that do not directly contribute to satisfying the customers/patients requirements – delays/duplication etc.

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Value in healthcare

The mission therefore is to achieve:

– 100% quality (e.g. adverse events, readmissions) – 100% quality ( the best treatment, the best care) – 100% service (no waits) – Minimum stock & space but available when required and good contingency plans

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Segmentation

Runners – high or sufficient volume to have dedicated facilities (even if not constantly used) Repeaters – intermediate volume that can be scheduled at regular slots (weekly) Strangers – low or intermittent volume

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Activity

In relation to your current work based role who are your customers and what do they value? Value can include ‘wants, needs and demand’ How does your organisation identify what patients want/value?

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Coffee break

11.30am Identifying waste 12.15pm Introduction to value stream mapping 1.00pm Lunch Clinical Systems Improvement www.warwick.ac.uk/go/csi

Identifying waste

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Examples of healthcare wastes

• Over production - requesting unnecessary tests
• Waiting – for patients, results, prescriptions
• Transport – staff walking to the other end to collect

patient notes

• Over-processing – duplication of information, asking for

patient details several times

• Inventory – excess stock in store rooms not being used
• Motion – unnecessary staff movement looking for

paperwork (e.g. drug sheets)

• Defects (Correction) – readmission due to failed

discharge, adverse drug reaction

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Activity

Refer to your watch and listen exercise – identify and classify wastes which

• ccurred

Are these wastes symptoms/effects or a root cause of the problem identified

Handout - waste handout- watch and listen

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Relation of Value, Cost/Waste

Customer Perceived Value

Waste/Cost (of product/service)

x

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Creating Lean Solutions:

• 1. Reduce Internal Waste
• 2. Develop Customer Value

Creating Lean Solutions:

• 1. Reduce Internal Waste
• 2. Develop Customer Value

Cost-Value Equilibrium

x

2

Source: Hines, et al (2004), Learning to Evolve, A Review of Contemporary Lean Thinking, IJOPM

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Value Stream Mapping

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Identify the Value Stream

• The Value Stream includes the complete

activities or all the organisations/ depts/ functions involved in adding value to a product or service

– From receipt of order to dispatch of goods – From referral/arrival to discharge of patient – From receipt of test request to collection

• To understand a Value Stream we map

inter-organisation & intra-organisation value adding processes

Identify the Value stream

2 Clinical Systems Improvement www.warwick.ac.uk/go/csi

Identify the Value Stream

• Identify waste to reduce/ remove it
• Identifying the elements of the patient

journey that add value to their experience & care

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Current state mapping

Handout- mapping Clinical Systems Improvement www.warwick.ac.uk/go/csi

Process mapping (1)

• Enables us to expose waste in our processes
• Bring a team together who are involved in the

various steps along the patient journey

• The team map out how the process currently
• perates (current state map)
• Identify all the waste, delays by collecting data
• Add data to map – quantifiable information,

measurements & actual times

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Process mapping (2)

• Map will highlight duplicate steps, unnecessary

work, unclear roles & responsibilities

• Team to design how they want the process to
• perate without the delays & waste (future state)
• Involve patients in the process
• Devise an action plan with clear timescales
• Nominate a lead person who is responsible for

implementing the improved process

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Process map

Referral letter sent by GP Patient waits Acknowledg ement letter received Patient waits Appointment letter received Patient telephones to confirm appt Patient waits Patient arrives at

• utpatients

Patient waits Patient’s

• bservations

checked Patient waits Patient sees consultant Patient waits Patient sees specialist nurse Patient leaves

• utpatients

How can we redesign the process to remove some or all of the non- value adding activities?

Clinical Systems Improvement www.warwick.ac.uk/go/csi 999

Self refer

NHS Direct

Self care

Prioritise Ambulance Scene Assess Transport Arrive A&E See & treat triage Assess Test Discharge home Refer Senior Assess Assess Senior DTA

Leave A&E Bed

Tests Treatment Recovery Supportive care

Home

Patient flows in emergency care

GP

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Source: NHS Institute

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Lunch break

1.45pm Mapping & improving the patient journey 2.30pm See & Treat case study 3.15pm Tea Clinical Systems Improvement www.warwick.ac.uk/go/csi

Group activity

Stage 1 : Create a process map for one of the following: Group 1: Getting a coffee/tea during this morning’s break Group 2: Getting your lunch Group 3: Getting on a training course in the NHS Stage 2: After completing the current state map consider whether you can redesign/improve the process to eliminate any of the steps/activities?

Clinical Systems Improvement www.warwick.ac.uk/go/csi

See & Treat Case Study

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Tea break

3.30pm Leadership & Teams 4.30pm Break 5.15pm Lean simulation activity 7.15pm Summary, feedback & questions 7.30pm Close Clinical Systems Improvement www.warwick.ac.uk/go/csi

Apollo Syndrome

Details on the handout Clinical Systems Improvement www.warwick.ac.uk/go/csi

• Successful change

management

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

If Harry Potter ran General Electric

by Tom Morris

Prepare for the challenge

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Prepare for the challenge

Surround yourself with support

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Prepare for the challenge Surround yourself with support

Engage in positive self talk

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Prepare for the challenge Surround yourself with support Engage in positive self talk

Focus on what’s at stake

Clinical Systems Improvement www.warwick.ac.uk/go/csi

Prepare for the challenge Surround yourself with support Engage in positive self talk Focus on what’s at stake

Take appropriate action

Clinical Systems Improvement www.warwick.ac.uk/go/csi

“Success can only be achieved through repeated failure and introspection” “I must create a workshop where everybody will enjoy working” Soichiro Honda

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Leadership

‘The very essence of leadership is that you have to have vision. You can't blow an uncertain trumpet.’ Theodore M. Hesburgh “Leadership: the art of getting someone else to do something you want done because he wants to do it.” Dwight D. Eisenhower Clinical Systems Improvement www.warwick.ac.uk/go/csi

Your boss

My best bosses inspired confidence were humble had integrity knew what they were talking about let me get on with things were always there when I needed help usually said ‘yes, try it’

My worst bosses never seemed to be around when I needed them always asked me to justify what I wanted to do always wanted to know what I was doing

• ften said ‘no, we can’t do that'

gave the impression of being distrustful didn’t smile much talked about themselves a lot http://www.simplicityisthekey.com/ Clinical Systems Improvement www.warwick.ac.uk/go/csi

Teamwork

Empowering the staff Giving them time to improve

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Clinical Systems Improvement www.warwick.ac.uk/go/csi

Simplicity

Simplicity Tip Number 1 - Staff at the front line know ALL the answers ALL the time. Simplicity Tip Number 2 - If managers have a job at all in 2008 it is to make it easy for front line staff to do their job with freedom. Simplicity Tip Number 3 - Give all the budget – YES ALL THE BUDGET to front line staff http://www.simplicityisthekey.com/

Clinical Systems Improvement www.warwick.ac.uk/go/csi

The power of the user

Clinical Systems Improvement www.warwick.ac.uk/go/csi

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Value Stream & Patient Journey

• Clinical Systems Improvement

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• Clinical Systems Improvement

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See and Treat

One clinician Decision maker Single Flow Do everything themselves No other commitments

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4.30pm - Afternoon Break 5.15pm – Lean Simulation Activity