We are not Japanese and we dont make cars: Lean in the Public Sector

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We are not Japanese and we dont make cars
Lean in the Public Sector

• Dr Zoe Radnor
• Paul Walley
• Warwick Business School

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Objectives of Presentation

• Lean Thinking in HealthcareHistory of what has
  happenedExamples of Existing Practice
• Research for the Scottish Executive to evaluate
  Lean and its applicability to Public Services
• Gershon report on public sector efficiency and
  associated target savings
• Value For Money

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Lean in Healthcare

• Championed by the US Institute for Healthcare
  Improvement (IHI)
• Large Scale collaborative programmes since late
  1990s in US, Europe and Australia
• Focus on Pursuing Perfection and managing
  Healthcare variation

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In the UK

• Cancer collaborative started much of the initial
  work
• Ideas taken up by the Emergency Services
  Collaborative
• Whole Systems working enhanced by the
  Improvement Partnership for Hospitals
• P2 pilot sites in the UK
• Friends of flow research in US UK

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In the NHS, we know the problems

• Departmental optimisation creating typical supply
  chain inefficiencies
• Lack of process-based view
• Lack of process standardisation (clinical pathway
  work has not helped so far)
• Lack of process capability
• Lack of management of variation
• System dynamics
• The process bottleneck is usually hospital
  discharge

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Supply chain inefficiencies
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Lack of process-based view
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New Process Streams
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Lack of management of variation
Emergencies create problems of bed availability
for elective work ?
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Lack of management of variation
We need to prioritise patients in the queue ?
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Supply Chain Dynamics
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Weekly of Majors (admissions) through AE lt 4
hrs
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0
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May 2002 - November 2004
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There are some notable successes
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Reduction in Patient Hand-Offs
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The Process for assessment, minor treatment
discharge was redesigned to achieve lower waits
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Some Lean Tools really work
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An imaginative approach to demand-pull
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Were quite handy with the XmR Charts
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Expanding Lean to Other Public Sector
ApplicationsResearch methods

• Systematic Literature review
• Survey across Scottish public sector
  organisations 26 responses
• Eight case studies - sites where Lean and/or
  Lean-type initiatives had been applied
• 2 healthcare applications
• 2 local government sites
• 3 national/agency sites
• 1 military site
• Three pilot case studies sites where a Lean
  methodology was introduced

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Public Service Approach to Lean

• A focus on customer needs using a demand-pull
  principle
• A design principle that resources should be
  organised around processes
• A systems perspective of behaviour within complex
  organisations
• A focus on waste reduction
• Employee-led continuous improvement (kaizen)
• Management style to move from a command and
  control to one that allows front-line staff to
  take much more responsibility for the maintenance
  and improvement of their processes.

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Literature Review

• Systematic Literature Review
• Approximately 70 articles identified through
  searching selected strings, sub-strings and
  databases
• Lean making a transition from Manufacturing to
  service and public service
• Lean Manufacturing, Lean Service, Lean
  Enterprise, Lean Thinking, Lean Supply and Lean
  Consumption
• Little doubt over the theoretical applicability
  of Lean
• Particularly the tools and techniques related to
  process flow and, developing a customer
  perspective
• Little evidence, except in Health, of application
  of Lean philosophy
• Many change management and improvement approaches
  issues regarding organisational readiness and
  prerequisites also relevant to the implementation
  of a Lean Approach
• Criticisms of adoption of Lean to the Service
  and Public Sector environment

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Approaches to Lean Implementation

• Consultants were used as external support by 36
  of public sector organisations.
• 21 of public sector organisations used training
  to engage the staff
• Two approaches used
• Full Implementation of the philosophy was
  considered to be embedding of the principles and
  broad use of the tools. One of the case studies
  had a model for Lean that had been implemented by
  a consultancy, as a very careful translation of
  the original implementation model used by Toyota.
  
• The approach used by most sites was a Kaizen-type
  approach, often described as a Kaizen Blitz or
  Rapid Improvement Event (RIE) . Kaizen
  provides a way of making improvement manageable
  by cutting problems into bite-sized chunks.
  Kaizen works because it is a process which
  delivers quick and visible but also sustainable
  wins. (CS3)

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Impact of the Lean Approach

• The percentage of patients meetings their fixed
  target from around 40 in 2003 to 75 - 80
• An average reduction in time to first appointment
  from 23 to 12 days.
• In six months the time taken for planning
  application was reduced from an average of five
  days to an average of two.
• A reduction in flow time of 48.
• Benefits for both customers and staff
• Most people think it is a nice place to work.
• Failure demand was reduced from 82 to 15 in
  four weeks.

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Lean Thinking in the Public Sector
Manufacturinglean
Servicelean
Watch out for the Toolheads
Eliminatevariation
Necessaryvariation
Inherentvariety
Modularvariety
MassCustomisation
Standardiseprocesses
Toolkit
5 Principles
Eliminatecommand control
Managedteams
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Barriers to a Lean Approach

• People - attitude that it was all about money
  and cost reductions. Although the results
  clearly show that headcount and cost reduction
  was not a primary objective for any case study.
• Lack of ownership -My job as a doctor is to just
  make sure that the patient gets better. This is
  more of a management exercise (CS1)
• Identity of improvement team members - The ones
  who did want to get involved did so. (CS7)
• Failure of leadership need clear commitment
  from senior management
• Compartmentalisation
• Weak link between improvement programmes and
  strategy
• Lack of resources - Also concerns about the lack
  of capacity, knowledge, experience and skill to
  drive and implement improvement.
• Poor communication - use of jargon, lack of a
  clear message about improvement, and over-control
  of information released
• Lack of understanding of the effect of variation,
  systems thinking, customer focus and process flow

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Conclusions

• Can Lean work in the public sector?
• Yes it can, but Lean in the public sector was
  found not to be the adoption of Lean from
  manufacturing. Engaged with principles of Lean at
  an operational, not strategic, level and not
  through using the tools developed from
  manufacturing.
• So, how can Lean work in the public sector?
• Lean was found to work in the public sector by
  focussing on the principles of reducing waste,
  improving flow, developing an understanding of
  the customer, developing a process view, often
  though a rapid improvement event.
• Can Lean embed a culture of continuous
  improvement?
• The research clearly shows that the RIE/ Blitz
  approach started to generate an improvement
  culture and engagement with the Lean concept.
• Outcomes which were, in some cases, dramatic and,
  in all cases, critical in developing an
  improvement culture.