This document discusses using lean principles to improve elective care pathways and avoid unnecessary delays. It summarizes the following: 1. The NHS has committed staff struggling within broken processes. Lean can help see things from the patient's perspective, identify problems and waste, and engage staff as problem solvers. 2. An initial lean project in Bolton engaged 350 staff over 9 months. Early results included reduced mortality and length of stay. Additional specialties are now using lean. 3. Lean is being used to reduce mortality, improve staff morale, enhance patient experience, boost productivity, and achieve the 18-week waiting time target. This requires understanding end-to-end processes and removing non-value adding steps

1. Mapping the elective Journey:Mapping the elective Journey:
using lean to avoid needlessusing lean to avoid needless
delaysdelays
Mike Maguire
Director of Commissioning
Bolton PCT
David Fillingham
Chief Executive
Bolton Hospital

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WaitingTransportation/
Motion
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Inappropriate
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Inappropriate
Processing

5. The NHS is full of
committed staff who
struggle to deliver good
care within a set of broken
processes

6. Lean can help us to:-
• See things through the patients eyes
• See the hidden problems and waste
• Create safe, clean, calm work
environments
• Fix our broken processes
• Turn every staff member into a problem
solver every single day

8. The Beginnings of a Lean
Journey…….
• 350 staff engaged (10%) over 9 months
• Early results promising
- Trauma: 50% mortality reduction post #NOF; 33%
LOS reduction
- Pathology: Blood specimen processing
- 40% floor space saving
- 20% productivity gain
• Antenatal; Radiology; Laundry; Musculo-skeletal
• Focus is on quality and safety not cutting cost
• We now know just how much we don’t know!

9. We are using lean to:-
• Reduce mortality rates
• Improve staff morale
• Improve patients’ experience
• Improve productivity
• Achieve (then better) the 18 week wait

10. Achieving an 18 week maximum wait
• Wont be achieved just by working harder
• Wont be achieved by a 6/6/6 mentality
• Can only be delivered by working across
organisational boundaries
• Requires deep understanding of end to end
processes
• Demands removal of waste and non-value
adding steps and creation of flow

11. The Bolton Approach
1. Understand the current state
- analyse, observe and map
2. Design the Future State
- cells
- linkages
- flow
3. Deliver the Future State
4. Repeat the Cycle

12. Lean in practice – A recipe for
success
The MSK experience

13. ELECTIVE PATIENT JOURNEY: GETTING THE LEAN DATA
OPD
Tier 2/
ICATs
(currently Surgical
but ?medical for future):
Pre-Assess
WLs/
Queue
Mngt
Ward/
DC IP
Beds
Tx and/or;
Theatre
Discharge
Diagnostics:
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
•Demand
•Activity/throughput
•Capacity
(planned v
supplied)
•Queue/inventory
•Blockage
•Delay
Select High Volume Groups – Where are your flow problems?
The above data gives a current state of delivery and shows the mismatches (this gives you your baseline to measure
improvements against. For the future state it is important to work out the essential value steps you are working
towards. The pace will need to flex to meet demand (a no waste system), and your data should be focused on this
journey. Old ways use data to calculate what we can and do deliver, rather than how we need to work differently to
deliver a one piece flow system…. very different!

14. MSK - Current State: MSK - Future State:
MEASURE CURRENT STATE FUTURE STATE
Total Steps DC: 28
IP: 40
DC: 5
IP: 5
Value Added Steps DC: 7
IP: 11
Key steps only + customer
delighters
Flow Time Max:
DC: 20 weeks
IP: 40 weeks
Max:
DC & IP: 18 weeks
Pure Value Added Time: DC: 71 mins
IP: 106 mins

15. Lessons from the current state
analysis
• Multiple OP visits
• Diagnostics not fully aligned with OPD
• OP wait – 40 to 60% of journey
• Patients on waiting lists that need their health
optimising first
• System not compatible with 18 weeks
• Waste and inefficiencies exist within surgical
processes

16. Integrated Clinical Assessment
Services in GMSHA
• Trauma and Orthopaedics (inc Rheumatology)
• General Surgery
• ENT
• Gynaecology
• Urology
• Range of supporting diagnostics
• 2/3 National IS procurement, 1/3 Local
procurement or NHS provision

17. SYSTEM TRANSFORMATION USING
ICATS
Hospital 1
2nd Line
Diag
1ry
Treat
Triage
1st line
Diag
Assess
& Pre op
“Choice”
C&B
Select
ICATS
(RBMS)
Patient
Referred by
GP,
Optometrist
or Dentist
Community
Services
Hospital 2
ICATS
Hospital 3
Hospital 4
IS
provider
Free
choice
2008
Patient Flow

18. Benefits of ICATs
• Patients arrive fully worked up to a
common standard in 1 stop shop
• Only patients who need, want and are fit for
surgery arrive at hospital
• Increased predictability and precision
through choose and book
• Patients make choice with full treatment
plan
• Removes unnecessary steps and waste

19. But this could still happen…..

20. SYSTEM TRANSFORMATION WITH ICATs
Referral
Management
Patient Referred by
GP, Optometrist or
Dentist
Choose
And
Book
centre
IS
H 1
H 2
H 3
H 4
ICATS
Diagnostics/Initial pre op done
here
OP Theatre
Additional
diagnostics
Pre
op
Timeline – 4 weeks Timeline – 6 weeks
Present Acute
System will not hit 6
week time line
ICATS must have a 4
week timeline

21. Using “Lean” to redesign the
Acute System
• Future state vision
• Creation of efficient Preoperative and
Surgical Cells
• “Lean” length of stay improvements
• Implement through Rapid Improvement
Events, Projects and “Just Do its”

22. ORTHOPAEDICS – FOLLOWING ICATs and LEAN
Referral
Management
Patient Referred by
GP, Optometrist or
Dentist
Choose
And
Book
centre
IS
H 1
H 2
H 3
H 4
ICATS
Diagnostics/Initial pre op done
here
Theatre
Consenting
Visit
Final preop
Timeline – 4 weeks Timeline – 6 weeks

23. Understanding Real Acute Capacity
Operating Capacity
GP admissions for surgery
% Removals other than Treatment
% Conversion from Outpatients
% Cancellations & DNAs
% Other Referrals
% GP referrals
Other OP Slots to service Theatres
NET RESULT – Know number of GP OP slots to service theatres

24. The Result
• An effective predictable system
• Transformational change
• Fit for purpose for 18 weeks

25. Lessons so far
• Lean analysis gives a much better
understanding of the real processes and
demands
• Some radical changes are needed (eg
ICATs)
• Achieving flow reduces waste but also
exposes the problems
• Active and enthusiastic involvement of
frontline staff is the key to success