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Parallel Session 3.2 Innovations in Acute Flow and Capacity Management

Patient flow refers to the movement of patients through the healthcare system. Slow patient flow can negatively impact quality of care and increase costs. When patient flow slows down, more patients are at risk of dying from delays in treatment or medical errors. It also increases costs due to longer lengths of stay, increased use of expensive hospital resources, and less efficient use of staff time. Improving patient flow requires considering the entire patient journey, separating elective and emergency care streams, eliminating unnecessary variability, and ensuring capacity matches demand.

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3.2 Innovations in Acute Flow and Capacity Management
Session Outline • Working definition • How we have prioritised flow • How we might want to think about flow in future • What are the issues – why raise our ambition? • Celebrating our existing work & what it tells us • Next Steps
Flow 1. a. To move or run smoothly with unbroken continuity, as in the manner characteristic of a fluid. 1. b. To issue in a stream; pour forth: Sap flowed from the gash in the tree. 2. To circulate, as the blood in the body. 3. To move with a continual shifting of the component particles: wheat flowing into the bin; traffic flowing through the tunnel.
Right treatment area Right time Right team Right care (as efficiently as possible and within available resources)
Flow = People
How we traditionally consider flow • Access targets and standards (point improvements) • Evolved from point improvements to pathway management (unscheduled care / 18 weeks RTT/ cancer/mental health) • Chunking up strategies and goals for the system (i.e. elective and unscheduled) • Focus on improving constraints (delayed discharge) • Strategies having competing impacts (patient boarding) • Insufficient emphasis on individual patient experience? • Insufficient recognition of workforce design on flow and of improvement and workforce relationship?
How we should consider flow? – Access/equity – safety issue – experience – efficiency – 20/20 Vision demands on acute services are such that optimising throughput is critical – Poor flow and inefficient use of capacity can drive up costs and may be compromising efficiency in all parts of the system
Efficiency & Productivity Framework SR10 Aim, Objectives & Scope “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets.” Key objectives: Acute Flow & Capacity work- • Quality is not compromised, stream formed to support NHS • NHSScotland will achieve financial Boards to improve/optimise flow balance over the SR10 period, and to challenge unwarranted • NHS Boards are supported in variation. achieving efficiency targets and improving services, and Productive Opportunity (based on • Central co-ordination of McKinsey DoH study and applied support, monitoring, benefits pro-rata up to £300m) realisation and challenge will be available to NHS Boards.
The Problems of Patient Flow – Why raise our game? Marilyn E Rudolph • Peaks and valleys • Resource utilisation • Internal diversion – boarding • Increases in medical errors • Delays in patient care • Boarders and ED diversion (non IP areas) • Left without being seen • Decreased throughput = increased costs? • Increased length of stay • Staff and patient satisfaction
Theory: The Quality Pyramid
How Complex?
Born this Way? People and Reform Reform agenda domains Medical Medical General Nurse Nurse clinicians managers managers managers clinicians Recognise interconnections Ambivalent Accept Strongly Accept Strongly between the clinical and accept reject Resource dimensions of care. Adopt a perspective that Reject Accept Strongly Accept Ambivalent balances autonomy with accept transparent accountability. Participate in processes that are Strongly reject Strongly Accept Accept Accept oriented to bring clinical work reject within the ambit of work process control. Accept the multidisciplinary Reject Ambivalent Accept Strongly Accept and hence team-based nature accept of clinical service provision. Peter Diegling
National Results & Examples of Flow Improvement across NHS Boards
Patient journeys within 18 weeks 50% 60% 70% 80% 90% 100% Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Month Sep-11 Oct-11 Elective Performance: Nov-11 Dec-11 Jan-12 Feb-12 % of Patient Journeys within 18 Weeks Mar-12
Median and 90th Percentile Waits for IP/DC Median (days) 90th percentile (days) 120 105 100 Wait (days) 80 63 60 35 40 25 20 0 Ju 8 Ju 9 Ju 0 Ju 1 2 M 8 M 9 M 0 M 1 N 8 N 9 N 0 N 1 -0 -0 -1 -1 -1 -0 -0 -1 -1 l-0 l-0 l-1 l-1 ar ar ar ar ar ov ov ov ov M Quarter ending
4 Hour Emergency Standard Compliance
Emergency Care Pathways
Elective/Unscheduled Admissions by Day of Week
Variation within our Control?
Smooth Elective Flows?
