lean midland presentation-161013

Lean Midland Forum

16 October 2013 Education Centre, Good Hope Hospital

For more information, please email [email protected] or telephone 0207 824 8448

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Confidential not to be used without consent

We have some broad aims of the forum

•  Create the environment where Lean Solutions in the NHS are shared, discussed and acted upon by practitioners in the health service

•  Engage in a debate about strengths and weakness of lean/service improvement methods in the current NHS climate –  The QIPP agenda in reducing costs across the health system

–  Clinical Commissioning Groups that will redefine ‘end to end’ health systems processes

•  To network with colleagues and friends

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Agenda

•  1800 - 1810 Welcome and introductions

•  1810 - 1835 “Improvement; Infection; Impossible? – Dr Mathew Diggle (Consultant, Nottingham University Hospitals NHS Trust)

•  1835 - 1900 “How effective use of SPC in the NHS results in better decision making” – Mike Davidge (Director, NHS Elect)

•  1900 - 1930 Hot seat session

•  1930 - 2000 Networking and drinks

Where?

Clinical Microbiology Department No7ngham University Hospitals NHS Trust Queens Medical Centre Derby Road No7ngham UK NG7 2UH hFp://www.nuh.nhs.uk/microbiology/

The No7ngham Experience •  DiagnosOc service: 24/7, 365 days per year •  PopulaOon served: >2.5 million (> 5 million)

•  Workload: 970,000 pa (> 1.8 Million)

•  IsolaOon, idenOficaOon and detecOon of •  medically important bacteria,

•  viruses and parasites.

And now for something completely different...

NHS Improvement -‐ EM SHA Microbiology Sites

LEAN

Microbiology

What the…………….

The Path-‐ology

The Project

Challenges •  CollaboraOons •  ConsolidaOon •  CompeOOon

The “C”s……….

The No7ngham Experience

Challenges •  Developing a lean culture

•  Find a champion •  Engagement of your staff

•  What is engagement? •  CommunicaOon

•  While under a seize mentality

h:p://www.improvement.nhs.uk/documents/Microbiology_Guide.pdf

Thank you!

How effective use of SPC in the NHS results in better decision making

Mike Davidge

How we assess performance: RAG raGngs

Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 1290 97 77 93 76 84 76 89 84 84 93 70

Why has performance deteriorated so badly in August 2012? What decision are you going to make?

Indicator YTD Perf Vs Target

Perf Trend -‐Sustainability (latest 3mths)

ExcepOon Report

Produced Perf View on

Quality of Plan

Improve-‐ Date set by

Owner/In-‐Month Performance

Target Owner

Risks/Comments and likely delivery against Improvement date

PosiOon vs. last month & PMO Monitor

NoF G G Not required Not required G CH

Patient Safety Perf Notice Rec

Loss of Income in 2012 Improvement Date

slippage

A & E -‐ 4 hours

R R G Not required G CH


Loss of income in 2013/14

A & E -‐ CQIs

A A G A A CH


Loss of Income in 2013/14

CQC visits Regulatory issues

Stroke Unit -‐ 90%

G G Not required Not required R CH

Patient Safety Increased risk of perf

measures. Feb has met target – and sustained

HSMR G G Not required Not required Not Req’d RC-H

CDiff A A G Not required R CO Patient Safety

CQC/Regulatory Issues

Performance Overview – April 2013

Follow up metric

Monitor Q1

Return

Monitor Q2

ReturnDec

Monitor Q3

ReturnJan Feb RAG YTD

TargetYTD

Actual

YTD RAG &

12 month Trend

l 95% 96.7% Ç96.7% 96.2% 97.4% 96.5% 96.9% 97.6%

Indicator description

2012 /13 Annual/Year end Target

Receiving follow up within 7 days of discharge (all discharges)

95%

What you get presented with What do you decide to do?

A&E performance

Area

•  Minor aFendances •  Thursdays •  Q3 2004/05

Performance

•  96.9% seen and discharged within 4 hours

Verdict: Ok?

