There are published examples of the use of Lean in many types of health care. There are fewer descriptions of the use of Lean in mental health, but they are beginning to appear. Kislinsky and Younger, from St Joseph’s Healthcare in Hamilton, Ontario, have produced a useful description of work to improve flow in an acute mental health service.
Their work included several techniques and approaches that are relevant to many services. Their work increased standard work, identified skills across staff members, used visual indicators, and sought to level activity by matching capacity and demand, any by identifying an extended value stream, including pre- and post-hospital activity.
Standard processes are often maligned in health care. The idea comes in for the same criticism as clinical guidelines and managed clinical networks. Some staff worry that it will restrict their choices to a lowest common denominator. Patients worry that the clinicians working with them are restricted to a few actions that may not fit their clinical needs. Quality is a constant juggling act between different dimensions, however – equity often trades off against efficiency, for example. Delivering effective care to many people with the same condition can mean that some treatments are offered every time. In patient safety work, this has produced the idea of ‘treatment bundles’ – interventions that are offered together to reduce risk to the service user.
Standard processes in Lean have elements of all of these, but it is useful to consider the similarities and differences. The point of a standard process is to help achieve an aim – which might be reducing waiting times, or increasing consistency and so increasing safety. Standard processes are relevant in many types of services. In one surgical Rapid Process Improvement Workshop in which I took part, staff asked service users to comment on their experience of the service. They valued the function – it was a crucial step on a surgical pathway – but some were unhappy with the process. There were long waits, they moved from room to room, and sometimes staff asked them the same questions several times.
We mapped out the process used by the service, and with the permission of patients, followed some of them through their time in the department. When we looked at the timings, it was clear that they spent much of their time in the department waiting – waiting for a room, waiting for a staff member or waiting while a staff member found the equipment they needed. Very little of the time added value to the patient – it didn’t get them any nearer their aim, which was to complete their assessment and obtain a date for their surgery. The staff found it frustrating as well, as they had to spend time working round the process which they would have preferred to spend with the patient.
The staff who worked on the Rapid Process Improvement Workshop did many things to improve the patient experience, but one of the most important was developing a standard process. In the original state of the service, staff members did the same things, but in a different order from one another. This meant that, at hand overs, it wasn’t always clear what had already been done, leading to the same questions being asked on several occasions. Some nurses liked things done in one way, others in a different way. That meant that health care assistants had to run to keep up – it was very difficult to have everything ready for the nurse, as it was not always clear what equipment they would need, leading to delays for the patient, while the staff located the equipment. Rooms had different lay outs, resulting in further delay while people checked in drawers or cupboards for what they needed to do their jobs.
This was not a question over the specifics of clinical care – the tasks the staff needed to undertake were well understood – but rather an issue of how to organise the delivery of care to stop re-work, increase consistency, and reduce waiting for patients. Part of the process was standardisation of the rooms using 5S, so that it was easier for staff to find things, and so reduce the time spent looking. They also agreed which tasks could only be undertaken by a trained nurse, and which could be done by a health care assistant, so that health care assistants knew what they could do before the nurse arrived.
The most important achievement was the development of a list of standard processes, which stated the required tasks, and the expected order. This meant that, together with the agreement on who could do what and the better organisation of the clinic rooms, it was clear to everyone where each patient was in the process, This reduced re-work, made it easier for the health care assistants and administrative staff to support the nurses, and had the added benefit of reducing waiting.
A concern from some staff could be that this fitted patients in to a template that is not appropriate for their care. This standard process made no change at all to the clinical care. It specified the order of activities, but made no changes to the processes developed by the specialist surgical departments. It was still possible to undertake additional work when a patient needed it, and to obtain a medical opinion when required. Even in these circumstances, it was now clear what was happening. Additional developments, such as a re-designed board showing staff where each patient was on the pathway, and a shift co-ordinator who kept an eye on the flow of patients through the department, made it easier to keep track of waiting times. It was easier for the co-ordinator to move staff to bottleneck because of the agreement on which staff could undertake what activity, and to know who was waiting for a medical opinion, or for further assessment.
A key part of standard processes are that they are the best current processes. That does not mean that they cannot be changed. Staff or patients often identify better ways of doing things, guidelines may change, or new techniques emerge. In that case, the standard process can be revised to reflect the improved process, turning this in to continuous quality improvement.
Photo by ronnieb.