Ipswich leaders offer next steps on Lean

As we ended our Lean training workshops at Ipswich Hospital NHS Trust, I asked the participants to send me an email indicating what concrete steps or actions they would take in the next week to practice or implement some of the principles we had discussed.  Understand that I was not asking for a full implementation of the Lean philosophy in the hospital:  That requires a huge commitment at all levels of the organization and is something not lightly entered into.  Rather, I suggested that the basic principles of Lean can be practiced by managers and leaders at any time.  Quoting Don Berwick's line that "soon is not a time," I suggested that if you don't actually begin to practice those principles, they are easily left aside during day-to-day activities.  Here are some responses, with names omitted:

-- I think we do not do enough of this, that is the reflecting on the work we do and how we do it. There have been a few gems over these events, but one for me to highlight was the response that I did not get time to write after the second day of the course, when I was going to tell you how much I hated my office. It’s actually a nice room, light, airy, and well located, but I’m in it too much, and that’s why I don’t like it. The trip we had to stores was an important reminder for me to get out and about more – and I have now scheduled time in my weekly diary to do just this. In my own unit we have initiated a new ideas scheme, and I think this is a good practice, but your element of calling out issues, build on that even more, and I am now thinking about how we can recognise and encourage such behaviour. It’s funny that last night I realised that one of our excellent middle grades in the Oral department has called out just recently, pointing out an important issue with our outcome forms that we are now resolving. I intend to write about this in my next newsletter.

-- You might have already worked out the NHS problems such as long waiting period for clinic appointment, long waiting list for routine surgical operations, failure to meet targets,  ineffective utilization of theatre and some of the staffing issues in the department. I observed the measures the management teams are taking and miserably failing to sort out the problem or fixing it temporarily and finding them in the same situation again. I do not have any management training, but I try to put myself in a mangers position and think. Often, I think if they try a certain approach it could work. As a clinician, being in similar situation at other hospitals and seen different management strategies which work, I wish I could shout out my ideas and open a dialogue, eventually solve the crisis. But often people in management or power don't listen. I feel embarrassed and often apprehensive as how others take your opinion. Also, I do not want to offend my colleagues and consultants with ideas which will direct implication on them.  I sincerely hope this Lean workshop will help Ipswich Hospital to work out the areas which needs careful management intervention.

-- I will use every opportunity to visit the shop floor and in doing so change my approach to one of observation and learning. I will start referring to little changes that I have made each week when I meet with my senior team, and I will begin to ask them the same so that we can all learn from our changes and how these have been achieved.

-- In the next few weeks I want to implement a number of small projects implementing the Lean principles. These include looking at the way my colleague and I process colorectal referrals, which currently come to us in batches and take ages to work through, with the resultant work being delivered to the secretary all in one go. I am sure we can turn this into a continuous work flow.

This morning, I saw in the store room, theatre gowns, which I was told had stopped being ordered. They prevent my forearms being covered in blood after long abdominal and pelvic surgery. I will speak to the relevant people to ensure they are delivered to theatres on a regular basis. 

-- I have long thought that Lean is a system that we must embrace. I have read often of the benefits of its application in healthcare. However from your tutelage I now understand that it is a methodology first and foremost to improve the quality of care we give our patients. Any financial benefits are as a result of this ‘the virtuous relationship between quality and finance’ as you put it.  I think this fact is lost often in translation (the pun is intended!) and certainly has been an impediment to its dissemination in healthcare in the Ipswich.

It is my hope that as a result of your visit we now have a nidus of colleagues who have seen the huge potential of working in this way. I will try to bring us together, initially informally, once a fortnight to share our experiences and our successes. I am going to suggest that we each try to cascade Lean to one other individual every month and so on and so forth (a bit like Amway!). In time incrementally we will develop a philosophy across our shop floor of continuous improvements.  From our group we will identify someone to receive more comprehensive training to become our Lean coordinator or sensei.

-- I believe that the changes we make have to be sustainable. Small changes will make a difference. As an organisation facing many challenges, we must ensure we do not waste energy by repeating processes that do not work.

My mission will be to engender a 'can do ' attitude.I will challenge any negativity from staff, and  I will challenge myself to ensure I have the systems in place to allow all my staff the opportunity to contribute ideas and comments. I will work with my team leaders to action these.

