Materiales a) 01 balanza digital

During the operating year 2007/08 (T1), a count of 80 acute general hospital Trusts (53%) in a study population of 152 English hospitals were identified as citing the implementation of Lean in their annual reports and/or on their corresponding websites. During the operating year 2009/10 (T2), the study population size is reduced to 143 hospital Trusts (due to a

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number of hospital mergers), and the number of hospitals citing an implementation of Lean in their annual reports and/or on their corresponding websites rose to 111 Trusts or 78% of the population sample.

The depiction of Lean implementation in the annual reports was found to vary considerably - from Trusts describing one or two projects to those announcing improvement programmes based on Lean principles. The spectrum of approaches to Lean implementation are found to range from ‘tentative’, where a Trust is contemplating the use of Lean, to a whole organisation approach (‘systemic’), where Lean becomes ‘the way we do things around here’.

The following section describes with examples the range of approaches identified.

4.1.1 Identification of Divergent approaches

4.1.1.1 Tentative Lean

A number of annual reports, particularly in T1, confer a very early and tentative approach to Lean. These trusts cite Lean in their annual reports but do not appear to have adopted the methodology at this point. For example, Northumbria Healthcare NHS Foundation Trust (case 28, Volume II), highlights a 1 day Lean Thinking in healthcare event led by Dan Jones (one of the authors of the book The machine that changed the world). Similarly, Trafford Healthcare NHS Trust cites attendance at a Lean conference. Thus these Trusts indicated a clear awareness of Lean as a methodology that may offer benefits to the organisation and were actively seeking to learn more about Lean from others. Some annual reports referred to a trial of Lean for example, Pennine Acute Hospitals NHS Trust (case 39, Volume II) cited the successful application of the cytology department to become one of ten national pilot sites to use the adoption of ‘Lean Management’ practices. The inference made by the researcher is that this was the first and only ‘project’ involving Lean methodology at the Pennine Trust given that Lean was not cited in any other context and that the project appeared to be a standalone project. Further examples of a tentative approach to Lean were identified not necessarily from the annual reports but from the archived documents identified through searching keywords on the Trust websites. For example, a search of ‘Lean’ on the website14

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of Royal Liverpool and Broadgreen University Hospitals NHS Trust (case 41, Volume II) retrieved a document dated 2008 that referred to the tendering of management consultants to help the organisation implement Lean.

Each of the above descriptions offer slight variations of a tentative approach, from illustrating an awareness of Lean to the implementation of a small project or tendering for external management consultants; however all of the above examples reflected a very early stage of (potential) Lean implementation. Such Trusts were thus classified Tentative.

4.1.1.2 Productive Ward only

Productive Ward (PW) is an initiative that helps nurses to improve efficiency in their working environment. The PW is delivered as a structured set of training modules that began with a few pilot wards in selected Trusts during 2007/2008 and has since been rolled out nationally. The NHS Institute for Innovation and Improvement developed PW to improve efficiency and effectiveness through the removal of waste and an application of 5S, a common ‘housekeeping tool’ designed to bring order and stability to the workplace.

Data collected during T1 and T2 identified a number of Trusts that made little or no reference to Lean implementation other than to state an adoption of PW on one or more of their wards. For example:

‘Kingston Hospital’s Worcester Ward has successfully implemented The Productive Ward, an innovation which, when implemented, releases time for Midwives and other staff to directly care for women and which has delivered positive results for patients and the hospital’ (Source: Kingston Hospital NHS Trust, Annual Report 09/10, p.18)

In common with Lean methodology PW focuses improvement around the elimination of waste involving staff on the front line. However, given the very structured nature of PW and its restriction to specific areas i.e. the wards, it is felt that a PW only approach is distinct from other approaches that apply more broadly across the organisation.

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4.1.1.3 Few Projects

A number of annual reports highlighted Lean projects in the Trust during the operating period T1 and/or T2. For example, St Helens and Knowsley Hospitals NHS Trust (case 45, Volume II) cites national recognition for redesign within the (Pathology) laboratory using Lean methodology in their annual report 2007/08 (p.11). The annual report for Wrightington, Wigan and Leigh NHS Foundation Trust (case 53, Volume II) stated its intention of:

‘embarking on leveraging LEAN [sic] approach to facilitate future efficiency savings ... [the objective is] to complete four Lean value stream improvement projects’ (Wrightington,

Wigan and Leigh NHS Foundation Trust Annual Report, 2007/08, p.12)

Thus a ‘few projects’ approach was found to be distinct from a ‘PW only’ because it did not follow a standard template of implementation, as dictated by a set of training modules but was more ad-hoc in terms of where and how Lean was used.

4.1.1.4 Programme

A further approach emerged from the data that was distinct from a ‘few projects’ approach on the basis that the Trust had officially launched a ‘programme’ underpinned by Lean methodology. Whilst a ‘few projects’ approach might refer to two or more projects, a ‘programme’ approach confers a managed approach to Lean implementation. Here, the approach was found to differ from a ‘few projects’ approach because the projects were planned and connected often within a set duration, for example, across two years. A clear example of this approach can be seen in the Annual report (2009/10) of Ashford and St Peters Hospitals NHS Trust (case 63, Volume II).

‘Last summer we introduced a programme to improve our services called EQUIP (Efficiency, Quality, Improvement and Productivity). It is based on the Lean methodology used extensively in the car industry. This methodology has helped us to transform services to deliver higher quality with less waste and inefficiency. Our EQUIP team has been working alongside a company called Simpler who are experts in applying lean techniques in different environments.’ (p.40)

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In taking a programme approach, the emphasis was more on the planning of improvements that extend beyond discrete functions; to continue the example of Ashford and St Peters, the report goes on to describe the aims and objectives of improvements the programme focusing on patient flow. A further example of the planning element of a ‘programme’ can be seen in the following extract from East Kent Hospitals where the focus was on the patient pathway, an aspect of which had been marked out as a ‘priority’:

‘The Trust has adopted the LEAN [sic] methodology to identify service improvements that improve the effectiveness of the patient pathway whilst contributing to economy and efficiency. The patient booking system has been prioritised as part of this programme.’ (Source: East Kent Hospitals Annual Report 2009/10:81)

4.1.1.5 A Systemic approach

A final category of approach emerged from the data that extends beyond that of a

Programme. Some annual reports showed evidence of the Trust adopting Lean methodology as ‘the way we do things around here’. This was evidenced by the development of a unique system of working (underpinned by Lean methodology) that was championed at an executive level as a whole hospital approach. Some examples are ‘the Blackpool way’ (case 33,

Volume II) ‘the Bolton Improving Care System’ (case 40, Volume II), ‘the North East

Transformation System Programme (NETS)’ (case 26, Volume II),'The Countess Way' (case 24, Volume II), and ‘The South Manchester Way’ (case 49, Volume II). Often this type of approach was announced in the opening commentary by the Chairman and/or the Chief Executive and was aligned with the strategic goals of the Trust. For example, Airedale NHS Trust (case 113, Volume II) announces its objective in their annual report 2007/08 to: Deliver our financial plan through rigorous financial management and Lean operational activity – operating efficiently, effectively and economically (p.7).

Unlike a programme approach there was no suggestion that this approach was for a fixed time period; this approach to Lean was inferred as a long term approach with no end date, evidenced in particular by investment in specialist staff and an objective to train all Trust members. A systemic approach was ultimately a whole organisation approach, and was not described as a ‘project’ that was taking place in one area of the Trust, rather it was based on the ideal of involving and engaging everyone in improvement every day.

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