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LEAN – A Prohealthservicezone Special Report

Virtual College (Lean Healthcare Academy) : 18 April, 2008  (Special Report)
The words ‘lean’ and ‘healthcare’ are being increasingly drawn together with more and more ‘lean’ management initiatives and programmes being introduced around the UK.
The ‘lean’ approach strives to streamline working practices, cut waiting times and improve the quality of patient care and safety.

Essentially ‘lean’ is a management system based on scientific methods. It is not just an improvement method as many believe. The ‘lean’ approach focuses on managing processes to create value - as well as allocating resources.


Earler this month the Hull and East Yorkshire Hospitals NHS Trust’s executive team, divisional managers and external support agencies made a presentation at Hull Royal Infirmary to highlight how successful its first major project following the adoption of ‘lean’ thinking had been in relation to the Trust’s Trauma Services Pathway Project.

To tackle the project the Trust set up a flagship public and private sector partnership with the Lean Healthcare Academy based in Ilkley, West Yorkshire, which works extensively in the UK healthcare sector delivering services similar to those widely used in the manufacturing industry to streamline operational procedures and boost productivity.

The Lean Healthcare Academy delivers a range of services, including staff training, development and implementation support, complemented by flexible online e-learning programmes.

Hull and East Yorkshire Hospitals NHS Trust is one of the larger acute trusts in the UK, providing a full range of acute services to almost 600,000 people in the Hull and East Yorkshire region. The Trust acts not only a large District general Hospital, but also a trauma, cancer and tertiary centre, as well as being the major player in the local medical school with strong links to the University

Trauma Services, which involves patients with orthopaedic bone injuries sustained as a result of accidents, is regarded as one of the toughest pathway challenges for the NHS nationally.

The Hull and East Yorkshire Hospitals NHS Trust receives 4,000 admissions a year. The Trust handles 570 hip fracture patients every year and these account for 50 percent of bed days occupied.

The ‘lean’ initiative saw three working groups, made up of nursing, medical, therapy and other staff, being used to diagnose which areas along the patient’s treatment pathway - from admission, though surgery to discharge – cause the largest bottlenecks.

Major areas for improvement were identified at an early stage included:

• unacceptable delays;
• inconsistencies throughout the pathway;
• communications problems;
• lack of facilities and resources;
• staffing issues.

A number of solutions have already been put in place, with actions already being taken to enhance the process as part of the overall objective to make the entire pathway much more efficient and patient-friendly.

Ann Hunt, divisional manager of surgery 1 and Lean co-ordinator at Hull Royal Infirmary, said: “It has made us focus on the patient – and the patient must always be regarded as number one. Improvements have occurred since we adopted the Lean process, which can be put down greater empowerment of the clinical team, coupled with enhanced communication and awareness of each other’s responsibilities.”

Lean Healthcare Academy facilitator Abdul Ghani, who has been working closely with Hull and East Yorkshire Hospitals NHS Trust, explained the Academy’s role: “The Academy’s task is to empower and enable people to achieve on ‘lean’ and reduce wasteful practices. If you think back to when we first started this project last year and look at where we are now, it is obvious that considerable improvements have been made.”

“There is a real buzz about the place. Belief and confidence have grown – you have a workforce that wants to make a difference.

“Everything you do has to be linked back to best use of resources, not only to demonstrate to senior managers that such initiatives are well worth undertaking, but also to show to members of the public that your are making the best use of the resources at your disposal.”

Lean Healthcare Academy manager Sarah Ellis explained: “A key element within the Lean adoption strategy is the use of spotlight projects which help NHS Trusts establish quick ‘wins’ and spread the message of the benefit of Lean thinking and procedures.

“Another keynote objective is also to facilitate the sharing of ideas throughout the healthcare sector nationally, to unlock the potential thinking and enthusiasm in everybody and let them make the improvements for themselves.”

