Lean into change

This is article twenty-four in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

Scenario 

It’s a busy morning on the production line. Bill takes a moment to look up - he can hear the sound of heavy rain above the din of machinery. ‘Glad I’m working inside on a day like today,’ he thinks to himself. The shower passes and the noise subsides. Bill’s job involves bolting the front seats into an upmarket SUV. Somebody told him once how much each one costs – with handstitched leather and speakers in the head-rests – he tries not to think about it as he slots another one into position. Suddenly, to his horror, he notices a rip in the beautiful chair he’s just installed. It looks terrible – his heart starts pumping a bit faster. ‘S**T! Perhaps I should just ignore it - leave it for someone else to sort out?’ he thinks, but then his training kicks in. He walks to a long red chord that hangs in the corner of his workstation and gives it a good pull. An alarm rings, and across the factory floor work comes to a controlled stop.

The so-called Andon Chord¹ is a simple tool which allows workers to pause the production line if they notice a quality issue. It means that faults and potential problems can be addressed immediately, preventing more serious issues developing in the future. It is part of an approach to work called ‘Lean’ – a philosophy with a laser focus on quality first developed by the car company Toyota after the Second World War.²

Let’s take up the story again

Jenny, Bill’s supervisor walks over to see what the issue is.

“You alright Bill. Have you got a problem?”

“Yeah, I honestly don’t know how it happened, but look at this,” he shows Jenny the tear.

“Ooh, nasty. Right I think we need a quick meeting before we re-start the line, that’s a serious quality issue! No problem, thanks for the heads up Bill – good work.”

More recently Lean has been recognised in the medical profession as a way to improve quality and reduce delays. By adopting some of the Lean tools and behaviours, hospitals have been able to improve reliability and outcomes, while also cutting waste – both physical waste and time waste.² 

How has this been done? Lean represents a group of methodologies and a philosophy that develops a unified, organisation-wide approach to work, and a strong culture.³  Lets explore this philosophy further.

Efficiency: minimising waste and maximising the benefits of resources

Among other things, the Lean philosophy says that any manufacturing, or indeed medical process, consists of steps. Whether this process happens in a hospital or on a factory floor it can in all likelihood be improved upon, and ‘waste’ reduced, if we are willing to spend some time analysing those steps.⁴  In a veterinary practice, for example, placing an intravenous catheter involves collecting the necessary items - the tape, the catheter, the T-connector etc - restraining the animal, and placing the catheter into the appropriate vein using the right technique. But what if we were to look at this process from the perspective of 'waste’?

Waste can take one of several forms and we will explore these further in this article. But for now, we could think about the wasted time that a nurse might spend looking for tape that isn’t in the normal place. If we formalise where tape is kept or how the tape draw is kept stocked, some waste is eliminated from the act of placing an IV cannula. In short, eliminate more ’waste’ from our care processes, our care gets better.

In our previous articles, we have described efficiency as minimising waste and maximising resources, including skills, equipment, finance, ideas and energy. We have also discussed how improving efficiency translates into using the teams' time and experience most effectively, while safely working towards the right outcome for the patient.

Consider the impact of excess medicine supplies. We should all be aiming to keep the minimum stock of medicines and supplies necessary – this helps in our push toward sustainability through a focus on waste, and this is obviously important for the planet, not just healthcare.

As we have already alluded to, time is one of the most valuable commodities in practice at the moment with the huge caseload we are all experiencing - efficiency is also about not wasting time in the practice day. For example, if the nurses are ready to go and the animal is pre-medicated, but the vet is held up with phone calls that could be dealt with later, re-organising client call-back times can hasten procedures and leave the animal more time to safely recover before the end of the working day. Being able to save a little time can have a big impact in the long run - it will benefit the quality of care you can provide to your patients, and you might even grab a lunch break!

Being more efficient by improving workflow can have other advantages too - if the ops start earlier then patients will be awake and ready to go home sooner, taking pressure off team members during evening surgeries.

