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New Development: Using Lean Techniques to Reduce Radiology Waiting Times

Amy Lodge and David Bamford
This article reports on how systems were enhanced through the application of Lean principles within a hospital division of diagnostics and clinical support. Patients were diagnosed faster, treatment started earlier and departmental managers were better able to manage capacity to meet demand.
This article outlines a Lean approach to patient waiting list management in a UK National Health Service (NHS) hospital trust. Pennine Acute Hospitals NHS trust (hereafter described as the hospital trust) was established following the merger of five acute hospitals in April 2002 in north west England. It serves a population of nearly one million people. The division of diagnostics and clinical support (the division) at the trust provides a range of services across five acute sites including: radiology, pathology, physiotherapy, critical care, anaesthetics and dietetics in an inpatient, outpatient and some community settings. The division has over 2,000 staff, including over 150 medical consultants. Lean had not been implemented previously. An action research methodology was adopted. French and Bell (1990) defined action research as the process of collecting research data about an ongoing system relative to some objective or need of that system; feeding these data back into the system; taking action by altering selected variables based on the data; evaluating the results. Its distinguishing feature is that it integrates something of real, practical worth into an organization (Moore, 1983). A weakness of the adopted research methodology is its very public nature: if the project does not produce tangible real-time results, those supporting it may lose interest and bias any future initiatives. Another limitation is the single case approach, however Remenyi et al. (1998) argue this can be enough to add to the body of knowledge, if it is comprehensive enough with a longitudinal dimension. Direct intervention (over 24 months), informal interviews (with 48 staff in various roles), participant observation and company documentation were all used. Findings The NHS Improvement Plan (Department of Health, 2004) requires that by 2008 the
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maximum wait from a general practitioner referring a patient, to that patient commencing definitive treatment should be 18 weeks. Early estimates in the division indicated that in order to meet this 18-week target, access to services must be in a zero- to four-week window. Before Lean In the radiology services (a subset of the division) all management information and waiting lists were manually produced and a wait of 26 weeks was considered normal in November 2005. To improve this situation, the division needed to redefine the services they were delivering in relation to customer (patients, staff and other stakeholders) needs. To do this one of the authors (as service improvement manager) proposed using Lean tools and techniques. Working groups, comprising a cross-section of professional disciplines and grades, were set up with membership from across the department, division and the wider organization to understand the current performance of radiology services. The views of service users (patients and referrers) were sought, along with those of staff working in the departments in order to generate a picture of the current service provision from which to model the required changes. Proposed Changes The working groups wanted to provide an intranet-based waiting list for radiology services. Three different radiology information systems were in use to record radiology reports and images. None of these was able to generate meaningful waiting list or waiting time information. It was established that an extract of raw data at a patient level could be collected and collated, however clerical and clinical staff would need to start using each of the software packages in a different way. The division

Amy Lodge is a service improvement manager in the NHS and has recently completed a master's degree investigating the application of operations management principles to healthcare. David Bamford is a lecturer in operations management at Manchester Business School.

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compiled an outline of what the radiology staff would need to do to generate a waiting list from their software packages. Once extracted, this data would eventually feed an intranet-based waiting list module from which waiting lists could be managed centrally. Implementation Providing information via the intranet was a first step to improving the process. Users of the system were encouraged to comment on the first screenshot and suggest improvements, increasing their ownership of the potential solution. Multiple referral and booking systems were mapped and adapted to reduce error rates, reduce failure demand and streamline processes from the end users perspective (the end user being the patient). The application of Lean techniques across the referral and booking processes in radiology resulted in changes being made that were felt at all steps in the process from referral to examination to report. Each of the four departmental clerical teams was introduced to the vision for the service (to provide an intranetbased waiting list module for radiology services which would improve attendance rates through enabling instant waiting list management). The benefits of this for them was outlined emphasizing: Increased control. Better understanding of capacity requirements. Easy access to patient information to answer queries. While implementation of the data changes was resisted (why cant we do it the way we always have?), once the waiting list was produced from a centrally-generated database the advantages were openly recognized (how did

