Tag Archives: Streamlining

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

Digital knowledge resources: rethinking NHS investment

Digital knowledge resources are high on the agenda. We know that NHS library services across England will recently have spent time finalising subscriptions for 2020. Those with April-March subscriptions will be gearing up for a similar round of activity in the Spring, involving publishers and local procurement and finance departments. Next there is all the associated work of updating holdings in catalogues and link resolvers to be done.

Elsewhere in the UK healthcare library staff now spend very little time on activity relating to e-resources. In Scotland, Wales and Ireland, the vast majority of NHS-funded digital knowledge resources are purchased and managed centrally, freeing up time for local library staff to focus their expertise on delivering knowledge services to users.

In England only 25% of total NHS spend on e-resources is invested nationally, and all the work associated with 75% of investment has to take place locally. Given the commonality of the resources we see being purchased locally for acute, mental health and community staff, and in the context of the principles of Knowledge for Healthcare principles relating to equity, efficiency and economy of scale, these proportions should surely be the other way around.

Open access publishing is advancing. The transition from payment for access to payment for publication is gathering pace. In our knowledge-based industry embracing the administration involved in article processing fees hardly seems a good use of the time and expertise of already-stretched NHS library staff. A nationally coordinated approach makes even more sense.

With the majority of HEE library funding distributed to trusts within education tariff, we can currently only take small steps towards this. We continue to engage with suppliers about the need for fair and transparent pricing which incentivises collaborative procurement, uses appropriate workforce numbers rather than bed numbers, recognise the value of content over platform-specific ‘bells and whistles’, and will support cost-neutral transition to open access, and some have responded very positively. HEE has commissioned NICE to procure a new Framework Agreement to replace the one which expires in September 2020 and we expect it to reflect all these principles.

We’re working hard to seek the introduction of a separate LKS Tariff which may provide a mechanism for pooling funded, but re-stacking public investment in digital collections will continue to rely on the willingness of library teams and host trusts to share costs and combine effort. The signs are promising: our 2018 survey of managers indicated that 86% would definitely or possibly be willing to pool e-resource funding nationally. We see lots of potential to scale up successful local collaborative procurement schemes. Greater central and national procurement will avoid replication of effort, freeing up staff time that local service managers can choose to direct resource into services to staff and learners, in the best interest of patients.

As we go into a new decade, the future lies in your hands. We are gearing up for the challenge of the new decade! Are we ready?

Season’s Greetings from the HEE Library Leads Resource Discovery Team
Helen Bingham, Richard Bridgen, Dominic Gilroy, Helene Gorring, Lucy Reid and Jenny Toller

Who are our change-makers?

Are you sitting comfortably? Well I will begin……

Once upon a time a company needed to change and offer an improved service to its users. The senior leadership team (SLT) called the managers into a series of meetings and a plan was drawn up and agreed. The senior leadership team sat back and waited for the change to happen. Every month they monitored what was going on but nothing had changed. The SLT called the managers back into another series of meetings and again the plan was agreed. The SLT waited and still no changes took place.

The SLT tried a different approach. It decided to look at the informal networks that were operating across the company and used the free open source software Gephi to create a visualization of the networks; to see who the key people were. To their surprise one of the key people at the centre of the network was the man from the post-room. He visited every office twice a day with the post. They dug a little deeper and saw that although they had engaged with the managers in their company, they hadn’t engaged with the other key influencers in their company; people like the man from the post-room. The key influencers were surprised to be called to a meeting to discuss the proposed changes as they did not recognise that they had a role to play and ideas to offer that would improve the service. However, they participated positively and the change that needed to take place, happened.

The same is true of our strategic framework Knowledge for Healthcare. We all have a role to play in suggesting ways that these changes can happen. I work in the South as a knowledge services development lead; David works in the North as a learning resource advisor. We work together on the streamlining task & finish group and he will now describe how he has contributed to change and why that is important for our group.

Library change–maker David

As a learning resource advisor I’ve dealt with document delivery for a long time, I understand the day-to-day workings of document supply and have identified areas that could potentially cause bottlenecks. Over the years, I have been able to make suggestions to my colleagues and managers for ways in which we can streamline the processes and improve the service offered to our users. Sometimes these changes have been instigated by my manager, sometimes by me and sometimes the changes have been due to external factors such as changes in copyright law or the introduction of the CLA Licence Plus.

Since I joined the Streamlining Task & Finish group my knowledge of how other libraries approach document supply has increased and my understanding of copyright has also increased with our ‘copyright first responder’ training. This has been invaluable for me and for the library team. But my first-hand knowledge of document supply has also informed the decisions and recommendations the streamlining group has made; helping guide the group understanding of the library assistant’s role and highlighting areas of change which may help in this role. One of which was easier access to copyright advice and information.

As a result of this ‘three-way conversation’ between the task& finish group, myself and my manager some major improvements have been made to the service we offer our users in the area of document supply.

The challenge to us all is to become “change –makers” and work together to influence and deliver Knowledge for healthcare in our library and knowledge services. Oh and as you ask, the story above is a true one.

Sue Robertson
Knowledge Services Development Lead, South
Health Education England
4150 Chancellor Court | Oxford Business Park South | Oxford | OX4 2GX
T. 07557 256204
E. sue.robertson@hee.nhs.uk
W. www.hee.nhs.uk

David Watson
Learning Resources Advisor
Rodney Cove-Smith Library
South Tees Institute of Learning, Research and Innovation
South Tees NHS Foundation Trust
The James Cook University Hospital
Marton Road
Middlesbrough
TS4 3BW
Tel: 01642 854820