How long does it take

you to get to work? How many patients need a

home visit today?

How long does it take to take a patients

BP?

In the real world, everything varies....

What’s a person’s normal body temperature?

“Data contains both signal and noise. To be able to extract

information, one must separate the signal from the noise within

the data.”

Walter Shewhart

There are two types of variaGon

While every process displays variaOon: •  some processes display controlled variaOon (common cause) –  Stable pa)ern of varia0on = noise –  constant causes/ “chance”

•  while others display uncontrolled variaOon –  pa)ern changes over 0me = signal –  special cause varia0on/“assignable” cause eg infec0on or hypothermia

We should display data in a way that shows which is present

Control charts

• Plot data in time order • Calculate and display mean as a line and

control limits as lines • Analyse chart by studying how values fall

around mean and between control limits

Control charts

SPC chart of RAG score

Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Apr 12 May 12 Jun 12 Jul 12 Aug 1290 97 77 93 76 84 76 89 84 84 93 70

Indicator YTD Perf Vs Target

Perf Trend -‐Sustainability (latest 3mths)

ExcepOon Report

Produced Perf View on

Quality of Plan

Improve-‐ Date set by

Owner/In-‐Month Performance

Target Owner

Risks/Comments and likely delivery against Improvement date

PosiOon vs. last month & PMO Monitor

NoF G G Not required Not required G CH


Loss of Income in 2012 Improvement Date

slippage

A & E -‐ 4 hours

R R G Not required G CH


Loss of income in 2013/14

A & E -‐ CQIs

A A G A A CH


Loss of Income in 2013/14

CQC visits Regulatory issues

Stroke Unit -‐ 90%

G G Not required Not required R CH

Patient Safety Increased risk of perf

measures. Feb has met target – and sustained

HSMR G G Not required Not required Not Req’d RC-H

CDiff A A G Not required R CO Patient Safety

CQC/Regulatory Issues

Performance Overview – April 2013

Not so peachy

Apr 2012

May 2012

Jun 2012

Jul 2012

Aug 2012

Sep 2012

Oct 2012

Nov 2012

Dec 2012

Jan 2013

Feb 2013

Mar 2013

Apr 2013

Month

50

60

70

80

90

100

percentage % patients achieving 90% time in stroke unit

BaseLine

Verdict Stable within

limits (66 -100)

Not Capable of

achieving target

Apr 2012

May 2012

Jun 2012

Jul 2012

Aug 2012

Sep 2012

Oct 2012

Nov 2012

Dec 2012

Jan 2013

Feb 2013

Months

90

92

94

96

98

100

102

104

Percent Receiving follow up within 7 days of discharge

BaseLine

Verdict Stable within

limits (93 -100)

Not Capable of

achieving target

Monitor Q1

Return

Monitor Q2

ReturnDec

Monitor Q3

ReturnJan Feb RAG YTD

TargetYTD

Actual

YTD RAG &

12 month Trend

l 95% 96.7% Ç96.7% 96.2% 97.4% 96.5% 96.9% 97.6%

Indicator description

2012 /13 Annual/Year end Target

Receiving follow up within 7 days of discharge (all discharges)

95%

A&E – the real situaGon

0

200

400

600

800

1000

1200

06/01 00:12

06/01 12:12

06/01 18:36

13/01 10:18

13/01 15:51

13/01 23:02

20/01 11:10

20/01 16:47

27/01 00:02

27/01 12:22

27/01 18:44

03/02 09:11

03/02 15:30

03/02 22:48

10/02 11:46

10/02 17:20

17/02 03:08

17/02 13:46

17/02 18:31

24/02 04:37

24/02 14:08

24/02 21:29

03/03 12:17

03/03 19:26

10/03 09:33

10/03 16:01

10/03 22:39

17/03 11:15

17/03 16:33

17/03 21:31

24/03 12:09

24/03 18:43

31/03 07:57

31/03 15:00

Time in A&E department Jan-Mar 2005Infirmary : Minor attendance : Thursday

Time inDept

Average(01:50)

