Lean Healthcare: BICS

I led the Bolton Improving Care System (BICS) at Bolton NHS Foundation Trust (formerly Royal Bolton Hospital NHS Foundation Trust) between 2008 and 2013.  I think it was the best job I ever had, aiming to improve quality, safety, cost, experience and morale in healthcare on a huge scale. Maasaki Imai describes lean as ‘highest possible quality at lowest possible cost’, what an aspiration: brilliant for patients and families, brilliant for taxpayers.  The system in Bolton was one of the first lean implementations in the UK in the NHS and healthcare and one of the few that tried and risked – with many issues, problems and learning –  to implement lean across the whole organisation and to systematise it and build dynamic change capabilities and most importantly make things better for staff and patients.

I get contacted frequently asking for insights and comments as to ‘how to do lean healthcare’ and for information and documents regarding BICS, mostly on Twitter.   To save me a lot of time and to reduce duplication, I have curated the publically available information that I know of regarding BICS from both the academic and grey literature on this post.  Some of it is pretty old now and out of date, but I hope this provides an historical record and also gives and idea of how the thinking evolved over time.

During my PhD literature searching, I keep coming across more stuff, some that I didn’t know of at the time and so I will add more as I find it, if you find any broken links or information that is not on here please let me know, so I can add more.  Hope this is useful to those of you that inquire! Please bear in mind I no longer work in Bolton.  For information about what happened next for quality improvement in Bolton please contact the Trust directly.

Academic Literature (Journal Access is required)

Bene, J. (2010) Lean: Where to start. International Journal of Care Pathways, 14(1), p36.

Burgess, N. & Radnor, Z. (2012) Service improvement in the English National Health Service: Complexities and tensions. Journal of Management & Organization, 18(5), 594-607.

Burgess, N. & Radnor,Z. (2013) “Evaluating Lean in healthcare”, International Journal of Health Care Quality Assurance, Vol. 26 Iss: 3, pp.220 – 235

Burgess, N.  Worthington, C,. Davis, N.D., Radnor, Z.J., Robinson, S., & Cooke, M. (2011).  SimLean healthcare: handbook.  SIAM Journal on Numerical Analysis, 2524

Martin, A. J., Hogg, P. & Mackay, S. (2013) A mixed model study evaluating lean in the transformation of an Orthopaedic Radiology service. Radiography, 19(1), 2-6.   [A Martin, Thesis on this topic also available]

Fillingham, D. (2007) “Can lean save lives?”, Leadership in Health Services, Vol. 20 Iss: 4, pp.231 – 241

Robinson, S., Radnor, Z.J., Burgess, N., & Worthington, C. (2012).  SimLean: Utilising simulation in the implementation of lean in healthcare. European Journal of Operational Research, 219(1), 188-197

Singh, S., Lipscomb, G., Padmakumar, K., Ramamoorthy, R., Ryan, S., Bates, V., Crompton, S., Dermody, E. & Moriarty, K. (2012) Republished: Daily consultant gastroenterologist ward rounds: reduced length of stay and improved inpatient mortality. Postgraduate Medical Journal, 88(1044), 583-587.

Tyldsley, S. and Wyton, P. (2011). Lean: Changing the organizational discourse for facilities management? In: 10th EuroFM Research Symposium: Cracking the productivity nut, Vienna, 24-25 May 2011.


Fillingham, D. (2007) Lean Healthcare.  UK: Kingsham Press.

Hafer, M.S. (2012) Simpler Healthcare.  USA: Amazon

Burgess, N., Radnor, Z.J, and Furnival, J. (2016). A case study of a whole organisation approach to lean implementation across an English hospital. Public Service Operations Management – A research handbook. Z. Radnor, N. Bateman, A. Esain et al. Abingdon, UK, Routledge: 310-327.

Grey Literature

Bradley, B,. Bowden, M., Furnival, J., Walton, C. (2011). Service redesign: A change is in the air“, Health Service Journal, 13th October, pp29-31.

BICS Academy – Lean Management Journal (2010)

Furnival, J.; Bernstein, C. and Doherty, L. (2011). Lean Leadership. Health Manager. Health Management Institute of Ireland. 18th January.

Winn, D (2009)  Human Givens.

