In the work, which began with a Rapid Process Improvement Workshop, the focus was on easing pressures in a pre-operative assessment service. Pre-operative assessment is undertaken as standard now, to make sure that patients are as ready for surgery as possible. This service had been a success, but had become so busy that staff found it difficult to keep up. Demand had increased by a quarter in four years, and people were feeling the strain.
There were many frustrations for staff, and for patients. When we observed staff undertaking their work, we found that they had to spend time looking for things – for paperwork, for equipment, and sometimes for patients, when it was not clear which interview room was in use. Staff also found the variety of paperwork caused them problems: there were at least nine routes of referral into the department, and the information supplied varied depending on the route.
Attendance at the department varied markedly by the time of day. People usually began to arrive after out-patient clinic appointments, which meant that the department could be quiet early in the morning, but very busy towards lunchtime. Depending on the specific pattern of out-patient clinics, which was not in the department’s control, sessions could be quiet or busy overall.
When we followed patients through their journey in the department, we found that, while staff were very busy indeed at peak times, patients could have long waits. For some patients, most of their time in the department was spent waiting for different parts of their assessment to happen, despite the fact that staff were working hard to keep up.
When we asked staff to identify things that got in the way of doing their job, they had no trouble identifying wastes, and in producing ideas for change. The staff had many ideas on how to improve their service, but had felt that they were powerless to make changes. We felt that another reason staff had not made changes themselves were that they simply felt too busy to think about it.
Taking a week out was a huge commitment for the service. One of the challenges in working with very busy services is that the staff who take part in the Workshop can feel guilty that they are increasing the workload for their beleaguered colleagues. There are arguments against rapid improvement events, but they can be a very useful way of kick starting work, and providing an organisational framework for improvement.
We had undertaken preparatory work, including creating an Information Flow Map and a Value Stream Map. We had also identified demand, and how demand varied over time including a process called Product Quantity Analysis (an earlier post describes Pareto charts, which are often used in this process). The BMJ Quality Improvement Reports paper describes the work.
In summary, staff decided to:
- Decrease the number of routes of referral in to the department
- Room the patient, and move staff to the patient as required
- Develop standard work
- Produce a system to allow visual monitoring of the process
- Balance staff numbers against demand, including altering the times at which pre-booked patients attended
The effect was to reduce the average time that patients spend in the department by 25%, to decrease the number of patients who needed further anaesthetic referral by a third, and to largely avoid the need for patients to return on another day because of insufficient capacity. The work undertaken by the department’s staff had an important impact on their work, and Lean provided a valuable framework to support change.