Benefits Realisation · • Reflected in health status – SMR - Cancers – up to 123 -...

Benefits Realisation

4 years of the Bolton Improving Care System;driving sustainable quality, safety and

productivity across the Trust

About Bolton

• Population 270,000• Northern industrial town• 12% ethnic minority population (>18% childhood

population)• Significant levels of deprivation and inequality• Reflected in health status

– SMR - Cancers – up to 123- Circulatory disease – up to 136

• Part of Greater Manchester – 2.5m population

About the Trust• Approximately 700 beds• Busy emergency services – catchment about 310,000• 3,200 staff• £170m turnover• Most secondary elective and non-elective acute

specialties:» Medicine» Surgery/Urology» Orthopaedics» ENT, Ophthalmology, Oral» Children’s» Obstetrics» Diagnostics» A&E

Information

All work is a process…. this is true of hospitals too!

Clinical assessment

Investigations Clinical decision

Patients

Information

Admission Treatment Discharge

9WEEK11

WaitingTransportation/Motion

Waiting Waiting

Waiting

Waiting Waiting

Waiting

Mistakes

UncoordinatedActivity

TransportationTransportation

Transportation

Transportation/Motion

InappropriateProcessing

The NHS is full of committed staff who struggle to deliver good care within a set of broken processes.

Lean aims to tackle this by:“Respect for People & Society” “Continuous elimination of Waste”

What does “Lean” mean?

Current

Traditional

Waste (NVA) Work (VA)

New Work?

The Eight WastesInjuries Damage to people, including anxiety, stress

and physical injury.Transportation Unnecessary movement of materials e.g.

recordsInventory Parts or product being stored e.g. ward stocks

Motion Unnecessary movement of workers e.g. nurses

Waiting Delays in the process e.g. 18 weeks!

Over-production Too much product or service being produced e.g. tests and x-rays

Over-processing Unnecessary steps or activities e.g. duplicate histories

Defects Errors or deficiencies that require re-work e.g. drug errors

Proven Sequence of Implementation: 5 Steps

1. VALUE ~ What is the customer really buying

2. VALUE STREAM ~ How value is created & delivered

3. FLOW ~ Improve the value stream

4. PULL ~ triggering every flow from actual demand

5. PERFECTION ~ Continuous improvement forever

VISUAL MANAGEMENT:

1 PIECE FLOW

STANDARDWORK

6 S PULLSYSTEMS

Move away from

batching, backlog and

queues.

Reduce

variation &

complexity.

SortStraightenScrubSafetyStandardiseSustain

Create signals to

pull patients. Obvious

when something

empty.

“ability to see the process”

Basic Lean Principles

So……why do we need Lean?

Our Vision

Possible

Joy and Pride in Work

Improving

Health

Value for Money

No Defects

Highest Morale

No Needless Deaths

No Waste

Patients

Public

Taxpayers

From the Patients’ Perspective

Want to know they are receiving the“Best Possible Care”

To be confident in outcomesWant access on demandTo feel safe

“A Health Service we can be proud of”

Improving Health

Value for Money

Joy & Pride in

Best Possible

No Defects38% of staff saw errors in one month2006

No Needless Deaths

HSMR – 124.205-06

From the Staff PerspectiveWe should enjoy coming to work

It should be a place where we give and gain respect

Nobody comes to work to do a bad job

Employer of choice

Best Place to Work

Best Possible Care

Improving Health

Value for Money

Highest Morale

Staff satisfaction in lowest 20%2006

Taxpayers PerspectiveThe Service should offer

Value for Money

Payment by Results – money follows the patient.

Paid for work at National Tariff.

Best practice tariffs are now with us.

We must be the best to compete.

Best Possible Care

Improving Health

Value for Money

No WasteReference costs 101.6 07-08

Trust Strategy

• Centre of excellence for Women's and Children's Services - “MAKING IT BETTER”

• Major Emergency Centre/redesign of urgent care

• Re-focused range of elective services• Opportunities for new services in community

settings e.g. CATS• (LEAN) driving sustainable quality,

safety and productivity improvements

18 Week referral to treatment

•Achieved as early adopter December 07

Trust Wide Results (‘05 to ‘09)Releasing Benefits

*Data taken from Dr Foster December 2009

Safety •40% reduction in HSMR from 2005 to Sept 2009 (using 2008-2009 baseline)*. However

risk weighted mortality calculations suggest further challenges to improve Trust wide HSMR.

