The Health Improvement team, housed within the Public Health Department of National
Health Service (NHS) Highland, deliver key objectives around health improvement, tackling
health inequalities and building capacity. The processes surrounding the delivery
of the building capacity objective had been built up over a period of time and historically
were administered by different staff members. This led to different ways of organising
training and no overall agreed approach.
The impact of a non-standard approach meant that it was often difficult to get an
overview of what was being delivered and who was attending the various training offered.
Furthermore, there were duplicate processes in place that were person dependent that
could be done in a more effective way. Our overall aim for the project was to introduce
a standard approach to how training was organised and a way of ensuring that data
could be collected and reviewed instantly so that we could report out on a monthly
We began by applying a tool called process mapping,2 which sets out the steps that
take place within any specific function. The particular function that we looked at
was organising and booking the health improvement motivation interviewing training.
Once the map was completed, it is then interrogated in order to understand why some
of the steps were required and whether there is any duplication (non-value-added waste).
See figure 1.
Current state administrative training processes. BHC, behaviour change; MI, motivational
interviewing; NHSH, National Health Service Highland.
Following on from this, we mapped out what a desired process or future state might
look like and developed standard work.3 We tested out the standard work with two members
of staff initially and amended accordingly before applying it further. See figure
Future state training administration—flowchart. HPD, Health Promotion Department.
We also tested out using a PDSA (Plan, Do, Study, Act) cycle the introduction of a
standard evaluation tool in order to compare results across different training courses
By carrying out observations, it was apparent that staff were recording information
in different ways which resulted in duplication of work. To improve the process, we
developed a database which set out agreed steps for all administration staff about
how a course should be managed. The database records all the information in one place
and enables instant reporting of numbers of attendees, role and location of courses.
The success of the training programme is underpinned by access to and use of training
resources. Observations showed that staff had developed their own resources, and these
were often housed in different places making it difficult to locate the desired items.
Furthermore, this led to poor stock control. We used a lean tool called 5S,4 which
consists of five different stages in ensuring resources are effectively managed. The
five steps consist of sort, simplify, sweep, standardise and self-discipline. The
photographs below illustrate an example of how the resources were managed before we
began the process and the results after we applied 5S. See figures 3 and 4.
Before the 5S process was applied.
After the 5S process was applied.
Stock control was improved for three standard training packs by introducing a kanban
inventory control system of cards that outlined the information needed when re-ordering
items. This has resulted in timely restocking and less waste as we now only order
We collected measurements (table 1) before we applied the lean tools that demonstrated
it took between 4 and 5 days to find the information and then produce a training activity
report. With the new capacity of the database, a report can be generated in minutes.
We estimated that we were able to reduce the length of time taken in organising a
course from 2 hours to 1 hour. This allowed the team to reallocate the time saved
in administration to other health improvement programmes. The staff delivering training
and staff involved in the administration were often being asked to organise training
at the last minute resulting in additional pressure. By introducing a standard operating
procedure (SOP), which included the minimum notice required for staff, this was breached
on one occasion only within the test period.
Metrics training programme
Intermediate lean training Improvement project measurement
Title: Applying Improvement Methodology within a Public Health Context
Date of reporting: 26 May 2017
Report by: team leaders
Change against baseline
Length of time to collate training data
98.3% reduction (4 days)
Generate report for Motivational Interviewing course
Training requests sent to administration 10 weeks in advance of training taking place
50%–60% of courses requested less than 10 weeks’ notice
90% compliance within first month of testing
90% compliance within first month of testing
Reduction in length of time taken in organising training
2 hours administration time per course
1 hour 30 min
PDSA, Plan, Do, Study, Act.
Other metrics, showing an improvement, included training requests being 10 weeks in
advance of the start date and a reduction in length of time spent in organising the
training. The 5S audit was also included in the metric sheet.
Lean is about identifying value-added activity and non value activity in systems and
ensuring that in eliminating the waste, we can operate in a much more efficient manner.
The application of lean within a Public Health context was less well known; however,
this project demonstrates that lean can be as easily applied to processes within public
health as to a clinical setting. Furthermore, given the pressures on NHS budgets it
is vital that Health Improvement programmes are run as efficiently as possible. We
estimated that by introducing these improvement tools, we saved 25% of each hour spent
on the training administration at a cost of £9.38 per hour (Agenda for Change), which
was then reallocated to support other work. The introduction of a SOP is key to sustaining
this work. The next steps are to apply our learning in larger-scale pieces of health