I went to a conference recently, well a celebratory event about improvement in the NHS (it wasn’t actually a birthday party). It was a fairly typical regional type conference designed to encourage and enthuse front-line staff in improvement activity, specifically lean activity and provide a networking forum. When I worked in the NHS, I went to quite a lot of sessions like these, and I loved going to them, to network, to share learning, to hear new ways of doing things, to get new ideas, but it is about a year since I last went to some.
Yet despite this absence, of course much was the same and it was lovely to see some friends in the room. The front line teams did some fabulous presentations detailing their work, their ‘journeys’, the tools, the training, the resistance the change, and they all shared their work well. Stories of improvements for patient care, less admin time, more patient facing time, less waiting time, frameworks, models, and so on. All of the work with a real impact for patient care and for staff experiences. Even the questions being asked to the improvement teams, were startling familiar and typically practical. How did you start? How do you get leadership buy in? How do you deal with/overcome resistance from staff, particularly doctors? How did you persuade the ‘management’ to support the activity and release staff for improvement activity? How can you measure improvements? How to manage competing priorities at the front line? How can improvements be sustained?
Despite this, I came away less enthused but rather dis-heartened, probably unfairly. Different parts of the NHS started playing with lean as an approach over ten years ago now in many departments in Trusts and via work initially started in the Modernisation Agency, and other bodies. Case studies, that I first saw when I joined the NHS (around 2006/2007 and attended the first Lean Healthcare Forum at the National Motorcycling Museum nr. Birmingham), talked up and exhorted the benefits and shared examples of value stream mapping, 6S and the 8 Wastes (or 5S or 7 Wastes depending on where you learnt this!). Pioneering work at the time, in Bolton, the Wirral, and other areas put their toe into the water of lean and tried it out, with all the challenges, successes and mistakes that early adopters of new approaches can make. There has also been the work of the Productive Series, first piloted in Liverpool, Barnsley, Basingstoke and Luton and now spread to many places across the world, developed from lean principles and there are many other stories of improvements developed with lean principles across the NHS including the innovative work at NHS NETS. Even NHS Confed wrote about lean and again now stories of organisations who are using lean thinking through listening to patients to improve care and patient safety are being upheld nationally, such as Virginia Mason in the US, (I previously wrote about this here).
My reflection from the event was how can it be that lean in healthcare in the UK is over ten years old (or older if you add in older terminology and methods with similar routes) and yet the questions and concerns regarding this activity have broadly stayed the same? Was it because more experienced staff wouldn’t attend these kinds of sessions unless presenting (possibly), or was it something else? How come that despite ten years and vehicles like the Productive Series; 6S and whiteboards to know how you are doing, still are not mainstream (with few organisational/system wide applications), and can seem radical despite the benefits and low costs?
What I have wondered since is that, sometimes there is much push for ‘improvement capacity’ and spread, that improvement teams objectives can include things such as train up ‘X many staff this year to this level’. Ensuring all staff have some improvement skills, (process flow mapping, etc.) is vital, but the risk is that the resource to train up staff in improvement is on a never ending wheel of training new recruits and inductees and the new skills fall by the wayside and aren’t practiced. Of course basic improvement skills are needed by all, but if that leads few resources left to move to more intermediate or advanced activities (like heijunka [e.g.here], hoshin kanri and yokoten) and for time to use the skills, how will the skills develop from basic problem solving to much deeper complicated problems and organisational systems for improvement – with potentially bigger returns for safety, quality, money and staff and patient experiences and lean learning? Though harder and riskier to do.
Why does it feel to me that the same questions being asked, how to start? how to gain leadership buy in? etc.? So many potential reasons for this, different language, beliefs, ways of working, roles, mis-aligned incentives, organisational and health economy contexts, leadership continuity, inadequate results/evidence etc, But, really ten years on, are we still barely past starting blocks in the UK, falling behind on lean healthcare learning when compared to the US experience, (with some UK exceptions). Perhaps, we are focusing too much on quantity of improvement skills rather than quality and depth of learning as well?
I’m sticking my neck out here a little bit, and I know there is much marvellous improvement work in healthcare, using many approaches as well as lean, and maybe I have been out of the loop too long and not up to date and completely wrong. If so, I would really like your views, I am I just seeing the glass half empty? Why is it seemingly so difficult to progress lean healthcare learning – and improve lean healthcare improvement – when it can add so much value for patient care? My view, Lean healthcare, in the UK at least, still needs to come of age.