•0.5% reduction in readmissions

•Participation in Safer Clinical Systems

•Involvement in Patient Safety First Campaign – Implementing the WHO Patient Checklist

(Highly Commended, HSJ Patient Safety Awards 2010)

Staff Engagement•67% completed Green Training or Rapid Improvement Events

LoS•13% reduction in Non-elective LoS*

•26 bed ward closed

•Additional 26 bed ward closed for 3

months over summer, recurrently

Increased Activity

• 11% increase in admitted activity*

• 22% increase in Daycase activity for “trolley” of 33

procedures*

Theatre Performance•20% saving in time due to improved start times (Theatres)•Shortlisted for Patient Safety Awards 2010

18 Week referral to treatment

•Achieved as early adopter December 07

Trust Wide Results (‘05 to ‘09)Releasing Benefits

*Data taken from Dr Foster December 2009

Safety •40% reduction in HSMR from 2005 to Sept 2009 (using 2008-2009 baseline)*. However

risk weighted mortality calculations suggest further challenges to improve Trust wide HSMR.

•0.5% reduction in readmissions

•Participation in Safer Clinical Systems

•Involvement in Patient Safety First Campaign – Implementing the WHO Patient Checklist

Staff Engagement•67% completed Green Training or Rapid Improvement Events

LoS•13% reduction in Non-elective LoS*

•26 bed ward closed

•Additional 26 bed ward closed for 3

months over summer, recurrently

Increased Activity

• 11% increase in admitted activity*

• 22% increase in Daycase activity for “trolley” of 33

procedures*

Theatre Performance•20% saving in time due to improved start times (Theatres)•Shortlisted for Patient Safety Awards 2010

However, despite all this fantastic work, it is still not widespread, there is still a long way to go, only now are we beginning to see all the waste and problems that there really are….

“We just about know, what we don’t know!”

We still have many challenges regarding our mortality rate, and sustaining the 4 hour 98% standard for A&E

2008/2009• Direct Savings £3.1m*

Annual Income contribution potential from reduction in Length of Stay: £2.4m

• Improvements in LoS have released 3,283 overnight bed days at month 12

• Current unreleased potential cost saving £356K (3,283 BDS x £109)in acute medicine at month 12

• Increased potential productivity gain through beds 1,001patients** in 12 months, subject to demand

• Potential productivity gain from bed days already released £2.4m (1001 patients x £2,404 average income)

*Source benefits tracker agreed Sept 2008

**Bed days released / average LoS

Reduction in HSMR Using 2008-2009 as Baseline Year

• Developing the response to deteriorating patient • Focus on end of life care• Implementing Standard work/care bundles • Coding and record keeping• Focus on Respiratory / high-risk pathways

Data from Dr Foster,Dec 09

Similar Charts are available to demonstrate reductions in the Respiratory and Trauma pathways

It should be noted that despite these fantastic results, overall Hospital HSMR is still significantly over ideal state and much more work to reduce this is still required. For this we have developed a 5 point plan to assist in HSMR reduction this includes:

HSMR: Stroke 2005 - 2009 Baselined with 2008-2009 Data

Programme 2005 - 2008• EVSA for whole Trust November 2006

– Development of Mission Control– Development of Policy Deployment

• Divisional Priorities– Individual Divisions burning bridges

» #NOF Mortality» Blood Sciences service pressures» Estates services» Stroke Services

• Engagement and involvement of staff

Programme 2009 - 2011 • Whole hospital focus on Urgent Care, Mortality & financial stability.

Policy Deployment

Second Level (L2)• Improvement owner develops second level.• Transfer strategies & breakthrough priorities.• The Divisional team develop detailed

strategies and measures as appropriate.

Top Level (L1)

• 5 year breakthrough goals set.

• Annual breakthrough priorities decided.

• Strategic improvement priorities agreed.

• Measures set.

• Identify director ownership.

Further Deployment

• Do not exceed three deployment levels.

• Individual action plans created from level 3 matrix.

Designed and led by the

Director of Nursing Exemplar WardsUsing BICS in daily work

Exemplar Wards demonstrate our commitment to provide a clean, safe and efficient environment of care, underpinned by Patient Safety.

Uses the BICS principles of standard work, removing variation, removal of waste, improving quality and reducing cost.

Target Measures

• HSMR reduction i.e. MINAP <85%• Defects 50% reduction p.a.• Increase patient experience 85% good /

'excellent' on comment cards• 10% reduction in cardiac arrests• 2% reduction in pressure sore incidence• 10% reduction in patient falls

9 wards validated22 In progress 2 waiting for decision

5 ready for validation

3 wards working towards Model ward status

Fractured Neck of Femur (#NOF)

2005 2009

Average Length of Stay 30 days 20 days

Average Time to Theatre 2.4 days 1.6 days

HSMR 173.9 95.2

The Trust focused attention on reducing mortality associated with hip fractures, developed a Trauma Stabilisation Unit and confirmed; much of which was initially presumed to be unavoidable, was found to be preventable.