The sharing of ideas is an underlying theme of ‘lean’ but it does require commitment from management and staff alike. One undeniable fact about ‘lean’ is that it does some seem to produce improvements in efficiency but like any management system it is only really effective if the staff and management personnel ‘buy’ into the ‘lean’ philosophy. One of the criticisms of ‘lean’ is that it does not always achieve sustainable results.

To ensure hard won results are sustained the Airedale NHS Trust has recently reinforced its commitment to ‘lean’ working practices by stepping up the delivery of ‘lean’ principles that have already overhauled. The Trust’s ‘lean’ inspired hospital working practices have reduced waiting times and seen improvements being achieved in patient care and safety.

A major part of the commitment improvements has been the appointment of a head of ‘lean’ improvement, Sue Speak, who is the matron for hospital midwifery at Airedale General Hospital.

Speak is working on a 12-month secondment and has been involved in ‘lean’ initiatives since they were introduced at Airedale Hospital in 2007. Speak’s role is to be responsible for rolling out ‘lean’ more widely across the trust and healthcare communities.

Airedale NHS Trust has been working closely with the Lean Healthcare Academy to put in place a series of pilot projects through a new training facility based at Airedale Hospital.

One ‘lean’ project involving hospital’s midwifery unit, has helped reduce waiting times for scans for pregnant women with undersize baby concerns. The result has seen a reduction in waiting times go from six weeks to within 24 hours.

Another ‘lean’project has seen referral times to diagnosis for patients with suspected bowel cancer become halved to 41 days.

Speak explained: “Lean has made a major impact – and a big difference - in a number of areas at the hospital. We are now looking to roll it out not only across Airedale NHS Trust, but also to other NHS Trusts and the wider health care communities in general.

“Lean is all about improvement. You can look at a particular process and redesign it so it is much more efficient, both for staff and patients. It is about communicating what can be achieved in an individual department and we have had some fantastic feedback from staff about the benefits that have been seen.”

Speak works closely with Airedale’s ‘lean’ champions – a ten-strong cross-section of Trust staff who was among the first in the UK healthcare sector to gain the Business Improvement Techniques (BIT) NVQ.

A second group of Airedale ‘lean’ champions is currently working towards the BIT NVQ, with a third group scheduled to commence training in April 2008.


One of the interesting aspects of the ‘lean’ approach is that it is equally effective in different countries. The concept seems to have the ability and flexibility to overcome different management styles and cultures.

The ‘lean’ concept was originally a Japanese creation born on the production floor of Toyota but it has become popular all around the world and its application to the healthcare sector has proved particularly effective in the USA.

Some of that American ‘lean’ expertise has recently been introduced to the UK. Only last month a UK/US alliance of world leading experts in ‘lean’ healthcare was established to help the NHS get in better shape to achieve gold standard service.

In March it was announced that Michael Rona and Christina Saint Martin, from the US-based Virginia Mason Medical Center in Seattle, have joined Manchester’s Manufacturing Institute to apply the best practice ‘lean’ methodologies that have revolutionised performance in industry and the US healthcare sector – to UK hospitals.

Rona and Saint Martin are the architects behind The Toyota Production System in Healthcare. They studied in Japan with the original masters of ‘lean’ and have translated the organisational improvement programme to achieve impressive results at Virginia Mason.

The Virginia Mason Production System which Rona and Saint Martin designed and implemented has improved healthcare delivery, promoted a culture of seeking zero defects and created a more affordable product. Outcomes include:

• cutting infection rates to almost zero;
• freeing up more than 13,000ft2 of space;
• reducing staff walking by 50 miles a day.

To spearhead the ‘lean’ healthcare service, Saint Martin, who was the former vice president of Virginia Mason, a $650 million tertiary healthcare operation, has moved to Manchester, UK.

Rona, who is America’s leading expert on ‘lean’ healthcare, plans to spend one week each month working as a consultant to The Manufacturing Institute.

