Paul Walley

Learning to Walk Before We Try to Run: Adapting Lean for the Public Sector

This article considers whether public sector organizations regard Lean merely as a set of tools and techniques without considering either the underlying conditions and principles or regard Lean as a philosophy. The authors analyse a series of case studies of Lean in the public sector around four themes—process-based view, focus on value, elimination of waste and employee-driven change—before considering the implementation approach taken and outcomes achieved. The outcomes were significant, but the authors warn against an implementation approach which focuses solely on Lean tools.

Quality of medication use in primary care - mapping the problem, working to a solution: a systematic review of the literature

BackgroundThe UK, USA and the World Health Organization have identified improved patient safety in healthcare as a priority. Medication error has been identified as one of the most frequent forms of medical error and is associated with significant medical harm. Errors are the result of the systems that produce them. In industrial settings, a range of systematic techniques have been designed to reduce error and waste. The first stage of these processes is to map out the whole system and its reliability at each stage. However, to date, studies of medication error and solutions have concentrated on individual parts of the whole system. In this paper we wished to conduct a systematic review of the literature, in order to map out the medication system with its associated errors and failures in quality, to assess the strength of the evidence and to use approaches from quality management to identify ways in which the system could be made safer.MethodsWe mapped out the medicines management system in primary care in the UK. We conducted a systematic literature review in order to refine our map of the system and to establish the quality of the research and reliability of the system.ResultsThe map demonstrated that the proportion of errors in the management system for medicines in primary care is very high. Several stages of the process had error rates of 50% or more: repeat prescribing reviews, interface prescribing and communication and patient adherence. When including the efficacy of the medicine in the system, the available evidence suggested that only between 4% and 21% of patients achieved the optimum benefit from their medication. Whilst there were some limitations in the evidence base, including the error rate measurement and the sampling strategies employed, there was sufficient information to indicate the ways in which the system could be improved, using management approaches. The first step to improving the overall quality would be routine monitoring of adherence, clinical effectiveness and hospital admissions.ConclusionBy adopting the whole system approach from a management perspective we have found where failures in quality occur in medication use in primary care in the UK, and where weaknesses occur in the associated evidence base. Quality management approaches have allowed us to develop a coherent change and research agenda in order to tackle these, so far, fairly intractable problems.

Managing variation in demand: lessons from the UK National Health Service.

EXECUTIVE SUMMARY Managers within the U.S. healthcare system are becoming more aware of the impact of variation in demand on healthcare processes. The UK National Health Service provides a prime example of a system that has experienced the consequences when the issue is not dealt with satisfactorily, having suffered from excessive queues for a prolonged period. These delays are mostly caused by a lack of attention to variation and inappropriate responses to the queues, rather than a capacity shortage. A number of collaborative programs recently have come to grips with many of the causes of the queues in both elective care and emergency care. Although there are still areas that need large‐scale improvement, good progress has been made, especially within emergency care. The authors of this article have acted as technical advisors to a number of these improvement programs and have been able to document many of the practices that have helped to reduce or eliminate unnecessary queues and delays across the 200 sites in England that have 24‐hour emergency care facilities. Local program managers at these sites continuously reported progress for a period of 18 months. A number of important lessons for both the design and control of healthcare processes have emerged from the collaborative work. These lessons focus on understanding and measurement of demand, capacity planning, reduction of introduced variation, segmentation and streaming of work, process design, capacity yield management, and measurement of variation.

Call centre capacity management

Call centres often experience large fluctuations in demand over relatively short periods of time. However, most centres also need to maintain short response times to the demand. This places great emphasis upon capacity management practices within call centre operations. A total of 12 UK‐based call centres from one retail bank were studied to investigate how they managed forecasting, capacity management and scheduling tasks. Provides evidence of the difficulties associated with capacity management in call centres. Regression modelling is used to link forecasting and capacity planning practices to performance. Shows that random variation is a very important factor when assessing call centre performance. The results suggest that call centre managers can have only a small influence upon short‐term performance. Existing mathematical models, such as the Erlang queuing system methodologies, have only limited value as the assumptions concerning demand patterns made in their derivation contradict observations made within the 12 sites. Spiked demand patterns present special capacity management problems, including a direct trade‐off between high service levels and operator boredom. Conventional methods of flexing capacity cannot respond sufficiently well to some of the short‐term fluctuations in demand.

Implementing IT in NHS hospitals - internal barriers to technological advancement

There remains an ambitious objective to develop high specification Hospital Information Systems within the UK National Health Service, but progress has been slow. Successful implementation requires both effective project management and process change. The literature already acknowledges the difficult environment that healthcare IT projects operate within. This paper uses a longitudinal case study to examine the presence or absence of critical success factors in an NHS Hospital, for both the implementation and operationalisation of technology. The findings suggest that external factors are not the only reason for the slow introduction and limited impact of new technology. Internal barriers that significantly limit the implementation process include an unsupportive organisation structure, irreconcilable differences in stakeholder requirements, the low status of the project team, a poor understanding of process management issues and organisation politics.

