At the height of the second wave of the pandemic in the UK the National Health Service (NHS) was conducting 1.3 million tests a day.
That the NHS was able to ramp up its pathology system so quickly in the face of a national emergency was down to the type of innovation that Leeds Teaching Hospitals NHS Trust was able to quickly organise.
The Trust vastly reduced the turnaround time for testing COVID swabs by attaching Radio Frequency Identification (RFID) tags to track them through the system. It helped identify hold-ups and allowed the Trust to streamline the system and significantly boost the number tested each day.
This is one example of the speed and collaboration that filled the evidence-void in healthcare to tackle the pandemic; where in a matter of weeks hospitals exceeded targets that were set many years ahead.
And it comes from one of five UK hospital trusts that has been in a trial partnership with US health group Virginia Mason, which adapted lean principles pioneered by car giant Toyota to its hospitals to stunning affect.
Led by my colleague Nicola Burgess, Reader of Operations Management, we have been assessing how this partnership has worked since 2018.
The report will be available later this year, but in the meantime we wanted to assess to what extent, and in what way, did the Trusts use what they had learned from Virginia Mason to combat the pandemic?
Between June and September in 2020 we interviewed 40 people, from executives to clinicians and frontline staff; observed 20 hours of meetings and analysed a vast number of documents to find five ways Virginia Mason’s lean principles were used in the biggest health emergency the UK has seen since the Second World War.
1 Quality Improvement
In all five Trusts the use of Quality Improvement – a structured way to assess systems and processes to find performance gains - was central to rapid decision-making, strategic oversight and communication.
In all five Trusts Kaizen – the Japanese business philosophy of continuous improvement – was adopted with Production Office Specialists (POS), trained and deployed across the Trusts to oversee command structures.
They put in place daily management of the response and organised Production Boards that gave a visual way of seeing what was going on in the hospital at any one time. They also ensured dissemination of information up and down the line of command, which was vital as facts and data were changing hour-by-hour in the early stages of the pandemic.
The POS' worked with the executive leadership and clinical leaders to ensure listening and learning were done across the Trust, which allowed people to ‘connect the dots’.
2 The tools of lean
Specific methods and tools from Virginia Mason became central for frontline staff during the pandemic. Prominent in all five Trusts were:
- Plan Do Study Act (PDSA) cycles - A framework for developing, testing and implementing changes leading to improvements. It enables healthcare workers to test out changes on a small scale, building on the learning in a structured way before wholesale implementation.
- Setup reduction – A method of reducing the amount of time needed to change over to the next process.
- PAR levels – Predicting likely demand for stocks and setting a certain quantity and maintaining that level.
- Value stream mapping – The detailed mapping of processes to remove waste.
These tools were deployed to many issues, such as personal protective equipment (PPE) management, re-purposing wards and departments, turnaround times for test results, and innovations for allowing communication with loved ones.
3 Lean by osmosis
Many staff were redeployed to high demand areas during the pandemic, so quickly getting up to speed with what was going on in the department was vital.
This was helped by using Production Boards, huddles, and Standard Work Documentation. Production Boards give a visual display of the performance of the department with a running score of key performance indicators.
Huddles were usually done around the Production Board, with the quick stand-up meeting giving team members any updates and a briefing on the day ahead. While Standard Work Documentation laid out the best practice process for various tasks on the ward.
It meant even those with limited exposure to lean picked up the terms in ‘learning by osmosis’ as they heard the terms over and over again. These approaches were critical for staff who were redeployed and allowed them to quickly understand what was going on in the department.
4 Clarity of purpose
Senior leaders all said despite the many challenges presented by the pandemic, the clarity of the shared goal of ‘keep patients and staff safe, save lives’ really helped maintain focus and the urgency to respond.
They all hoped such a clear message of purpose could be maintained beyond the pandemic. Indeed, several of the major process changes made are now regarded as long-term approaches by the Trusts to service delivery. For example, accelerating the use of remote and virtual consultations.
The partnership with Virginia Mason helped Trusts prioritise what tools would work in the emergency, as some, like Rapid Process Improvement Workshops, were less valuable in circumstances where the process to be studied was a radical departure from that which was followed in more normal times.
5 The speed of lean
The pandemic proved Quality Improvement methods can be applied at pace. The Virginia Mason approach is described as ‘inch-wide, mile-deep’ and Trusts were coached to take a measured approach that some criticised as being too slow.
But we recorded countless examples from the pandemic that challenged this assumption, where over a matter of hours and days, improvements were made using these key processes from Virginia Mason.
For example, many staff were working in identical uniforms and PPE, so the simple innovation of wearing different coloured hats for specific purposes helped identify who was who.
Also, ventilation hoods worn by doctors working around COVID-19 patients needed to be sterilised with ultraviolet light. This was speeded up safely and effectively at Surrey and Sussex Healthcare NHS Trust by putting the hoods on the same devices that turn disco balls so they could rotate quickly.
This study was confined to Trusts in the NHS Virginia Mason partnership, but was extremely helpful to see how the tools had been deployed with such great results.
The sustained impact on staff over the long term of this period of rapid change and intensity is concerning, with the risk of burnout a challenging issue, especially as the focus begins to switch to the backlog of treatments arising from those that could not be offered at the height of the crisis.
But the pandemic has highlighted how simplifying healthcare’s purpose and the unifying focus of the emergency can reduce some of the complexity of the system.
Expertise has been at the centre of decision-making, with clinical leadership partnerships being made across the world, and this has been so important in guiding the direction of travel.
A strict hierarchy does not work in the emergency of a pandemic, with executive leaders, working closely with clinical leaders, being given more authority and autonomy locally, rather than having requirements placed on them from above.
The challenge now is how the lessons of the pandemic can be taken forward into the new normal of our post-pandemic world.
Bernard Crump is Professor of Practice in Healthcare and Leadership and Course Director for Leading Strategic Innovation in Healthcare.
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