Delivering Results in Healthcare by Marc Baker, Ian Taylor and Dr Paul Jarvis
1. Delivering Results in Healthcare
Marc Baker & Paul Jarvis
Doing the Right Thing for Every Patient
2. www.leanuk.org
Our Core Tenet
Our Core Tenet is a patient centred approach to re-design
and has been the underlying principle of all our work in
healthcare, we refuse to do local optimisation work.
Over the years we have learned what works, and what does
not, in healthcare (and why). This has been codified into our
book ‘Making Hospitals work’.
3. www.leanuk.org
Making Hospitals Work
How to improve patient care while saving
everyone’s time and hospitals’ resources
by Marc Baker and Ian Taylor
Foreword by Daniel T. Jones
A Lean Action Workbook from the Lean Enterprise Academy
Version 1.0 Goodrich UK
May 2009 www.leanuk.org
5. www.leanuk.org
Pull and Flow
We believe that our job in healthcare is to enable each
individual patient to ‘pull’ themselves through the system and
to ensure that our services ‘flow’ to provide exactly that
which the patient needs exactly when they need it (pulled by
the patient) during their journey through our system.
There exists a natural pace or beat at which patients require
our services and it is only when we can identify this pace or
beat that can our services truly flow to meet the patient
needs
11. www.leanuk.org
Takt Time comes from the German word for Pace
or Beat & is used to describe the Rate at which
Patients require a Service
Takt Time
12. www.leanuk.org
Takt Time is used to enable flow by matching the ‘Rate of
Delivery’ with the ‘Rate of Demand’
Takt Time dictates how often one Request/Activity should be
Completed – in line with Patient Demand
Why is Takt Time so Important?
Takt Time is used to scientifically calculate staffing levels
Everything in the System Must be Synchronised to meet Takt
otherwise queues WILL form
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It is quite normal in Acute Hospitals that during the busiest time
of day, patients are presenting on average at A&E Majors
Departments every ten minutes or so.
Service Level Agreements (SLAs) are now commonplace in
healthcare. For example the path lab may have a SLA to
turnaround blood results to A&E within 90 minutes but is this
good enough?
If at the busiest time of the day, patients are arriving on average,
at A&E Majors every ten minutes - but cannot be admitted or
discharged until the results are available - we have to ask “is a
SLA of 90 minutes good enough?”
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The diagram below illustrates that in this scenario with patients
arriving every ten minutes and blood result ‘turn around time’ of
ninety minutes
Nine bays will be occupied by patients just requiring blood results
alone.
10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170
Patient 1 X X X X X X X X X
Patient 2 X X X X X X X X X
Patient 3 X X X X X X X X X
Patient 4 X X X X X X X X X
Patient 5 X X X X X X X X X
Patient 6 X X X X X X X X X
Patient 7 X X X X X X X X X
Patient 8 X X X X X X X X X
Patient 9 X X X X X X X X X
Minutes
19. www.leanuk.org
JPUH Medical Takt Times
44 Mins
55 Mins
28 Mins
Due to Opening Hours the Back Door Must work to a
quicker Pace than the Front Door
20. www.leanuk.org
Levelled Discharges being used in
conjunction with the Visual Hospital
Levelled Discharges – Small Numbers ‘Drip Fed’ Throughout the Day
(As Legitimate as the A&E Target)
23. What is Quality?
You want to go out
for dinner with some
friends
What constitutes
a quality experience
for you and your
friends?
24. You run a restaurant
What would constitute
quality now?
What is Quality?
25. Which is the more objective view of quality:
Customer or Service Provider perspective?
26. Healthcare is a unique industry because a
patient is both the customer and the product
Quality should always be viewed
from the patient’s perspective
27. 3 characteristics of quality:
• Service
• Product
• Environment
For a quality patient experience all of these
need to be right
Understanding Quality
28. • Would you go back to a hotel that wakes you up at 3am so they can
move you to a different room?
• Would you return to a shop that makes you wait several hours
before they serve you?
• How would you feel if the person serving you talked to you like you
were an idiot?
• Would you carry on using the same garage if your car had to go
back in because the work done was inadequate 10% of the time?
These are everyday examples – Why are they tolerated
in healthcare?
Why do we need Quality Improvement in Healthcare?
29. We’re not a hotel, a shop or a garage, but
we do provide a service.
