Lean working, aka ‘working smarter not harder’ has its root in car manufacturing, specifically the ‘Toyota Production System’. It is a productivity improvement strategy that works to improve both quality and worker satisfaction.
Lean thinking has crossed over into healthcare, with a number of NHS initiatives ‘promoted’ via the NHS confederation (2006) and the NHS Institution for Innovation and Improvement (2007). Lean initiatives are popular within the NHS as they focus on improving processes and efficiencies for patients, staff and the organisation.
The authors describe the ‘5 principles of lean’ and how these principles have implications for healthcare practice. Within healthcare, the patient or ‘customer’ is the focus of the initiative.
Lean processes should lead to patients experiencing an improved quality of service that is safer and less wasteful of resources. The organisation itself is led by the needs of the patient, it organises services, so they enable the patient to ‘pull’ what they need (assessments, procedures) rather than rely on how the service organises its resources. The service also seeks to continually review and improve how it operates.
The authors discuss the benefits of using the ‘lean toolkit’ in healthcare settings, by ‘enhancing quality by improving flow and eliminating waste in the patient journey.’
This study set out to evaluate community learning disability team members’ experiences of a ‘pilot lean initiative’. This was conducted by a private consultancy, its aims were to ‘increase services provision whilst reducing waste in operational and administrative tasks’.
External consultants focused on the processes of lean planning, design and implementation with staff from teams within the learning disability service.
The specific aims of the study were to evaluate staff experiences of:
- The implementation of a standardised referral process,
- The introduction of visual information boards (as a key instrument designed to improve communication in working practice)
- The benefits and challenges of implementation.
The method used was to distribute questionnaires to selected staff members who were actively involved in using the changed referral process 8 months after the lean working initiative had taken place.
Each questionnaire contained 12 questions asking staff to evaluate their experiences using a standard Likert scale: poor, fair, satisfactory, good and excellent.
The 12 questions covered the process of ‘lean working’.
- 5 focused on the implementation of the process; the information and training received, the resources, support and advice received.
- 1 question focused on the implementation on the standardised referral process.
- 6 questions then focused on the implementation of the visual information board in how its use; informed daily work, tracked performance, identified problems, helped with long-term planning and service improvement.
- 1 final question asked staff to rate their experience of the whole process.
Three open questions were incorporated within the questionnaire to capture staffs opinions of the benefits and challenges experienced in implementing lean working practices.
The authors broke down their findings initially into ‘staff responses’ to the 3 areas of concern within the study: its implementation, the referral process and the visual information board.
- The staff’s overall view of how lean practices were implemented and their understanding of the process, was on the whole rated between poor to fair.
- Staff responses to the implementation of the standardised referral process were rated from fair to good.
- Staff experience of how the visual information board was used in terms of its practical application varied more widely between poor and good, with most responses rated as satisfactory.
The authors then looked at ’emergent themes from the open questions’.
Staff responses to the benefits of this lean approach identified 3 themes:
- There were benefits in team working, in improved communication, improved daily working practices and an ‘increased shared responsibility’.
- The visual information board had helped increase the reliability of allocating, managing and tracking referrals.
- The explicit identification and discussion of service issues helped with service planning.
A further 4 themes identified under the heading of ‘Lean implementation challenges’
- A perceived lack of training was a barrier in understanding lean.
- Staff experienced a duplication of processes, in recording information on computerised systems and the visual information board.
- The new referral processes did not capture all relevant information and created more work for the referrer.
- Meetings and recording information. It was difficult to arrange the lengthy meetings to enable all team members to attend.
Staff also highlighted a number of concerns based on their experience. They requested further practical sessions and support to enable them to better understand the lean process.
Staff expressed concerns there was a lack of an ‘evidence base’ for lean working in their sphere of practice. They also felt that the process was overly focused on implementing ‘lean tools’ rather than on sharing longer-term strategic plans.
The authors suggest that the results identified a disparity between quantitative (ratings) and qualitative results (themes).
On the whole staff ratings were more positive, particularly towards the standardised referral process and visual information boards, whereas staff feedback (themes) was mixed.