NHS Board Examples
NHS Tayside: Exploring Improvements for Effective Management of Capacity and Demand • Demand activity calculated for each medical specialty • Reason code tracker completed by each Specialty to ascertain reasons why capacity not achieved • Reason code tracker includes: Patients on EDISON / Patients due for discharge who are placed out with speciality ward for non clinical reasons / Awaiting script / Awaiting tests/investigations (state what) / No bed in receiving hospital • Improvement methodology applied to tailor improvements to each Specialty • Development of Capacity and Flow page on staff intranet which has daily activity info, RAG status for each directorate/CHP, access to escalation plan and action cards • Developing a 7 day acute physician delivered service model to ensure senior clinical decision making at the front door • Interactive whiteboards with real time information •
NHS Fife Waits 230/ 4,8,12 hrs Add. Capacity ~60 / Boarding 250 31 (52) A&E Slow Ad Unit Queue 7.7(6.4) 52 (62) pts/d Q Assess. 8.8(6) Home 49(49) Sp Beds ~46/d pts/d Improving Flow and Emergency Access Programme •Work streams = Front Door, Acute Admissions and Specialty Flow, Community Flow Q •Metrics and PDSA‟s in each work stream Q Community Assess. Assess. Beds/IRT ~20 •Front Door examples – • Flow 1 and 2 / 4 hours ~18 • Fast track triage (time to 1st assessment) • Junior check in with Cons (referral rate / clinical safety) • Specialty Review (time to specialty review) NH • Increased Consultant cover at peak times Beds (overall performance at 4 hours) 15/6/2012
NHS Greater Glasgow & Clyde Management of Inpatient Flow Glasgow Royal Infirmary – Creation of Emergency Receiving Complex – patients streamed directly to the following areas : • Minor Injury Unit • ED Majors and Resus • Medical Assessment Unit – GP referred medical patients go directly • Impact of the above has demonstrated a significant reduction in breachers and in particular breach reason “wait for bed”
NHS Greater Glasgow & Clyde NHS Board NHS GREATER GLASGOW & CLYDE Hospital GLASGOW ROYAL INFIRMARY Note: When choosing board to view, do not choose '(All)' as will double count. Select NHS Scotland as board if wanting to view Scotland level data. ED 4 Hour Breach Reasons by month: October 2010 - April 2012 800 700 Breach Reason 99 Not Known 600 98 Other reason 08 Major incident Monthly ED 4 hr Breaches 07 Clinical reason(s) 500 06 Wait for 1st assessment 05B Wait for diagnostics test(s) - awaiting results 05A Wait for diagnostics test(s) - to be performed 05 Wait for diagnostics test(s) 400 04B Wait for initial A&E treatment - to be completed 04A Wait for initial A&E treatment - to commence 04 Wait for initial A&E treatment 300 03C Wait for a specialist - Wait for Mental Health/Psychiatrist 03B Wait for a specialist - Wait for Medical Specialty 03A Wait for a specialist - Wait for Orthopaedics 03 Wait for a specialist 200 02 Wait for transport 01 Wait for bed 100 0 Source: ISD A&E2 datamart Management May-11 Mar-11 Mar-12 Nov-10 Nov-11 Oct-10 Feb-11 Feb-12 Dec-10 Jan-11 Apr-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Dec-11 Jan-12 Apr-12 information Reports covering October 2010 - April 2012. Data is for management information purposes only and subject to change. Month
NHS Greater Glasgow & Clyde Management of Inpatient Flow Use of Lean methodology • Three teams configured to work at Western Infirmary; Royal Alexandra Hospital; Victoria Infirmary to : – Improve discharge process with increased number of beds available before midday – Improve flow through ED/wards by addressing relationship issues between Medicine and DME
NHS Lothian • Implementation of Real Time Demand and Capacity Management (Resar, et al, 2011) • Estimate of 10-15% in day capacity gains through implementing this methodology • Project/Improvement Manager in place, estimate 6 months for implementation, further 6 for sustainability • Focus on „Discharge Huddles‟ and change in bed meeting process – accuracy of predictions – key issues to „unblock‟
What the World of Improvement Science says….
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Key principles: – System-wide not silos – Science-based, data-driven – Right structure before improving micro-processes – Compliance review and enforcement • Operations Management – Critical path – minimise delays – Queuing theory – mismatch between demand and resources – Simulation
Natural Variability Artificial Variability • Random • Non-random • Predictable • Non-predictable (driven • Can not be eliminated (or by unknown individual even reduced) priorities) • Must be optimally • Should not be managed managed, must be identified and eliminated
A. N. Other Hospital • Overcrowded • Safety? • Experience? • Waits/Boarding
The Natural Variation The Artificial Variation Hospital Hospital – Emergencies only – Electives only – Queuing theory to decide size – Smooth all admissions and and staffing discharges – Run at 80% capacity – Run at 95% capacity
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Artificial Variability – Inadvertence e.g. LoS in HDU awaiting bed – Provider scheduling – „dysfunctional scheduling of elective admissions‟ – Inappropriate management of flows emergency/elective predictions, complexity • Effects „Artificial variability cannot be predicted or managed but must be investigated and eliminated‟ – Compromised quality of care – Decreased patient satisfaction – Decreased staff satisfaction – Operational inefficiency/ high cost of care
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Variability Methodology Peaks in scheduled admissions is artificial variability caused by dysfunctional scheduling of elective admissions – Identify variability – Classify as natural or artificial – Statistical test for randomness – Quantify – as deviation from ideal expected pattern – Eliminate/ significantly decrease – Manage natural variability by stratifying patients
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Variability Methodology IHO – Eliminating variability where you can – Optimally managing it where you can‟t – Different types of variability in health care • Clinical variability – illness and response to treatment • Flow variability – when • Professional variability – time taken
Strategies for Managing Patient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak Phases • Separate flows • Smooth elective and queuing theory to emergencies • Once optimised estimate resource for system
20/20 A Balanced Flow Hospital • Flow = Quality • Separate Flows • Variation Smoothed • Real Time Queuing Theory • Whole System with Integrated Community Teams
Intelligent Flow • Making the flows/processes visible/separating them • Measurement & balancing measures • Patient experience & co-design • Complex adaptive thinking – the whole system • Counter-intuitive - most variation is in elective care and is a supply not a demand problem • Generating the evidence base that poor flow is a patient safety, efficiency and experience issue • Sustainable improvement will require a focus on quality, workforce and governance
NHS Scotland’s Focus on Flow Whole Hospital Acute Flow and Capacity Management
Key Improvement Messages • Separate scheduled and unscheduled patient flows • Eliminate / minimise artificial variability wherever possible • Assign separate resources for scheduled and unscheduled patients • Resources for unscheduled patients should be based on clinically driven maximum acceptable waiting times – match capacity to the profile of demand • Resources for scheduled patients should be based on maximising patient throughput and minimising unnecessary waiting • Only after separation and matching capacity to demand examine fixed resources
Next Steps - 2012 • Acute Flow & Capacity Management workstream progresses improvement projects and maintains close links to unscheduled care groups. Overarching improvement context • Acute Flow & Capacity Management Programme Board receives proposals to test/implement a whole systems approach to flow and capacity planning – August 2012 • HSCMB, QAB and Efficiency Portfolio Board invited to agree proposals
The Relationship between Flow, Quality and Cost
Thanks to
Question: • If Patient Flow slows down: – do more patients die? – does cost go up?
Agenda • Programme Structure • High level measures – What are we trying to improve? • Patient Flow – Emergency and Elective • The constraints • The policies that need changing • How to make changes happen
Structure for an Improvement Programme DH, SHA, Monitor, Health Commission etc. Board Board GP GP Flow Emergency Planned care Clinical subspecialties Medicine Intermediate care Surgery Community hospitals Paediatrics A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions Seattle Children‟s Hospital
Board Report Comments?
Weekly A&E performance & crude death rate April 2007 to Feb 2011 Dec 07 Dec 08 Dec 09 Dec 10 Foundation Weekly number Status Non elective deferred of A&E breaches death rate What happened In Sept 2009? Non elective deaths / non elective discharges inc deaths by Date of ADMISSION Comments?
