Introducing Lean in Healthcare 9781846636738, 9781846636721

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ISSN 1751-1879

Volume 20 Number 4 2007

Leadership in Health Services Introducing lean in healthcare

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Leadership in Health Services

ISSN 1751-1879 Volume 20 Number 4 2007

Introducing lean in healthcare Editors Jennifer Bowerman and Jo Lamb-White

Access this journal online ______________________________ Editorial advisory board ________________________________ Editorial __________________________________________________ VIEWPOINT Can lean save lives?

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David Fillingham_______________________________________________

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Can Six Sigma be the ‘‘cure’’ for our ‘‘ailing’’ NHS? Jiju Antony, Kay Downey-Ennis, Frenie Antony and Chris Seow ________

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Health service improvement through diagnostic waiting list management Amy Lodge and David Bamford __________________________________

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PRACTICE PAPER Should doctors stop taking the generic history? A comparison of house officers’ and nursing staff clerking in general surgery R. Gudena, N. Khetan, S. Luwemba and L.R. Jenkinson _______________

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END SECTION News and views __________________________________________ Recent publications ______________________________________

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CONTENTS

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Editorial advisory board

EDITORIAL ADVISORY BOARD

Michael Aherne Senior Consulting Principal, Responsive Strategies Inc., Edmonton, Alberta, Canada Professor Jiju Antony Strathclyde Institute for Operations Management, University of Strathclyde, Glasgow, UK Sue Antrobus Senior Researcher, Royal College of Nursing, UK David Birnbaum University of British Columbia, Canada Phil Glanfield Ex-Director of Modernisation Agency, UK Dr Neil Goodwin Visiting Professor: Leadership Studies, Manchester Business School, UK Dr Michael Goodyear Department of Medical Oncology, Dalhousie University, Halifax, Nova Scotia P. Gary Jarrett Jacksonville, Florida, USA

Jan McGuinness Vancouver Coastal Health, Canada Victor Maddalena School of Health Services Administration, Dalhousie University, Halifax, Nova Scotia Peter Milford Acting Director: Workforce and Development, South West Peninsula Strategic Health Authority, UK

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Calum R. Paton Director and Professor of Health Policy, Centre for Health Planning and Management, Keele University, UK Professor Irene Scott Director of Nursing, Surrey and Sussex Hospital, UK Iain Snelling Centre for Professional and Organisation Development, Faculty of Health and Wellbeing, Sheffield Hallam University, UK

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Leadership in Health Services Vol. 20 No. 4, 2007 pp. 228-230 q Emerald Group Publishing Limited 1751-1879

Editorial Welcome to the LHS special issue. This issue has been dedicated to contributions that discuss Lean and other related Quality Programs as they help to reduce or eliminate waste specifically in health delivery systems. Our interest in the concept of Lean was piqued as a result of Michael Balle and Anne Regnier’s article on the subject in LHS, Vol. 20 No. 1. Here, the writers describe how the process of lean has been used to build a learning environment on the part of the nursing staff and transform a Paris hospital. Next, a conference on the subject in Manchester in the early months of 2006 which was attended by two of our editors meant that they were able to speak to a number of working health care professionals who were actively involved in implementing lean initiatives in their workplaces, and who wanted to share their learning experiences with others. Some of the papers in this issue originate from the Manchester conference. As such, they may not all be papers with an academic or professorial tone. Rather, in the form of stories, they represent the practical issues working staff have to deal with when they either personally initiate research or else lead initiatives intended to reduce or eliminate duplication. Thus they have immediate knowledge sharing value and should be of immediate and practical interest to those readers implementing lean initiatives or else thinking about them. The concept of lean originates from the auto manufacturing environment of Toyota. For those of us who would prefer a less scientifically technical and more generous world, it is therefore viewed with some suspicion, especially when it comes to dealing with people who are sick, who are human beings rather than machine components, and whose lives are not about profit. However, it is safe to say that lean is viewed here not as a means to greater profitability, but rather as a means of helping patients in the health care system receive faster and more efficient treatment. In human terms this means translating waste in the form of duplication and unnecessary procedures into resources, so that more can be spread over an ever increasing population of need – so that people who are sick can be treated faster – in less time. With ever-increasing pressures on the delivery of health services, the application of leaner practices can only mean that ideally we can do more with less – minimize waste, eliminate patient backlogs, and treat more patients in a more timely and ultimately humane manner. From this perspective, lean initiatives are leading initiatives, with enormous implications for professional practice and healthcare outcomes. Focusing on what the patient feels to be of value, all activities and processes within the system must be closely examined to determine whether they contribute to this end. To the extent that they may add cost or time without contributing to the end goal means that they become potential targets for elimination. Balle and Regnier emphasize that “lean is well adapted to solve the operational problems presented by organizing the work of a large number of staff with a great variety of patients in a very demanding environment” (LHS, Vol. 20 No. 1, p. 33). This is certainly the case for modern health care organizations, which are large and complex, located within ever increasingly critical external environments, and under enormous pressure to change. And like all complex organizations, hospitals and health care services each have their unique cultures dominated by professions with their own

histories, particular sets of practices and legislative boundaries. Lean requirements mean that interacting individuals from different professions, often operating within different systems and interacting within one large system, start to assess their own practices. Hence they become reflective practitioners, noting where the areas of overlap are, where the flows of patient care are interrupted, and where they can work together more effectively. As Balle notes, lean is first and foremost a system that must be constructed by the actors themselves. Lean is not a tool box of quick fixes. Nor is it about applying piecemeal applications of industrial practices to the various components of the medical environment. It requires an understanding of the big picture and the necessary awareness of how one’s role fits into that picture. The system becomes one of active learning, where the potential benefits are that patients experience greater safety and shorter lead times, and the health professions themselves achieve better understanding and greater mastery of their own practices (LHS, Vol. 20 No. 1, p. 33-4). To be sure they may be some disadvantages to the introduction of lean initiatives in the health care field. For health care professionals already burned out as a result of the never ending pressure of constant change implemented by “external powers that be”, they may be viewed as just another change fad. But as potentially exciting initiatives involving folks themselves with real time for reflection and assessment, they could be just the “breath of fresh air” that this industry so sorely needs. In part it depends on how the change is led and managed. As a case in point, David Fillingham’s article on the Bolton Hospitals National Health Services Trust reminds us that leading a major lean initiative is a long term patient outcome improvement project anticipated to last over a ten to twenty year time period and perhaps even longer. In the Bolton Trust, the lean initiative has been systematized as the Bolton Improved Care Service. Using a process known as Rapid Improvement Events (RIEs), (to this reader reminiscent of GE’s WorkOuts), Fillingham explains that “week long, hands-on change activities – involving more than 650 frontline staff over a two year period – sit within a rolling seven week cycle of planning, executing and following up change which piece by piece build better end to end processes for patient journeys”. Such a process allows change as a journey of never ending improvement to become embedded within the organizational culture, thus overcoming the natural change inertia afflicting organizations. These reflective activities help to prevent the organizational difficulties and inefficiencies that so often occur when a change in one part of the system adversely affects another part, thus cancelling out any potential benefits. Fillingham reminds us that Lean is not costly in terms of money, but it does require time to be built into the system for reflection, ongoing assessment and review – all components of a learning organization, thus bringing us back to Balle’s and Regnier’s main point that lean first and foremost is a system of thinking and learning. It is the ultimate in continuous improvement. What is special about the Bolton case study is not just the lean process itself but in addition, that the CEO is so supportive in setting the environment for the ongoing change initiatives to occur. Providing a more limited perspective on the unnecessary duplication of medical administrative practices but certainly within the spirit of lean, Jenkinson et al. document how both junior doctors and nurses are required to take generic patient medical histories. This group of medical consultants point out that such duplication does not necessarily lead to better outcomes for the patients and that the nurses record more accurate patient histories. In the interests of efficiency therefore, their

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recommendation is for doctors to discontinue this generic practice. What makes this paper particularly interesting is that it is written by medical professionals, not administrators or professional researchers. It therefore could be said to represent a degree of self interest. At the same time any initiative that encourages more accurate medical history from patients and unnecessary duplication of activities between professional staff is certainly worthy of further research. The paper presented by Bamford and Lodge documents a research initiative in the spirit of lean conducted in the Pennine Acute Hospitals NHS Trust. Using action research, the paper focuses on how the transformation to the use of electronic waiting lists and a logical approach to their management has led to much shorter wait times for patients. The paper speaks of the difficulty in bringing changes about in a system replete with change fatigue, and the need to involve the front line staff in change initiatives early in the process. Documenting lessons learned, what went well and what went not so well, the paper reminds us that senior level support for these kinds of major change initiatives tends to be present only when a national target is introduced, and is a timely reminder once more of the overriding importance of leadership in embedding continuous improvement within an organization. Finally, Antony et al. present us with more of a general research paper on six sigma and its application to health care. Six Sigma is a variation of lean because of its emphasis on the reduction of process variation. In this case, the authors walk us through an explanation of what six sigma is, demonstrate its applicability to health care as a means of increasing customer and client satisfaction, while at the same time providing excellent service levels at minimal cost. Once again we are reminded of the importance of senior management and leadership buy-in for continuous improvement initiatives, and the importance of involving front line staff through ongoing training programs to bring about culture change. The concept of lean is undoubtedly a hot topic in the field of management science today, and has particular relevance to the messy and very human world of health care today. To achieve greater efficiencies, provide more people with better care faster and more efficiently, at less cost, is surely the dream of every health care administrator. Lean first came to importance through Toyota which started out small but which came to the fore as the biggest and best automobile company in the world because it was able to apply the lean process to its manufacturing plant so effectively. It was and remains a learning company committed to continuous improvement and revolutionary rather than incremental change. In a recent HBR interview with Katsuaki Watanabe, President of Toyota (HBR July-August 2007, pp. 74-83), Watanabe notes that “when people are heading in the right direction, the small movements and the major ones will stay aligned”. He says “there’s no genius in our company. We just do whatever we believe is right, trying every day to improve every little bit and piece” (p. 83). The idea of continuous improvement through Lean or Six Sigma in the world of health care may not be quite so straight forward. Given the complexity of health care organizational cultures, incremental improvements may be all we can hope to achieve. However, as the articles in this issue demonstrate, lean initiatives hold great promise for changing the culture of health care organizations and the improved delivery of health care services to their clients. Jennifer Bowerman

The current issue and full text archive of this journal is available at www.emeraldinsight.com/1751-1879.htm

VIEWPOINT

Viewpoint

Can lean save lives? David Fillingham Bolton Hospitals NHS Trust, Royal Bolton Hospital, Bolton, UK

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Abstract Purpose – The purpose of this paper is to show how over the last 18 months Bolton Hospitals NHS Trust have been exploring whether or not lean methodologies, often known as the Toyota Production System, can indeed be applied to healthcare. Design/methodology/approach – This paper is a viewpoint. Findings – One’s early experience is that lean really can save lives. The Toyota Production System is an amazingly successful way of manufacturing cars. It cannot be simply translated unthinkingly into a hospital but lessons can be learned from it and the method can be adapted and developed so that it becomes owned by healthcare staff and focused towards the goal of improved patient care. Originality/value – Working in healthcare is a stressful and difficult thing. 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. Keywords Health services, Organizations, Economic planning Paper type Viewpoint

Healthcare is a risky business. Doctors, nurses and other healthcare professionals deal with a group of customers who are often frail, vulnerable and frightened. The degree of organizational complexity is high and many procedures have a significant level of risk. It is therefore perhaps not surprising that a recent report from the National Audit Office at the Department of Health (2005) highlighted that one in ten patients passing through NHS hospitals suffer an adverse event of some kind. Drug errors, falls, infections, misdiagnoses can all lead to harm to patients within the healthcare system. At the same time both the popular press and medical journals run constant stories of low morale within healthcare “Doctors and Nurses are Sick of the NHS” was one typical headline from the Daily Express in October 2006. The government response to this in the UK in recent years has been a huge investment of public funds in to healthcare. This has undoubtedly brought about improvements in access times for services and in the quality of the physical environment. However improvements in the quality of the patient experience are harder to substantiate with evidence. What is more the money is due to run out. The projections of the Treasury in the UK are that public spending will be increasingly constrained in the years ahead and that the times of increases in allocations to the English National Health Service many points ahead of inflation are shortly to come to an end. The introduction of the Payment by Results system is utilizing a national tariff to drive productivity improvements, particularly in the hospital sector. Healthcare managers, Boards and clinical leaders are therefore faced with a significant challenge. They desperately need something that can simultaneously improve quality, morale and productivity. Such a method would indeed be the holy grail of healthcare

