Identifying waste in acute care

University College Hospitals Foundation Trust was in its second year of a service transformation programme involving staff and patients in 2011 when the programme management team launched research into the key areas of work to address in future.

Staff and patient engagement is a key part of developing services within any organisation and the object of this research was to find out what was perceived to be general areas of waste across the organisation.  

Views were gathered using focus groups that debated a set of questions based on the Toyota Production System’s (TPS) eight areas of waste (see table). Patients and staff were asked for examples on each area of waste.

Figure One: Frequency of each type of waste discussed (numbers of time mentioned)

From January to June 2012, five focus groups were undertaken. Three were with staff; the participants were 30 members of nursing staff and seven members of therapy staff. Two focus groups were undertaken with a total of 16 patients. 

The results summarised the most common areas of waste highlighted by members of the groups. The eight areas are tabled in figure one (above) together with the number of times these were mentioned as causes of waste by staff and patients within the five focus groups.

Patients cited numerous letters for different appointments, letters received late and time spent chasing letters as areas of waste

Patient results

Patients described 27 examples of defects, the largest number of these related to poor communication between teams and across healthcare providers.

They also highlighted four themes for overproduction. The first of these related to where tests where undertaken and patients questioned whether repeated tests were required.

The highest area for overproduction related to patient letters. Patients cited receiving numerous letters for different appointments, letters received late and time spent chasing letters as areas of waste. There were also examples of medication being prescribed for lengthier periods of time than was required, and of food that was not eaten.

Figure Two - Patient examples of waste

Waiting and motion were two categories frequently cited by patients for waste. They highlighted two areas of waiting: the first of these was waiting for medication and the second was the amount of time waiting upon arrival at the clinic to be seen.

There were two types of waste outlined in the category of motion and these related to moving a patient around the hospital and waiting for transport. The final area of waste highlighted by patients came under the category of using human potential, and two examples were cited.  

The first was that patients called for greater use of patients as experts in their care and ensuring there was greater use of different methods for gathering feedback. The second area related to staff spending a greater amount of time listening to patients, using patient knowledge, increasing a patient’s responsibility for their own care, and improving overall levels of communication.

Motion was highlighted as an area of waste. Examples included; interruptions while in motion, time wasted looking for items and time spent moving between clinical areas

Staff results

Staff identified waste in each of the eight areas outlined by the TPS. There were four areas of waste cited more than 20 times within the staff focus groups. The most common area was within the waiting category. Examples of waste include waiting for texts, medication, and delays caused by poor communication.

There were also areas of process waits where decisions had been changed and communication had not reached all people across teams. 

The next highest area related to inventory. Staff cited problems with the regular replenishing and ordering of stock, a difficult e-procurement system and equipment going missing after being borrowed. Staff also mentioned difficulties in contacting people via the telephone. 

Motion was also highlighted as an area of waste. Examples included interruptions while in motion, time wasted looking for items and time spent moving between clinical areas.

Examples in areas of over production included undertaking blood tests where it may not be entirely necessary and the lack of standardised processes. Examples of overprocessing all related to the duplication of documentation. 

Other areas of waste related to patients being assessed by different members of staff and the assessments being similar. Examples of defects related to communication and lack of multidisciplinary working.  

The final area of waste that scored highly was human potential that included improving multidisciplinary working, working across departments and listening to all staff groups equally. 

Many of the examples given here will not be new to those of us treated by health services or to those of us who work in the NHS, but they do help identify the areas where there is scope for significant improvement.

Lisa Hollins is deputy chief operating officer at Barts Health Trust and former acting director at University College Hospital Foundation Trust.