“It is certainly a radically different and exciting way to improve patient pathways quickly, efficiently and safely.” Operations Director

“The work really complements the improvement work we already have to do, but brings a refreshing, high impact approach to our traditional methods.” Service Improvement Manager

S - Sustaining the Gain

Making improvements in Health is one thing, sustaining them is another and the fourth element of the PRISM model is concerned with Sustaining Improvements through a ‘Change Agent Development’ (CAD) programme which focuses on developing the technical and leadership skills of the ‘Process Leaders’ who lead the areas being improved, by combining profiling with leadership and ‘Lean’, enabling them to sustain and improve the process which have been transformed.

M - Maintaining the Momentum

It is important to recognise that sustainable transformational change takes time, and we have found that it can require up to 1 year to become embedded and for organisations to realise all the benefits that are possible, including the teams becoming familiar with the process. This doesn’t mean that hospitals have to spend a year before there are any improvements as these accrue every month, actually it means that to realise

Due to client confidentiality issues, the names and identities of the client hospitals who have benefited from this process have been obscured as no self-respecting management team would like the press to know about their problems with finance and efficiency.

Are We Healthy?

Many people within the UK’s National Health Service (NHS) would recognise that there have been a number of significant improvements to the service over the last few years, but these same people would also recognise that there are many further improvements that could (and need to) be made, especially with so many hospitals facing deficits.

This short article has arisen from a number of projects carried out within the NHS to rapidly improve patient pathways in both elective care and emergency admissions, as well as in administrative functions. The aims of this work have been three fold:

• Significantly improve financial performance

• Maintain or improve standards of care

• Increase the overall patient experience

Healthy & Sustainable

Before we start, it is worth stating that many organisations have been able to ‘ram-raid’ hospitals, making short term, low gain and unsustainable improvements that have irritated administrative staff and lost the support of the clinical teams.

Therefore, there is a balance to be walked, on the one hand, the need to focus on significant improvements, and on the other hand the need to bring the teams with you as they pass through the process.

Over a period of time, we have been trialling a sustainable model for improvement in Health, Local Authorities/Council, Emergency Services and other public sector organisations, based around the PRISM model which is described below:

• P - Prepare the Organisation

• R - Roadmap

• I - Implement

• S - Sustain the Improvement

• M - Maintain the Momentum

• A – Accelerate Improvements

The PRISM model uses concepts from Lean, coupled with key tools from Risk Management, Management Development and Cultural Change to provide a framework for sustainable change in complex process environments.

P - Preparing the Organisation

The first, and most important, activity in delivering the PRISM model is to scope the improvement so that the organisation is clearly focused on the right targets. We achieved this with the NHS through a management team level ‘Scoping Meeting’ to discuss such things as: Objectives, Focus of Improvements, ‘Fixed Points’ – or things that could not be changed, ‘Impact Points’ – or things that could influence the success or otherwise of the improvement work, and also identified who would lead the improvements. This was followed by training for the identified ‘Process Leaders’ who were to lead each stream of improvement.

R - Roadmap

Having got the organisational ‘aligned’ (in itself not an easy task), the next stage is to gain alignment from those involved in improving the process, which we have achieved through Value Stream Analysis Events (VSE) which are undertaken over a 2.5 day period of concentrated effort and use a variety of tools from Lean, Programme Management & Creative Thinking.

The concept of the VSE is to help the participants to see the ‘waste’ or inefficiency in the current process, using this information to help develop a vision of how good the organisation could be in a ‘Blue Sky’ state and then coming back to reality by creating a realistic ‘Future State’ which tries to get them as close to their ‘Blue Sky’ as possible, taking into account the realism of budgets, resources etc.

Because we then have reference points, as in where the team are starting from (Current State) and where they want to go (Future State), it is then possible to create an implementation plan to execute.

I - Implementing the Improvement

Taking the next element of the PRISM model, we then assisted the team to Implement Improvements through a series of Rapid Improvement Events (RIE) – each lasting 3-4 days and covering up to 4 improvement events. For example, in a recent RIE the teams led three improvement programmes:

1. Using Breast Reconstruction and Total Knee Replacement as examples of common outpatient activity, the first team focused on improving flow through outpatients to enable them to cope with the 18 weeks rule coming in from 2007 onwards for fully booked appointments. The work achieved a saving of over ?300k and reduced the lead-time from some 7.5 months to 2 weeks to get a fully booked appointment.