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management. But can techniques developed in manufacturing really work in hospitals? Could it possibly be that “lean” can save lives? Over the last eighteen months Bolton Hospitals NHS Trust have been exploring whether or not lean methodologies, often known as the Toyota Production System, can indeed be applied to healthcare. The early experience is that they can and the potential is enormous. However the practical difficulties of implementation cannot be overstated and the gains to be had from applying lean in healthcare are only likely to be realized over years or indeed decades, not over weeks or months. Bolton Hospitals NHS Trust is a large, busy District General Hospital on the north-west edge of Greater Manchester. With just under 800 beds and over 3,000 staff it is a complex organization delivering the general hospital needs of a population with high levels of sickness. In 2004 the hospital had a spiralling financial deficit, significant problems with long waits for diagnostics and many treatments. The future of the hospital as a viable entity was in question. By 2007 things are still far from perfect, however the first steps on the road to recovery have been taken. Financial balance has been restored, waiting times greatly reduced and a clear vision for the future established. At the centre of this has been the application of lessons from Toyota and from others of the world’s leading lean organizations. What is “Lean”? So what is lean? Unfortunately the term is widely misunderstood. “Lean and Mean” is all too often what is assumed, particularly by frontline staff and staff representatives. Lean is taken to mean paring things back to the bone, asking staff to work harder and doing more with less. It is not this. In fact by removing many of the frustrations and timewasters that staff encounter lean can make work a move fulfilling experience. But undoubtedly, the first reaction of staff is often the natural one that a manufacturing approach simply cannot work in a hospital setting. “We’re not Japanese and we don’t make cars” is the inevitable initial response of many. In their books Lean Thinking and Lean Solutions Womack and Jones (1996, 2005), describe how the underpinning principles of a Toyota like approach can be applied to any form of work. In their studies of Toyota and other organizations subsequently they demonstrated that first we must see all work as it contributes to an overall end-to-end process. This is because only having seen the end-to-end process can we be in a position to know how to safely improve it. Further to this end-to-end view, being Toyota-like requires that we decide for each step in the process whether it is either “adding value” or not. Such a black-and-white distinction is difficult to learn but essential. Unlike 99 per cent of traditional management approaches Toyota suggests that the most effective way of making improvement is to focus on eliminating the non-value added steps as opposed to seeking the more obvious but smaller improvements to be had by improving the value adding steps. We have learned that in any given process, non value added steps, or put more simply wasteful steps, typically out-number the value added steps 9:1. The big insight therefore is that going after waste is a much more effective way to improve. Unfortunately most organizations simply do not have this process focus. In hospitals staff work in departmental silos such as the A&E department, Radiology, the wards and the theatres. Indeed often the only person who sees the whole of the patient journey is the patient themselves! This becomes even more complex when the

administrative and information processes that surround the patient journey are taken in to account as these are often five or six times more complex than the journey itself. The result is a process that is riddled with errors, duplication and delay. It is this which is highly frustrating and dispiriting for frontline staff and leaves many feeling that they are working as hard as they can and yet still failing to deliver a good quality service. Much of the work that goes on within the healthcare setting does not directly add value from the patient’s point of view. Our processes have rarely been consciously designed – they have evolved in a hotch potch way, often over many years. By learning to see our processes in all of their full horror with the problems clearly set out we can then take the first step along the road towards improving them. This is the journey which Bolton Hospitals embarked upon late in 2005. Applying lean to healthcare So how did our lean journey come about? Prior to taking up my post at Bolton Hospitals NHS Trust I was Director of the NHS Modernisation Agency. This was a national body with responsibility for spreading quality improvement methods throughout the NHS. We were fortunate to get Dan Jones’ (Chairman of the Lean Enterprise Academy) support to work with us on the emergency services collaborative which was established to improve the turnaround times of A&E departments. By applying lean principles of process management, flow and pull hospitals were able to bring about radical improvements. But the Modernisation Agency was successful only on a programme by programme basis. It did not have the facility to bring about whole organization improvement. And it is undoubtedly true that it is much easier exhorting others to improve than it is doing it in practice! In reality it is all too easy for Trust chief Executives and Boards, even with those with the best of intentions, to become swamped by day to day firefighting and so struggle to create a systematic organization wide approach to improving quality. Perhaps for this reason, no one before 2005 in the NHS had tried to apply lean principles across a hospital as a whole. Indeed by 2005 there were only a few hospitals world-wide who were attempting this such as Virginia Mason in Seattle, Flinders in Adelaide and Thedacare in Wisconsin. Beginning in late 2005 Bolton secured the support of an external consultancy, Simpler, who have a track record in helping organizations carry out lean transformations. With their help Bolton has taken its first tentative steps towards becoming a lean hospital. We are learning that this is likely to be a ten or even twenty-year journey! Simpler have been keen to point out that the Toyota way must be interpreted into our own language and adapted to suit a healthcare culture. This has resulted in our approach becoming systematized as the Bolton Improving Care System. The main elements of that system are set out in the diagram below. The remainder of this article describes the steps of the BICS improvement cycle one by one and illuminates them by using a specific case study – that of trauma services (see Figure 1). The fundamental method for embedding culture change and achieving ever-improving transformation is the use of “Rapid Improvement Events” (RIEs). These week long hands-on change activities sit within a rolling seven week cycle of planning, executing and following up change which piece-by-piece build better end-to-end processes for patient journeys. The RIE approach has a sixty year history of success and is indeed being re-discovered by many as the only sure fire way of

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Figure 1.

mobilizing and sustaining the level of activity to fundamentally shift the culture to that of never-ending improvement. Since late 2005 over 650 frontline hospital staff in Bolton have been involved in these week long events. These have tackled many different aspects of the patient journey in areas such as antenatal care, radiology, pathology, trauma services, cataracts, surgery, stroke care and even the laundry. All of these are linked to strategic Trust wide transformation plans to avoid isolated pockets of improvement that ultimately do not connect together for improved care. The best way to understand the Bolton Improving Care System (BICS) in action is to consider one of these case examples in more depth that of trauma care. BICS in action: trauma as a case study Bolton is a busy emergency hospital. Indeed due to its location between major motorways and metropolitan centres it is the main emergency receiving centre for Greater Manchester with over 30,000 emergency ambulances arrivals each year. Over 1,500 of these are complex fractures. Many of these patients are elderly and have other presenting problems such as a respiratory condition, heart disease, diabetes or other chronic illness. Historically there have been serious concerns in Bolton regarding mortality, productivity and morale within this service. The hospitals’ length of stay for fractured hips was higher than the national average. The service was prone to cancellations of surgery and at times felt chaotic. Despite many attempts at improvement using clinical audit and other approaches the problems remained. Most worryingly of all mortality rates were high. The relative adjusted risk of mortality for a fractured hip in Bolton in 2004/2005 was 173.9, in other words over a 70 per cent higher than expected chance of a death from this condition. The problem was serious and urgent action was needed. As a consequence this was the first area chosen as a trial for lean methodologies.

Understanding value The first step in the BICS cycle is to understand what is really valuable to the patient. Only by doing this can we identify what is value added as opposed to non-value added work and then seek to eliminate the non-value added steps. Often in healthcare, doctors, nurses and other care professionals will say “of course we know what patients want we are with them all day every day”. But being in daily contact with patients is not necessarily the same as really understanding what is valuable to them. The first step in the BICS cycle is to use rigorous techniques to truly understand value through the eyes of our customer. This includes a variety of approaches such as direct observation which is sometimes called the Ohno Circle. This was named after Tahichi Ohno one of the founding fathers of Toyota (he was a particularly robust character and some people have said that “Ohno” was also what people said when they saw him coming!). He used to ask newly appointed young engineers to stand in a chalk circle on the factory floor for up to eight hours at a time just watching what was going on. He would then quiz them ruthlessly about the problems that they saw and the need for improvement. We have not been quite so draconian in Bolton but the first step of the process is indeed direct observation to watch what is going on in the clinical area, to see how patients flow through the system, what the obstacles and barriers are and to get an understanding of what it feels like to be a patient. Other techniques used include patient diaries, questionnaires, interviews and focus groups. As far as possible in our lean events we actually get patients on the team and this proves particularly valuable as they are constantly challenging the preconceived notions of staff. When this was done for trauma services we had a much clearer understanding of what was truly valuable to patients. Not surprisingly pain relief came high up on the list followed closely by a wish for information given in a clear and co-ordinated way and high levels of anxiety about cleanliness, hygiene and infection. Learning to see Once value is understood through the customers’ eyes we need to establish whether or not what we are delivering is valuable. All too often we become so used to problems that we “work around them” and accept them as part of the necessities of day to day hospital life. Learning to see is about asking staff to put on their “waste goggles” and to try to see the waste inherent in all of our processes. We have adapted Toyota’s seven wastes to be relevant to healthcare (see Figure 2). All too often hospitals are so cluttered and untidy it is hard to see where the waste is, and almost impossible to create a smooth workflow. A lean consultant who worked with us remembered that he used to tell clients their factories should be well organized and orderly as a hospital; after working in a hospital he no longer does so! A lean technique for creating order and cleanliness is “6S” (sometimes called 5S). This translates imperfectly from the Japanese but in Bolton it means: (1) Sort. Separate needed from not needed. (2) Straighten. A place for everything. . . (3) Shine. Clean and wash. (4) Standardise. Build into accepted routines. (5) Sustain. Discipline to ensure maintained. (6) Safety. Checking for hazards and defects.

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Figure 2.

A 6S exercise is more than just a clean up of the workplace, it is a way of ensuring that calm and orderliness are built in to the day to day way of doing things. This has now been carried out on a range of clinical areas. As a spin off of our trauma work a 6S exercise was undertaken in the A&E resuscitation room. One might imagine that this would have already have been in good order, however staff found that there were a wide range of improvements that could be made. During a single week long 6S event 71 separate improvements were made in the A&E resuscitation room. This has led to fewer clinical incidents, fewer medication errors and higher staff morale. There is always a danger that a 6S exercise will be seen as a one-off clean up. In reality it should only prepare the ground for what needs to be a daily discipline. With the help of Michael Balle´ (2005), author of the lean novel The Goldmine, Bolton has been working to instill this discipline at ward level. This has been termed the “Go and See Approach”. Nurse Managers at ward level are encouraged to regularly look at their wards with fresh eyes to spot the waste and potential for harm to patients. Each week they are asked to identify at least three problems. They then work with their staff to identify and implement solutions before tackling a further three problems the following week. Over a period of weeks and months the cumulative effect can be dramatic. Most importantly it creates a culture where looking for and solving problems is the norm rather than simply working around them as is all too often the case. Establishing such a discipline is far from easy! Whilst this has begun to take hold in some areas in Bolton there remains a long way to go and other ways are needed of enabling staff to see the defects that exist within the hospitals processes. The most developed form of “learning to see” is a valuestream analysis event. This sounds like a fairly dry bit of jargon but in reality it is an extremely powerful way of engaging frontline staff to identify problems and come up with solutions. The valuestream analysis event for the trauma service took place late in 2005. A multidisciplinary team of doctors, nurses, therapists, managers and patients, spent a week removed from their other duties focusing just on this task. They were taught the method and then put it into practice by mapping in detail the progress of the patient’s journey from arrival at A&E through radiology, the wards, theatres, back to the wards and the discharge process. In doing this they identified enormous waste, error and duplication. In fact a number of staff were visibly moved by what they found. One doctor said he did not realize that the service we were delivering was so poor and

reflected that he had never seen the whole journey end to end. On observing the complexity of our discharge processes one of the patients who had been invited to participate asked the question “how did I ever get out?” From a low point early in the week when they fully understood all of the problems the team moved to develop an exciting vision of how the service could be in the future. That future state was made challenging but achievable and pitched some 12-18 months into the future. Finally the team ended the week by developing an improvement plan to deliver their future state. This consisted of some major projects that would be needed; some “just do it’s” simple things which staff could do quickly to put things right; and other areas where further week long rapid improvement events would be beneficial in helping to transform the service. Redesigning care Throughout the early part of 2006 the trauma team worked to implement their future state vision for the service. Six week long rapid improvement events were run looking at flow through A&E, the way the radiology service worked, the establishment of a trauma stabilization unit with significant input from the physicians, the processes within theatres, the discharge process, and multidisciplinary team working. It is at the redesigning care stage of the BICS cycle that we have really begun to creatively adapt lean methodology for a healthcare setting. Our consulting partners Simpler have shared with us a simple model which they use to help get lean principles embedded in any organization they work with. Arranged in a deliberate order of implementation the logic (starting in the 12 o’clock position in Figure 3) is as follows: (1) Get the process flowing one-by-one from one value adding step to the next without waste. For us this is the flow of patients and of information. (2) Underpin this new and counterintuitive working into staff habits through simple visual standard work that not only captures the current best way of performing the flow but also calculates correct staffing for given demand scenarios. (3) Make this flow and standard work easy to do through good 6S (correct arrangement, housekeeping and use of the workspace). (4) Next never try to force things through the process by pushing patients through in a false hope that things will speed up. Instead smooth out the irregularities in flow and ensure success by only having downstream steps; pull patients from upstream steps when they are ready. (5) Finally design visual management aids so that leaders can simply go-and-see what is happening and (because they have flow) exactly the next problem they should be solving without disturbing staff from their value added tasks. The trauma team worked creatively to apply this in a healthcare setting. They quickly came to see that standard work should be what we have in the past termed effective clinical practice. The trick is not just to identify it but to embed it so it is carried out consistently on a daily basis. The team also concentrated on ensuring that patients flowed in a smooth manner through the unit. Previously very sick and more stable patients had been muddled together on the same ward. The team redesigned the area to

