Regina Qu’Appelle Health Region use Lean in their mental health service planning. They have a good example of using Lean methods to decrease waiting times in a mental health service. You can see the summary at this web page, where they describe a Rapid Process Improvement Workshop. The page includes links to two YouTube videos of their Report Out.
This workshop was, by any measure, a success. The service doubled the number of new service referrals they could see in a day, mainly by decreasing the time taken for an initial assessment. This was not done by cutting face to face clinical time – which is most of the value of the process – but by decreasing wasted time, like patients walking from room to room, staff walking to printers or trying to locate supplies, and so on.
The service also decreased the time for determining which service was likely to meet a client’s needs from seven days to one day. One of the ways they did this was by decreasing batching.
Batching refers to saving up referrals, clients, laboratory tests or whatever, and dealing with them all at one time. This is attractive to services. It seems to make obvious sense to bring staff together for a referral meeting once a week, rather than pulling staff in more frequently, and disrupting their work.
The problem with this arrangement is that it builds in a one week wait for some people – or sometimes even longer. If a referral meeting is on a Monday morning, for example, and my referral arrives on Monday afternoon – or even too late on Monday morning for inclusion in the meeting – then it automatically waits a further seven days before it is discussed. It is far from uncommon for referral meetings not to get through all the referrals – in which case my referral might wait a further week, taking me up to fourteen days before anyone has made a decision on offering me an appointment.
Many clinical staff will object to this description, and will point out that referrals may be screened as they come in, and urgent problems prioritised for action, or for discussion at a referral meeting. From a service user perspective, however, what if I am not one of the people who is prioritised? Many mental health staff will have seen systems with ‘non-urgent’ referrals, in which people with some conditions wait much longer than other people. In effect, we create different queues, some of which move more quickly than others.
This feels inevitable, and there is no doubt that some people do need to be seen and assessed very urgently. Most services will have arrangements for that, and may identify some capacity to allow response to an average number of emergency referrals. For everyone else, however, batching often produces delays, and tends to make waiting lists more difficult to manage.
In the Regina example, they tried to solve this by moving to daily review of referrals. There are several ways to do this. In some services, there is a brief team meeting lasting ten or fifteen minutes to review referrals each day. In other services, one or two senior staff screen referrals and make an allocation decision. My experience is that the most appropriate allocation of referrals, based on the information provided, is fairly clear in about 80% of referrals. If it is not clear because of insufficient or unclear information, the staff reviewing the referral information can go straight back to the referrer that day, to ask for clarification. By asking while it still fresh in the referrers mind, it is usually possible to get a quick answer, adding only a day or so to the process, rather than going back a week later for further information, and then putting the referral back in to the list for a future referral meeting, with inevitable delays. Quick review of referrals identifies problems – defects – very rapidly, which helps to decrease waiting times.
In a minority of referrals, clinical discussion is needed to decide. In a traditional referral meeting, everyone sits through the discussion on every referral, even if there is no likelihood that their particular skills will be needed. In an arrangement where referrals are reviewed regularly, they are either discussed with the people likely to be involved, and a decision made by them, or a few referrals are saved for a traditional meeting for further discussion (not my preferred option, but most people still have their average waiting time reduced).
In the Lean terminology, daily or even more frequent review of referrals is closer to one piece flow. If you are patient, there is a video at this link that shows a simulation of batching and one piece flow in envelope stuffing – not terribly relevant to health care, but a useful illustration of the principle for anyone who wants to watch it.
Are there examples of batching in your work that might be better converted to one piece flow? If so, perhaps you could try a PDSA cycle and see if it makes a difference to the service you offer.
Photo by Ben Grader http://bengrader.blogspot.co.uk/