LCL(00:00)

UCL(05:05)

4 hr target

The two types of mistake

Mistake One •  InterpreOng the rouOne variaOon of noise as if it amounted to a

signal of a change in the underlying process, thereby sounding a false alarm. [false posiOve]

Mistake Two •  Thinking that a signal of a change in the underlying process is

merely the noise of rouOne variaOon, thereby missing a signal. [false negaOve]

SPC – do it right

•  Use the correct way of determining the measure of variaOon

•  Use the correct mulOple of variaOon to derive the control limits

•  Don’t exclude data points just because they’re ‘odd’

Using the wrong calculaGon

0

100

200

300

400

500

600

700

800

02 Apr 12

30 Apr 12

28 May 12

25 Jun 12

23 Jul 12

20 Aug 12

17 Sep 12

15 Oct 12

12 Nov 12

10 Dec 12

07 Jan 13

04 Feb 13

04 Mar 13

Number

A&E 4 hr breaches52 weeks from 2 April 2012

St Elsewhere's Hospital

A&E 4 hr breaches Average (497.9) Lower limit (340.8) Upper limit (655.0)

Shaded area using standard

deviation statistic gives

lower limit if 272 and upper limit

of 723

Using the wrong limits

01 Apr 2012

01 May 2012

01 Jun 2012

01 Jul 2012

01 Aug 2012

01 Sep 2012

01 Oct 2012

01 Nov 2012

01 Dec 2012

01 Jan 2013

01 Feb 2013

Months

0

10

20

30

40

50

60

70

80

Number Delayed transfers of care

BaseLine

2 sigma limits

IniGal chart with special causes flagged

01/10/2012

08/10/2012

15/10/2012

22/10/2012

29/10/2012

05/11/2012

12/11/2012

19/11/2012

26/11/2012

03/12/2012

10/12/2012

17/12/2012

24/12/2012

Week

0

50

100

150

200

250

300

350

400

Hours Weekly referral hours into MRI

BaseLine

Average and limits driven by 2 final data points

that are very low. Should we exclude them?

Modified chart

01/10/2012

08/10/2012

15/10/2012

22/10/2012

29/10/2012

05/11/2012

12/11/2012

19/11/2012

26/11/2012

03/12/2012

10/12/2012

17/12/2012

24/12/2012

Week

0

50

100

150

200

250

300

350

400

Hours Weekly referral hours into MRI

BaseLine

A proper RAG status

•  Green = stable and capable i.e. no special causes and process limits within specificaOon limits –  Ac0on: masterly inac0vity and catlike observa0on

•  Amber = unstable i.e. special causes –  Ac0on: inves0gate special causes, diagnose and treat with a countermeasure.

•  Red = stable but incapable i.e. no special causes and process limits outside specificaOon limits –  Ac0on: improve or redesign depending on level of experience/skill

My final slide: Shipman

Source: Malcolm Gall in The Times, 1 February 2000 Taken from “Bristol, Shipman and clinical governance: Shewhart’s forgotten lessons” Mohammed et all, The Lancet, volume 357, 2001

•  Focus on Value from a Customer (Patient) point of view on every step of process

•  Obsession on removing waste within the ‘whole system’ •  Bottom up approach in identifying value and waste – assumption that

much of waste and value is hidden •  A true lean system would “flow” and need little command and control

Recap – What is Lean?

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What’s Next?

