Professor David Keegan:

Lean principles are a methodology devised by the Toyota corporation to eliminate waste from doing things for production. Over the past few decades, this methodology has been applied successfully in healthcare settings. For example, Michael Dowling, a Limerick man who runs the largest hospital group in the US - it is based in New York state and Long Island - adopted lean principles about ten or 12 years ago and reduced waste significantly and improved throughput and patient care. The hospitals in that group are down to a ten-minute wait for patients when they are in the actual setting and an on-demand service. You cannot directly compare with the US because it is a different healthcare system. I am just talking about adoptees of this. A colleague of mine in Milwaukee invited me to visit his laboratory. He is an adaptive optics expert. He knew I was interested in lean principles and introduced me to the head of the service there, who is a sceptic. They had been adopting this across a few units in the US and he reluctantly came to the party to institute lean management. He was totally converted and wrote a book. We have given that book, Synchronicity, out to the team. It is about eliminating waste. It improves the patients' outcome, they get in to see you quicker, they are not waiting there as long, they get out on time, the doctors and the staff get out on time, and that is something we are looking at doing.

There is a great deal of science and methodology behind this. That is what we are being coached on. We bring everybody with us. It is a collaborative effort. The nurses, doctors, administrators, porters, staff nurses and ward attendants come into a room and we go through our current state asking "How are we doing things" and we all agree we are here today because we are not doing things well or well enough. Then with some free thinking and some tools we identify what the ideal would be and ask ourselves what would be the best way to run our service in an ideal world. We have integrated healthcare, on-demand care and people waiting two weeks for cataract operations. That is the ideal state. In between, there is a future state that is attainable. We write up these what are called ideal principles.

I do not wish to sound too evangelical about it, but we write all these down. In that process, the team asks "What are we in control of?" We say there are 26 things that would be our route to an ideal state. Then we grab control of it because they say "What can we do now as a group?" When it comes to patients having a nicer experience when they come it, we state that we can do that now and that it is up to ourselves. So we tick that box. When it comes to integrated IT system that runs throughout the country, we will say that we cannot do anything about that because it is in the hands of others and that we have to lobby in respect of it. The box in that regard will remain empty. We go through everything in that way. It is remarkable how much of it is actually in our own hands. It is empowering for the teams, and they get on and start doing it. We have been through 11 of those events. People give up their time, rearrange their lives and come in to participate in them.

I came into this at a very basic level, having just read a book on lean principles. With the guidance we get from the experts or the transformation office in NERIECS, and with external facilitation, we are now at a wholly different level in our thinking. It is about empowering people. We talk as a group about our thinking and we bring that into other aspects of what we do. The core principle is to eliminate waste, go again, eliminate more waste and go again. That is patient-focused, and it never stops. That is the goal.

There have been a few breakthroughs. I refer to the purpose pyramid developed by the Royal National Lifeboat Institution, RNLI. In very simple terms, the purpose of the RNLI is to save lives at sea. It does so by having highly-trained staff available at short notice. Underpinning that is the funding and training to support it. In our case, the purpose is to reduce the burden of vision impairment and blindness and improve measures to supportive measures. It is supported. Our goal is not to reduce waiting lists. I will be absolutely honest. Our goal is not to have the right patient in the right place first time. That is not our primary goal; it is our secondary goal, because doing that helps us helps us to attain our primary goal of the reduction of avoidable preventable blindness.