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Figure 3.

create a trauma stabilization unit in which the sickest patients were received and stabilized medically prior to theatre. A good flow was then established to allow quicker access to theatre, proper rehabilitation and effective multidisciplinary team working after patients had had their operation. A single set of much reduced paperwork was created for use by medical staff, nurses and therapists alike eliminating much of the form filling that had grown in an ad hoc way over the years. This greatly reduced the number of non-value adding steps and alleviated a large source of staff dissatisfaction and frustration. 6S was introduced into the area, particularly into the trauma stabilization unit, so that all of the equipment and information that would be needed for the most poorly patients was always in the same place and always to hand. Finally visual management systems were set up so that staff could see on a continuing basis whether or not the process was operating as it should and what quality problems and defects were occurring. Delivering benefit The final step in the BICS cycle is to close the loop and make sure that the changes that are implemented really are delivering benefit. This phase also builds in reflection on what has worked and what has not as a precursor to starting the cycle again. One of the surprising things about a lean approach, as well as one of the most encouraging, in that even though a single pass through produces a large percentage improvement repeated cycles can also produce a similar scale of gain. In a healthcare setting delivering benefit is one of the most difficult phases. We have found that the key is to be clear at the outset about aims whether these be for reductions in mortality, improvements in productivity or increases in patient satisfaction. Unless line managers fully own the

programme of work and are committed to implementing the changes and sustaining them on a continuing basis then gains made during the heady days of a rapid improvement event are likely to be quickly lost. In the case of trauma the strong commitment of the orthogeriatrician, the lead orthopaedic surgeon, the matron, the nurse ward manager and the senior therapist were absolutely critical in sustaining the improvements which the teams identified during rapid improvement weeks. We have learned that it is vital for senior leadership to show a genuine interest in this work and pay attention to the results that are being delivered. In Bolton the Executive Board (made up of directors and senior clinical leaders which meets once a month), now considers all of the previous months lean improvement activity, checking that the expected results have been delivered and asking questions as to why if they have not. It is necessary to program manage lean benefits realization in as disciplined and systematic a way as any other aspect of the hospital’s core business. So what was achieved? The outcomes delivered in the trauma pathway were surprising to us both in terms of their scale and their sustainability. Over a period of just nine months the team delivered: . a 42 per cent reduction in paperwork; . better multidisciplinary team working; . a reduction in the time taken to get patients into theatre with a fractured hip from 2.3 days to 1.7 days (a 38 per cent decrease); . faster recovery and lower demand on the rehabilitation ward; . total length of stay reduced by 33 per cent; and . mortality reduced by 36 per cent resulting in a relative risk adjusted mortality rate of 105.5. These improvements were spectacular. Clearly however they do not go far enough as mortality has only been reduced to the expected national average level. The team are therefore about to embark on a further cycle of improvement to find ways of taking the service forward and achieving still higher levels of performance. In other parts of the hospital where BICS has been applied, similar successes have been achieved. In pathology there has been a reduction in floor space of almost 50 per cent which has allowed the Trust to bring in new work at a fraction of the expected cost. The routine sample processing time in the blood sciences area has reduced from an average of five hours to less than 60 minutes. 6S has created a much better working environment in the laboratory which is now designed for flow whilst visual management means that staff know on a daily basis how well they are doing and are actively engaged in solving problems as they arise. The pathology department has increased its income by 10 per cent in the last year with 2 per cent fewer staff and the management team believe that BICs has been a highly important contributor to this. Similarly in the laundry the productivity improvements have been impressive. This was an area which the Trust was previously considering moving out to an external contractor. Pressure from laundry management and staff side representatives led to us using lean techniques to see whether or not the in-house service could be improved. It certainly could! To date the laundry has generated almost £300,000 worth of savings

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and additional commercial income using its lean approach. This in itself has more than funded the total cash outlay on the first two years of our lean initiative. The approach taken in trauma is now being replicated in other areas. Four end-to-end patient journeys are being tackled - cataract surgery, joint replacements, stroke care and patients with acute abdominal pain. All of this is intended to move us towards a desired future state for the hospital as a whole, our vision of what a truly “lean” hospital should be. Our vision is that we should move rapidly to assess patients upon admission and stream them as simple or complex whether or not they are elective or emergency patients. For simple patients we are concentrating on reducing batch sizes, putting patients in to flow, taking out unnecessary steps and non-value adding work and making sure that we give the right kind of customer care at key points in the process to achieve a good patient experience. Our aim for this group of simple patients is to improve throughput and improve patient and staff satisfaction. For complex patients we have quickly learned that the challenge is somewhat different and unlike any car factory! It is often in these areas that we have higher mortality rates and unsatisfactory outcomes. Our work here is not so much about putting the patients themselves into flow as achieving “one decision flow” i.e. getting the right information and clinical decision makers together in a timely manner to get a speedy diagnosis and the right treatment plan. This will lead to improved outcomes and also improve productivity through lower infection rates, quicker recovery and shorter lengths of stay. Reflections and lessons Bolton’s early progress on its lean journey has been encouraging but it has not been without its dilemmas and challenges. The cash outlay on BICS has been relatively small but the input of staff time has been considerable. Inevitably there is a feeling from many that “we are too busy to do this”. We have tackled this by recognizing that we already create dedicated time and resources for frontline staff for training and development, clinical audit, research and other activities. However these do not always produce the gains in terms of improved patient care or staff satisfaction that we are seeing from the BICS programme and so we have been trying to find ways to redirect those efforts to create the dedicated time and resource that staff need to be involved in BICS. Secondly, much of this is counter-cultural for the NHS. It is certainly true that we are not Japanese and we do not make cars! However staff can quickly come to understand that all work is a process and all processes can be improved. The result is the revelation that good quality can cost less not more. This is something that staff will rarely accept when told it in theory but are beginning to see for themselves through their hands on involvement with the BICS work. General managers at times have perhaps felt that the effort going in to BICS is a distraction from the importance business of hitting targets and delivering financial balance. It is true that this has been a challenge as to some extent we are trying to build the aeroplane whilst flying it! In the long term however it is clear that the BICS approach is a sustainable way of achieving targets and financial balance whilst at the same time improving staff morale and patient satisfaction. This is a prize worth fighting for. Finally we are all too well aware that the NHS suffers from “initiativitis”. It feels as if every possible improvement methodology, programme or fad has been tried out in

the NHS in recent years. As a result staff can become battle weary and cynical. There is the temptation for some to see lean as the latest new idea that will go away again in a year or two when the Chief Executive thinks of something new. The only way of rising to this particular challenge is to show resilience, consistency and perseverance. Implementing lean in a healthcare setting is far from easy but the potential gains are enormous. Our early experience is that lean really can save lives. The Toyota production system is an amazingly successful way of manufacturing cars. It cannot be simply translated unthinkingly into a hospital but lessons can be learned from it and the method can be adapted and developed so that it becomes owned by healthcare staff and focused towards the goal of improved patient care. Perhaps most heart-warming of all has been the response of frontline staff themselves. Working in healthcare is a stressful and difficult thing to do. 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. References Balle´, M. (2005), The Goldmine, Lean Enterprise Institute, Cambridge, MA. National Audit Office at the Department of Health (2005), A Safer Place for Patients: Learning to Improve Patient Safety, TSO, London. Womack, J. and Jones, D. (1996), Lean Thinking, Simon & Schuster, New York, NY. Womack, J. and Jones, D. (2005), Lean Solutions, Simon & Schuster, London. Corresponding author David Fillingham can be contacted at: [email protected]

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Can Six Sigma be the “cure” for our “ailing” NHS?

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Strathclyde Institute for Operations Management, University of Strathclyde, Glasgow, UK

Jiju Antony Kay Downey-Ennis Daughters Charity of St Vincent de Paul, Central Management Office, St Vincent’s Centre, Dublin, Ireland

Frenie Antony Caledonian Business School, Glasgow Caledonian University, Glasgow, UK, and

Chris Seow University of East London Business School, University of East London, London, UK Abstract Purpose – The purpose of this research is to analyse whether Six Sigma business strategy can be used to improve the financial and operational performance of the NHS. The paper will also look at some of the major challenges and barriers in the implementation of this powerful process improvement strategy within the healthcare sector. Design/methodology/approach – This paper discusses whether Six Sigma DMAIC methodology can be a useful and disciplined approach to tackle process- and quality-related problems in the NHS. Findings – The paper presents some key findings from other researchers in the field, followed by some comments on whether Six Sigma is a useful approach to be considered by the NHS for cost reduction and defect reduction strategies. Originality/value – The paper illustrates the point that Six Sigma is not confined just to manufacturing industry, rather it is equally applicable to service industry, especially the healthcare and financial sectors. The application of Six Sigma in the UK health sector is relatively new and the purpose of the paper is to increase the awareness of this powerful business strategy in healthcare discipline. Keywords Quality, Performance management, Six sigma, National Health Service, Health services Paper type Research paper

Leadership in Health Services Vol. 20 No. 4, 2007 pp. 242-253 q Emerald Group Publishing Limited 1751-1879 DOI 10.1108/17511870710829355

Introduction Six Sigma is a process-focused data driven methodology aimed at near elimination of defects in all processes which are critical to customers (Antony et al., 2007). Six Sigma as a powerful business strategy has been around for almost twenty years and has grown exponentially in healthcare industry during the past five years mainly in the USA. Initially applied in manufacturing industry, it has now dispersed into service industries, most importantly to the healthcare sector. Sigma is a Greek letter used to describe process variability or in mathematical terms, standard deviation of a random variable. A number of times Sigma indicates the amount of defects that are likely to occur in a given process (manufacturing, service

or transactional). For example, a 3 sigma process has a defect rate of approximately 67,000 (6.7 per cent) whereas a Six Sigma process has less than 4 defects per million opportunities. Defects in processes cause increase in costs due to scrap, rework, repair, re-test and so on. For instance, the cycle time for reporting radiology results in a hospital as defined by physicians is 18 hours. This implies that if the turnaround time for any report produced by a physician is over 18 hours, then it may be viewed as a defect. We can calculate the defect per million opportunities (DPMO) and the corresponding Sigma Quality Level (SQL) once we know the number of patient visits per year to the radiology department. NHS challenges Whilst improvements have been made within the NHS, services are still not good enough. Moreover the NHS is entering a very uncertain period through using market forces and promoting patient choice. The transformation of the whole system by making “big changes, very quickly” is now required as the NHS enters the latter part of the ten-year implementation plan (Hewitt, 2005). Many healthcare systems are now deeply dysfunctional and all require redesign with many indicating that this should be a radical redesign (Shalala, 2005). The challenges that face the NHS in order to respond to and meet the ever changing needs services need to be: . well defined; . co-ordinated; . efficient; . cost effective; and . supported by core processes and systems and require multiple improvement strategies. To achieve this, Six Sigma as a framework offers the NHS a realistic structured methodology for process improvements (Natarajan, 2006). Overview of Six Sigma Six Sigma allows for more careful analysis and more effective decision-making aiming for the optimal solution rather than what is simply “good enough”. It really takes TQM efforts to the next level and has a great future in healthcare (Lazarus and Butler, 2001). As a methodology for process and quality improvement, Six Sigma has demonstrated its ability to adapt to virtually any process – including healthcare. When appropriately implemented with uncompromising leadership support and the utilisation of change management tools to address cultural barriers and build acceptance, Six Sigma has achieved measurable success (Stahl et al., 2003). Lean Thinking is a philosophy which requires the continuous elimination of waste and non-value-added elements from processes and is identified as being closely linked to Six Sigma. Six Sigma made a beachhead in healthcare around the year 2000, although its growth was slow and steady. Two years after this, a number of hospitals in the USA have adopted Six Sigma as their core business process improvement strategy (Black and Revere, 2006). Throughout the last five years, many leading healthcare institutions in the USA have implemented Six Sigma with remarkable results in terms of reducing