Foundation What Status happened in deferred September 2009? Weekly Flow Cost Quality Ap 07 to Ap – Jan 11 A&E breaches & Non elective deaths / discharges by date of admission Palliative Infection control Care > %15-64 years excluded admissions Adult Non elective Rami (Rate Adjusted Mortality Index) (excl paeds, obs & midwifery) compared to average for peer group Open new wards Recruit Total Pay costs Agenda for change (elective and non elective) Comments?
What have we learned?
What the Warwick and Sheffield teams learned • Plot the dots! – weekly data – reviewed monthly: Board • Monthly 2 hour meeting: – Executives, senior clinicians and Dpt. heads from across the health & social care system • Study, Adjust, Plan, Do – When did the statistically significant changes happen? – Why? » What did WE change?
Understanding Flow DH, SHA, Monitor, Health Commission etc. Board Board Emergency GP GP Flow Planned care Clinical subspecialties Medicine Surgery Intermediate care Paediatrics Community hospitals A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
High Level Emergency System Map Death Hospital Community Ambulance Hospitals Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence
Emergency Demand Comment?
Emergency Admissions Comment?
Relationship between flow in, A&E performance and deaths and emergency admissions Comments?
Closure of Foundation Community Hospital Status deferred Sept 2009 Weekly Flow Cost Quality Ap 07 to Ap – Jan 11 A&E breaches & Non elective deaths / discharges by date of admission Palliative Infection control Care > %15-64 years excluded admissions Adult Non elective Rami (Rate Adjusted Mortality Index) (excl paeds, obs & midwifery) compared to average for peer group Open new wards Recruit Total Pay costs Agenda for change (elective and non elective)
High Level System Map Death Hospital Closed 40 Community beds Ambulance Hospitals Sept 2009 Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence Continuing Health Care funding process changed Oct 2009
Lesson for Boards: Poor A&E performance is due to poor flow OUT – Constraints are under our control
Lesson for Performance Management • Plot the dots! – Trend lines should be removed from Excel – Statistical Process Control • Reveals the voice of the process
What did we learn? • Plot the weekly emergency admissions by age group: • 0 to 15 • 16 to 64 Correlates with the high level patient flows • 65 to 79 • 80 and plus • Plot Patients-in-Progress (work-in-progress): – very sensitive to changes in demand x LOS: • A&E performance (breaches) • Midnight bed occupancy – See later
Emergency admissions 80 years + Confirms that poor flow is NOT due to increased admissions of patients > 80 years
High Level Emergency System Map Death Hospital Community Ambulance Hospitals Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence (0 to15) 16 to 64 65 to 79 80 and plus years Warwick Sheffield: GSM
GSM: How Many Bed Nights Do They Stay? Pareto of Bed Nights for Home to Home Patients 100% 90% 80% 70% 60% Cum Freq 50% 40% 30% 20% 10% 0% 0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120 126 132 138 144 150 156 164 175 189 205 263 Bed Nights
Day to day Admissions Discharge mismatch NEL Admission Discharge mismatch number of NEL patients admtted and dicharged 80 70 60 Total NEL admissions (NEL 50 40 + NEL other) 1. 30 Total NEL discharges (NEL 20 + NEL other) Reduce daily 10 0 variation in discharges 7 07 7 7 07 8 8 08 08 08 00 22 00 29 00 12 00 19 00 20 20 20 20 2 2 2 2 2 2/ 2/ 2/ 2/ 2/ 1/ 1/ 1/ 1/ /1 /1 /1 /1 /1 /0 /0 /0 /0 01 15 05 26 date Elective Admission Discharge mismatch Nubmer of elective patients admitted and discharged 80 70 60 50 40 EL admissions 2. Smooth 30 EL discharges 20 Variation in 10 0 PLANNED 01/12/2007 08/12/2007 15/12/2007 22/12/2007 29/12/2007 05/01/2008 12/01/2008 19/01/2008 26/01/2008 Elective Admissions date
In-day mismatch between Emergency admissions and Specialist capacity Time of Arrival into A&E Time of Departure out of A&E to Main Hospital 450 400 Patients admitted when capacity is not 350 300 250 200 150 available 100 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Assessment units are storage units to When is the Specialist Capacity available? hold the patients until the specialist capacity X junior is available the staff + following day Minimal Y Minimal capacity specialist capacity consultants? 00.00 06.00 12.00 18.00 23.59
Assessment Process at April 2009 Up to 24 4 hours. Up to 12 hours overnight hours post arrival at hospital Arrive History & Requests Perform tests Perform tests At Triage Nursing examination Test & Obs‟ & imaging & imaging A&E & initial imaging treatment Senior review Transfer to Assessment Unit Nursing History & Senior Review Obs examination Plan definitive treatment ? A&E Assessment Unit = value
What do we need to do instead? Pull patients forward into the working day: 450 Time of Arrival into A&E Time of Departure out of A&E to Main Hospital •Stop making them wait 3:59 minutes….. 400 •Stop duplication 350 300 250 200 150 100 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 The specialty capacity needs to be available: Right decisions On time 08:00 21:00 Every time Specialists available In full Seeing patients on wards Minimal Discharging patients capacity Admitting patients 00.00 06.00 12.00 18.00 23.59
„Future‟ Assessment Process (Now current as at April 2012) 2 hours Transfer to Appropriate History & Senior specialist Arrive Plan Requests specialist area Nursing examination Perform tests Review At for Test & including home Obs‟ & initial & imaging Plan definitive A&E diagnosis imaging with PT/OT /SS treatment treatment home assessment at home 1 hour Safe ambulatory care process now possible
Demand: numbers by day
All admissions from A&E by hour Mondays May to Oct 08 8 7 Reduce daily 6 variation in discharges 5 Max Admission Min 4 Avg Av + 1 SD Av +2 SD 3 2 1 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour of arrival What is the rate of production required?
