Feature / Leaning towards quality

Standardising and streamlining processes at one mental health trust means patients are treated and discharged quickly, and there are financial benefits. Steve Brown reports


There is nothing unusual about the vision statement at Tees, Esk and Wear Valleys NHS Foundation Trust. It focuses on the delivery of high-quality services and its underpinning strategic goals are liberally infused with references to quality and continuous improvement. But what marks the trust out from others is its comprehensive use of lean principles to help it achieve these goals.

Created from the merger of two organisations in 2006, the trust gained FT status two years later. In the meantime, the trust had set its sights on transforming service quality and identified lean methodologies, which look to redesign processes that maximise value and minimise waste, as the way to make it happen.

A strategic health authority initiative introduced the organisation to lean. It involved site visits to Virginia Mason Medical Centre in Seattle, Washington. A leading US healthcare provider in terms of resource use and quality, the hospital had developed the Virginia Mason production system, which applied the lean-based Toyota production system to healthcare.

Clinicians and managers were converted to the lean cause and the Tees, Esk and Wear Valleys quality improvement system (QIS) was born. Six years on, the system is at the heart of the trust’s quality improvement work, helping to deliver big financial savings as a byproduct.

The trust is the first to point out that quality improvement is a journey, and the trust has a long way to go. ‘The more you look, the more you find, and we know we are miles from being perfect,’ says senior clinical director Dr Angus Bell. ‘But we are at least striving for perfection.’

The ‘room for improvement’ message is underlined by a recent Care Quality Commission enforcement action. This relates to a failure at one of the trust’s sites to make individual assessments about patients’ capacity to make decisions. The trust has taken action, acknowledges it should have got this right first time and has promised to learn from the experience.

The QIS pulls together several commonly used lean tools. But central to the approach is the use of rapid process improvement workshops (RPIWs). These five-day events bring together staff involved in delivering a process or service with a trained leader to identify problems, process blockages and waste, and design a better process.

Early RPIWs, first on an elderly medical ward, then on one of the trust’s adult mental health wards, led to the redesigned system getting its own brand – the purposeful inpatient admission (PIPA) model. It has been rolled out from inpatient wards to the whole trust.

‘The key change involves moving away from batching in decision-making,’ says Maureen Raine, deputy head of the trust’s Kaizen Promotion Office, the lean nerve centre at the trust. Weekly ward rounds by up to five consultants have been replaced by a daily multidisciplinary team ‘report out’ meeting. Nursing staff no longer spend hours on ward rounds but can focus on patient care.

The daily meeting lasts half an hour and starts at 9am. Arrive late and the door will be locked. ‘It’s about respect for patients and for other members of staff,’ says Ms Raine.

Each patient is discussed, looking at progress and next steps. There is no high tech, just a white board – the visual control board. Each patient is listed down one side, with standardised tasks to be completed within the first seven days forming the columns of a table.

So, for example, the trust now stipulates that a formulation meeting should be held within three days of a patient’s admission. This multi-disciplinary meeting, involving all key practitioners including the responsible consultant, pharmacist and community team, effectively produces the care plan. Each patient is rated as follows:

• Red – no formulation meeting, no care plan
• Amber – formulation meeting and care plan in place
• Green – treatment completed, awaiting discharge.

A green rating means that anyone from the multidisciplinary team can make the decision to discharge once other factors are taken into consideration, such as suitable housing for the patient to be discharged to.

An associated task board enables all tasks for specific disciplines (medics, nursing, pharmacy for example), identified as required in the daily meetings, to be recorded. The completion of these tasks is then reviewed the following day.

‘We’ve just reduced the delays in the patient experience,’ says Ms Raine. ‘We’ve got rid of a lot of waits and delays between key decisions.’ 

The results are better experiences for patients. One example is that decisions are taken on a daily basis. For example a patient request for leave can be considered the next morning. Previously, this might have waited for a week or longer for consideration by a consultant as part of a ward round.

The headline results are impressive too. On one ward, average length of stay has fallen from 80 days to 30. And across the whole trust average length of stay for adult and elderly patients is now 35 days compared with an average of 47 in 2009/10.

Bed numbers have fallen by 218 across adult and older people wards since 2006/07. Trust finance director Colin Martin says this has had an impact on costs as well as providing a better patient experience. The reduced need for beds means the trust has been able to ‘recycle’ two planned wards in its new Roseberry Park hospital, which opened in 2010.

‘We’ve turned them into forensic beds, which commissioners have filled with patients previously placed in the private sector,’ he says. In total, Mr Martin estimates the bed reductions have saved close to £20m – £8m in adult services, £12m in older people services.

Drew Kendall, associate director of finance at the trust, says the trust has not quantified financially all the impacts from the QIS process – there have been 93 workshops among other lean improvement work. ‘The real focus has been on quality; the money has been a byproduct,’ he says. But there is a firm belief that higher quality should mean lower costs.

Mr Kendall says that improved flow of patients aligns with an overall mental health strategy of reserving the more expensive inpatient facilities for patients with the greatest needs, while developing enhanced community support for service users.

But it also supports the improvement of services at lower cost. ‘If we can rationalise beds, it provides the opportunity to generate efficiencies associated with those beds as well as potentially releasing assets for sale.’

The whole premise of lean and the RPIWs is that staff will know best how to improve services, so they need to buy into the process. Tees, Esk and Wear Valleys seems to have the staff onside, in part because those involved with the process have felt empowered by it and in part due to a staff compact. Crucially this compact promises staff will be given ‘choices to ensure no compulsory redundancies’ as a result of quality improvement work.

The trust has certainly had good staff feedback in the last two annual staff surveys. It says the trust has been rated in the top two of all mental health trusts in 2011 and 2012. More broadly it is encouraged that patient surveys put it in the top 20% of mental health trusts and can boast a clutch of innovation and best practice awards and low reference costs. It suggests this is all evidence that it is on the right track, even if there is still a long way to go.

Dr Bell says the new approach has been ‘life changing’ for him personally. ‘Sometimes you uncover so much that needs improving that it can be a bit depressing,’ he says. ‘But you need to look back at where you have come from.’

Ms Raine agrees both in terms of progress and the work remaining. ‘We’ve done something in every specialty and service area, but we’ve not touched every team. The more we do, the more we realise we have to do.’ Linking the changes to outcomes is clearly vital. ‘The aim is to improve quality of care so we do monitor readmission rates and we are using the methodology to develop clinical pathways,’ she says.

She believes that the approach could have much wider benefits if applied by other mental health and acute bodies. And with increasing numbers of NHS bodies visiting the trust to hear about its experiences first hand, others are clearly starting to think the same way.