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ER cycle time, increasing timely completion of medical records, increasing bed availability, reducing medication errors, etc. (Lazarus and Stamps, 2002). The Red Cross Hospital in Netherlands (Europe) has successfully initiated Six Sigma programme with savings generated from a total of 44 Six Sigma projects amount to over e1.2 million (Heuvel et al., 2005). Table I outlines outcomes and financial savings from the implementation of Six Sigma programmes. The fact that Six Sigma successfully combines quality improvement and cost reduction substantiates that it could be a solution to current financial problems in healthcare. An important motivation luring different healthcare organisations towards Six Sigma is its effectiveness in increasing customer satisfaction (i.e. patients, physicians and employees), provision of excellent service levels at minimal cost, effectively utilising existing resources and driving out non value added activities. In service industries Six Sigma is proving its worth by improving transactional process performance with customer satisfaction in a wide range of sectors (Steele, 2004). Results from the UK service industry indicate that the majority of service organisations have been engaged in a six sigma initiative throughout the past three years with the average sigma quality level reached was around 2.8 (approximately 98,000 DPMO). Critical success factors cited for successful implementation according to (Anthony et al., 2007) are: management commitment and involvement, customer focus, linking six sigma to business strategy, organisational infrastructure, project management skills, and understanding of the six sigma methodology. The benefits from the adoption of Six Sigma in service industries is in the form of considerable improvement in the bottom line result but it also increases customer satisfaction and employee morale, improves cross functional teams, increased awareness of problem solving tools and techniques leading to an improved consistent level of service. In the manufacturing sector, it is quite possible to reduce or even eliminate (in some cases) most of human variability through automation. In the healthcare industry, the delivery of patient care is largely a human process, and hence the causes of variability are often difficult to identify and quantify. The challenge for the healthcare sector and staff is to find a way to leverage the data to drive human behaviour. Financial results and their validation continue to be a challenge in the healthcare industry. It is often a difficult task to place a dollar value on a faster test result that may yield a shorter length of stay or the value of a more satisfied patient. The following are some of the typical characteristics of Six Sigma: . emphasises a data-driven methodology rather than feeling and intuition in the decision making process; . places a strong emphasis on customer needs and expectations such as service level, service cost, clinical excellence, patient satisfaction, etc.; . focuses on elimination of defects or errors in processes due to unacceptable process variation; . offers a structured approach to get into the root causes of problems using the DMAIC (Define-Measure-Analyse-Improve-Control) methodology; and . Places a greater emphasis on hard-dollar savings from projects which are aligned with strategic objectives of organisation’s business.

Increased analytical errors in an automated lab Unacceptable number of hospital acquired infections in three key operational areas Excessive inventory levels, poor supplier relationships

Virtua Health

Slower turnaround time in hospital lab results Low radiology through-put and unacceptable associated costs per radiology procedure in a hospital

Baptist Medical Centre Inefficient hospital discharge process

Charleston Area Medical Centre

North Share-LIJ Health System Decatur Memorial Hospital

Commonwealth Health Increased instances of wound Corporation integrity problems in small and large bowel surgical cases

Overcrowded emergency department

Scottsdale Healthcare

Outcome

Reduced patient waiting times, improved staff scheduling, 25 per cent increase in through-put ER Reduced time to transfer a patient from the ER to an in-patient hospital bed Infection Control Group Resulted in significant reduction in post-op infection, reduced infection rate by over 65 per cent Reduced analytical errors by 35 per cent Significant reduction in the Intensive care, intermediate number of hospital-acquired care and the cardiovascular infections unit Supply chain management for Reduced inventory levels and surgical supplies improved supplier relationships The process mean (discharge order entry to patient leaving time) has been improved by over 70 per cent and process variation has been reduced by 60 per cent Reduced turnaround time by 40 per cent Radiology Significant improvement in radiology through-put (about 33 per cent) and reduction in cost per radiology procedure

Project

Excessive patient waiting time Radiology

Nature of the problem

CHC

Company

(continued)

Hard cash savings are yet to be quantified Approximately $1.2 million

Hard cash savings are not quantified in the case study

Estimated savings from the project are over $500,000

Hard cash savings are not quantified in the case study Hard cash savings are not quantified in the project

The annual savings generated from the project is over $60,000

$600,000 (approx.)

$800,000 (approx.)

Hard cash savings generated

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Table I. Benefits of Six Sigma projects in healthcare services

Table I. Project

Memorial Hermann Southwest Hospital

Unacceptable delays in admitting patients

Emergency Department Alaska Medical Centre Increase in the number of ambulance diversions (from 3 per cent to 24 per cent) Emergency Department LDS Hospital Rapid treatment of painful conditions in the emergency department

Poor patient safety due to high medication and laboratory errors

Nature of the problem

Hard cash savings generated

Time to pain management went from 67 minutes to 45 minutes and untreated pain dropped from 39 to 11 per cent. Overall patient satisfaction has significantly improved Turnover time decreased from 325 minutes to less than 180 minutes, defects in the process have been reduced from 90 per cent to 55 per cent

Hard cash savings are not quantified for the project

Hard cash savings are yet to be determined

$600,000/year in profit Reduced medication and laboratory errors and thereby improved patient safety significantly Decrease diversions due to Net revenue increase of $1 “critical care at capacity” million (US) per annum

Outcome

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An overview of Six Sigma methodology (DMAIC) The Six Sigma methodology encompasses five stages: (1) Define (D) the problem within a process. (2) Measure (M) the defects. (3) Analyse (A) the causes of defects. (4) Improve (I) the process performance to remove causes of defects. (5) Control (C) the process to make sure defects do not recur. Define the problem The problem statement should not contain its cause or prescribe a solution. The problem statement should describe what you want to accomplish from the Six Sigma project. A well defined problem leads to achieve the objective of the customer whereas inadequately defined problem might lead to an undesired outcome resulting in unhappy customers. In the define phase, it is important to determine the voice of the customer (VOC) and translate it into measurable critical-to-quality (CTQ) or critical-to-cost (CTC) or critical-to-delivery (CTD) parameters. The operational definition of a defect must be determined by the Six Sigma project team. Anything which is not acceptable in the eyes of the customer (patient or physician) can be treated as a defect. In the define phase, it is strongly advised to develop a project charter showing the nature of the project, team members involved in executing the project, key milestones of the project, project goals, business case, project sponsor, etc. Measure the problem In this stage, one should assess the baseline measure of the process performance. Once we determine what should be measured in a process, it is then important to link the data collection to key issues affecting the process. It is also vital to ensure that we have a valid and capable measurement system in place. This aspect is quite often overlooked in many service organisations. The following questions may be asked by the team during the measure stage of the methodology: (1) Who will be affected by the problem at hand? List all the departments, processes and the individuals, if possible. (2) How often is the problem occurring? (3) Where is the problem occurring? (4) What is the impact of the problem on our business? (5) What is the impact of the problem on customers? Analyse the problem In this phase, the team identifies the causal factors likely to impact the problem. In the context of Six Sigma, this is often represented as: Y ¼ f (X), where Y is the CTQ, CTC or CTD and X ¼ X 1 , X2, X3, . . . Xn represent the list of potential causal factors which affect Y. Many factors in healthcare are quite predictable, though uncontrollable such as arrival rate at the emergency room. Some useful tools which can be used to identify the causal factors are brainstorming, root cause analysis or cause and effect analysis, Pareto analysis and hypothesis testing.

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Improve processes The improve phase can be quite challenging in healthcare sector as it often involves changing human behaviour. It probably comes as no surprise to healthcare professionals that organisational structure can actually inhibit process thinking. In this phase, the team have to change the process to address the root causes identified in the analyse phase and thereby improve the process performance. Several rounds of improvement may be required to achieve the desired level of performance. In a group environment, creative and innovative solutions can sometimes be suppressed by poor team dynamics and non-supportive environment. The choice of solution to a process problem can be determined by effectively employing an impact-effort matrix. Solutions that offer a high impact need to be examined to determine how much time, resources, budget, etc. will need to be invested for implementation. .

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Control processes In the control phase, we generally determine the control plans that will assure that improved process performance is sustained over a period of time after the completion of the project. The most appropriate tool to use in the phase is control chart. The purpose of a control chart is to monitor the process and identify special causes of variation (e.g.: operator error, errors in recording of measurements, etc.) in processes. A root cause analysis can be carried out once the special causes of variation are identified. Having identified special causes of variation, appropriate remedial action plan should be developed. Six Sigma projects and financial benefits Projects are the primary vehicle used to drive product, process and service quality improvements in organisations. Using projects to improve process performance, yield, throughput, process capability and stability etc. that result in overall business performance are pretty fashionable in many organisations today which are engaged in a Six Sigma programme. The selection of right projects in the first place is quite critical in a Six Sigma initiative to gain the appreciation of top management personnel and many others interested in the survival of such an initiative. This section briefly outlines some guidelines of selecting projects, followed by illustrating the financial benefits of some healthcare related projects in a Six Sigma initiative. Project selection: The project selection process must incorporate three important voices: the voice of the process, the voice of the customer, and the voice of strategic business goals (Pande et al., 2000). Snee (2001) identified the following as important criteria for improving project selection which can produce significant financial impact for the organisation: . Areas to improve. Waste reduction, capacity improvement, downtime reduction, etc. . Effect on customer satisfaction. On-time delivery and defect reduction . Effect on the bottom line. Significant financial impact, doable in 4-6 months, and benefits realised in 6-12 months period.

Antony (2004) and Pyzdek (2003) accentuated the following guidelines in selecting any Six Sigma projects: . linkage to strategic business plan and organizational goals; . sense of urgency (how important the project is); . project scope (doable within 4-6 months); . project objectives must be clear, succinct, specific, achievable, realistic and measurable; . project selection criteria must be established; . project must have the approval and support of senior manager; . focus on critical business process performance characteristics (CTQ, CTC; CTD); and . project selection should be based on realistic and good metrics (defect per million opportunities, yield, process capability, etc). The following table (see Table I) illustrates some of the Six Sigma projects with their key benefits obtained. Critical Success Factors (CSFs) of Six Sigma deployment in healthcare sector The idea of identifying the CSFs as a basis for determining the information needs of managers was popularised by Rockart (1979). In the context of Six Sigma, CSFs represent the essential ingredients without which the initiative stands little chance of success. Each one must receive constant and careful attention from management as these are the areas that must “go right” for the organisation to flourish. If results in these areas are not adequate then the efforts of the organisation will be less than desired. The leaders of health care industry should consider the application of Six Sigma from the perspective of improving the quality and capability of current processes as well as the ability of processes to deliver patient care and safety. The following CSFs are essential for the successful development and deployment of Six Sigma in a hospital environment. Uncompromising top management support and commitment Applying Six Sigma in a health care sector is not easy, and if the senior management team is not on board, it is almost certainly a formula for failure. The deployment of Six Sigma should begin with a two day broad overview of Six Sigma business strategy for the senior management team, ensuring buy-in and commitment for the implementation. Six Sigma project champions responsible for identifying and overseeing projects must be carefully chosen before the training program. In order to buy-in senior management support and commitment, it is also essential to select projects which are tied to strategic business focus. Formation of Six Sigma infrastructure and the appropriate training The selection of right people is crucial for the execution of Six Sigma projects. Once the Six Sigma infrastructure is defined with the assistance of person with adequate experience of Six Sigma in the service industry, training may begin. Project champions known as “Black Belts” should receive a good overview of Six Sigma fundamentals

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and the skills required for project selection, project prioritisation, project scoping and project execution. The “Black Belts” must receive four weeks of intensive training, one week each month for four months. The focus of the training must be on the execution of Six Sigma projects and the required tools and techniques for statistical analysis, problem solving and project management. The Black Belts should work on two Six Sigma projects as part of their certification process with each black belt expected to spend at least 80 per cent of their time on Six Sigma projects. Green Belts are the next level within the organisation and must receive two weeks of training on six sigma quality management and have the ability to execute and complete six sigma projects. Green Belts may work part-time and are expected to select a project from their own processes at the work place. They may also get involved with those projects which are executed by Black Belts but are also expected to complete at least 2-3 projects annually.

Project selection and the associated financial returns to the bottom-line Potential Six Sigma projects within a healthcare setting may relate to operational processes such as billing, registration or work flow or they may involve clinical procedures such as medication administration. When identifying and prioritising projects in a healthcare industry, the first consideration should be the customer and knowing the Critical-to-Quality characteristics (CTQs) that drives the project. The customer in this context may be the patient, physician, nursing staff, department manager or other stakeholder, depending on the process being reviewed. The following tips may be useful while selecting potential Six Sigma projects in health care industry: . projects must be aligned with critical hospital issues, patient care issues and strategic objectives of the business; . projects must be feasible to execute from a resource and data standpoint; . project objectives must be clear to everyone involved in the project; . ensure that projects can be completed on time; . ensure that a tollgate review must be performed at every stage of the Six Sigma methodology; and . select those projects which have the ability to show measurable improvements in quality, cost and timeliness parameters. Goldstein (2001) presented the following attributes of good projects: . focus on critical to quality (CTQ) characteristics; . the response variable can easily be measured; . financial benefit to business; . easy collection of data; . high probability of success; . project completion in four to six weeks; . not to leave on black belt to select their own project; and . use of correct approach.