Planning Capacity of the workforce Junior Doc Nurse X-ray Consultant doc Medical Emergencies Arrival Time 08:00 08:15 08:30 08:45 4 09:00 09:15 09:30 admissions 09:45 10:00 /hr. 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 All Emergencies Arrival Time 08:00 08:10 08:20 6 08:30 08:40 admissions 08:50 09:00 09:10 /hr. 09:20 09:30 09:40 09:50 10:00 10:10 10:20 10:30 10:40 10:50 11:00 11:10 11:20 11:30 11:40
Improving Flow (front end) • Pooled junior docs – A&E, MAU and specialty on call – Staggered start times on A&E/MAU = Increased availability from 08:00 to 10:00 • MAU consultants continuous flow • Speciality take every day: admissions • Heartbeat system for tracking patients • Wards – Consultant ward round every day: discharges
Functional departments DH, SHA, Monitor, Health Commission etc. Board Board GP GP Flow Emergency Planned care Clinical subspecialties Medicine Intermediate care Surgery Community hospitals Paediatrics A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
Do this hour‟s work this hour: • Emergency Blood turnaround: – Bottleneck for emergency samples = centrifuges Change: • Now a centrifuge starts every 3 minutes whether full or not • IP blood monitoring on wards – Bottleneck: Phlebotomists & transport to lab Change: • Porters running between phleb‟s and lab • Steady flow of samples into lab • all results back by 10:30 a.m. for ward rounds
1 year later • Warwick • Focus on: – A&E, – Assessment units and wards – Diagnostics – Ward rounds – TTOs
Foundation Close Status Community Dec 2010: flow improvements start deferred Hsp Sept 09 Increased % 16 to 64 years Flow doesn‟t recover from Sept 2009 bed + staff closures Infection control Palliative Care excluded Reduction in death rate Nobody addressed the CHC admin delays Acquire causing the Community long LOS services Open new wards Organisation Recruit Agenda for change change disrupted the Admin flow even more Comments?
1 Year later • Sheffield Geriatric and stroke medicine – Focus on reducing the admin constraints (policies) – Check List and CHC assessment process • 42 page document • 18 man hours of work • Min time (LOS) = 30 days+ – Home assessment at home on day of discharge • Referral to Social Services by physio to social services • SS package in place within 48 hours (Upper process limit) – Home of choice: • out to residential home, CHC afterwards
Home of choice Weekly Daily
Lessons for executive support services DH, SHA, Monitor, Health Commission etc.. Board Board Emergency GP GP Flow Planned care Clinical subspecialties Medicine Surgery Intermediate care Paediatrics Community hospitals A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
Lessons for executive support services • HR: – Systems thinking and improvement science for A4C 8 & above – Match staff capacity to patient demand: 7/7, 365 – Heads of functions = responsibility for end-to-end process Focus is on Flow, WIP incurred accountable to the Dpt. concerned. • IT – Information in real time – Time series data • Estates: – Reduce transport and motion – Co-location of process resources • Supplies – Just-in-time
Finance
Pareto analysis of the pay costs in one Trust for one month by employee. 50% of cost Role of senior managers is to improve process flow 20% of staff through the most expensive value adding staff =clinicians
Change the Finance Paradigm Economies of Scale Economies of Flow Capacity Nu,ber of Patients Patients/hr treated successfully Land lives „saved‟ Demand Patients /hr Activity £5 £2 x PbR £1 /hr /hr £1 income Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 /hr £2 £1 /hr /hr /hr Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 Department Cost Activity = waste = unit cost constraint So focus is on improving value delivered and income Drives Dpt manager to This depends on moving resources to support the constraint do more activity at less cost The constraint should be the most expensive resource Acquires „new business‟ in the process = in Dpt 2. But what happens to flow? How can we optimise productivity through the most expensive resource?
Finance • John Darlington‟s paper • http://www.leanuk.org/downloads/LS_2010/paper_lean_b usiness_case.pdf
How to make changes happen
Get Everyone on Board Patient‟s experience of waste Discussion History Full Endoscopy Discharge Nil by Rest & Check Cross with cardiac Examination blood & Transfuse With Plan mouth dehydrate FBC match centre Assessment Count Breath test 8 hours And Rx 4 hours for 20 5 minutes 40 mins Re stent 30 minutes 5 minutes 30 minutes 15 minutes hours 15 minutes Value adding 34 hours = 18% of time value adding Non Value adding 8 days x 24 hours 82% of time and resource wasted Poor quality experience and outcome From a Poor Quality System
The Doctors can lead the change….. • Very complex system: – Like a human body! • Understand – Anatomy – Physiology (flows) – Plot the dots: BP, temp, pulse, resp‟s …. – Diagnosis – Treatment (releave the constraints) – Look for changes in the pattern of variation (SPC)
Get the Managers on Board • Top Down Command and Control is impossible: – Not possible for one person to understand whole end- to-end process or System. • Facilitate Big Room Meetings – Get the everyone in a room – Listening to each other – Conversations based on facts: – Study, Adjust, Plan, Do, – Monthly and Weekly reviews
Big Room Process
Summary • Quality is a System property • Track patient flow (WIP), death rate and cost over time. – Increasing cost doesn‟t always improve flow – Reducing cost can have grave consequences • Improve processes to reduce delays and inventory (WIP) – Match staff capacity to patient demand – Do this hour‟s work this hour • Shift from: – Unit Costing: Dpt cost/activity – to Flow Accounting: throughput at constraint/total process cost – The constraints are policies or availability of staff, not beds.
What have we learned ? • Nuggets • Niggles • Nice-if • NoNos
Parallel Session 3.2 Innovations in Acute Flow and Capacity Management

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Parallel Session 3.2 Innovations in Acute Flow and Capacity Management

  • 1.
    3.2 Innovations inAcute Flow and Capacity Management
  • 2.
    Session Outline • Workingdefinition • How we have prioritised flow • How we might want to think about flow in future • What are the issues – why raise our ambition? • Celebrating our existing work & what it tells us • Next Steps
  • 3.
    Flow 1. a. Tomove or run smoothly with unbroken continuity, as in the manner characteristic of a fluid. 1. b. To issue in a stream; pour forth: Sap flowed from the gash in the tree. 2. To circulate, as the blood in the body. 3. To move with a continual shifting of the component particles: wheat flowing into the bin; traffic flowing through the tunnel.
  • 4.
    Right treatment area Right time Right team Right care (as efficiently as possible and within available resources)
  • 5.
