Lean approaches have been widely adopted by hospitals, but application in the primary care setting has received less attention. Primary care can use a Lean approach to structure and sustain quality improvement work but, as with all quality improvement approaches, needs energy and committed leadership.
Primary care has altogether a different quality improvement environment and a different organisational and management structure compared to a hospital care setting. It reflects a different role, purpose and a different organisational culture. See Table 1 for characteristics of primary care general practice in England.
A hospital has many specialist teams within the same organisation (and under the same management), each delivering a limited range of patient pathways. In contrast, each primary care team is a small independently managed hub that links to a huge range of potential pathways and onward referral points.
The quality improvement strategy, managed and practiced in primary care on a day-to-day basis is necessarily different from the approaches that are taken in a hospital setting.
In particular, a hospital that is implementing a quality improvement strategy is in a position to provide dedicated improvement support and expertise. Some commentators (Westwood and Silvester, 2007) argue that this sort of support is essential. But for small primary care teams, this is less likely to be available, and there is greater emphasis on the quality of the leadership from within the primary care practice itself.
Over the recent years there has been an increase in attempts being made to find out what patients value the most. This links to a policy in the UK to focus directly on improving patient experience. The methods used may involve paper questionnaires, real-time electronic data collection, various focus groups or patient participation groups. A useful development was the use of discovery interviews (a technique of in-depth interviews with patients to inspire quality improvement) and more recently the model of experience-based design (Bate & Robert, 2006) where patients record episodes of emotional importance by either using video, audio or written media. These emotional ‘touch points’ are then discussed in a facilitated meeting between the patient and care provider. This process has led to a greater understanding by clinicians of what is valuable to their patients.
These insights are then the basis for eliminating waste and confidently directing resources towards what increases value to patients (see Table 2 for a summary of Lean principles applied to healthcare).
Delays in the patient journey (at all stages from presentation, through diagnosis, to treatment and aftercare) are the most significant ‘non-value adding’ challenges to any healthcare system, as they increase the risk of adverse outcomes and errors being associated with significant inconvenience and cost. The following examples of increasing patient value and reducing waste are taken from the author’s own experience in primary care practice.
Example 1: Helping GP appointments to run on time
An example of the 5 Ss (sort, simplify, shine, standardise, sustain)
Recently, a local peer support system has been set up for GPs to see how colleagues manage their appointment times without getting late. A significant learning from this has been the finding that those doctors that run on time have their consulting rooms in order, with all forms and equipment handy and with very little need for the doctor to leave the room during the consultation for equipment or patient details.
Example 2: Streamlining processes with suppliers
An example of managing the value stream
The practice has developed an arrangement with the pathology laboratory that if a haemoglobin test is low the laboratory will automatically undertake a B12 / foliate and ferritin assay without the need for a further blood test. Previously, either all these blood tests were ordered on suspicion of anaemia (wasteful ordering of tests), or just a Hb was ordered and the patient was asked to return for further blood tests when the low Hb was discovered (wasteful of patients’ time and introducing delay). In addition, electronic links enable the GP to see the results within minutes of having been processed by logging into the hospital pathology system.
Example 3: Patients getting appointments on the day they need
An example of a pull system
Traditionally, general practice has suffered due to appointment systems that appeared to be designed to control a perceived high demand. Many different approaches to the problem were taken but all had a basic flaw. In order to protect ‘today’s’ appointments, various sanctions or ‘carve outs’ were imposed, hence reducing routine appointments and pushing work onto subsequent days. The problem is not really one of an overall lack of capacity for the demand (If this was the case, then the waiting list would continue to increase). The problem is one of a mismatch between capacity and demand on a daily basis. Lean principles have been used in the ‘Advanced Access’ approach, supported and developed by the Improvement Foundation, and now employed by many practices in NHS primary care (Improvement Foundation, 2008). This involves:
1. Carefully measuring daily demand over a period of weeks to see how this varies from day to day
2. Removing the backlog of appointments by a one-off concerted increase in capacity
3. Re-shaping demand by providing different types of consultation (using nurses, providing telephone or email consultations)
4. Matching capacity to the calculated demand on a daily basis
5. Monitoring the system daily and having contingency plans in place for situations where capacity could fall (for example, doctors’ holidays)
Instead of postponing work to another day, the work will be completed on the same day. The calculated demand (both type and volume) from patients acts as a trigger to ‘pull’ the correct capacity into place. The result is that patients are seen on the day they want to be seen, staff are less stressed and there is less waste in the appointment system.
An example of managing the value stream
In the author’s practice, recent improvements in the electronic patient record have meant that if an opinion is required from a renal consultation at the local hospital, then instead of taking several weeks, (sending a referral letter, then the patient attending the hospital, and the consultant sending a letter back to the GP) the system has been redesigned by removing many intermediate stages so that when a GP has a query about what to do next, he sends an electronic message to the consultant and gives the consultant access rights for a few days to look at the patient’s electronic record. The consultant reviews the problem with access to the complete patient record including all previous investigations and medications. He then types directly into the primary care record from his office in the hospital and an electronic message is sent to the GP informing him of the opinion. The consultant’s access to the record is then terminated. This process adds value to the patient, saves time and saves patients from travelling to the hospital
The fifth Lean principle is to pursue perfection, continuously, reducing waste by developing and amending processes (Table 2). This then is the challenge: how to make improvement a habit and a continuous process?
Applying a set of Lean tools or using a one-off Kaizen Blitz (rapid improvement event) will not in itself deliver sustainable continuous improvement. For sustainable quality improvement in primary care, there is a key requirement for someone within the practice who is able to lead, encourage and develop an improvement culture. This may be a clinician or a manager, anyone with a passion for quality improvement. The leader’s task is to set the environment for learning, communicate the benefits of continuous improvement, provide the right support and demonstrate how to learn.
Hines and colleagues’ 2004 review of Lean thinking shows how Lean has evolved from its narrow origins in 1950s car manufacturing to the extended application in service industries (such as health) today. Real understanding of the customer value stream was developed during the 1990s. With this understanding now driving business processes, rather than relying on a mechanistic application of specific Lean tools, present day Lean draws on a range of tools from diverse management approaches.
One such quality improvement tool that has great value in setting a learning culture and sustaining improvement in primary care is the improvement model, with the ‘three questions’ followed by Plan-Do-Study-Act (PDSA) rapid change cycles (Figure 1).
Lean in primary care is more likely about applying ‘Lean thinking’ flexibly rather than a programmatic step-by-step application of Lean tools. The Lean approach can be used by primary care to structure and sustain quality improvement work but, as with all quality improvement approaches, needs energy and committed leadership.