Effective communication at all levels Effective clear communication channels at all levels of the organisation is considered to be crucial to ensure active participation of team members and engagement of these members on projects. Lack of communication was a common cited implementation failure for many quality management initiatives in healthcare industry. Through effective communication, organisations can establish a common language for change and improvement. Developing organisational readiness A thorough assessment on cultural readiness to determine whether an organisation is ready or not to embark on Six Sigma initiative may be a worthwhile exercise. How successful an organisation has been with previous initiatives will reflect the culture and leadership of the organisation. The lack of sustainable, relevant and related quantifiable results will indicate whether or not an organisation is in a position to embrace the Six Sigma business strategy. Effective leadership Leadership is the key characteristic to keep in mind when selecting the people for launching the Six Sigma initiative. Achieving the desired results will require changing the way we work and changing the mindset of people. In other words, there is a need move people successfully from the old way of doing things to new way of working which demands supportive leadership. The following issues may be considered for measuring leadership commitment within a Six Sigma initiative: . clear direction and guidance on deploying Six Sigma; . commitment of both financial and personnel resources for the initiative; . a clear strategic deployment plan showing the tangible objectives and goals of the initiative; . development of a communication plan (i.e. need for the initiative, the benefits of implementation, roles and responsibilities of everyone in the new way of thinking, etc.); . focus on tangible results; and . reward and recognition system. Some common barriers and challenges in the implementation of Six Sigma within the health care industry There are several barriers and challenges lurking below the surface that healthcare organisations need to consider prior to the implementation and deployment of Six Sigma business strategy. The first and foremost challenge is the initial investment in Six Sigma Belt System training. Secondly the absence or difficulty of obtaining baseline data on process performance is another major challenge. There will be lots of data available in the health care sector, however, most of the time these data are not readily available for its analysis. For the health care industry, it is often a struggle to understand identify processes which can be measured in terms of defects or errors per million opportunities which can lead to poor analysis of problem situations. Another barrier to Six Sigma deployment in health care industry is the psychology of the workforce. Compared to manufacturing processes, healthcare service processes

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are subject to more noise or uncontrollable factors such as sociological factors, personal factors, etc. The measurement of patient satisfaction in a hospital environment is more difficult due to the human behavioural interaction associated with the delivery of service. Changing the machine parameter settings on a machine is quite a different matter than training staff or adjusting work procedures or tasks. Last but not the least, it is important to present recommendations and improvement report using the business language rather than the statistical language. What does the future hold for Six Sigma in healthcare? Six Sigma has maintained momentum for over 15 years now, much longer than many non-Six Sigma advocates expected. The question now remains how long can Six Sigma survive in leading organisations who are practising this strategy for solving business problems. In our opinion, the integration of Six Sigma with Lean thinking will be the next big step for such organisations. Although the integrated approach is widely accepted by many manufacturing organisations for the last few years, service industries are still far behind in the integration of Lean and Six Sigma strategies. In the authors’ opinion, we will witness the introduction of Six Sigma principles in the design and development of new service processes and products within service industry. This is also referred to as Design for Six Sigma (DFSS). DFSS is more useful if new processes have to be designed for achieving world class capabilities. In the future, we will see the integration of Six Sigma within an holistic quality improvement strategy in an organisation rather than treating it as a separate initiative for improving process, product and service quality. Conclusion Although Six Sigma has been used by world class companies for several years with immense success, its application in healthcare sector is still in its infancy. Appropriately implemented, Six Sigma clearly produces benefits in terms of laboratory and medication error reduction, improved patient care, etc. Some of the early successful applications of Six Sigma in health care have resulted in a reduction of surgical inventory costs, reduction in length of stay at ER and an improvement in patient satisfaction. The success stories of Six Sigma are rapidly growing, all touting the impact of this powerful and rigorous methodology to problem solving. The authors believe that Six Sigma as a business strategy allows health care sector to deliver a truly high class service to patients. Think of the true impact that Six Sigma could have if we focus on the core issues of health care and improving the quality of lives of patients. In authors’ opinion, the application of Six Sigma in health care industry will continue to grow, especially here in the UK over the next five years or so. This powerful business strategy could be something NHS should seriously consider in the next five years or so to tackle operational costs, inefficient process problems and enhance patient safety. We will witness the integration of Lean and Six Sigma methodologies in the next few years in Europe for reducing operational costs in health care and enhancing patient safety. Lean may be used to reduce waste and non-valued added steps in processes and thereby obtain a better flow and reduce cycle time whereas Six Sigma may be used to reduce process variation and achieve consistency in the quality of service and delivery parameters. As with all improvement strategies all it takes a couple of brave leaders willing to take the right course and confront resistance to core issues once and for all.

References Antony, J. (2004), “Six Sigma in the UK service organisations: results from a pilot survey”, Managerial Auditing Journal, Vol. 19 No. 8, pp. 1006-13. Antony, J., Antony, F.J., Kumar, M. and Cho, B.R. (2007), “Six Sigma in service organisations; benefits, challenges and difficulties, common myths, empirical observations and success factors”, International Journal of Quality & Reliability Management, Vol. 24 No. 3, p. 294. Black, K. and Revere, L. (2006), “Six Sigma arises from the ashes of TQM with a twist”, International Journal of Healthcare Quality Assurance, Vol. 19 No. 3, pp. 259-66. Goldstein, M.D. (2001), “Six Sigma program success factors”, Six Sigma Forum Magazine, Vol. 1 No. 1, pp. 36-45. Heuvel, J., Does, R.J. and Verver, J.P. (2005), “Six Sigma in healthcare: lessons learned from a hospital”, International Journal of Six Sigma and Competitive Advantage, Vol. 1 No. 4, pp. 380-8. Hewitt, P. (2005), “Hewitt warns managers of NHS reform challenges”, available at: www. societyGuardian.co.uk (accessed 17 July 2007). Lazarus, I.R. and Butler, K. (2001), “The promise of Six Sigma (Part 1)”, Managed Healthcare Executive, Vol. 11 No. 9, pp. 22-6. Lazarus, I. and Stamps, B. (2002), “The promise of Six Sigma (Part 2)”, Managed Healthcare Executive, Vol. 12 No. 1, pp. 27-30. Natarajan, R.N. (2006), “Transferring best practice to healthcare: opportunities and challenges”, The TQM Magazine, Vol. 18 No. 6. Pande, P., Neuman, R.P. and Cavanagh, R.R. (2000), The Six Sigma Way, McGraw-Hill, New York, NY. Pyzdek, T. (2003), The Six Sigma Handbook, McGraw-Hill, New York, NY. Rockart, J.F. (1979), “Chief executives define their own data needs”, Harvard Business Review, Vol. 57, March/April, pp. 81-93. Shalala, D. (2005), “Call to address ‘deeply dysfunctional’ healthcare systems”, available at: www.SocietyGuardian.co.uk (accessed 17 July 2007). Snee, R.D. (2001), “Dealing with the Achilles Heel of Six Sigma initiatives”, Quality Progress, March, pp. 66-72. Stahl, R., Schiltz, B. and Pexton, C. (2003), “Healthcare’s horizon”, Six Sigma Forum Magazine, Vol. 2 No. 2, pp. 17-26. Steele, A.D. (2004), “Six Sigma toolkit at your service”, Six Sigma Forum Magazine, February, p. 30. Further reading Antony, J., Kumar, M. and Madu, C. (2005), “Six Sigma in small and medium sized enterprises: some empirical observations”, International Journal of Quality & Reliability Management, Vol. 22 No. 8, pp. 860-74. Corresponding author Jiju Antony can be contacted at: [email protected]

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Amy Lodge Pennine Acute Hospitals NHS Trust, Fairfield General Hospital, Bury, UK, and

David Bamford Manchester Business School, The University of Manchester, Manchester, UK Abstract Purpose – The purpose of this research is to focus on a hospital Division of Diagnostics and Clinical Support (150 medical, 1,975 non-medical staff) and how systems were enhanced through lean principles application to facilitate quality and performance improvement. Design/methodology/approach – An action research methodology was adopted. The research involved: review of available performance and quality improvement literature; identification of the systems that required improvement; adoption and implementation of new working methods. Findings – The results were recognised as being beneficial to all parties, especially the patients! Staff recognised the need for change; the process transformation was actually welcomed. Patient waiting times reduced from 26 to 13 weeks. Fast-track/“query cancer” service for out-patients now within ten days; the majority of in-patients receive imaging within 72 hours. Ultimately, patients are diagnosed faster and treatment commences earlier. Departmental managers can effectively manage capacity to meet demand because they now understand the waiting “profile”. Research limitations/implications – The methodology applied was appropriate, generating data to facilitate discussion and from which to draw conclusions. A perceived limitation is the single case approach; however, Remenyi et al. argue that this can be enough to add to the body of knowledge. Practical implications – Guidelines indicating “What went well?” and “What could have gone better?” were produced. These centred on the practical application aspects. The implementation methodology developed is being used elsewhere within the same hospital group. Originality/value – The paper demonstrates that the application of improvement techniques, such as “Lean”, can focus efforts to improve performance. This is of value to those working in the UK healthcare and wider public sector. Keywords Service improvements, Hospital management, National Health Service Paper type Research paper

Leadership in Health Services Vol. 20 No. 4, 2007 pp. 254-265 q Emerald Group Publishing Limited 1751-1879 DOI 10.1108/17511870710829364

Introduction Due to the perishable nature of healthcare services, it is vital that capacity is managed appropriately through the use of effective waiting list management. In order to do this it is essential that a service works towards matching demand and capacity. In healthcare the need to effectively manage services is magnified by the high value placed on delivery by the recipient, the patient (Bamford and Chatziaslan, 2005). In the United Kingdom, the Department of Health sets performance targets centrally for organisations to achieve within specified timeframes, e.g. “No patient is to wait longer than thirteen weeks for diagnostic imaging” (Department of Health, 2004). This paper outlines the approach to waiting list management in a National Health Service (NHS) hospital Trust in the North-West of England. Following an action

research approach to the application of lean principles, the paper focuses on what was done to produce electronic waiting lists and to facilitate a logical attitude to their management across the organisation and what can be done in the future. The Trust undertakes up to one million radiological examinations each year and faces challenging waiting times targets for achievement by 2008. Effective waiting list management will enable the departments to reduce the capacity lost through patient non-attendance – Did Not Attends (DNAs) 5-12 per cent, late cancellations 1-2 per cent and duplications, allowing the right patient to receive the right examination at the right time.