Themes identified both concerns about ‘duplicated processes’ and how the lean process was supported. The authors felt that staff frustrations with a perceived lack of management support in the process contributed to negative feedback. The more positive feedback was linked to how the process brought staff together as a team and helped them develop a ‘shared ownership of information’.
The results appeared to mirror two previous studies in implementing lean working in health visiting teams; which found the need for commitment from managers, strong leadership, for support for staff to ensure they understood the aims and processes and a need to link change to a longer-term vision.
Strengths, limitations and discussion.
The authors acknowledged this was a pilot that did not fully implement Lean processes. This study adds a positive contribution to outlining how lean processes should be implemented in health teams to maximise the potential of improving processes and improving patient experience.
The study has some limitations; there is no mention about how the staff were selected for inclusion, only that if staff were not actively using the revised referral process they were excluded.
Although the 5 principles of lean are explained, how these were explicitly followed in the study is not fully explained; value stream mapping and waste removal are mentioned as 2 principles that were explained to staff but the actual processes used by the consultants are not referred to. Although ‘missing data’ is acknowledged, its effect on results is explored in a limited way.
The response rate of 100% of accounted for questionnaires is highly unusual, this could be explained by a high commitment from staff to be involved, but could also result if staff felt they had to complete returns, particularly given that the process was led by an external consultancy. This may have skewed some of the responses, with staff feeling ‘done to’ rather than ‘part of’?
The evaluation did suggest that more care was needed in the implementation of the initiative.
The use of lean working in learning disability service development initiatives published appears cursory and linked to reviews of services e.g Hertfordshire (2012).
Nationally within Learning Disability research/policy there has been a focus on determining the function, values and aim of teams rather than analysing processes to improve function: The need to focus on core outcomes and indicators in the Confirm & Challenge model (2011) The 5 quality focuses of strengthening practice in the Modernising Learning Disability Nursing review (2012) and the need to define practice and why focus of the National LD Professional Senate (2015).
This study has shown that there are benefits to implementing ‘lean service initiatives’ in a Community Learning Disability team, although staff perceptions of these benefits are ‘mixed’. The studies principle aim of ‘understanding staff experiences’ was achieved by analysing staff perceptions of benefits and challenges of the process, through rating scores and emergent themes.
Benefits relate to the ‘lessons learnt’ from the process:
- That a collaborative approach and leadership from all levels of management is important.
- That a vision to improve services need to be linked to the experiences of the staff, in terms of support and resources.
The evaluation has led to a reappraisal of the change strategy used within the organisation.
This study found me reflecting on how management ‘trends’ within the NHS have been previously implemented. There tends to be a focus on using new ‘exciting’ models to change processes for short-term gain. This is done without fully understanding the service and involving staff to implement longer-term sustainable changes that fully benefit patient experience. As someone who works in a community Learning Disability team, the ‘mixed staff reaction’ to this initiative is something I identify with.
Lean in a community learning disability service: Gemma Lees-Warley & John Rose. British Journal of Healthcare Management 2014 Vol 20 No 1pp 32-39.
Delivering Effective Specialist Community Learning Disabilities Health Team Support to People with Learning Disabilities and their Families or Carers. National LD Professional Senate. March 2015. https://www.bps.org.uk
Going Lean in the NHS. NHS Institute for Innovation and Improvement 2007. http://www.institute.nhs.uk
Health & Community Services Transformation Proposals. Hertfordshire County Council Cabinet: 2012 Document. www.hertsdirect.org/mm/15520666/…/cabinetitem320120220.doc
Lean thinking for the NHS. Daniel Jones and Alan Mitchell, Lean Enterprise Academy UK NHS Confederation 2006. http://www.nhsconfed.org/resources/2008/12/lean-thinking-for-the-nhs
Strengthening the Commitment: The Report of the Modernising Learning Disabilities Nursing Review 2012. Scottish Government, Edinburgh
The role of specialist health services in supporting the health needs of people with learning disability. Community Learning Disability Teams 2011: Debra Moore Associates, NHS East Midlands: jan-net.co.uk/archive/cldt.pdf