NHS change strategy: everything going like clockwork

Little more than a year has passed since the leadership team at Stockport foundation trust committed the organisation to working with business advisory service the Manufacturing Institute on a transformational strategy grounded in lean principles.

But this has been plenty of time for the Stockport improvement programme to demonstrate considerable benefits in one surgical pathway and to make a significant contribution to the trust's successful early compliance with the European working time directive.

As Stockport acknowledges, it is by no means the first NHS trust to introduce lean principles into the way it goes about its business. However, it is keen to put lean at the heart of a transformational journey rather than use it along isolated pathways.

"Lean thinking is there as one of our four key principles, along with every patient matters, quality and empowerment," says human resources director Nicola Reucroft.

"For me, learning to do lean well is similar to a balanced scale - you need to have the right level of tools and techniques to equip staff to find different solutions, but these have to be offset with ensuring the right attitude and culture is in place to sustain improvements.

"We looked to the Manufacturing Institute to develop our understanding and application of lean principles," says Ms Reucroft. "As a not-for-profit organisation, it has a similar philosophy to ours, seeking to add value and sustainability through the working relationship."

A true organisation-wide lean transformation begins with the senior leadership and this was very much the case at Stockport. A lean leadership day held last summer instilled the philosophy of the journey behind the process of continuous improvement and the central place of the improvement programme as a lever for moving forward.

To prepare for the first projects, lean champions (15 in total and from a wide range of areas) went on to complete the Manufacturing Institute's 10-day intensive accelerated route to lean healthcare training using the relevant tools and techniques of lean - including value stream and process mapping, rapid improvement events layout, maintenance processes, 5S and problem-solving quality tools.

"We set out to pick enthusiastic people," says Ms Reucroft. "Not necessarily managers but definitely those who had been involved in some change management activity and could spot development opportunities."

The trust identified lower limb orthopaedics as its first strategic pathway or "value stream" for mapping. Stockport is acknowledged as having a good reputation, especially in knee surgery. But because demand for its services is high and this is a complex area, meeting 18-week targets is a genuine pressure point.

Value stream mapping involved everybody from consultants to ward clerks, and helped pick out four areas within the pathway (call centres, medical records, radiology and wards) for rapid improvement events held in October and November of 2007.

Self-sufficiency

These projects are ongoing but already show discernible benefits. For example, radiology throughput is up by a third, there has been a 43 per cent increase in optical scanning and there is a 99.9 per cent availability of case notes.

"For this first pathway, and the emergency admissions stream, we are making sure that change is reinforced and sustainable," says Ms Reucroft. "We have given a high profile to the lean projects so that key senior staff from across the trust visit the areas regularly and discuss visual management boards and action plans. Also, as we increase levels of lean self-sufficiency, our champions are going on to lead improvement events."

The Manufacturing Institute maintains a presence on the strategic project board, with its principal consultant Paul Glossop continuing to provide an objective overview and expert advice.

"I encourage them to press hard with key projects, quantifying the benefits that are accruing, and set challenging targets for their teams," he says. "I also like to check with the trust that it is giving their lean champions the dedicated time and resources they need to facilitate improvement activities and, having had our earlier support, can now go on to run their own workshops."

Bringing lean from its traditional manufacturing "home" environment and into healthcare at Stockport has in many respects been less of a challenge than Mr Glossop might have expected. Some of this, he believes, is down to its chief executive, Dr Chris Burke, and his understanding of the merits of the approach.

Other trusts, such as Bolton Hospitals, have actively been using lean for some years and across the sector the principles are becoming established.

"Many organisations have experimented with lean tools and techniques and there are some islands of expertise in the NHS," says Mr Glossop. "It has certainly been rewarding working with Stockport foundation trust as they take the first steps to embed lean principles in all of their activities and start to realise the benefits."

More fluid ways of working

Faced with the challenge of delivering working time directive compliance a full year ahead of national implementation deadlines, Stockport incorporated lean principles into its processes for reducing junior doctors' rotas from 56-48 hours.

The trust now has full compliance while employing just six additional medical posts - three at senior house officer level, three at trust grade. Across emergency and general medicine, value stream mapping has examined the mechanisms of acute admissions, support services and the demands on junior doctors at the trust.

This identified resource and time wastage alongside opportunities for more fluid ways of working and increases in staff numbers. Projects have identified several initiatives, including those looking at equipment renewal, relocation of the triage suite and a specified emergency medicine pharmacist - with the benefits being realised.

Measurable benefits include a 64 per cent reduced time to prepare IV medication, a 33 per cent increase in treatment room capacity in emergency medicine and a 33 per cent increase in radiology throughput.