Streamlining – System Change an Inch Wide and a Mile Deep

Surrey and Sussex Healthcare NHS Trust (SASH) is one of the five NHS organisations[1] that have been working in partnership with the Virginia Mason Institute[2] (VMI) to develop a culture of continuous improvement in the NHS based on lean principles.   At Surrey and Sussex Healthcare this work is known as “SASH+”[3].

The small system change, or in Lean parlance “value stream”, relating to the processing of document supply requests from users which is described here was implemented using some of these lean processes.

The need to make some changes to our ILL (inter library loan) process was identified during a “Waste Walk[4]. A Waste Walk involves team members walking around the “Gemba”[5] (the place where work happens i.e. the library) identifying the seven different types of waste (time, processing, defects, motion, transportation, inventory and overproduction).  Waste can be a contentious word to use, here it means any activity, product etc that does not add value for the patient or customer[6].  On this occasion I was carrying out the waste walk with our two senior library assistants.  One of them identified that the way we currently processed ILL requests when a user sends in multiple requests via email (ie not on ILL request forms) was a type of processing waste, this was a particular issue when a user requested a lot of items from one literature search, in such cases the user replies back to the librarian saying “I would like the following items please”.  Yes, we do encourage users to click on the links and yes, when we send the search results we do send them a link to our online request form, but once they have replied requesting a number of items, the library assistants question whether it is helpful to go back to the user and to ask them to complete this process.  In lean terms this would not be the option to choose.

However the current process was time consuming for the library assistants and involved them filling out the user’s contact details on a request form, copying it multiple times and then cutting and pasting the individual article details onto the request forms; a time consuming and fiddly process which actually was taking up their time when they could have been doing more valuable work for our customers. This therefore became our Value Stream.

The next stage was to identify what was currently happening, how long it was currently taking to complete, and how much of that was waste.  One of the Lean methodology’s mantras is when dealing with a problem you break it down so that you address only a small part at a time that is “an inch wide but a mile deep[7] .  The boundaries for this value stream were from: when the librarian sends the user the search results, to: the library assistant getting the individual requests onto the ILL request forms ready for processing.  We then narrowed the focus down to just looking at getting the multiple requests onto individual request forms.

By observing the library assistants carrying out this work I was able to create a diagram to show the flow of the work (flows of medicine[8]).  Having drawn the flow of work we (library assistants and I) were able to step back from the process and see clearly that there was a lot of going to and from the photocopier/printer, which was not only wasteful but meant the library assistants were often interrupted during the process of completing the request forms.

Flows of Medicine

Using a process called “standard operations”[9], which included timing the process seven times, I was able to establish the that the whole process took on average took 25 minutes per request item of which 53% was non value added (i.e. waste), and the specific part that we wanted to improve (writing out the request form) took 13.9 minutes and 12.3 minutes (88.5%) were not value added.  Not necessarily an easy thing to discuss with your team members, but because of the flows of medicine diagram and the timings they agreed that this was where we needed to focus our attentions.

To get a clear picture of the activity and the sub-stages, value and non-value added activity a “value stream map”[10] was developed. Using this we were able to identify opportunities for improvement (kaizen bursts), but at this stage not the solutions.

Value Stream Map

Having established what the issues were, we could then start to address them.  We wanted to reduce the “internal set-up” time when processing multiple ILL requests from one user i.e. the time it took to get each article request onto a request form. We needed to find a way to reduce the internal set up by either getting rid of steps in the process altogether or by moving some activities to “external set-up” i.e. creating a standard work process that takes place in advance, having a standard ILL request form was standard work, but in this case when there were multiple requests from one user it was not effective, a process known as “set-up reduction”[11]. We did address other issues but our main external set-up solution was a multi sheet spreadsheet. The spreadsheet had multiple sheets with the same form on each sheet.  When the user’s details were entered on the first sheet they were automatically copied across to the other sheets and the library assistant then just needed to copy and paste the individual article details from the literature search results document into the spreadsheet, send it to print and go to the printer/copier to collect the completed forms.

By introducing an electronic form on a spreadsheet we were able to reduce the time taken for the whole process to 14 minutes i.e. reducing the time taken by 44%, and crucially the specific element of getting the requests onto the ILL forms down to 5 seconds. That is a 99.4% time reduction.  My thanks in particular go to Adam Blackwell Senior Library Assistant who allowed me to observe and time him at work and worked with me on finding and testing out solutions.

Rachel Cooke
Head of Library Services & Knowledge Management
Surrey and Sussex Healthcare NHS Trust


[1] https://improvement.nhs.uk/resources/virginia-mason-institute/ accessed 17/02/20

[2] https://www.virginiamasoninstitute.org/ accessed 17/02/20

[3] https://www.surreyandsussex.nhs.uk/about-us/about-the-trust/sash/ accessed 17/02/20

[4] https://www.virginiamasoninstitute.org/2016/06/identifying-the-seven-wastes-to-build-a-lean-foundation/ accessed 18/02/20

[5] Graban, M (2016) Lean hospitals: Improving quality, patient safety and employee engagement 3rd edn. Boca Raton, CRC Press, p316

[6] P 319 Graban, M

[7] https://www.hfma.org.uk/docs/default-source/healthcare-finance-pdfs/June-2016/20-24_jun16_virginiamason-final.pdf?sfvrsn=0 accessed 17/02/2020

[8] Plsek, P (2014)  Accelerating Healthcare Transformation with Lean and Innovation: The Virginia Mason Experience. Boca Raton, CRC Press, p189

[9] Plesk, P p189

[10] Graban, M pp75-78

[11] Stark, C and Hookway, G (2019) Applying Lean in Health and Social Care Services: Improving Quality and the Patient Experience at NHS Highland. Milton Keynes, Routledge Productivity Press.  pp117-119

2 thoughts on “Streamlining – System Change an Inch Wide and a Mile Deep

  1. Freeing up 14 minutes to spend on greater value added activities – reducing the time taken from 25 to 11 minutes – that’s fantastic. Thank you Rachel and Adam

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