This article was downloaded by: [McMaster University]

On: 24 October 2014, At: 09:24

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer
House, 37-41 Mortimer Street, London W1T 3JH, UK

Public Money & Management

Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/rpmm20

New Development: Using Lean Techniques to Reduce

Radiology Waiting Times
a b
Amy Lodge & David Bamford
a
Service improvement manager in the NHS
b
Lecturer in operations management , Manchester Business School
Published online: 15 Mar 2010.

To cite this article: Amy Lodge & David Bamford (2008) New Development: Using Lean Techniques to Reduce Radiology
Waiting Times, Public Money & Management, 28:1, 49-52

To link to this article: http://dx.doi.org/10.1111/j.1467-9302.2008.00618.x

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained
in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no
representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of
the Content. Any opinions and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied
upon and should be independently verified with primary sources of information. Taylor and Francis shall
not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other
liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or
arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any
form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://
www.tandfonline.com/page/terms-and-conditions

New Development: Using Lean
Techniques to Reduce Radiology
Waiting Times
Amy Lodge and David Bamford
This article reports on how systems were enhanced through the application of
Lean principles within a hospital division of diagnostics and clinical support.
Patients were diagnosed faster, treatment started earlier and departmental
managers were better able to manage capacity to meet demand.
This article outlines a Lean approach to patient
Downloaded by [McMaster University] at 09:24 24 October 2014
waiting list management in a UK National
Health Service (NHS) hospital trust. Pennine
Acute Hospitals NHS trust (hereafter described
as the ‘hospital trust‘) was established following
the merger of five acute hospitals in April 2002
in north west England. It serves a population of
nearly one million people. The division of
diagnostics and clinical support (the ‘division’)
at the trust provides a range of services across
five acute sites including: radiology, pathology,
physiotherapy, critical care, anaesthetics and
dietetics in an inpatient, outpatient and some
community settings. The division has over 2,000
staff, including over 150 medical consultants.
Lean had not been implemented previously.
An action research methodology was
adopted. French and Bell (1990) defined action
research as the process of collecting research
data about an ongoing system relative to some
objective or need of that system; feeding these
data back into the system; taking action by
altering selected variables based on the data;
evaluating the results. Its distinguishing feature
is that it integrates something of real, practical
worth into an organization (Moore, 1983). A
weakness of the adopted research methodology
is its very public nature: if the project does not
produce tangible real-time results, those
supporting it may lose interest and bias any
future initiatives. Another limitation is the single
case approach, however Remenyi et al. (1998)
argue this can be enough to add to the body of
knowledge, if it is comprehensive enough with
a longitudinal dimension. Direct intervention
(over 24 months), informal interviews (with 48
staff in various roles), participant observation
and company documentation were all used.
Findings
The NHS Improvement Plan (Department of
Health, 2004) requires that by 2008 the
© 2008 THE AUTHORS
JOURNAL COMPILATION © 2008 CIPFA
49
maximum wait from a general practitioner Amy Lodge is a
referring a patient, to that patient commencing service improvement
definitive treatment should be 18 weeks. Early manager in the NHS
estimates in the division indicated that in order and has recently
to meet this 18-week target, access to services completed a master's
must be in a zero- to four-week window. degree investigating
the application of
Before Lean operations
In the radiology services (a subset of the division) management
all management information and waiting lists principles to
were manually produced and a wait of 26 healthcare.
weeks was considered normal in November
2005. To improve this situation, the division David Bamford is a
needed to redefine the services they were lecturer in operations
delivering in relation to customer (patients, management at
staff and other stakeholders) needs. To do this Manchester Business
one of the authors (as service improvement School.
manager) proposed using Lean tools and
techniques. Working groups, comprising a
cross-section of professional disciplines and
grades, were set up with membership from
across the department, division and the wider
organization to understand the current
performance of radiology services. The views
of service users (patients and referrers) were
sought, along with those of staff working in the
departments in order to generate a picture of
the current service provision from which to
model the required changes.
Proposed Changes
The working groups wanted to provide an
intranet-based waiting list for radiology services.
Three different radiology information systems
were in use to record radiology reports and
images. None of these was able to generate
meaningful waiting list or waiting time
information. It was established that an extract
of raw data at a patient level could be collected
and collated, however clerical and clinical staff
would need to start using each of the software
packages in a different way. The division
PUBLIC MONEY & MANAGEMENT FEBRUARY 2008
 50
compiled an outline of what the radiology staff
would need to do to generate a waiting list from
their software packages. Once extracted, this
data would eventually feed an intranet-based
waiting list module from which waiting lists
could be managed centrally.
Implementation
Providing information via the intranet was a
first step to improving the process. Users of the
system were encouraged to comment on the
first screenshot and suggest improvements,
increasing their ownership of the potential
solution. Multiple referral and booking systems
were mapped and adapted to reduce error
rates, reduce failure demand and streamline
processes from the end user’s perspective (the
end user being the patient).
Downloaded by [McMaster University] at 09:24 24 October 2014
The application of Lean techniques across
the referral and booking processes in radiology
resulted in changes being made that were felt
at all steps in the process from referral to
examination to report. Each of the four
departmental clerical teams was introduced to
the vision for the service (to provide an intranet-
based waiting list module for radiology services
which would improve attendance rates through
enabling instant waiting list management). The
benefits of this for them was outlined
emphasizing:
•Increased control.
•Better understanding of capacity
requirements.
•Easy access to patient information to answer
queries.
While implementation of the data changes was
resisted (‘why can’t we do it the way we always
have?’), once the waiting list was produced
from a centrally-generated database the
advantages were openly recognized (‘how did
Table 1. Comparative waiting times and volumes September 2006 to February 2007.
List List
volume volume
Sep 2006 Feb 2007
Magnetic resonance
imaging (MRI) 953 903
Computed
tomography (CT) 846 1136
Non-obstetric
ultrasound (NOUS) 2254 3205
PUBLIC MONEY & MANAGEMENT FEBRUARY 2008
we do the job without this?’).
In addition, the departmental teams were
retrained in the Key Principles of Waiting List
Management set out by the NHS Institute for
Innovation and Improvement (2006) and basic
standard operating procedures were developed
for all processes. The new system allowed the a
patient’s status and position on the list to be
easily understood, so when clerical staff saw
that a patient would be waiting longer than
agreed for their appointment they had
mechanisms to expedite appointments and
could take ownership of that part of the patient’s
journey.
Culturally, in the NHS the overriding ethic
of staff members is to provide the best possible
treatment for the patient. By being able to
prove that patients were seen quicker ‘sold’ the
change and therefore encouraged
sustainability. Support from the executive level
bubbled to the surface as national targets for
radiology loomed large—solutions were needed
to assist in the reduction of waiting lists, this
system could achieve them. The executive team
were kept informed through the high-level
data produced by the intranet-based waiting
list.
Results
All radiology departments began using the
intranet-based waiting list module in September
2006 and since then it has contributed to a
significant reduction in waiting times across
the different imaging modalities. The longest
waiting time has decreased by over 30% in all
areas and this is due to more efficient waiting
list management (see table 1).
The final version of the Diagnostic Services
Patient Target List (DPTL) was made available
from the hospital trust intranet. This
contributed to a reduction in waiting times as
patients were given a choice of appointment—
Longest Modal Longest Modal
wait wait wait wait
Sep 2006 Sep 2006 Feb 2007 Feb 2007
18 13 12 8
20 14 13 7
20 13 13 8
© 2008 THE AUTHORS
JOURNAL COMPILATION © 2008 CIPFA

