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Improving Improvement

A toolkit for Engineering Better Care

 

Lean Thinking

The Lean Thinking model is a process to facilitate improvement in patient care with existing resources, meaning the same things can be achieved using fewer people.

Contents

 

Introduction

Lean thinking is an approach to improvement developed at Toyota in the 1950s to create the Toyota Production System. It is a strategic approach that focuses on dramatically improving flow in the value stream and eliminating waste. It initially came to prominence in health and care systems through The Productive Series: Releasing Time to Care1, a programme developed by the NHS institute for Innovation and Improvement and has been the subject of other reports on methods for improvement2.

Lean is typically a team process involving many people across an organisation. The Virginia Mason Medical Center in Seattle, Washington has been using lean thinking principles since 2002. By working to eliminate waste, they have created more capacity in existing programmes and practices so that planned expansions were scrapped, saving significant capital expenses. Using lean principles, staff, providers and patients have continuously improved or redesigned processes to eliminate waste, reduce rework and improve quality. Five UK Trusts are now piloting Virginia Mason’s approach.

Lean thinking is founded on five principles designed to:

  • Specify the value desired by the patient,
  • Map the value stream and identify those steps that do not create value,
  • Create a smooth flow through the value-added steps,
  • Establish pull between the steps,
  • Seek perfection so that the number of steps and the amount of time and information needed to serve the patient are minimised.

In essence, it focuses on improving patient flow, reducing opportunities for error, developing standards and engaging teams in improvement, and it is increasingly used in conjunction with Six Sigma3.

Footnotes

  1. Putting patients first — The Productive Series. NHS Institute for Improvement, 2012.
  2. Lean thinking for the NHS. Jones and Mitchell, The NHS Confederation, 2006.
  3. Lean Six Sigma: some basic concepts. Bevan, Westwood, Crowe and O’Connor, NHS Institute for Improvement, 2013.

Getting Started

Improvement teams in health and care already have a range of theories of change and improvement approaches available: the IHI model for improvement, human factors in healthcare, lean in healthcare, experience-based co-design, root cause analysis, and six sigma to name a few.

While a number of these approaches already include tools, such as Failure Modes and Effect Analysis (FMEA) and mapping techniques that may be found in engineering methods, the systems approach presented in this toolkit has the potential to add further value to the improvement agenda in two distinct forms. The provision of new tools and ways of thinking can supplement existing approaches and the adoption of a systems approach can guide a design from a set of complex needs through to validated, effective operational systems.

There are other key areas in which new ways of thinking, derived from a systems approach, can supplement existing methods. This includes, measuring and designing system interfaces to alleviate service integration issues and using systems safety assessment to proactively design risk out of systems and avoid incidents rather than merely reactively preventing a recurrence. In such cases, existing improvement approaches may be enhanced by using techniques from a systems approach.

The Systems Approach is also a method in its own right that applies tools to answer a series of questions in an iterative and systematic way in order to guide a design from a set of complex needs through to validated, effective operational systems.

During this process, experienced improvers can use their own tools, frameworks and experiences of change to help teams understand people, deliver systems, facilitate design and manage risk. A systems approach can enhance existing approaches through additional tools and techniques, encouraging improvements to be guided by a series of critical questions or simple stage gate processes.

The following map can be used to understand the coverage of the Lean model and to suggest areas where a systems approach may assist in the provision of additional questions, activities and tools to supplement existing practice.

Comparison

The questions, activities and tools from this toolkit can be mapped to the Lean Thinking model of improvement to better understand the relative coverage of the two approaches. Resource material for the Lean Thinking model has been analysed in detail to ascertain how it relates to the systems approach in this toolkit, both in terms of the mention of common topics and in terms of the provision of detailed descriptions or advice relating to the same topics.

Questions, activities and tools that have particular potential to add value to the Lean Thinking model:

Identify value

The first principle of lean thinking relates to general project issues, such as: the creation of the team, definition of the project aim, scope and plans, and creation of a sense of urgency; exploration of the problem and its context; and investigation of the high-level system processes, their elements, interfaces and boundaries. There is particular focus of the definition of value from the users’ perspective, through the identification of patients and other stakeholders, capture of their views, and understanding of their problems, needs and expectations.

Activities from the systems approach, not frequently mentioned in the literature on lean thinking relating to this principle, that may add value include: Generate Personas, Generate Scenarios, Benchmark Current Performance, Calculate Resources Required, Present Case for Change and Review Project Performance.

