Achieving a breakthrough in health and social care using Theory of Constraints. Patrick Hoefsmit

Achieving a breakthrough in health and social care using

the Theory of Constraints

Patrick Hoefsmit

27th September 2012

Innovative Developments in Operations Management

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Agenda

• History of progress to date• Theory in practice

− Identifying and explaining the inherent simplicity

• What next for health and social care?• Evidence based research

Time

€

As the costs of medical treatment increases rapidly in comparison to growth of the available

budget

Why do we feel the problem is intensifying?

Budget

Medical costs

The Theory of Constraints, developed by Dr Eli Goldratt and described in his famous novels, focuses on achieving

breakthroughs in

performance in large, complex environments, dominated

by high uncertainty.

History of progress to date

• The starting point – “Yes, but will it ever work in the health environment?”

• Over 30 successful implementations in the UK, Holland, Australia and USA.

• To date, penetrated more than 10% of the UK acute health market

• Now have proven applications in emergency and planned care (emergency, discharge, operating theatres and outpatients).

• New research and implementations underway in mental health care and the wider social care environment.

Example resultsOrganisation Results achieved

Barnet & Chase Farm Hospitals NHS Trust

Length of stay reduced by 27%Emergency access improved from 90% within 4 hours to 98% within 4 hours

Frimley Park NHS Foundation Trust, England

Length of stay improved by 20% in one of the previously best performing hospitals in the UK.

St Maartenskliniek Nijmegen, The Netherlands

Higher quality and more timely treatment of outpatients without extra resources

Derbyshire Community Hospitals, England

30% reduction in length of stay in a matter of weeks

Amphia Ziekenhuis, The Netherlands 16-18% reduction in length of stay in 12 weeks and still improving

In times of fundamental transition, the first substantial actions of any major initiative must produce immediate substantial benefits.

When we started it took us eighteen months to produce ‘immediate substantial benefits’. The same project today will deliver bigger results in twelve weeks or less. Some implementations have now sustained and built on these improvement for more than seven years.

A customer’s view

“We have been able to move from one of the worst to one of the top performing Trusts in England. By working with QFI to apply the Theory of Constraints to our discharge process, we have been able to reduce our length of stay by 27% and we know we can improve on this. I have seen many methodologies but, putting it simply, the combination of the Theory of Constraints and QFI Consulting delivers results much faster than anything else around.” Averil Dongworth, Chief Executive

“We decided to invest in the QFI-Jonah approach as part of our broad-ranging strategy to reduce length of stay and I’m pleased to say that this overall strategy has produced very positive results with a reduction of more than 20% on those wards where QFI-Jonah is used”. Andrew Morris, Chief Executive

“We had a two-day meeting with Alex Knight and at some point in the second day I realised this must be the solution. It was quite a different view of how to manage an outpatient clinic. It was a paradigm shift because it is a completely different way of working.” Frank van den Hoogen, Lead Consultant Rheumatology

A customer’s view

“By working with QFI to apply their Theory of Constraints approach, we have been able to reduce our length of stay by a third within a matter of weeks and make big improvements to the quality of our patients’ rehabilitation and discharge. The process has developed staff’s confidence in their ability to take control and make changes which improve quality and productivity and has significantly improved multi-agency working across health and social care in Derbyshire.”Tracy Allen, Managing Director

With the start of the TOC-program, hospitals in the UK, USA and Australia were able to see their results in healthcare improve. This success was a reason why we worked with QFI, the developers of this simple Jonah-approach. Within a few months the first results were visible: the average length of stay decreased. A practical approach and not just a beautiful story in a book!Mary Groenewoud, Service Director

Theory in practice

- Identifying and explaining the inherent simplicity

HomeCommunity Hospitals

Social Services → Home

Surgical Unit

SpecialistUnit

Theatre

Outpatient Schedule

Emergency Department

Home

Assessment Unit

Home

MedicalUnit

Home

The Emergency Stream

GP Referrals MajorsMinors

Beds

KEY

Other non-bottleneck resources:

HomeCommunity Hospitals

Social Services → Home

Surgical Unit

SpecialistUnit

Theatre Schedule

Outpatient Schedule

Home

Beds

KEY

Other non-bottleneck resources:

GP Referrals

The Planned Care Stream

HomeCommunity Hospitals

Social Services → Home

Surgical Unit

SpecialistUnit

MedicalUnit

Theatre Assessment

Unit

Outpatient Schedule

Emergency Department

HomeHome

Home

GP Referrals MajorsMinors

Beds

KEY

Other non-bottleneck resources:

The System

GP Referrals

How to solve such a seemingly complex problem

The Five Focusing Steps

Step 1: Identify the system’s constraint(s)

Step 2: Decide how to exploit the system’s constraint(s)

Step 3: Subordinate everything else to the above decision

Step 4: Elevate the system’s constraint(s)

Step 5: If in the previous steps a constraint has been broken, goback to Step 1. Warning: do not allow inertia to causea system constraint(s)

Capitalising on the inherent simplicity of the system

To achieve a system wide breakthrough requires answers to these questions

• Of all the patients I could work on next, which one should I work on next?

• Of all the things I could change:– Where are the few places in the whole system I need to change?– What are the necessary actions to take in these few key places?– If I take these actions what will be the impact on the performance of

the whole system and over what timescale?– If I leave things as they are what will be the outcome?