Clinical governance and operations management methodologies

The clinical governance mechanism, introduced since 1998 in the UK National Health Service (NHS), aims to deliver high quality care with efficient, effective and cost-effective patient services. Scally and Donaldson recognised that new approaches are needed, and operations management techniques comprise potentially powerful methodologies in understanding the process of care, which can be applied both within and across professional boundaries. This paper summarises four studies in hospital Trusts which took approaches to improving process that were different from and less structured than business process re-engineering (BPR). The problems were then amenable to change at a relatively low cost and short timescale, producing significant improvement to patient care. This less structured approach to operations management avoided incurring overhead costs of large scale and costly change such as new information technology (IT) systems. The most successful changes were brought about by formal tools to control quantity, content and timing of changes.

Integrating manufacturing and management accounting strategy: case study insights

Abstract In recent years various new accounting techniques or new approaches to existing techniques have emerged in response to changes in manufacturing practices or the competitive positions of businesses. These techniques such as activity-based costing, throughput accounting, JIT-accounting and the emphasis on non-financial performance measures have featured in a range of accounting and management journals. There is, however, less clear guidance on when to adopt new techniques, when and whether to adapt old systems and which parts of the information system to emphasise, in particular, environmental and internal circumstances. That is, there is an absence of emphasis on the development of a management accounting strategy. The authors maintain that accounting practices such as product costing and the generation and use of performance measures should be considered in the context of an overall set of functional strategies. It is necessary to assess each accounting technique or measure, to determine under what environmental and internal conditions it is appropriate. This approach parallels, for example, the existing theory of manufacturing strategy which suggests that “best practice” manufacturing systems and procedures can be determined by the consideration of other functional strategies. The paper argues the case for the development of a coherent management accounting—manufacturing strategy and through selected case studies demonstrates the importance of the integration of accounting with other strategies. It uses insights from manufacturing strategy to evaluate how the emphasis on management accounting practices may change as a result of a change in competitive, marketing and manufacturing strategy. It argues that “best practice” management accounting techniques and measures are dictated by a companys manufacturing and marketing environment. As the pace of change within organisations increases, there will be an increasing need to swiftly adapt systems to cope with external and internal changes and hence a framework to assist with the development of appropriate management accounting practices will become more important.

A study of the efficacy and cost-effectiveness of MRSA screening and monitoring on surgical wards using a new, rapid molecular test (EMMS)

BackgroundMRSA is a significant contributor to prolonged hospital stay, poor clinical outcome and increased healthcare costs amongst surgical patients. A PCR test has been developed for rapid detection of MRSA in nasal swabs. The aims of this study are (1) to estimate the effectiveness of screening using this rapid PCR tests vs culture in reducing MRSA cross-infection rates; (2) to compare the cost of each testing strategy, including subsequent health care costs; and (3) to model different policies for the early identification and control of MRSA infection in surgical patients.Methods/DesignThe study is a prospective two-period cross-over study set in 7 surgical wards covering different surgical specialities. A total of 10,000 patients > 18 years will be tested over 16 months. The only difference between the two study periods is the method used for the detection of MRSA in each ward (rapid v conventional culture), with all other infection control practices remaining consistent between the arms. The study has been designed to complement routine practice in the NHS. Outcomes are MRSA cross-infection rates (primary outcome) and need for antibiotic therapy and MRSA-related morbidity. Parallel economic and modelling studies are being conducted to aid in the interpretation of the results and to evaluate the cost-effectiveness of the rapid PCR screening strategy.DiscussionThis paper highlights the design, methods and operational aspects of a study evaluating rapid MRSA screening in the surgical ward setting.

Managing variation through system redesign

Previous studies of reengineering in healthcare have identified a lack of process standardisation and inherent process variability as barriers to successful redesign. Some regard healthcare as unsuitable for a process redesign approach. The pilot studies and longitudinal case study presented here demonstrate that process stability can be achieved using a reengineering approach and that this can help reduce patient journey times and the variation in flow times. Furthermore, a cellular approach to process streaming did not create process stability at the expense of system flexibility. The process-based view that was introduced by the redesign activity was seen to be extremely valuable because of the way in which it helped to define patient flows.

The redesign practices and capabilities of NHS Trusts in England: a snapshot study

The ability of any healthcare system to improve outcomes for patients through the use of information technology or through process improvement depends very much on the implementation of process redesign methodologies. In this paper, the redesign capabilities of 29 UK National Health Service (NHS) Trusts are assessed to gain an insight into the current situation within the NHS as a whole. It was found that very few individual organisations possessed internal capability to redesign processes effectively. Furthermore, in many organisations, there was little integration of redesign and improvement strategy with the strategy of the organisation as a whole. Those organisations that were successful had probably developed a capability over many years. Some Trusts had performance levels poor enough to require emergency measures to remedy the situation. These sites had actively recruited people with skills to introduce a redesign capability. The paper discusses the barriers to the development of a redesign capability.