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The organisation Pennine Acute Hospitals NHS Trust (PAHT) is a public sector organisation, established following the merger of five acute hospitals in April 2002 in the North-West of England. PAHT manages hospitals in Bury, North Manchester, Oldham and Rochdale serving a population of nearly one million (Figure 1). The Trust is one of the largest non-teaching hospitals in the United Kingdom. The Division of Diagnostics and Clinical Support (DDCS) at PAHT provides a wide range of services across five acute sites including: Radiology, Pathology, Physiotherapy, Critical Care, Anaesthetics and Dietetics within an inpatient, outpatient and some community settings. Most services are provided on at least four of the five sites and therefore management of multiple sites across a relatively large geographical area can prove problematic. The DDCS consists of over 2000 staff including over 150 Medical Consultants. The problem Hospitals within the UK must achieve targets prescribed centrally by the Department of Health. A target set at national level must be operationalised and achieved locally, often without additional resources. The NHS Improvement Plan (Department of Health, 2004) set out the requirement that by 2008 the maximum wait from a General Practitioner referring a patient, to that patient commencing upon their first definitive treatment should be eighteen weeks. At this stage, waiting times for some diagnostic services were over one year, access to these services therefore required expediting in

Figure 1. PAHT location map

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order for the target to be achieved. Early estimates within the DDCS indicated that in order to meet the eighteen week referral to treatment target, access to services must be within a zero to four week window. In September 2005 the Department of Health released Choice of Scan Guidance (Department of Health, 2004) which stated that by November 2005 no patient should be waiting longer than twenty-six weeks for Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). The DDCS agreed to focus on improving access to these services, and Radiology in particular. Within the Radiology services across PAHT waiting lists were held manually and all management information was manually produced. It was therefore apparent that the management of waiting lists within the DDCS would be paramount to achieve the pending targets and meet the Department of Health requirements to electronically report waiting times. A working group was set-up consisting of a senior member of the DDCS (Performance and Service Improvement Manager) and Information Technology specialists (Modernisation Information Analyst and Modernisation Information Lead) from within PAHT. It was decided that a scoping exercise should be undertaken to determine what management information was available for the Radiology services across PAHT and whether current systems could be manipulated to provide useful waiting list information. The technology The vision of the working group was to provide an intranet-based waiting list module for Radiology services which could potentially be rolled out across other services within the DDCS. PAHT Radiology services were operating three different Radiology Information Systems (RIS) – software packages – to record radiology reports and in some cases images. None of the RIS were able to generate meaningful waiting list or waiting time information. The working group established that an extract of raw data at a patient level could be collected and collated, however, clerical and clinical staff would need to start using each of the RIS in a different way. The DDCS compiled an Access to Diagnostics Policy based on the requirements of the Department of Health policies (Department of Health, 2004, 2006a), outlining what the departmental staff within Radiology would need to do in order that a waiting list could be generated from their RIS. Once extracted, this data would eventually feed an intranet-based waiting list module from which waiting lists could be managed centrally. The change The NHS is dynamic and complex (Iles and Sutherland, 2001) as are the organisations it is made up of. This complexity derives from many factors, the majority of which pre-date or are external to the NHS itself – professional socialisation, differing needs of customers, local priorities, resource constraints, pressure groups etc. PAHT is a culturally diverse organisation which serves a number of socio-economic groupings. Each PAHT site is different from the others and these differences have to be recognised and managed. In undertaking any changes within an organisation, the culture must be taken into consideration. Johnson and Scholes (1999) represented the culture of the NHS through the use of the Cultural Web (Figure 2) which represents the “taken for granted” attributes of an organisation, the under currents as to why certain things happen or people do things in a particular way.

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Figure 2. NHS cultural web

From this it can be ascertained that change is often viewed cynically and that managers and change facilitators can be perceived as “villains”. At PAHT the experience is that change is achieved through perseverance – change programmes work when they have been locally agreed but have executive level support (Bamford and Lodge, 2006a, 2006b; Lodge, 2006). Change in the NHS has been evident since its introduction in 1948 (Bamford and Daniel, 2005; Pollock, 2004). All organisations experience change, but in the NHS the scale of the change is greater due to its size, at over 1.3 million employees it is one of the largest in the world (Department of Health, 2006b). Bamford and Daniel (2005, p. 2) reflect on change in the NHS as often leaving people feeling “bruised, disenchanted and demotivated”. Changes implemented within one area of the hospital can potentially have a knock-on effect in other areas as it is rare for a patient pathway to take place solely within one department (de Brujin, 2002; Iles and Sutherland, 2001) and therefore it was vital to bear this in mind when making any changes. The changes made were in relation to how patient referrals were managed. Patient referrals for radiological examinations at PAHT are made using a paper-based system and therefore it was necessary to turn this information into electronic data. Each of the four departmental clerical teams was introduced to the vision for the service – to provide an intranet-based waiting list module for Radiology services – and the

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Figure 3. Diagnostics patient target list, screen shot

benefits of this for them was outlined emphasizing the increased control, better understanding of capacity requirements and easy access to patient information to answer queries. The changes in data input required differed at each site from a few key strokes to minute detailed inputting regarding suspensions to lists and planned procedures. Whilst implementation of the data changes was resisted, once the waiting list could be produced for the department, from a centrally generated database in the first instance then on the intranet-based system (see Figure 3) then the advantages were openly recognised. Staff reported that they could not remember how they had been able to do their jobs without the waiting list tool, praise indeed! In addition to the data entry changes, the departmental teams were re-trained in the “Key Principles of Waiting List Management” as set out by the Institute for Innovation and Improvement (2006). These principles include only adding patients to the list who are fit, ready and able to attend an appointment, treat all patients in order of clinical priority and chronological order and only suspend patients from a list if they are socially or medically unable to attend. The new system allowed the patients’ status and position on the list to be easily understood and therefore improved their overall management. The success of the introduction of an intranet-based waiting list system in addition to the re-training in waiting list management principles demonstrates a successful change initiative in PAHT. The cultures of the departments and their composite team members on each site differ widely in general terms, however amongst them there were

recognisable characters whose support would be necessary for any changes to be sustainable – those who would champion the process and could see the benefits helped to drive the changes, those who were vehemently opposed have to be kept informed and eventually brought on board with the changes (these can sometimes become your best advocate if you can convince them of the change). Culturally within the NHS the over-riding ethic of the majority of staff members is to provide the best possible treatment for the patient and being able to prove that patients were seen quicker and at an appropriate time in relation to others referred, “sold” the change and has therefore encouraged sustainability. Support from the executive level bubbled to the surface as the national targets for radiology loomed large – solutions were needed to assist in the reduction of waiting lists and this system was recommended to the executive team as a way in which this could be achieved. The intranet-based Diagnostic Services Patient Target List (DPTL) was made available from the PAHT intranet and developed in conjunction with an external software company. The DPTL allowed for partial booking to be introduced within some services which contributed to a reduction in waiting times as patients are given a choice of appointment; they are more likely to attend as the appointment is “negotiated” with them (Institute for Innovation and Improvement, 2006). The DPTL can be viewed by referrers to the services and they are able to generate information specific to their own patients, reducing a need to contact departments directly. Although this paper focuses on Radiology, the DPTL was also made operational in Cardio-Respiratory and Neurophysiology across PAHT.

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The results All radiology departments actively began using the intranet-based waiting list module in September 2006 and since this time it has contributed to the overall reduction in waiting times across the different imaging modalities (Figures 4, 5 and 6). In one department the list is used as the focus for a weekly meeting where capacity is discussed, another site use it daily to monitor, manage and book their patients. The

Figure 4. Comparative waits magnetic resonance imaging

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Figure 5. Comparative waits computed tomography

Figure 6. Comparative waits non-obstetric ultrasound

DPTL has given the departments meaningful information which they can use to manage their patients. Although in two of the three key modalities the list size has increased, the longest waiting time has decreased by over 30 per cent in all areas and this is due to more efficient waiting list management (Table I). Waiting times did not drop dramatically from the first day of implementation of the DPTL, however over a few months it became evident that some departments were able to operate the new system much better than others. This was evidenced in a rapid reduction in the waiting list “tail” (the low volume drag at the back of each list which often signals poor management or booking systems) at the more co-operative sites. This allowed for a focus on the other sites, using the more successful departments as an example and support for those who were failing to grasp the changes. The total

impact of the DPTL was felt across PAHT from the beginning of February 2007 when all departments were utilising it appropriately.

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Discussion . . . We confuse the measurement with the reality . . . a number is as far from a story as a wedding ring is from a marriage . . . (Berwick, 2004, p. 227).

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The overriding message from the research is that performance measurement and management in the way that it is prescribed nationally, provides only a small part of the operational picture. In order to determine the need for service improvement, it is necessary to first understand the processes concerned and measurement provides a method of defining and diagnosing the problem. The techniques used to undertake this work can include – process mapping, demand analysis, capacity analysis and flow. It is vital that all key stakeholders are involved in the determination and diagnosis of the problem, as well as in the formulation of the proposed solution using techniques such as focus groups. It is essential that underlying, and even qualitative, measures are taken in order to provide an all encompassing picture of performance and not a headline view. Where measures are used in benchmarking, it is vital that the information presented is taken from appropriate sources and is comparable: . . . public sector organisations have been encouraged – even “forced” – into adopting private sector techniques . . . (Bolton, 2003, p. 21).

The project demonstrated that where departments were able to influence the measurements chosen, ownership was much greater than where the measures had been enforced from elsewhere. The applicability of “lean principles” to the NHS and public sector in general has been discussed over the last year (Radnor et al., 2006). The change undertaken can be linked to the reduction of time-wasting activities with departments including – working with badly designed information systems, working from unreliable information and dealing with failure demand amongst other things. The implementation allowed the departments to work more efficiently – the right person delivering a job role appropriate to their grading and expertise: . . . there is always a kind of contempt in the act of measuring . . . we confuse the measurement with the reality . . . (Berwick, 2004, p. 227).

Where measures were enforced the required level of performance has, on the whole, been achieved despite the reservations of capability by operational staff. This could be indicative of staff not understanding the improvements that could be achieved through changes in ways of working. The timescales for improvements have been relatively

MRI CT NOUS

List volume September 2006

List volume February 2007

Longest wait September 2006

Modal wait September 2006

Longest wait February 2007

Modal wait February 2007

953 846 2,254

903 1,136 3,205

18 20 20

13 14 13

12 13 13

8 7 8

Table I. Comparative waiting times and volumes September 2006-February 2007

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short in consideration of the volume of change required. It is frustrating that senior level interest has, on the whole, only been felt when a national target has been introduced: . . . I couldn’t think that we need anybody else to come in and borrow our watch and tell us what the time is . . . (Radnor and Lovell, 2003, p. 107).

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Staff delivering a service are the experts in its delivery. With coaching, they can also become the experts in the way that service could be delivered more efficiently and effectively. The role of one the authors as a consultant in the organisation is vital to the development of the understanding of current capabilities and how they can be improved through process change. There is still however a distinct resentment of measurement and that the measures reported are going to be used to reprimand those delivering the service. It is vital in developing a performance management system that employees are consulted and collaborated with in order for any measurements to be accepted: . . . The difference between what we do and what we are capable of doing, would suffice to solve most of the world’s problems . . . (Gandhi Institute, 2006).

The overriding departmental responses to national targets is that they cannot be achieved within existing resources. There is evidence that the lack of operational management capabilities in front-line departmental managers contributes to the difficulties faced when trying to achieve targets (Bamford Lodge, 2006a, 2006b; Lodge, 2006): . . . Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is as far as he knows, the only way of coming downstairs, but sometimes he feels that there is another way, if only he could stop bumping for a moment and think of it . . . (Milne, 1926, p. 38).

There is a reluctance within the public sector for “thinking time” to be acknowledged as a pre-requisite for successful management – if a person is caught thinking then they are immediately assumed to be idle: . . . Change means movement. Movement means friction. Only in the frictionless vacuum of a nonexistent abstract world can movement or change occur without that abrasive friction of conflict . . . (Horwitt, 1992, p. 76).

Any change programme should expect resistance within a socially organised process and the NHS is not an exception to this rule. Some staff within the NHS have become change fatigued and are suspicious and resistant to change agents without considering the possibility that change could be beneficial. A change agent within the NHS must have credibility and must gain the trust of those with whom they are working: . . . when programme champions play an active role in the development, spread and implementation of innovation, these processes are generally more effective . . . (Greenhalgh, 2004, p. 165).

Convincing staff that change is for the benefit of the patients is vital to achieving a successful change programme.

If we had to do it all again . . . What went well? Belief in the vision. The working group were told by senior members of the Information Technology Division that they were trying to achieve the impossible, and that they did not believe that the work could be done. The working group believed from their scoping exercise that it could be done and that it would be of benefit to all stakeholders as well as providing management information for local and national use. Through persistence the work was completed and the vision achieved. Consistency in the message. It was vital that staff at all levels were given the same message and that this was used to develop further understanding of the need to effectively manage waiting lists. It was explained that this would benefit staff as well as patients – as waits reduce then fewer patients and referrers are disgruntled with the service and therefore fewer patients call in which in turn reduces the amount of time spent answering queries. Provide hands-on training. The training was delivered to by the working group to key members of each department who then in turn trained a group of their peers. This training was backed up by a manual which was produced by the DDCS Performance and Service Improvement Manager. What could we have done better? Involve shopfloor staff earlier. Although targets are talked about at all levels of the organisation, experience suggests that until there is a requirement for members of a team to change their own practices then the implications of that target will not hit home (Bamford and Lodge, 2006a, b; Lodge, 2006). It is difficult to know therefore whether there is an optimal length for a consultation period – the targets have been in the public domain for nearly three years, and on DDCS agendas for the same period. Publicise achievements locally. The DPTL has been in use since September 2006 and had not built momentum until the 1 April 2007 target of all patients to be seen within thirteen weeks loomed large in January. In the experience of the authors it is often the case that the need for change is not recognized until it is almost too late (Bamford and Lodge, 2006a, 2006b; Lodge, 2006). More publicity at a local level in the form of posters and presentations might have improved this, but again would staff have taken this on board before it affected them? Time for reflection during and after each phase. It has been recognised by the working group that reflection throughout the diagnostic, development and action phases might have resolved some of the problems encountered before they happened – e.g. usability of the intranet front-end, ability of users to adapt data entry methods, lack of support from departmental managers. After the completion of the next phase of the roll-out a reflection exercise has been planned which will feed into further development and planning. The future It is the intention of the DDCS to utilise the DPTL across all services to ensure that waiting lists are being efficiently, effectively and fairly managed. Work is currently underway within the therapy services, where there are paper records only. A Referrals Management System has been developed into which all patient information is entered from referral to first appointment to last follow-up. This can be reported via the DPTL

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and not only provides waiting times information, but activity and detailed pathway analysis – e.g. how many physiotherapy follow-ups are required following a hip replacement. The possibilities of this have not as yet been fully explored, but the potential has been recognised and this work has been prioritised by the PAHT Executive Board who agree that the vision for DDCS should be for the right patient to receive the right examination at the right time.