Using care bundles is another example of a ‘Lean’ approach to work – a care bundle is a group of items ‘bundled’ together with the intention of saving time and improving outcomes in a particular scenario.⁵ Having equipment and medicines ready to go can save time by reducing movement around the practice in an urgent situation, for example a brachycephalic anaesthesia.⁶ This can save a few precious minutes – which all adds up over time. If equipment is kept away from where it is needed, valuable time can be wasted in an emergency. Having a directory of where all those seldom used bits of kit are can also be really helpful.

The Lean mindset: respect for people

Respect for people irrespective of their role is another founding principle of Lean.³  Research shows that respect and trust in our working relationships improves innovation and outcomes – in a veterinary setting, respect helps a team work together effectively and safely. Managers at Toyota were quick to understand the potential benefits for their products when they used this approach.

Equally, in a medical context, respect allows staff to speak up with ideas to improve care. On the flip side, not listening to team members, ignoring their suggestions for improvement, and assuming without asking, can lead to dissatisfaction and lost opportunities to reduce waste in the system and improve the quality of our service.

Too much bureaucracy and ‘administrivia’ can sap team members energy as well as waste time, according to Harvard Business Review, so streamlining processes can also help efficiency.⁷ An example of this could be avoiding duplicating forms for lab tests, using practice management systems to make life easier and automatically fill in forms and reports.

Errors are a drain on team morale and on practice resources, for example, when we need to address complaints. Investing time in robust error-reducing systems, like organising the dispensary to clearly separate and label medicines which are routinely confused, can pay dividends.⁸ 

Bill’s intervention on the production line, and Jenny’s supervision could have an almost incalculable effect on the efficiency of car production in this hypothetical scenario. By using Lean principles including speaking up, respect and teamwork, they were able to eliminate a problem in a process, resulting in improved quality. Lean really is a different way of working and represents a set of ideas that perhaps don’t immediately look that relevant in veterinary medicine. When Lean has been used in a new setting, it has been found to have a powerful effect on the ability of workers to get things done safely, in a timely manner. This leads to a higher quality service and improved client satisfaction. Human medicine has found this out for itself. Of course, changing a system can seem scary if it is something that we are not used to doing routinely.

If you catch yourself feeling anxious, try to remember these words from a great Lean expert, W. Edwards Deming, “We are here to make another world.” ⁹ 

Checklist – What you can do next?

• Improving efficiency translates into using the teams' time and experience most effectively, while safely working toward the right outcome for the animal. Read our previous QI Feature ‘Rapping your way to better care – Why understanding work matters’ to see why understanding how work is done can help us to design tasks, jobs, equipment, work environments, and systems of care to make life better for people at work and make it easier to deliver the right care to our patients.
• Listen to our short CPD session on how improvement science and QI can help reduce waste in veterinary healthcare. This is part of the QI Boxset, our free QI CPD which is available in bite-sized episodes to help you establish a quality improvement structure in practice.
• Helen Ballantyne, dual-qualified medical and veterinary nurse, shares her experience in human nursing with why veterinary teams should be implementing care bundles to save time, promote teamwork, and improve patient outcomes. 
• Listen to Suzette Woodward, a paediatric nurse who is now a Professor in Patient Safety, discuss the lessons we can learn from the NHS’s approach to patient safety concepts and the science of improvement to reduce the likelihood of repeating outcomes that didn’t go well, and increase the likelihood of repeating outcomes that did go well.
• Listen to Richard Killen, former Director of Clinical Services at CVS and Angela Rayner, RCVS Knowledge Quality Improvement Advisor, as they discuss how to embed systems thinking into a practice team to improve patient safety as well as the efficiency and quality of the care we provide.
• Download the ‘What matters to you – Conversation Guide for Leaders’, adapted from the Institute for Healthcare Improvement (IHI) original framework, to support leaders within the veterinary sector in introducing the Joy in Work concept to their team. This guide will help you to identify workplace frustrations, or ‘pebbles in your shoes’, engaging and empowering the team to find potential solutions.

