Análisis de la Deformación vs Temperatura

The inferred approach to Lean implementation based on the annual report for 2007/08 (see Volume II, case 36), was that Lean was initially designed to be implemented as a programme, however the interviews reveal little evidence of any formal planning regarding the process of selecting projects and monitoring projects. The process of Lean described by respondents resembles more of an adhoc approach to Lean implementation which is perhaps better categorised as ‘few projects’.

Lean has stalled in the Trust

There was consensus across all interviews that Lean had stalled in the Trust. The Trust was not seen to be supporting Lean at any level despite an ‘initial high level of enthusiasm’ (Learning and Development Manager). Some respondents viewed this lack of support with clear disappointment:

“[Lean] is different, that is why I was so fired up about it, it was something that could really work” (Learning and Development Manager)

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The view of the Business Improvement manager was that despite the cessation of Lean implementation in the Trust there was still ‘a lot of love for Lean.’ The Director of Business Improvement confirmed that productive ward was being used in the Trust, thereby validating the category of PW only in T2 emergent from document analysis.

6.4.3.2 Training in Lean

The majority of respondents who had received training in Lean spoke of a two day event with Applied Angle. Almost all respondents who attended the two day event clearly remembered and remarked upon a Lego based simulation game to simulate the flow of patients through a system; no other aspects of training were mentioned. One respondent even remarked that the Lego was the only useful bit.

“One afternoon was really particularly useful, the rest was not…we played with Lego trying to make people see how processes could be leaned. It was a very good example, I loved it, very very clever. The rest of it was just reiterating what I already feel” (Administrator)

“I did enjoy the training, especially the model with the Lego” (Radiology Services Manager)

“The afternoon was a really good exercise with Lego to demonstrate the push and pull theory. It kind of made you think along those lines” (Dietetics Team Manager)

With the exception of the Lego game, some were quite resentful about the content of the Lean training:

“I was quite cynical about the whole sort of Applied Angle approach; this is people making money out of telling us to use common sense” (Consultant Anaesthetist)

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Awareness Sessions were conducted by the Learning and Development Team to inform people across the Trust of the sort of things that were happening and encouraging them to go back to their own areas and look at waste, particularly around housekeeping issues and using 5S. The team found that the message of quality was far more attractive to Nurses than the pursuit of financial savings.

“As soon as you talk to nurses in particular about a process to save money it switches them off totally; if you tell them it improves quality of patient care then you will get a different response, how you win hearts and minds. It’s not a case of money falls out of doing lean it’s about ensuring quality and then the pennies fall out of improving quality” (Learning and Development Manager)

6.4.4 The Content of Lean implementation

6.4.4.1 Description of Impact and outcomes

The impact of the Lean work as perceived by respondents is described under the following seven sub-headings:

i. Learning to see

ii. Implementing new standards

iii. Improved patient safety

iv. Reduced DNA rates

i. Learning to see

The nature of a Rapid Improvement Event (RIE) is that employees come together from all aspects of the pathway to create a short term multi-skilled team. This aspect of the Lean work was considered to be very beneficial to understanding the whole process from all relevant perspectives rather than that of just one department. Furthermore, the process creates synergies with others across the pathway resulting in benefits that were ‘multifactorial’:

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“we had more dialogue with the emergency department, we set up quite a big group, so we had paramedic involvement, we had emergency department involvement both from nurses and doctors. There was a radiographer there and that’s before we’ve got to the orthopaedic and theatre involvement; so it was good in that you were able to meet these people, put a name to a face. I still see them now, they will be a lot more helpful now because I know them.” (Consultant Orthopaedic Surgeon)

“I had never understood how the paramedics dealt with [Neck of Femur patients] but having done the audit where we got a load of data from the paramedics we got a far better understanding of the process really” (Consultant Orthopaedic Surgeon)

ii. Implementing new standards

New standards were implemented to improve stock control, reduce variation and improve patient safety:

Stock control - A number of respondents made reference to the high levels of stock in the Trust. A simple but effective tool associated with Lean and arising from the Lean work is known as the ‘2-bin’ system which appears to have mixed reactions within the Trust with some referring to the 2-bin as very useful and effective in gaining Trust and avoiding the need to ‘stockpile’ as demonstrated in the two examples described below.

In medical records, one respondent claimed to have ‘exploded the myth when you didn’t get a

case note in clinical area it was medical records fault’, the Lean work revealed that people had been stockpiling the records in various locations:

“Consultants had notes in their cars, they had them at home, we had a thousand notes in secretaries’ offices, and we wondered why we couldn’t get case notes!” (Learning and Development Manager)

The consequence of such stockpiling was quantified by the respondent as two people walking seven miles per day to find them. The resultant impact of the event was “setting clear strict

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boundaries and rules of what should and shouldn’t happen within that department”

(Learning and Development Manager).

A further example of improving stock control in the Trust was in HSDU (Hospital Sterilisation & Disinfection Unit) following the use of 5S to create more space. The impact upon staff morale was clear:

“The girl working in there said afterwards it was absolutely marvellous, she’d wanted to do it for ages but never had the time or felt she had the authority to do that, she felt she had to work in that environment. Changed her working day tremendously”

(Theatres Matron)

Reduced variation – HSDU (which is the sterile supplies unit supplying all the instruments to theatres and maternity), appeared a particularly prolific Lean project. The unit was said to be ideal for Lean because it was a ‘production line’ (although the respondent as a Lean facilitator was quick to point out that Lean can/should also work on wards). The example of HSDU exemplifies the effect of high levels of variation, an example was given:

“We had 26 different types of infusion pumps in this Trust, so every time someone went for an infusion pump you could get a different one. If you think there are 26 different variations and you need to be trained to use them you are likely to come across one you haven’t used before and thus your instances for mistakes increases. We got it down to three…” (Learning and Development Manager)

Another example of realising the impact of variation in the system is proffered in relation to the ambulance crews and Neck-of-Femur patients.

“Some patients go through the standard [Neck of Femur] pathway quite well but others didn’t, depending on which ambulance crew turned up, whether it was a paramedic or a technical crew… we are talking major governance issues and it did highlight lots of stuff like that.” (Learning and Development Manager)

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iii. Improved patient safety

Some of the Lean work was considered to be particularly useful in exposing risk factors and potential patient safety issues. The work in orthopaedics described how they identified; “5

basic things you would think were first aid, just weren’t there” (Consultant Orthopaedic Surgeon). Other examples are given:

“[In pharmacy] we found in the region of 60% or it might be 70% of prescriptions going to Pharmacy had no drug intolerance information on it. We had many where the full prescription wasn’t filled out so the Pharmacists couldn’t dispense because they didn’t have all the information.” (Learning and Development Manager)

“Auxillary nurses had been trained by midwives to do extended roles…but when I asked them what sort of qualification they had it was all word of mouth training”

(Learning and Development Manager)

“We were recruiting consultants from Africa and they did the usual medical checks…did any of them get HIV checks? No. That was a major risk so that had to be rectified.” (Learning and Development Manager)

iv. Reduced DNA rates

One respondent explained that DNA rates (patients who Did Not Attend) were lowered by changing the existing book-in system for ultrasound from a postal based system where a letter would be sent second class to the patient four weeks before they were going to x-ray the patient. The delays present in such a system comprised of 4-5 days for letter to arrive with patient, up to 10 days for a response from the patient. Upon recognising these time gaps the new system tried to book such appointments face to face ensuring an immediate response and a mutually agreeable time and date.