Patients tolerate poor care because there
is very little alternative (and it’s free)
Huge initiative throughout health service
on improving the patient experience
Need for Change
30. X Y
Patient encounter Healthy & satisfied
with Dr patient
Sadly, life isn’t this simple?
How Complex is one patient’s
Journey
31. Reality is more like this…
This is one patient’s real hospital journey!
32. Old System
Traditional ED System
Treatment
CT = 20 min
Disposal
CT = 3min
Triage
CT=6 min
Dr Review
CT = 37 min
Investigations
CT = 63 min
Nurse
Assessment
CT= 27min
Dr Review
CT = 15 min
Walking
Ambulance
Consultant
33. Old System
Traditional ED System
Treatment
CT = 20 min
Disposal
CT = 3min
Triage
CT=6 min
Dr Review
CT = 37 min
Investigations
CT = 63 min
Nurse
Assessment
CT= 27min
Dr Review
CT = 15 min
Walking
Ambulance
Consultant
32 41 9 32 7 201
28
15
34. What is the problem?
• System designed to make patients wait
(Triage is a step to decide how long you should wait)
• Two access points to the service
• Investigations requested late
• Potential for inexperienced staff to order
unnecessary investigations
34
36. Old System
Traditional ED System
Treatment
CT = 20 min
Disposal
CT = 3min
Triage
CT=6 min
Dr Review
CT = 37 min
Investigations
CT = 63 min
Nurse
Assessment
CT= 27min
Dr Review
CT = 15 min
Walking
Ambulance
Consultant
32 41 9 32 7 201
28
15
9am – 9pm Takt is 12 mins
Exercise: Draw Bar Chart of Delay/ CycleTimes v Takt for
walking patients
38. EDIT
CT= 16 min
ED Dr
CT = 37min
Treatment
CT = 20min
Disposal
CT = 3min
Ambulance
Walking
Consultant 1 Consultant 2
Emergency Dept Intervention Team System
Redesign ED Process
201
9am – 9pm Takt is 12 mins
784
Exercise: Draw Bar Chart of Delay/ CycleTimes v Takt
41. Phase 1 – Evaluate the performance of the
traditional ED model - 1st April to 24th May 2013
(3835 patients)
Phase 2 – Evaluate introducing POCT into
traditional ED model - 28th May to 29th September
2013 (7033 patients)
Phase 3 – Evaluate POCT and EDIT model
together – 30th September to 18th October 2013
(1200 patients)
3 Phase Trial
42. Before Trial
Median Blood Results being available: 63 minutes
Trial Results
Median: 3 minutes
Able to do 60% of ED bloods using iStat
Point of Care Testing
43. Effect of the 3 Different Working Models on the Median ED Times
68%
Overall
Reduction
40%
Overall
Reduction
60%
Overall
Reduction
Time
hh:mm
Results
44. • Introduction of Point of Care Testing
(POCT)
•
• i-Stat® System
Introduced Point of Care Testing
45. With traditional model 9 patients are undergoing ED Care
in the ED central area at any one time (Monday to Friday 9-
5)
EDIT & iStat reduces this to 5 due to quicker processing of
patients
45
Results
Reduces Overcrowding
Frees up time to Care
46. With Traditional Model 3% of patients seen in ED Central
Area Monday to Friday 9-5 are discharged with 30 minutes
of arriving.
With EDIT & iStat this is increased to 10% with the
additional benefit of being seen by a consultant.
Results
Reduces Overcrowding
Frees up time to Care
47. With Traditional Model 11.4% of patients seen in ED
Central Area Monday to Friday 9-5 return within 7 days of
their initial presentation
With EDIT & iStat this is 9.1%
Shorter patient journey times do not equate to more
patients having to return to the ED within 7 days
Results
48. 48
Results
*
- only 1 consultant
When only 1 consultant causes special cause variation in performance r = -0.8
UCL
*
*
49. Before Trial
Median Blood Results being available: 63 minutes
Trial Results
Median: 3 minutes
Able to do 60% of ED bloods using iStat
Point of Care Testing
50. 360 ED attendances per day cross site
2.5% reduction = 9 few admissions per day
Rates of Admission
51. Introduction of a consultant-led assessment
process (EDIT) and POCT provides a 40%
reduction in the time from patient arrival to
being declared ‘ED Ready’ and 2.5%
reduction in the number of patients admitted
Conclusion