2. Using primarily elective care examples, complicated by issues arising from trauma, or emergency admissions, the second team focused on increasing the ability of theatre to start on time, which resulted in lists starting ‘on-time’ increasing from 37% to greater than 70%. A secondary benefit of this is that the hospital will be able to operate on 10% more patients without increasing staff workload.

3. The third team focused on Emergency Admission procedures, particularly looking at ‘Fractured Neck of Femur’ - a problem suffered mostly by older women who have fallen over - and ‘Max Fax’ (Maxillofacial) – often suffered by young, drunk men in fights, where the focus was on reducing the time from DTA (Decision to Admit) to the patient being operated on, as well as increasing efficiency. The result was that processing times have dropped from an average of 9 hours to around 3 and there is a potential to save more lives every week through a significantly improved patient pathway.

One of the greatest side effects of the work undertaken has been some of the comments we have received on our journey, including such things as:

“The process is stressful, but delivers more than any other change programme we have done previously.” Assistant Director (Elective Care)

“It is certainly a radically different and exciting way to improve patient pathways quickly, efficiently and safely.” Operations Director

“The work really complements the improvement work we already have to do, but brings a refreshing, high impact approach to our traditional methods.” Service Improvement Manager

S - Sustaining the Gain

Making improvements in Health is one thing, sustaining them is another and the fourth element of the PRISM model is concerned with Sustaining Improvements through a ‘Change Agent Development’ (CAD) programme which focuses on developing the technical and leadership skills of the ‘Process Leaders’ who lead the areas being improved, by combining profiling with leadership and ‘Lean’, enabling them to sustain and improve the process which have been transformed.

M - Maintaining the Momentum

It is important to recognise that sustainable transformational change takes time, and we have found that it can require up to 1 year to become embedded and for organisations to realise all the benefits that are possible, including the teams becoming familiar with the process. This doesn’t mean that hospitals have to spend a year before there are any improvements as these accrue every month, actually it means that to realise t

Over a period of time, we have been trialling a sustainable model for improvement in Health, Local Authorities/Council, Emergency Services and other public sector organisations, based around the PRISM model which is described below:

• P - Prepare the Organisation

• R - Roadmap

• I - Implement

• S - Sustain the Improvement

• M - Maintain the Momentum

• A – Accelerate Improvements

The PRISM model uses concepts from Lean, coupled with key tools from Risk Management, Management Development and Cultural Change to provide a framework for sustainable change in complex process environments.

P - Preparing the Organisation

The first, and most important, activity in delivering the PRISM model is to scope the improvement so that the organisation is clearly focused on the right targets. We achieved this with the NHS through a management team level ‘Scoping Meeting’ to discuss such things as: Objectives, Focus of Improvements, ‘Fixed Points’ – or things that could not be changed, ‘Impact Points’ – or things that could influence the success or otherwise of the improvement work, and also identified who would lead the improvements. This was followed by training for the identified ‘Process Leaders’ who were to lead each stream of improvement.

R - Roadmap

Having got the organisational ‘aligned’ (in itself not an easy task), the next stage is to gain alignment from those involved in improving the process, which we have achieved through Value Stream Analysis Events (VSE) which are undertaken over a 2.5 day period of concentrated effort and use a variety of tools from Lean, Programme Management & Creative Thinking.

The concept of the VSE is to help the participants to see the ‘waste’ or inefficiency in the current process, using this information to help develop a vision of how good the organisation could be in a ‘Blue Sky’ state and then coming back to reality by creating a realistic ‘Future State’ which tries to get them as close to their ‘Blue Sky’ as possible, taking into account the realism of budgets, resources etc.

Because we then have reference points, as in where the team are starting from (Current State) and where they want to go (Future State), it is then possible to create an implementation plan to execute.

I - Implementing the Improvement

Taking the next element of the PRISM model, we then assisted the team to Implement Improvements through a series of Rapid Improvement Events (RIE) – each lasting 3-4 days and covering up to 4 improvement events. For example, in a recent RIE the teams led three improvement programmes:

1. Using Breast Reconstruction and Total Knee Replacement as examples of common outpatient activity, the first team focused on improving flow through outpatients to enable them to cope with the 18 weeks rule coming in from 2007 onwards for fully booked appointments. The work achieved a saving of over ?300k and reduced the lead-time from some 7.5 months to 2 weeks to get a fully booked appointment.