• Hear from Jesse McCall, who co-leads the Joy in Work Results-Oriented Learning Network at the Institute for Healthcare Improvement discuss the factors that diminish joy in work, and practical steps that teams can take to work together to nurture their workforce and address the issues that drive burnout and sap joy in work.

References

1. The Andon Cord: A way to stop work while boosting productivity [Six Sigma Daily] [online]. Available from: https://www.sixsigmadaily.com/what-is-an-andon-cord/ [Accessed 10 January 2023]
2. Spagnol, G.S., Min, L.L. and Newbold, D. (2013) Lean principles in healthcare: An overview of challenges and improvements. IFAC Proceedings Volumes, 46 (24), pp. p. 229–34. https://doi.org/10.3182/20130911-3-BR-3021.00035
3. Lawal, A.K. et al. (2014) Lean management in health care: definition, concepts, methodology and effects reported (systematic review protocol). Systematic Reviews, 3, no. 103. https://doi.org/10.1186/2046-4053-3-103
4. Liker, J.K. (2004) The heart of the Toyota production System: Eliminating waste [Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer] [online]. Available from: http://accessengineeringlibrary.com/browse/toyota-way-14-management-principles-from-the-worlds-greatest-manufacturer/c9780071392310ch03 [Accessed 27 December 2022] [Subscription required]
5. Horner, D.L and Bellamy, M.C. (2012) Care bundles in intensive care. Continuing Education in Anaesthesia Critical Care & Pain, 12 (4), pp. 199–202. https://academic.oup.com/bjaed/article/12/4/199/275352
6. Knowledge Award 2019 highly commended runner up: Creating a BOAS box after a significant event [RCVS Knowledge] [online]. Available from: https://knowledge.rcvs.org.uk/document-library/boas-box-sea-case-example/ [Accessed 29 December 2022]
7. Garton, E. (2017) Your organization wastes time. Here’s how to fix it [Harvard Business Review] [online]. Available from: https://hbr.org/2017/03/your-organization-wastes-time-heres-how-to-fix-it [Accessed 29 December 2022]
8. The role of improvement science and QI in reducing waste in veterinary healthcare [RCVS Knowledge Learn] [online]. Available from: https://learn.rcvsknowledge.org/course/view.php?id=156 [Accessed 29 December 2022]
9. Doss, H. Innovation: W. Edwards Deming and John Keats got it right [Forbes] [online]. Available from: https://www.forbes.com/sites/henrydoss/2013/03/12/innovation-w-edwards-deming-and-john-keats-got-it-right/?sh=393669e54791[Accessed 22 December 2022]

About the authors 

Pam Mosedale BVetMed MRCVS

Pam is QI Clinical lead for RCVS Knowledge and Chair of the RCVS Knowledge Quality Improvement Advisory Board. She was Lead Assessor for the RCVS Practice Standards Scheme until very recently. Pam has worked in first opinion practice for most of her career. She is also an SQP assessor for AMTRA and edits the BSAVA Guide to the Use of Veterinary Medicines and organises the BSAVA Dispensing Course.

Pam has been involved in establishing Quality Improvement resources for the veterinary practice team. She is passionate about QI becoming part of the normal working day for veterinary teams and contributing to a just learning culture in practice.

Mark Turner BVSc MRes MRCVS

Mark graduated from the University of Liverpool in 1996 and in 2017 completed a Masters degree at the RVC investigating patient safety culture in the UK veterinary professions.

The research project investigated contemporary knowledge of patient safety behaviours in practice including significant event reporting and auditing.

He has an interest in the application of patient safety as a tool for improving staff engagement and success. He has written for Vet Times, Companion magazine and appeared as a guest blogger for the BVA/RCVS Vet Futures project.

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January 2023