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NHS Productivity: Weathering the Storm

18th September 2014 Manchester

• Dr Nathan Proudlove, Manchester Business School, University of Manchester– nathan.proudlove@mbs.ac.uk

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Housekeeping

Timings! … blocks of speakers: please make notes of your questions for the Q&As

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Weathering the Storm…

• New models of care• QIPP2 Call to Action• Cost Improvement Plans, Leaner not meaner… transformational

improvements

• NHS value for money• The potential of communications technology and data-driven business

intelligence

• Greater value • improving medical education and training

• Integrating service improvement strategy (inc. lean)• …how will we finance the NHS

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Worms’ (moles’?) eye-view

• Chipping away with service/quality/value improvement– Practice: e.g. WEST, MA, NHSI I&I, AQUA, CLAHRC2 etc.– Education: e.g. NHS MTS, Elizabeth Garrett Anderson, Nye Bevan, DClinSci?, NW

Deanery etc

• We feel the storm too… political & financial turbulence:– Intakes for NHS Leadership Academy on hold?– £1M NHS policy research project pulled at last moment

Higher Specialty Trainees 2013-14

New clinicians and managers:• With little knowledge• Into non-enabling cultures

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Productivity: knowledge, systems and incentives

• A big body of knowledge– 60+ years– Ways of thinking, tools, principles– Some organisations in some industries have really ‘got it’

• Over a long period of time

• As have some in the NHS, e.g. (?)– Salford Royal FT

• Strategic aim: zero-harm– Tees, Esk & Wear Valleys FT

• Driving hard towards Toyota lean– Both top 10 best trusts to work for (HSJ, 2014)– Simon Dodds (Heart of England FT, Improvement Science blog, Journal of

Improvement Science, SAASoft Ltd and FISH)• 3 wins: patients, staff and organisation (Dodds, 2007). • Winner of first NHS Innovation prizes (2004, 2005)

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Bodies of knowledge:

W. Edwards DEMING + Operations Management + …

• Deming: ‘System of profound knowledge’– Appreciation for a system

• UNDERSTANDING systems– Knowledge of variation

• Effects, causes treatments– Theory of knowledge

• TESTING: Experiment, modelling– Psychology of people

• Intrinsic motivators, teamwork

• PRINCIPLES for organising systems

• Examples, ‘brands’– Toyota Production System, lean, six sigma etc

• ‘Operations Management’

Deming’s ideas industry, Toyota (‘lean’) etc US Nat. Demonstrators (1980s) IHI: Breakthrough Collabs, MfI NHS MA NHS Institute for Innov & Imp ……

“W E Deming made an important contribution to the science of improvement by recognizing the elements of knowledge that underpin improvement over a wide range of applications” (Langley et al, 1996)

W. Edwards Deming1900 - 1993

There is a lot out there... Deductive & inductive knowledge… academic & practical

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A way of thinkingSystems Thinking:

• Purpose?

• Metrics?

• Method?

• Experiment!

The Model for Improvement

Cf. Reflective Learning,Action Research, etc.

IHI, MA, NHSI, NHS Change Model, NHS IQ

A useful ‘roadmap’ for healthcare improvement… good systems thinking…

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Reducing the level of slack in the system (the water; in manufacturing this is usually inventory)

allows operations (the ship) to see (or encounter!) the previously-hidden problems (the

rocks) in the operation and work to reduce them. Lower the water temporarily, identify the next rocks, replace the water, remove the rocks,

lower the water permanently, repeat…ACT PLAN

STUDY DO

ACT PLAN

STUDY DO

Learning through a culture of continual, informed EXPERIMENTATION!

Slack et al. (2008), p.468

In healthcare, what might the slack (excess water) be?

Experimentation requires tolerance or encouragement of ‘honest failure’

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For Deming (and the Japanese industrial leaders) it all started with 2 diagrams back in the 50s

• Quality (Value) is a key input. Costs etc are outputs (consequences)

• The whole ‘value chain’ needs to be seen as a system

(Deming, 1986, pp. 3-4) 

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(Slack et al. 2007, p.593)

Quality (VALUE) First!

Organisation profits from sickness, or from health? e.g. Kaiser PermanenteUS primary care examples (especially Intermountain Healthcare Inc.): • quality & value .. cost ... access (coverage) Salford Royal; Tees, Esk & Wear Valleys…

QIPP?!

