Lean in Diagnostics - Where do I start?

Every organisation needs to be equipped to face everyday challenges and tasks and have a formidable plan for improvement. But it’s no use having a plan when you don’t understand what you’re trying to solve!

And whilst empowering and challenging staff to identify and surface problems is imperative in a Lean organisation, it’s no use if they do not have sufficient ongoing support from the leaders of the value streams. Yes, teams should be able to effectively organise strategies to attack problems and solve them, but often, we’ve made so many ‘work arounds’ in our systems that it’s difficult to know where to begin.

There is a saying; “You get what you deserve and you deserve what you tolerate.” But how do you know how much you are merely ‘tolerating?’ How do you know what the real problem is? Everyone has some anecdotal tale to tell, usually based on an opinion – and very often voiced as an emotional response as the system isn’t working ‘for them!’ Before starting any improvement efforts, you need to understand what the real issue is. This requires acknowledging what is ‘fact.’ For that, you need some data.

Data
So, what do we want to measure? Obviously the time taken between the key steps of the pathway is a good starting place. But this will only tell us about the ‘delivery’ of the service through the current processes.

In healthcare, it would make sense to want to understand what our current levels of ‘quality’ and ‘safety’ were. Usually, we think we are providing a good service but it’s often only because we are tolerating defects all the way down the line and, quite simply, that we are increasing patient risk at every stage we do so.

To frontline staff, it may not be so obvious that we need to consider ‘cost.’ But to our managerial and executive colleagues, with finite budgets and financial accountability processes, this measure is essential.

Seriously important, and, sadly, seldom undertaken, is a true measure of ‘morale.’ Proxy measures of ‘staff turnover’ or ‘sickness’ rates are often used, but when staff are feeling stressed and demoralised yet continuing to do their work each day (however bad the system is!) it’s difficult to gauge the impact of the current situation on morale.

Perhaps your Human Resources department could help you here, or the HSE stress tool click HERE would give you a good indication of how it feels in your work area. Alternatively, NHS Improvement has a series of 12 questions that are currently being piloted with National Cervical cytology Screening Pilot sites.

Whatever you are measuring, you need a baseline. Without this, how will you know whether the changes you implement are actually an improvement or not? Baselining the above measures are not are not always easy and a good relationship between your accountancy and IT departments is encouraged!

Within your baseline data you should be able to ascertain how reliable your processes actually are. You must begin to question any variation from patient to patient or episode to episode. Why is there variation? To what extent is the variation? Can you identify any special causes or is this just natural for the current process system you are operating? How repeatable are the processes?

The only way you will answer some of these initial questions is by running your data through a Statistical Process Control (SPC) package and displaying as a graph with median average, upper and lower control limits identified. For more information on SPC click HERE.

Acting upon the right data to improve the process will deliver the right results. But the key to Lean is in fact the ‘display’ of the data. Visual management and standard work are key guiding principles that show the ‘flow’ of patients, staff, information and material through our processes. Data needs to be accessible to everyone for a culture of continual improvement to be embedded into all parts of the system. Only then, will staff be able to determine: “What is expected at this process step or workstation” and “Am I on track or behind the schedule?” Every individual should be able to walk into a workplace and know the ‘actual’ current state compared to the ‘expected.’ The work area should ‘speak’ to you as you walk through it. Coaching of all staff in data interpretation is essential.

Then, documentation of problems must be encouraged on a sessional, if not minute-by-minute basis. Diagnosing these problems, getting to their root cause, and eliminating them at source, is key to a Lean organisation.

Value stream mapping
Value stream thinking is seeing the combination of processes required to bring the service to the customer (remember: the customer for each individual process is not always the patient – it’s often our next colleague down the line!). Without a value stream map, departments often start to optimize their measures in their own work area without considering the impact on others.

A value stream map is different from other types of process mapping in that the steps or process flows are shown at the bottom of the map and the information that drives the steps are documented at the top. The waste between the processes becomes easily identifiable and the timeline gives us the snapshot ‘fact’ of how long we are taking to deliver the service, Further, simple, calculations allow us to be honest about the value we are adding at each stage. This can be a big eye opener!