The assumptions upon which the analysis can be conducted

• Dissect the system into manageable parts

Dissect the system into manageable parts

Outpatient Schedule

HomeEmergency Department

Home

Assessment Unit

Home

Mis-synchronisation, silo

mentality and local optima

conflicts, to name a few.

What are the drawbacks?

LOCAL OPTIMA DO NOT ADD UP TO GLOBAL OPTIMUM

The assumptions upon which the analysis can be conducted

• Dissect the system into manageable parts• Dissect the system into distinctive pathways

Community HospitalsHome

Community Hospitals

Social Services → Home

Surgical Unit

SpecialistUnit

MedicalUnit

Theatre Assessment

Unit

Outpatient Schedule

Emergency Department

HomeHome

Home

GP Referrals MajorsMinors

Beds

KEY

Other non-bottleneck resources:

GP ReferralsMajors

Emergency Department

Assessment Unit

Theatre

Surgical Unit

HomeSocial Services

→ Home

Dissect the system into distinct pathways

SpecialistUnit

Community HospitalsHome

Community Hospitals

Social Services → Home

Surgical Unit

SpecialistUnit

MedicalUnit

Theatre Assessment

Unit

Outpatient Schedule

Emergency Department

HomeHome

Home

GP Referrals MajorsMinors

Beds

KEY

Other non-bottleneck resources:

GP ReferralsGP Referrals

Outpatient Schedule

HomeSocial Services

→ Home

Dissect the system into distinct pathways

What are the problems with this approach?

• Key to success is improving the flow through the whole system

• Key resources that impact the flow of the whole system often work across many streams of the flow

• Improving any one stream of flow will not improve the whole system and can actually damage the flow through the whole system

Dissect the system into distinct pathways

The assumptions upon which the analysis can be conducted

• Dissect the system into manageable parts• Dissect the system into distinctive pathways• Dissect the system by resource type

HomeCommunity Hospitals

Social Services → Home

Surgical Unit

SpecialistUnit

MedicalUnit

Theatre Assessment

Unit

Outpatient Schedule

Emergency Department

HomeHome

Home

GP Referrals MajorsMinors

Beds

KEY

Other non-bottleneck resources:

GP Referrals

Dissect the system by resource type

What are the problems with this approach?

• Most resources are non-bottlenecks• Improving non-bottlenecks does not improve the

flow through the whole system• Saving money on non-bottleneck resources by

reducing capacity often creates a system of wandering bottlenecks, which can become a nightmare to manage

Dissect the system by resource type

Underpinning assumption: the more complex the system the more “inherent simplicity” that exists

• Identifying the inherent simplicity– Set a clinically-based treatment time for all patients– Sequence all resources to meet the clinically- based

treatment time– Identify which resource is most often causing the

most time delay to the most patients across the whole system?

– Focus ALL improvement efforts on this key resource – Initiate a process of focused system-wide

improvement

Time Buffers

Patient 1

Admission date

Clinically based Planned Discharge

DateMDT

This patient is in the red and the blue resource is the cause of the patient being in the red

Patient 5

Admission date

PDD 5MDT

Admission date

PDD 4MDT

Patient 4

Patient 3

Admission date

PDD 3MDT

Admission date

PDD 2MDT

Patient 2

Patient 1

Admission date

PDD 1MDT

Question: Which resource is most often causing the most time delay to the most patients across the whole system?

Answer: The blue resource is causing the most delay across the most patients! Would you like to know the size of the delayed days and which period of the week or year this is at its worse? By the way the blue department is already on the case and is following the updated sequence to overcome these delays. The Continuous Improvement teams are looking into offloading the blue and training up the red to avoid this problem in the future.

HomeCommunity Hospitals

Social Services → Home

Surgical Discharge

SpecialistDischarge

MedicalDischarge

Theatre Schedule

Assessment Unit

Outpatient Schedule

Emergency Department

GP Referrals MajorsMinors

Beds

HomeHome

Home

KEY

Other non-bottleneck resources:

GP Referrals

Buffer Buffer Buffer

Buffer

Buffer

BufferTheatre drum schedule

ROPE

Buffer

Buffer

Outcomes• Every patient has a plan and the status of that plan is clear

to everyone during the patient journey.• Every task manager has a clear priority list and is clear on

the impact they are having on every patients journey.• If a patient’s journey is being delayed it is clear who is the

primary cause of the delay and what recovery actions are necessary.

• At all times clinicians and managers know the size of the total delays across the system and the impact on current and future performance.

• Improvement efforts can be focussed on the resource causing the most delay across the most patients

• A sustainable breakthrough is quickly and safely achieved.

Complex systems

Seemingly complex systems do not require complex solutions.

Dissecting a seemingly complex system into its parts and analysing and improving the performance of each part will not improve the system as a whole

The more complex the system appears the more simple the solution must be.

What next for health and social care?

• Complete our work on key ingredients of success:– Solution development– Software development– Our own marketing development– Consulting capability development

• Build irrefutable evidence of success in more countries

• Document and publish

Revenue

Time

€

The revenue increases faster than The growth in medical costs

A true breakthrough

QuestionsThank you