References Bamford, D.R. and Chatziaslan, E.A. (2005), “Matching demand and capacity of patient services within the UK National Health Service”, Proceedings of EurOMA 2005 Conference, Budapest, Hungary, pp. 2159-68. Bamford, D.R. and Daniel, S. (2005), “A case study of change management effectiveness within the NHS”, Journal of Change Management, Vol. 5 No. 4, pp. 391-406. Bamford, D. and Lodge, A. (2006b), “Improvement and service delivery in an NHS radiology department”, Proceedings of EurOMA 2006 Conference, Glasgow, Scotland. Bamford, D. and Lodge, A. (2006a), “Quality improvement and quality service delivery in radiology”, Proceedings of 11th European Forum (BMA) on Quality Improvement in Health Care, Prague, Czech Republic. Berwick, D.M. (2004), Escape Fire: Designs for the Future of Health Care, Institute for Healthcare Improvement, Jossey-Bass, San Francisco, CA. Bolton, M. (2003), “Public sector performance measurement: delivering greater accountability”, Work Study, Vol. 52 No. 1, pp. 20-4. de Bruijn, H. (2002), “Performance measurement in the public sector: strategies to cope with the risks of performance measurement”, The International Journal of Public Sector Management, Vol. 59 No. 7, pp. 578-94. Department of Health (2004), NHS Improvement Plan: Putting People at the Heart of Public Services, Her Majesty’s Stationery Office, London. Department of Health (2006a), Choice of Scan Phase 2: Guidance, Her Majesty’s Stationery Office, London. Department of Health (2006b), “Careers PDF”, available at: www.dh.gov.uk Gandhi Institute (2006), Gandhi Institute, web site, available at: www.gandhiinstitute.org/ Greenhalgh, T. (2004), How to Spread Good Ideas. A Systematic Review of the Literature on Diffusion, Dissemination and Sustainability of Innovations in Health Service Delivery and Organisation, National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, London. Horwitt, S.D. (1992), Let Them Call me Rebel: Saul Alinsky, His Life and Legacy, Vintage Books, New York, NY. Iles, V. and Sutherland, K. (2001), Managing Change in the NHS – Organisational Change: A Review for Health Care Managers, Professionals and Researchers, National Co-Ordinating Centre for NHS Service Delivery and Organisation R&D, London. Institute for Innovation and Improvement (2006), “No delays achiever: service improvement tools”, available at: www.nodelaysachiever.nhs.uk/ServiceImprovement.htm Johnson, G. and Scholes, K. (1999), Exploring Corporate Strategy, 5th ed., Prentice-Hall, Englewood Cliffs, NJ, p. 75.

Lodge, A. (2006), “An empirical investigation into the application of operations management principles to healthcare delivery”, MPhil thesis, Faculty of Humanities, Manchester Business School, Manchester. Milne, A.A. (1926), Winnie-the-Pooh, Egmont Books Ltd, London (reprinted March 2006). Pollock, A.M. (2004), NHS plc: The Privatisation of Our Health Care, Verso, London. Radnor, Z. and Lovell, B. (2003), “Success factors for implementation of the balanced scorecard in an NHS multi-agency setting”, International Journal of Health Care Quality Assurance, Vol. 16 No. 2, pp. 99-108. Radnor, Z., Walley, P., Stephens, A. and Bucci, G. (2006), Evaluation of the Lean Approach to Business Management and its Use in the Public Sector, Scottish National Parliament, Edinburgh. Remenyi, D., Williams, B,, Money, A. and Swartz, E. (1998), Doing Research in Business and Management, Sage Publications, London. Corresponding author David Bamford can be contacted at: [email protected]

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PRACTICE PAPER

Should doctors stop taking the generic history? A comparison of house officers’ and nursing staff clerking in general surgery R. Gudena, N. Khetan, S. Luwemba and L.R. Jenkinson Department of General Surgery, Ysbyty Gwynedd, Bangor, UK Abstract Purpose – The purpose of this paper is to show how the implementation of the European Working Time Directive in August 2004 has dramatically decreased junior doctors’ working hours, as a consequence of which new ways of working will need to be found. Traditionally both doctors and nurses record the same generic history (past medical history, social and family history, drug history and allergies) in their own notes. This is unnecessary duplication and maybe only nursing staff should record this information. This study is undertaken to identify the differences between junior doctors’ and nurses’ clerking to assess whether they are comparable. Design/methodology/approach – A prospective study of 100 case notes from elective and emergency admissions was undertaken. The completeness of various parts of the history and the recording of the vital signs were compared between nurses and house officers. Findings – The Past Medical History was complete in only 30 per cent of the house officers’ notes and 42 per cent of nursing records. The social history was complete in all the nursing records but only 35 per cent of the doctors’ notes. Nurses recorded a complete personal history more than doctors (62 per cent v. 13 per cent respectively). The drug history was poorly recorded in house officers’ notes, being complete in 22 per cent, whereas this was complete in 73 per cent of nursing records. The record of the history of allergies was poor in both groups at just over 10 per cent. Finally 87 per cent of nurses managed to record vital signs but these were missing from nearly half of the house officers’ notes. Originality/value – The study has shown that details of the generic medical history are recorded more completely by the nursing staff and only they should record this information. This will allow junior doctors more time to deal with the increased demands and reduced hours of work. Keywords Doctors, Nurses, European directives Paper type Research paper

Leadership in Health Services Vol. 20 No. 4, 2007 pp. 266-269 q Emerald Group Publishing Limited 1751-1879 DOI 10.1108/17511870710829373

Introduction The implementation of the European Working Time Directive combined with the New Deal reduced working hours from 72 to 56 hours. This, together with shift work and the introduction of the Hospital at Night concept, has reduced the numbers of doctors who work at night (European Council, 1993; NHS Management Executive, 1991; Pickersgill, 2001). There are now fewer doctors to help with elective admissions, outpatients and operating sessions. Over the years we have been improving the quality of information gathered from patients and first introduced a generic history sheet, which was completed by patients attending clinic. Patients who were admitted as in-patients still had the generic history recorded both by the nurse and doctor in different documents, which are not seen by the other. This is common practice

throughout out the NHS with nursing records being entirely separate from medical records. Could we prevent this duplication amongst doctors and nurses producing a “leaner” service for patients? This study was the first of several in our department to formally look at ways of improving the medical history and asked the question – could the “generic history” (past medical history, social and family history, current medication and allergies and vital signs) be recorded by nurses alone. We conducted a prospective comparison of doctors’ and nurses’ records with a view to reducing the amount of unnecessary duplicate data entry. Patients and methods We conducted a prospective study of 100 concurrent medical and nursing notes of patients admitted to the general surgical unit during the period of March 2002 to July 2002. We compared the completeness of the past medical history, the social and family history, the drug history and allergies, and the record of vital signs (Pulse rate, Blood pressure and temperature) between the house officers’ and nurses’ notes. A pre-defined protocol and standard proforma were used to collect the data. The results were categorised as complete if all the details were mentioned, incomplete if some of the details were missing, absent if the details were missing completely. We confirmed details of the history by checking with the previous records in the case-notes, the prescription charts and, if necessary, the GP. Results The results are illustrated in Figure 1. The Past medical history was complete in only 30 per cent of the house officers’ notes while the nurses were marginally better with 42 per cent complete. The social history was complete in all the nursing records but only 35 per cent of the doctors’ notes. Nurses recorded the personal history more frequently than doctors (62 per cent v. 13 per cent respectively). The drug history was poorly recorded in house officers’ notes being complete in 22 per cent whereas this was complete in 73 per cent of nursing records. Full details of the allergy history were present in just over 10 per cent of the nurses and house officers’ notes, a poor performance on both counts. Finally 87 per cent of nurses managed to record vital signs but these were missing from nearly half of the house officers’ notes. Discussion This study has shown that the nurses are recording the same or more details of the generic medical history than house officers, often within minutes of each other, but this information is still incomplete. The age-old tradition of a nurse taking the history followed shortly by the house officer repeating some of the same questions should be abandoned. This is an unnecessary duplication of work that could be done by either of them. This study proves that nurses are capable of eliciting parts of the medical history and this is usually more complete than their medical counterparts. The marked reduction in medical support means will now have to our processes “leaner” to optimise this valuable resource. We recommend that the generic medical history (past medical history, social and family history, drug history and allergies) should be recorded once by the admitting nurse. This information should be available in the medical notes together with the base-line vital signs. This will prevent unnecessary duplication of effort by the junior doctors and allow them to concentrate on areas where their

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Figure 1.

expertise is needed. Other areas of duplication should be identified and we should move towards a single paper record, which is used by all professionals until the electronic patient record has been produced. We are currently evaluating a generic questionnaire for in-patients similar to that used by our outpatients and this will further make our service learner by reducing the demands on the nursing staff.

Taking the generic history

269 References European Council (1993), Council directive 93/104/EC, Official Journal of the European Community, L307, Brussels. NHS Management Executive (1991), Executive Junior Doctors – The New Deal, Department of Health, London. Pickersgill, T. (2001), “The European working time directive for doctors in training”, British Medical Journal, Vol. 323 No. 1266. Corresponding author L.R. Jenkinson can be contacted at: [email protected]

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News and views Edited by Jo Lamb-White

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Nursing leaders from around the world demand that UN member states move quickly on a women’s agency Keywords Leadership, Public health, Healthcare equality

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Nurse leaders from more than 80 countries who gathered for the International Council of Nurses’ global nursing conference, were distressed and perplexed to learn of inaction and stalling on the strong recommendation for the UN to establish a special agency for women. “ICN’s Council of Representatives, and the 13 million nurses working worldwide, ask the UN Secretary General and UN member states to move quickly on the clear recommendation that the UN High Level Coherence Panel delivered to the Secretary General in November 2006 for a dedicated women’s agency” declared Hiroko Minami, President of the International Council of Nurses. “There is no time to lose, no reason to pander to the deeply rooted forces that work against women’s empowerment and gender equality”, continued Dr Minami. “Without a women’s agency every global goal, including each of the Millennium Development Goals, will be unreachable.” “Across the globe and within the UN system itself, women are oppressed, marginalized, under-represented and neglected. They make up a huge majority of the world’s poor, illiterate, exploited and abused, and a tiny minority of decision-makers. This is not just unacceptable for women and girls, it is the biggest barrier to peace, health and prosperity globally.” The UN and the world need a full-fledged women’s agency: robustly funded, operational and with on-the-ground presence in every country. And we need it now. At the same, the healthy development of all citizens and communities is inextricably tied to the education and empowerment of women and the strengthening of their health. Where women participate on an equal footing, societies flourish. The absolute importance of gender equity in all realms of life and areas of social and economic development cannot be understated. ICN appeals to all – women, men, international agencies, national and regional organisation and governments – for robust support in ensuring the establishment of a well funded, independent gender entity with programme capacity at the country level. For further information: www.icn.ch

