Feature / The way forward

The challenge facing the NHS is easy to articulate. Deliver higher quality within restricted resources. While many may subscribe to the theory that higher quality equals lower cost, turning this into practice across wide-ranging services is a daunting prospect. What they need is a tried and tested toolkit that they can use to drive quality improvement.

One such toolkit is the Virginia Mason Production System (VMPS). A scheme was launched last year by the then NHS Trust Development Authority to support five NHS providers to adopt this approach across their organisations.

The basic approach of the VMPS, which is built on the Toyota lean management system, works on the assumption that it is staff who know what the problems are and have the best solutions. It then uses a number of observation and data analysis tools to describe how patients experience the service. This helps staff identify how to improve the patient’s journey. This is tested and, where appropriate, implemented – with the aim of standardising processes wherever possible.

These tools include established quality and lean management techniques such as process mapping, 5S (sort, simplify, sweep, standardise, self-discipline) and SMED (single-minute exchange of die). And they are put to use by multi-disciplinary improvement teams (from consultants down to the most junior members of staff) brought together in rapid process improvement workshops (RPIWs).

Leeds Teaching Hospitals NHS Trust was one of the five trusts selected as part of the TDA initiative, now supported by NHS Improvement. With a recognition that processes need to be adapted to local context, the trust has styled its take on the VMPS as the Leeds Improvement Method.

Julian Hartley (centre), chief executive at the Leeds trust, says that the difference with the Virginia Mason approach, as opposed to earlier NHS improvement initiatives, is the structure. ‘There is an absolute focus on patients and respect for people and an incredible rigour and discipline in the system’s methodology, which is all about achieving a level of standardised work to reduce waste and increase value.

‘It is about looking at services inch wide but mile deep,’ he continues. ‘We are not trying to take on too complex a process, but use narrow terms of reference to achieve a level of depth.’

And he insists it is about changing the way Leeds does business, not about completing an initiative. ‘Virginia Mason has been at this for 15 years, it is not about overnight success. But the aim is to, inch-by-inch, get through broken operating processes and redesign those processes by applying standard work.’

Focus of improvement

Leading the way at Leeds has been work on elective orthopaedics – with a focus on total hip and knee replacements – an area highlighted by Lord Carter as offering potential for productivity improvements.

The trust was keen to focus on the day of admission and surgery and staff had set reducing patient waits on the day as a key priority. But it was soon realised that to have maximum impact on this, the team would have to look earlier in the process – at the way theatre lists were constructed and then managed up to the day of surgery.

At the beginning of May, an improvement team made up of nurses, managers and consultants gave its 90-day ‘report out’ – its third feedback event giving an update of work done to date and lessons learnt since its RPIW at the end of January.

The sense of staff enthusiasm and engagement at the lunchtime event was clear – although they were also open about the challenges they had faced and continued to face. And there was a definite sense that they were fixing things that had both frustrated staff and had had a negative impact on patient experience of services.

The RPIW on theatre list order changes was a direct reaction to the realisation that about 80% of the operation scheduling team’s time for these procedures was taken up with dealing with patient cancellations – often in the week running up to the scheduled procedure. This would leave the scheduling and pre-assessment teams making multiple calls to line up a replacement and sort out the necessary pre-assessments.

In some ways, this wasn’t surprising given the process in place. The decision to operate would be taken at an outpatient appointment, at which point a patient was put on the inpatient waiting list. This then effectively became an administrative task of finding an available timeslot that complied with national referral-to-treatment targets.

Adhering to internal policies, a letter was then sent to the patient three weeks before their operation date. For many patients this was simply too little notice, leading to cancellations in some 10% of cases.

Consultant diaries

One of the ideas hatched in the RPIW that the improvement team was keen to test was for consultants to take their surgery diaries into outpatient consultations and to give patients a date for their operation immediately.

This has been a significant success. Patients are now typically getting six weeks’ notice and of 120 patients ‘dated’ by the beginning of May, 39 had had their surgery and just three had cancelled. Building slowly, the approach has been rolled out to involve nine consultants.

This small change has already had a major impact on the scheduling team. With list churn minimised, it is now spending just 10% of its time on rescheduling patients. This frees up time to spend more proactively preparing surgeons’ diaries ahead of outpatient clinics. And the scheduling team can also pay more attention to future lists. Draft lists reflecting the proposed optimum order are put together by the scheduling team and then reviewed by the relevant surgeons and anaesthetists a week, or even several weeks, in advance. This leads to patients being allocated in advance more definite timings for their time in surgery, which can have major implications for the fasting regimes that patients have to follow.