  • 6.
    How we traditionallyconsider flow • Access targets and standards (point improvements) • Evolved from point improvements to pathway management (unscheduled care / 18 weeks RTT/ cancer/mental health) • Chunking up strategies and goals for the system (i.e. elective and unscheduled) • Focus on improving constraints (delayed discharge) • Strategies having competing impacts (patient boarding) • Insufficient emphasis on individual patient experience? • Insufficient recognition of workforce design on flow and of improvement and workforce relationship?
  • 7.
    How we shouldconsider flow? – Access/equity – safety issue – experience – efficiency – 20/20 Vision demands on acute services are such that optimising throughput is critical – Poor flow and inefficient use of capacity can drive up costs and may be compromising efficiency in all parts of the system
  • 8.
    Efficiency & ProductivityFramework SR10 Aim, Objectives & Scope “To improve the overall quality and efficiency of NHSScotland while ensuring good value for money and achieving financial targets.” Key objectives: Acute Flow & Capacity work- • Quality is not compromised, stream formed to support NHS • NHSScotland will achieve financial Boards to improve/optimise flow balance over the SR10 period, and to challenge unwarranted • NHS Boards are supported in variation. achieving efficiency targets and improving services, and Productive Opportunity (based on • Central co-ordination of McKinsey DoH study and applied support, monitoring, benefits pro-rata up to £300m) realisation and challenge will be available to NHS Boards.
  • 9.
    The Problems ofPatient Flow – Why raise our game? Marilyn E Rudolph • Peaks and valleys • Resource utilisation • Internal diversion – boarding • Increases in medical errors • Delays in patient care • Boarders and ED diversion (non IP areas) • Left without being seen • Decreased throughput = increased costs? • Increased length of stay • Staff and patient satisfaction
  • 10.
  • 11.
  • 12.
    Born this Way?People and Reform Reform agenda domains Medical Medical General Nurse Nurse clinicians managers managers managers clinicians Recognise interconnections Ambivalent Accept Strongly Accept Strongly between the clinical and accept reject Resource dimensions of care. Adopt a perspective that Reject Accept Strongly Accept Ambivalent balances autonomy with accept transparent accountability. Participate in processes that are Strongly reject Strongly Accept Accept Accept oriented to bring clinical work reject within the ambit of work process control. Accept the multidisciplinary Reject Ambivalent Accept Strongly Accept and hence team-based nature accept of clinical service provision. Peter Diegling
  • 13.
    National Results &Examples of Flow Improvement across NHS Boards
  • 14.
    Patient journeys within18 weeks 50% 60% 70% 80% 90% 100% Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Month Sep-11 Oct-11 Elective Performance: Nov-11 Dec-11 Jan-12 Feb-12 % of Patient Journeys within 18 Weeks Mar-12
  • 15.
    Median and 90thPercentile Waits for IP/DC Median (days) 90th percentile (days) 120 105 100 Wait (days) 80 63 60 35 40 25 20 0 Ju 8 Ju 9 Ju 0 Ju 1 2 M 8 M 9 M 0 M 1 N 8 N 9 N 0 N 1 -0 -0 -1 -1 -1 -0 -0 -1 -1 l-0 l-0 l-1 l-1 ar ar ar ar ar ov ov ov ov M Quarter ending
  • 16.
    4 Hour EmergencyStandard Compliance
  • 17.
  • 18.
  • 19.
  • 22.
  • 24.
  • 25.
    NHS Tayside: ExploringImprovements for Effective Management of Capacity and Demand • Demand activity calculated for each medical specialty • Reason code tracker completed by each Specialty to ascertain reasons why capacity not achieved • Reason code tracker includes: Patients on EDISON / Patients due for discharge who are placed out with speciality ward for non clinical reasons / Awaiting script / Awaiting tests/investigations (state what) / No bed in receiving hospital • Improvement methodology applied to tailor improvements to each Specialty • Development of Capacity and Flow page on staff intranet which has daily activity info, RAG status for each directorate/CHP, access to escalation plan and action cards • Developing a 7 day acute physician delivered service model to ensure senior clinical decision making at the front door • Interactive whiteboards with real time information •
  • 26.
    NHS Fife Waits 230/ 4,8,12 hrs Add. Capacity ~60 / Boarding 250 31 (52) A&E Slow Ad Unit Queue 7.7(6.4) 52 (62) pts/d Q Assess. 8.8(6) Home 49(49) Sp Beds ~46/d pts/d Improving Flow and Emergency Access Programme •Work streams = Front Door, Acute Admissions and Specialty Flow, Community Flow Q •Metrics and PDSA‟s in each work stream Q Community Assess. Assess. Beds/IRT ~20 •Front Door examples – • Flow 1 and 2 / 4 hours ~18 • Fast track triage (time to 1st assessment) • Junior check in with Cons (referral rate / clinical safety) • Specialty Review (time to specialty review) NH • Increased Consultant cover at peak times Beds (overall performance at 4 hours) 15/6/2012
  • 27.
    NHS Greater Glasgow& Clyde Management of Inpatient Flow Glasgow Royal Infirmary – Creation of Emergency Receiving Complex – patients streamed directly to the following areas : • Minor Injury Unit • ED Majors and Resus • Medical Assessment Unit – GP referred medical patients go directly • Impact of the above has demonstrated a significant reduction in breachers and in particular breach reason “wait for bed”
  • 28.
    NHS Greater Glasgow& Clyde NHS Board NHS GREATER GLASGOW & CLYDE Hospital GLASGOW ROYAL INFIRMARY Note: When choosing board to view, do not choose '(All)' as will double count. Select NHS Scotland as board if wanting to view Scotland level data. ED 4 Hour Breach Reasons by month: October 2010 - April 2012 800 700 Breach Reason 99 Not Known 600 98 Other reason 08 Major incident Monthly ED 4 hr Breaches 07 Clinical reason(s) 500 06 Wait for 1st assessment 05B Wait for diagnostics test(s) - awaiting results 05A Wait for diagnostics test(s) - to be performed 05 Wait for diagnostics test(s) 400 04B Wait for initial A&E treatment - to be completed 04A Wait for initial A&E treatment - to commence 04 Wait for initial A&E treatment 300 03C Wait for a specialist - Wait for Mental Health/Psychiatrist 03B Wait for a specialist - Wait for Medical Specialty 03A Wait for a specialist - Wait for Orthopaedics 03 Wait for a specialist 200 02 Wait for transport 01 Wait for bed 100 0 Source: ISD A&E2 datamart Management May-11 Mar-11 Mar-12 Nov-10 Nov-11 Oct-10 Feb-11 Feb-12 Dec-10 Jan-11 Apr-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Dec-11 Jan-12 Apr-12 information Reports covering October 2010 - April 2012. Data is for management information purposes only and subject to change. Month
  • 29.