The sandcone model of improvement: cost reduction relies on a cumulative foundation of improvement in the other performance objectives

Start with meaningful and motivating (patient) QUALITY improvement, COST (LoS etc) reduction should be the last of the goals (or a by-product)!

and for frontline services … safety as a fundamental part

of Quality! + staff satisfaction!

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Poster Boys 1 : Salford Royal

Building a deep culture • CE+ in place for 13 years; ‘back-to-the-floor’ every month• Clinical directors = separate contract inc. Quality Improvement, peer pressure• Expertise & support from IHI in US

• Focus on Quality: zero harm (no defects)– Started with bed sores, hospital acquired infections– Aim to be a High Reliability Organisation

• Deference to expertise, ‘Code Red’ – everyone’s responsibility, ward-round checklists

• Method! : Model for Improvement

+ Have a range of approaches in the toolkit (Lean, Clinical Microsystems)• Data!:

– SPC (inc. Board dashboard), process mapping, driver diagrams etc– Real-time information system, electronic patient records

• Lesson: be reluctant to simplify too soon!– Understand the complexity then focus!

Top acute on staff satisfaction (2013), top 10 trust to work in (HSJ 2014)• Inc. Clinicians?!• Tours…

Quality … Costs ? dark green dollars?

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Poster Boys 2 : Tees, Esk & Wear Valleys (TEWV)

Taking service improvement seriously…• Massive drive, support and enthusiasm from Board & clinical directors

– Focus ~50:50 quality & efficiency (?)• Totality of Lean approach, inc. terminology…

– Toyota Virginia Mason TEWV• Systematic use of the “tools and techniques”

– measurement + feedback• Not an add-on: part of everything they do

– “Seems to be what we do around here”!

• Development of staff compact, trust

Key methodology (but not a panacea) for achieving vision and strategic goals:• 5-day cycle (Rapid Process Development Workshop)

– Then becomes part of practice for everyone • Staff empowered to start own PDSAs

awards (2012), top 5% staff satisfaction, 2nd on reference costs; top 10 trust to work in (HSJ 2014)“a long way to go!”

Quality Efficiency … Costs • buying back PFI facilities?• Trips to Seattle…

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But spreading improvement sideways…?• 1 example of 3 Centres (trusts) running similar pilots on infection reduction in a chronic

condition• Estimated savings per Centre (trust) ≈ £¼M per year; for UK NHS ≈ £20M per year; &…• So …?

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1. What is the Goal of the system? – Look upwards to goal of wider system

• Hierarchy of aligned goals & performance measures

2. What does the customer want? – Is this what we measure?– end-to-end measures

Remembering..• Staff behaviour is influenced by local performance

measures– Dysfunctional?!

• Use measures for understanding (“bowling scores”)– How are we really doing? Why?– Deming: 80% …. 96%... of the performance is due to the

system not the staff!– “Every system is perfectly designed to get the results it

gets.” (Paul Batalden)• Be careful about rewards/punishments!

“Three Wins” (Dodds, 2007)

•Quality for Patients “No mistakes”•Motivation of Staff “No threats”•Performance of Organisation “No waste”

Management:Incentivising, motivating, enabling…A systems view…

Also see Fillingham (2007)and Seddon (2008)

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References• Deming, W.E. (1986), Out of the crisis, Centre of Advanced Engineering Study, MIT, Cambridge,

Mass. • Dodds S (2007). Three Wins: Service improvement using value stream design. lulu.com: 978-1-

84753-631-0 www.amazon.co.uk/Three-Wins-Service-Improvement-Stream/dp/184753631X• Fillingham D (2007). "Can lean save lives?". Leadership in Health Services 20:4, 231-241.• Seddon J (2008). Systems thinking in the public sector. Triarchy Press: Axminster, UK.

The main points are available here: http://webbrain.com/attach?brain=20DD893D-19A2-04E3-950C-3DA53FAB3BE1&attach=273&type=1

• Slack N, Chambers S and Johnston R (2007). Operations Management 5th ed. FT Prentice Hall: Harlow.

Also…• A playlist of service improvement and systems thinking videos:

• www.youtube.com/playlist?list=PLn9NeaqL-Xj9dZweG-6uOyqbE4tldIn5Z