‘Previously, people might have been asked to fast from the evening before an operation but not operated on until the following afternoon,’ says Helen Gilbert (above right) Leeds Teaching Hospitals’ kaizen promotion officer, who is leading the improvement work.

‘Now a patient may be able to have a light meal the evening before or a drink of water in the morning if they are guaranteed to be the  last on the list.’

This not only impacts on patient experience but can help recovery time, if patients avoid unnecessary dehydration.

The team is now looking to progress further improvements. For example its aspiration is to undertake patient pre-assessments on the same day as the outpatient appointment at which the decision to operate is taken.

To take this forward, the trust needs to find a fixed location to do the pre-assessment, but a half-way house has seen patients leave their hospital outpatient appointment with both a date for surgery and for their pre-assessment.

There may have been financial benefits from the work – avoiding spaces in theatre lists due to cancellations – and reassigning staff onto more value added work. Certainly the volume of activity has increased.

But Ms Gilbert stresses that this is not the goal. ‘Our philosophy is that cost improvement is a consequence, not the point of our work,’ she says. ‘It is about spending the money we have more wisely.’

This ‘quality first’ approach is underpinned by deliberately keeping the improvement work separate from the trust’s cost improvement programme. ‘We haven’t had a CIP target imposed on us,’ she says – an approach that appears to have been adopted across other trusts in the programme (see box).

If cost savings are identified and delivered, they may contribute towards a unit’s cost improvement target – but that is not the over-riding goal.

Inventory focus

A second RPIW in March looked at theatre inventory for total hip and knee replacements, including the implants, theatre trays and loan kit. In particular it aimed to examine the potential for rationalisation of the various instruments used and to reduce the time taken to get these instruments ready to use for each operation.

The RPIW was instrumental in helping different parts of the theatres’ team to understand each other’s roles and to challenge parts of the process. For example, there was little awareness among the surgeons that picking the surgical instrument trays (seven in total, see right) along with additional individual instruments to meet the needs of the surgical team took nearly 20 minutes. Preparing those trays and instruments for use – opening packs, counting the instruments in and quality checking – took a further 29 minutes.

Yet orthopaedic surgeon Campbell Maceachern admitted that ‘some of these instruments I have never seen before and wouldn’t know what they were used for.’

Theatre staff reviewed the instrument requirements of all the surgical team and specified new trays – reducing the number needed from seven to just four. And then the stock room was redesigned, creating dedicated aisles for different procedures along with a ‘basics’ section.

These combined actions slashed the tray picking time by 19 minutes – with just 55 seconds now needed to select the right trays. Preparation time has also been cut by more than 20 minutes.

More ambitious plans to create a single instrument pack for a given procedure are under development – the necessary instruments are not all available currently from the same supplier.

With theatres being one of hospitals’ most expensive resources, reducing turnaround time between patients is a valuable prize – which ultimately could enable more patients to be treated within the same session.

There are quicker paybacks too. There could be a saving in the instrumentation the trust needs to stock, but certainly in its sterilisation costs, which have already been reduced.

Once the process is locked down – the focus to date has been on the use of one particular knee joint – then it can be applied more widely across orthopaedics, and then lessons learned across other surgical departments. 

Challenging agenda

There are challenges. While the improvement work (at Leeds and elsewhere) may not operate under its own cost improvement targets, it is not immune from the current financial challenges.

Staff at the Leeds report outs talked of the time pressures. One spoke of their frustration about not being able to advance the improvement work faster because of the pressures of ‘the day job’.

The current financial climate does not allow for backfilling of staff tasked with the improvement work. And while the eventual plan is for the Leeds Improvement Method
to become business as usual, for now there remains a steep and time-consuming learning curve for all staff.

IT is also a common obstacle – or lack of relevant data to inform optimum decision-making. Some changes will inevitably need capital or revenue investment, which can be difficult in a climate of significant cost improvement requirements.

And inevitably some staff will be opposed to the changes that will emerge from the process, even if these might be short-lived.

Both Ms Gilbert and Mr Hartley accept these challenges, but say that moving to a rigorous system of continuous improvement is simply the right thing to do. And the Leeds Improvement Method is not about quick fixes, it is about introducing sustainable improvements. These improvements may take years to materialise in some areas or in terms of some national indicators, but it makes sense to start the journey as soon as possible.