    NHS Greater Glasgow& Clyde Management of Inpatient Flow Use of Lean methodology • Three teams configured to work at Western Infirmary; Royal Alexandra Hospital; Victoria Infirmary to : – Improve discharge process with increased number of beds available before midday – Improve flow through ED/wards by addressing relationship issues between Medicine and DME
  • 30.
    NHS Lothian • Implementationof Real Time Demand and Capacity Management (Resar, et al, 2011) • Estimate of 10-15% in day capacity gains through implementing this methodology • Project/Improvement Manager in place, estimate 6 months for implementation, further 6 for sustainability • Focus on „Discharge Huddles‟ and change in bed meeting process – accuracy of predictions – key issues to „unblock‟
  • 31.
    What the Worldof Improvement Science says….
  • 32.
    Strategies for ManagingPatient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Key principles: – System-wide not silos – Science-based, data-driven – Right structure before improving micro-processes – Compliance review and enforcement • Operations Management – Critical path – minimise delays – Queuing theory – mismatch between demand and resources – Simulation
  • 33.
    Natural Variability Artificial Variability • Random • Non-random • Predictable • Non-predictable (driven • Can not be eliminated (or by unknown individual even reduced) priorities) • Must be optimally • Should not be managed managed, must be identified and eliminated
  • 34.
    A. N. OtherHospital • Overcrowded • Safety? • Experience? • Waits/Boarding
  • 35.
    The Natural Variation The Artificial Variation Hospital Hospital – Emergencies only – Electives only – Queuing theory to decide size – Smooth all admissions and and staffing discharges – Run at 80% capacity – Run at 95% capacity
  • 36.
    Strategies for ManagingPatient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Artificial Variability – Inadvertence e.g. LoS in HDU awaiting bed – Provider scheduling – „dysfunctional scheduling of elective admissions‟ – Inappropriate management of flows emergency/elective predictions, complexity • Effects „Artificial variability cannot be predicted or managed but must be investigated and eliminated‟ – Compromised quality of care – Decreased patient satisfaction – Decreased staff satisfaction – Operational inefficiency/ high cost of care
  • 37.
    Strategies for ManagingPatient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Variability Methodology Peaks in scheduled admissions is artificial variability caused by dysfunctional scheduling of elective admissions – Identify variability – Classify as natural or artificial – Statistical test for randomness – Quantify – as deviation from ideal expected pattern – Eliminate/ significantly decrease – Manage natural variability by stratifying patients
  • 38.
    Strategies for ManagingPatient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak • Variability Methodology IHO – Eliminating variability where you can – Optimally managing it where you can‟t – Different types of variability in health care • Clinical variability – illness and response to treatment • Flow variability – when • Professional variability – time taken
  • 39.
    Strategies for ManagingPatient Flow S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak Phases • Separate flows • Smooth elective and queuing theory to emergencies • Once optimised estimate resource for system
  • 40.
    20/20 A BalancedFlow Hospital • Flow = Quality • Separate Flows • Variation Smoothed • Real Time Queuing Theory • Whole System with Integrated Community Teams
  • 41.
    Intelligent Flow • Makingthe flows/processes visible/separating them • Measurement & balancing measures • Patient experience & co-design • Complex adaptive thinking – the whole system • Counter-intuitive - most variation is in elective care and is a supply not a demand problem • Generating the evidence base that poor flow is a patient safety, efficiency and experience issue • Sustainable improvement will require a focus on quality, workforce and governance
  • 42.
    NHS Scotland’s Focuson Flow Whole Hospital Acute Flow and Capacity Management
  • 43.
    Key Improvement Messages •Separate scheduled and unscheduled patient flows • Eliminate / minimise artificial variability wherever possible • Assign separate resources for scheduled and unscheduled patients • Resources for unscheduled patients should be based on clinically driven maximum acceptable waiting times – match capacity to the profile of demand • Resources for scheduled patients should be based on maximising patient throughput and minimising unnecessary waiting • Only after separation and matching capacity to demand examine fixed resources
  • 44.
    Next Steps -2012 • Acute Flow & Capacity Management workstream progresses improvement projects and maintains close links to unscheduled care groups. Overarching improvement context • Acute Flow & Capacity Management Programme Board receives proposals to test/implement a whole systems approach to flow and capacity planning – August 2012 • HSCMB, QAB and Efficiency Portfolio Board invited to agree proposals
  • 45.
    The Relationship between Flow, Quality and Cost
  • 46.
  • 47.
    Question: • If PatientFlow slows down: – do more patients die? – does cost go up?
  • 48.
    Agenda • Programme Structure •High level measures – What are we trying to improve? • Patient Flow – Emergency and Elective • The constraints • The policies that need changing • How to make changes happen
  • 49.
    Structure for anImprovement Programme DH, SHA, Monitor, Health Commission etc. Board Board GP GP Flow Emergency Planned care Clinical subspecialties Medicine Intermediate care Surgery Community hospitals Paediatrics A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions Seattle Children‟s Hospital
  • 50.
    Board Report Comments?
  • 51.
    Weekly A&E performance& crude death rate April 2007 to Feb 2011 Dec 07 Dec 08 Dec 09 Dec 10 Foundation Weekly number Status Non elective deferred of A&E breaches death rate What happened In Sept 2009? Non elective deaths / non elective discharges inc deaths by Date of ADMISSION Comments?
  • 52.
    Foundation What Status happened in deferred September 2009? Weekly Flow Cost Quality Ap 07 to Ap – Jan 11 A&E breaches & Non elective deaths / discharges by date of admission Palliative Infection control Care > %15-64 years excluded admissions Adult Non elective Rami (Rate Adjusted Mortality Index) (excl paeds, obs & midwifery) compared to average for peer group Open new wards Recruit Total Pay costs Agenda for change (elective and non elective) Comments?