Over 6,179 bed days

HSMR reduced by 45%

H S M R : #N O F 2004 - 2009 B ase lined w ith 2008 - 2009 D a ta

Mar-04

May-04

4Sep-0

4Nov-0

Mar-05

May-05

5Sep-0

5Nov-0

Mar-06

May-06

6Sep-0

6Nov-0

Mar-07

May-07

7Sep-0

7Nov-0

Mar-08

May-08

8Sep-0

8Nov-0

Mar-09

May-09

9Sep-0

9Nov-0

M o nth

LEAN JOURNEYProductivity Rise

(Relative to 1994/95)

1994/95 1995/96 1996/97 1997/98 1998/99 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09

Productivity (%) Predicted Productivity

Blood SciencesWhere have we been? Where are we now?

Sustainment and Growth

Turnaround times reduced from 2 days to 2 hours

Income from

New contract

in blood sciences

£0.3m pa.

Visual Management

Pull 1 piece flow

6S Standard Work

Workload v TAT

Workload

Workload TAT>4days

Stroke TeamSentinel Audit Criteria

2006 2008

CT Scan within 24 hours

46% 100%

Patients on Acute Stroke Unit

Aspirin within 24 hours

63% 100%

Physio within 72 hoursSentinel Audit Score

65%60%

98%92%

HSMRLength of Stay

Sentinel Audit Results:2006 Bottom

Quartile 2009 5th Best

Nationally

NHS Bolton

Diamond Care

Award Winners

A&E1 WIP

Admission Units

(AMRU etc)1xWIP

Specialty Ward

2/hr 3/hr 1/hr

Delays building In A&E during

the day17/hr(10/hr minors)

Increasing+1/hr Safety

issues growing

Delayed patients

GP Direct 1/hr

CAPACITYMade from previous night (12 by evening)Home/

6 7 8 9 10 11

7 – 11 amFlow

NB: Sunday & Monday am A&E demand is slightly higher, by approx 1 person / hour

Hospital Urgent Care - Current State

Discharge

A&E Patient FlowUnderstand A&E

Takt Time helps us understand how much time we have to see each patient, supporting flow within A&E.

Productivity Realisation Medical Urgent Care Wards B3, B4, C3, D3 & D4

Ward Closed for 3 months as part of cash releasing savings during same period

*Source: Finance October 2009

April - October 2008 April – October 2009

Length of Stay (days) 14.13 10.85

Occupancy (%) 96% 95%

Patient Throughput 2753 3337

Income Related Benefit*

Average income/med patient £2404*

Increased throughput 584 pts

£1,403,936Beds Saved Bed Days saved 1915.52

Time period 214 days

Reduction in Non-Elective Length of StayNon-Elective Length of Stay 2005 - 2009

All Non-Elective Admissions

Sep-05

Nov-05

Sep-06

Nov-06

Sep-07

Nov-07

Sep-08

Nov-08

Sep-09

Nov-09

Length of Stay Average LOS UCL LCLSource : Dr Foster 25/02/2010

Patient Experience Based Design

The patient experience is also showing evidence of improvement - patient reported pain scores have fallen over the same time period

Orthopaedic patients % Pain Rating

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90-100Pain rating (0 - no pain,100 - in pain all day)

no of pts sample 1 no of pts sample 2

Sample 1 - 46 patientsSample 2 - 26 patients

No Pain In Pain All Day

Developed a structure and methodology for involving patients as co-designers in improving services.

Benefits:Improvements in pain management. Proactively involving patients in bedside handoversDaily multi-disciplinary meetings to ensure patients care is managed‘Top tips’ leaflet, devised by the patients.Escorting patients to their cars and improved car transfer awareness for patients and carers Education for staff - Diabetic awareness.

NHS Bolton

Diamond Care

Award Winners2009

Shortlisted

Capital Scheme Savings

Blood SciencesBlood Sciences avoided a new build to accommodate

existing work, and took on extra work within the original

template after creating a reception cell, avoiding a cost

of £1,100,000

By using flow & Lean tools to design the layout of new builds and refurbishments, the Trust has made significant savings and avoided unnecessary costs.

A planning event enabled

the design of the building to

be changed to better

support flow, resulting in the

cost of the build design

being reduced by

£31,272,000

BEFORE AFTER

Savings £27K to date at least

Out of date stock £10K

Theatre Improvements Creating a Safe Environment & Processes

40 hours per week

BICS Academy

BPC86% delegates felt

improvement work quality increased since training.

