To be successful, lean principles have to inform everything an NHS organisation does. Here, the chief executive of Royal Bolton Hospital foundation trust explains how he and his staff are putting this into practice

Over the past two years, Royal Bolton Hospital foundation trust has seen some highly encouraging early results from applying lean management principles. We have also begun to see how we might go beyond just improving a few processes to transform our whole hospital.

The risk in creatively adapting lean initiatives to suit your own organisation is that their essence can easily be lost. It can degenerate into just another quality drive, or worse still, a set of talking shops in which nothing gets done. The trick is to recognise the core elements of a lean approach and embody them in all you do.

Awakening staff

This means finding ways to open staff's eyes to the waste that surrounds them in their processes. Care must be redesigned so patients and work flow smoothly. Problems should be solved using data and rapid experimentation rather than anecdotes and power politics.

Alongside these technical aspects of lean are a critical set of cultural changes. Jeffrey Liker in his book The Toyota Way shows how it is the underpinning culture at Toyota that makes the company special, not just its adoption of lean methods. This involves managers getting out of their offices to go and see what is actually happening in the workplace. It requires a step change in the investment made in training and development for improvement. It implies a genuine belief that every employee can become a problem solver every day.

One of the most powerful mechanisms for teaching the technical skills and achieving this cultural change is the rapid improvement event. These are week-long events in which multidisciplinary teams focus on a particular problem. They work together to deeply understand the processes involved, identify and eliminate waste and bring about improvements.

Energising weeks

Event weeks can be emotional and stressful for the staff involved as well as hugely energising. As one consultant geriatrician put it to me: "I didn't know we were doing this to patients." Finding out about the problems in the service is the first step to fixing them but it can be an unsettling experience.

But leading a lean transformation of a hospital is about much more than running rapid improvement events. It requires a systematic approach to changing how the hospital works. In Bolton, we have developed the Bolton improving care system cycle to help us do this.

*081016/bolton diagram

The more ambitious will want to use lean techniques to transform patients' experiences throughout their journey. In Bolton, we have already seen big improvements in safety and efficiency through the redesign of patient pathways in trauma, stroke services, cataracts and joint replacements.

We have now set out on a 10-year journey to transform everything the hospital does. This means applying lean principles in every part of the organisation. We have established an academy to give all 3,500 members of staff a lean mindset and skills. We are also re-educating leaders in a new approach to how they go about doing their jobs.

Whole system change

Most ambitiously of all, lean could be used to rethink the way the whole healthcare system works. Achieving a whole health system lean transformation will require individual institutions and leaders to put aside their egos and work together to use lean principles to redesign services in the best interests of patients rather than the interests of their own organisation.

My biggest personal reflection is just how satisfying and energising this work can be. The last two years have been the most stimulating of my career. It is gratifying to see so many patients benefit directly from this work. It is also inspiring to see staff who were disenchanted given a new lease of life. Nothing motivates NHS staff more than the conviction that they can take matters into their own hands and improve services for the patients for whom they care so passionately.

Measuring results

Trauma - fractured hip mortality cut by 50 per cent, length of stay down 33 per cent;

Pathology - test turnaround times three to 10 times quicker, 40 per cent floor space saving;

Cataracts - new one-stop shop established, patient visits cut by 50 per cent;

High-risk joint replacements - complications reduced by 85 per cent;

Laundry, estates, finance and many others - extensive cost savings delivered.