Patient safety goes international

News and views

Keywords Leadership capacity, Patient safety, Accountability

Don Berwick said the UK had hit milestones in improving healthcare Don Berwick, President of the Institute for Healthcare Improvement, has praised The Health Foundation for its work in improving patient safety in the UK, as part of the global patient safety movement that he said is now entering a “maturation phase”. Speaking at the International Forum on Quality and Safety in Health Care in Barcelona yesterday, Don likened patient safety to major social movements such as feminism and environmentalism. “We clearly have hit some milestones in the development of our shared efforts to improve healthcare”, Don said. “I have tracked these most closely in the UK, where there has been a tremendous maturation of the capacity to lead and cause improvements in a large system. The Safer Patients Initiative, for example, was an effort to go back to square one and redesign patient safety.” Between 2004 and 2006, the IHI ran one of the world’s most successful initiatives to date to reduce patient deaths from medical errors – the 100,000 Lives campaign. Over 3,000 hospitals from across the USA signed up to implement six key safety measures identified by the IHI and saw their death rates fall by up to 43 per cent as a result. Don revealed that one of the key factors in the campaign’s success was copying the tactics of political campaigns, including a bus tour and campaign rallies. Martin Fletcher, Patient Safety Lead at the World Health Organisation (WHO), also highlighted The Health Foundation’s role in supporting “pioneer hospitals” who are spreading best practice internationally. “One area we’re very interested in developing is pioneer hospitals”, Martin said. “There are some organisations around the world who have made very good gains in patient safety. We want to better understand the active ingredients of what they’ve done and make that learning available to others. We’re in the early stages of this work in partnership with The Health Foundation in the UK.” He gave the example of a hospital in Tokyo, visited by Chief Medical Officer for England Sir Liam Donaldson, where staff members’ safety proficiency level and accountability are clearly shown on their name badges. Teams from South Africa and Malawi led a discussion on how to improve healthcare in developing countries, where resources are scarce and the working culture is very different. The Malawi team, which is supported by The Health Foundation, is working to halve the death rates of women and babies during childbirth. They found that using local teams to devise solutions when systems broke down was key. “We want to ensure that when a patient arrives at the hospital, she receives friendly care, is taken care of when she goes into labour and delivers a live and healthy baby with no complications”, said Rose Kumwenda-Ng’oma, Programme Manager for The Health Foundation Consortium. “In the event that a complication arises, we want to ensure that it is identified promptly and dealt with appropriately.” Some of the innovations developed by the local teams include giving hospital admission forms to traditional birth attendants, allowing volunteer companions or family members to accompany patients and call when they need help, and installing an

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emergency box in each ward which contains all the equipment needed in the event of complications. For further information: www.health.org.uk/

Americas Canada’s new government signs first nations health agreement with BC and first nations leadership council Keywords Healthcare leadership, Healthcare equality, Collaboration

The Honourable Tony Clement, Federal Minister of Health, Premier Gordon Campbell of British Columbia (BC) and the British Columbia First Nations Leadership Council have signed Canada’s first-ever Tripartite First Nations Health Plan with the goal of improving the health and well-being of First Nations in British Columbia, closing the gaps in health between First Nations people and other British Columbians, and ensuring First Nations are fully involved in decision-making regarding the health of their peoples. In the ten-year trilateral agreement, all three parties have committed to action in four priority areas: (1) governance, relationships and accountability; (2) health promotion and disease and injury prevention; (3) health services; and (4) performance tracking. “First Nations people in Canada deserve quality, accessible and timely health care, and they have valuable insight to share that will improve health services in their communities”, said Minister Clement. “By signing this tripartite agreement – which is the first of its kind in the country – our goal is to ensure that First Nations in British Columbia can have an effective role in the design and delivery of health care services for their people, and they have responsibility for achieving results.” “The ten-year Tripartite Health Plan signed today is the first in Canada and supports our commitment to ensuring that First Nations are fully involved in decision-making regarding the health of their peoples”, said Premier Campbell. “This builds on British Columbia’s First Nations Health Plan released last year that will help us to close the health gap between First Nations people and other British Columbians in areas like life expectancy, mortality, youth suicide, infant mortality, diabetes rates and childhood obesity. It will also increase the number of First Nations health professionals and supports our other initiatives such as the appointment earlier this year of BC’s first-ever Aboriginal Health Physician Advisor.” The new First Nations Tripartite Health Plan outlines a shared vision for health and health services affecting First Nations in British Columbia. It describes the shared principles that will guide the interaction and collaboration among the three Parties. The plan also commits all Parties to work together to create a new governance

structure that will enhance First Nations involvement in the delivery of health services, and promote better integration and coordination of federally and provincially funded health services. “Studies have shown that self determination is fundamental in closing the social and economic gaps faced by First Nations. The BC First Nations Tripartite Health Plan contains key commitments to implement a new structure for the governance of First Nations Health Services in concert with other efforts targeted at specific health priorities facing our communities. Taken together, these efforts will improve the health and well being of First Nations people and communities in BC”, said Grand Chief Edward John, a member of the First Nations Summit political executive and First Nations Leadership Council. Today’s signing of the new First Nations Tripartite Health Plan fulfils a commitment made by all three parties in a Memorandum of Understanding on November 27, 2006, to enter into negotiations to develop a tripartite ten-year health plan. All three parties have been working together over the last six months to produce the final Tripartite Health Plan. For further information: www.hc-sc.gc.ca/ahc-asc

Leading edge and Daniels College of Business launch a new lean healthcare education initiative Keywords Change management, Process improvement, Building capacity

The Leading Edge Group and The Daniels College of Business at the University of Denver announced an agreement to launch a new and unique Lean Healthcare Education initiative. At a conference in Dublin last Friday, as part of Enterprise Ireland’s Technology Showcase, representatives from both sides of the new strategic partnership discussed their academic program aimed at preparing health professionals for managing change through process improvement across the global healthcare sector. The first deliverable will be a Lean Healthcare Black Belt program and will be available from October of this year. The Lean Healthcare Black Belt program is the first of its kind in the world and is aimed at doctors, consultants, nurses, administrators, allied health professionals and other professionals in the healthcare sector. Scott McLagan, Executive Director of Executive and Corporate Programs at the Daniels College of Business is very enthusiastic about the program. “The healthcare system worldwide has many challenges and we are committed to helping the organizations in this industry build new capabilities. We have tremendous expertise the areas of executive education and leadership development. This coupled with the Lean expertise and skill sets within the Leading Edge Group will go a long way towards ensuring the programs international success. Education in lean thinking should be part of an organisations competency framework to ensure consistency across all functions.” Joe Aherne CPA, Managing Director of the Leading Edge Group is delighted with this new strategic arrangement. “Applying lean thinking to the healthcare sector can

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provide significant cost and process efficiencies. However, in order to realise and sustain these benefits fully, there is an urgent requirement to educate and empower healthcare staff in the principles and methodologies involved.” The Daniels College of Business at the University of Denver is focused on creating leaders equipped to thrive within the complexities of business today. Their academic excellence is fast making Daniels the top choice for students around the globe who are seeking to develop distinct careers that bring together personal and professional goals. The Wall Street Journal ranks Daniels College of Business number three in the world for Ethical Standards and ninth in the world for academic excellence in corporate social responsibility. For further information: www.leanhealthcareservices.com

UK Business improvement techniques NVQ – champion profile Keywords Educational development, Continuous improvement, Leadership competencies

To support the training of the Lean Champions, the Lean Healthcare Academy is coordinating the delivery of the Business Improvement Techniques (BIT) NVQ to ten employees within Airedale NHS Trust. The Lean Healthcare Academy (LHA) has chosen to offer the NVQ as, in addition to the Lean training, it also offers a robust structure for implementation and sustaining of improvements. It encourages an organisational culture, which is focused on the benefits of continuous improvement, as well as ensuring a safer, more organised workplace. Joanne Davy has already been involved in the process mapping stage of a number of Lean Spotlight Projects at Airedale, which have provided her with a real insight into the affect Lean can have on patient care and waiting times. Therefore she was keen to put her name forward to be part of the first cohort of Airedale employees to be trained as Lean Champions. As a participant on the NHS Graduate Management Training Scheme (MTS) Joanne feels that the training she will undertake through the NVQ will provide her with invaluable skills, which she is looking forward to implementing in her current role at Airedale and throughout her future career within the NHS. As part of the MTS, Joanne is studying for an MSc in Healthcare Leadership and Management from the Universities of Birmingham and Manchester. A module of this course is entitled-“Healthcare Improvement Science” where Joanne and her fellow students were introduced to the principles of Lean. Delivering the BIT NVQ in the healthcare sector is a real groundbreaking move and will give the Lean Champions at Airedale the ability to implement and sustain Lean activities. For more information about delivering the Business Improvement Techniques NVQ in healthcare please contact Sarah Ellis, Lean Healthcare Academy Manger on 01943 605 976 or email [email protected]

More details about the NHS Graduate Management Training Scheme can be found at www.bringingleadershiptolife.nhs.uk/ For more information: www.leanhealthcareacademy.co.uk/

News and views

NHS leaders vow to improve customer focus and look to John Lewis for advice

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Keywords Leadership capacity, Customer care improvement, Patient information

The NHS is looking to successful companies, as well as leaders from within the health service at home and abroad, in a drive to improve customer focus and the service it offers patients. A new NHS Confederation report Great Expectations: what does customer focus mean for the NHS? highlights examples of excellence in customer focus in organisations including John Lewis, Lloyds pharmacy, Turning Point and BT as well as health bodies, and draws conclusions for the whole of the NHS. The report is launched as research by Ipsos MORI, commissioned by the NHS Confederation, reveals that 93 per cent of the public think it is important for the NHS to pay more attention to customer services such as friendlier staff, easier appointment booking systems, clearer information about treatment and better bedside manner. In addition, in a survey of 337 NHS chief executives and chairs, 100 per cent of NHS leaders concede that the NHS is not sufficiently customer focused at present. Of those, 43 per cent said that a significant change in customer focus is required and 22 per cent believe a fundamental change is needed. Great Expectations says that the key to good customer focus is happy staff – as a contented workforce will provide more customer-focused services. The report also emphasises that customer focus needs to be driven from the top of any organisation and NHS leaders must endeavour to make sure that their staff receive job satisfaction. Great Expectations concludes that a customer-focused workplace will give staff greater confidence and increase their ability to respond to patients’ needs, as well dealing with the stresses and strains of working life. Dr Gill Morgan, chief executive of the NHS Confederation which represents over 90 per cent of NHS organisations, said: “Customer focus is about doing everything we can to make the patient’s experience as pleasant, straightforward and unstressful as possible. High satisfaction ratings in patient surveys show that NHS providers are already doing well in this area, but there is always more that can be done. And in this age of rising expectations, customer focus has become a critical issue for all healthcare providers.” “The report shows that there is a great deal of good practice on excellent customer service – not only from the private and voluntary sectors, but also from within the NHS itself. We all need to learn from the best to deliver a first class, customer-focused NHS fit for the 21st century.” “Getting the best outcomes from the care we give to patients is vital but is not sufficient. We must think about the patient experience as a whole. It is about seeing things from the patient’s point of view and treating them as we would expect to be

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treated ourselves. Caring as well as curing is not an optional extra it is at the heart of good practice. When you are in pain it is the hand that you hold that reminds you of your humanity.” “What is striking from this report is that all the examples of excellent customer focus involve giving staff and the systems they work in more attention. Staff are of course also customers of the NHS and the same care needs to be extended to them as our more traditional customers – the patients. As we move towards a more customer-focused health service, staff will have a key role in redesigning systems to ensure they are customer focused.” Nine leaders of organisations who have pursued excellence in customer focus were interviewed for the report. Their observations include: Our message is that customer service is a priority for our organisation and we are committed to it. The pay-off comes in greater success in user care, fewer complaints and better health outcomes in the longer term (Nikki Richardson, South Essex Partnership Foundation Trust). You have to see your organisation through the eyes of your customers, and match this to your organisation’s vision of itself. Then you can spot the gaps between the two. You have to recognise that gaps do exist and that you need effective arrangements to put them right. What matters is the way you sort it out (Simon Fowler, Director of customer services, John Lewis Partnership). You have to measure your own performance in the eyes of your customer. It’s pointless to look at internal measures. You have to think about what the customer is thinking: How was it for me? Good? Bad? Or indifferent? (Adam Smith, BT Global Services). Providing health services requires a personal interaction and the establishment of trust. Customers must feel that they have been treated with respect and as individuals. This is how customer focus feels (Justin Ash, Lloyds pharmacy). The point is that as people become more aware of us and our services, they become more engaged in how the services are provided and run. So the process of customer-focus starts to be self-fulfilling (Alwen Williams, Tower Hamlets PCT).

For further information: www.nhsconfed.org/

Recent publications

Recent publications

Please note that, unless expressly stated, these are not reviews of titles given. They are descriptions of the book, based on information provided by the publishers.

277 A Lean Guide to Transforming Healthcare Thomas G. Zidel American Society for Quality ISBN: 978-0-87389-701-3 Keywords Leadership development, Healthcare delivery, Quality improvement This book is an implementation manual for lean tools and principles in a healthcare environment. Lean is a growth strategy, a survival strategy, and an improvement strategy. The goal of lean is, first and foremost, to provide value to the patient/customer, and in so doing eliminate the delays, overcrowding, and frustration associated with the existing care delivery system. Lean creates a better working environment where what is supposed to happen does happen. On time, every time. It allows clinicians to spend more of their time caring for patients and improves the quality of care these patients receive. A lean organization values its employees and encourages their involvement in organizational initiatives which, in turn, sustains hospital-wide quality improvements. The opportunities for lean in healthcare are limitless. This is not a book to be read and forgotten, nor is it meant to sit on a book shelf as another addition to an impressive but underutilized collection of how-to books. As the name implies, it is a guide; a companion to be referenced again and again as the organization moves forward with its lean transformation.

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