“Lean Thinking” implies, using less to do more. This concept of lean thinking has led to the great success of Toyota, which is the world’s largest car manufacturer in terms of overall sales. Thanks to the Toyota manufacturing, lean thinking started to gather shape after Second World War, swiftly developed into principles and philosophy, and had wide spread outside Toyota to reach other organisations in Europe by seventies (1).

Lean thinking places customers (patient) at the centre of an organisation strive and existence. Its ethos is maximising value to customer (patient) while minimising waste (2).

Lean thinking is already being applied to various aspects of health care. Although they appear very different, there are remarkably many similarities between manufacturing and healthcare. Whether building a car or providing healthcare to a patient, the people involved must rely on a variety of complex processes to accomplish tasks and provide value to a customer or a patient. By identifying all the steps in these complex processes and removing the steps that do not add value, one can create lean processes.

In essence, the aim of lean thinking is to identify value-added steps in any process, retain them and remove all non-value-added steps, so as to reduce waste. Waste can be of many forms – money, time, supplies or good will (1).

Value Stream Mapping

Value stream mapping (VSM) is diagramming and analyzing services (value streams) into their component steps and eliminating any steps (or even entire groups of steps or value streams) that do not deliver value (1).

Flow is one of the fundamental concepts of value stream where waste is eliminated and where processes merge into each other, so that there is a smooth flow in the system. The focus is not on waste, but on waste reduction and flow. The concept is applied to the system as a whole, so that, the benefits are optimised (1).

The concept of lean thinking and value stream mapping are very much suited for pull systems (or demand-driven systems), as is healthcare (3). Here, the patient initiates the initial request for a service and that in turn initiates pull in the system. For example, a patient is sent to the surgeon with a problem requiring surgery. This in turn initiates requests for investigations and other consultations (3).

This is in contrast to a push system where, the manufacturer estimates the demand and produces goods. This creates a stockpile in anticipation of customers needs. In healthcare this is the concept on which services are largely, still provided, based on estimates i.e. demand driven or push systems (3).

Our experience

It is currently known more than 85% of surgical cases could be carried out as day surgery. The lists of cases suitable for such practice continuously increases thanks to new added medicines and technologies. Day surgery is becoming a necessity due to pressure on beds, increased health expenses and change in people expectations.

Day surgery is defined as a surgical procedure undertaken in operating theatres settings under a form of anaesthesia.

It has many advantages. It allows rapid recovery of patient, reduces the risk of hospital-acquired infection and venous thrombosis events to almost zero, reduces bed occupancy; increase work efficiency, while reducing cost.

In view of these advantages and as our Hospital had an ambition to deliver care services to a larger population despite a limited bed capacity that was 205 beds; we carried out a project of development of a day surgery service.

Day surgical procedures were in fact undertaken in our Hospital, but were sporadic, patients were not properly informed and prepared, which led to overnight admission and sometimes cancellation. There was also variability of practices among many surgeons and lack of standardization, which crippled operating theatre planning and bed management. Patients overstaying in Hospital in an already limited bed capacity, generated cancellation of surgical cases that caused inconvenience to patients and generated income loss to the Hospital.

Value Stream mapping in action

Over a period of 10 months, we carried out a day surgery service development programme. The first step of project was to organize a value stream mapping of patient’s pathway from the ‘time of decision to operate’ until discharge from Hospital.

We organized a 4-hour session value stream-mapping workshop that included all staff that directly or indirectly have influence patient’s journey. We had 30 staff form different specialties under one roof. These included representation from admission and booking, pre-assessment service, bed managers, operation division, surgeons, anesthetists, pharmacists, information technology, infection control, radiology, operating theatres, wards, operation managers.

A Consultant Anaesthetist led on the event with the help of the Medical Director and Quality Managers.

Our preparation for the VSM included brainstorming on the list of participants; We then carried out an invitation campaign using different ways communication and negotiation to maximize attendance.

On the day of VSM, we explained how the process mapping would work; we introduced the aims and objectives of the event and stressed importance to put patient in the centre of the whole exercise.

We created three teams with equal distribution of skills and specialty backgrounds. Each team concentrated on a segment of the patient’s pathway:

  • First segment: from ‘decision to operate’ to ‘admission to hospital bed’
  • Second segment: from ‘arrival to bed’ to ‘return from operating theatres’
  • Third segment: from ‘return to bed’ to ‘discharge home’

Flipcharts and a variety of markers and colored post-its were used to aid trace the pathway.