they are more likely to attend as the
appointment is ‘negotiated’ with them (NHS
Institute for Innovation and Improvement,
2006). The DPTL can be viewed by referrers to
the services, reducing the need to contact
departments directly. However, waiting times
did not drop immediately—some departments
were able to operate the new system better than
others. This was evidenced in a rapid reduction
in the waiting list ‘tail’ (the low volume drag at
the back of each list which often signals poor
management or booking systems) at the more
‘advanced’ sites. The more successful
departments were used to provide support for
those who were failing to grasp the changes.
Total impact of the DPTL was felt across the
hospital trust from the beginning of February
2007 when all departments were using it
Downloaded by [McMaster University] at 09:24 24 October 2014
appropriately.
Conclusions
There was resistance to using Lean techniques
in this case study NHS trust, but it was overcome.
We have three main lessons from this work for
applying Lean in the public sector:
Belief in the Vision
The working group was told by senior members
of the information technology division that
they were trying to achieve the impossible. The
working group believed from their scoping
exercise that it could and would be of benefit to
all stakeholders, as well as providing
management information for local and national
use. Through persistence, the work was
completed and the vision achieved. The
resistance to change felt and demonstrated
during the implementation and use of Lean
techniques was similar to that during other
periods of change (for example Bamford and
Forrester, 2003; Bamford and Daniels, 2005).
Resistance was displayed in many ways—
verbally, silence, denial, defacing of reports,
refusal to consider the new ways of working.
Convincing staff that change is for the benefit
of the patients is vital to achieving a successful
change programme. Greenhalgh (2004, p. 165)
states ‘when programme champions play an
active role in the development, spread and
implementation of innovation, these processes
are generally more effective’.
Consistency in the Message
It is vital that staff at all levels are given the same
message. In this case they needed to understand
why waiting lists had to ne more effectively
managed. It was explained this would benefit
staff as well as patients: as waits reduce then
© 2008 THE AUTHORS
JOURNAL COMPILATION © 2008 CIPFA
51
fewer patients and referrers are unhappy with
the service.
Providing Hands’-On Training
The training was delivered by the working
group to key members of each department
who then trained a group of their peers.
Training was backed up by a manual which
provided a practical guide to improvement
tools; Lean was not explicitly ‘advertised’. The
guide provided details of a collection of so-
called ‘older’ tools and techniques (Pareto
analysis, tally charts, cause and effect diagrams,
flowcharting, brainstorming, graph analysis,
control charts etc.). These actions were essential
for knowledge transfer and the embedding of
key skills.
The division plans to utilize the DPTL
across all services to ensure that waiting lists are
being efficiently, effectively and fairly managed.
Work is currently underway in the therapy
services, where only paper records exist. A
referrals management system has been
developed into which all patient information is
entered from referral to first appointment to
last follow-up. This can be reported via the
DPTL and not only provides waiting times
information, but activity and detailed pathway
analysis, for example how many physiotherapy
follow-ups are required following a hip
replacement. The potential has been recognized
and this work has been prioritized by the
hospital trust’s executive board. As a result of
this work, patients are diagnosed faster,
treatment commences earlier and departmental
managers can effectively manage capacity to
meet demand because they now understand
the waiting ‘profile’.
What Should be Done Differently Next
Time?
Next time round we will:
•Involve shop floor staff throughout—
performance targets were discussed at all
levels of the division, but our direct
experience suggests that, until a requirement
exists for team members to change their
practices, the implications of that target will
not be fully understood (Bamford and Lodge,
2006).
•Publicise achievements locally—the DPTL has
been in use since September 2006 but did
not build momentum until the April 2007
target of all patients to be seen in 18 weeks
loomed large (for January 2008). The need
for change is not recognized until it is almost
too late. More publicity at a local level in the
PUBLIC MONEY & MANAGEMENT FEBRUARY 2008
 52

