Shown at the Lean Summit 2013 - Lean Transformation: Frontiers and Fundamentals on 5th, 6th & 7th November

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

4. www.leanuk.org
Exercise
What is Takt Time?
How is it Calculated?
Why is it Important?

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

6. www.leanuk.org
Staff/Departmental Availability V’s Opportunities for Patient Flow (Door to Door)
Example - Royal Gwent Staff Overflow Car Park

7. www.leanuk.org
We Are Obsessed by Demand
(and crave to see it)

8. HRI’s Medical Demand Map
Where do they come from?
What happens to them?
Where do they go?
Lean Enterprise Academy
www.leanuk.org

9. www.leanuk.org
Why is Demand so Important

10. www.leanuk.org
Because we can translate Demand
into Takt time

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

13. www.leanuk.org
TAKT Time =
360 minutes
72 patients
TAKT Time Calculation Example Cont’d
One Patient Every 5 Minutes

14. www.leanuk.org
Using Takt to calculate the
Number of Staff Required
Total Work Content
Takt Time
=
=
=
120
30
4 staff

15. www.leanuk.org
ED Takt Example – Calderdale & Huddersfield

16. www.leanuk.org
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?”

17. www.leanuk.org
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

18. www.leanuk.org
Takt at the Back Door

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)

21. HSJ Best Acute Hospital 2010
Commissioners saved £1.1 m
Trust saved £2.2 m from safely
closing 100 medical beds
50% reduction in
Locum/ Bank and Agency spend
No compulsory redundancies
Calderdale & Huddersfield
NHS Foundation Trust
Shortest Length of Stay
Static readmission rate
Continuing to improve
www.leanuk.org© LEA

22. www.leanuk.org

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

35. www.leanuk.org
ED Takt Example – Calderdale & Huddersfield
9am – 9pm Takt is 12 mins

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

37. Takt Time
201

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

39. Takt Time
201
2 x Resource
3 x Resource

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