Process Excellence Award 2012 – Best Mature Process Improvement Programme Case Study

Mackillican, R. (2009) Bolton’s road to lean.  National Health Executive. Sept/Oct 2009, pg.65.

Institute for Innovation and Improvement (2009).  Lean Thinking.  Cross-Current, Winter 2009.

Patterson, P. & Leach, J. (2009). A leaner care system.  Health Informatics NOw, June 2009, pg 20-21.

Conference Material

Global Lean Healthcare Conference 2007

Genova Lean Healthcare conference (I think 2009)

Global Lean healthcare – Redesign Summit Australia 2012 (to add)

Hong Kong Conference 2014

Web Material

Going lean in the NHS

BICS Case Study 1

BICS Case Study 2

BICS Case Study 3: PEX Award incl CAMHS info.

BICS Presentation 2010  incl. stroke, methods, academy and urgent care work

Schenk, A.; Interview re BICS with McKinsey  (note need to log in to the Operations Extranet and then search for Bolton)

Interview re Lean healthcare

Dave Hamer Presentation for Nuffield Trust re: BICS

Lean Blood Sciences Presentation

Lean Blood Sciences Video Interview

Lean Blood Sciences – Case Study

Multiple Case Studies – No Delays

Multiple Case Studies – NHS Confederation

Visitor Blog

EWin Case Study – Staff Engagement

A Guide to Finance for Hospital Doctors, Audit Commission



Trauma poster

Maternity and Fetal Screening

Mark Graban’s Blog





Radiology  & Orthopaedics 18 weeks

Respiratory Specialist Nurses (PEX winners)

Mortality (see case study data in presentation)

Patient Experience Based Design in Elective Orthopaedics

Kings Fund Experience Based Design Toolkit

Feeling Better – Patient Experience Based Design from NHS Confed

Patient Gateways – Reducing Mortality and NEL LoS

Lean Leadership


Annual Review 2011

Leading Lean

Communication & Strategic Reviews

Junior Doctor BICS Leadership Fellows  – BICS Academy work

Lean IT – interview

Safer Clinical Systems incl. human factors (with Bolton PCT and the Health Foundation)

‘3P’ work to redesign Maternity Services, for new capital programme – Making it Better


British Geriatrics Society – Falls Reduction


The Exemplar Programme (sort of productive ward with accreditation – BICS as daily work, results shown include harms such as Falls and Pressure Ulcers)

Many posters have been presented at IHI International Forums and at other conferences and will be on their poster repositories on for example, Trauma, Stroke, Respiratory, BICS itself etc. between the period 2005-2013.  Oral Presentations were also given on Trauma and BICS in 2010; and on Safer Clinical Systems in 2011.

Orthopaedic Trauma redesign and mortality reduction work won best poster at the IHI Forum in Berlin in 2009.


BBC News

Awards Information

A3 Thinking – Adopt, Adapt, Improve – Health and Social Care Award 2008

Dr Bradley, Respiratory, BMJ  Clinical Leader of the Year 2011, Runner up

Dr Dufton, CAMHS, BMJ, Clinical Leader of the Year 2011, Winner

HSJ Patient Safety Award 2010 (highly commended) 2011 (winner) – Theatres WHO Checklist

HSJ Efficiency Awards 2011, 2012 – Health Records, District Nursing, Laboratory Medicine

David Fillingham:  NHS Leadership Awards Quality Champion of the Year 2010

Michaela Bowden (Runner up) Nursing Leader for Respiratory Improvement work using BICS

Suzanne Lomax  (Winner) Nursing Leader for Stroke Improvement work using BICS

Mortality Improvement – BMJ Awards – 2012 Shortlisted –

                       40% reduction in HSMR from 2005 to Sept 2009 (using 2008-2009 baseline)                         0.5% reduction in readmissions over same period  (Source Trust website)

Patient Experience Based Design – Elective orthopaedics – Bolton Diamond Care Award Winner 2009;. Shortlisted HSJ Awards 2009

BICS Academy – Bolton Diamond Care Award Winner 2009

European Process Excellence Network – 2011; 2012 Winner; Best Improvement Project (Respiratory); Best Mature Improvement Programme (BICS)

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