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Potential Barriers to Lean implementation at Hospitals

This article discusses lean implementation in hospitals and uses Chaswick and Wallasey NHS Hospital Trust, UK, as a case study.
© University of Warwick
Here we illustrate some of the potential barriers to lean implementation. To do so we look at the specific example of one hospital trust in the UK national health service (NHS): Chaswick and Wallasey NHS Hospital Trust (CWHT). Please read the short case that follows and try to engage with the talking points that follow.
The decision to implement lean thinking at CWHT was initially taken in July 2011. The trust set an ambitious goal of ‘transforming’ itself into a total ‘lean organisation’. Emphasis was placed on developing ‘soft skills’ training and ‘project facilitation’ that would equip the trust with an internal change team capable of rolling out lean throughout the organisation. This team was led by a ‘Head of Lean’ and several lean leaders, many of whom were temporarily seconded from their full-time clinical roles. The lean team comprised 11 staff employed on two-year contracts.
During the period September-December 2011 preparations for implementing lean throughout the trust took place led by an external consulting firm: ‘Change M’. 18 projects were planned across three streams of work (each corresponding to a patient pathway). The aim was to move staff out of their functional ‘silos’ and to help them see their role within the whole patient pathway rather than within their own specialist field or department. Meanwhile, the lean facilitators underwent training in project facilitation and change management skills. The project roll-out was set to begin in January 2012.

A new Chief Executive

In October 2011 a new Chief Executive Sir William Oberon was appointed to begin work in January. Following his appointment, Sir William immediately instructed a different firm of consultants (who he had worked with before) – TOC-Health – to enter CWHT and begin work (also on lean implementation) straight away in the Accident and Emergency (A&E) department. TOC-Health had been employed with a very clear responsibility to sort out problems in A&E only in a bid to meet government targets specifying that 98% of patients must be seen within 4 hours of arrival. Given the perceived urgency of the situation, the new CEO had felt it necessary to use TOC-Health to achieve rapid change – despite the possible overlap with the work of the internal change team and ‘Change M’ consultants.

Approaches to Improvement

The Director of TOC-Health explained: ‘the whole point about our approach is fast, focused breakthroughs in performance. You must identify the one true bottleneck and focus on fixing that. In our opinion, if you improve process by process you are chasing your tail, you’re just never going to get there; it will take you so long that by the time you’ve improved, it will have changed anyway.’ It soon became clear, however, that the two consultancy firms (TOC-Health and Change M) had very different approaches to the improvement projects that they were running concurrently. TOC-Health was driven by the idea that an organisation should target a small number of projects (to address bottlenecks) rather than have multiple projects running at the same time. Change M, on the other hand, was happy to let many projects take place in various parts of the organisation using the rapid improvement event (RIE) approach.
Although the Head of Lean had begun her projects on schedule, the instruction to keep away from A&E (where TOC-Health was working), meant her planned activities had to be rescheduled. Nor was she happy with the changes in responsibilities: ‘I think we had a reasonably clear understanding of how lean would be implemented until we had a change of Chief Executive. I now feel we don’t have a clear way forward to becoming a lean organisation. The emphasis has shifted to get some events done and get some money out, that isn’t what lean is about”. Concerns were also expressed about how to evaluate the performance of the lean team. She noted: ‘the emphasis has shifted. Originally it was about having a positive impact, getting people involved in lean, engaging and empowering them towards continuous improvement and following a set of key principles, but now it’s changed to ‘save some money’, and people are forgetting the cultural side of it.’
The ‘principles’ that the Head of Lean was referring to had been adapted from the lessons learned from lean practitioners in healthcare. The main principles were as follows.
  1. Focus on the patient (not the organisation and its employees, suppliers, etc.) in order to determine what real value represents and design care around them.
  2. Identify the value stream (or patient pathway) providing this value to identify where value is actually created while removing all waste (including the large numbers of errors causing the rework that drives up costs).
  3. Reduce the time required to go from start to finish along every pathway (which creates more value at less cost).
  4. Pursue principles 1, 2, and 3 endlessly through continuous improvement that engages everyone (doctors, nurses, technicians, managers, suppliers and patients and their families) who ‘touches’ the patient pathways.
In February, and much to the Head of Lean’s surprise, a third set of consultants was appointed to focus on the application of the work-study method to operating theatres. This had caused further confusion over the running of projects and seemed to mark a departure from the four principles listed above. As the Head of Lean explained: ‘I think the timescales have changed. Before, there was a recognition that we’re in it for the long haul, it wasn’t going to be a quick fix, I think now the driver is that ‘you will become a high performing trust come hell or high water and if what we need to do to get there is to bring a hundred management consultants in who’ve all got a different approach then that’s what we’ll do’. My worry is that in the longer term we’ll fall over again because actually all we’ve done is stick sticking plaster over again which is what we were doing before.’

The Impact of Lean

Consultants and nurses in the trust were divided on the impact of lean. Those who had experienced Change M’s rapid improvement events (RIEs) in their area tended to be enthusiastic about the benefits and the changes they had made. Small, but significant, changes could produce benefits including reduced confusion, increased staff morale and better patient flow. For example, improved prominence and clarity of signage stopped patients getting lost and leaving clinicians to wait for them. A reduction in stock levels produced cost and space savings as well as reducing the amount of time spent looking for the correct items. In one store cupboard, 25,000 pairs of surgical gloves were identified from 500 different suppliers. Another RIE blew the myth on the effectiveness of the medical records department: ‘It was amazing. We just exploded the myth that when you didn’t get case notes in a clinical area it was medical records fault, but it hardly ever was. Consultants had notes in their cars, they had them at home, we had a thousand notes in the secretary’s offices, and we wondered why we couldn’t get case notes! Two people walked 7 miles a day looking for them – they were all over the place. Now that was a good RIE because we did manage to sort out medical records and create some semblance of order in their lives.’
However, those who had no direct involvement in the lean activity remained sceptical. According to one Consultant Surgeon: ‘we’re not making cars, people are different and the processes that we put people through repeatedly are more complicated than the processes that you go through to make a car. These ideas may be OK in manufacturing, but all it has resulted in here is teams of expensive [Management] consultants crawling all over the Hospital’. Nevertheless, although frustrated by the confusion caused by using multiple consultants, the Head of Lean was optimistic. ‘We are starting to see some quite significant, if limited, results. The real issue is getting everyone to change the way they behave. It is tackling doctors who are used to doing their own thing and having no performance measures. It is negotiating with suppliers familiar with a culture that allows them to offer new apparatus with little attention to cost or clinical benefits. It is gradually persuading nurses that constantly working around problems in the care delivery process will not make deep-seated problems go away. It is slowly educating administrators to accept that you cannot simply run broken processes harder. Ultimately we have seen that lean can potentially work in healthcare, what we have yet to discover is a method for communicating the benefits and value of Llan to others, and quantifying this value in a manner that is significant at an executive level of the organisation.’

Talking point

  • What complexities and barriers to lean implementation are demonstrated in the case study?
  • How do the complexities and barriers identified above relate to your own organisation?
  • How might an organisation overcome these barriers?
© University of Warwick
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