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Lean Healthcare Review |
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Resources:
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Improving Quality, Time and Cost in Health Care: The Three Wins |
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Welcome to the latest issue of our New Quarterly Newsletter |
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This is the story of how a small team of healthcare professionals embarked on a brave quest to improve quality of care; reduce waiting times; and reduce the costs of treatment for a vulnerable group of patients - those suffering with chronic leg ulcers. The year was 2000 and four years later the team were awarded the NHS Innovation Award for Service Improvement for achieving their vision. In 2005 we first heard the term “Lean” and realised at once that we had been using “Lean Thinking” and inadvertently had demonstrated that lean works in healthcare – so long as the goals are quality, time, and cost. These are what we called the “three wins”.
In 2000 the current state was an outpatient service with long waits, poor communication, frustrated staff, angry patients, poor outcomes and unknown costs. It was a lose-lose-lose situation. This unhappy state was progressively transformed through a series of rapid improvements to the award winning service we have today. The transformation cost nothing except the enthusiasm of the clinical staff who owned the process. The returns for the staff alone far outweigh the investment. No one would now go back to the “bad old days”.
The first step was relatively easy- convert the conventional three stage new-test-review process to one stage, a one-stop clinic.
All this required was to bring the test equipment - an ultrasound machine - to the clinic, and, in so doing, we eliminated two handoffs, two queues, a whole raft of administrative non-value-adding work - creating, sending and
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Improving Quality, Time and Cost in Health Care: The Three Wins |
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reading requests and reports. The effect was to cut out 18 weeks of waiting for the patient, not to mention two visits to hospital. It cost nothing.
The second step was more difficult - improving the quality and flow of information along the supply chain, specifically between the nurses who managed these patients in the community and the specialist nurses at the hospital. This was achieved by developing and testing a replacement for the complex, slow, and error prone practice of letters, phone calls, hand written notes, and patient held records. The solution was a secure, shared electronic wound care record – the leg ulcer telemedicine system.
This innovative solution took two years to develop and was formally tested with a clinical trial. It demonstrated a dramatic improvement in outcomes for patients by improving the quality and speed of the information flow. We also proved that this step alone reduced the cost of treatment by over 25%.
The third step was the most challenging - managing the referral of patients to the one stop clinic as a first-in-first-out queue; irrespective of the sequence, type, or complexity of the patient demand.
The one stop clinic was for more than just leg ulcer patients; we see a wide range of patients with many different conditions. The design constraints for the clinic were clear; the patients should not wait for more |
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than 30 minutes in total; the clinic must not overrun; the capacity of the clinic must be increased to be able to handle the high demand variation; and the clinic must run with existing staff and resources. The solution was to apply the principles of a product matrix, streaming, pull, and level scheduling in the design of a crossed-stream clinic booking schedule. The method I used was to handle the complexity of the crossed-stream problem using an iterative process simulation technique rather like “virtual PDSA” until the solution met the design constraints. This final design was then implemented as the standard work – and capacity increased 40% overnight! The schedule is easier to use than the previous “booking rules” and balances the work across the resources in clinic so that no one is over or under utilised. We’ve been using the “Lean” booking template for the last three years with only minor changes, and the benefits have been sustained.
The most recent change was another easy one. The secretary now comes to clinic as well, so that all letters are typed immediately, signed, and put in the post – therefore eliminating the need to have notes transported to and from offices, and ensuring the information gets to the GP much sooner. Patients can even take a copy of their letter with them if they want! Quality, time and cost; win-win-win!
Simon Dodds, Author of “Three Wins: Service Improvement using Value Stream Design”.
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