Using Lean to redesign pathways

NHS England and NHS Improvement’s freely available Lean online programme1 introduces Lean improvement concepts and tools through practical, structured sessions. It emphasises the benefits of applying the learning to a small, focused area of improvement, as David Smith did when looking at the East Lancashire Hospitals paediatrics pathway. 

David joined the NHS after being furloughed from his retail job. In his paediatrics service bank role, he investigated the pathway for children with neurodevelopmental concerns. He cleaned patient lists of duplicated data and mapped out a pathway that streamlined processes from two separate pathways. The team decided to roll out the new pathway, applying the Lean principles and learning David had acquired through the course. 

David spoke with Q peer interviewer Joe Home, Q’s Insight and Evaluation Officer Henry Cann and Iain Smith, National Improvement Lead for NHS England and NHS Improvement (who worked on the development of the programme), to share learning.

Iain reflected that the Lean online programme was designed to help teams ​‘to learn really simple techniques and apply them to small’. However, as evaluations of improvement training programmes frequently reflect, participants are often not supported to find the time or opportunity to apply their learning.2 David secured senior staff’s trust and backing to facilitate some of the potentially counter-cultural changes; highlighting the potential longer-term benefits.

Getting buy-in for improvement work from already over-stretched staff can be a real challenge. Disjointed and often duplicated departmental processes meant a lot of the workload that overburdened clinicians was administrative work that could be safely and effectively done by non-clinical teams. Highlighting this helped get staff on board for fairly fundamental changes.

After the data cleansing process to remove discharged patients or to request information for records with incomplete referral information, the existing waiting list reduced from around 1,200 to just over 200. This reduced waiting times from an average of over a year to just over three months.3 Merging two previously separate pathways reduced unnecessary duplication, thus saving time and money, while also providing a clearer and more navigable process for those accessing the service.

Fundamentally changing the structure of work for staff freed up clinicians’ time to see more patients. A temporary increase from six to twelve patients seen in clinic by the multi-disciplinary team reduced its backlog of cases.

This is having a positive effect on staff in both clinical and non-clinical roles. David suggests it has improved staff productivity, morale and retention:

Organisational support for improvement was essential in enabling improvers to apply the Lean improvement structure and create ​‘a connection between what happens at the front line being fed right back up to the top of the office’. Senior accountability, with a commitment to follow through and review the changes implemented, is vital for service-level change to be made sustainable.

A common challenge that David and Iain see is maintaining changes over time when project managers brought in to implement a change move on. ​‘With the NHS… we fix something, we take our eye off it, we move to a different area, and we don’t maintain it.’ Developing improvement capabilities in-house, in this case through accessible online training, ensures staff such as ward managers and matrons have the skills to sustain improvements, decreasing reliance on external support.