2. Using primarily elective care examples, complicated by issues arising from trauma, or emergency admissions, the second team focused on increasing the ability of theatre to start on time, which resulted in lists starting ‘on-time’ increasing from 37% to greater than 70%. A secondary benefit of this is that the hospital will be able to operate on 10% more patients without increasing staff workload.

3. The third team focused on Emergency Admission procedures, particularly looking at ‘Fractured Neck of Femur’ - a problem suffered mostly by older women who have fallen over - and ‘Max Fax’ (Maxillofacial) – often suffered by young, drunk men in fights, where the focus was on reducing the time from DTA (Decision to Admit) to the patient being operated on, as well as increasing efficiency. The result was that processing times have dropped from an average of 9 hours to around 3 and there is a potential to save more lives every week through a significantly improved patient pathway.

One of the greatest side effects of the work undertaken has been some of the comments we have received on our journey, including such things as:

“The process is stressful, but delivers more than any other change programme we have done previously.” Assistant Director (Elective Care)

“It is certainly a radically different and exciting way to improve patient pathways quickly, efficiently and safely.” Operations Director

“The work really complements the improvement work we already have to do, but brings a refreshing, high impact approach to our traditional methods.” Service Improvement Manager

S - Sustaining the Gain

Making improvements in Health is one thing, sustaining them is another and the fourth element of the PRISM model is concerned with Sustaining Improvements through a ‘Change Agent Development’ (CAD) programme which focuses on developing the technical and leadership skills of the ‘Process Leaders’ who lead the areas being improved, by combining profiling with leadership and ‘Lean’, enabling them to sustain and improve the process which have been transformed.

M - Maintaining the Momentum

It is important to recognise that sustainable transformational change takes time, and we have found that it can require up to 1 year to become embedded and for organisations to realise all the benefits that are possible, including the teams becoming familiar with the process. This doesn’t mean that hospitals have to spend a year before there are any improvements as these accrue every month, actually it means that to realise

The concept of the VSE is to help the participants to see the ‘waste’ or inefficiency in the current process, using this information to help develop a vision of how good the organisation could be in a ‘Blue Sky’ state and then coming back to reality by creating a realistic ‘Future State’ which tries to get them as close to their ‘Blue Sky’ as possible, taking into account the realism of budgets, resources etc.

Because we then have reference points, as in where the team are starting from (Current State) and where they want to go (Future State), it is then possible to create an implementation plan to execute.

I - Implementing the Improvement

Taking the next element of the PRISM model, we then assisted the team to Implement Improvements through a series of Rapid Improvement Events (RIE) – each lasting 3-4 days and covering up to 4 improvement events. For example, in a recent RIE the teams led three improvement programmes:

1. Using Breast Reconstruction and Total Knee Replacement as examples of common outpatient activity, the first team focused on improving flow through outpatients to enable them to cope with the 18 weeks rule coming in from 2007 onwards for fully booked appointments. The work achieved a saving of over ?300k and reduced the lead-time from some 7.5 months to 2 weeks to get a fully booked appointment.

2. Using primarily elective care examples, complicated by issues arising from trauma, or emergency admissions, the second team focused on increasing the ability of theatre to start on time, which resulted in lists starting ‘on-time’ increasing from 37% to greater than 70%. A secondary benefit of this is that the hospital will be able to operate on 10% more patients without increasing staff workload.

3. The third team focused on Emergency Admission procedures, particularly looking at ‘Fractured Neck of Femur’ - a problem suffered mostly by older women who have fallen over - and ‘Max Fax’ (Maxillofacial) – often suffered by young, drunk men in fights, where the focus was on reducing the time from DTA (Decision to Admit) to the patient being operated on, as well as increasing efficiency. The result was that processing times have dropped from an average of 9 hours to around 3 and there is a potential to save more lives every week through a significantly improved patient pathway.

One of the greatest side effects of the work undertaken has been some of the comments we have received on our journey, including such things as:

“The process is stressful, but delivers more than any other change programme we have done previously.” Assistant Director (Elective Care)

“It is certainly a radically different and exciting way to improve patient pathways quickly, efficiently and safely.” Operations Director

“The work really complements the improvement work we already have to do, but brings a refreshing, high impact approach to our traditional methods.” Service Improvement Manager

S - Sustaining the Gain

Making improvements in Health is one thing, sustaining them is another and the fourth element of the PRISM model is concerned with Sustaining Improvements through a ‘Change Agent Development’ (CAD) programme which focuses on developing the technical and leadership skills of the ‘Process Leaders’ who lead the areas being improved, by combining profiling with leadership and ‘Lean’, enabling them to sustain and improve the process which have been transformed.

