Tag Archives: Inter Library Loans

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

LKDN Statistics – what can we learn from them?

I have been trying to turn statistical data from the national collection into information that tells me something about trends and/or the health of our libraries in the south. My thoughts from this exercise may help the Metrics Task and Finish group as one of our next tasks is to review the statistics collection.

First of all I had to decide which of the 139 lines of figures submitted would work well in comparison across the years. I couldn’t compare everything as there probably aren’t enough hours in the day to go through the whole lot, besides which I think a certain boredom factor might intrude on the thinking processes. I worked with Tricia Ellis to decide which lines to include. We wanted some analysis that would identify trends and patterns of progress, investment and activity. We tried to work out which statistics would show our successes and went for 1. Income and expenditure  2. Staffing levels  3. Library activities, i.e. loans from stock, user education sessions, literature searches undertaken, etc. and  4. Changes to library infrastructure, e.g. WI-FI access

These are the specific areas I looked at comparing three years of submissions for the South West: 2012-13, 2013-14 and 2014-15

What did I learn?
Income and Expenditure
 – Library income has not changed very much over this period, some libraries have lost income where staff have moved to other Trusts but this meant that another library in the area then gained that income. However, the non-recurring income has fluctuated wildly, only one library has non-recurring funds which remained fairly static.  For some libraries this may be significant as they rely on these for their service.  I felt that these funding figures didn’t really tell me a lot so I had the idea of looking at the number of users and maybe working out what each library spent per user.

Total number of users – is this an indicator of the busy-ness of the library? Of course this depends on data cleansing – if some libraries do not clear out expired users from their systems they may be over counting memberships.  In order to get a more meaningful comparison of libraries I split them into two groups – small and large libraries based on library staffing figures. I compared memberships with expenditure and was able to work out the average spend per user.   This made me ask a question  – to show value for money should we be increasing our library membership and decreasing our expenditure so that the average spend per user would actually get smaller?
Staffing levels  (wte and staffing mix)  – the data includes library qualifications, other qualifications, none.  I did not pick up on any trends in staffing levels, most remaining static, there are some discrepancies due to reported vacancies.  In the South West over 50% of staff have a professional qualification and are paid on Band 5 or over.  12% of staff have a paraprofessional qualification. I found out that we have had and have maintained a well-qualified set of staff.

Loans from stock  – includes renewals, but there are variants as each library has a different number of loans and renewals allowed. In some libraries book loans to own readers have gone down but overall figures look fairly static showing that our book stock is still of importance to library users. Loans to local networks have gone down slightly as would be expected with the increase in ebooks.  This figure could be an indicator of the importance of the collection to others and shared resources remain vital to the cost effectiveness of libraries and ease of access to our readers.

Copies supplied by other libraries – local networks, British Library, or others – I was looking for trends. Most libraries show a downward trend for document supply but there are exceptions with two or three libraries trending upward.  No conclusions to be drawn here.

Literature searches – total number of mediated searches – are these increasing or decreasing?  In the South West there has been a steady increase which is encouraging as this is one of the areas where some analysis of searches can show how the service impacts on management and clinical decision making.

User education and induction – numbers being made aware of our services. There appears to be a lack of consistency in the way librarians collect these and figures vary greatly – for example, one library has done nearly 5000 inductions in one year whereas all the other libraries have figures nearer to the figure of 700. Two libraries simply can’t supply these figures but don’t say why.  Without comparing membership figures it is hard to tell whether the smaller libraries are doing just as well as the larger ones in providing user education.

Current awareness  – bulletins, blogs, RSS feeds and social media – the number of blogs increased,  RSS feeds figures are static, Social Networking has increased but some Trusts don’t allow libraries to do this so it feels unfair to compare them. As we are simply counting yes or no in this area I can see the activity but this figure does not tell me about outreach or impact. Do library managers analyse the activity in this area to get a more meaningful result?

Journals – print titles, electronic only, print with electronic. Electronic only titles have increased.  Nothing really useful to be learned here so why record it?

Collaborative purchase scheme – figures went up and then back down. Although this collaborative purchases is key to getting good value for money the way we record it doesn’t tell us enough, how many resources were made available to how many libraries through these different schemes?

eBooks  and Databases – these figures don’t have story to tell – why count?

WiFi – most libraries have WiFi now can we now assume that this is the norm and stop counting it?

I would be interested to know if anyone else has tried to get a “story” from the annual statistics collection and if not, are there other statistics that you have used to plan services or make a decision?

Dorothy Curtis
Deputy Library Service Manager
Gloucestershire Hospitals NHS FT
Dorothycurtis@nhs.net

To Charge, or not to Charge…..

…that is the question and it’s a hugely contentious question when it comes to charging for supplying articles to our staff.

Charging

Libraries that charge do so for a number of reasons

  • Customers are more selective about the items they order.
  • Controls the costs of ILLs and provides some income generation
  • Easier to manage workload as the flow of requests are generally more manageable.
  • Less wastage – customers are more likely to collect items they have paid for

But then there are some major disadvantages

  • It may discourage customers from ordering items
  • Creates extra administration for the library (and possibly for other departments if re-charging is involved)
  • Handling cash creates additional problems for libraries – till issues, audit, cashing-up etc
  • Charging in advance sometimes creates a delay if the customer does not have the money on them
  • Pay on collection may mean they do not collect, so the library has incurred a cost but is not able to recoup any of this cost
  • Payment on collection may delay them receiving the item as they have to make a trip to the library to pick-up

Not charging

Libraries that don’t charge have equally good reasons for doing so….

  • Fewer barriers for the customer so it is much more convenient for the customer (and the library)
  • Reduces “monetary conflict” with the customer (no chasing for payment)
  • Reduced delays for payment etc

Again there is a downside

  • Sometimes customers do not give careful consideration to what they order
  • libraries may be presented with reading lists or search lists and asked to get everything they can
  • More items ordered – creates additional workload for the library
  • Little control over costs for the library

Charging after a bit.

Some libraries give a free allocation of articles requested then charge once the limit is reached… One could argue that this gives the benefits of both systems (but maybe also the disadvantages) and there is the extra admin required to keep track of everyone’s tally for the year.

Talk to any library manager and they will argue that their way is the right way to do it. It may not be perfect, their approach may have its disadvantages but it will be appropriate for the circumstances in which their library must operate……

…….but what about the customer

What if we had no charging, no limits and a simple web based form. The customer completes the online form with their NHS email address and a few days later an article (provided by a NHS library) appears in their inbox. Sounds great – the customer has got the article with minimal delay, at no cost to them and without bothering their local NHS library.

This creates a problem for libraries. The local NHS libraries that drive this system are hidden from view. As far as the customer is concerned they don’t need their local library for document supply as the national web based system can meet most of their requirements.   To increase the NHS Library’s visibility in this process you could send the article via their local NHS library but is it worth creating an extra step/delay for the customer just to make a point?

Somehow a national document supply system/scheme will have to take this “sea of troubles” into account…..

K4H’s guiding principles and values (p.17) challenges us to think differently- to work together to deliver a coordinated, streamlined national library service to our users. How will we do this?

We want to understand your views so that we can take them into consideration as we move towards our recommendations for streamlining document supply.

Please send your comments to sue.robertson@thamesvalley.hee.nhs.uk