I will challenge myself to visit areas in the Hospital I am unfamiliar with, in relation to the patient pathways and processes that affect patients who are cared for in my areas. This will help me understand the real experience the patient has and allow me to examine ways to improve the systems.

I will also invest some time to reorganise my office to improve my access to information etc!

-- Pledge to spend 1 hour a week with a colleague observing work with an aim to make improvements to their working life. And do this with respect for a co-worker who knows more about their job than I (as a manager) will ever know. Then ask that person to do the same for 1 of their colleagues to rapidly spread lean principles across the organisation.

-- After an energised afternoon looking at the 5S, I and my other 'Lean' colleagues returned to our offices. At least four of these colleagues took this opportunity to check their inbox. As responses hit my inbox during the time I sat also responding to emails. I asked myself 'Is email the best way to communicate this message?'

There must be alternative ways of conveying a message. I plan to involve staff by asking them to discuss the benefits and drawbacks of looking at other channels of communication

Could we consider a no email day? Why do we send an email when a face to face meeting or a phone call maybe more effective & even quicker than waiting for an email response.

Perhaps a coffee or lunch break with a group could be utilised to share information and we can encourage staff to think of alternative ways of communicating information.

I will review the types of information that I regularly send and receive. Many of them are to request information required on weekly or monthly. Instead of chasing on a weekly or monthly basis perhaps develop a timetable of the information required. 

My initial thoughts are that perhaps phone calls and face to face meetings could be more time consuming however as an organisation we need to make a real effort to reduce email overload and I believe this has the potential to ensure better teamwork, a quicker problem solving approach and a happier workforce.

-- Next week I plan to improve our ultrasound scanning service to inpatients.

At present, at the start of the day, all the pending inpatient ultrasound scan request forms are reviewed by the radiologist scheduled to perform the scans. This means there is a flurry of activity (batching of work) in the early morning with the radiologist sorting through a large pile of paper forms, the imaging assistant ringing the wards with instructions and writing out collection slips for the porters, the ward clerks receiving those instructions and passing on the information to the relevant nursing staff who in turn speak to their patients about what is about to happen. It is all a mini whirlwind as this needs to occur before the radiologist starts scanning the first patients on the list (who are outpatients arranged in advance - to prevent downtime whilst waiting for the first inpatient to arrive). 

The rush means it is stressful for all in the chain. For the imaging assistant it means time on the phone and liaising with the porters when she should be helping with the first (out)patients. On the ward other tasks are interrupted to prepare their patients to come down for their scan. Because of the short notice often the doctors on the ward rounds do not know that the scans have been scheduled and ring up to enquire if and when the scans will be performed thereby disturbing the radiologist who has to stop scanning the patient of the moment. Additionally, there is frequently inadequate time to get the necessary preparation right, e.g. the patient for a pelvic scan has an under filled bladder and the scan is inadequate or worse still needs to be repeated. Most importantly, the patient and their relatives, who have usually been told by their attending ward doctors that they need a scan, are anxiously waiting not knowing what is happening for longer. 

How can we make this better? 

One possible way would be to review all outstanding request forms at the end of each afternoon and schedule the scans for the next day. That way everyone knows well in advance and can be planned to fit in around other activities. Waste could be reduced. 

Can I persuade my colleagues to change? Will they come up with a better solution? Watch this space.

-- Have largely been doing this process for the last 7 years thus the result of a large well functioning AMU which is Nationally acclaimed for its results.  My steps now will be to insist other departments work with us in the same way to allow a smooth patient journey...first e mail has been met with horror so far!!

-- I am currently tidying my office!

Last week we had a crisis meeting about an inability to find slots for patients to have lung function tests. I now realise how we can make the situation better but using existing capacity in a smarter way. In the next week I intent to meet with our lung function unit manager to find a way of better matching his work load to the chest clinics. His team appear to run the same timetable every day even though the chest clinics are not evenly distributed.  Also, if I go on holiday, I don’t warn him that this is the case and so he can’t plan a different task for his technicians.  Given enough warning they could book more patients for routine tests on these days that don’t have to be coordinated with my clinic.

-- I have today agreed to mentor a colleague who works at a supervisory level in the Trust, meeting her once a fortnight to discuss the issues she faces, and help her to work through them.  I plan to share practical Lean principles during these sessions with her.

Whatever I am doing I will always watch, listen to and spend time with my teams to truly identify the root of problems/obstacles; working with the team to resolve them together – this is the crux of every manager’s job!