IHDelegates lead

improvements to many services

VfM• Shared learning with other organisations.

• Visitor Programmecreated income

J&P• Empowers staff to make

improvements

• Supportive leadership

• 95% delegates more confident

A structured learning and development programme that forms a key foundation for the Trust-wide service improvement transformation, to develop a culture of safety first and continuous improvement.

67% of staff engaged in

training or Rapid Improvement

Events (RIE’s)4 Key Aims:

Raising staff awareness and engagement.

Developing and supporting appropriate leadership skills.

Improving the quality and sustainment of improvement work.

Developing highly skilled improvement practitioners.

“The training promotes organisation wide

understanding of this being an inclusive, not

top down process.” Green Level Candidate

NHS Bolton

Diamond Care

Award Winners2009

2010 International Forum

on Quality and SafetyShortlistedOral Presentations:Stroke #NOF

International Forum

on Quality and Safety

Best Overall Poster Winner

Trauma Unit Saves Lives

2008Health & Social Care Award Winners Adopt, Adapt & ImproveA3 Thinking

Patient Safety

Awards

Highly Commended for

Implementing the Safe

Surgery Checklist

HSJ Awards

Shortlisted

Patient Experience

Based Design

Local Healthcare

Awards

WINNERS

Diamond Care x3

Excellence Awards

Creating Awareness of BICSAwardsAwards

Sharing the LearningWinn D (2009) Transformation in the NHS. Human Givens Journal, Volume 16, No2.

“What is being undertaken at Bolton is utterly inspirational”

Academy of Medical Royal Colleges (2009) A Guide to Finance for Hospital Doctors. Audit Commission.

“significant improvements have been made…. The capacity created has resulted in additional activity being undertaken within existing staff levels.”

Fillingham D (2008) Lean Healthcare. Improving the Patient’s Experience. Kingham Press, Chichester, UK.

Fillingham D (2007) Can Lean Save Lives? Leadership in Health Services, Volume 20 Issue 4.

“Everyone needs a touch of inspiration and encouragement. Applying lean to healthcare in Bolton seems to be achieving just that for those who work there.”

Patterson P & Leach J (2009) A Leaner Care System. Health Informatics Now, June 2009, pg 20- 21.

Publications

Institute for Innovation and Improvement (2009) Lean Thinking. Cross Current, Winter 2009.

Richard Mackillican (200?) Bolton’s Road to Lean. National Health Executive. Sept/Oct 2009, pg 65.

Sharing the LearningSharing with external organisations

Conferences & Study DaysMany and clinicians and managershave shared their experiences at national and international conferences and study days

Friday Outbrief Sessions

Average 12 visitors / month

Attendance increased by 40%

since June 2009

International VisitorsColleagues from Australia,

Singapore, Italy, Norway, USAF

and Denmark have joined us to experience the Rapid

Improvement ProcessVisits to Other Organisations

Thank you to all those organisations who shared their learning with us

including Thedacare USA, Warburtons, Toyota (GB) Plc, Unipart

Group, and many others…….

Visitors Day: June 2009

66 attendees from health &

social care and other public

sector organisations

Lessons LearnedBest

Possible

Joy and Pride in

Improving

Health

Value for Money

Consider how to link improvement work with other initiatives. Identify conflicts.

It is easy to celebrate success too early.

You cannot communicate enough. Work in partnership with the staff side.

Usual savings tracking methods don’t appropriately measure all benefits of lean work.

Non-healthcare organisations are a good source of learning.

Engagement of the Clinicians is key to sustaining changes.

It is essential to cultivate a coaching style of leadership.

Scope event carefully: if the scope is too big outcomes will be less significant & benefits will not

sustain.

Identify the key areas to target improvement. Consider organisation’s priorities; does the proposed work fit within them?

Train staff in change management and tools early.

Using examples outside of healthcare can help create greater understanding among

managers.

Acknowledging that the existing service isn’t the best possible service can be difficult for many staff.

Benefits Tracking is very difficult.

Board level support & engagement is key.

Do your priorities fit with those of the organisation?

Change can be threatening, and Lean used as a scapegoat.

Team leader role is key to sustaining change.

Use the right data

For the FutureAlthough we have taken great steps our

journey is only just beginning.

Many challenges lay ahead.

A&E 98% Target

Financial

pressures Spread

Thank You

For further Information please contact

BICS@rbh.nhs.ukTelephone 01204 390099

Benefits Realisation · • Reflected in health status – SMR - Cancers – up to 123 -...

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