  • 53.
    What have welearned?
  • 54.
    What the Warwickand Sheffield teams learned • Plot the dots! – weekly data – reviewed monthly: Board • Monthly 2 hour meeting: – Executives, senior clinicians and Dpt. heads from across the health & social care system • Study, Adjust, Plan, Do – When did the statistically significant changes happen? – Why? » What did WE change?
  • 55.
    Understanding Flow DH, SHA, Monitor, Health Commission etc. Board Board Emergency GP GP Flow Planned care Clinical subspecialties Medicine Surgery Intermediate care Paediatrics Community hospitals A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
  • 56.
    High Level EmergencySystem Map Death Hospital Community Ambulance Hospitals Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence
  • 57.
  • 58.
  • 59.
    Relationship between flowin, A&E performance and deaths and emergency admissions Comments?
  • 60.
    Closure of Foundation Community Hospital Status deferred Sept 2009 Weekly Flow Cost Quality Ap 07 to Ap – Jan 11 A&E breaches & Non elective deaths / discharges by date of admission Palliative Infection control Care > %15-64 years excluded admissions Adult Non elective Rami (Rate Adjusted Mortality Index) (excl paeds, obs & midwifery) compared to average for peer group Open new wards Recruit Total Pay costs Agenda for change (elective and non elective)
  • 61.
    High Level SystemMap Death Hospital Closed 40 Community beds Ambulance Hospitals Sept 2009 Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence Continuing Health Care funding process changed Oct 2009
  • 62.
    Lesson for Boards: PoorA&E performance is due to poor flow OUT – Constraints are under our control
  • 63.
    Lesson for PerformanceManagement • Plot the dots! – Trend lines should be removed from Excel – Statistical Process Control • Reveals the voice of the process
  • 64.
    What did welearn? • Plot the weekly emergency admissions by age group: • 0 to 15 • 16 to 64 Correlates with the high level patient flows • 65 to 79 • 80 and plus • Plot Patients-in-Progress (work-in-progress): – very sensitive to changes in demand x LOS: • A&E performance (breaches) • Midnight bed occupancy – See later
  • 65.
    Emergency admissions 80years + Confirms that poor flow is NOT due to increased admissions of patients > 80 years
  • 66.
    High Level EmergencySystem Map Death Hospital Community Ambulance Hospitals Accident Assessment and Unit(s) Specialist Intermediate GP Emergency Ward Care (services delivered in the patient‟s home) Permanent place of residence (0 to15) 16 to 64 65 to 79 80 and plus years Warwick Sheffield: GSM
  • 67.
    GSM: How ManyBed Nights Do They Stay? Pareto of Bed Nights for Home to Home Patients 100% 90% 80% 70% 60% Cum Freq 50% 40% 30% 20% 10% 0% 0 6 12 18 24 30 36 42 48 54 60 66 72 78 84 90 96 102 108 114 120 126 132 138 144 150 156 164 175 189 205 263 Bed Nights
  • 68.
    Day to day Admissions Discharge mismatch NEL Admission Discharge mismatch number of NEL patients admtted and dicharged 80 70 60 Total NEL admissions (NEL 50 40 + NEL other) 1. 30 Total NEL discharges (NEL 20 + NEL other) Reduce daily 10 0 variation in discharges 7 07 7 7 07 8 8 08 08 08 00 22 00 29 00 12 00 19 00 20 20 20 20 2 2 2 2 2 2/ 2/ 2/ 2/ 2/ 1/ 1/ 1/ 1/ /1 /1 /1 /1 /1 /0 /0 /0 /0 01 15 05 26 date Elective Admission Discharge mismatch Nubmer of elective patients admitted and discharged 80 70 60 50 40 EL admissions 2. Smooth 30 EL discharges 20 Variation in 10 0 PLANNED 01/12/2007 08/12/2007 15/12/2007 22/12/2007 29/12/2007 05/01/2008 12/01/2008 19/01/2008 26/01/2008 Elective Admissions date
  • 69.
    In-day mismatch between Emergencyadmissions and Specialist capacity Time of Arrival into A&E Time of Departure out of A&E to Main Hospital 450 400 Patients admitted when capacity is not 350 300 250 200 150 available 100 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Assessment units are storage units to When is the Specialist Capacity available? hold the patients until the specialist capacity X junior is available the staff + following day Minimal Y Minimal capacity specialist capacity consultants? 00.00 06.00 12.00 18.00 23.59
  • 70.
    Assessment Process atApril 2009 Up to 24 4 hours. Up to 12 hours overnight hours post arrival at hospital Arrive History & Requests Perform tests Perform tests At Triage Nursing examination Test & Obs‟ & imaging & imaging A&E & initial imaging treatment Senior review Transfer to Assessment Unit Nursing History & Senior Review Obs examination Plan definitive treatment ? A&E Assessment Unit = value
  • 71.
    What do weneed to do instead? Pull patients forward into the working day: 450 Time of Arrival into A&E Time of Departure out of A&E to Main Hospital •Stop making them wait 3:59 minutes….. 400 •Stop duplication 350 300 250 200 150 100 50 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 The specialty capacity needs to be available: Right decisions On time 08:00 21:00 Every time Specialists available In full Seeing patients on wards Minimal Discharging patients capacity Admitting patients 00.00 06.00 12.00 18.00 23.59
  • 72.
    „Future‟ Assessment Process (Now current as at April 2012) 2 hours Transfer to Appropriate History & Senior specialist Arrive Plan Requests specialist area Nursing examination Perform tests Review At for Test & including home Obs‟ & initial & imaging Plan definitive A&E diagnosis imaging with PT/OT /SS treatment treatment home assessment at home 1 hour Safe ambulatory care process now possible
  • 73.
  • 74.
    All admissions fromA&E by hour Mondays May to Oct 08 8 7 Reduce daily 6 variation in discharges 5 Max Admission Min 4 Avg Av + 1 SD Av +2 SD 3 2 1 0 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Hour of arrival What is the rate of production required?
  • 75.