The session was divided into 3 main parts:

  • 1st part: Current pathway

Participants mapped the then patient’s pathway. Participants traced every step patient goes through to have surgery. Participants were advised at that stage not criticize the pathway or find better solutions of that journey.

  • 2nd part: Analysis value

Participants analysed and critically appraised each step of the pathway by indicating steps that add value to patient’s care and those that are bottlenecks.

A green colored post-it was added if a step added value. A pink post-it was added if the step was a waste and n orange post-it was chosen if the team did not reach an agreement about the value of the step.

  • 3rd part: desired pathway

At that stage, participants removed waste and linked steps together to form the desired pathway.

Figure 1 and 2 illustrate then and desired pathway during the value stream-mapping event.

How did the service look after implementing all changes?

The value stream mapping events formulated a new patient’s journey. However, it did not fully answer to what was needed to develop a day surgery service. At the end of the session, a long to-do-list was created.

The leading team on the project refined the to-do-list and allocated mini-project to different groups of stakeholders.

During the following 8 months before implementation of day surgery, we created and standardized more than 25 procedures and protocols in order to establish the desired pathway and facilitate day surgery procedures. We also standardized communication means to ensure timely and effective transfer of information to all key cares; we created a new pre-admission procedure that eliminated patient waiting time on the day of surgery. A newly dedicated patient’s information leaflet was produced. We rallied surgeons to agree on lists of surgical cases that were eligible for day surgery setting. We set up performance outcome indicators, which evaluated our intervention and monitored the service performance. A development programme for nurses was set up. Decision-making algorithms based on latest evidence were introduced to empower nurses to take clinically sound decision. It also assisted standardization of clinical practice among surgeons and anaesthetists.

The new service was introduced ten months later and following were its main characteristics.

  • Patient’s education and consenting began at the out-patient clinic soon after decision to operate was taken
  • Pre-admission: Pre-operative assessment by an anaesthetist and administrative tasks were carried out before day of surgery
  • A dedicated admission space was created to facilitate patient’s journey and avoid delays on the day of surgery
  • Admission and preparation to operating theatres were standardized
  • Patient’s passport was introduced and included information about patient’s pathway, to do and not to do checklists, and essential contacts phone numbers.
  • Discharge criteria and standardized post-operative pain prescriptions to avoid patient’s discharge delays
  • A new pathway for readmission in case post-operative care complications was introduced
  • The number of day surgery cases markedly increased in piloted specialties. The Urology and Ear-nose and throat cases increased respectively by…. before and after introducing the new set up.

Good things about the value stream-mapping event

Having people gathered at the same place and time enhances team bonding; align aims and objectives and enthuse people to be engaged. It is amazing how one could learn about how much patient goes trough and how many players influence patient’s journey. It is an education for all participants as they broaden their knowledge on how and why things happen one way or the other.

Everybody feels empowered to express his or her views and inform on a better change.

Having achieved a desired pathway gave participants great feeling of satisfaction.

Things to be aware of and act on quickly and assertively

  • VSM, as mentioned above is a management tool that is widely used in the industry. Adapting it to patient care is feasible. However, It is important that the ‘added value’ is well defined and customer that is ‘patient’ is well identified.
  • Participants may need time to engage and get them to talk to each other. Some participants may embank in blame and shame exercise. Others may try to overpower and intimidate others.
  • There is tendency people derail from the process by moving forward and backward of different stages.
  • Desired situation is the ideal one, but not always the best one. It is the one an organization could afford to have at that time, within its existing resources and external constraints.
  • Such event enthuse people and raise their hopes. It takes time, energy and patience to organize such event. At the end of the day, there is a desired pathway along with a long to-do-list. Therefore, the hard work comes later. People would judge success of the event only when recommendations are implemented.
  • Meticulous stakeholder exercise while preparing for the events is vital. It is important to include every key player in patient care to ensure good understanding of the whole process. Omitting some may cost you people engagement and good will.

Conclusion

This programme was an extensive one and included use of management tools, research and audits. It was aimed at improving patient care but also into increasing service delivery. It was also about better planning and predictability while improving service efficiency. It involved many key players including clinicians and managers.

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