Ideally, prior to the map being documented, everyone should have walked through the end to end process - the scope of the value stream map. If this has not been facilitated prior to the mapping session, then it should be done soon after. Collective documentation of the map to define the system in its current state ensures vigilance to map the process exactly ‘as it is’ and creates direct ‘ownership’ of the system as it stands. The real power is to get people to be dissatisfied with the waste in the system and to share a vision for the future. This, they must document as a foundation for the future state map and develop an action plan – via the A3 click HERE for a template - to work towards the future state system. Value Stream Mapping is a tool great tool and helps us see the ‘whole’ end to end process but remember: the value stream map and the A3 are just ‘tools’ – the real challenge of Lean is to “Go and do it!” For a short ‘how to’ presentation on Value Stream Mapping click HERE.

Identifying waste for its elimination often gets individuals ‘hooked in.’ However, since we do become ‘blind’ to our ‘work arounds,’ people need coaching on how to spot waste. Sample waste forms can be downloaded : (for the office click here, for the Pathology Department click here).

So far, it sounds fairly easy but as anyone who has previously attempted change implementation – even for the benefit of individuals – knows how difficult it is getting everyone to accept that a change is necessary - and ensuring they ‘have a go!’ In healthcare, we are used to the concept of the ‘clinical trial.’ Therefore, it’s often easier to suggest any change as a ‘process trial’ initially. And after all, that’s exactly what it is. We are, perhaps, all familiar with the Plan Do Check Act (PDCA) cycles of improvement.

Plan

• clearly stating the problem
• documenting and getting some background so we have collective agreement and common understanding
• conducting a “5 Whys” analysis to identify root causes
• brainstorming countermeasures and how to test them

Do

• collecting baseline data to test our proposed countermeasures
• trying it! – testing/experimentation
• gathering data throughout the testing phase

Check

• analysing the results we’ve got and facing the facts
• compare the results to the target or the predicted outcome
• reflect on what worked and what didn’t - asking “why”

Act

• make the effective countermeasures the standard and set an audit system in place to monitor
• observe the new current position and set targets for the new future condition return to the A3 plan
• if the countermeasures were not successful, return to the plan phase - remedial action is necessary

A3 thinking and problem solving
A3 reports are literally the communication tool that records the main results from the PDCA cycle. Unsurprisingly, they are called A3 because they fit on a single side of A3 (11 x 17 inch) sheet of paper. The templates click HERE serve as guidelines for addressing root cause of problems. You can create your own template – and you probably should. The A3 must work for you – remember that the report structure is not the important thing – although it should follow the PDCA cycle – it’s the thinking that goes behind it that matters. Therefore, don’t merely conform to someone else’s template.

Initially, for good A3 documentation use a pencil and paper - only progressing to electronic means when you are well practiced at it. Remember, the aim of the document is to visually communicate, so use images if it ‘tells the story’ of the problem and the potential solutions. Use the A3 as the daily discussion focal point. The whole point is that a structured approach to summarising, presenting, proposing and analysing processes is maintained.

Steps of the A3 Problem Solving Process

• Step 0: Identify a problem or need
• Step 1: Conduct research to understand the current situation
• Step 2: Conduct root cause analysis
• Step 3: Devise countermeasures to address root causes
• Step 4: Develop a target state
• Step 5: Create an implementation plan
• Step 6: Develop a follow-up plan with predicted outcomes
• Step 7: Discuss plans with all affected parties
• Step 8: Obtain approval for implementation
• Step 9: Implement plans
• Step 10: Evaluate the results

So, defining the problem, identifying the root cause, obtaining reliable and verified data of the current situation, identifying the waste in order to systematically remove it, mapping the current and future state, developing an action plan with PDCA cycles and undertaking A3 thinking should just about get you started! Visual management, standard work and accountability will soon follow to ensure the daily rigour of Lean becomes the norm for the people working in the value stream.

Final Advice
Lean is a ‘doing’ philosophy. You have to ‘believe’ in the philosophy, ‘think‘ through its principles, adopt an ‘attitude’ that expects Lean behaviour and live your working day through individual ‘Lean habits.’ These habits, you’ll only ever attain by repeating, repeating and repeating Lean methods. Lean isn’t a toolbox that you should blindly open and have a tinker with a few gizmos. Indeed, the right tools are all there, but they must be used appropriately – and certainly only when supported by fundamental changes to the organisations operating methodology. So, these first steps are merely a guide; your long journey to whole system improvement has only just begun. Suggested further reading click HERE.