    Planning Capacity ofthe workforce Junior Doc Nurse X-ray Consultant doc Medical Emergencies Arrival Time 08:00 08:15 08:30 08:45 4 09:00 09:15 09:30 admissions 09:45 10:00 /hr. 10:15 10:30 10:45 11:00 11:15 11:30 11:45 12:00 12:15 12:30 12:45 All Emergencies Arrival Time 08:00 08:10 08:20 6 08:30 08:40 admissions 08:50 09:00 09:10 /hr. 09:20 09:30 09:40 09:50 10:00 10:10 10:20 10:30 10:40 10:50 11:00 11:10 11:20 11:30 11:40
  • 76.
    Improving Flow (frontend) • Pooled junior docs – A&E, MAU and specialty on call – Staggered start times on A&E/MAU = Increased availability from 08:00 to 10:00 • MAU consultants continuous flow • Speciality take every day: admissions • Heartbeat system for tracking patients • Wards – Consultant ward round every day: discharges
  • 77.
    Functional departments DH, SHA, Monitor, Health Commission etc. Board Board GP GP Flow Emergency Planned care Clinical subspecialties Medicine Intermediate care Surgery Community hospitals Paediatrics A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
  • 78.
    Do this hour‟swork this hour: • Emergency Blood turnaround: – Bottleneck for emergency samples = centrifuges Change: • Now a centrifuge starts every 3 minutes whether full or not • IP blood monitoring on wards – Bottleneck: Phlebotomists & transport to lab Change: • Porters running between phleb‟s and lab • Steady flow of samples into lab • all results back by 10:30 a.m. for ward rounds
  • 79.
    1 year later •Warwick • Focus on: – A&E, – Assessment units and wards – Diagnostics – Ward rounds – TTOs
  • 80.
    Foundation Close Status Community Dec 2010: flow improvements start deferred Hsp Sept 09 Increased % 16 to 64 years Flow doesn‟t recover from Sept 2009 bed + staff closures Infection control Palliative Care excluded Reduction in death rate Nobody addressed the CHC admin delays Acquire causing the Community long LOS services Open new wards Organisation Recruit Agenda for change change disrupted the Admin flow even more Comments?
  • 81.
    1 Year later •Sheffield Geriatric and stroke medicine – Focus on reducing the admin constraints (policies) – Check List and CHC assessment process • 42 page document • 18 man hours of work • Min time (LOS) = 30 days+ – Home assessment at home on day of discharge • Referral to Social Services by physio to social services • SS package in place within 48 hours (Upper process limit) – Home of choice: • out to residential home, CHC afterwards
  • 82.
  • 83.
    Lessons for executivesupport services DH, SHA, Monitor, Health Commission etc.. Board Board Emergency GP GP Flow Planned care Clinical subspecialties Medicine Surgery Intermediate care Paediatrics Community hospitals A&E Long term care Functional Ambulance Departments Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport HR IT Finance Estates Supplies Support functions
  • 84.
    Lessons for executivesupport services • HR: – Systems thinking and improvement science for A4C 8 & above – Match staff capacity to patient demand: 7/7, 365 – Heads of functions = responsibility for end-to-end process Focus is on Flow, WIP incurred accountable to the Dpt. concerned. • IT – Information in real time – Time series data • Estates: – Reduce transport and motion – Co-location of process resources • Supplies – Just-in-time
  • 85.
  • 86.
    Pareto analysis ofthe pay costs in one Trust for one month by employee. 50% of cost Role of senior managers is to improve process flow 20% of staff through the most expensive value adding staff =clinicians
  • 87.
    Change the FinanceParadigm Economies of Scale Economies of Flow Capacity Nu,ber of Patients Patients/hr treated successfully Land lives „saved‟ Demand Patients /hr Activity £5 £2 x PbR £1 /hr /hr £1 income Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 /hr £2 £1 /hr /hr /hr Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 Department Cost Activity = waste = unit cost constraint So focus is on improving value delivered and income Drives Dpt manager to This depends on moving resources to support the constraint do more activity at less cost The constraint should be the most expensive resource Acquires „new business‟ in the process = in Dpt 2. But what happens to flow? How can we optimise productivity through the most expensive resource?
  • 88.
    Finance • John Darlington‟spaper • http://www.leanuk.org/downloads/LS_2010/paper_lean_b usiness_case.pdf
  • 89.
    How to makechanges happen
  • 90.
    Get Everyone onBoard Patient‟s experience of waste Discussion History Full Endoscopy Discharge Nil by Rest & Check Cross with cardiac Examination blood & Transfuse With Plan mouth dehydrate FBC match centre Assessment Count Breath test 8 hours And Rx 4 hours for 20 5 minutes 40 mins Re stent 30 minutes 5 minutes 30 minutes 15 minutes hours 15 minutes Value adding 34 hours = 18% of time value adding Non Value adding 8 days x 24 hours 82% of time and resource wasted Poor quality experience and outcome From a Poor Quality System
  • 91.
    The Doctors canlead the change….. • Very complex system: – Like a human body! • Understand – Anatomy – Physiology (flows) – Plot the dots: BP, temp, pulse, resp‟s …. – Diagnosis – Treatment (releave the constraints) – Look for changes in the pattern of variation (SPC)
  • 92.
    Get the Managerson Board • Top Down Command and Control is impossible: – Not possible for one person to understand whole end- to-end process or System. • Facilitate Big Room Meetings – Get the everyone in a room – Listening to each other – Conversations based on facts: – Study, Adjust, Plan, Do, – Monthly and Weekly reviews
  • 93.
  • 94.
    Summary • Quality isa System property • Track patient flow (WIP), death rate and cost over time. – Increasing cost doesn‟t always improve flow – Reducing cost can have grave consequences • Improve processes to reduce delays and inventory (WIP) – Match staff capacity to patient demand – Do this hour‟s work this hour • Shift from: – Unit Costing: Dpt cost/activity – to Flow Accounting: throughput at constraint/total process cost – The constraints are policies or availability of staff, not beds.
  • 95.
    What have welearned ? • Nuggets • Niggles • Nice-if • NoNos

Editor's Notes

  • #70 Using our data to understand our flow, we were able to highlight the impact of our current system on the timeliness of patient care delivery.