M - Maintaining the Momentum

It is important to recognise that sustainable transformational change takes time, and we have found that it can require up to 1 year to become embedded and for organisations to realise all the benefits that are possible, including the teams becoming familiar with the process. This doesn’t mean that hospitals have to spend a year before there are any improvements as these accrue every month, actually it means that to realise

2. Using primarily elective care examples, complicated by issues arising from trauma, or emergency admissions, the second team focused on increasing the ability of theatre to start on time, which resulted in lists starting ‘on-time’ increasing from 37% to greater than 70%. A secondary benefit of this is that the hospital will be able to operate on 10% more patients without increasing staff workload.

3. The third team focused on Emergency Admission procedures, particularly looking at ‘Fractured Neck of Femur’ - a problem suffered mostly by older women who have fallen over - and ‘Max Fax’ (Maxillofacial) – often suffered by young, drunk men in fights, where the focus was on reducing the time from DTA (Decision to Admit) to the patient being operated on, as well as increasing efficiency. The result was that processing times have dropped from an average of 9 hours to around 3 and there is a potential to save more lives every week through a significantly improved patient pathway.

One of the greatest side effects of the work undertaken has been some of the comments we have received on our journey, including such things as:

“The process is stressful, but delivers more than any other change programme we have done previously.” Assistant Director (Elective Care)

“It is certainly a radically different and exciting way to improve patient pathways quickly, efficiently and safely.” Operations Director

“The work really complements the improvement work we already have to do, but brings a refreshing, high impact approach to our traditional methods.” Service Improvement Manager

S - Sustaining the Gain

Making improvements in Health is one thing, sustaining them is another and the fourth element of the PRISM model is concerned with Sustaining Improvements through a ‘Change Agent Development’ (CAD) programme which focuses on developing the technical and leadership skills of the ‘Process Leaders’ who lead the areas being improved, by combining profiling with leadership and ‘Lean’, enabling them to sustain and improve the process which have been transformed.

M - Maintaining the Momentum

It is important to recognise that sustainable transformational change takes time, and we have found that it can require up to 1 year to become embedded and for organisations to realise all the benefits that are possible, including the teams becoming familiar with the process. This doesn’t mean that hospitals have to spend a year before there are any improvements as these accrue every month, actually it means that to realise

“It is certainly a radically different and exciting way to improve patient pathways quickly, efficiently and safely.” Operations Director

“The work really complements the improvement work we already have to do, but brings a refreshing, high impact approach to our traditional methods.” Service Improvement Manager

S - Sustaining the Gain

Making improvements in Health is one thing, sustaining them is another and the fourth element of the PRISM model is concerned with Sustaining Improvements through a ‘Change Agent Development’ (CAD) programme which focuses on developing the technical and leadership skills of the ‘Process Leaders’ who lead the areas being improved, by combining profiling with leadership and ‘Lean’, enabling them to sustain and improve the process which have been transformed.

M - Maintaining the Momentum

It is important to recognise that sustainable transformational change takes time, and we have found that it can require up to 1 year to become embedded and for organisations to realise all the benefits that are possible, including the teams becoming familiar with the process. This doesn’t mean that hospitals have to spend a year before there are any improvements as these accrue every month, actually it means that to realise the full benefits, which are measured in millions and sometimes tens of millions, whilst also improving the patient experience and staff morale, requires continual focus over an extended period.

The last element of the PRISM model is to 'Maintain Momentum' which is concerned with ensuring the organisation continues to achieve benefits over the extended journey it needs to go through. This includes re-scoping the improvement, planning further activities and getting the Change Agents 'up to speed' and capable of running events in their own right.

Without this on-going focus, there will be a tendency to ‘drift’ and for people to revert to previous ways of working and more importantly, previous ways of making improvements, which without the focus on Rapid Improvement will often prove to have less impact and take much longer to achieve.

Closing Comments

The NHS have made significant improvements over the last few years and the professionals who work within it are performing brilliantly, often with broken processes which cause financial as well as ‘people’ problems, for example some 65% of complaints received by one hospital worked with were related to delays in the way they handled bookings in outpatients.

Combining the professional expertise, with existing improvement tools within the NHS, combined with external expertise and Rapid Improvement tools, is a winning combination for the 21st Century Health Service.

In the words of one Chief Executive, "I would never have believed that so much could be achieved in such a short time and in such a professional and exciting fashion."