we do the job without this?). In addition, the departmental teams were retrained in the Key Principles of Waiting List Management set out by the NHS Institute for Innovation and Improvement (2006) and basic standard operating procedures were developed for all processes. The new system allowed the a patients status and position on the list to be easily understood, so when clerical staff saw that a patient would be waiting longer than agreed for their appointment they had mechanisms to expedite appointments and could take ownership of that part of the patients journey. Culturally, in the NHS the overriding ethic of staff members is to provide the best possible treatment for the patient. By being able to prove that patients were seen quicker sold the change and therefore encouraged sustainability. Support from the executive level bubbled to the surface as national targets for radiology loomed largesolutions were needed to assist in the reduction of waiting lists, this system could achieve them. The executive team were kept informed through the high-level data produced by the intranet-based waiting list. Results All radiology departments began using the intranet-based waiting list module in September 2006 and since then it has contributed to a significant reduction in waiting times across the different imaging modalities. The longest waiting time has decreased by over 30% in all areas and this is due to more efficient waiting list management (see table 1). The final version of the Diagnostic Services Patient Target List (DPTL) was made available from the hospital trust intranet. This contributed to a reduction in waiting times as patients were given a choice of appointment

Table 1. Comparative waiting times and volumes September 2006 to February 2007.
List volume Sep 2006 Magnetic resonance imaging (MRI) Computed tomography (CT) Non-obstetric ultrasound (NOUS) List volume Feb 2007 Longest wait Sep 2006 Modal wait Sep 2006 Longest wait Feb 2007 Modal wait Feb 2007

953

903

18

13

12

846

1136

20

14

13

2254

3205

20

13

13

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they are more likely to attend as the appointment is negotiated with them (NHS Institute for Innovation and Improvement, 2006). The DPTL can be viewed by referrers to the services, reducing the need to contact departments directly. However, waiting times did not drop immediatelysome departments were able to operate the new system better than others. This was evidenced in a rapid reduction in the waiting list tail (the low volume drag at the back of each list which often signals poor management or booking systems) at the more advanced sites. The more successful departments were used to provide support for those who were failing to grasp the changes. Total impact of the DPTL was felt across the hospital trust from the beginning of February 2007 when all departments were using it appropriately. Conclusions There was resistance to using Lean techniques in this case study NHS trust, but it was overcome. We have three main lessons from this work for applying Lean in the public sector: Belief in the Vision The working group was told by senior members of the information technology division that they were trying to achieve the impossible. The working group believed from their scoping exercise that it could and would be of benefit to all stakeholders, as well as providing management information for local and national use. Through persistence, the work was completed and the vision achieved. The resistance to change felt and demonstrated during the implementation and use of Lean techniques was similar to that during other periods of change (for example Bamford and Forrester, 2003; Bamford and Daniels, 2005). Resistance was displayed in many ways verbally, silence, denial, defacing of reports, refusal to consider the new ways of working. Convincing staff that change is for the benefit of the patients is vital to achieving a successful change programme. Greenhalgh (2004, p. 165) states when programme champions play an active role in the development, spread and implementation of innovation, these processes are generally more effective. Consistency in the Message It is vital that staff at all levels are given the same message. In this case they needed to understand why waiting lists had to ne more effectively managed. It was explained this would benefit staff as well as patients: as waits reduce then
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fewer patients and referrers are unhappy with the service. Providing Hands-On Training The training was delivered by the working group to key members of each department who then trained a group of their peers. Training was backed up by a manual which provided a practical guide to improvement tools; Lean was not explicitly advertised. The guide provided details of a collection of socalled older tools and techniques (Pareto analysis, tally charts, cause and effect diagrams, flowcharting, brainstorming, graph analysis, control charts etc.). These actions were essential for knowledge transfer and the embedding of key skills. The division plans to utilize the DPTL across all services to ensure that waiting lists are being efficiently, effectively and fairly managed. Work is currently underway in the therapy services, where only paper records exist. A referrals management system has been developed into which all patient information is entered from referral to first appointment to last follow-up. This can be reported via the DPTL and not only provides waiting times information, but activity and detailed pathway analysis, for example how many physiotherapy follow-ups are required following a hip replacement. The potential has been recognized and this work has been prioritized by the hospital trusts executive board. As a result of this work, patients are diagnosed faster, treatment commences earlier and departmental managers can effectively manage capacity to meet demand because they now understand the waiting profile. What Should be Done Differently Next Time? Next time round we will: Involve shop floor staff throughout performance targets were discussed at all levels of the division, but our direct experience suggests that, until a requirement exists for team members to change their practices, the implications of that target will not be fully understood (Bamford and Lodge, 2006). Publicise achievements locallythe DPTL has been in use since September 2006 but did not build momentum until the April 2007 target of all patients to be seen in 18 weeks loomed large (for January 2008). The need for change is not recognized until it is almost too late. More publicity at a local level in the
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form of posters and presentations might have improved this, but again would staff have taken this on board before it affected them? Time for reflection during and after each phaseit was recognized by the working group that reflection throughout the diagnostic, development and action phases might have resolved some of the problems encountered before they happened (usability of the intranet front-end, ability of users to adapt data entry methods, lack of support from departmental managers). After the completion of the next phase of the roll-out, a reflection exercise has been planned which will feed into further development and planning. There is evidence that the lack of operational management capabilities in front-line departmental managers contributes to the difficulties faced when trying to achieve targets. There is a reluctance in the public sector for thinking time to be acknowledged as a prerequisite for successful managementif a person is caught thinking then they are immediately assumed to be idle. The potential of the DPTL has been recognized and this work has been prioritized by the hospital trust executive board. Waiting times across services are now less than 13 weeks (from 26 in November 2005) and there is a single waiting list across four hospital sites. Furthermore, the rate of patients not attending has decreased from 8% to 4% (4,032 more appointments now attended first time) and the average inpatient wait for scanning services has decreased from five days to three days, freeing up 18,000 bed days per year. This work clearly demonstrates the application of

