Achieving a leaner and better hospital

Lean is founded on the principle that every individual should be a problem solver and that it is the job of leaders to educate and empower staff to find the answers for themselves, writes David Fillingham, CEO, AQuA (Advancing Quality Alliance) and former CEO of the Royal Bolton Hospital, where the introduction of lean brought about dramatic improvements in quality, patient experience, and staff morale.

If you ask any group of hospital executives anywhere in the world about their biggest challenges, then the answers would fly at you thick and fast: keeping patients safe, achieving high quality outcomes, balancing the books, providing a good experience, engaging and motivating staff, coping with a seemingly ever rising tide of demand.  Given that medicine is a scientific discipline isn’t it surprising that a more scientific way hasn’t been found of tackling these problems?

David Fillingham
David Fillingham

A growing number of healthcare organisations are doing just that by applying Toyota production system methods, popularly known as lean, to the way that they organise care.  One such example is the Royal Bolton Hospital in the North West of England.  Since 2005 the Royal Bolton have been developing the Bolton Improving Care Systems (BICS) which is founded on lean principles.  Through it the hospital has brought about dramatic improvements in quality, patient experience, and staff morale.  It enabled the hospital to move from a significant deficit into relative financial health.  What’s more, over two thirds of the hospital’s staff have been actively engaged in this work.

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There are many myths about lean.  To its detractors it’s “lean and mean”, paring back to the bone, or making do with less.  Nothing could be further from the true application of Toyota’s principles.  Of course Toyota’s recent highly publicised problems with one of its suppliers have led some to cast doubts on the method.  But it remains the fact that for decades Toyota has outstripped all its competitors in terms of quality, service and profitability.  What’s more, the method has been adopted by almost every successful organisation in the manufacturing and service sectors.  At its heart are two simple principles, the continual elimination of waste, and respect for people, both customers and staff.

The Royal Bolton Hospital has invested in leadership development, including working with School of Coaching to develop a new leadership style

The Royal Bolton Hospital is a busy emergency orientated hospital to the North West of Manchester.  In 2004 it was facing many challenges.  It had an operating deficit of five per cent of its turnover, long waiting times, poor outcomes in many areas, and a lack of engagement amongst some key groups of staff.  The hospital’s first step on its road to recovery was to be clear about its vision and goals, what Toyota would describe as its true norths.  These were established as:

  • Improved Health for people who live in Bolton and the surrounding areas
  • Best Possible Care for those who need it
  • Value for Money for the taxpayer
  • Joy and pride in work for all staff

What the hospital now needed was a system to engage everyone to continually drive up both quality and productivity.

Lean tools

The Royal Bolton took the decision in 2005 to adopt the use of lean as its overall organising framework.  The result was the Bolton Improving Care System, or “BICS”.  This involved the vigorous application of lean tools, methods and mind sets, but within a healthcare context that emphasises safety, high quality outcomes and a good experience for both patients and staff.

Some of the improvements have been startling.  They include reductions in mortality for stroke and fractured neck of femur patients of over 30 per cent, with reductions in length of stay of over 35 per cent in those specialities.  Turnaround times for pathology tests have been reduced from days to hours, and in some cases to minutes.  Increased capacity has been created in some areas such as imaging and theatre throughput, and significant reductions in length of stay, bed occupancy and readmission rates for respiratory patients.  BICS has also been a vital enabler to the Trust’s productivity programmes, enabling financial recovery in a tough economic climate.

The BICS approach involves a four stage cycle:

  • Understanding value: Deeply understanding patients needs and wishes through surveys, interviews, the direct involvement of patients and innovative techniques such as experience based design
  • Learning to see: Deeply understanding the true nature of the processes through process mapping and a range of learning tools and techniques
  • Redesigning care: To embody lean principles, making sure that services flow smoothly, that waste is eliminated and that work environments are clean, orderly and well organised
  • Delivering benefit with a strong emphasis on managing change successfully and robust implementation and follow up.

The Royal Bolton found that simply applying these lean tools was not enough to achieve sustainable improvement.  What was also needed was a management system that would focus lean methods on the areas of greatest need and deliver a change in the way in which the whole hospital went about its business.  This involved applying policy deployment to cascade the hospital’s aims throughout each layer of the organisation and to focus lean improvements on the areas of greatest need.  Staff were typically involved in lean activity through week long rapid improvement events where multidisciplinary teams came together to use the method and to solve real problems.  The well attended out briefs at the end of these weeks were both uplifting celebrations and opportunities for everyone to learn about improvement.

Traditional management

The traditional style of management and leadership in healthcare doesn’t lend itself well to an approach such as this.  Lean is founded on the principle that every individual should be a problem solver and that it is the job of leaders to educate and empower staff to find the answers for themselves.  This is not an easy approach to take for hard pressed managers and clinical leaders.  Consequently the Royal Bolton Hospital has invested in leadership development, including working with School of Coaching to develop a new leadership style.

Most attempted lean transformations fail after the first two years due to lack of commitment from senior leadership and a failure to embed it in the organisation’s culture

Most attempted lean transformations fail after the first two years due to lack of commitment from senior leadership and a failure to embed it in the organisation’s culture.  The Board at the Royal Bolton Hospital were clear from the outset that they needed to exercise personal leadership if BICS was to be a long term success.  This involved undertaking training themselves and getting hands on involved in the lean improvement work.  The hospital also invested in the BICS Academy which has now trained over two thirds of the hospital’s staff, many to an advanced level, in the use of the BICS approach.

In the summer of 2010, I left the Royal Bolton Hospital after six challenging but very happy years there as Chief Executive.  My new job is as CEO of AQuA, the Advancing Quality Alliance.  This is an improvement agency for the North West of England.  It is a membership organisation comprising 60 of the 64 Primary Care Trusts and Providers.  Our role is to stimulate innovation, to spread best practice, and support the development of local improvement capability.  Needless to say the promotion of lean methods and approaches is at the heart of our work.  Almost a third of our membership are using lean methods, and we are working to accelerate and deepen its application across the North West as a whole.

So what of the Royal Bolton Hospital?  I was delighted that my long term deputy has succeeded me as CEO.  Lesley Doherty, formerly the Director of Nursing, is now helping the hospital think about how BICS should move on to the next stage in its evolution.  This includes an integration between the hospital and community based staff, with an increased emphasis on prevention and chronic disease management.  In healthcare a patient falling ill when they could remain healthy is the biggest waste of all, and it’s the hospital’s challenge to refocus its sights on this much prized goal.  If they succeed lean will not only be transforming the hospital’s services, but also improving the health and well being of the community it serves.

Editor’s note:

  1. For further information on the BICS programme including case studies and achievements click here:  http://www.boltonhospitals.nhs.uk/bics/default.html
  2. The next edition of Health Manager will bring you examples of lean in action