•  Today’s presentation and feedback survey sent out by email within 72 hours

•  The Next Lean Midland Forum will be held on 26 February 2014. –  Register at www.leanmidland.org.uk

–  We will send out reminders to all participants from today

–  We have a Lean London Forum on 5 March 2014 taking place in London. Register at www.leanlondon.org.uk

–  If you’d like to take up one of our presentation slots, please do let us know. We are keen to hear from Community Trust and GP Groups

•  Find us on and - LeanNHS

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Past Presentations at the Forum http://kinetik.uk.com/pdf/Lean London.pdf

1. The 'Leaning' of Bedford Hospital - the story so far, Susan Whittaker, Bedford Hospital 2. Future Developments in Lean, Rob Worth, Kinetik Solutions 3. Transformation of Camberwell Sexual Health Centre, Rachel Paxford-Jenkins, Camberwell Sexual Heath Centre 4. Building Lean Expertise, Daniel McDonald, Lean Executives 5. Use of Data in Lean Projects, Andrew Castle

http://kinetik.uk.com/pdf/Lean_London_Sep_09_web.pdf

1. Radiology Lean Review - The Journey has begun, Carol Darnell, Bedford Hospital Trust 2. Recruiting for the Lean & Service Transformation, Daniel McDonald, Lean Executives 3. Lean and Systems Thinking, Rob Worth, Kinetik Solutions 4. Don't water your weeds - starting afresh with Lean, Ian Greddor, Cyril Swett

http://kinetik.uk.com/pdf/Lean London_Feb.pdf

1. Challenges in Implementing Lean - A Clinical Perspective, Dr Ahmed Chekairi, Whittington Hospital 2. A Better Definition of 'Value' in Lean, Ketan Varia, Kinetik Solutions 3. Lean in the pharmaceutical drugs supply process, Niall Ferguson, Milton Keynes Hospital

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Past Presentations at the Forum http://kinetik.uk.com/pdf/leanlondon_sep11.pdf

1. Transforming Surgical Productivity, Christopher Kennedy, Guy's & St Thomas NHS Foundation Trust 2. Transforming Treatment Rooms, Dr Rebecca Hewitson, The Whittington Hospital NHS Trust

http://kinetik.uk.com/pdf/leanlondon_mar12_presentation.pdf

1. The Path-ology to Lean Thinking - Dr Mathew Diggle, Nottingham Hospital Trust & Suzanne Horobin, NHS Improvement - Diagnostics 2. Pre-Operative Health Evaluation - Engagement with Primary Care, Dr Ahmed Chekairi, Whittington Hospital

http://kinetik.uk.com/pdf/leanmidland0712.pdf

1. How many appointments do we need to make?, Kate Silvester, South Warwickshire NHS Trust 2. The Path-ology to Lean Thinking - Dr Mathew Diggle, Nottingham Hospital Trust

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Past Presentations at the Forum http://kinetik.uk.com/pdf/leanlondon_sep12.pdf

1. Sleek & Slim Hearing for Children - Dr Sebastian Hendrick, Barnet & Chase Farm Hospital 2. Developing value through transformation of care - What does it take?, Peter Lachman, Great Ormond Hospital

http://kinetik.uk.com/pdf/kinetik_dec_12.pdf

1. Network Improvement Services in Tower Hamlets, Florence Cantle, Tower Hamlets NHS Trust 2. Using improvement science in Ambulatory Care, Simon Dodds, Heart of England Trust

http://kinetik.uk.com/pdf/Lean Midland_June11.pdf

1. Lean Transformation at Bedford Hospital, Susan Whittaker, Bedford Hospital 2. How do drive change by understanding patient value?, Ketan Varia, Kinetik Solutions 3. Global Lean Knowledge: The Effects of Culture, Maria Gilgeous, Kinetik Solutions

http://kinetik.uk.com/pdf/leanlondon_19sep13.pdf

1. Takeing a new look at your service - "Lean" a process approach to change, Pauline Connor, North Middlesex University Hospital Trust 2. "Improvement; Infestion; Impossible?", Dr Mathew Diggle, Nottingham University Hospital Trust

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Big Thanks To Our Presenters

Dr Mathew Diggle

Mr Mike Davidge

..and to you all for attending

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Thanks to Our Sponsors

Assisting with Lean Transformations in the health sector and beyond

www.kinetik.uk.com

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