Saint Martin said: “While a growing number of NHS managers and clinicians understand the basic concepts of ‘lean’, nobody has taken this powerful methodology all the way. Our new team will set out to change that.”

“With challenging targets on patient waiting times, environmental performance and control of infection – as well as the drive to balance budgets and achieve Foundation Trust status, the NHS has an opportunity to transform itself beyond all recognition. I know this is possible, because this is what has been achieved at Virginia Mason.”

Rona explained: “The potential gains of using ‘lean’ in the NHS are huge, with the key benefit that improvements will be sustainable in the long term because ‘lean’ embeds a new culture of continual checks and improvements. The NHS has a long history of trying to improve services against aggressive goals, but it lacks a sustainable methodology to achieve those goals and avoid the need to constantly set new ones.

The Manufacturing Institute’s ‘lean’ healthcare team has already been achieving powerful results in partnership with UK hospitals.

They helped University Hospitals of Morecambe Bay NHS Trust to apply ‘lean’ to three areas at Lancaster Royal Infirmary. During the project they found duplication of effort, overstuffed filing systems, badly-designed working areas and wasted internal capacity which impacted on patients, consultants and staff. ‘lean’ techniques have now led to easier and quicker retrieval of medical records, more patients seen and fewer missing clinic notes.

A similar programme at Stockport NHS Foundation Trust achieved throughput improvements in radiology at Stepping Hill Hospital by up to 50 per cent.

At Royal Devon and Exeter NHS Foundation Trust, the ‘lean’ healthcare team helped to improve ‘flow’ in the dispensary for prescriptions by reducing the average picking time from 1.5 hours to 20 minutes. They also showed how to reduce inventory by £150,000 without affecting supply.


The Lean Enterprise Academy is led by Prof Daniel T Jones who helped Tesco to implement ‘lean’ management in its organization. The Lean Enterprise Academy is also a member of the Lean Global Network established by the Lean Enterprise Institute (LEI) based in Cambridge, Massachusetts, USA.

Prof Jones will be a semi-plenary speaker at the HC2008 conference in Harrogate, Yorkshire, UK,taking place on 21 to 23 April 2008. He will be focusing on the application of lean thinking to support the transformation of healthcare.

As an experienced proponent of ‘lean’ Prof Jones recognizes that not all ‘lean’ initiatives have the capacity sustain their initial success.

In one of The Lean Enterprise Institute’s email newsletters last year Jim Womack, chairman and founder of the Institute focused on the problem of sustainability of ‘lean’ programmes.

He commented on the example of a friend of his that had sustainability problems. The friend’s programme had seen “Dramatic results. Faster patient flows, better outcomes, lower costs.” But the friend continued: “But we couldn’t sustain the gains. The improvement efforts weren’t connected to the way the organization was managed and the value streams started to regress to the mean as the improvement team left.”

Womack admits that it is a familiar scenario to see “improvement efforts backsliding to the old way of working after initial progress.” One of the key reasons for this regression is the resistance to change of middle management.

Womack said: “The root cause of regression is confusion about priorities at different levels of the organization compounded by a failure to make anyone responsible for the performance of important value streams as they flow horizontally across the enterprise. To prevent regression, someone needs to periodically clarify priorities for each value stream and identify the performance gap between what the customer needs and what the value stream is providing.”

As Prof Jones points out we are beginning to see what new ‘lean’ hospitals might look like and new business models that they require.

Last year Prof Jones spelled out the key lessons learnt from the first Lean Global Healthcare Summit. These included:

• The place to start is to follow acute patients through hospitals from primary care to tertiary care;

• There are big opportunities from following the material flow through the supply chain to healthcare;

• The challenge now is the transition path and lean healthcare management.

The ‘lean’ concept has been inspiring several other NHS Trusts in recent years including tasks as diverse as midwifery and pathology. Whatever the application the common objective remains that ‘lean’ principles can be used to improve patient pathways by optimising workflow efficiencies and eliminating wasteful practices.
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