Allied Healthcare Professions Service Improvement Projects Regional Event

1. Allied Healthcare Professions Service Improvement ProjectsRegional Event Process and Service Redesign Resource Pack

2. Aims of the session • understand principles and history of process redesign • introduce tools and techniques to map and fully understand processes • introduce a range of tools and techniques to use in redesigning services

3. Evolution of improvement 20’s W Shewhart – Statistical Process Control, PDSA 30-40 (Toyota) Lean thinking 50’s W E Deming – System of Profound Knowledge Since the 1980s: Adapt, not adopt in the NHS 70’s E Goldratt - Theory of Constraints (Motorola) 6 Sigma 80’s Total Quality Management M Hammer - Business Process Re-engineering 90’s

4. Any improvement is a change not every change is an improvement but we cannot improve something unless we change it Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts Theory of constraints

5. What does process re-design give us? • optimises flow by eliminating waste and bottlenecks – things run smoothly and to plan • therefore maximises outputs for any given resource • this minimises cost per case • improves patient’s experience – fewer hold ups, delays and unexpected glitches • improves staff morale – things run more smoothly, start and finish when planned, fewer frustrations

6. Process redesign Eliminate waste Reduce batching Match capacity and demand Linked processes Process mapping NO2704-202

7. A process map

8. Process mapping Every system is perfectly designed to get the results it achieves NO2704-202

9. How to build a process map • get everyone involved in delivering the process together • choose an (independent) facilitator to run the session • agree scope - start and end points • have plenty of flipchart (brown paper) and post it notes handy • map at a high level to begin with • focus on the process steps – don’t jump to solutions! • delve in to detailed areas if needed ( a separate process map may be required) • have fun but gain a consensus and agree further actions • do you want to practice? NO2704-202

10. Benefits of process mapping • simple exercise – easy, creative and FUN • powerful way for MDT understand real problems from patient (customer) perspective • identifies opportunities for improvement • provides forum for innovation • Interactive • end product, visual and owned NO2704-202

11. Symptoms and examples of ‘waste’

12. TIME: 3 5 5 Total Time = 188 s1 s1 s2 Value added time = 13 20 120 35 s3 s4 s9 Steps: Total Steps = 20 Value adding steps = 3 Calculating value added

13. Patient has • cardiac catheter 1 • Letter dictated to surgeon 2 • Tape to ward clerk 3 • Tape sent to • post room CHH 4 • Tape sent to post room HR 5 • Tape sent to secretary at HR 6 7 • Secretary types letter 13 • Letter delivered to secretary • Letter sent to post room CHH 12 • Letter sent to post room HR 11 10 • Letter returned to secretary 9 • Letter signed 8 • Letter to doctor for signature • Secretary request angiogram 14a 14 • Letter to surgeon 15 • Letter to secretary for OPD • Letter to post room CHH 16 • Letter to appoint-ments 17 18 • Letter sent to patient 19 • Patient seen in clinic 15a • Radio-grapher finds angiogram • Angiogram given to porter 16a 17a • Angiogram delivered to secretary 18a • Angiogram reviewed by surgeon 19a • Arteries suitable for surgery 20a • Surgeon considers patient suitable 20 • Patient put on waiting list Process map for cardiac referral

14. Patient has angiogram 1 Data input into computer 2 Print out data as referral letter 3 Letter and angiogram delivered to secretary 4 Secretary make OPD appointment 5 Patient seen in clinic 6 Angiogram tape 7 Simplified process

15. Batching • a key reason why setting the pace and achieving smooth flow is very difficult • batching is where multiple patients are processed at the same time eg assessment by medical on-call in A&E, ward rounds, reporting of x-ray results, old style appointment times • batching means that patients can only move between stages at the rate at which each batch is processed • this means lots of waste in the form of waiting and work-in-progress

16. Activity – Batching Clinical assessment Investigations Clinical decision Clinical decision Admission 1 every 10 minutes Phlebotomist arrives on the hour and half hour to take blood Results available 30 mins later Med SHO visits every hour on the hour A&E informed beds available at 11am and every 2 hrs thereafter Patient 1 arrives at 8am - how long will they wait at each stage? Patient 2 arrives at 12.25pm - how long will they wait at each stage? Patient 3 arrives at 4.35pm - how long will they wait at each stage?

17. Batching results 2hrs 50 2hrs 25 2hrs 15

18. Batching – Summary • identify where batching takes place • try and quantify the impact it has on the flow by undertaking the type of exercise we have done • which batch has the biggest impact on flow? • can you eliminate it (batch size = 1)? • if not, what could you reduce the batch size to? • use this information to try to influence behavior • measure the impact

19. More resources or better use of existing? • we often hear… • “what we need is more resources” • but what we should be asking is… • are we making best use of existing resources? • is investment in additional resources targeted at the right areas? • are capacity and demand matched? • how should we redesign to match capacity and demand?

20. Queue Demand Capacity time Average demand = average capacity causes a queue Can’t pass unused capacity forward to next week

21. Bottlenecks and constraints • bottleneck • part of a system where the patient flow is obstructed, causing waits and delays • constraint • cause of bottleneck, usually a skill or piece of equipment • eg patient waits for surgery (bottleneck), constraint might be availability of surgeon or anaesthetist

22. Types of bottlenecks • process bottlenecks • the step in a process that takes the longest time to complete • functional bottlenecks • shared resources, eg radiology, pathology, radiotherapy, physiotherapy “an hour lost at a bottleneck is an hour lost throughout the process…an hour gained at a non-bottleneck is a mirage”……..Eli Goldrat “The Goal” (Theory of Constraints)

23. Managing out bottlenecks • measurement to predict and manage • demand and capacity patterns • manage the bottleneck • maximise work of bottleneck • checking stage in front of bottleneck • free up expert skill • redistribute work • resolve capacity problems at the bottlenecks • increase capacity at the constraint • reduce inappropriate demand

24. Setting the pace • processes that feed into each other need to be linked, so that the receiving one can see what’s coming and cope with it Clinical assessment Investi-gations Treat-ment Dis-charge Clinical decision Admi-ssion If 5 patients arrive an hour, how many patients need to move between each step each hour? If 10?

25. Clinical assessment Investi-gations Clinical decision Admi-ssion Treat-ment Dis-charge Overall coordination • requires visibility of the process as whole • flows that have a single individual/team/area responsible for the whole flow from start to finish enable action to be taken quickly Flow manager

26. Pull don’t push! • prevents queues • improves flow • requires less effort! • can reduce process bottlenecks • requires courage…just in case seen as a safeguard against variation…..but can actually produce variation • patients can provide a pull system – demand driven

27. Lindsay Winterton Mobile 07801 376 011 e-mail: lindsay.winterton@frontlinemc.com