form of posters and presentations might improvement techniques, such as ‘Lean’,

have improved this, but again would staff
have taken this on board before it affected
them?
•Time for reflection during and after each
phase—it was recognized by the working
group that reflection throughout the
diagnostic, development and action phases
might have resolved some of the problems
encountered before they happened (usability
of the intranet front-end, ability of users to
adapt data entry methods, lack of support
from departmental managers). After the
completion of the next phase of the roll-out,
a reflection exercise has been planned which
will feed into further development and
planning. There is evidence that the lack of
operational management capabilities in
Downloaded by [McMaster University] at 09:24 24 October 2014
focus efforts and tangibly improve
performance. ■
References
Bamford, D. R. and Daniels, S. (2005), A case
study of change management effectiveness in
the NHS. Journal of Change Management, 5, 4,
pp. 391–406.
Bamford, D. R. and Forrester, P. L. (2003),
Managing planned and emergent change in
an operations environment. International
Journal of Operations and Production Management,
23, 5, pp. 546–564.
Bamford, D. and Lodge, A. (2006), Quality
improvement and quality service delivery in
radiology. In Proceedings of 11th European Forum

front-line departmental managers (BMA) on Quality Improvement in Health Care

contributes to the difficulties faced when
trying to achieve targets. There is a reluctance
in the public sector for ‘thinking time’ to be
acknowledged as a prerequisite for successful
management—if a person is caught thinking
then they are immediately assumed to be
idle.
The potential of the DPTL has been recognized
and this work has been prioritized by the
hospital trust executive board. Waiting times
across services are now less than 13 weeks
(from 26 in November 2005) and there is a
single waiting list across four hospital sites.
Furthermore, the rate of patients not attending
has decreased from 8% to 4% (4,032 more
appointments now attended first time) and the
average inpatient wait for scanning services
has decreased from five days to three days,
freeing up 18,000 bed days per year. This work
clearly demonstrates the application of
(Prague).
Department of Health (2004), NHS Improvement
Plan: Putting People at the Heart of Public Services
(HMSO, London).
French, W. and Bell, C. Jr. (1990) Organization
Development (Prentice-Hall, Englewood
Cliffs).
Greenhalgh, T. (April 2004), How to Spread Good
Ideas. A Systematic Review of the Literature on
Diffusion, Dissemination and Sustainability of
Innovations in Health Service Delivery and
Organization (National Co-ordinating Centre
for NHS Service Delivery and Organization).
Moore, N. (1983), How to do Research (Library
Association Publishing, London).
NHS Institute for Innovation and Improvement
(2006), No Delays Achiever: Service Improvement
Tools (Coventry).
Remenyi, D., Williams, B., Money, A. and
Swartz, E. (1998), Doing Research in Business
and Management (Sage Publications, London).

Universities and Public Management

The Pubic Management and Policy Association (PMPA), the National School of
Government and the Public Administration Committee are planning a joint workshop
in September 2008 on the skills and capacity required by today’s public managers and
how universities can contribute to developing these. The plan is to seek the views of public
managers, their employers, current and recent students of public administration, and
the university public administration community on this question in order to feed into the
workshop preparation.

If you’d like to be involved in this event, contact Janet Grauberg on janet.grauberg@cipfa.org

© 2008 THE AUTHORS

PUBLIC MONEY & MANAGEMENT FEBRUARY 2008 JOURNAL COMPILATION © 2008 CIPFA