improvement techniques, such as Lean, focus efforts and tangibly improve performance.

References
Bamford, D. R. and Daniels, S. (2005), A case study of change management effectiveness in the NHS. Journal of Change Management, 5, 4, pp. 391406. Bamford, D. R. and Forrester, P. L. (2003), Managing planned and emergent change in an operations environment. International Journal of Operations and Production Management, 23, 5, pp. 546564. Bamford, D. and Lodge, A. (2006), Quality improvement and quality service delivery in radiology. In Proceedings of 11th European Forum (BMA) on Quality Improvement in Health Care (Prague). Department of Health (2004), NHS Improvement Plan: Putting People at the Heart of Public Services (HMSO, London). French, W. and Bell, C. Jr. (1990) Organization Development (Prentice-Hall, Englewood Cliffs). Greenhalgh, T. (April 2004), How to Spread Good Ideas. A Systematic Review of the Literature on Diffusion, Dissemination and Sustainability of Innovations in Health Service Delivery and Organization (National Co-ordinating Centre for NHS Service Delivery and Organization). Moore, N. (1983), How to do Research (Library Association Publishing, London). NHS Institute for Innovation and Improvement (2006), No Delays Achiever: Service Improvement Tools (Coventry). Remenyi, D., Williams, B., Money, A. and Swartz, E. (1998), Doing Research in Business and Management (Sage Publications, London).

Universities and Public Management

The Pubic Management and Policy Association (PMPA), the National School of Government and the Public Administration Committee are planning a joint workshop in September 2008 on the skills and capacity required by todays public managers and how universities can contribute to developing these. The plan is to seek the views of public managers, their employers, current and recent students of public administration, and the university public administration community on this question in order to feed into the workshop preparation. If youd like to be involved in this event, contact Janet Grauberg on janet.grauberg@cipfa.org
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