Tools from the systems approach that may be useful include: Literature Review, Delphi Study, Participant Observation, Designing Personas, Designing Scenarios, Life Café, PEST(LE) Analysis, SWOT Analysis, The Five Ws and two Hs, Wardley Map, Gantt Chart, Activity Dependency Diagram and LoMo.

Map the value stream

The second principle focuses on the elaboration of the high-level system processes previously captured. Process maps are used to visualise the current end-to-end processes in some detail, distinguishing value-add and non-value-add steps. For a step to add value, a user or stakeholder must care about it, it must change them or knowledge about them, and it must executed right first time. If these criteria are not met, that step is deemed to be waste. The timing of the process steps is also reviewed in the light of identifiable priorities, potential bottlenecks and constraints.

Activities from the systems approach that may add value include: Generate Personas, Generate Scenarios and Ensure Shared Understanding.

Tools from the systems approach that may be useful include: Soft Systems Method, Causal Loop Diagram, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Flow Chart, Dependency Structure Matrix, Delphi Study, Participant Observation, Designing Personas, Designing Scenarios, MoSCoW, Exclusion Audit, Expert Review, User Trials, Fault Tree Analysis, Hazard and Operability Analysis, Structured What-if Technique, Risk Matrix, Gantt Chart, Activity Dependency Diagram and LoMo.

Create flow

The third principle focuses on the elimination of waste, avoidance of uneven flow, batching and queuing, and establishment of a smooth flow of users or other entities in the value stream. Lean fundamentals and standard solutions to common problems are considered to develop ideas for the elimination of waste and improvement of flow. A new value stream is proposed and gaps between this and the current state identified and reviewed.

Activities from the systems approach that may add value include: Analyse Relevant Documents, Generate Personas, Generate Scenarios, Benchmark Current Performance, Review Safety, Review Experience, Calculate Resources Required, Estimate Time Required, Manage Team and Review Project Progress.

Tools from the systems approach that may be useful include: Literature Review, Soft Systems Method, Causal Loop Diagram, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Flow Chart, Dependency Structure Matrix, Delphi Study, Participant Observation, Designing Personas, Designing Scenarios, Storyboarding, Disney, Six Thinking Hats, Morphological Chart, Exclusion Audit, Expert Review, User Trials, Fault Tree Analysis, Hazard and Operability Analysis, Structured What-If Technique, Risk Matrix, PEST(LE) Analysis, SWOT Analysis, Driver Diagram, Activity Dependency Diagram and LoMo.

Establish pull

The fourth principle focuses on letting the users or stakeholders pull value rather than pushing it, without delay or reliance on excessive resources. Creation of a pull mechanism aligns with the need for smooth flow, where every step in the process should pull people, skills, materials and information as required. This requires good evaluation of resource usage against demand, and communication and visibility of the progress being made.

Activities from the systems approach that may add value include: Analyse Relevant Documents and Review Project Progress.

Tools from the systems approach that may be useful include: One-to-one Interviews, Delphi Study, Participant Observation and LoMo.

Seek perfection

The fifth principle emphasises the importance of maintaining the gains made after the implementation of changes and the continuous effort for achieving perfection. The performance of the revised system, along with the perceptions of users and stakeholders about the new practices, are monitored. This involves a mix of training, measurement, documentation and visualisation in order to remove barriers, and sustain and spread improvements.

Activities from the systems approach that may add value include: Analyse Relevant Documents, Create Stakeholder Map, Generate Personas, Generate Scenarios, Review Safety and Synthesise Evidence.

Tools from the systems approach that may be useful include: Literature Review, Causal Loop Diagram, Entity Relationship Diagram, Data Flow Diagram, State Transition Diagram, Flow Chart, Participant Observation, Designing Personas, Designing Scenarios, Exclusion Audit, Expert Review, User Trials, Fault Tree Analysis, Hazard and Operability Analysis, Structured What-If Technique, Risk Matrix, PEST(LE) Analysis, SWOT Analysis, Wardley Map, Activity Dependency Diagram and LoMo.

Literature

Moraros J, Lemstra M & Chijioke N (2016) Lean interventions in healthcare: do they actually work? A systematic literature review. International Journal for Quality in Health Care, 28(2):150-165.

NHS Institute (2012) Putting patients first — The Productive Series. NHS Institute for Innovation and Improvement.

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